How to Insert a Ring Pessary: Step-by-Step Instructions

Inserting a ring pessary is a straightforward process once you understand the basic technique: fold the flexible silicone ring, slide it into the vaginal canal at an angle, and let it spring open behind the pubic bone. The first fitting is almost always done by a clinician who selects the correct size, but many women learn to remove, clean, and reinsert the device themselves. The process gets easier with practice, and understanding a few details about positioning and anatomy makes a real difference in comfort and effectiveness.

How a Ring Pessary Actually Stays in Place

Before you put a pessary in, it helps to know what keeps it from falling out. A common assumption is that the pubic bone acts like a shelf, physically blocking the pessary from descending. Imaging studies tell a different story. Research using upright MRI found that when a woman stands, the lowest edge of the pessary often sits below the pubic bone, meaning the bone is not directly propping it up. Instead, the pelvic floor muscles, specifically the levator ani muscle group, act like a hammock beneath the pessary. As you move from lying down to standing, the pessary settles into that muscular sling, which is consistently positioned below the widest part of the device in women with a successful fit. The cervix also plays a role: it tends to sit near the center of the ring, and because the pessary tilts slightly inside the body, the uterus pushes the ring against the posterior vaginal wall, adding stability.

This means that pessary success depends heavily on having enough pelvic floor muscle tone to cradle the device. Women with very weak or damaged pelvic floors may have a harder time keeping a ring pessary in place, which is one reason the initial fitting with a clinician matters so much.

Getting the Right Size

Ring pessaries come in a wide range of diameters, typically from about 44 mm up to 95 mm or more. Your clinician selects the size during a fitting appointment by performing a pelvic exam, estimating the width and length of your vaginal canal, and then trying a pessary to see if it stays in comfortably. The goal is the largest ring that fits without causing pain or pressure. Too small, and it will slip out; too large, and it will press uncomfortably against the vaginal walls or make it hard to urinate.

Several factors predict whether a fitting will succeed. Research on women with advanced prolapse found that a history of hysterectomy, a wider vaginal opening relative to vaginal length, and a higher number of vaginal deliveries were all independent predictors of a failed fitting.

If the first size doesn’t work, your clinician will try a different one. It’s common to go through two or three sizes before landing on the right fit. You’ll typically be asked to stand, walk around, sit down, and try to urinate with the pessary in place before leaving the office. If you can do all of that comfortably and the pessary stays put, the size is right.

Step-by-Step Insertion

Whether your clinician is teaching you or you’re reinserting at home after cleaning, the technique follows the same basic steps. You’ll need clean hands, a water-based lubricant, and the pessary itself.

Wash your hands thoroughly with soap and water. Rinse and dry the pessary if it has just been cleaned.
Apply lubricant: put a thin layer of water-based lubricant around the rim of the pessary and, if you like, around the vaginal opening. Avoid silicone-based or oil-based lubricants, which can degrade the silicone material over time.
Find a comfortable position: most women stand with one foot raised on a stool or the edge of the bathtub, similar to the position for inserting a tampon. Others prefer to squat or lie on their back with knees bent. Whichever position lets you relax your pelvic floor works.
Fold the pessary: squeeze the ring at two opposite points so it collapses into a narrow, elongated oval. A ring pessary is flexible enough to fold roughly in half. Hold it firmly so it doesn’t spring open prematurely.
Insert at an angle: with your free hand, gently separate the labia. Slide the folded pessary into the vaginal opening with the curved edge pointing downward, aiming toward the small of your back rather than straight up. The angle matters because the vaginal canal naturally tilts backward toward the sacrum.
Push past the pubic bone: continue guiding the pessary inward and slightly upward until you feel it move past the pubic bone. This is usually only a few inches in. Once it clears that point, release the pessary and let it spring open.
Tuck the leading edge: use a finger to push the front rim of the pessary up behind the pubic bone. The back edge should rest in the posterior fornix, the deeper space behind the cervix. The cervix should sit within or just above the ring’s opening.

The whole process takes less than a minute once you’re comfortable with it. If the pessary feels like it’s sitting too low or you can feel its edge at the vaginal opening, push it a bit deeper or try repositioning. If it consistently won’t stay, the size may need to be reassessed.

