Learning Objectives #
1. To understand the purpose of the speculum examination
2. To be able to perform a through speculum examination, including proper insertion of the speculum and optimal visualization of the cervix
3. Be familiar with the common normal and abnormal cervical findings on a speculum examination
Introduction #
The speculum consists of two bills that are introduced closed into the vagina and are then opened by squeezing the handle mechanism to inspect the vagina and cervix. The vaginal walls are held apart by the bills, and adequate visualization of the vagina and cervix is achieved. There are several types of specula. The plastic disposable speculum is currently becoming more common. Its colorless scheme allows for good visualization of the vaginal walls. In addition, a fibro-optic light source can be attached to the speculum handle directly, allowing the exam to proceed more smoothly. Of the reusable specula, the Graves’ speculum is used more commonly. The bills are wider and are curved on the sides. Pedersens’ speculum has narrower, flat bills and is used for women with small interoitus.
Before using the speculum in a patient, practice opening and closing it. If the patient has never had a speculum examination, show the speculum to her. Put on a clean pair of gloves and warm the speculum with warm water. Ensure the temperature is comfortable for her by touching it to her thigh. Jelly lubricant should not be used because it may interfere with cervical cytologic examinations and gonococcal cultures. Tell the patient that you are now going to perform the speculum part of the internal examination. For some patients gently pushing down on the posterior forchette with a lubricated index finger will help them understand what sensation they can expect. At all times, during the examination, you must tell your patient what to expect next, before proceeding. This again gives them a chance to stop you if needs be.
Technique:
While the examiner’s left index and middle fingers separate the labia and firmly depress the perineum, the closed speculum, held in the examiner’s right hand, is introduced slowly into the interoitus . The bills can be horizontal on entry as long as the labia are held clear. Any turning of the speculum as it first enters the vagina can catch hair or skin. Do not introduce the speculum vertically, because injury to the urethral meatus may occur. Slight downward pressure is usually helpful during complete insertion of speculum.
As the bills enter the full length of the vaginal canal, open them slightly to visualize the cervix. The speculum handle should be approximately 2 cm away from the interoitus before opening the speculum bills. The part of the cervix that comes in to view will determine how to move the speculum to open fully on to the cervix. If the cervix is not visualized close the speculum, back up 1 to 2 cm and then gently insert and turn the blades in various directions, reopen the blades to expose the cervix. This manoeuvre may need to be repeated several times. The cervix often drops down within the bills of the speculum once it is properly positioned. The most common reason for not visualizing the cervix is failure to insert the speculum far enough before opening it. Once the cervix is visualized, open the speculum further to encircle the cervix and then lock the speculum in place by turning down the screw on the speculum thumb piece.
Inspect the cervix for color, discharge, erythema, erosion, ulceration, leukoplakia, scars, and masses. A bluish discoloration of the cervix may be an indication of pregnancy or a large pelvic tumor. I n a woman who has never had a vaginal delivery the external cervical os is usually round. The external os becomes irregular and oval shaped after vaginal birth. A Pap smear should be performed at this stage, if needed.
The patient is told that the speculum will now be removed. The set screw is released with the examiner’s right index finger. When the speculum is removed it is very important to slightly open the bills to loosen the cervix so the speculum can be brought out without pulling down on the cervix. Then with control, slowly withdraw the speculum visualizing the vaginal canal as you go. The bills should be completely closed when exiting the introitus. A moderate amount of colorless or white mucus is usually present