See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/236475662

Vaginal examination, have we forgotten the

basics?

Article in European Clinics in Obstetrics and Gynaecology November 2007

DOI: 10.1007/s11296-007-0071-z

CITATIONS READS

0 130

1 author:

Costas Panayotidis
Isle Of Wight NHS Trust
28 PUBLICATIONS 181 CITATIONS

SEE PROFILE

All content following this page was uploaded by Costas Panayotidis on 20 March 2015.

The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document
and are linked to publications on ResearchGate, letting you access and read them immediately.
Eur Clinics Obstet Gynaecol (2007) 3:103110
DOI 10.1007/s11296-007-0071-z
TIPS AND TRICKS
Vaginal examination, have we forgotten the basics?
Costas Panayotidis
Received: 22 June 2007 / Accepted: 15 October 2007 / Published online: 8 November 2007
# European Board and College of Obstetrics and Gynaecology 2007
Abstract This article discusses the actual practice of the
vaginal examination and compare the different methods that
commonly are used in Europe, particularly the UK and the
north European way. The advantages and disadvantages for
the patient and the gynaecologist are described in a
comprehensive way explaining why different gynaecolog-
ical positions may be more efficient for both the patient and
the gynaecologist. Emphasis is given on the training
validation for the junior doctors and the future general
practitioners.
Keywords Vaginal digital examination .
Speculum examination . Cusco speculum . Stirrups .
Examination couch . Clinical teaching
Background
Vaginal examination (VE; speculum and digital examina-
tion) is the most common method of examination in
gynaecology. From the early stages of training, the students
and junior doctors become familiar with it. In Europe,
different traditional ways of examination are practiced.
These can vary from examination using a couch with or
without stirrups, on a flat bed, and different types of vaginal
speculums. The knowledge of the advantages and dis-
C. Panayotidis (*)
University of Manchester,
6 Angela Avenue, Royton,
Oldham OL2 6AQ, UK
e-mail: costapan@hotmail.com
advantages of each way is of great importance because of
the following:
Examination method should be adapted to the patient
each time.
Doctors qualified from the European Union can
practice in other EU countries and should be accus-
tomed to the local method of examination.
The setting of the examination room should have some
common standards in all hospitals.
The validation of the examination skills should take
into account appropriate teaching (demonstration and
assessment in a early stage of training that includes
explanations about the benefits of one to the other
examination method).
The gynaecological module in undergraduate level
includes VE teaching. Usually, it is based on textbooks
with schematic demonstrations (how to use the fingers and
the speculums). Occasionally, there are available plastic
models or manikins for practice in university teaching
hospitals. Life demonstrations in outpatient clinics are
succeeded with a couple of supervised attempts of VE. It
is of importance to mention that in UK ,written consent is
required before any examination by undergraduates even if
the VE will be performed under general anaesthesia.
Later, as postgraduate doctor, the teaching is not
systematic. Independently, if the junior doctor will be a
general practitioner (GP) or gynaecologist, the recall of the
VE skill is based only on direct hands-on practice in the
outpatient clinics (which is not necessarily directly super-
vised). The more senior colleague demonstrates couple of
times his way, a way that was taught in previous years
that follows the dogma See once, be supervised once and
do it alone afterwards. With practice, the VE skill is
104 Eur Clinics Obstet Gynaecol (2007) 3:103110

