Is a Pessary Effective for Urinary Incontinence?
Yes, a continence pessary is an appropriate and effective non-surgical treatment option for stress urinary incontinence, though the evidence quality is limited. 1
Evidence Quality and Positioning
The AUA/SUFU guidelines explicitly list continence pessaries as a non-surgical treatment option for stress urinary incontinence (SUI) or stress-predominant mixed urinary incontinence (MUI), though they acknowledge there are no comparative or direct observational data concerning their effectiveness. 1 The American College of Physicians found insufficient evidence to determine the effectiveness of pessaries versus no active treatment for stress incontinence. 1
Despite limited high-quality evidence, pessaries remain a guideline-recommended option because they are low-risk interventions that can be considered before more invasive treatments. 1
When to Offer a Pessary
Pessaries should be offered to patients with stress urinary incontinence who:
- Prefer less invasive therapy than surgical intervention 1
- Are not bothered enough to pursue surgery 1
- Are not candidates for other forms of therapy (e.g., poor surgical candidates) 1
- Have not completed childbearing 2
- Are awaiting surgery 3
Treatment Algorithm for Stress Incontinence
First-line treatment should be pelvic floor muscle training (PFMT) for at least 3 months, not pessaries. 1, 4 The ACP provides a strong recommendation with high-quality evidence that PFMT should be the initial treatment for stress incontinence. 1
If PFMT fails or the patient prefers a device-based approach, then consider a continence pessary or vaginal insert. 1, 4
Surgical intervention (midurethral slings, autologous fascia slings, or Burch colposuspension) should be reserved for patients whose symptoms persist despite conservative management and who have significant quality of life impact. 1, 4
Pessaries for Urgency Incontinence
Pessaries are NOT recommended for urgency urinary incontinence. For urgency incontinence, bladder training is the first-line treatment, followed by antimuscarinic medications if bladder training fails. 1, 5 Pessaries have no established role in treating urgency symptoms.
Practical Considerations
Long-term pessary use is safe and effective when properly managed. 3, 2, 6 Studies show that women can use pessaries for extended periods (mean 4.5 years, range 1-15 years) with good symptom control. 7
Continuation rates are approximately 60% at 12 months. 6 This means about 40% of patients discontinue pessary use within the first year, often due to discomfort, difficulty with self-care, or inadequate symptom relief.
Most patients require clinic visits every 3 months for pessary care if not performing self-care. 7 Proper fitting by trial is essential for effectiveness. 8
Common Pitfalls to Avoid
Do not use pessaries as first-line treatment before attempting PFMT. The evidence strongly supports PFMT as the initial intervention for stress incontinence. 1
Do not neglect regular follow-up. Major complications (vaginal erosion, fistula formation) occur only when pessaries are neglected. 3 Minor complications like vaginal discharge, odor, and erosions are common but usually manageable. 3, 7
Do not assume all patients can perform self-care. Insertion and removal pose challenges for many patients, particularly older women. 2 Assess the patient's ability and willingness to perform self-care versus requiring clinic visits.
Recognize that pessaries may unmask occult stress incontinence in women with pelvic organ prolapse. 1 If a patient has high-grade prolapse without stress incontinence symptoms, stress testing with prolapse reduction should be performed before surgical repair to identify occult incontinence.
Cost-Effectiveness
Pessaries are cost-effective within a stepped care model for both POP and SUI. 6 When compared to surgery alone, pessaries had an incremental cost-effectiveness ratio of $1,033 per QALY gained for SUI. 6 Out-of-pocket expenses may be a barrier for patients without extended insurance coverage. 6