Pessary Use for Posterior Vaginal Wall Prolapse (Rectocele)
Yes, a postmenopausal woman with rectocele can absolutely use a pessary—this is a well-established first-line treatment option recommended by the American Urological Association for symptomatic pelvic organ prolapse, particularly for patients who prefer non-surgical management or are not surgical candidates. 1
Primary Indication and Patient Selection
Pessary therapy is specifically recommended for symptomatic pelvic organ prolapse affecting any compartment, including posterior wall prolapse (rectocele), when patients decline surgery, are not surgical candidates, or desire less invasive management 1
The key prerequisite is patient preference for non-surgical management over definitive surgical repair, as pessaries provide symptom relief rather than definitive anatomic correction 1
Treatment decisions should align with the degree of patient bother from prolapse symptoms and their impact on quality of life 1
Multi-Compartment Assessment Required
Before pessary fitting, you must systematically assess all three compartments—anterior (cystocele/urethrocele), apical (uterine/vaginal), and posterior (rectocele)—because multi-compartment involvement is extremely common and influences pessary selection and success 1, 2
Physical examination should determine which vaginal compartments are involved and the degree of prolapse in each 3
Failing to assess all compartments, including lateral vaginal wall defects that often coexist with posterior prolapse, is a critical clinical pitfall 2
Expected Outcomes and Management
Pessaries combined with pelvic floor muscle training (PFMT) probably lead to more women perceiving improvement in prolapse symptoms compared with PFMT alone (RR 2.15,95% CI 1.58 to 2.94) 4
Pessary plus PFMT probably improves prolapse-specific quality of life compared with PFMT alone (median POPIQ score: 0.3 vs 8.9, P = 0.02) 4
Patient satisfaction with pessary treatment is generally high, though follow-up data in published literature is often short 5
Common Side Effects and Follow-Up
Increased vaginal discharge is nearly universal but manageable, and approximately 14% of patients require pessary repositioning 1
Pessaries may result in increased risk of adverse events including increased vaginal discharge, increased urinary incontinence, and erosion or irritation of vaginal walls compared with PFMT alone 4
Pessaries may slightly increase the risk of abnormal vaginal bleeding (RR 2.18,95% CI 0.69 to 6.91) 4
Critical Safety Considerations
Regular follow-up is paramount—neglected pessaries can lead to serious complications including vesicovaginal and rectovaginal fistulas, with case reports of pessaries migrating completely into the bladder 6
Patient education, local estrogen treatment (particularly important in postmenopausal women), excellent fitting, and careful follow-up are essential for preventing complications 6
Long-term follow-up by primary care or specialist physician is required after pessary placement, with monitoring for complications and treatment efficacy 2