thought to be easily acquired. The GP, however, may not

work for enough time (usually 36 months) on gynaeco-
logical departments during their training.
Women may feel very vulnerable and uncomfortable
during their gynaecological examination. Some of them
react, as it is one of the most horrible experiences, with
pains and discomfort, and most of them may tend to avoid
an examination or not tolerate it, making the whole
examination unsuccessful.
Uncomfortable positioning of the patient and gynaecol-
ogist, inadequate technique and method of examination
accentuates the above situation. This crucial subject will be Fig. 1 Uncomfortable body posture for the doctor, bending between
discussed. The VE can be successfully performed only if knees of the patient (simulated by a nurse). Doctor eyes should be
almost parallel to the surface of the couch to see clearly the cervix
the patient is comfortable, prepared and informed for what
is done and why. However, the aim of this article is not to
emphasise the appropriate counselling and physiological Speculum insertion
parameters that should be taken in consideration before the
examination and necessary communication skills that are After the light is adjusted, the Cusco speculum is usually
required for this. used and introduced with the handle looking upwards
because of the flat bed layout surface. Having inserted with
the Cusco inverted, the cervix, most of the times, can be
visualised but not in its entire surface. Further adjustment
The Anglo-Saxon-way examination method using the valves of the speculum in and out is necessary to
expose the entire cervix. These manoeuvres can be very
In UK, most women are examined flat on the bed or the uncomfortable for the patient (especially the pressure on the
examination couch in clinics. Few outpatient gynaecolog- anterior vestibule from the speculum and hand that try to
ical clinics use a couch with semi-lithotomy position. The secure the screw of the Cusco). The positioning of the
patient has to take a position where she is bending her doctor is completely unnatural bending in extension (see
knees up wards and laterally and leaving floppy her legs Fig. 1) to visualise and control the adjustment of the
joining her feet (froggy position). She is usually covered speculum valves.
with a sheet. Chaperons (female nurse) are always present
during examination. The examination requires the follow- Cervical samples
ing steps.
The cervical swabs or smears are more difficult to perform
Light source in this position because of the short access and difficulty to
visualise the cervix. There are more risks of external
Doctors have to adjust the light source parallel to the bed. contamination of the sample. In case of excessive dis-
The light must be positioned proximal to the legs; charges or bleeding, there is no possibility to collect them
otherwise, the feet are in frond of the light, decreasing or without the patient to be wet or dirty.
obstructing the light beam. If the light is positioned before
the feet, the space between the vulva and the doctors head
is narrower, making the inspection difficult. If the doctors
head is in front of the light source, it will provoke shadows,
and the inspection is not optimal. If the light source is
positioned, for example, at 45 degrees higher of the bed,
shadows are avoided but the light beams do not reach the
far end of the vagina or the cervix. To aim better with the
light, the examiner should position his/her body in an
uncomfortable position laterally to the bed and patient
(Fig. 1). Often, the light source is not powerful and is
connected on the nearest wall (Fig. 2). Sometimes, a
torch between the feet and vulva is used as a simplistic Fig. 2 Couch for flat examination, light attached on the wall. Couch
solution; however, the quality of vision is not optimal. near the wall
Eur Clinics Obstet Gynaecol (2007) 3:103110
The vaginal examination
The vaginal digital examinations usually use two fingers.
Again, the lateral positioning of the examiner affects the
accuracy of the VE. The examiner cannot rotate his hand
more than 180, and the cervical surface is not the entirely
felted. It is very difficult to examine the profound posterior
end of the vagina without pain. It is impossible to perform
an accurate examination for deep endometriosis, as it is
difficult to elevate with the index finger the cervix and with
the third finger to palpate retrovaginal nodules or feel the
hole parts of the uterosacral ligaments.
The north-European way
Most women are examined in semi-lithotomy position see
(Fig. 3). The patient is examined on a couch that has
detachable stir-ups. She puts her feet on special supports
where she does not hyperextend her knees or legs. The edge
of the couch is free.
A chaperon is not always present during examination.
The examination is performed as in colposcopy clinics. The
doctor is seated down on a mobile chair. The level of the
couch is adjusted in a way that the vulva is up to the level
of the examiner eye. There is space under the buttocks of
the patient. The Cusco speculum is used as it was designed
for, with the handles facing down. The light is adjusted
lateral of the examiner head not obstructing the view and
the light beam reaches directly the vulva. The light source
can be adjusted easily without intermediate obstacles. In
Belgium, most of the examination rooms have a small
colposcope that is used as light source. The visualisation of
Fig. 3 Semi-lithotomy position (nurse simulating patient)
105
the cervix can be done with magnification. The Grave
speculums or modified Cusco are often used (Fig. 4)
depending the examination needs. However, flexible light
source is just enough for a good view, and not all the
general outpatient clinics in Europe may have the financial
resources to be equipped with colposcopes.
The lower valve of the speculum can open wider than
the superior, and more pressure can be applied on the
posterior perineum without excessive discomfort (as when
the posterior valve is applied inverse on the anterior vaginal
wall). This is achieved because the blades are held
obliquely and the pressure exerted towards the posterior
vaginal wall avoiding the more sensitive anterior wall and
urethra, carefully without pulling on the pubic hair or
pinching the labia with the speculum.
The examiner can move and adjust the speculum much
easier and with less discomfort for the patient using the
speculum handles down. The visualisation of the cervix can
