A pessary is a removable device placed inside the vagina to support organs that have shifted out of position, most commonly due to pelvic organ prolapse. Learning to insert, remove, and care for one is straightforward once you get the hang of it, though the first few attempts can feel awkward. Most people are fitted by a healthcare provider and then taught to manage the device on their own, and research suggests that self-management works just as well as repeated clinic visits for ongoing care.
What a Pessary Does and Who Uses One
Pelvic organ prolapse, where the bladder, uterus, or rectum drops into or against the vaginal wall, is the most common reason someone ends up with a pessary. Doctors typically offer one as a first option for people who want to avoid surgery, plan future pregnancies, have early-stage prolapse, or are not good candidates for an operation. Pessaries are also used for stress urinary incontinence, particularly when leaking worsens during exercise or physical activity.1PubMed Central. Pessary Use in Pelvic Organ Prolapse and Urinary Incontinence – Section: Indications and Contraindications for Pessary Use
Modern pessaries are made from medical-grade silicone, a shift from the cork, brass, and rubber materials used historically.2PubMed. The history and evolution of pessaries for pelvic organ prolapse Silicone is flexible, non-allergenic for most people, and easy to clean. The devices come in two broad categories: support pessaries, like rings, which hold tissue in place much like a shelf; and space-occupying pessaries, like the Gellhorn, donut, and cube, which fill the vaginal canal more completely and are used for more advanced prolapse.3PubMed Central. Pessary Use in Pelvic Organ Prolapse and Urinary Incontinence – Section: Types of Pessaries
The Fitting Process
You cannot simply buy a pessary off the shelf and start using it. The first step is a fitting appointment, usually with a gynecologist or urogynecologist, where the provider selects the type and size most likely to work for your anatomy. This involves a pelvic exam and often a trial-and-error process: the provider inserts a pessary, asks you to stand, cough, bear down, and walk around, then checks whether the device stays in place without causing discomfort. It is not unusual for the first size or shape tried to be wrong. Some people need two or three fitting visits before landing on the right one.
Certain anatomical factors make fitting harder. A wider vaginal opening relative to overall vaginal length, a history of multiple vaginal deliveries, and prior hysterectomy can all reduce the chances of a successful fit.4PubMed Central. Outcomes of pessary fitting trials for patients with stage IV pelvic organ prolapse: a prospective study On the other hand, a longer vaginal canal, a smaller genital hiatus, and a higher body mass index have been linked to better odds of fitting success.5Journal of Gynecological Research and Obstetrics. Predictors of successful fitting of vaginal pessary for female pelvic organ prolapse If the first type does not work, providers typically try a different shape before concluding that a pessary is not viable. A ring pessary that keeps falling out might be replaced by a Gellhorn or cube that fills more space.
How to Insert a Pessary
Once you have the right fit, your provider will demonstrate insertion and removal, and you will practice in the office before going home. The basic technique varies slightly by pessary type, but the principles are the same.
For a ring pessary, the most commonly used type, you fold it in half (like folding a taco shell) to narrow its profile. In a comfortable position, whether standing with one foot on a stool, squatting, or lying on your back with knees bent, you apply a water-based lubricant to the leading edge and guide it into the vagina with steady pressure angled toward your lower back. Once past the pubic bone, you release the fold and let it spring open. Then you push it gently up and back so it sits behind the pubic bone, surrounding the cervix if your uterus is still in place. You should not feel it once it is positioned correctly. If you feel pressure or pinching, it likely needs to be repositioned or may be the wrong size.
For a Gellhorn pessary, the stem is held between two fingers while the disc end is angled and slid in. The disc sits flat against the top of the vaginal canal with the stem pointing downward. A cube pessary is compressed by squeezing out the air before insertion and then allowed to expand once inside, where it holds itself in place through gentle suction against the vaginal walls.
The cube is worth singling out because it is the one type specifically designed for daily removal. Its suction grip means it needs to be taken out each night, cleaned, and reinserted in the morning. Ring and Gellhorn pessaries, by contrast, can stay in place continuously and be removed less frequently.
