Female Pelvic Examination OSCE — Speculum, Bimanual, and Cervical Smear Guide

Why This Station Is Tested

Pelvic examination is a core gynaecological skill tested in OSCEs at most UK medical schools. It assesses procedural competence, communication skills, and the ability to maintain patient dignity. In exam conditions this is typically performed on a model, with a simulated patient and examiner watching your communication and technique.

Before You Begin — Preparation

Speculum Examination

1. 1Warm the speculum — run under warm water or check temperature on your wrist
2. 2Part the labia gently with your non-dominant hand
3. 3Insert at 45° (oblique angle) then rotate to horizontal as you advance
4. 4Open the blades slowly until the cervix comes into view
5. 5Inspect the cervix: colour, os shape (nulliparous/parous), ectropion, discharge, lesions, polyps
6. 6Take samples if indicated: cervical smear (ectocervix/endocervix), high vaginal swab, endocervical swab
7. 7Close blades before removing — do not close on cervical tissue
8. 8Remove slowly at 45° as you withdraw

Bimanual Examination

1. 1Apply lubricant to gloved index and middle fingers
2. 2Insert two fingers into the vagina (palm upward)
3. 3Locate the cervix — assess: consistency (firm = normal; soft = pregnancy), mobility, and cervical excitation (pain on moving the cervix = positive — suggests PID or ectopic)
4. 4Place external hand suprapubically and press down to meet internal fingers
5. 5Assess the uterus: size, shape, position (anteverted/retroverted), regularity, tenderness
6. 6Assess adnexa: sweep fingers laterally to each fornix — note any masses, tenderness (adnexal tenderness = PID, ovarian cyst, ectopic)

Common Findings and Significance

Cervical Smear (Cervical Screening)

• Use a Cervex-Brush (broom device) — insert central bristles into the os, rotate 5 times clockwise
• Transfer sample to liquid-based cytology (LBC) vial — rinse brush into vial and agitate
• Label correctly and complete request form
• Explain the process to the patient beforehand and results timing (~2 weeks)

Mark Scheme Checklist

• ✓Introduces self, checks identity, gains consent
• ✓Offers and documents chaperone
• ✓Correctly positions and drapes patient
• ✓Selects appropriate speculum and warms it
• ✓Inserts speculum at correct angle, opens blades, identifies cervix
• ✓Inspects cervix systematically and describes findings
• ✓Performs bimanual examination: uterus and adnexa
• ✓Assesses cervical excitation
• ✓Communicates throughout, checks comfort
• ✓Maintains dignity throughout
• ✓Disposes of equipment safely

Common Mistakes

• Forgetting to offer a chaperone before starting
• Using cold lubricant or speculum without warming
• Failing to rotate speculum on insertion
• Not assessing cervical excitation during bimanual
• Closing speculum blades before fully withdrawing
• Failing to explain each step before doing it

Frequently Asked Questions

"What is cervical excitation and why is it clinically important in an OSCE?"

Cervical excitation (also called cervical motion tenderness or chandelier sign) is elicited during bimanual examination by gently moving the cervix from side to side. A positive result — pain on cervical movement — indicates inflammation or irritation of the pelvic peritoneum adjacent to the cervix. It is a key sign of pelvic inflammatory disease (PID) and is also present in ectopic pregnancy. In an OSCE, you must demonstrate you know how to elicit it and interpret it: if positive, state "This is consistent with PID or ectopic pregnancy — I would request a pregnancy test, FBC, CRP, and pelvic ultrasound."

"When should you use a small vs standard speculum?"

Speculum size selection should be based on the patient's anatomy and history: use a small (Cusco's) speculum for nulliparous patients, those with a history of vaginismus, post-menopausal patients with vaginal atrophy, or where insertion is difficult. A standard medium speculum is appropriate for most parous patients. In an OSCE, stating your reasoning aloud ("I'll use a medium speculum as the patient is parous and has had no previous difficulties") demonstrates clinical thinking and gains marks for communication.

"What is the difference between an ectropion and cervical carcinoma on speculum examination?"

Cervical ectropion (previously called erosion) is the normal presence of columnar epithelium on the ectocervix — it appears as a red, velvety area surrounding the os that bleeds easily on contact. It is a benign, common finding (especially in those on the combined pill or pregnant) and requires no treatment unless symptomatic. Cervical carcinoma may present as an irregular, cauliflower-like lesion, ulceration, or contact bleeding — it is firm and friable. Any suspicious cervical lesion should prompt urgent referral under the 2-week wait pathway, not reassurance.

"How do you perform a cervical smear correctly in an OSCE?"

Insert the central bristles of the Cervex-Brush into the cervical os until the shorter outer bristles are flush with the ectocervix. Rotate the brush five times clockwise — this samples both the ectocervix and the transformation zone. Immediately rinse the brush into the liquid-based cytology (LBC) vial by pushing it to the bottom and rotating 10 times, then discard the brush. Label the vial with the patient's name, DOB, and date. Explain to the patient that results take approximately 2 weeks and that they will be contacted by letter.

"What must you say at the start of a pelvic examination station to score maximum marks?"

The opening sequence that scores highest on mark schemes is: introduce yourself by name and role, confirm the patient's name and date of birth, explain what the examination involves and why it's being performed, obtain verbal consent, offer a chaperone (document whether accepted or declined), and ask about relevant history (last menstrual period, any pain or discharge, previous gynaecological procedures, possibility of pregnancy). This sequence takes under 60 seconds and is worth a disproportionate number of marks — candidates who rush straight to the examination consistently lose marks even when their technique is good.

"What is the difference between a bimanual examination finding of a bulky irregular uterus vs a smooth enlarged uterus?"

A bulky, irregular uterus with a firm, lobulated contour suggests uterine fibroids (leiomyomata) — the irregularity reflects the nodular fibroid masses. A smooth, uniformly enlarged uterus in a woman of reproductive age suggests either pregnancy (soft — Hegar's sign), adenomyosis (tender, symmetrically enlarged, especially premenstrually), or a large fibroid without surface irregularity. Adnexal masses felt separately from the uterus suggest ovarian pathology. Always correlate with menstrual history and pelvic ultrasound — bimanual examination has limited sensitivity and specificity in isolation.

Related guides: Gynaecology and Obstetric History OSCE · Consent and Capacity OSCE · Breast Examination OSCE · Sexual Health History OSCE