Selection
When selecting a pessary, you may be overwhelmed by the choices in size and style and wonder which to choose for which condition. Each woman's anatomy is unique. For some, the initial fitting may be accomplished in one visit with excellent control of symptoms and comfort. In other cases, such as when laxity is more pronounced, a series of visits may be required. As stated earlier, there certainly is a learning curve, but it does get easier with experience. Even after 15 years of fitting pessaries, I often have to try three or four before determining the best fit for a patient.

Selection of the proper pessary mainly depends on the patient's comfort level as well as the pessary's ability to correct the diagnosed problem. Pessary fitting is unique in that its selection is also influenced by the provider's ability to insert a certain pessary and the patient's comfort in accepting it. Many providers become adept at fitting a certain kind of pessary and tend to use it frequently to treat a variety of conditions. This seems to work well. Pessaries that are difficult to insert and remove are less likely to be used. An exception is the Gellhorn, which works well and is used often but is difficult to remove. While a manufacturer may recommend a certain pessary for a particular condition, many pessaries are appropriate for a variety of conditions.

It is not necessary to have a full supply of potential pessaries, but you should have a representative selection readily available in your office. My advice is to have three or four sizes of three to four of the most commonly used pessaries (Table 3). If the majority of your population is older, you might consider sizes 0 through 3; if they tend to be younger, sizes 3 through 6 might be more useful.

A pessary known as the ring is an excellent choice for the treatment of urinary incontinence and is available as a simple ring or as a ring with a knob (shown in Figure 2). The knob exerts direct pressure on the urethra, pushing it against the pubic bone, stabilizing the bladder neck and decreasing incontinence. It is also available with a support membrane, which is beneficial for supporting a mild cystocele. I do not have much experience with the Marland, but it has the potential to work well in supporting the bladder neck and is easy to insert and remove. The patient is often able to care for it herself. For the inexperienced provider, both the Marland and the ring can be fit in a similar manner to the vaginal diaphragm, so they are less intimidating to use in your first fittings.

Considerations
Sexual activity is an important consideration when using the pessary. Ask about the woman's sexual relationships - never assume that she is not sexually active simply because she is older. Coitus is possible with many pessaries that are not vaginally occlusive. For example, intercourse is not possible with the Gellhorn or donut, but the ring is fine. To use an occlusive pessary, the woman must have the dexterity to remove and reinsert the pessary for intercourse.

Another important consideration is the future gynecologic care a woman will be receiving. For example, she may have an upcoming routine physical exam with her primary care provider, who may be unfamiliar with pessary removal and reinsertion. A pessary needs to be removed prior to a Pap smear but can stay in place for a colonoscopy.

General Fitting Principles
The goals of pessary fitting are to achieve proper fit and correct the incontinence problem while avoiding patient discomfort.⁴ Pessaries are generally fit by trial and error. Fittings may require many attempts with pessaries of different sizes and shapes. Do not let this deter you! It is part of the normal fitting process. As you try the different pessaries, note and record the various pessaries used so you have an accurate record of which ones didn't work. Pessaries used during the fitting process can be resterilized and reused.

Inform each patient that the fitting process may take a while and that three to four pessaries may be tried before the proper fit is achieved. Do not attempt to fit any more than four during a single session. Bring in a box of the pessaries you would like to try first. It is disrupting to have to repeatedly leave the room in search of the correct pessary. Always show the patient the pessary before you insert it. Have her hold it and bend it to feel its size, shape and consistency.

The patient should arrive with her rectum as empty as possible. Nothing interferes with the fitting of the pessary more than a rectum that is full of stool. She should also empty her bladder immediately prior to insertion. If she has a cystocele and does not completely empty her bladder, perform a straight catheterization to drain any residual. Prior to insertion, reduce any prolapse.

Once the patient has an empty bladder, perform a bimanual exam to rule out any pathology and to assess the size and shape of the vaginal vault and the position of the uterus, if present. Perform a wet mount since a pessary is contraindicated in the presence of an active vaginal or cervical infection.