Hanson reported very good results in 1,216 patients with vaginal pessaries [6]. The overall success rate was 71 % in patients with POP and ring pessaries were successful in 89 % and Gellhorn pessaries in 85 %. In patients with stress urinary incontinence, ring pessaries with or without urethral support, were effective in 78 % and 63 % of patients, respectively. Local hormone replacement treatment seemed to improve the success rate with pessary fitting in this study [6].

In a prospective study, Wu et al. used the ring pessary as a first-line treatment in all patients with all degrees of pelvic organ prolapse, and when a ring pessary failed, other models were used. The success rate was 79 % in this study and they were unable to identify any predictive factors for success with pessaries [7]. Wu et al. found that prior hysterectomy did not influence the success of pessary fitting. In our experience, a long and wide vagina is not a contraindication for management with a pessary.

The compartment of prolapse also does not influence the success of pessary and this should not be taken into account when considering pessaries for POP [8]. Most gynecologists prefer surgical option over pessaries in advanced stages of prolapse in elderly population. In a study by Powers (2006), in those with advanced POP (stages 3 and 4), there was a significant likelihood of success with a success rate of 62 %, among those willing to try the pessary [9].

Urinary tract symptoms however seem to influence the success of pessary fitting. Sulak (1993) showed that only one third of patients with urinary incontinence reported a decrease of their symptoms with pessary and two thirds underwent surgery [10].

In general the success rates with pessary have varied from 41 to 74 %, with variable lengths of follow-up from a week and up to 5 years [7, 11–15]. The majority who decide to go for surgical intervention after a pessary trial, do so within 12 months of pessary fitting. A prospective study on pessary use over a period of 5 years found that if the fitting was successful at the end of 4 weeks, most women continue to use it over 5 years [16]. With the use of supportive pessaries, it has also been noted that there is no progression of the prolapse stage and improvement of the stage in 21 % of the women [11].

In a study comparing surgical intervention with pessary use in 554 women, 1 year after treatment, there was similar improvement in bladder, bowel, sexual function and quality of life parameters in both groups [17].

Complications associated with pessary use include discharge, pain, discomfort, ulceration, bleeding, disimpaction and constipation which occur in 12 % of women [16]. Of these, vaginal discharge is the most common.

All pessaries are generally contraindicated in the presence of cervical or vaginal ulcerations, undiagnosed vaginal bleeding, active local pelvic infection and patients allergic to silicone and latex. Patients who are unable to attend for regular pessary change and follow-up should not be fitted with one. Space-occupying pessaries ideally should be avoided in sexually active women, unless they are adept at its removal and self-insertion.

Before inserting a pessary, the patient is examined to rule out atrophy, infection and ulceration of the vagina. Pelvic examination includes quantification of the prolapse and assessment of the width and depth of the vagina. Local treatment with vaginal estrogen for 3–4 weeks prior to pessary insertion is recommended in those with atrophic changes. The provider estimates the size and type of pessary to be used.

The aims of pessary fitting are proper correction of prolapse and proper size of pessary to avoid pain and ulceration of vaginal mucosa and bleeding. Most women can be successfully fitted with a pessary 70–90 % of the time [18].

We usually begin pessary fitting with a ring pessary and move over to other types as indicated.