Had a patient today for whom speculum insertion was extremely difficult. This is a common experience, especially if the patient is feeling anxious about their procedure. I welcome further tips, but there are a few things that have helped my patients that I'd like to share.

First, some patients already know that they have difficulty as well as what normally helps them, so don't feel compelled to reinvent the wheel if there is something that they already know can help. Listen first.

If they have had difficulty in the past but don't know what might help, ask if they would like to try inserting the speculum themselves. The vast majority of patients decline this offer, but knowing that that option is on the table might help them in the future.

If they decline self-insertion, I'll begin the process with trying to achieve ideal positioning. I usually ask my patients to come all the way down on the table "until you feel your back start to curve down over the edge." Tailbone on the edge seems to be ideal for most patients.

Having them in position, I then bring the footrests out to the side and ask them to allow their knees to fall as far apart as they can. This position helps to make relaxation of the pelvic floor an easier task.

This positioning also allows for the use of a smaller speculum than might be needed if positioning were less ideal. Smaller speculums also have the added benefit of bringing the cervix much closer to me during procedures, and also decreases uterine flexion, which is very helpful.

Context matters a lot, so I try to give my patient as much information as possible about what they may feel. While beginning insertion, if I feel resistance I simply hold steady pressure and allow the speculum to move inwards as the muscles relax ahead of it. I do NOT force it.

If the muscles are not relaxing after a minute or two (and I'm being literal here), then I'll ask the patient if they would like to help me with the insertion. I will bring their hand to the speculum and allow them to control the pressure while I gently guide it into position.

Remember that for most patients, posterior pressure is more comfortable than anterior pressure, so gently retracting downwards with the handle can often be beneficial.

If they continue to have difficulty, (if I haven't already) I will ask to perform an examination with two fingers inserted very slowly and gently. This is often easier for patients than a speculum and gives reassurance that the difficulty is functional rather than structural.

Once I'm comfortable that everything seems anatomically normal, it can sometimes help to ask the patient to try to squeeze the inserted fingers with their pelvic floor muscles. This can help them identify what muscles are causing them discomfort.

If they would like, practicing squeezing and relaxing these muscles with feedback from their examiner can help, or even offering them a glove so that they can feel themselves.

If all of these efforts are not enough, having them return another day with the assistance of anxiolytics or even moderate sedation may help. Reassure them that they are not being difficult. If they feel that you are patient and non-judgmental, that can only help.

Thank you to all who have added further suggestions, and I completely agree that this kind of a difficult exam should trigger questions about pelvic pain in other contexts or with sexual penetration. Referral for pelvic floor PT can be extremely beneficial to these patients.