Vaginal Specula in the ED… Why, When and How

Authors: Madeline Payne / Editor: Charlotte Davies / Codes:  / Published: 24/05/2022

We have a reluctance to perform speculum and vaginal examinations in the ED, despite the “lost condom” being a regular MRCEM OSCE station. Many times our hesitancy is justifiable, but here are a few considerations for why ED practitioners should all be comfortable at performing speculum examinations and bimanual examinations. It could be life saving.


No-one likes a speculum or bimanual examination, doctors included, but sometimes you just have to accept the inevitable. As a general rule, as with anything else, its going to be worth doing if it will change immediate management, fix the problem completely or help to stabilise the patient.

Cervical shock

Cervical stimulation or stretching can produce a vasovagal response with bradycardia and hypotension. If the stimulation is not removed, this can cause circulatory compromise. As it requires something to be in the os of the cervix, rather than in the canal, the most common scenario would be during a miscarriage with products of conception getting stuck.

Heavy PV bleeding in pregnancy with haemodynamic instability

Late term miscarriages are more likely to bleed heavily, as are patients on anticoagulation (unsurprisingly). If a patient is bleeding heavily and is beginning to decompensate, you may be able to stop/slow the bleeding if youre able to remove clots and any visible products of conception which will cause ongoing bleeding until removed.

Foreign bodies

The classic PV FB would be a stuck tampon or condom, although as with rectal FBs you never quite know The first thing to consider is that theres a decent chance its not there, and the patient will usually have already had a good feel, with ED likely to be their absolute last resort. If they havent tried to remove it themselves for whatever reason, you could consider asking them to go to the patient toilet themselves and having a go, with reassurance that this is safe.


  • If you do not feel confident/comfortable performing a speculum examination
  • If the patient doesnt consent
  • If there is any question of sexual assault that may require forensic evidence to be taken (unless the patient is unstable and it is clinically indicated)


  • Lube – lots of lube!
  • PPE (especially gloves)
  • Speculum
    • The specula in ED are generally the single use plastic double-bladed ones – make sure you know how to open the speculum and how to screw it open before going anywhere near the patient (its not terribly reassuring for the patient if you have to stop halfway through to mess around and work out how to use the equipment) Open vaginal speculum
      • They most commonly come in three sizes (although only medium may be available) – the medium size should be fine for the majority of women.

Closed vaginal speculum

  • Forceps
    • Preferably polyp/sponge holding forceps as they have a wider end, or long Spencer Wells artery forceps also work anything long with interlocking handles.
  • Light source
    • Ideally a lamp but pen torch will do
  • Specimen pot
    • Youll need something to put any products of conception or foreign bodies into if removed
  • Lots of gauze
  • Paper towels to clean up after
  • ?swabs
    • If youre thinking infected retained tampon and youre doing the speculum exam anyway, you might consider doing a high vaginal swab (usually the same swabs as wound swabs) to send for MCS
    • If the patient is concerned about STIs, they should really be re-directed to local sexual health services instead
  • Chaperone
    • Preferably female
    • Make sure you explain what youre going to do to your chaperone as well – its hard to re-direct the light source or open the swabs yourself once youve started examining, so having someone who knows what theyre doing or who has done specula before themself is a bonus


  • Ideally, any intimate examination would be done in a private room (preferably with a lock!) but we all know that thats a challenging prospect in ED
  • If you have to use a cubicle, one top tip is to turn the trolley around so that the patients head is towards the entrance – that way if youre interrupted, at least some of their dignity is preserved.
  • Make sure you explain what youre going to do very carefully before you go anywhere near the patient, including digital examination if youre planning to do this.
  • Make sure you know whether theyre pregnant or not.
  • Dont assume they have had a speculum examination before, and remember that theres a lot of stigma/horror stories about vaginal examination so lots of reassurance may be needed.
  • Once the patient has consented to the examination, ask them to remove their bottoms and underwear and lie on the bed (covered with the second sheet), and leave the room to give them some privacy.
  • Make sure theyve been to the loo if needed.
  • Make sure the second sheet is covering them as much as possible too, particularly while still preparing your equipment.
  • If youre anticipating any bleeding/discharge/removal of objects, put an inco pad under the patient and have some more handy.



