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Speculum examination

6 steps1 video

Seeing the cervix and vaginal walls: for screening, discharge, bleeding, rupture of membranes and the cervix in labour by inspection.

Speculum examination (OSCE guide)Geeky Medics on YouTube
A Cusco bivalve speculum, closed, seen from the side

Consent and trauma-informed practice

  • Explain what the examination involves, why it is proposed, and what the alternatives are, in plain language, before anyone undresses.
  • Ask for permission, and make clear the patient can stop at any point, by saying so or by raising a hand. Stopping is honoured immediately, without persuasion.
  • Offer a chaperone and record the offer and the response; a student never examines without the supervising clinician present and the patient's specific agreement to the student's involvement.
  • Privacy: a door that locks or a sign, a sheet, undressing only what is needed, time to undress and dress alone.
  • Trauma-informed: assume a history you have not been told. Explain each step before it happens, keep talking, avoid sudden touch, ask about pace, and notice dissociation or distress and pause.
  • Never examine a patient under anaesthesia for teaching without their specific prior consent to that examination.

The sequence

6 steps
  1. 01

    Inspect the vulva

    Skin, discharge, lesions, atrophy, prolapse with a cough.

  2. 02

    Insert

    Part the labia, insert the closed speculum obliquely then rotate to horizontal, angled slightly downward towards the sacrum, following the vaginal axis, with gentle steady pressure on the posterior wall and away from the urethra.

  3. 03

    Open

    Open the blades slowly to bring the cervix into view; adjust depth and angle rather than opening wider. Lock the screw only once the cervix is seen.

  4. 04

    Look

    The cervix: os shape (round in nulliparous, slit in parous), ectropion, polyps, lesions, contact bleeding, discharge from the os, threads. The vaginal walls on withdrawal.

  5. 05

    Sample

    Screening sample from the transformation zone; swabs from the endocervix or vaginal wall as needed.

  6. 06

    Withdraw

    Unlock, close the blades partly while withdrawing so the cervix is not pinched, rotate back obliquely, and withdraw gently.

Indications

  • Cervical screening
  • Vaginal discharge or bleeding: source and character
  • Suspected rupture of membranes (sterile speculum, pooling)
  • Cervical assessment by inspection, IUD thread check, foreign body

Preparation

  • Consent as below; empty bladder; lithotomy or a position the patient prefers (left lateral is an alternative)
  • Choose the speculum size (a small Cusco for nulliparous or postmenopausal patients); warm it; water-based lubricant on the blades (small amounts do not affect cytology)
  • Good light; swabs and screening equipment ready before starting

Complications

  • Discomfort, particularly with atrophy or vaginismus: a smaller speculum, lubricant, and time
  • Contact bleeding from an ectropion (benign)
  • Pinching the cervix or vaginal wall on withdrawal

Watch for

  • A cervix that cannot be found: it is usually posterior; withdraw slightly and angle down
  • Any lesion, ulcer or friable area: describe it and refer for colposcopy or biopsy, never screen it

More to see

A sagittal diagram of the pelvis with a speculum in place, blades open to show the cervix
A cervix seen through a speculum with a small round os
A nulliparous cervix seen through a speculum, with a red ring of columnar epithelium around the os, an ectropion

Sources

  • Canadian Task Force on Preventive Health Care / provincial programmes: Cervical cancer screening recommendations and provincial HPV-based screening programmes (2025).

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