Pessary Placement in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS:

• Women with symptomatic POP-Q Stage II–IV pelvic organ prolapse (cystocele, rectocele, uterine prolapse, or vaginal vault prolapse) who prefer to avoid or defer surgical reconstruction

• Patients with stress urinary incontinence (SUI) not responding adequately to pelvic floor muscle training (Kegel exercises) seeking a bridging or permanent non-surgical option

• Elderly or medically complex patients who are high-risk surgical candidates due to cardiovascular disease, diabetes, obesity (BMI >35), or anticoagulation therapy

• Women in the reproductive years wishing to preserve uterine function or planning future pregnancies

• Patients awaiting surgical scheduling who require interim symptomatic relief

• Post-hysterectomy vaginal vault prolapse (suitable for supportive pessary types such as Gellhorn or cube)

• Women with incomplete bladder emptying (post-void residual >100 mL) secondary to advanced anterior wall prolapse causing urethral kinking

• REQUIRED DIAGNOSTICS (pre-fitting evaluation):

• Detailed pelvic examination with POP-Q staging

• Urine dipstick and midstream urine culture (to exclude active UTI before fitting)

• Post-void residual urine volume measurement (bladder scan or catheterisation)

• Urodynamic studies (multichannel cystometry) — indicated for mixed incontinence, voiding dysfunction, or pre-surgical planning

• 3D/4D transperineal pelvic floor ultrasound — for levator ani integrity assessment, hiatal dimensions, and pessary sizing guidance

• Dynamic pelvic MRI (MR defecography) — reserved for complex multi-compartment prolapse or suspected enterocele/sigmoidocele

• Cervical cytology (Pap smear) — must be current per national screening guidelines before initiation of pessary therapy

• Vaginal pH and atrophic vaginitis assessment — genitourinary syndrome of menopause (GSM) may require concurrent topical oestrogen therapy for optimal pessary tolerance

• CONTRAINDICATIONS:

• Active vaginal, cervical, or pelvic infection (including bacterial vaginosis, trichomoniasis, or pelvic inflammatory disease)

• Severe vaginal stenosis or obliterative vaginitis precluding safe device placement

• Known allergy or sensitivity to medical-grade silicone or latex

• Patients unable or unwilling to attend scheduled follow-up for pessary maintenance (high risk of erosion, fistula formation, and incarceration with neglected pessaries)

• Active vaginal or cervical malignancy

• Genital fistula (vesicovaginal, rectovaginal) — requires surgical correction first

PESSARY TYPE SELECTION — EVIDENCE-BASED CLASSIFICATION:

The choice of pessary design is the cornerstone of successful fitting and is guided by prolapse compartment, POP-Q stage, vaginal anatomy, and patient self-management capability.

1. RING PESSARY (with or without support membrane): The first-line device for Stage II–III anterior and uterine prolapse. Available in sizes 0–13 (diameter 44–113 mm). The ring-with-support variant manages concurrent cystocele; the ring-with-knob variant provides urethral compression for coexistent SUI. Self-removal-capable; ideal for sexually active patients.

2. GELLHORN PESSARY: The gold-standard device for advanced (Stage III–IV) or post-hysterectomy vault prolapse. Its concave disc-and-stem design creates a suction mechanism providing robust apical support. Requires clinician removal for cleaning; recommended follow-up every 3 months.

3. CUBE PESSARY: Reserved for complete procidentia or cases where ring and Gellhorn devices have failed. Retention is achieved via six suction-cup faces against the vaginal walls. Requires daily self-removal and cleaning; highest risk of vaginal wall pressure effects if neglected.

4. DISH/DONUT PESSARY: Used for severe anterior compartment defects and high-grade cystocele where a ring pessary provides insufficient anterior support.

5. HODGE/SMITH PESSARY: Specifically designed for uterine retroversion with associated prolapse or for SUI in patients with a retroverted uterus.

6. INCONTINENCE DISH WITH SUPPORT: A flat, membrane-filled design providing simultaneous urethral support and bladder neck elevation; preferred for dominant SUI with mild cystocele.

FITTING METHODOLOGY — STEP-BY-STEP CLINICAL PROCESS:

Fitting is conducted as a structured trial. The clinician estimates pessary size using vaginal examination (measuring the diagonal distance from the posterior fornix to the pubic symphysis). The trial pessary is inserted into the posterior vaginal fornix, and the patient is asked to ambulate, perform Valsalva maneuvers, and attempt voiding. A correctly fitted pessary: (a) is retained during Valsalva, (b) allows passage of one examining finger between device and vaginal wall, (c) permits comfortable voiding with post-void residual <100 mL, and (d) is not perceived by the patient during normal activity. Multiple sizes and types may be trialled in one session.

