I would like to comment on Dr. Bachmann's editorial1 about the importance of obtaining a sexual history. Dr. Bachmann discusses the difficulty, at times, in performing a proper vaginal examination with the patient in the usual lithotomy position, mainly because of patient resistance. There is another examination position that is rarely used in the United States—the Sims position, using a Sims speculum (although described and invented by the American surgeon, Dr. Marion Sims, it is used mainly overseas).
I was taught this technique while an American medical student in Australia during the early 1950s. It is especially useful for noting cystocele, rectocele and uterine prolapse. This technique is illustrated in Pye's Surgical Handicraft.2 The patient lies in the Sims position, the Sims speculum is introduced easily laterally and the vagina falls open—the entire anterior wall and both lateral walls are fully revealed. Rotating the speculum reveals the posterior wall, together with the lateral walls again. Bartholin's gland is easily palpated, and cervical smears are easily obtained.
The advantages of this technique are (1) less embarrassment for the patient, (2) better visualization of all of the vagina, (3) better visualization of the cervix for biopsy or smears, (4) easily palpated glands and (5) visualization of cystocele, rectocele and uterine prolapse and degree thereof.
I truly wish this method would be taught and reintroduced into the country of its origin. Examination in the lithotomy position with the patient's feet in stirrups seems to be designed for the advantage of the examiner with little consideration for the patient.
in reply: I concur with Dr. Schnur's plea for considering other positions to fully evaluate the pelvis of women; however, like all techniques in medicine, the examiner must be familiar and comfortable in examining the patient in the position he or she uses. Good mentoring for performing the gynecologic examination in different pelvic positions is usually lacking in the United States.
Regardless of the examination position, however, it is critical that the pelvic examination remains an integral part of the general health check-up for every woman. The examiner must be knowledgeable not only in the technical aspects of how to perform a pelvic examination but also must be aware of the distress and fear the examination often evokes in the patient and be responsive to this. As an obstetrics and gynecology resident during the 1970s, I read an excellent piece on the pelvic examination that serves as a great reminder of how sensitive we as physicians must be when performing a pelvic examination.1