Graves Speculum
Bivalve ("duckbill") vaginal speculum — the standard workhorse vaginal speculum for routine pelvic examination, cervical visualization, Pap smear collection, IUD insertion, colposcopy, and most office gynecologic procedures. Two wide curved (concave) blades joined at a hinge with a thumbscrew lock; opens into a broad cylindrical opening with a large viewing window at the cervix. Named for William P. Graves, the early-20th-century Boston gynecologist who described this design — not Robert James Graves of Graves' disease fame, who was a physician rather than a gynecologic surgeon.[1][2]
The Graves and the Pedersen speculum together comprise the dominant pair of office vaginal specula; the choice between them is one of the most fundamental selection decisions in gynecologic and urogyn practice.
Design
- Two wide curved (concave) blades joined at a hinge — wider and more rounded than the Pedersen.
- Thumbscrew or ratchet lock at the handle — holds the blades open at the chosen separation; the speculum is self-retaining without continuous manual pressure.
- Multiple sizes: small, medium, large, extra-large.
- Material: reusable stainless steel or single-use disposable plastic.[3]
- Wide cylindrical opening at the distal end creates a large viewing window for cervical visualization and instrument passage.
Reconstructive-Urology and Urogyn Uses
The Graves is the office and procedure-room default for urogyn work whenever the patient's anatomy supports a wide-blade fit:
Office urogyn examination and screening
- Routine pelvic examination in the urogyn / reconstructive-urology clinic — assessment for cystocele, rectocele, vault prolapse, vaginal-mucosa atrophy, mesh exposure, suture extrusion.
- Cervical cancer screening (Pap, HPV) — the standard instrument for cervical-cytology sampling.[4]
- Colposcopy — detailed examination of the cervix, vagina, and vulva.
- Mesh-exposure / mesh-erosion evaluation — the wide viewing window facilitates inspection of the entire vaginal vault after mesh procedures.
- Vaginal-cuff inspection after vaginal hysterectomy / sacrocolpopexy / sling procedures.
- Urethral examination — anterior-wall inspection during workup for urethral diverticulum, fistula, caruncle.
Office procedures
- IUD insertion and removal — the wide viewing window facilitates os visualization.
- Endometrial biopsy — for access to the cervical canal in the urogyn-adjacent workup of postmenopausal bleeding.
- Cervical biopsy, LEEP, cryotherapy, polypectomy — adjunctive office gyn during pelvic-reconstruction workup.
- Vaginal pessary fitting and management — placement, removal, and inspection during prolapse management.
- Periurethral and vestibular biopsy — anterior-wall and vestibular tissue sampling.
- Office cystoscopy in some workflows — the speculum is used to expose the urethral meatus before flexible cystoscope passage.
- Office bulking-agent injection for SUI under direct vision.
Operative adjunct
- Brief vaginal-canal inspection during operative urogyn workflows — initial exposure before transition to operative retractors (Auvard weighted speculum, Sims, Breisky-Navratil, or self-retaining systems).
Graves vs Pedersen — The Choice
| Feature | Graves | Pedersen |
|---|---|---|
| Blade profile | Wider, more rounded / concave | Narrower, flatter |
| Opening | Wide cylindrical | Narrower, slit-like |
| Best patient | Multiparous, routine adult exam, wider vaginal caliber | Nulliparous, adolescents, postmenopausal atrophy, narrow introitus |
| Cervical visualization | Excellent — wide field | Adequate; may require more manipulation |
| Patient comfort | More discomfort in nulliparous / atrophic | Generally better for narrow introitus |
| Best urogyn use | Multiparous prolapse-and-incontinence patients (the majority of urogyn) | Postmenopausal atrophic patients, virgo intacta evaluation, adolescents |
ACOG recommendation: speculum selection is determined by pubertal status, hymenal opening, and sexual experience. For adolescents, the narrow Pedersen or Huffman speculum is typically preferred. For multiparous adults, the Graves is the routine default.[6]
For the postmenopausal urogynecology patient with vaginal atrophy — a substantial fraction of the urogyn clinic population — the Pedersen is the more comfortable and often the more appropriate choice even though the patient is parous.
