Does a Pessary Help a Rectocele?

A pessary can meaningfully reduce many of the symptoms caused by a rectocele, particularly the feeling of vaginal bulge and the difficulty emptying the bowel that often accompanies it. The evidence shows that women who use a pessary for posterior compartment prolapse report improvements in bowel-related quality of life, less straining, and fewer episodes of incomplete evacuation. That said, a pessary does not reverse the underlying structural defect, and not everyone finds it comfortable or sufficient as a long-term solution.

What a Rectocele Actually Is

A rectocele is a herniation of the front wall of the rectum into the back wall of the vagina. It happens when the tissue separating the two structures weakens or tears, allowing the rectum to bulge forward. This creates a noticeable vaginal bulge that you can sometimes feel or even see, and it often traps stool in a pocket during bowel movements.¹ The condition is closely tied to aging, childbirth, chronic straining, and hormonal changes after menopause.

The symptoms that bother women most are not always the bulge itself. Many describe a sense of incomplete evacuation, meaning you feel like the bowel hasn’t fully emptied even after spending a long time straining. Some women find they need to press a finger against the back vaginal wall (a technique called splinting) to push stool past the pocket and complete a bowel movement. Others experience fecal urgency, pelvic pressure, or low back discomfort. These bowel-related symptoms are often the main driver of treatment-seeking, more so than the bulge alone.

How a Pessary Addresses Rectocele Symptoms

A pessary is a removable device, usually made of medical-grade silicone, that sits inside the vagina and physically supports the prolapsing tissue. For a rectocele, the pessary presses against the posterior vaginal wall, essentially acting as a buttress that keeps the rectal wall from bulging forward. This mechanical support can relieve the pocket where stool gets trapped and reduce the need to strain or splint.

A systematic review that pooled data from multiple pessary studies found significant improvements on standardized bowel symptom questionnaires after pessary use, along with better stool evacuation.² A separate study tracking women over twelve months of pessary use confirmed significant improvements in both bowel-related symptoms and bowel-related quality of life.³ Research using a vaginal stent (a device with a similar mechanism) showed it decreased straining intensity, shortened straining time, reduced laxative use, and improved feelings of incomplete evacuation, while also increasing rectal pressure and shortening balloon expulsion time during testing.⁴

Beyond bowel symptoms, a broader study of women who successfully used pessaries for pelvic organ prolapse found that about 28% reported improved bowel evacuation, about 23% saw improvement in fecal urgency, and roughly 20% experienced less urge fecal incontinence after four months.⁵ These numbers reflect women with various types of prolapse, not only rectocele, but they give a sense of the realistic improvement range. A pessary isn’t a magic fix for everyone. Some women experience substantial relief, while others notice modest changes or find the device doesn’t help their particular symptom pattern enough.

How Pessaries Compare to Surgery

The question nearly everyone with a rectocele eventually asks is whether they should try a pessary first or just go ahead with surgery. The short answer: try the pessary first, because surgery can always come later, but it carries its own risks and is not always clearly superior in the long run.

A large randomized trial compared pessary treatment with surgery for symptomatic pelvic organ prolapse and found that roughly three-quarters of women in the pessary group reported subjective improvement, compared with about four-fifths of women in the surgery group. That gap wasn’t large enough for pessary treatment to be declared equivalent, and the trial could not confirm that pessaries were “noninferior” to surgery by the statistical threshold set in advance.⁶ One striking detail: over half of the women assigned to pessary eventually crossed over to surgery, suggesting that a substantial proportion found the pessary insufficient or inconvenient over time.

A separate prospective study in which the same patients tried both pessary and then surgery confirmed that while both treatments led to meaningful improvements over baseline, women generally rated their improvement as greater after surgery.⁷ Still, that doesn’t mean every woman should rush to the operating room. Surgery for prolapse carries risks of recurrence, mesh complications (when mesh is used), pain, infection, and anesthesia-related issues. For women who aren’t good surgical candidates, who want to delay surgery, or who find adequate relief with a pessary, the device offers a reasonable and reversible alternative.