  • Positioning
    • Put the trolley up to a height thats comfortable for you and your back, and make sure you can stand on the side of the patient that corresponds to your dominant side (ie. if youre left handed and will be holding the speculum in your left hand, stand on the patients left
    • Ask the patient to lie flat (or as flat as able), with the back of the bed/trolley down
    • Ask them to bend their knees as much as possible, and keep their feet together
    • Once the knees are bent, get them to open the legs whilst keeping their feet together and drawn as far up as possible
    • Its easiest to explain it as something like bring your feet up to your bum as far as possible and then let your knees flop open
  • Basic speculum technique
    • Start with external examination, including any signs of FGM (female genital mutilation), any ulcers or any other abnormalities
    • Gently part the labia with your non-dominant hand and insert the speculum closed with the blades perpendicular to the bed using your dominant hand.

      Fig 1 Female perineum1

      • Once inserted, turn the speculum so the handle is pointing up and the blades are parallel to the bed
      • Reassure the patient and encourage relaxing breathing and relaxation if needed.
      • Slowly open the speculum (make sure you warn the patient first!) and adjust until the cervix is visible and central
      • Turn the screw on the speculum clockwise until the blade position is fixed – this will free up the dominant hand if needing to remove things
      • Once youre done, SLOWLY loosen the screw holding the speculum open and gradually withdraw. If you close the speculum too quickly, its very easy to catch the cervix between the blades which is incredibly uncomfortable for the patient.
      • This is summarised well on Geeky Medics.
  • What you might see
    • Cervix should be smooth, os may be round or slit depending on parity

      Round os, slitted os

Fig. 2 Cervix birth2

    • Other stuff you may see:
      • Ectropion
        • This is the spread of the inner cervical epithelium to the external cervix. It looks like a redder rougher area around the os, and may bleed on contact.
        • Ectropion is common and benign. It is more likely in women on hormonal contraception, who are pregnant, or who are closer to menarche.
      • Coil strings
        • These are to be expected if someone has an IUD in – if you cant see them and the patient has told you they have a coil, they will need to see a GP/GUM clinic for a coil check
        • They look like bits of wire coming from the os – usually there will be two
        • Colour can vary but is generally white or black.
      • Discharge
        • Discharge is normal! Everyone will have some physiological discharge, which is usually whitish or pale yellow
        • Other discharge differentials:
          • Smelly/watery/grey: bacterial vaginosis
          • Thick/lumpy/cottage cheese: vaginal candidiasis/thrush
          • Purulent, especially around os: cervicitis (chlamydial or gonorrhoeal)
          • Smelly/brown/excessive in the context of retained foreign body: likely to be infected
      • Anything else: if you have any concerns or just arent sure what youre seeing, advise the patient to see their GP or consider referring to colposcopy/2WW depending on local protocols and the specific case context


  • Removal of objects
    • Make sure you get a good view of the whole vagina, including the cervix and the posterior fornix (the bit under/behind the cervix)
    • If you have a clear view of what youre trying to remove, you can just grab it with forceps and gently pull it out.
    • If they have an IUD in, try not to pull it out.
    • If there is a retained tampon (or any other object thats been there a while), be prepared for the smell
  • Heavy bleeding
    • If theres a lot of clots obscuring the view of the cervix, you can remove any clots in the canal with forceps and gauze to get a good look at the cervix.
    • If anything looks like tissue (more rough texture, anything that doesnt just look like blood), try and remove separately into a histology pot.
    • If the clots are large, gently pull them out with the forceps (theyll break if you try to grab them)
    • Remember to try and keep track of clots/blood removed for an overall estimated blood loss figure.
  • Products of conception
    • If you can see anything that looks like POC, be as gentle as possible in pulling out the tissue – if it breaks and part is retained in the cervix or uterus, you may cause more issues
    • If POC is stuck in the cervix and the patient has signs of cervical shock, try and gently pull it out without further cervical stimulation – this might be hard, and may require an urgent call to gynae if the patient is decompensating
    • You can also try sweeping the cervix with gauze to see if that helps move things
  • Digital examination for foreign bodies
    • If youre unable to visualise a foreign body but have a high level of concern that something is there, you can do a bimanual/digital exam (EPV)
    • In a patient who is very anxious or who hasnt been sexually active, this may also be more comfortable as the initial port of call, although it obviously doesnt allow for visualisation
    • Put on sterile gloves, and apply plenty of lube to the first two fingers of your dominant hand
    • Gently insert two fingers into the vagina and feel for the cervix
    • Feel around cervix and sweep the fornices for any objects. Note any cervical excitation (very tender cervix) or adnexal tenderness which could point to PID
    • For a full bimanual, perform abdominal palpation at the same time and feel for adnexal masses or tenderness – probably not strictly necessary if youre just trying to remove an object


