Pelvic organ prolapse (POP) is a common chronic health issue. Pessary rings are used for conservative management. To date, there is little evidence on objective anatomical findings as predictors of successful ring pessary management.

To determine any association between history, clinical and four‐dimensional translabial ultrasound (TLUS)/pelvic floor ultrasound examination and pessary success.

Materials and Methods
From November 2013 to November 1015, all new patients presenting with symptomatic prolapse to a tertiary urogynaecological unit underwent an assessment including interview, clinical examination, that is, International Continence Society POPQ (pelvic organ prolapse quantification) and TLUS. Women with symptomatic prolapse were offered conservative management with a ring pessary. Those who agreed had a ring inserted that day. Successful trial of pessary use was defined as continued use for at least three months. Retrospective analysis of imaging data was performed blinded to other data. Statistical analysis was performed to assess the relationship between history, examination and imaging and pessary success.

Of 525 patients seen during the inclusion period, 177 had symptomatic prolapse. One hundred and twenty‐eight were offered a pessary, 89 accepted. Five had incomplete data, leaving 84. Forty‐ Two (50%) were still using the pessary at a three‐month follow‐up. Predictors associated with failure included being pre‐menopausal (P = 0.031), a previous hysterectomy (P = 0.051), increasing genital hiatus and perineal body (Gh + Pb) (P = 0.013), posterior compartment prolapse (P = 0.027) and a larger hiatal area on Valsalva on TLUS (P = 0.049). Pre‐menopausal status (P = 0.003), increasing Gh + Pb (P = 0.011) and previous hysterectomy (P = 0.001) remained significant on multivariate analysis.

A history of previous hysterectomy is a predictor of pessary failure as are Gh+Pb on Valsalva and premenopausal status.