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
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
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A frog-leg position can provide for a very
- Elevating the buttocks with a pillow,
rolled-up blanket, or bedpan facilitates the conventional placement of the
- 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.