Pelvic Exam Variations (5 Minutes):
The dorsal lithotomy position is generally used for pelvic exams, because it provides for good access to pelvis while inspecting the vulva, inserting a vaginal speculum, and performing a bimanual exam.
Because of illness or injury, some individuals cannot be examined in the conventional dorsal lithotomy position. Others may need to be examined in alternative positions due to special circumstances or location.
- A frog-leg position can provide for a very satisfactory exam.
- Elevating the buttocks with a pillow, rolled-up blanket, or bedpan facilitates the conventional placement of the speculum.
- When the buttocks cannot be raised, turning the speculum upside down can still allow for a good exam.
- The knee-chest position can be very useful, particularly with children. While the orientation of the pelvic structures is reversed, this is a manageable issue. The bimanual examination can also be performed in this position.
Some patients are unable to lie flat on their back. With the patient lying on her side, raising the upper leg allows for good pelvic access.
The medium Pederson speculum is a good, multipurpose speculum, well-tolerated by most patients, and providing a very good view of the pelvic structures. When the introitus is narrow, due to atrophy, the patient is tense, or virginal, the thin virginal speculum usually allows for a satisfactory exam.
For parous patients, the Graves speculum, with its’ broader blade, often gives better visualization of the vagina and cervix.
With vaginal prolapse, the lateral vaginal walls may obstruct your view of the cervix. In these cases, placing a condom over the speculum, with a hole cut in the tip will help keep the lateral vaginal walls separated. A latex glove with fingertip cut off can accomplish the same task. This technique can also be used during cryosurgery of the cervix to keep the vaginal walls away from the cryosurgical probe.
Particularly when inspecting the introitus, using only a single blade may provide better visualization. Simply disarticulate the speculum and use the unhinged blade.
Sometimes in isolated settings, vaginal specula are not available. In such cases, good use can be made of bent spoons to examine the vagina and cervix. If the bowl of the spoon is too large for the patient, the narrower handle of the spoon can be used instead.
Ultrasound is a very useful tool. It can reveal the presence of endometrial polyps, or ovarian cysts, or other gynecologic abnormalities. Ultrasound can also be used dynamically during a pelvic exam, providing more information than either alone. Using the vaginal ultrasound probe as though it were the examining fingers, the probe can mechanically lift structures toward the abdominal hand.
Alternatively, the abdominal probe can be used to identify structures coming in contact with the vaginal fingers.