A ring pessary is inserted by folding it in half, sliding it into the vagina at a downward angle, and releasing it so it opens behind the pubic bone, much like placing a diaphragm. The process takes under a minute once you know the steps, but getting the right size and confirming correct placement are what make it work well long-term. Most people have their first fitting done by a clinician, then learn to handle insertion and removal on their own, a skill that significantly improves satisfaction and long-term use.
Why Ring Pessaries Are Used
Ring pessaries are one of the most common nonsurgical treatments for pelvic organ prolapse, a condition where the bladder, uterus, or rectum shifts downward into the vaginal canal. They work by sitting in the vagina and providing structural support, essentially holding the prolapsed tissue in a more anatomically normal position. Clinicians tend to offer them as a first-line option for people who prefer to avoid surgery, who want to preserve the option of future pregnancy, who have early-stage prolapse, or who have health conditions that make surgery risky.1PubMed Central. Pessary Use in Pelvic Organ Prolapse and Urinary Incontinence Some people also use ring pessaries for stress urinary incontinence, particularly when leakage worsens during exercise or physical activity.
Ring pessaries specifically are among the simplest designs: a flexible silicone ring, sometimes with a central support membrane, that sits in the upper vagina. Compared to space-filling pessaries like the Gellhorn or cube, ring pessaries are easier to insert and remove independently, which is a major reason they are frequently the first type tried.
Getting the Right Size
Correct sizing is the single most important factor in whether a pessary works comfortably. A pessary that is too small will slip out; one that is too large will cause pain or pressure. Most clinicians determine size by combining two measurements taken during a vaginal exam: the length from the back of the vagina to the pubic bone, and the width of the vaginal canal at the level of the cervix or vaginal cuff.2Global Library of Women’s Medicine. Pessaries for Treatment of Pelvic Organ Prolapse These two measurements together guide the starting size.
The goal is to fit the largest pessary that sits comfortably. After the initial placement, the clinician checks that a single finger can slide freely around the entire circumference of the ring. If you cannot pass a finger between the pessary and the vaginal wall, the device is too large. The fit is then tested in both a lying-down and standing position, and you will be asked to bear down (the Valsalva maneuver) and squat to confirm the pessary stays in place.3PubMed Central. Pessary Use in Pelvic Organ Prolapse and Urinary Incontinence – Section: Patient Evaluation and Pessary Placement If it pops out during these tests, the clinician will try the next size up. If it is painful, the next size down.
It is not unusual to go through two or three sizes before finding the right one. Some people also find that their ideal size changes over time, particularly after weight changes, menopause, or if vaginal tissue tone shifts. If a pessary that once fit well starts slipping out or feeling uncomfortable, a resizing visit is worth scheduling rather than pushing through.
Step-by-Step Insertion
Whether your clinician is inserting the pessary for the first time or you are learning to do it yourself at home, the process follows the same basic sequence. Before you begin, wash your hands thoroughly with soap and water.
- Lubricate: Apply a small amount of water-based lubricant to the rim of the pessary and to the vaginal opening. Avoid silicone-based lubricants, which can degrade the silicone material of the pessary over time.
- Fold the ring: Compress the ring pessary by pressing opposite sides together so it collapses into an oval or figure-eight shape. A ring pessary is flexible enough to fold easily with one hand.
- Find your position: Stand with one foot up on a stool, squat, or lie on your back with knees bent, whichever feels most comfortable. Many people find the one-foot-up position easiest for self-insertion because it opens the vaginal canal.
- Insert at a downward angle: With the folded pessary in your dominant hand, gently guide it into the vaginal opening. Aim slightly downward toward the small of your back, not straight up. This follows the natural angle of the vaginal canal.
- Push past the pubic bone: Slide the folded pessary inward until it passes behind the pubic bone. You will feel a slight natural resistance and then a sense of the pessary settling into position as it moves past the bone.
- Release: Once the pessary is past the pubic bone, let go and allow it to spring open. It should unfold into its ring shape and sit in the upper vagina, with the pubic bone in front preventing it from sliding out.
- Tuck the rim: With your index finger, push the front rim of the pessary up and behind the pubic bone so the entire ring sits above it. This is the step people most commonly skip, and it makes the difference between a pessary that stays put and one that feels like it is falling out.
Once positioned, you should not feel the pessary. If you feel constant pressure, a sense of something pushing outward, or pain, the pessary may be the wrong size or may not be seated fully behind the pubic bone. Try removing it and reinserting, making sure to push it deeper and tuck the front edge. If discomfort persists after repositioning, contact your clinician for a sizing reassessment.
Checking Correct Placement
After insertion, run your finger around the edge of the pessary. You should be able to slide a fingertip between the ring and the vaginal wall on all sides. The cervix (or vaginal cuff, if you have had a hysterectomy) should sit above or within the ring, not below it. If you can feel the cervix protruding below the pessary, the ring is not positioned high enough.
