How to Insert a Pessary With a Knob

A pessary with a knob is inserted by folding it, applying water-based lubricant to the leading edge, and guiding it into the vagina so it sits behind the pubic bone with the knob positioned against the urethra. The knob adds a small bump to an otherwise standard ring pessary, designed to gently compress the urethra and reduce stress urinary incontinence, so its orientation matters during placement. The process is straightforward once you understand where the knob needs to end up, but there are details about sizing, comfort checks, and ongoing care that make the difference between a pessary that stays put and one that causes problems.

What the Knob Actually Does

Ring pessaries come in a few variations. Some are plain rings, some have a flat support membrane stretched across the center to help with prolapse, and some include a knob on the outer rim. That knob is specifically there for stress urinary incontinence, the kind of leaking that happens when you cough, sneeze, laugh, or lift something heavy.¹ It works by pressing against the tissue beneath the urethra, creating gentle compression that helps prevent urine from escaping during sudden increases in abdominal pressure. Think of it as a small structural brace aimed at one specific spot.

This is different from a Gellhorn pessary, which also has a prominent knob or stem but is an entirely different shape, resembling a flat disc with a handle sticking off it. Gellhorn pessaries are used for more advanced prolapse and are harder to insert and remove on your own. If your provider gave you a ring with a knob, the insertion technique is much simpler than for a Gellhorn, and self-management is realistic for most people.

Step-by-Step Insertion

Before you begin, wash your hands thoroughly and have water-based lubricant within reach. Silicone-based lubricants can degrade some pessary materials over time, so water-based is the standard recommendation. Find a comfortable position: many people prefer standing with one foot up on a stool or the edge of the bathtub, while others do better lying on their back with knees bent. Either works. The goal is to relax your pelvic muscles as much as possible.

Pick up the ring pessary and fold it in half so it forms a narrow oval shape. The flexible silicone or medical-grade material bends easily. Apply a small amount of lubricant to the leading edge, the part that will enter the vagina first.¹ You do not need to coat the entire device, just enough to help the tip glide in smoothly.

With one hand, gently separate the labia. With the other, guide the folded pessary into the vaginal opening at a slight downward angle, similar to inserting a tampon. Push it back and slightly upward until it passes behind the pubic bone. Once it is past that bony ridge, let go, and the ring will spring open and settle into place around the cervix. The pubic bone in front and the deeper vaginal tissue behind act as natural shelves that hold the ring in position.

Here is the part specific to the knob: once the ring has unfolded, you need to rotate it so the knob faces forward, toward your belly button. The knob should rest just beneath the urethra, roughly behind the pubic bone. You can feel for it with a fingertip to confirm it is pointing in the right direction. If the knob is rotated sideways or facing backward, it will not provide the urethral support it is designed for, and it may feel uncomfortable against the wrong tissue. A gentle twist with your finger corrects the orientation.

Checking Whether It Fits Properly

Getting the pessary inside is only half the job. A properly fitted pessary should feel like it is barely there. After insertion, your provider will typically examine you in both a lying and standing position and ask you to bear down as if having a bowel movement. The examiner should be able to slide a finger comfortably between the pessary rim and the vaginal wall on both sides.² If the fit is too snug, a smaller size is needed. If the pessary shifts around too much or slides out when you bear down, a larger one may work better.

After the initial check, you will be asked to walk around, sit on a toilet, and bear down again to simulate real-life activities.² If the pessary stays in place and you can urinate without difficulty, the fit is good. If you feel pressure, pinching, or a sensation of the device pressing uncomfortably against your bladder or rectum, tell your provider immediately so they can try a different size or shape. In clinical trials comparing pessary use with surgery, participants needed to complete a successful fitting trial before proceeding, which gives you a sense of how seriously the fitting process is taken.³

Certain physical factors make dislodgment more likely. Research has found that damage to the pelvic floor muscles, particularly complete avulsion of the levator ani, substantially raises the odds of the pessary falling out.⁴ If you have difficulty keeping a pessary in place, it does not mean you are doing something wrong. It may mean a different size, a different pessary type, or a different management approach is the better option for your anatomy.

