Today I want to talk about the use of speculum exams in the emergency department. A recent post on Life in the Fastlane discussed this topic and questioned whether there is much valuable information to be gained, and whether that warrants doing an invasive procedure. The post laid out a stringent set of presentations that definitively require a speculum exam in the ED. Those presentations are;
Cervical shock – vaginal bleeding with associated hypotension and bradycardia. This is due to products on conception stuck in the cervix, and causing a vagal response. Removing these products will reverse the shock.
Heavy PV Bleeding – similar idea as above, remove clots or products of conception, in this instance to encourage the uterus to contract and slow bleeding.
Suspected vaginal foreign body – this is obvious. These need to be removed to prevent infection and potential toxic shock syndrome.
The article goes on to argue against doing speculum exams in certain presentations. Here are the instances it argues against speculum exams;
Light bleeding in early pregnancy – speculum exam does not rule out ectopic and ultimately that is the priority over whether something is a threatened vs inevitable miscarriage. Imaging and likely follow up will be necessary in these patients regardless of speculum exam.
Suspected PID or torsion – suspicion of either of these diagnoses will require further testing, rendering the examination superfluous. Some combination of imaging, swabs, or empiric treatment will all be necessary regardless of pelvic examination.
A prospective cohort study in 2011 surveyed providers in the emergency department to ask whether pelvic examination changed management plans or not. 171 of the 187 patients (91%) in this study did not have a change in clinical plan before and after pelvic examination.
While neither of these articles are arguing against speculum examinations as an important tool for emergency providers, they are arguing against speculum examinations for all female patients with lower abdominal pain. The procedure is invasive, time intensive given space limitations, and some of the actual exam findings (adnexal tenderness) are nonspecific and will require imaging or other testing anyways. Should we as a practice reexamine the clinical use of this procedure? Should our threshold for doing speculum examinations be higher?
Brown J, Fleming R, Aristzabel J, Gishta R. Does pelvic exam in the emergency department add useful information? West J Emerg Med. 2011 May;12(2):208-12. PMID: 21691528; PMCID: PMC3099609.
Mackenzie, J., & Beech, A. (2024, January 11). Procedure: Speculum examination. Life in the Fast Lane • LITFL. https://litfl.com/procedure-speculum-examination/