always be achieved using adequate speculums in length,
and a larger view angle is achieved. All the vaginal walls
can be seen, specially the anterior wall, which is impossible
to see on a flat bed examination. As it concerns the VE, the
examiner can lower the level of the couch and examine the
patient in an adequate height (level of his elbow),
performing the bimanual examination, avoiding bending
and twisting his back. The doctor is usually in front of the
patient and stands up. The examiner can use his right or left
hand for the VE. The fingers can be angled more
posteriorly so that adnexal masses can be felt easily without
excessive abdominal pressure, which is necessary when we
examine on a flat bed. There is more space for complete
rotation of the wrist, and the fingers can reach the profound
part of the fornix and vagina. This can be uncomfortable by
the patient. Detection of small nodules of the retrovaginal
space and of the uterosacral ligaments can be felt. Only
with this manoeuvre that precocious diagnosis of rectova-
ginal nodule can be achieved. For cervical samples and
smears, the semi-lithotomy position is the best ergonomi-
cally characterised with overall better view, easier access
and less contamination risks for the specimen.
The south-European way
Here, the examination is performed often in complete
lithotomy position (Fig. 5). On the examination table, the
woman is laying flat on back, her thighs flexed and
abducted (knees up). Her legs are in complete flexion, as
in a position of labour, her feet are not resting in stirrups for
support, and her buttocks are extending slightly beyond the
edge of the examining table. A pillow should support her
head. Similarly with the north-European way, the patient
may be completely naked. Chaperon is not an obligation.
106
Fig. 4 Modified GravesCusco
speculum
Light source is not often a colposcope but a mobile flexible
source. Cuscos speculums are often used.
Discussion
There is a published evidence [1] supporting that patients
feel less uncomfortable and vulnerable when they are
examined on a flat couch without stirrups. This method of
examination has the advantage to be more patient concen-
trated, giving to the patient control of the procedure. The
patient is draped with a full-sized sheet maximising the
cover of the patient, allowing visualisation of the perineum.
The presence of chaperon is an additional factor that helps
the patient to feel more secure during an intimate
examination. Women prefer to be examined this way if
they have the option and regard it as more women
friendly. However, the real physical discomfort that they
express, apart from the psychological component, can be
accentuated with an inappropriate setting of the examina-
tion room and examination technique. It is very difficult to
evaluate this observation. Literature research found limited
and heterogenic evidence concerning patients attitudes
towards gynaecological examination methods with or
without stirrups. A part from how the patient feels with
one or other method of examination, there is no published
evaluation about the quality of the vaginal examination in
terms of clinical findings and comfort for the gynaecologist.
Most of the evidence is based on articles using question-
naires of patient satisfaction, letter to the editors and
subjective opinions. These articles [19] do not explain
how the speculums are inserted into the vagina and how
systematic the digital vaginal examination is performed
(what anatomic points are searched for, length of cervix,
fornix, ligaments, ovaries, uterus, etc). Using the Cusco
speculum inverted may accentuate discomfort in the
anterior vestibule (see Fig. 6). It seems that the lower valve
opens at a greater angle than the superior one (see Fig. 7).
This observation has never been investigated properly. If it
is true, adapted instruments should be used to decrease the
physical discomfort of the woman. There are significant
Eur Clinics Obstet Gynaecol (2007) 3:103110
bias of co-factors that influence what is felt by the patient
as discomfort (physical or psychological) especially in
studies that use questionnaires. No published paper evalu-
ated this part of the VE examination and, moreover, the
impact of an uncomfortable doctors position during the
examination. In the UK, the GPs play an important role for
the fist gynaecological examinations (before referrals to a
specialist) and cervical smear screening. More women will
be examined by the GP than by a gynaecologist. Adequate
method of examination and thorough VE technique is of
extreme importance, which should be assured during the
training of junior GPs. The advantage of a flat examination
is of great importance for the national care system, as
theoretically, more women will be happy to be examined
and participate in screening campaigns. A routine VE is not
performed in the same way in different countries of Europe.
Clinical assessment with VE is of great heterogeneity, and
this should be taken in account when evaluating results of
published articles concerning VE. The semi-lithotomy
position is thought to be much more embarrassing for the
patient. However, this method has more advantages. It
allows the doctor to be more flexible, performing the VE
with comfort and allowing more systematic anatomical
digital palpation. There is little evidence comparing the two
methods flat vs stirrups or lithotomy concerning the quality
of clinical findings and smears. Under experienced hands,
examination without stirrups may not produce a higher than
acceptable number of inadequate samples or cervical
Fig. 5 Lithotomy position couch, ergonomic with colposcope
Eur Clinics Obstet Gynaecol (2007) 3:103110
Fig. 6 Schematic representation using speculum in an inverted way.
Red arrow illustrates the opening angle of the lower valve compress-
ing the anterior vestibule. The green arrow represent the axe of the
smears. The communication skills and preparation of the
patient is completely different before the VE for each
method. Under good conditions (equipment), both methods
should be very efficient and mastered by the modern
gynaecologist. Senior consultants with significant clinical
experience do not agree that the flat bed examination
compromise their clinical accuracy or findings. There is no
trial to assess this opinion. For the gynaecologist, bending
and flexing the spine and neck is needed more often during
