Incontinence Rings and Pessaries

By Barbara C. Bourassa

Although pessaries, or incontinence rings, have been around for centuries, they are not necessarily a well-known treatment for stress incontinence. They are often used to treat uterine prolapse (a condition where the uterus slips into the vaginal canal), but urogynecologists and other specialists in women's pelvic health say there's a growing interest in using them to prevent urinary leaks.

A pessary is a small, ring-shaped device made from silicone or latex. It fits inside the vagina and works by supporting the urethra, or neck of the bladder. There are very few studies that diagram exactly how pessaries work, but one theory is that the ring effectively narrows the size of the opening through which urine can leak.

Pessaries are best suited for "patients who don't get better with pelvic floor exercises or behavioral therapies," says Rebecca Rogers, MD, director of the division of urogynecology at the University of New Mexico in Albuquerque, New Mexico. They are also a good alternative to surgery, she notes, especially in patients who may not tolerate surgery, such as pregnant women or the elderly. "In studies, about half of all women who try pessaries end up using them long term," she notes.

Pessaries come in many different styles and sizes, and patients must be fitted for one in a medical office. In general, though, "using a pessary is not complicated at all," notes Rogers.

In fact, the process of finding the right style or size may be more work than actually using one. The process is largely a matter of trial and error, in part because there are several different styles used for treating stress incontinence. "It's a lot like trying on shoes-you don't know until you put it on if it works," she notes. "The ring pessary is the most commonly used, because it's easy to put in and remove, but if that style doesn't work we might try a pessary with a knob, for instance."

At the University of New Mexico Health Sciences Center, midwives do all the fitting of pessaries, and they help teach the patient the ins and outs of necessary care and maintenance. The fitting process has two parts to it: the patient is outfitted with a pessary in the office, and they must be comfortable wearing the device. In addition, they make sure it stays in when they stand up and that it relieves their symptoms, and the patient either has to void with the device in place or be able to remove it for voiding.

After that portion of the process is complete, the patient continues the trial at home. "Is it still comfortable? Can they void with the device in place? And are there any new symptoms?" says Rogers. If this is successful, the patient can continue wearing the device for two to four weeks before returning to the office for cleaning and re-insertion. If there are problems during the home trial the midwife may recommend a different style of device, she notes.

The routine for cleaning and maintenance varies by doctor, however. Rogers says her practice wants their patients to be as autonomous as possible, in part because "it's hard to hurt yourself with a pessary." Some patients with arthritis in their hands may have trouble removing or inserting the device, and some menopausal women with thin vagina tissue may need to use the device with estrogen cream to prevent irritation.

For more information about pessaries, consult your OB/GYN, or ask for a referral to a subspecialist, such as a urogynecologist.