Choosing the Right Pessary Type

Not all pessaries are the same, and the choice of shape and size matters for comfort, effectiveness, and how long you stick with it. For pelvic organ prolapse including rectocele, the two most commonly used designs are the ring pessary (often a ring with a central support membrane) and the Gellhorn pessary, which has a wider, disc-shaped base and a stem. Ring pessaries are typically the first device tried because they are easier for both the clinician and the patient to insert and remove.⁸

Interestingly, though ring pessaries are more commonly tolerated at first, a study of women with advanced prolapse found that the Gellhorn pessary was associated with significantly longer use over time, averaging over ten years, compared with shorter durations for other types.⁹ This might seem contradictory, but the explanation is straightforward: women who progress to a Gellhorn after a ring pessary fails tend to have more advanced prolapse, and the Gellhorn’s stronger support may be exactly what they need, keeping them satisfied for longer. If your rectocele is mild to moderate, a ring with support is likely the starting point. If that doesn’t hold, your provider will usually try a Gellhorn next.

Cube and donut pessaries are other options, but they tend to be used less frequently and don’t have the same track record for long-term retention. The fitting process is trial-and-error: your clinician will try different sizes and shapes, and you might need a few visits before finding one that stays in place, doesn’t cause discomfort, and doesn’t fall out when you stand, cough, or bear down.

Complications and What to Watch For

Pessaries are generally safe, but “safe” doesn’t mean side-effect-free. The most common issues are vaginal discharge, minor bleeding, and tissue erosion where the device contacts the vaginal wall.¹⁰ One prospective study found adverse events in roughly 84% of women over a year of pessary use, with vaginal discharge, bleeding, and erosions being the most frequent. That number sounds alarming until you realize most of these events were minor and manageable, not serious medical emergencies.¹¹

Pessary shape influences complication risk. Gellhorn and donut pessaries were roughly twice as likely to cause erosions compared with ring-with-support pessaries or incontinence rings in that same study. Serious complications, such as fistula formation between the vagina and adjacent organs, are exceedingly rare and typically linked to neglected pessaries left in place for months or years without any medical follow-up. A comprehensive review found that while all five grades of complication severity have been reported with pessary use, including a handful of extreme cases, these severe outcomes are associated with pessaries left unmonitored, not with routine supervised use.¹²

In practical terms, watch for new or worsening discharge (especially if it’s foul-smelling), any spotting or bleeding, pain, or difficulty removing the device. None of these are reasons to panic, but all are reasons to see your provider. Most complications resolve with a temporary break from the pessary, a size adjustment, or treatment of any irritated tissue.

Does Vaginal Estrogen Help With Pessary Use?

Many clinicians prescribe topical vaginal estrogen alongside a pessary, especially for postmenopausal women. The thinking is that estrogen thickens and moisturizes vaginal tissue, making it more resilient against erosion from the device. The evidence here is more mixed than the confident clinical consensus might suggest.

One retrospective study found that women who used vaginal estrogen alongside their pessary were less likely to discontinue using the pessary (about 31% discontinuation versus 59% without estrogen) and had less vaginal discharge, but estrogen did not significantly reduce the rate of erosions themselves.¹³ A randomized trial also found no significant difference in erosion rates between estrogen and control groups after six months.¹⁴

So what’s going on? Vaginal estrogen may not prevent erosions directly, but it seems to improve overall comfort and satisfaction enough that women are more willing to keep using the pessary. If the tissue is healthier and more lubricated, the device likely feels less irritating day to day, even if microscopic erosions still occur at similar rates. Some researchers are developing estrogen-eluting pessaries that slowly release estrogen directly, which could simplify the routine and avoid the hassle of applying creams separately.¹⁵ These aren’t widely available yet, but the concept addresses a real practical barrier: many women find the additional step of applying vaginal cream multiple times per week annoying enough to skip it.

Self-Management Versus Clinic Visits

Traditionally, women using pessaries have been told to return to their doctor’s office every few months for removal, cleaning, and reinsertion. This model works, but it’s time-consuming and creates a dependency on clinic access. A growing body of evidence supports teaching women to manage their pessaries at home.

