Assess the Support of the Vaginal Walls. With the labia separated Bulging from a cystocele or recto-by your middle and index fingers, ask the patient to strain down. Note any cele. See Table 11-2, Bulges and bulging of the vaginal walls. Swelling of Vulva, Vagina, and Urethra (p._).
Insert the Speculum. Select a speculum of appropriate size and shape, and lubricate it with warm water. (Other lubricants may interfere with cytologic studies and bacterial or viral cultures.) You can enlarge the vaginal in-troitus by lubricating one finger with water and applying downward pressure at its lower margin. (You may also wish to check the location of the cervix to help angle the speculum more accurately.) Enlarging the introitus greatly eases insertion of the speculum and the patient's comfort. With your other hand (usually the left), introduce the closed speculum past your fingers at a somewhat downward slope. Be careful not to pull on the pubic hair or pinch the labia with the speculum. Separating the labia majora with your other hand can help to avoid this.
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