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In patients who do not wish surgical therapy or who are not good surgical candidates, the usage of a vaginal pessary allows for effective non-surgical management. Typically, women with vaginal vault prolapse have an exteriorized prolapse and enlargement of the vaginal hiatus. The pessary must thus be large enough to fill the levator hiatus and not be nexpelled easily. The most commonly used pessaries for large prolapse are Gelhorn pessaries. Alternatively, donut or cube pessaries can be used. Care should be taken when using cube pessaries to not disrupt vaginal epithelial integrity. Pessaries can also be used as temporizing devices in patients for whom surgery is not appropriate in the short term. I typically recommend that women be fit with a vaginal pessary if they will not be undergoing surgical therapy within the upcoming 3 months. Low dose estrogen cream should be routinely used by women wearing a pessary.