How to Remove and Reinsert It Yourself

One of the advantages of a ring pessary with a knob is that most people can learn to manage it independently. To remove it, get into the same position you used for insertion. Reach in with a finger, hook the rim of the ring, and gently pull it downward while folding it in half as it comes out.¹ The folding is important because removing a fully open ring would be uncomfortable. A slow, steady pull while collapsing the ring makes it pass through the vaginal opening more easily.

Removal technique differs for a Gellhorn pessary, which cannot simply be folded out. Gellhorn removal involves grasping the knob, rotating the concave disc to break its suction against the vaginal walls, then pulling it downward and folding it.¹ Many people with Gellhorns rely on a provider for removal rather than doing it themselves. If you are not sure which type you have, the physical difference is easy to spot: a ring with a knob looks like a bracelet with a small bump, while a Gellhorn looks like a shallow cup with a stem.

After removal, wash the pessary with mild soap and warm water, rinse it thoroughly, and let it air dry before reinserting. Some providers recommend removing the pessary nightly, while others suggest removing it once or twice a week for cleaning. Your provider will give you a schedule tailored to your situation. The key is that regular removal and reinsertion prevents the device from sitting in place uninterrupted for weeks, which is when complications become more likely.

Overcoming Common Barriers to Self-Care

Even with clear instructions, many people find self-insertion and removal daunting at first. Research into patient experiences with pessary self-care has identified several categories of barriers. Some are physical: arthritis, reduced hand strength, obesity, and decreased flexibility can all make reaching the pessary difficult. Others are structural, related to the device itself, including difficulty grasping a pessary that does not have an obvious handle and challenges bending it during insertion.⁵

Mental and emotional barriers matter too. Some people feel anxious about touching the pessary or worry that they will hurt themselves during insertion. Others simply believe that a healthcare provider will do a better job and prefer clinic-based care. Fear and anxiety around the process were commonly reported by both patients and their providers.⁵ Social taboo also plays a role. Some people want to keep their pessary use private and feel uncomfortable discussing it, which can limit the support they get at home.

If any of these barriers sound familiar, the evidence is reassuring. In one mixed-methods study, most long-term users eventually described the pessary as a habit, something they stopped thinking about the same way you stop thinking about putting on glasses in the morning.⁶ Several participants in that study reported that their self-esteem actually improved after starting pessary therapy, because the prolapse or incontinence symptoms that had been affecting their confidence were now under control. The learning curve is real, but it flattens out faster than most people expect.

Why Your Provider Might Prescribe Vaginal Estrogen

If you are postmenopausal or have vaginal tissue that appears thin and dry, your provider will likely recommend using vaginal estrogen alongside your pessary. Estrogen cream, a vaginal tablet, or a hormone-releasing ring helps keep the vaginal walls supple and well-lubricated, which reduces friction between the pessary and surrounding tissue. In a large randomized, double-blind trial, women who used vaginal estrogen alongside their pessary had lower rates of excessive discharge, vaginal erosions, and vaginal bleeding compared with those using a placebo.⁷

An earlier observational study found that women in the estrogen group were far less likely to discontinue pessary use altogether compared to those without estrogen. They were also less likely to develop increased vaginal discharge.⁸ That same study found estrogen was not particularly protective against erosions or vaginal bleeding on its own, but the later, larger trial showed more encouraging results for those outcomes. Researchers have also explored pessaries that slowly release estrogen directly from the device itself, which could simplify things further by eliminating the need to apply cream separately.⁹ That technology is not widely available yet, but it signals where the field is heading.

The practical takeaway is straightforward: if your provider prescribes vaginal estrogen, use it as directed. It makes the pessary more comfortable and makes you more likely to stick with it long-term, which is ultimately how the pessary does its job.

Complications Worth Knowing About

No medical device sits inside the body without some potential for side effects, and pessaries are no exception. The most frequently reported issues are vaginal discharge, erosion of the vaginal wall, and minor bleeding.¹⁰ These are generally mild and manageable, especially when the pessary is removed and cleaned on a regular schedule. Discharge in particular is common enough that it should be considered a normal part of pessary use rather than a sign that something has gone wrong.