Checking That the Pessary Is Seated Correctly

After insertion, run a finger around the rim of the pessary. You should be able to sweep a fingertip between the pessary and the vaginal wall on all sides without difficulty. If the pessary is pinching tissue or you can’t get a finger between the rim and the wall, it may be too large or not positioned correctly. You should also be able to feel your cervix through the center of the ring or just above it.

Stand up and walk around for a few minutes. Cough, bear down gently, and squat. If the pessary stays in place and you don’t feel it pressing uncomfortably, the fit and position are good. You should be able to urinate without straining. If urination feels blocked or you develop a sudden urge to go that wasn’t there before, the pessary may be angled against the urethra or bladder and needs to be repositioned.

Learning to Remove and Reinsert on Your Own

Many clinics now teach self-management from the start, and research shows it’s associated with better long-term use. Women who can remove and reinsert their own pessaries report greater satisfaction and tend to continue using them longer. A multi-center study found that successful self-management was more common in younger women, those with lower parity, and those with less advanced stages of prolapse. Interestingly, women using a slightly larger pessary were more likely to succeed at self-management, possibly because a larger ring is easier to hook with a finger during removal.

To remove the pessary, get into the same position you use for insertion. Slide a finger (usually the index finger) into the vagina, hook it under the rim of the pessary, and pull it gently downward and outward. The ring will fold as it comes through the vaginal opening, just as it did going in. Don’t be alarmed if it takes a few tries at first; the angle and the need to relax the pelvic floor muscles can make the first few removals feel awkward.

If you can’t reach the rim or it feels stuck, bearing down slightly while pulling can help. Some women find it easier to remove the pessary while squatting. If removal is consistently difficult, mention it at your next appointment, because a pessary with a removal notch or a slightly smaller size may make things easier.

Cleaning and Maintenance Schedule

How often you need to remove and clean the pessary depends on your individual situation and your clinician’s guidance. Women who manage their own pessaries often develop a routine of removing and washing the device once a week or every few days. In a large trial of self-management, women described removing the pessary more frequently than the traditional six-month clinic interval for cleaning, sexual activity, or to rest the vaginal tissues, and they reported high satisfaction with this approach.

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Cleaning is simple: wash the pessary with warm water and mild, unscented soap. Rinse thoroughly, let it air dry or pat it dry, then reinsert using the same technique. Avoid harsh detergents, antiseptics, or boiling the silicone, as these can degrade the material.

Women who prefer not to self-manage, or who find removal difficult, typically visit their clinician every three to six months for removal, cleaning, and a check of the vaginal tissue. These visits also let your provider look for any irritation or erosion early on.

How Long a Ring Pessary Lasts Before Replacement

A silicone ring pessary doesn’t wear out quickly. Modern devices made from medical-grade silicone are durable and non-reactive. A prospective study looking at continuous use found that a ring pessary can be safely used for up to four years in women who have not had a hysterectomy, and up to two years in women who have, as long as no complications develop.

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In practice, most clinicians will check the pessary at each visit and replace it if it shows discoloration, stiffness, cracks, or any loss of flexibility. If your pessary still looks and feels good at your check-up, there’s no need to swap it out just because a set number of months has passed. The difference in recommended duration between hysterectomized and non-hysterectomized women likely reflects changes in vaginal tissue and support structures after the uterus is removed.

Common Side Effects and Warning Signs

Some side effects are expected, and some signal a problem. A review of the literature found that the most common issues are odor, vaginal discharge, minor bleeding, pain, and constipation, with about half of pessary users reporting at least one of these at some point. Most are mild and manageable with more frequent cleaning or a change in pessary size.

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A study of postmenopausal women using ring pessaries for advanced prolapse reported an adverse event rate of about 32%, but every event was classified as low-grade. The most frequent issue was the pessary coming out on its own, which happened in about 18% of cases. Bleeding or superficial skin breakdown occurred in roughly 11%, and pain or discharge in a small percentage.

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Serious complications are rare but almost always related to neglected care: leaving a pessary in place for months or years without removal or clinical follow-up. In extreme cases, this has led to tissue erosion, fistula formation, and impacted stool. With regular cleaning and periodic check-ups, the risk of these serious problems drops to nearly zero.

