Pederson Speculum
Bivalve vaginal speculum with narrow, flat blades — the preferred bivalve for nulliparous, adolescent, postmenopausal, and atrophic-vagina patients in whom the wider Graves does not fit comfortably. Together with the Graves, the Pederson is one of the two dominant office vaginal specula in gynecologic and urogyn practice.[1][2]
Design
- Narrow, flat blades — thinner and flatter than the Graves, producing a slim closed profile that fits through a tight introitus.
- Minimal blade curvature — less concavity than the Graves' duckbill shape; the trade-off is somewhat less vaginal distension at the apex.
- Thumbscrew lock at the handle — opens and locks at the chosen separation for hands-free cervical visualization; self-retaining.
- Multiple sizes (small / medium / long) and both metal (reusable) and plastic (disposable) versions.[2][3]
Reconstructive-Urology and Urogyn Uses
The Pederson is the default speculum for the postmenopausal urogyn patient — a substantial fraction of the prolapse / incontinence / mesh-evaluation population — and for any patient whose vaginal caliber will not comfortably accept a Graves.
Office urogyn examination
- Postmenopausal / atrophic-vagina pelvic exam — atrophy narrows the canal; the Pederson's slim profile is the comfortable choice for prolapse staging, vault inspection, and mesh-exposure surveillance.
- Adolescent reproductive-health visit — ACOG recommends the narrow Pederson or Huffman speculum for the initial reproductive-health visit, with selection guided by pubertal status, hymenal opening, and sexual experience.[4]
- Nulliparous pelvic exam — the narrower blade accommodates a tighter introitus with less discomfort.
- Trauma-informed and gender-dysphoric patients — the smaller profile reduces anxiety and dyspareunia; ACOG recommends a trauma-informed, patient-driven approach.[4]
- Cervical-cytology and HPV sampling, colposcopy, IUD management in patients in whom the Graves does not fit.
- Mesh-exposure / suture-extrusion inspection in atrophic vaginas after prior pelvic reconstruction.
- Urethral / anterior-wall examination for diverticulum, caruncle, fistula in narrow-caliber vaginas.
Office procedures
- Periurethral bulking-agent injection, vestibular and periurethral biopsy, pessary fitting in nulliparous or atrophic patients.
- Office cystoscopy adjunct — exposing the urethral meatus in narrow-introitus patients before flexible cystoscope passage.
Pederson vs Graves — The Choice
| Feature | Pederson | Graves |
|---|---|---|
| Blade profile | Narrow, flat | Wider, more concave (duckbill) |
| Vaginal distension | Less | Greater |
| Best patient | Nulliparous, adolescent, postmenopausal / atrophic, virgo intacta | Multiparous, routine adult, lax vaginal walls |
| Cervical visualization | Adequate; may be limited in multiparous patients with redundant walls | Excellent in multiparous patients |
| Patient comfort | Better in narrow introitus | More discomfort in nulliparous / atrophic |
| Best urogyn use | Postmenopausal urogyn patient (the typical clinic patient), adolescent eval | Younger multiparous prolapse / incontinence patient |
For the postmenopausal urogynecology patient with vaginal atrophy, the Pederson is often the more appropriate choice even though the patient is parous — atrophy, not parity, is the limiting variable.
Pederson vs Other Specula
| Feature | Pederson | Graves | Huffman | Sims |
|---|---|---|---|---|
| Blades | 2 narrow flat | 2 wide curved | 2 very narrow (longer, narrower than Pederson) | 1 (single-blade retractor) |
| Self-retaining | Yes (thumbscrew) | Yes (thumbscrew) | Yes | No (handheld) |
| Best fit | Nulliparous / atrophic | Routine multiparous adult | Virginal / prepubertal | Lateral-position exam, operative vaginal retraction |
| Position | Lithotomy | Lithotomy | Lithotomy | Left lateral decubitus / operative |
For operative vaginal surgery, the Auvard weighted speculum, Breisky-Navratil, or Heaney retractor replace the bivalve specula.
Practical Tips for Use
Evidence-based techniques for maximizing comfort during Pederson examination:
- Lubrication — water-based lubricant does not interfere with cytology and significantly improves comfort.
- Warm the speculum before insertion (warm water or speculum warmer).
- Oblique-angle insertion with gentle rotation — insert at ~ 45° relative to vertical, rotate as the speculum advances.
- Verbal coaching — communicate each step before performing it; especially important in trauma-informed and adolescent exams.
- Vaginal estrogen in advance of the visit for postmenopausal patients with severe atrophy when speculum exam is anticipated to be repeatedly necessary (eg, mesh-exposure surveillance).
- Sheathed speculum modification — improved cervical visualization (95.1% vs 78.2% of cervix fully visualized) without increased pain in the Hill 2014 RCT.[6]
Patient-Comfort Evidence
Patient discomfort during speculum examination is a substantial and well-documented barrier to gynecologic care:
- Thomas 2001 RCT — only 38–62% of women found the Pederson bivalve examination comfortable, vs 94% who preferred the dilating Veda-scope for comfort.[1]
- Kalaskey 2026 — in a survey of 203 patients, the speculum was identified as the most uncomfortable aspect of the pelvic exam by 34.4% of respondents; temperature and positioning were also frequently cited.[2]
- Plastic vs metal — plastic specula were preferred by 49.8% of patients vs 17.7% for metal in Kalaskey 2026; metal was perceived as more environmentally sustainable, and patients expressed willingness to trade some comfort for sustainability in the Ten Buuren 2024 climate-change cross-sectional study.[2][3]
Limitations
- Limited cervical visualization in multiparous patients with lax / redundant vaginal walls — the narrow blades do not retract redundant tissue; switch to a Graves.
- Inadequate for operative vaginal work — narrow profile and short blade length; switch to operative retractors.
- Not appropriate for the prepubertal or virgo-intacta patient — Huffman speculum or vaginoscopy preferred.
Historical Context
The Pederson speculum is the narrow-blade counterpart to the Graves design and entered routine gynecologic practice in the mid-20th century. It evolved alongside the Graves bivalve and the Huffman (even narrower; pediatric / virginal) speculum as the bivalve family diversified to fit the full range of vaginal calibers — in contrast to the single-bladed lever speculum genealogy descended from J. Marion Sims' bent pewter spoon, now represented by the modern Sims retractor.[5]
See also: Graves Speculum, Sims Retractor, Auvard Weighted Speculum, Breisky-Navratil, Nasal Speculum.
References
1. 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
2. Kalaskey TA, Quillen KG, Knutsen KR, Bushko KR, Dueñas-Garcia OF. "Comfort or conservation? Investigating patient choices between plastic and metal speculums." PLoS One. 2026;21(4):e0346819. doi:10.1371/journal.pone.0346819
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. 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
5. 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
6. 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