Stand up and walk around the room. Cough a few times. Squat. If the pessary stays in place and you cannot feel it, the placement is correct. Many clinicians will also ask you to urinate before leaving the office, because a pessary that is too large can press on the urethra and make it difficult to empty your bladder. If you have trouble starting or completing urination, the pessary likely needs to be one size smaller.
How to Remove a Ring Pessary
Removal is the step that causes the most anxiety for people learning self-care, but the ring pessary’s design makes it one of the simplest types to take out. Wash your hands, get into the same position you used for insertion, and bear down gently as if having a bowel movement. This pushes the pessary downward. Reach in with your index finger (or index and middle fingers), hook the rim of the ring, and pull it out at a downward angle. The ring will fold as it exits, so it does not need to come out as a full circle.
If you have difficulty reaching the pessary, try squatting deeply, which shortens the vaginal canal and brings the pessary closer to the opening. Some people find that removing the pessary in the shower, where warm water relaxes the muscles, makes the process easier. If you truly cannot reach it after several attempts, your clinician can remove it at your next visit, and it is safe to leave in place in the meantime.
Cleaning and Maintenance Schedule
Ring pessaries should be cleaned regularly. For people who manage their own pessary, the typical routine is to remove it nightly or at least once a week, wash it with mild unscented soap and warm water, and reinsert it in the morning. Some people remove it every night and sleep without it; others prefer to leave it in for days at a time and clean it weekly. Either approach is reasonable.
For people who rely on clinic-based care rather than self-management, a clinician typically removes, cleans, and reinserts the pessary at regular intervals. In one large randomized trial, the median interval between clinic visits for pessary care was about six months.4eClinicalMedicine. Clinical effectiveness of vaginal pessary self-management vs clinic-based care for pelvic organ prolapse (TOPSY) A research comparison of women who replaced their own ring pessary versus those who kept it in continuously found that both groups had similar vaginal microbiota profiles, with low rates of abnormal bacterial shifts in either group.5PubMed Central. Vaginal microflora following the use of a disposable home-use vaginal device and a commercially available ring pessary for pelvic organ prolapse management The concern that frequent handling would introduce infections has not been borne out in the research.
Silicone ring pessaries are durable and can last for years with proper care. Inspect yours each time you clean it for cracks, tears, or discoloration. A damaged pessary should be replaced, as rough edges can irritate vaginal tissue.
Common Complications and What to Watch For
Most complications from ring pessary use are mild and manageable. Vaginal discharge, minor erosion of the vaginal wall, and occasional spotting are the issues that come up most frequently.6PubMed Central. Updates in Pessary Care for Pelvic Organ Prolapse: A Narrative Review In a long-term study of ring pessary users, about one in five experienced an adverse event, with vaginal erosion being the most common at roughly 19%, followed by vaginal discharge or infection at about 12%, and new-onset stress urinary incontinence in about 18%.7PubMed. Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse
Erosion refers to small areas where the pessary rubs against the vaginal lining and creates a raw spot. It can cause spotting or a pink-tinged discharge. This is more common in postmenopausal women whose vaginal tissue is thinner due to lower estrogen levels. If you notice persistent spotting, schedule a visit so your clinician can examine the tissue and decide whether the pessary needs to be left out temporarily to let the area heal.
Foul-smelling discharge is the most common reason women seek an unscheduled visit. Regular removal and cleaning typically prevents this. If discharge develops despite regular cleaning, a short course of vaginal antibiotics or antiseptic may be recommended. Serious complications like fistula formation or the pessary becoming embedded in vaginal tissue are extremely rare and almost exclusively associated with neglected pessaries that have not been removed or checked for years.
The Role of Vaginal Estrogen
Clinicians frequently prescribe topical vaginal estrogen alongside pessary use, especially for postmenopausal women. The reasoning is that estrogen helps keep vaginal tissue thicker and more resilient, which should theoretically reduce erosion. The evidence on erosion prevention is actually less clear-cut than many clinicians assume. One study found that vaginal estrogen did not significantly protect against erosion, but it did reduce the likelihood of bothersome vaginal discharge by about half.8PubMed Central. Effect of vaginal estrogen on pessary use The same study found that women who used vaginal estrogen were considerably more likely to continue using their pessary long-term compared to those who did not.
If your clinician prescribes estrogen cream or tablets, you typically apply them a few times per week, not daily. Researchers have explored the idea of building estrogen directly into the pessary material to provide a slow, steady release, which would eliminate the need to apply cream separately.9Scientific Reports. An estriol-eluting pessary to treat pelvic organ prolapse That technology is not yet widely available, but it reflects a real clinical need: anything that simplifies the routine tends to improve adherence.
Sex and Ring Pessaries
A common question is whether you need to remove the ring pessary before intercourse. The answer is that it is possible to have sex with a ring pessary in place, but most sexually active users choose to take it out. In one study, about 70% of sexually active pessary users removed it before sex most or all of the time.10PubMed Central. Sexual Function and Pessary Management Among Women Using a Pessary for Pelvic Floor Disorders The most common reasons were that a partner could feel the device during intercourse or that the pessary was uncomfortable during sex. About half of the women who removed the pessary for sex said their partner had asked them to, most often because the partner could feel it or was worried it might hurt them.
