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How Pessary Selection Works: A Clinical Guide for Pelvic Floor Specialists

UROGYNECOLOGY How Pessary Selection Works: A Clinical Guide for Pelvic Floor Specialists CincyMed Clinical Resource  ·  3 min read Pessary selection is both a science and a clinical art. The goal of any pessary selection guide is to match pessary type and size to the patient's specific pelvic floor defect, prolapse stage, activity level, and ability to perform self-management. Getting selection right maximizes symptom relief, minimizes displacement, and reduces the need for repeat fitting appointments. What Is a Pessary? A pessary is a removable intravaginal device inserted to support the pelvic organs and/or provide a urethral compression point for stress urinary incontinence (SUI). Pessaries are manufactured from medical-grade silicone (non-latex, MRI-compatible) in a range of shapes and sizes. They are a first-line, non-surgical treatment option for pelvic organ prolapse (POP) and SUI and are appropriate for patients who decline surgery, are poor surgical candidates, or desire conservative management during fertility planning. Pessary Types and Clinical Indications Pessary Type Design Primary Indication Self-Management Ring (with or without support) Flexible ring; flat or with membrane Stage I–II uterine prolapse, cystocele, SUI (incontinence dish variant) Easy; patient-removable Gehrung Bent ring; arch configuration Cystocele and rectocele; combined anterior and posterior defect Moderate; requires instruction Gellhorn Flat base with central stem and drainage holes Stage III–IV prolapse; procidentia; post-hysterectomy vault prolapse Difficult; usually provider-managed Donut (Torus) Thick, doughnut-shaped ring Complete uterine prolapse; short or stenotic vaginal vault Difficult; usually provider-managed Cube Cube with concave sides; suction retention Advanced prolapse with poor perineal body support; low vaginal tone Daily removal required; not for long-term wear Incontinence Dish / Ring Ring with urethral support knob Stress urinary incontinence without significant prolapse Easy; patient-removable Shaatz Similar to Gellhorn without stem; disc with perforations Advanced prolapse; alternative to Gellhorn for patients who cannot tolerate stem Provider-managed Sizing Principles Pessary sizing is determined by clinical examination and trial fitting — not by POP-Q stage alone. The cardinal rule is that the correctly fitted pessary should remain in place during Valsalva, ambulation, and voiding, without causing discomfort, urinary retention, or rectal pressure. The examiner should be able to insert one finger between the pessary and vaginal wall to confirm adequate fit without excessive compression of vaginal epithelium. Ring pessaries are typically sized 2–5 (corresponding to roughly 51–89 mm diameter) and are the best starting point for most patients — their flexibility tolerates a range of vault dimensions, and their ease of self-management maximizes patient adherence. Begin fitting with the ring and escalate to a support or space-filling design only if the ring fails to control symptoms. Patient Selection and Counseling The best candidates for self-managed pessaries (ring, incontinence dish) are patients with good manual dexterity, access to follow-up care, and Stage I–II prolapse. Provider-managed pessaries (Gellhorn, donut, cube) are appropriate for patients with advanced prolapse, limited manual dexterity, or narrow introital access. At each follow-up — typically every 3 months — examine the vaginal epithelium for erosion, discharge, or granulation tissue that may indicate excessive pessary pressure. Patients using hormone therapy (vaginal estrogen) have improved epithelial integrity and better pessary tolerance. For postmenopausal patients with atrophic vaginitis, local vaginal estrogen is a useful adjunct to pessary use when not contraindicated. View CincyMed's complete range of pessaries and our urogynecology instrument page for full product details. The American Urogynecologic Society (AUGS) publishes patient resources and clinical guidelines on pessary fitting that complement this selection framework. Conclusion A systematic approach to pessary selection — beginning with prolapse stage, adding patient anatomy and self-management capacity, and starting with the simplest effective device — allows clinicians to fit the majority of patients successfully at the first or second appointment. Ring pessaries cover the widest indication range; Gellhorn and donut designs address advanced prolapse; cube pessaries are reserved for refractory cases requiring maximum retention force. Regular follow-up and patient education are as important as device selection to achieving durable outcomes. Need instruments for this procedure? CincyMed supplies surgical and endoscopy instruments for hospitals and ASCs. Browse Our Catalog