Pessary or Pelvic Floor Therapy? The Best First Steps for Bladder Prolapse

Urethrocele and anterior vaginal wall prolapse happen when the front wall of the vagina becomes weak and allows the bladder and urethra to drop downward. Many women with this condition feel a bulge, pressure, or heaviness in the vagina. Some also have urine leakage or trouble emptying the bladder. The good news is that treatment does not always mean surgery. In fact, experts recommend starting with conservative, or non-surgical, treatments first. The two main first-line treatments are pessaries and pelvic floor physical therapy (PFPT). These options are safe, effective, and supported by strong medical research. 

Doctors, including those guided by the American College of Obstetricians and Gynecologists (ACOG), recommend offering a pessary to almost all women who are thinking about treatment for symptomatic pelvic organ prolapse. A pessary is a small medical device placed inside the vagina to support the bladder and vaginal walls. It works by holding the prolapsed organs in a better position.  

Studies show that up to 92% of women can be fitted with a pessary that fits well and feels comfortable. There are different types of pessaries. Ring pessaries are often used for stage II prolapse and work very well, with close to 100% success in fitting. They also work for many women with stage III prolapse. For more severe stage IV prolapse, a Gellhorn pessary is often needed. These are shaped differently and provide stronger support. 

Pessaries do more than just hold organs in place. They can greatly improve symptoms and quality of life. A large review study published in Obstetrics and Gynecology found that women using pessaries had big improvements in their symptom scores. Standardized questionnaires that measure pelvic floor distress and quality of life showed clear drops in symptom severity. This means women felt less pressure, less bulging, and fewer urinary problems after using a pessary. Many women report feeling more comfortable during daily activities and more confident socially. 

A major clinical trial published in JAMA compared pessary treatment to surgery over a 24-month period. In that study, 76.3% of women using a pessary said their symptoms improved. While surgery had a slightly higher improvement rate at 81.5%, pessaries still helped most women feel better. This shows that for many patients, surgery is not the only effective choice. 

The other main first-line treatment is pelvic floor physical therapy, or PFPT. This therapy focuses on strengthening the muscles that support the bladder, uterus, and rectum. These muscles form a sling at the bottom of the pelvis. When they are strong and coordinated, they help keep organs in the right place. PFPT is treatment provided by a specially trained physical therapist. Women learn how to correctly tighten and relax their pelvic floor muscles. These exercises are sometimes called Kegels, but proper training involves more than just squeezing. It includes improving strength, endurance, and timing. 

There is strong scientific evidence supporting PFPT. A large international review published in the International Urogynecology Journal analyzed multiple randomized controlled trials and concluded that PFPT should be recommended as first-line treatment for pelvic organ prolapse. Women who completed structured PFPT programs had better symptom relief compared to those who did not receive training. They also showed improvement in the actual stage of prolapse. 

A well-known study called the POPPY trial, published in The Lancet, followed women with stage I to III prolapse. Those who completed six months of supervised and individualized PFPT had both symptom improvement and measurable anatomical improvement. This means that not only did they feel better, but the physical support of their pelvic organs improved as well. Research shows that women doing PFPT are about 51% more likely to improve by at least one stage of prolapse compared to women who do not receive this training. 

One of the strengths of PFPT is its safety. No serious side effects have been reported in studies. It is safe for women of all ages and stages of prolapse. However, it does require effort and consistency. Women must practice the exercises regularly, and proper instruction is very important. Without guidance, some women may use the wrong muscles or strain instead of strengthen. Supervised training, especially in the first few months, increases the chance of success. Most studies show strong benefits in the short to medium term, around six to twelve months. Long-term results can vary, especially if exercises are stopped. 

Some research suggests that combining treatments may provide even better results. Women who use both a pessary and PFPT appear to have higher rates of symptom improvement than those who use PFPT alone. In some studies, women receiving both treatments were more than twice as likely to report improvement after one year compared to PFPT alone. They also reported better prolapse-specific quality of life scores. This combined approach can offer structural support from the pessary while building muscle strength through exercise. 

In addition to pessaries and PFPT, simple lifestyle changes can help manage symptoms. Maintaining a healthy weight reduces pressure on the pelvic floor. Making sure to have correct for with heavy lifting and treating chronic coughing can prevent extra strain. Eating enough fiber and drinking water can reduce constipation and straining during bowel movements. Some women find that sitting with their feet slightly elevated helps reduce the feeling of bulging. Vaginal estrogen cream may also help reduce irritation and dryness, especially in postmenopausal women, although it does not cure prolapse itself. 

Treatment for urethrocele and anterior vaginal wall prolapse should begin with conservative options. Pessaries and pelvic floor physical therapy are both recommended as first-line therapies before considering surgery. Pessaries provide physical support and can greatly reduce symptoms for most women. PFPT strengthens the body’s natural support system and can improve both symptoms and prolapse stage. These treatments are safe, effective, and supported by strong medical evidence. For many women, they provide meaningful relief and allow them to return to daily life with greater comfort and confidence. 

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Disclaimer: This blog is here for your help. It is the opinion of a Licensed Physical Therapist. If you experience the symptoms addressed you should seek the help of a medical professional who can diagnose and develop a treatment plan that is individualized for you.