How to Remove a Pessary
Removal is often the step people find more intimidating than insertion, but it gets easier with practice. For a ring pessary, you reach in with a finger, hook the rim, tilt it slightly to break the seal, and pull it out at an angle, folding it as it comes. Bearing down gently, as if having a bowel movement, helps push the pessary closer to the vaginal opening where you can reach it.
For a Gellhorn, you grasp the stem, gently rotate or rock the disc to release suction, then guide it out. A cube is removed by hooking a finger into the small hole or loop at its base and gently pulling while breaking the suction. Because the cube relies on suction, it can feel more “stuck” than other types, but pulling steadily while bearing down will release it.
If you cannot remove your pessary at home, do not panic. This is common, especially early on. Your provider’s office can remove it for you, and you can keep practicing the technique over time.
Cleaning and Ongoing Care
How often you remove and clean your pessary depends on the type you use and what your provider recommends. There is no single schedule that fits everyone. In a study of pessary users, about 5% cleaned theirs daily, roughly a third did so weekly, and about 40% cleaned monthly.6PubMed Central. Effect of pessary cleaning and optimal time interval for follow-up: a prospective cohort study Cube pessaries, as noted, need to come out nightly. Ring and Gellhorn types give you more flexibility.
Cleaning itself is simple: wash the pessary with mild soap and warm water, rinse thoroughly, and reinsert. Avoid harsh soaps, alcohol-based cleaners, or anything with fragrance, as these can degrade the silicone and irritate vaginal tissue. That same study found no meaningful difference in vaginal pain, discharge, or irritation when cleaning intervals were extended from every three months to every nine months, which is reassuring if you find frequent removal difficult.6PubMed Central. Effect of pessary cleaning and optimal time interval for follow-up: a prospective cohort study
One thing to be aware of: all pessaries develop bacterial biofilms over time. A study examining used ring pessaries under electron microscopy found biofilm on every single device tested, though the composition was largely the same bacteria normally found in the vagina.7PubMed. Bacterial biofilm formation on vaginal ring pessaries used for pelvic organ prolapse Biofilm buildup is a normal consequence of having a foreign body in the vaginal canal and is part of why regular cleaning matters. Pessaries do not last forever; most providers recommend replacing them every one to two years, or sooner if the silicone becomes discolored, cracked, or warped.
How Removal Frequency Affects Vaginal Health
The vaginal environment shifts when a pessary is in place. Research shows that women wearing pessaries are more likely to develop microscopic signs of vaginal inflammation, and these changes tend to appear within the first two weeks of use.8American Journal of Obstetrics and Gynecology. The effect of pessaries on the vaginal microenvironment However, bacterial vaginosis rates do not appear to be significantly higher in pessary users compared to other groups with similar prolapse.9PubMed Central. Can the Pessary Use Modify the Vaginal Microbiological Flora? A Cross-sectional Study
How often you remove the pessary does seem to matter for the balance of vaginal bacteria, at least in the first few months. At three months of use, women who removed their pessary less often than once a week were more likely to have a shift toward anaerobic bacteria compared to those who removed it more frequently.10PubMed Central. Changes in the Vaginal Microenvironment as Related to Frequency of Pessary Removal This does not necessarily mean more frequent removal is required for everyone, but it is one reason providers encourage self-management when feasible.
Vaginal Estrogen and Tissue Protection
Providers often prescribe a topical vaginal estrogen cream or ring alongside a pessary, especially for postmenopausal women. The rationale is that estrogen keeps vaginal tissue thicker and more resilient, reducing the risk of erosion, which is when the pessary rubs through thin tissue and creates a sore. A secondary analysis of a randomized trial found that continuous estrogen use for twelve months or more roughly halved the odds of vaginal tissue problems compared to no estrogen use.11PubMed. Factors for Vaginal Epithelium-Related Adverse Events in Pessary Users: A Secondary Analysis of a Randomized Controlled Trial Other protective factors in that analysis included being sexually active and having had more vaginal births, while more advanced prolapse and longer time since menopause increased risk.
