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Bacterial biofilm formation on vaginal ring pessaries used for pelvic organ prolapse


Introduction and hypothesis

The objective of this study was to characterize the bacterial biofilm on vaginal ring pessaries used to treat pelvic organ prolapse and investigate the relationship between biofilm phenotype and patient symptoms and clinical signs that are suggestive of inflammation.


This was a cross-sectional observational study of 40 women wearing a ring-shaped pessary continuously for at least 12 weeks. Participants underwent a clinical examination, and the pessary was removed. Clinical signs were recorded. A swab from the pessary surface and a high vaginal swab were collected from each woman. Participants completed a questionnaire on symptoms. Pessary biofilm presence and phenotype were determined by scanning electron microscopy (SEM). Vaginal and pessary bacterial composition was determined by 16S rRNA gene sequencing. The relationship between biofilm phenotype and symptoms and clinical signs was assessed using logistic regression.


SEM confirmed biofilm formation on all 40 pessaries. Microbiota data were available for 25 pessary swabs. The pessary biofilm microbiota was composed of bacteria typically found in the vagina and was categorized into Lactobacillus-dominated (n = 10/25 pessaries, 40%) communities and Lactobacillus-deficient communities with high relative abundance of anaerobic/facultative anaerobes (n = 15/25 pessaries, 60%). While increasing age was associated with presence of a Lactobacillus-deficient pessary biofilm (odds ratio = 3.60, 95% CI [1.16–11.22], p = 0.04), no associations between biofilm microbiota composition and symptoms or clinical signs were observed.


Lactobacillus-deficient biofilms commonly form on pessaries following long-term use. However, the contribution of biofilm phenotype to symptoms and clinical signs remains to be determined.

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The authors would like to acknowledge Saima Wani and Georgia Privato for contributions towards specimen collection and Marin Poljak for contributions towards laboratory work.


This work was supported by a grant from the Urogynaecology Special Purpose Fund, The Royal Women’s Hospital, Melbourne, Australia.

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Authors and Affiliations



F. G. Gould: Protocol/Project development, Data collection and management, Data analysis, Manuscript writing/editing.

M. P. Carey: Protocol/Project development, Manuscript writing/editing,

E. L. Plummer: Data analysis, Manuscript writing/editing.

G. L. Murray: Laboratory/experimental analysis, Manuscript writing/editing.

J. A. Danielewski: Laboratory/experimental analysis, Manuscript editing.

S. N. Tabrizi: Protocol/Project development, Manuscript editing.

S. M. Garland: Protocol/Project development, Manuscript editing.

Corresponding author

Correspondence to Felicity G. Gould.

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Figure S1

The microbiota composition of all pessary (blue) and vaginal specimens included in this study. The heatmap displays the relative abundance of the 15 most abundant taxa detected in all specimens. Hierarchical clustering of Jaccard distances with Ward linkage was used to generate the heatmap and demonstrates similarity of microbiota composition between specimens. The metadata above the heatmap indicate the participant ID and sample type (pessary and vaginal). Pessary and vaginal samples collected from the same woman frequently appear next to each other in the heatmap, indicating similarity in microbiota composition at the two sites. (PDF 28 kb)

Figure S2

Principal component analysis of pessary (blue) and vaginal (orange) samples included in this study. Pessary and vaginal samples collected from the same woman frequently cluster together (or overlap) in the plot, indicating similarity in microbiota composition at the two sites. Pessary samples are labeled with P followed by the study ID and vaginal samples are labeled with V followed by the study ID (i.e., P1 and V1 represent the pessary and vaginal samples collected from participant 1, respectively). (PDF 5 kb)


(DOCX 19 kb)


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Gould, F.G., Carey, M.P., Plummer, E.L. et al. Bacterial biofilm formation on vaginal ring pessaries used for pelvic organ prolapse. Int Urogynecol J 33, 287–295 (2022).

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  • Bacterial biofilm
  • Vaginal ring pessary
  • Pelvic organ prolapse
  • Vaginal microbiota
  • Pessary microbiota
  • Scanning electron microscopic