Can Pessaries Cause Toxic Shock Syndrome?
Vaginal pessaries used for pelvic organ prolapse are associated with extremely rare serious complications, and toxic shock syndrome (TSS) is not documented as a complication in the available evidence for these devices. 1
Evidence from Cervical Pessaries
The most comprehensive guideline data comes from the Society for Maternal-Fetal Medicine's 2017 statement on cervical pessaries (Arabin pessary) for preterm birth prevention. This guideline explicitly states that "serious adverse events (eg, cervical ischemia) are rare" and does not mention toxic shock syndrome as a recognized complication 1.
The documented side effects from large randomized controlled trials include:
- Increased vaginal discharge (15-20% requiring evaluation to exclude infection)
- Discomfort with placement and removal
- Vaginal bleeding
- Cervical ischemia (rare)
Importantly, rates of actual vaginal infection were similar between women with and without cervical pessary in RCTs 1.
Context from Other Vaginal Devices
While TSS is well-documented with:
The mechanism involves Staphylococcus aureus producing toxic shock syndrome toxin-1 (TSST-1) in the vaginal environment, particularly when devices absorb magnesium ions or create conditions favoring bacterial growth 4, 5.
Key Distinctions
Pessaries for pelvic organ prolapse differ fundamentally from menstrual products:
- They are typically silicone ring devices that don't absorb fluids
- They allow vaginal drainage
- Studies show no magnesium ion absorption capacity 4
- Regular cleaning protocols are standard practice
The 2024 data on pessary complications focuses on pain during removal (mean NRS 4.3/10) and vaginal discharge (mean NRS 2.5/10), not infectious complications like TSS 6, 7.
Clinical Bottom Line
TSS is not a recognized complication of pessary use for pelvic organ prolapse based on current evidence. The common complications are benign: vaginal discharge, discomfort, and rarely cervical erosion or ischemia. If a patient with a pessary presents with fever, rash, and hypotension, consider TSS in the differential but recognize this would be an extraordinarily rare presentation requiring investigation for other sources of S. aureus infection.
Routine pessary care should include regular cleaning and monitoring for vaginal erosions or excessive discharge, but specific TSS precautions are not indicated 1, 6.