flat couch examination. This is a very uncomfortable
posture and may accentuate low back pains for the
gynaecologists. Ageing does not help either. Junior doctors
may not consider their uncomfortable position during flat
couch examination, as their attention is more towards how
to detect pathology and not miss any, no matter how they
position their body. What is of great concerns is that
modern junior doctors do not have enough clinical
experience. Inappropriate application of speculums, less
confidence of the digital bimanual examination and fear to
admit this in early stage will make gynaecologist to
completely loose their palpation skills. In evidence-based
medicine era, we should question and reflect even on
routine procedures such as the VE. Can we improve further
our VE techniques? How sure are we that our junior doctors
will develop adequate VE skills during training? In a busy
clinic, adequate technique is essential for a quick and
comfortable examination both for the patient and the
gynaecologist. Lack of time jeopardises the quality of the
examination, especially for junior doctors. It is technically
very difficult to verify their skills (or findings) in all the
107
examiner view that should be achieved to inspect the cervix and the
anterior vaginal wall
outpatient consultations. The junior should work under the
best comfortable conditions and have adequate support
from the more senior colleagues. There is no doubt that
optimal working conditions improve quality and motivation
for the medical team. It is so discouraging to have an
unhappy patient because of a painful examination. GPs do
not have lot of time during their training (1 to 6 months
only) to get confidence with VE. A patient may feel more
uncomfortable having a painful VE due to inappropriate
positioning and applied instruments. Junior doctors need
more supervised time to become confident about the
technique that they use during VE and smear or vaginal
samples. Unnecessary requests of vaginal swabs and
cervical smears may be asked if this was not properly done
[10].
Nowadays, some gynaecologists directly rely more on
the ultrasound scanning (USS abdominal or transvaginal)
than on a systematic physical examination. In central
Europe, the USS can be performed during routine consul-
Fig. 7 Cusco speculum sche-
matic representation. Lower
valve opens more (red arrow)
than the superior (black arrow)
one as there is more pressure on
the anterior handle (blue arrow)
108
Fig. 8 Flat couch near the wall, mobile light source but not easily
adjustable
tation. Juniors are able to perform an abdominal and
transvaginal USS. There is a tendency that USS is
performed as part of the routine gynaecological examina-
tion. The adnexal pathologies are screened with USS
without a systematic and thorough VE before the USS.
Some gynaecologists perform the USS firstly before a VE.
However, the readily use of the USS can help in the
improvement of the VE skill. As the USS is performed by
the same doctor who performs the VE, it can help to
decrease false positive or negative findings and give more
confidence to the junior doctor about its VE skills. In the
UK, the use of USS during consultations is a double
problem because most of the gynaecologists do not have
intensive training as juniors for gynaecological USS, and
they do not perform the USS themselves. This means that
increased USS requests are often done by juniors inexpe-
rienced on VE, saturating the USS department with
appointments, provoking valuable time consumption for
both patient and ultrasonographer and sometimes over-
stressing the patient. Guidelines and protocols are more and
more introduced in hospitals to manage this problem.
Ergonomics is a notion that should be emphasised in
designing gynaecological consultation rooms. Examples of
inappropriate examination rooms that are currently used are
sown in Figs. 8, 9, 10, 11, and 12. For a flat bed
examination, appropriate source of light is essential to be
powerful with no dispersion of the beam, flexible and easy
adjustable. The couch or bed should not be installed near a
wall and therefore not allowing the examination of the
patient from both sides left or right. Some left-handed
gynaecologist find it very difficult to examine women with
their right hand if the examination couch is near the right
wall. There are numerous couches for comfortable exam-
ination with adapted stirrups or support for the feet. It is
true, however, that the flat examination bed is the cheapest
(Fig. 10). In the UK, the adjustable couches are reserved for
colposcopy clinics, as they are expensive. Not all gynaeco-
logical departments have their own rooms for outpatient
clinics. The consultations and VE are performed in general
Eur Clinics Obstet Gynaecol (2007) 3:103110
Fig. 9 Examination flat couch free from the wall, light source
attached from the sealing, no ergonomic examination possible
outpatient clinics where the rooms are common with other
departments. The bed-couch is static and flat without a
possibility for height modification. The same rules should
be applied for the flexible couch with stirrups including
space around the examination table, adjustable light source
and adequate instruments. The use of Graves, Sims,
Collins, Cuscos and modified speculums should be
mastered by the gynaecologist. The instruments should be
adapted to the needs of the patient and be available in
different sizes. The optimal set up of the examination rooms
is the responsibility of the local gynaecological directory,
but it depends from the financial budget of the hospital and
the financial priorities of each department. It is not a
personal responsibility to get the skill of the VE. Junior
gynaecologist and GPs should have intense training in VE
and verification of their findings by a nominated (and
trained for this purpose) gynaecologist and not just by a
more experienced colleague. Demonstrating initially a
systematic way to examine the patient and explaining how
to perform the VE and what manoeuvres to avoid is what
all junior doctors need initially. Using perineal models in
workshop laboratory (skill-labs) simulates conditions of
examination, and some novice doctors or students find that
this facilitates the life examination with less embarrass-
ment for both the junior and the patient. Some women
Fig. 10 Fixed flat couch (the cheapest set up), a torch between legs of
the patient will be used for light source
Eur Clinics Obstet Gynaecol (2007) 3:103110 109

