*8.1.1 Pelvic floor exercise*

Pelvic floor exercises helps limit the progression of mild prolapse and relief milder prolapse symptoms. However, pelvic floor exercises on its own does not to restore normal support and are not useful if the prolapse extends to or beyond the vaginal introitus. It is reported to salivate 42–53% of mild and moderate prolapses up to grade two descent but it is unlikely to have any improvement in patients with more than grade two descent [25, 27, 28].

Urogynaecology nurse specialist should be able to guide the patient through pelvic floor exercises along with the physiotherapist and assess the response in 3–4 months.

#### *8.1.2 Pessary management*

Vaginal pessaries offer help to women who decline surgery, who are unfit for surgery, or for whom surgery is contraindicated [29].

Long-term pessary use has a high drop rate because of side effects such as vaginal ulceration, discharge and bleeding. It has been reported that only 15–20% of women uses pessaries as long term approach [30, 31].

Fitting the correct pessary size requires a trial and error. A digital examination allows some estimate of vaginal size. In general, it is best to start with smaller pessaries, increasing the size if not staying in place. Change of pessaries usually with in 6 months if no complications such as ulceration and bleeding. If the vagina is atrophic, topical oestrogen cream should be used twice to reduce the risk of ulceration and bleeding. Pessaries can ring pessaries ranging in diameter from 52 to 129 mm and they placed between the back of symphysis pubis and posterior fornix. They usually help with prolapsed when there is uterus as the cervix fits in the middle of the ring. However patients who had hysterectomy they are more likely to benefit off shelf pessaries compared to the ring pessaries as the shape of those provides better support for the vaginal vault where shape and axis could have changed by the hysterectomy [32, 33].

Urogynaecology nurse specialist should be able to fit the pessaries and change them and identify any ulceration and bleeding caused by pessary use. The nurse led pesky clinic in primary and secondary care is a well established model and proved to be cost effective and reduces patient loads on the outpatients clinics with high patient satisfaction rate [34].