It is worth noting that one earlier study found erosion rates were actually similar regardless of whether women used vaginal estrogen, at about 28-37% across groups.12PubMed Central. Effect of vaginal estrogen on pessary use The evidence is not perfectly consistent, and the benefit of estrogen may depend on the duration of use. But given that topical vaginal estrogen has a good safety profile, most specialists still recommend it as part of pessary care for postmenopausal women.
Self-Management Versus Clinic-Based Care
Historically, many women relied on clinic visits every few months to have a nurse or doctor remove, clean, and reinsert their pessary. The TOPSY trial, a large randomized study, challenged that model. Women who were taught to manage their pessary at home had the same quality-of-life outcomes at 18 months as those receiving clinic-based care, and they actually reported fewer pessary complications: about 17% in the self-management group versus 22% in the clinic-based group.13eClinicalMedicine. Clinical effectiveness of vaginal pessary self-management vs clinic-based care for pelvic organ prolapse (TOPSY): a randomised controlled superiority trial Self-management was also less expensive, with an estimated savings per person and an 80% probability of being cost-effective compared to clinic care.14PubMed. Clinical and cost-effectiveness of pessary self-management versus clinic-based care for pelvic organ prolapse: the TOPSY RCT with process evaluation
Self-management is not for everyone. Some women, especially those who are older, have limited dexterity, or feel anxious about handling the device, prefer to keep their clinic appointments. And even self-managers should see their provider periodically, typically once or twice a year, for a vaginal exam to check for erosion or other tissue changes. But if you are comfortable with insertion and removal, there is strong evidence that taking care of the pessary yourself is safe and effective.
Common Side Effects and When to Worry
The most frequently reported side effects are increased vaginal discharge, mild odor, and occasional spotting. An integrative review found that discharge, erosion, and bleeding were the most common complications, and that these were related to pessary shape and how long the device stayed in place without removal.15PubMed Central. An integrative review and severity classification of complications related to pessary use in the treatment of female pelvic organ prolapse Most of these issues are minor and can be managed by adjusting how often you clean the pessary or by adding vaginal estrogen.
Rare but serious complications almost always involve pessaries that have been left in place for months or years without removal or follow-up. A systematic review of case reports found that the most severe events, including fistulas between the vagina and bladder or rectum, vaginal impaction of the device, and bowel evisceration, occurred predominantly in elderly women (median age 82) whose pessaries had gone unchecked for prolonged periods.16PubMed Central. Rare complications of pessary use: A systematic review of case reports These cases underscore why regular removal and follow-up visits matter. A pessary should not be placed in anyone with an active pelvic infection, severe vaginal ulceration, or an allergy to both silicone and latex.1PubMed Central. Pessary Use in Pelvic Organ Prolapse and Urinary Incontinence – Section: Indications and Contraindications for Pessary Use
Sexual Activity With a Pessary
Whether you can have intercourse with a pessary in place depends on the type. Ring pessaries sit high enough that penetrative sex is often possible without removing them, though some couples find it more comfortable to take the device out first. Gellhorn and donut pessaries generally need to be removed before intercourse because of their shape and position. Cube pessaries, since they come out nightly anyway, simply stay out during sex.
