BMJ  2006;333:158-159 (22 July), doi:10.1136/bmj.333.7560.158

Editorial

Vaginal speculum examinations without stirrups

US clinicians wonder if it will work

The pelvic examination using a vaginal speculum is one of the most common medical procedures performed by doctors and experienced by women. About 55 million smear tests are performed in the United States every year.¹ The article in this issue by Seehusen and colleagues is a provocative one for US clinicians, raising basic questions about how pelvic examinations are performed.² American medical schools uniformly teach a single way to position a woman for pelvic examinations—in the dorsal lithotomy position with feet in stirrups.^{3 4} The article raises the possibility that the standard use of stirrups may not be best for patients, and that other positioning options should be considered. Most clinicians I spoke with (admittedly, an unscientific sample) shared my initial reaction to the article's suggestion of performing a speculum exam without stirrups—how would that work? Given this reaction among providers of family medicine in the northeastern part of the United States, it is interesting—and somewhat surprising—to find that speculum examinations without stirrups are routine in the United Kingdom, Australia, and New Zealand.²

Seehusen and colleagues' well conducted randomised controlled trial shows that women who have speculum examinations without stirrups report less discomfort and feelings of vulnerability than do women who have examinations with stirrups. Overall, the study is of high quality with adequate randomisation, reasonable inclusion and exclusion criteria, adequate follow-up, and appropriate blinding of the investigators who recorded and reported the outcome measures.

Despite this strong methodology, the study has limitations. It does not fully consider the effect these alternative positions might have on clinical outcomes. Although the study was adequately powered to look for differences in patients' experiences, it was underpowered for assessing the adequacy of cervical specimens. The authors would have needed 382 patients (191 patients in each group) to have 80% power to detect a 50% difference in rates of cervical specimen adequacy. When this is combined with a slight trend towards an increase in inadequate cervical specimens in the no stirrups group, questions arise as to whether the use of the no stirrups position is as effective as the current US practice. In addition, the patients studied came from a somewhat homogeneous US military population, potentially limiting external validity for a more general and diverse population.

Even with these limitations, this article raises the question of whether US doctors who routinely perform speculum examinations should consider changing their practice to offer women a more patient centered option without stirrups. On the basis of my experience in another area of women's health, obstetrics, I am sceptical as to whether US doctors will change their behaviour to position patients in a way that is more comfortable for the patient, but perhaps less convenient for the doctor. Several studies, including a Cochrane review, indicate that there is clinical benefit and improved patient comfort if patients are allowed or encouraged to be in non-supine positions during the second stage of labour.^{5 6} Yet it is rare to see a US doctor use a non-supine position, both because these positions are often less comfortable for the doctor and because doctors are trained to deliver with the woman in a classic dorsal lithotomy position with the "bed broken" and her feet in stirrups. Many US obstetricians are concerned that these "difficult" non-supine positions without stirrups could become problematic if a shoulder dystocia develops or if an assisted delivery with forceps or vacuum is required, even though no medical evidence supports this belief.

When I discussed the article by Seehusen and colleagues with family medicine colleagues, their reactions were similar to those of many obstetricians on the issue of non-supine labour positions and keeping the birthing bed intact. Their concerns included ensuring sufficient space for the handle of the speculum and whether the speculum could be opened sufficiently for adequate visualisation of the cervix. And in contrast to the evidence of improved clinical outcomes with non-supine obstetric positioning, the study does not definitively answer similar questions for speculum examinations.

For US physicians to change patient positioning during pelvic examinations, additional randomised controlled trials will probably be necessary, both to determine if the quality of cervical specimens is different and to measure doctors' acceptance of this new technique. The trials would also need to provide more data supporting this study's outcomes of decreased patient discomfort and vulnerability in diverse patient populations. In addition, articles describing the examination techniques in detail will be needed—the article is unclear, for example, on how to avoid the speculum handle hitting the table when smaller patients are examined. (The video used by the investigators to train clinicians, available on bmj.com, will go some way towards meeting this.) Finally, this evidence will need to be published not only in primary care literature but also in gynaecology literature, since the vast majority of doctors learn their speculum exam techniques in medical school during their obstetrics and gynaecology rotations.

Beth Israel Residency in Urban Family Medicine, Institute for Urban Family Health, Albert Einstein College of Medicine, New York, NY 10003, USA
(wbarr{at}institute2000.org)

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Competing interests: None declared.

A video used for training in positioning techniques is on bmj.com

Research p 171

References

1. National Cancer Institute. The Pap test: questions and answers. 2003. www.cancer.gov/cancertopics/factsheet/Detection/Pap-test (accessed 1 Jul 2006).
2. Seehusen DA, Johnson DR, Earwood JS, Sethuraman SN, Cornali J, Gillespie K, et al. Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial. BMJ 2006;333: 171-4.[Abstract/Free Full Text]
3. Berek JS, Novak E. Novak's gynecology. Philadelphia: Lippincott Williams and Wilkins, 2002.
4. Bates B. A guide to physical examination and history taking. Philadelphia: Lippincott, 1995.
5. DeJonge A, Teunissen TAM, Lagro-Janssen ALM. Supine position compared to other positions during the second stage of labor: a meta-analytic review. J Psychosomatic Obstet Gynecol 2004;25: 35-45.[CrossRef]
6. Gupta JK, Hofmeyr GJ. Position for women during second stage of labour. Cochrane Database Syst Rev 2004;(1):CD002006.

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Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial

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