Table 1 Views of 85 specialist registrars in gynaecology

VE methods, speculums and examination conditions Percent

Cuscos position
Handle up 75
Handle down 16.6
Both 8.4
Cuscos design
Handle up 52.7
Handle down 38.9
Either 8.4
Larger angle blade
Fig. 11 Adjustable on height bed near to the wall, light source not Superior 55.5
adjustable with dispersed beam light (light beam can not be focused) Inferior 36.1
Dont know 8.4
Knowledge of Collins
volunteer to help in the training by letting the juniors
Yes 5.6
examine them in specific training sessions [11]. In clinics, No 94.4
however, consenting the patient for a second VE by the Routine use of Sims
apprentice junior usually works and gives the opportunity Yes 8.4
for the trainee to verify the VE findings directly. Some- No 91.6
times, a patient during an examination helps more the Time for examination (in minutes)
junior by indicating exactly where to palpate. A good <5 75
example is a patient with rectovaginal nodules who can 5 to 10 25
>10 0
direct the VE palpation of the junior on the nodule areas.
The training of VE under general anaesthesia has been
criticised because it avoids communication skill develop- A questionnaire survey (in one of the most busy
ment between the patient and trainee. Furthermore, the deaneries of UK; total specialist registrar n=85) asked the
palpation force may be more intense, something that could trainees, for example, about VE methods, speculums and
not be practiced if the patient was awake, as it will provoke examination conditions (unpublished data from the author).
pain or greater discomfort. Asking the patients about the The overall results are shown in the Table 1. It seems clear
examination is not a sign of inexperience and lack of that most of them do not know how the Cusco speculum
confidence but respect and care for the patient. Question- was designed to be used; their examination lasts less than
naires of how the patients perceive such type of examina- 5 min and nobody knew the existence of Collin speculum.
tions have a great value. The overall perception of the ideal Specific questionnaires concerning the clinical part of
VE should be continually assessed. Apart from the patient the VE can be used in outpatient clinics to evaluate and
views, questionnaires concerning the quality of the exam- audit the basics VE skills of the juniors (see Table 2).
ination are of great importance and should be used and
audited regularly to maintain a high level of clinical skills. Table 2 Questionnaire about VE doctors performance