The good news is that pessary use tends to improve rather than impair sexual function. A study of sexually active women found that desire, lubrication, and sexual satisfaction all improved after starting pessary therapy, while orgasm remained unchanged.17Fertility and Sterility. Sexual and organ function in patients with symptomatic prolapse: are pessaries helpful? This makes sense when you consider that the bulging and pressure of prolapse can be a significant barrier to comfortable sex. Longer-term data also support this: among women using self-managed cube pessaries, nearly three-quarters described their sexual wellbeing as better or much better than before treatment, and over 90% of sexually active users said removing the cube before sex was not disruptive.18PubMed Central. Long-Term Self-Management of Vaginal Cube Pessaries Can Improve Sexual Life in Patients with Pelvic Organ Prolapse, Results from a Secondary Analysis
Long-Term Use and the Question of Surgery
A pessary is not necessarily a forever solution, but many women use one for years. A retrospective study estimated the median duration of use at roughly 3.3 years, with about 47% of patients still using their pessary at the end of follow-up. Around 30% eventually opted for surgery, and most of those who did switched within the first four months.19Maturitas. Long-term adherence to pessary use in women with pelvic organ prolapse: A retrospective cohort study Among Medicare beneficiaries, about 12% had prolapse surgery within a year of being fitted, rising to about 31% over seven years. Older women were less likely to transition to surgery, while women who had prior prolapse surgery or urinary incontinence were more likely to.20PubMed Central. Transition to surgery after pessary among female Medicare beneficiaries with pelvic organ prolapse
In a randomized trial directly comparing pessary with surgery, 60% of women assigned to the pessary group discontinued use within 24 months, and about 54% ultimately crossed over to surgery. The most common reason was the pessary falling out, which happened in about a third of those who switched.21JAMA. Effect of Pessary vs Surgery on Patient-Reported Improvement in Patients With Symptomatic Pelvic Organ Prolapse: A Randomized Clinical Trial Among those who stopped for other reasons, pain was the leading cause in one long-term study.22PubMed. The Long-Term Effects of Pessary Treatment on Quality of Life, Symptoms, Sexual Function, and the Urinary System in Women with Pelvic Organ Prolapse None of this means a pessary has “failed” if you eventually want surgery. Many women use one as a bridge, either to buy time before deciding on an operation or to manage symptoms during periods when surgery is not practical.
Pessaries During Pregnancy and Postpartum
Prolapse can occur or worsen during pregnancy due to hormonal changes and the weight of the growing uterus. A pessary can manage symptoms safely in this context. Case reports support that conservative management with a pessary improves comfort without contraindicating vaginal delivery; cesarean section is only needed for standard obstetric reasons, not because of the pessary itself.23Case Reports in Women’s Health. Management of pelvic organ prolapse during pregnancy: Case report
A separate and more experimental application is using pessaries postpartum to support pelvic floor recovery. A prospective study tracked women who started using a pessary after delivery. Of those who used it, about 94% with prolapse symptoms and 72% with urinary incontinence reported improvement at three months postpartum, though adherence dropped over time, with fewer than half the initial users still wearing the device at six months.24PubMed Central. Evaluating compliance and applicability of postpartum pessary use for preventing and treating pelvic floor dysfunction: a prospective multicenter study Postpartum pessary use is still a relatively new idea, and the evidence base is small, but it offers an option for women dealing with pelvic floor symptoms in the early months after childbirth.
Cervical Pessaries for Preterm Birth Prevention
There is a completely different type of pessary, often called a cervical pessary or Arabin pessary, designed to sit around the cervix during pregnancy and reduce the risk of preterm birth in women with a short cervix. This is a distinct device from the prolapse pessaries discussed above, and the evidence around it is far less settled. A large U.S. randomized trial found that a cervical pessary did not reduce preterm birth before 37 weeks compared to usual care, and the pessary group actually had a higher rate of fetal or infant death.25JAMA. Cervical Pessary for Prevention of Preterm Birth in Individuals With A Short Cervix: The TOPS Randomized Clinical Trial A smaller prospective cohort study in Taiwan, by contrast, reported that about 88% of women given a cervical pessary delivered at or after 34 weeks.26Taiwanese Journal of Obstetrics and Gynecology. Cervical pessary for preterm-birth prevention among pregnant women with a short cervix: A prospective cohort study The discrepancy between studies likely reflects differences in patient populations, study designs, and comparison groups. At this point, cervical pessaries for preterm birth prevention remain investigational, and anyone considering one should discuss the current evidence carefully with their obstetrician.