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Guide to a Comfortable Speculum Exam
by Sonya Trejo
Opening the Speculum and Patient Comfort
The speculum examination can provoke anxiety for the patient and practitioner alike. Many of the medical and nursing students I have taught expressed concern over the insertion and placement of the speculum more than any other part of the pelvic examination. They worry that not being technically proficient with the speculum may cause undue pain. I always begin my classes with asking my students if they have ever watched a pelvic exam, and if so, was there anything that they wanted to ask at the time but didn't have the opportunity to do so? More than once the questions have been related to pain, "What part of the exam hurts?"
"How do I keep from hurting my patients?"
"Does the speculum hurt much?"
When I asked a group of friends what they would most like to me to teach medical students about performing the pelvic exam, three of five asked that I address comfortable speculum placement. The suggested that some of their past providers had either selected a speculum that was "too big" or that it was opened "too widely."
Oddly enough, it is exactly the practitioners' fear of causing their patients pain or opening the speculum too widely that can actually alter their technique in such a way that induces more pain than necessary.
The Mechanics of the Speculum and The Anatomy of the Vagina
Discomfort during the speculum examination is infrequently due to the speculum being too large. A medium Graves and medium Pederson's are exactly the same length, and differ in width by one-half inch. Most women can comfortably tolerate the length of the medium length speculum Ð 4.25 inches, with only about 3.75 being insertable. The discomfort and feeling of excess pressure and stretching can occur when the speculum is not placed properly in the vagina before it is opened.
Holding a speculum in your hand, open it by depressing the thumb-lever and observe how the bills of the instrument move apart from each other. The lower bill stays stationary, and the upper bill moves up at an angle. The distance between the ends of the bills is considerably greater than the distance between the bases of the bills. This design works well because the vagina increases in elasticity as you move from the introitus towards the cervix.
Now, imagine that the speculum is not placed deeply enough within the vagina before it is opened Ð the wider part of the speculum will now be stretching an area of the vagina much less capable of expanding comfortably.
Not only can this occur when the speculum is not placed deeply enough within the vagina, but as the speculum is opened. The vaginal muscles are strong and will resist - many people are impressed the first time they open a speculum with how much resistance they feel as they depress the thumb lever. However, many make the mistake of allowing the speculum to move slightly out of the vagina during this resistance, which again means the misplacement of the speculum is likely to cause undue pressure in the first third of her vagina Ð a sensation the patient will experience as the instrument being "too large."
Another error in placement can occur when the speculum is not placed with the bottom bill directly against the posterior wall of the vagina. Remember that the vagina tilts downward towards the back. If you place the speculum in horizontally the anterior wall will feel much more pressure than is necessary when it is opened.
There are many more aspects to be aware of during the speculum examination. We offer this essay as an example of one of the many details we teach our student practitioners, and we hope it is useful to you.
If you would like to hire a Pelvic Educator to assist in your education in how to perform a comfortable and technically competent pelvic exam, please contact Project Prepare.
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