Clinical factors

Examination position side or semi-lithotomy

Adequacy of the light source
Back pain for examiner
Number of patients examined by session (during 34 h consultations)
Type of couch available
Couch placement in the examination room (stick on the wall or central)
Dominant hand used
Possible examination with both hands VE
Accuracy of VE in lithotomy position
Individual experience (years in gynaecology)
In which way the Cusco speculum is used
Knowledge about Cusco speculum design
Fig. 12 Examination couch behind the office-table of the doctor, Knowledge of Collins speculum
couch near to the wall, light source not adjustable, narrow space for Use of Sims or other speculum
the doctor between couch and desk, patient facing the window making Overall time of examination
her feeling more uncomfortable
110
This information can be valuable for the adequate
training of the GP and junior gynaecologists in the future.
This information can reflect how adequate the training and
support the juniors receive in outpatient clinics where they
work.
Audits and long-term validation of VE skills will
improve the womens health care in a primary and
secondary level.
Conclusion
Evidence-based medicine needs continuous assessment and
audit on the techniques that we use even for basic skills.
Few gynaecologists reflected on how to optimise VE and
basic gynaecological examination training at a postgraduate
level. European practice of VE is different. Knowledge of
the benefits and difficulties of each method is useful to
adapt the best method to the individual needs of the patients
and maintain comfortable examination conditions for both
gynaecologist and patient. Lack of scientific research on
VE examination method in postgraduate level is striking in
the literature. The validation of the examination skills
should take into account appropriate teaching standards and
outpatient clinics setting.
View publication stats
Eur Clinics Obstet Gynaecol (2007) 3:103110
References
1. Seehusen DA, Johnson DR, Earwood JS, Sethuraman SN, Cornali
J, Gillespie K, Doria M, Farnell E IV, Lanham J (2006) Improving
womens experience during speculum examinations at routine
gynaecological visits: randomised clinical trial. BMJ 333
(7560):171
2. Barr WB (2006) Vaginal speculum examinations without stirrups.
BMJ 333(7560):158159
3. Larsen M, Oldeide CC, Malterud K (1997) Not so bad after all...
womens experiences of pelvic examinations. Fam Pract 14:14852
4. Greiver M (2001) No stirrups? Can Fam Physician 47:1979
5. Doig A (2002) De facto evidence for the no-stirrup method. Can
Fam Physician 48:876
6. Olson BK (1981) Patient comfort during pelvic examination. New
foot supports versus metal stirrups. JOGN Nurs 10:104107
7. Dickinson JA (2006) Letter. Stirrups or no stirrups for routine
speculum examinationsbut we do not need to do a trial of smear
quality. BMJ 333:305
8. Menage J (1993) Letter. Womens perception of obstetric and
gynecological examinations. BMJ 306:11271128
9. Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K (2007)
Pelvic examination. N England J Med 356:e26
10. Mokate T, Abidogun K, Watson A (2006) The quality of smear
taking training for hospital medical trainees. Cytopathology
17:361365
11. Pickard S, Baraitser P, Rymer J, Piper J (2003) Can gynaecology
teaching associates provide high quality effective training for
medical students in the United Kingdom? Comparative study.
BMJ 327:13891392