ADJUNCT TECHNOLOGIES AVAILABLE AT GAF PARTNER CENTERS:

• 3D/4D Transperineal Ultrasound-Guided Sizing: Real-time visualisation of the levator hiatus and pessary position, reducing the number of trial fittings needed and optimising device selection — particularly valuable in patients with prior pelvic surgery or atypical anatomy.

• Digital Pelvic Floor Assessment Tools: Perineometry (intravaginal pressure biofeedback) to quantify levator ani contractile strength, guiding concurrent PFMT prescription.

• Concurrent Topical Oestrogen Therapy: For patients with genitourinary syndrome of menopause (GSM), topical oestradiol or prasterone (intravaginal DHEA) is co-prescribed to improve vaginal epithelial integrity, reduce erosion risk, and optimise pessary comfort — an evidence-based adjunct supported by NAMS and IUGA guidelines.

• Urodynamics Suite: Full multichannel urodynamic testing (cystometry, pressure-flow studies, urethral pressure profilometry) for patients with mixed or occult incontinence, preventing unmasking of stress incontinence post-fitting without a management plan.

STEP 1 — PRE-TRAVEL CONSULTATION (Weeks 1–2 before travel): GAF Healthcare coordinates a secure telemedicine consultation with a subspecialty urogynecologist at the destination center. The patient submits prior imaging (pelvic ultrasound, MRI if available), urodynamic reports, obstetric history, BMI, and a completed PFDI-20 symptom questionnaire. The specialist reviews POP-Q staging, recommends the likely pessary type(s) for trial, and orders any outstanding diagnostics to be completed on arrival. A personalised care plan and cost estimate are issued.

STEP 2 — ARRIVAL & DIAGNOSTIC WORKUP (Day 1): The patient arrives at the destination city. GAF Healthcare provides airport transfer to the hospital or affiliated hotel. On Day 1, the urogynecology team conducts: (a) clinical pelvic examination with formal POP-Q staging, (b) 3D transperineal ultrasound for levator hiatus measurement and prolapse characterisation, (c) post-void residual bladder scan, (d) midstream urine culture, and (e) urodynamic assessment if mixed incontinence is present. Results are reviewed same-day.

STEP 3 — PESSARY FITTING SESSION (Day 1 or Day 2, Duration: 30–60 minutes): The fitting is performed in the urogynecology outpatient suite — no anaesthesia, no incision, no hospital admission required. The clinician systematically trials pessary types and sizes using vaginal examination landmarks and ultrasound guidance where available. Patient comfort, retention during Valsalva, and voiding function are all confirmed before the session concludes. A pessary care instruction session is provided, including self-removal technique (for ring-type devices), cleaning protocols (mild soap and water; avoid disinfectants), and symptom red-flag education (unusual discharge, bleeding, inability to void, pelvic pain).

STEP 4 — IMMEDIATE POST-FITTING OBSERVATION (Day 2): A follow-up assessment is scheduled 24 hours post-fitting to confirm: (a) absence of voiding dysfunction or urinary retention, (b) patient comfort during normal daily activities, (c) no de novo or worsened stress incontinence (unmasking phenomenon), and (d) device retention. Minor adjustments — such as upsizing, downsizing, or switching pessary type — are made at this visit if required.

STEP 5 — FIT-TO-FLY CLEARANCE (Day 2–3): Once comfortable voiding, device retention, and absence of complications are confirmed, the urogynecologist issues fit-to-fly documentation. The patient is provided with: a detailed pessary record card (device type, size, brand, insertion date), a structured follow-up schedule (2-week virtual check-in with GAF-coordinated telemedicine; 6-week in-person or virtual review), written emergency contact protocols, and a prescription for topical oestrogen where indicated.

STEP 6 — ONGOING REMOTE MANAGEMENT (Weeks 2–12): GAF Healthcare facilitates virtual follow-up consultations with the treating urogynecologist. Patients are advised to attend in-person pessary maintenance (cleaning and inspection by a clinician) every 3–6 months, either locally at a trained provider coordinated by GAF or at the original treatment center during a return visit. Annual review includes repeat POP-Q staging and pessary replacement as needed (typically every 2–5 years depending on device type).