  • If youre struggling to visualise the cervix, ask the patient to make a fist with both hands and put them in the small of their back – this should tilt the pelvis and can bring the cervix into view
  • A classic tactic is to ask the patient to cough as youre putting the speculum in as it can help the pelvic muscles relax and make it more comfortable for the patient. Asking the patient to cough and therefore increase intraabdominal pressure can also sometimes help with expelling clots or POC.
  • Make sure youre comfortable check the bed is high enough and that youre standing on the side of the patient that will allow you to use your dominant hand.



A check of the BASHH guidelines and even a general Google search doesnt actually give a definitive answer on when to give antibiotics following a vaginal retained foreign body. If there is any evidence of infection (excessive discharge, smell, fever, abdominal pain etc.), the consensus seems to be to give antibiotics, probably something with broad cover like co-amoxiclav. Any patients with retained foreign bodies should be safety netted regarding infection.

GUM/sexual health follow up

If a patient has had a retained condom, they should be managed as someone who has had unprotected sexual intercourse, including a risk assessment for PEPSE and any need for emergency contraception. They should also be advised to have an STI screen, and safety netted for signs of STIs, as well as infection secondary to the retained condom.


Heavy bleeding should improve with clot removal if the os is closed – if the os is still open, gynae referral may be appropriate as this indicates ongoing miscarriage. If the os is closed and patient stable, you may be able to discharge with Early Pregnancy or equivalent follow up.

Handling of products of conception

Products of conception are defined as any tissue that has developed from a pregnancy. Different hospitals have different guidance and regulations regarding management and disposal of POC. Legally, this is managed by the Human Tissue Authority, which states that a conversation must be had with the patient and carefully documented regarding disposal of remains (as long as the pregnancy did not progress past 24/40) and consent for any histological examination of POC as per local protocols. There may be forms or hospital-specific rules on this (e.g. a specific form to be filled in with consent for histological examination followed by communal cremation of remains).


  • Parity – in the form Gx Py where G is gravidity (number of pregnancies including any current) and P is parity (number of live births). Bonus marks for giving method of delivery for any children and outcomes of any other pregnancies.
  • Basic gynae history including last menstrual period (LMP), last smear test if eligible and any history of abnormal smears, and any contraception being used
  • Indications for admission that they might consider:
    • Is the os open – this is one of the most important questions as it will guide management, but unfortunately can be hard to answer, particularly if you dont do speculum examinations very often
    • Is the patient haemodynamically stable – are they tachycardic/hypotensive/have there been any syncopal/pre-syncopal episodes?
    • Has the Hb dropped?
    • Is there ongoing bleeding or severe pain?
  • Unless a patient is unwell/youre suspecting PID or TSS, most patients who have had a foreign body removed shouldnt need to see gynae.

Hopefully that’s provided some useful tips and suggestions for you. Add your tips in the comments!

For more RCEMLearning gynae content why not visit our induction module on gynae and bleeding in early pregnancy, and the linked sessions for ObP1 – ObP7 and ObC1 – ObC19 on the syllabus page.


  • Female perineum. staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). Wikimedia Commons.
  • Cervix birth. CFCF. Wikimedia Commons, 2014.

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