Next, approximate size by using your fingers to measure the vaginal opening (Figure 3). It is interesting to note that the widest diameter of the vaginal opening is neither parallel nor perpendicular, but rather oblique. The opening may seem quite small, but remember that the vaginal tissue is compliant and can stretch larger than its measured distance. The exception is the woman who has vaginal atrophism; her vaginal tissue may tear and bleed when stretched.

It is impossible to describe each device and its particular characteristics for fitting within a single article. Since the ring pessary with or without knob or support is the most common initial choice for stress incontinence, I will use this device as an example for the insertion process. The ring with support has two large holes and two smaller holes for the drainage of any vaginal secretions and menses. The size is written on the rim. Next to the larger holes are two indentations on the inner aspect of the ring. This is the point where the pessary flexes in half for insertion.

The fitting process is not typically uncomfortable. I sometimes mix equal parts of K-Y Jelly and xylocaine 2% gel and spread it around the vaginal introitus prior to a fitting session. The patient may be tense, since the concept of pessary use is foreign to her and she is not quite sure what to expect. The vagina is a pouch, so it is not possible to push it into a place where it does not belong. Most women tolerate the process very well. Lubricate the vaginal opening for ease of insertion using your non-dominant hand. The leading edge of the pessary may also be lubricated. Avoid getting lubricant on the hand holding the pessary or it will be difficult to fold and insert because it will be slippery.

A properly fitting pessary should take up redundant vaginal tissue, forming a sling that will support and elevate the uterus and flatten and support a cystocele.

Try to use the smallest pessary that can control the incontinence or reduce the prolapse, so that it can be easily removed and reinserted.5 Achieving the easiest possible removal is worth the risk of having a few pessaries fall out in the beginning. Unfortunately, the smaller pessaries tend to be the easiest expelled.

For insertion, separate the labia minor at the posterior introitus and the leading edge of the pessary. With the folded concavity facing downward, insert the pessary by curving it posteriorly (Figure 4). Once inside the vagina, release the ring and the pessary springs open. Make a quarter turn to secure its position, rotating the hinge of the pessary away from the introitus so it is less likely to fall out. When the ring pessary is in proper position, it should be parallel to the vaginal axis. The pubic bone is an important landmark. Push the pessary deep into the vagina and tuck it behind the pubic bone. The pessary should fit snugly behind it. The cervix can also act as an anchor, but many women with stress incontinence have had a hysterectomy. If a cervix is present, tuck the pessary in the posterior fornix below the cervix.

You should be able to sweep your fingers around the edge of the pessary, as with a diaphragm. This helps ensure that the pessary is not pressing too tightly against the vaginal epithelium, potentially causing erosions and ulcerations. It should also be possible to easily slide the ring of the pessary up and down along the vaginal sidewall. If the ring is properly placed, it will take up redundant vaginal tissue, forming a sling that will then support and elevate the cystocele.⁶ The pessary should always be comfortable. In fact, the woman should not feel the pessary at all.

Once the pessary is inserted, perform a series of checks and balances to assess proper fit. Separate the labia and ask the woman to bear down. Inform her that many women normally pass gas during this exercise, so that she will not be embarrassed by it. As she bears down, observe the introitus for any sign of the white pessary. A well-supported pessary should not be visible. A slight descent may occur, but it should retract back up into position when she has stopped pushing. If the pessary descends to the introitus and stays or slips out, try a larger ring pessary or a different shape. Also observe for the bulge of a cystocele or rectocele around the pessary. Next, have the woman stand in front of you and spread her legs. Have her hold onto your shoulders for stability. (This position may feel awkward for her.) Once again, feel inside the vagina as she bears down, noting any descent of the pessary.

If the pessary remains tucked comfortably inside the vagina, instruct her to walk around the room and sit down a couple of times. Ask whether she feels any pressure or discomfort from the pessary as she performs these maneuvers. Differentiate between true discomfort or pressure and the expected vaginal tenderness from the fitting process, particularly if three or four different sized have been tried.

Re-examine the woman one more time in the lithotomy position to ascertain whether the pessary has slipped or rotated its position. If not, you are on your way to a proper fit! Initial fitting is considered a success if the patient does not feel the pessary coming down and the examination confirms that it is comfortably staying in position.

Although these post-fitting maneuvers sound complicated and time consuming, they are well worth it. They require only a few minutes and can save the woman a trip from the parking lot back to the office with pessary in hand. In rare cases, the pessary may put too much pressure on the urethra, making urination impossible. It is a good idea to have the woman urinate before she leaves the office. This is not always possible, however. Some providers send the woman out shopping for an hour or so and have her return to be checked again, but this is probably not necessary. I have requested it on occasion when I was not quite sure of the fit. The biggest test of all is how well the pessary remains in place during straining at stool when the patient returns home.

Instruct the patient to call you if the pessary is uncomfortable or if urination or defecation is difficult. Sometimes a pessary that is too large can exert too much pressure against the urethra. Defecation may also be affected. The patient may feel some lower back pain from the pessary. Since the rectum is only separated from the vagina by a few millimeters of tissue, the pessary can potentially exert rectal pressure, particularly with a large amount of stool in the rectum.