If the thought of conducting an intimate examination or attempting to wield (without any embarrassing pitfalls) the contraption that is the speculum is enough to fill you with apprehension- fear not! The good news is that junior doctors are not typically expected to perform speculum/bimanual examinations unless you are on an O&G or GP placement. If this is the case for you, then I hope this article will be helpful.

Remember, you can always ask a more experienced colleague to supervise you if feel unsure about anything, and with more practice, you’ll become more confident and be able to differentiate pathology from normal anatomy. 

When might you need to perform a gynaecological examination?

Preparation

A smooth gynaecological exam relies on both the patient and yourself feeling comfortable. Good preparation beforehand will help achieve this and ultimately improve the patient experience.

• Obtaining verbal consent is a MUST.
• Give a full explanation of the procedure, the purpose of the examination and document everything.
  • Speculum: ‘This will involve placing a small plastic tube inside the vagina to look at the neck of the womb and vaginal walls. Swab tests may have to be obtained during the procedure’.
  • Bimanual: ‘This will involve me placing one hand on your lower abdomen and two lubricated fingers within the vagina to feel the neck of the womb and the corners of the vagina where the ovaries lie’.
  • Remind the patient: If they are very uncomfortable or experience pain, the examination can be stopped at any point. Offer analgesia before the exam if the patient is in severe pain.
• Do NOT use partners, friends or children as chaperones. ‘It is the hospital policy to have a member of staff present for private examinations. Would you like anyone else to be present?’ (Refer to GMC guidance on intimate examinations).
• Ask if the patient wants to empty her bladder before the exam.
• Perform an abdominal examination: note any distention, scars, tenderness or masses on palpation.
• Allow the patient to undress from the waist downwards in privacy and provide a blanket or sheet to cover herself with. Place IncoPad on the examination bed beforehand if expecting significant discharge/bleeding. Lock the door if the patient prefers.
• Optimal position: ‘Lie on your back, bring your heels together, bend your knees and bring heels towards your bottom, then let your knees fall apart’.
• Gather all the equipment before exposing patient: speculum, lubricant jelly, light source, charcoal swabs (HVS- candida, BV, GBS, staph, TV; endocervical- gonorrhoea), chlamydia NAAT swab (endocervical), Sponge-holding forceps +/- gauze (if products of conception remain stuck within cervix during miscarriage), extra pair of gloves.
• Inspect the vulva before internal examination for altered anatomy: lesions, warts, rashes, cysts, scarring, skin fissures, leucoplakia. Ask patient to cough and bear down checking for uterovaginal prolapse/stress incontinence.

Speculum

• Do the speculum examination BEFORE the bimanual examination
• Hold the lubricated speculum in your dominant hand with the blades closed and the lever to the right.
• Part the labia with your non-dominant hand
• Warn the patient on insertion of the speculum
• Slowly insert the speculum at a downwards angle towards the coccyx. Rotate anticlockwise about midway into the vagina and place fingers behind levers to protect pubic hair from getting trapped in the locking mechanism.
• The speculum should be inserted to the full length of the vagina with the blades in the posterior fornix before they are gently opened with the cervix then falling in-between the opened blades.
• Ask the chaperone to adjust the light to illuminate the cervix
• Inspect cervix for: the shape of cervical os (slit- parous, round- nulliparous) and how open it is (possible miscarriage?), presence of ectropion, Nabothian cysts, IUCD threads, polyps, cervicitis or lesions on cervix and discharge. Also inspect vaginal walls through speculum blades for atrophy, erythema or lesions.
• Take swabs if appropriate. HVS from the posterior fornix and endocervical swabs from the cervical os.
• To remove: unlock, keep blades open and withdraw until cervix falls out, then close blades and rotate speculum sideways and remove gently.

Tips for visualising the cervix

• Ask the patient to cough, move downwards, flatten the bed, and/or place fists underneath the bottom to lift the pelvis
• Withdraw the speculum and change the angle of insertion (posterior or anterior)
• For a retroverted uterus, insert the speculum with the levers pointing downwards
• If the patient has a high BMI or is pregnant, you can cut a finger of a latex glove and insert it over the speculum- this will prevent the vaginal walls from bulging in and obstructing the view.
• Use smaller size speculum if very painful or long size cervix if unable to reach posterior aspect of vagina

For more information visit Geeky Medics and BeautifulCevix.com

Bimanual

• Part the labia with your non-dominant hand and hold your hand in the ‘finger gun’ position with your hand sideways and your thumb pointing upwards.
• Warn patient on insertion
• Tilt your fingers so your palm is facing upwards when within the vagina and reach for the cervix
• Feel the cervix and note the consistency (soft & smooth or irregular & hard) and how wide the external cervical os is.
• Then place your fingers in the posterior fornix and push up on the cervix. At the same time, place your other hand midway between the umbilicus and the symphysis pubis and press downward toward the pelvic hand.
• Using the palmar surface of your fingers, palpate for the uterine fundus while gently pushing the cervix anteriorly with the pelvic hand.
• Feel the uterus and note size, position and if tender on palpation.
• The uterus will move upwards and you will be able to feel it unless it’s retroverted, or if the patient is obese. A fixed uterus (i.e. not mobile) is commonly seen in endometriosis/adhesions.
• Using a similar technique, feel each adnexa in turn and note any masses or tenderness by moving vaginal fingers into each lateral fornix and placing the abdominal hand on the lower lateral quadrant of the abdomen on the same side.
• Usually, you cannot palpate normal ovaries.
• For masses, note the size and if it is solid or cystic. Obesity can once again impair adnexal evaluation.
• Lastly, cervical excitation is elicited by moving the cervix side to side between the index and middle fingers – If positive, it will be exquisitely painful and can often make the patient jump in response.
• Remember to inspect fingers for blood/ discharge on removal.

Caution: You are NOT expected to conduct a digital examination on an obstetric patient. This should ONLY be performed if appropriate by a senior doctor or a midwife.

References

1. Gynaecological Examinations: Guidelines for Specialist Practice. Elearning.rcog.org.uk. (July 2002). Retrieved 20 March 2021, from https://elearning.rcog.org.uk/sites/default/files/Communication%20skills/rcog_gynaeexams4.pdf
2. Collins et al (2013). Oxford handbook of Obstetrics and Gynaecology. Ch14; page 462-463; 3^rd Edition
3. Magowan and Owen (2019). Clinical Obstetrics and Gynaecology. 4th edition.

Written by: Dr Mahrukh Hussain, FY2
Reviewed by: Dr Seena Radhakrishnan, Post-CCT O&G
Edited by: Dr Alisa Jivraj (GP trainee) & Mudassar Khan (Y3 Medical Student)