How Urinary Incontinence Pessaries Work
Continence pessaries work by mechanically supporting the urethra and bladder neck, restoring the urethrovesical angle and providing compression to prevent urinary leakage during activities that increase intra-abdominal pressure. 1
Mechanism of Action
Pessaries function as passive mechanical devices that physically reposition prolapsed pelvic organs and provide urethral support through the following mechanisms:
Urethral compression and support: The pessary elevates and compresses the urethra against the pubic symphysis, increasing urethral resistance and preventing involuntary urine loss during stress maneuvers like coughing, sneezing, or exercise 2, 3
Restoration of anatomical position: By holding the vaginal walls and supporting structures in their correct anatomical position, pessaries restore the normal urethrovesical angle that is critical for continence 3, 4
Bladder neck stabilization: The device prevents downward displacement of the bladder neck during increased abdominal pressure, maintaining the continence mechanism 2
Clinical Application and Effectiveness
Indications for Use
Continence pessaries are appropriate first-line conservative treatment options for women with stress urinary incontinence or stress-predominant mixed urinary incontinence who prefer non-surgical management 1, 5
The most recent European Urology guidelines (2025) position pessaries alongside pelvic floor muscle training as key conservative modalities before considering surgical intervention. 1
Patient Selection
Pessaries are particularly suitable for:
- Women not bothered enough to pursue surgical therapy 1
- Patients awaiting definitive surgical repair 3
- Women who are not surgical candidates due to medical comorbidities 3
- Younger women interested in maintaining childbearing capabilities 3
- Women with concomitant pelvic organ prolapse and stress incontinence 2, 6
Practical Considerations
Ring pessaries are the most commonly used type for incontinence, though the AUA/SUFU guidelines acknowledge there are no comparative data on different pessary types for stress urinary incontinence management. 1
The evidence shows that pessaries can successfully predict postoperative continence outcomes—when a pessary reveals bothersome stress incontinence in women with prolapse, it indicates the need for concomitant anti-incontinence surgery 6
Limitations and Caveats
Evidence Quality
A critical limitation is that current guidelines classify pessary recommendations as "Expert Opinion" rather than evidence-based recommendations, reflecting the lack of high-quality comparative trials. 1
The 2020 Cochrane review found very low to low-certainty evidence comparing pessaries to no treatment or pelvic floor muscle training alone, with uncertainty about symptom improvement 4
Adverse Events
Pessaries may cause:
- Increased vaginal discharge 4
- Vaginal wall erosion or irritation 4
- Abnormal vaginal bleeding 4
- Increased urinary incontinence in some cases 4
Major complications occur only when pessaries are neglected, while minor complications can usually be successfully treated with proper follow-up care. 2
Service Delivery Gaps
Significant variation exists in pessary care delivery, with more than 15% of clinicians providing pessary care reporting they had not received formal training 7. Follow-up protocols vary considerably across practices 7.
Integration with Other Treatments
The combination of pessary plus pelvic floor muscle training probably leads to more women perceiving improvement in prolapse symptoms compared with PFMT alone (RR 2.15,95% CI 1.58 to 2.94), representing the strongest evidence for pessary effectiveness. 4
This synergistic approach addresses both mechanical support (pessary) and active muscle strengthening (PFMT), providing comprehensive conservative management before considering surgical options 5, 4