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Should You Use Vaginal Estrogen With a Pessary?

Clinicians often prescribe topical vaginal estrogen alongside a pessary, especially for postmenopausal women, on the theory that it keeps vaginal tissue healthier and prevents erosions. The evidence on this is mixed. One study found no significant difference in erosion rates between pessary users who used vaginal estrogen and those who did not.

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However, more recent randomized data have shown a meaningful reduction in vaginal erosion and ulceration among pessary users who were assigned to vaginal estrogen compared with placebo. The inconsistency in the literature may reflect differences in the type and dose of estrogen, the duration of use, or how erosion was defined across studies. In practice, if your clinician recommends vaginal estrogen, it’s reasonable to use it, and if you’d prefer not to, the risk of erosion without it is still fairly low for most women. Discuss your preference at your fitting appointment.

Sex With a Ring Pessary in Place

A ring pessary is one of the pessary types compatible with intercourse because of its open center and relatively low profile. That said, many women choose to remove it before sex. In one study, about 70% of sexually active pessary users removed the device for intercourse “usually” or “always.” The most common reasons were that a partner could feel it or that it was uncomfortable during sex.

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Roughly half of the women who removed the pessary for sex said their partner wanted them to, and nearly all of those partners had communicated a specific reason. For women who kept the pessary in during sex, the evidence suggests they were generally satisfied and continued using the pessary long-term.

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If you’re comfortable with self-management, removing the pessary before sex and reinserting it afterward is a straightforward option. If you’d rather leave it in, try it and see how it feels for both you and your partner. There’s no medical reason you must remove it, and no harm in leaving it in place.

When a Ring Pessary May Not Work

There are very few absolute reasons a pessary cannot be used. Active pelvic infection, severe vaginal ulceration, and a known allergy to both silicone and latex are the main contraindications. Women who are unlikely to follow up for regular check-ups and who also cannot self-manage should be counseled carefully, since neglected pessaries carry real risks.

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Beyond those contraindications, some women simply cannot retain a ring pessary. A wide vaginal opening, weak pelvic floor tone, or a short vaginal canal (especially after hysterectomy) can make fitting impossible regardless of size. If a standard ring pessary won’t stay, a ring with support, a Gellhorn pessary, or another design may be tried before considering surgical options. A failed ring fitting does not mean all pessary types will fail.

How Pessary Therapy Compares to Surgery

For women considering their options, cost and outcomes matter. A randomized trial comparing pessary therapy to surgery for symptomatic prolapse found that pessaries cost significantly less on average, and while surgery produced slightly better patient-reported improvement, the difference in quality of life between the two groups was small and fell below what is considered clinically meaningful. The trial’s economic analysis concluded that pessary therapy as an initial treatment had a 100% probability of being cost-effective compared with immediate surgery.

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This doesn’t mean a pessary is always better than surgery. Some women prefer a more permanent solution, and advanced prolapse that cannot be managed with any pessary type may require surgical repair. But for most women, starting with a pessary and moving to surgery only if needed is a reasonable and well-supported approach. A pessary doesn’t burn any bridges: you can always stop using it and pursue other treatment later.

Cervical Pessaries in Pregnancy

Ring pessaries designed for prolapse are distinct from cervical pessaries used during pregnancy to prevent preterm birth, though the devices share a similar shape. The evidence for cervical pessaries in pregnancy is notably less encouraging. A large randomized trial found that in women with a short cervix and a singleton pregnancy, a cervical pessary did not reduce the risk of preterm birth compared with usual care, and was associated with a higher rate of fetal or neonatal death.

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Another trial comparing a cervical pessary to vaginal progesterone found that the pessary was not superior, and in women with very short cervixes it appeared less effective.

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One retrospective study did find that combining a cervical pessary with vaginal progesterone reduced preterm birth rates compared with progesterone alone, with the combination group showing fewer births before 34 weeks and better neonatal outcomes.

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The takeaway for pregnant women is that cervical pessary use during pregnancy is a separate clinical question from prolapse management, and the evidence is still evolving. If your obstetrician has mentioned a cervical pessary for preterm birth prevention, the decision should be based on your specific risk profile and the most current trial data rather than extrapolated from the prolapse literature.