All of these concerns emphasize the need for a periodic review of a patient's sexual function. I have found that women who have vaginismus experience difficulties in undergoing any type of pelvic examination in the dorsalis lithotomy position and, therefore, should be examined in an alternative position. Patients feel in a compromised position at this time, especially because they cannot see the examination of the perineal area. I have my patients stand while I perform a bimanual examination and try to feel for Bartholin's gland enlargement, prolapse, cystocele, rectocele and tightening of the vaginal muscles on digital insertion. In this way, the patient is standing and feels that she is in more control.
Patients can also squat during the initial part of the pelvic evaluation.
Once they are comfortable with these positions, they can be examined in the dorsalis lithotomy position. It may not allow total visualization of the vaginal vault and cervix, but it will again reinforce to the patient that you will not be harming her during the pelvic examination. The size of the speculum can gradually be increased as the patient becomes more comfortable with the pelvic examination. Often, patients do not feel comfortable discussing sexual problems the first time the physician attempts to obtain a sexual history. However, I have found that many patients remember that their practitioner is open to discussing their problem.