In a study tracking adverse events over one year at a pessary clinic, the overall rate of experiencing at least one side effect was quite high, but the vast majority were minor.¹¹ The same study found that Gellhorn and donut-shaped pessaries were more than twice as likely to cause erosions compared with ring pessaries. This is relevant if you have a ring with a knob: your erosion risk is lower than it would be with some other pessary types. A single erosion typically did not cause women to stop using their pessary, but repeated erosions did predict discontinuation.

Serious complications are rare but documented. An integrative review spanning over sixty published articles found that the severity spectrum included very uncommon outcomes like fistulas between the vagina and adjacent organs.¹⁰ These extreme cases were almost always associated with neglected pessaries, devices left in place for months or years without being removed for inspection and cleaning. Regular follow-up appointments and a self-care routine dramatically reduce this risk.

Call your provider if you notice foul-smelling discharge, persistent bleeding, difficulty urinating, or new pain. These can be signs that the pessary has shifted, that an erosion has developed, or that the fit needs reassessment.

What Happens to the Vaginal Environment Over Time

Any foreign body sitting in the vagina raises a reasonable question about whether it changes the bacterial balance. Research on this has been reassuring. A cross-sectional study comparing women using pessaries to a control group found no significant difference in vaginal flora types between the two groups. Bacterial vaginosis was numerically more common among pessary users, but the difference was not statistically meaningful.¹² Rates of yeast infections were similar as well.

Biofilm, a thin layer of bacteria that adheres to surfaces, does form on pessaries. One study using electron microscopy confirmed biofilm on every single pessary examined after long-term use. About 40% of those biofilms were dominated by protective Lactobacillus bacteria, while the remaining 60% had a mix of other organisms more typical of an older vaginal environment.¹³ Increasing age was associated with having a Lactobacillus-deficient biofilm, but the composition of the biofilm did not correlate with symptoms or clinical signs of infection. In other words, the biofilm forms, but it does not appear to cause problems for most people. Regular cleaning during removal keeps the buildup in check and is one more reason not to leave a pessary in place indefinitely without attention.

Sexuality and Daily Life With a Knob Pessary

One of the questions people hesitate to ask is whether a pessary affects sex. With a ring pessary, intercourse is generally possible without removing it, though some people and their partners find it more comfortable to take it out first. The knob adds a small protrusion that a partner may notice, and some couples prefer removal before sex for that reason. Removing and reinserting a ring pessary takes only a minute once you are practiced, so this does not have to be a significant disruption.

In interviews with long-term pessary users, two women reported initial insecurity about how the pessary would affect sexual activity. Both eventually resolved their concerns through experimentation and found that it did not significantly interfere.⁶ Participants in the same study noted that the prolapse or incontinence itself had a bigger negative effect on their self-image and sexual confidence than the pessary did. For most, the pessary was the solution to those concerns rather than a new source of them.

Day-to-day activities like exercise, swimming, and travel are all possible with a pessary in place. You should not feel the pessary during routine movement if it fits correctly. If you do feel it, especially during activities that increase abdominal pressure like heavy lifting or running, it may be shifting and a fitting reassessment is worth scheduling. Some people find it helpful to remove and reinsert the pessary before high-intensity exercise to confirm it is properly positioned, particularly in the early weeks while they are still building confidence with the device.

When a Ring With a Knob Is Not the Right Fit

Not everyone can use a ring pessary successfully. If the pelvic floor muscles are severely weakened or the vaginal opening is very wide, a ring may not stay in place regardless of size. Certain anatomical factors, including muscle avulsion, make dislodgment far more likely.⁴ In those cases, a space-filling pessary like a Gellhorn or a cube may be more effective, though those designs are harder to self-manage and come with a somewhat higher erosion risk.

The knob specifically addresses stress urinary incontinence, so if your primary issue is prolapse without incontinence, a plain ring or ring with support may be more appropriate, and the knob would be unnecessary. Conversely, if you have stress incontinence but no prolapse, an incontinence dish or continence ring might be considered instead. Your provider’s choice depends on which symptoms need managing and what your anatomy can support. Getting the right pessary type and size often involves trying more than one option during the fitting appointment, so do not be discouraged if the first attempt is not perfect.