A speculum is a medical instrument used during a Pap smear to gently hold the walls of the vagina open. This provides the healthcare provider with a clear view of the cervix, the lower, narrow part of the uterus that opens into the vagina. Its purpose is to allow the collection of cells for cancer screening, known as the Papanicolaou test or Pap smear. Understanding the mechanics of the speculum and the precise steps of the examination can help reduce anxiety often associated with the procedure.
Preparing for the Examination
The initial steps focus on optimizing the patient’s physical position and preparing the instrument itself. The patient is asked to position themselves in the lithotomy position, lying on their back with knees bent, hips flexed, and feet often resting in stirrups or on the examination table. This positioning allows the pelvic muscles to relax and provides the clinician with necessary access to the vaginal opening.
Selecting the appropriate speculum size is an important preliminary choice that directly affects patient comfort. Speculums come in various sizes, such as pediatric, small, medium, and large. The clinician chooses one based on the patient’s anatomy, influenced by factors like age or obstetric history. Once the correct size is chosen, the speculum is prepared by warming it, often by rinsing it under warm water, which prevents a cold shock that can cause involuntary muscle tension.
A water-based lubricant is applied sparingly to the exterior surfaces of the speculum blades, particularly the inferior or lower blade. While traditional teaching sometimes cautioned against lubrication, modern evidence confirms that a small amount of water-soluble gel significantly reduces patient discomfort without altering the results of liquid-based cytology or certain infection tests. The provider ensures all necessary sampling equipment, such as the cytobrush and spatula, is readily available before beginning the insertion.
The Insertion Procedure
The physical insertion begins with the clinician gently parting the labia with the non-dominant hand. The speculum, held in the dominant hand with the blades closed, is introduced into the vaginal opening. The instrument is inserted at an oblique angle, often around 45 degrees, toward the small of the back.
This oblique angle and the downward pressure, directed toward the posterior vaginal wall, helps the speculum follow the natural contour of the vagina. This technique also avoids the sensitive anterior wall and the urethra, which can be a source of significant discomfort if contacted directly. Once the closed speculum has passed the initial entrance, the provider removes the fingers and continues to advance the instrument fully.
When the tip of the speculum reaches the base of the cervix, the instrument is rotated to a horizontal plane, so the handle and the locking mechanism are facing upward. The blades are then slowly opened by manipulating the thumb lever or screw mechanism, which gently separates the vaginal walls. The blades are opened to bring the entire cervix into full view, avoiding excessive distension that can cause pain.
Once the cervix is centered between the blades, the speculum is locked into place using the mechanism on the handle, which secures the blades in the open position. The Pap smear sample is collected using a brush and spatula to gather cells from the outer surface and the canal of the cervix. After the sample collection is complete, the locking mechanism is released, and the blades are allowed to close slightly, but not fully, to prevent pinching the vaginal walls. The speculum is then gently and slowly withdrawn, often rotating it back to the oblique angle as it is removed.
Techniques to Ensure Comfort
Open and continuous communication from the healthcare provider is one of the most effective strategies for minimizing patient anxiety and discomfort during the procedure. The provider explains each step before it happens, giving the patient a sense of predictability and control over the process. Patients are often encouraged to focus on slow, deep breathing, which can help relax the pelvic floor muscles.
The choice of speculum material can also affect comfort. Plastic speculums are naturally closer to room temperature and provide a less jarring sensation than cold metal instruments. When appropriate, using the narrowest speculum possible, such as a pediatric size, can greatly reduce the pressure felt at the vaginal entrance. Some providers allow the patient to use their own hand to guide the speculum into the opening or to distract themselves with an object.
Patients can also advocate for specific positioning, such as placing a pillow under the hips to tilt the pelvis. This can make visualization easier for the clinician and reduce the need for excessive manipulation. The use of a small amount of lubricating gel, rather than just water, has been shown to significantly decrease the perception of pain during insertion. Ensuring the patient feels heard and involved in the process is paramount to a comfortable and successful examination.