A randomized trial called TOPSY compared self-management with clinic-based care. Women in the self-management group received a brief teaching session and a support call, then handled their own pessary removal and reinsertion at home. The study found that self-management was effective and that quality of life outcomes were comparable between the two approaches.¹⁶ Research on self-care users also found they had fewer vaginal erosions and needed fewer office visits than women managed entirely in-clinic, with no difference in how long they continued using the pessary.¹⁷

Self-management typically means removing the pessary every night or every few days, rinsing it with mild soap and water, and reinserting it. Ring pessaries lend themselves well to this because they’re relatively easy to fold and slip in and out. Gellhorn and cube pessaries are trickier. Not everyone is comfortable with self-management, and that’s fine. But if you are, it can reduce complications and give you more control over your own care.

Sexual Function With a Pessary in Place

Concerns about sex are among the most under-discussed aspects of pessary use. Some women wonder whether they can have intercourse with a pessary in place, while others worry about how the pessary might change sexual sensation or their partner’s experience.

Ring pessaries can generally remain in place during intercourse, though some couples find it noticeable. Gellhorn and cube pessaries need to be removed before sex. A multicenter study comparing sexual function in women who chose pessary versus surgery found that the picture was complicated. Women using pessaries reported some improvement in how prolapse affected their sex life, but they also reported a small decline in their overall rating of sexual quality.¹⁸ The effect sizes were small in both directions, meaning the changes were statistically detectable but not dramatic for most women.

For women who were not sexually active before treatment, introducing a pessary didn’t appear to open the door to resumed activity in most cases. The takeaway is pragmatic: if your rectocele is making sex uncomfortable because of the bulge, a pessary may help with that specific barrier. But the pessary itself introduces its own minor annoyances, especially the need to remove certain types beforehand and reinsert them after. If sexual function is a primary concern, discuss it explicitly with your provider so the pessary choice reflects your priorities.

When a Pessary Might Not Be the Right Fit

Pessaries work well for many women, but they’re not ideal for everyone. Certain factors make long-term use less likely to succeed. A very short vaginal canal or a widened vaginal opening (common after certain obstetric injuries or prior surgery) can make it hard for the pessary to stay in place. Women with very advanced prolapse sometimes find that no pessary shape provides adequate support, though Gellhorn and cube pessaries can often handle more severe cases.

Lifestyle matters too. Women who are highly active, do heavy lifting regularly, or have chronic cough may find the pessary dislodges more often. Some women simply don’t tolerate the feeling of having a device inside the vagina, regardless of fit or symptom relief. In these cases, surgery or targeted pelvic floor physical therapy, sometimes both, may be more appropriate paths forward.

Pelvic floor physical therapy deserves its own mention here because it’s often overlooked as a complementary strategy. While physical therapy alone is unlikely to reverse a significant rectocele, strengthening the pelvic floor muscles can improve support enough to make a smaller or simpler pessary work better, reduce symptoms even without a device, and improve bowel mechanics. Combining a pessary with supervised pelvic floor exercises is common in clinical practice and makes intuitive sense, even though there aren’t large head-to-head trials testing the combination specifically for rectocele.

Pessary Materials and How They Have Changed

Modern pessaries are made from non-reactive, medical-grade silicone, which is flexible, durable, easy to clean, and doesn’t absorb odors or discharge the way older materials did. This wasn’t always the case. Historically, pessaries were made from materials ranging from cork and brass to rubber, and earlier versions were far less comfortable and more prone to causing tissue reactions.¹⁹ The shift to silicone was a major practical advance. Silicone pessaries last for years, can be autoclaved or simply washed with soap and water, and come in a wide range of shapes and sizes that can be matched to individual anatomy.

This material evolution matters because many of the horror stories about pessary complications in older medical literature reflect an era of less suitable materials and less structured follow-up care. With modern silicone pessaries and reasonable monitoring, whether through clinic visits or self-management, the risk profile is substantially lower than historical accounts suggest.