Graves vs Other Specula
| Feature | Graves (bivalve) | Pedersen (bivalve) | Sims (single blade) | Huffman |
|---|---|---|---|---|
| Blades | 2 wide curved | 2 narrow flat | 1 (retractor) | 2 very narrow |
| Self-retaining | Yes (thumbscrew) | Yes (thumbscrew) | No (handheld) | Yes |
| Best fit | Routine adult exam | Nulliparous / atrophic | Lateral-position exam, surgical vaginal retraction | Virginal / pediatric |
| Position | Lithotomy | Lithotomy | Left lateral decubitus | Lithotomy |
For operative gynecology (D&C, hysteroscopy, vaginal surgery), the Auvard weighted speculum replaces the bivalve specula because the unobstructed anterior working channel matters more than circumferential retraction.
Practical Tips for Use
Evidence-based techniques for maximizing patient comfort during speculum examination:[5]
- Careful size selection by patient anatomy.
- Water-based lubrication — does not interfere with cytology; significantly improves comfort.
- Warm the speculum before insertion (running under warm water or using a speculum warmer).
- Oblique-angle insertion with rotation — insert at a 45° angle relative to the vertical, rotate as the speculum advances.
- Verbal coaching — communicate each step before performing it.
- Sheathed speculum modification — ~ 22% improvement in cervical visualization vs standard plastic specula without increased pain (Hill 2014).[7]
Limitations
- Discomfort in narrow / atrophic introitus — switch to Pedersen / Huffman / small Graves.
- Anterior blade obstruction during cervical-instrument passage — switch to a single-blade Sims or, for operative work, the Auvard weighted speculum.
- Cervical cancer / mesh / fistula evaluation in deep narrow vagina — may not reach the apex; switch to a long Graves, narrow Pedersen with anterior retractor, or operative speculum.
- Pediatric / adolescent / virgo intacta — Huffman or vaginoscopy preferred.
Historical Context — William P. Graves
William P. Graves was an early-20th-century Boston gynecologist whose bivalve speculum design became the standard office gynecologic instrument across the English-speaking world. The instrument is not named for Robert James Graves (1796–1853) of Graves' disease — Robert Graves was an Irish physician of internal medicine, not a gynecologic surgeon, and the chronologic and disciplinary lineages do not connect.[1][2]
The Graves and Pedersen designs evolved alongside the Sims single-bladed lever speculum (J. Marion Sims, mid-1800s) and represent the bivalve / dual-retraction evolutionary branch of the speculum genealogy.[2]
See also: Sims Retractor, Auvard Weighted Speculum, Breisky-Navratil, Heaney Retractor, Nasal Speculum.
References
1. Feliciano DV, DuBose JJ. "Robert James Graves (1796–1853), the Irish School of Medicine, and Graves' disease." Am Surg. 2023:31348231156771. doi:10.1177/00031348231156771
2. Wall LL. "The Sims position and the Sims vaginal speculum, re-examined." Int Urogynecol J. 2021;32(10):2595–601. doi:10.1007/s00192-021-04966-w
3. Ten Buuren AAA, Poolman TB, Bongers MY, et al. "Patient preferences for disposable and reusable vaginal specula and their willingness to compromise in the era of climate change: a cross-sectional study." BJOG. 2024;131(5):684–9. doi:10.1111/1471-0528.17733
4. Thomas A, Weisberg E, Lieberman D, Fraser IS. "A randomised controlled trial comparing a dilating vaginal speculum with a conventional bivalve speculum." Aust N Z J Obstet Gynaecol. 2001;41(4):379–86. doi:10.1111/j.1479-828x.2001.tb01313.x
5. Bates CK, Carroll N, Potter J. "The challenging pelvic examination." J Gen Intern Med. 2011;26(6):651–7. doi:10.1007/s11606-010-1610-8
6. Committee on Adolescent Health Care. "The initial reproductive health visit: ACOG Committee Opinion No. 811." Obstet Gynecol. 2020;136(4):e70–80. doi:10.1097/AOG.0000000000004094
7. Hill DA, Cacciatore ML, Lamvu G. "Sheathed versus standard speculum for visualization of the cervix." Int J Gynaecol Obstet. 2014;125(2):116–20. doi:10.1016/j.ijgo.2013.10.025