If you and your partner are comfortable leaving it in, that is fine from a medical standpoint. Ring pessaries, especially those without a central support membrane, generally allow penetrative intercourse. But if either of you finds it distracting or uncomfortable, removal and reinsertion before and after sex is a perfectly normal routine. The ease of self-removal is one of the ring pessary’s advantages over bulkier designs.
Self-Management Versus Clinic-Based Care
How you manage your pessary over time is one of the most important decisions for long-term success. Some people rely entirely on clinic visits for removal, cleaning, and reinsertion. Others learn self-care and handle everything at home, visiting the clinic only for periodic check-ups. The evidence increasingly favors self-management for people who are able and willing to learn it.
In a large study tracking ring pessary users over five years, the probability of still using the pessary after one year was about 83%, dropping to roughly 62% at five years.11PubMed. Vaginal ring pessary use for pelvic organ prolapse: continuation rates and predictors of continued use The most common reason for stopping in the first few years was choosing to have surgery instead. But after three years, self-care was the only factor that predicted whether someone kept using their pessary. People who could manage insertion and removal on their own were significantly more likely to stick with pessary use long-term. Frequent expulsion was the top reason for discontinuation overall, followed by vaginal erosion and dissatisfaction with symptom improvement.7PubMed. Long-term continuations rate of ring pessary use for symptomatic pelvic organ prolapse
If you are currently relying on clinic visits and finding the schedule inconvenient, ask your clinician to teach you self-care. Most people can learn to insert and remove a ring pessary confidently within a few practice sessions. Even if you plan to do most of your care at home, periodic check-ups (typically once or twice a year) are still a good idea so a clinician can inspect the vaginal tissue for any erosion you might not notice yourself.
Impact on Quality of Life
Pessary treatment consistently shows improvements in quality-of-life measures related to pelvic floor symptoms. In a recent study following women for over two years, scores on validated questionnaires measuring pelvic floor distress, the impact of pelvic symptoms on daily life, and sexual function all improved after starting pessary treatment.12PubMed. The Long-Term Effects of Pessary Treatment on Quality of Life, Symptoms, Sexual Function, and the Urinary System in Women with Pelvic Organ Prolapse This matters because prolapse symptoms go beyond the physical bulge: many people experience back pain, pelvic pressure, difficulty with bowel movements, and a persistent sense that something is falling out. When a pessary effectively supports the prolapsed tissue, those secondary symptoms often improve as well.
People sometimes wonder whether using a pessary is just delaying the inevitable surgery. For some, it is a bridge to a future procedure, and that is a valid use. But for a significant proportion of users, a pessary remains the definitive treatment for years or even indefinitely. The five-year continuation rates bear this out. Surgery carries its own risks and recovery time, and prolapse can recur after surgical repair, so a pessary that works well and is comfortable is not a lesser treatment. It is an alternative that many clinicians consider equal to surgery for the right patient.
Pessaries in Pregnancy
Ring pessaries are sometimes used in a completely different context: pregnancy. When a pregnant woman is found to have a short cervix, which increases the risk of preterm birth, a specially designed pessary (the Arabin pessary, which is not the same as a standard ring pessary for prolapse) can be placed around the cervix to redistribute the weight of the uterus and reduce pressure on the cervical opening. In a small study, this approach prolonged pregnancy by roughly four to fourteen weeks, with deliveries occurring between 33 and 39 weeks of gestation.13PubMed Central. Pessary use in pregnant women with short cervix
However, the evidence on obstetric pessaries is mixed. A comparative study found that cervical cerclage, a surgical stitch placed around the cervix, was more effective at preventing preterm birth than the Arabin pessary, with preterm delivery rates of about 21% versus 46%.14European Journal of Clinical Pharmacy. Comparative Analysis of Cervical Cerclage and Arabin Pessary in Preventing Preterm Births in Singleton Pregnancies with Cervical Insufficiency The pessary’s appeal in this setting is its noninvasiveness: it can be placed without anesthesia in a clinic visit. But if you are pregnant with a short cervix, this is a decision to make with your obstetrician based on the specifics of your situation, not a straightforward self-management scenario.
From Pomegranates to Silicone
People have been using devices to support prolapsed pelvic organs for a remarkably long time. Early Egyptian medical texts describe pessary-like interventions, and treatments over the centuries included everything from honey and hot oil to pomegranates and cotton wool soaked in various concoctions.15PubMed. The history and evolution of pessaries for pelvic organ prolapse Materials evolved through cork, brass, and rubber before arriving at the medical-grade silicone used today. Modern silicone pessaries are nonreactive, flexible, easy to clean, and long-lasting, which is why the ring pessary has become one of the most reliable and low-cost tools in gynecology. Despite being such an old concept, pessary research is still catching up: many of the randomized trials comparing self-management models, estrogen co-treatment, and different pessary designs have only been published in the last decade, meaning the clinical guidance around pessary care continues to be refined.