How Robotic Vaginas Could Revolutionize Gynecology

Gynecology is not a one-size-fits-all medicine. Vaginal dimensions can vary widely, making the fact that they’re all exquisitely different the one thing they truly have in common. Add to that disparity that vaginal exams are also largely unsighted — visual clues for doctors are minimal — and it makes diagnosing and treatment of gynecological issues especially difficult.

And let’s face it — this is to say nothing of the dominant feeling that the less time we have to spend in a humiliating paper gown with our legs splayed in hellish stirrups, the better.

To address this unfortunate combination of feeling like an inverted naked cowgirl who’s lost her horse, and the fact that doctors simply can’t see what the hell is going on, researchers at Imperial College London are introducing a robotic pelvis — also known as Virtual Reality Gynecological Examination Trainer (ViRGET).

“Internal examinations are by definition very difficult to learn and teach as they are unsighted, yet they are commonly performed and have important diagnostic value,” Dr. Fernando Bello told The Establishment. Bello is a professor in surgical computing and simulation science who leads the team.

“If we add the intimate nature of the examination and the fact that the patient may be naturally anxious, it is crucial that medical students and junior doctors are provided with the right tools to learn and practice the full set of skills (technical and non-technical) required to adequately perform a pelvic examination, without adding discomfort or putting the patient at risk.”

Vaginas Are Like Snowflakes

It’s no secret that health issues specific to people who are assigned female at birth have received significantly less attention than those that affect all bodies, or those specific to people assigned male at birth, so it’s not a surprise that this teaching and diagnostic tool has been a long time coming. (As one example of an undeniable phenomenon, a 2006 study in the Journal of Women’s Health found that women made up less than one-quarter of all patients enrolled in 46 examined clinical trials completed in 2004.)

Vaginas are not KitchenAid stand mixers — every model is not built the same. You may have operated on one before and have an idea of how it works, but this knowledge is not necessarily generalizable to all vaginas.

The brilliantly titled 2005 observational cross-sectional study “Female genital appearance: ‘normality’ unfolds,” published in the British Journal of Obstetrics & Gynecology, examined 50 premenopausal women and found that “women vary widely in genital dimensions.” Vaginas (well, technically, labia) also range in shape, color, texture, and amount of pubic hair.

While there is certainly no shortage of representations of female nudity in art, popular culture, and medical teaching tools, the authors of the study point out that accurate, detailed information on vulvas and vaginas is decidedly rare. This gives us the false perception that we are familiar with all aspects of what’s down there, which can be detrimental from both a medical standpoint and in terms of people with vagina’s sexual satisfaction.

Hardly surprising given the paternalistic and male-centric history of medicine, there are very few descriptions of the dimensions of normal vaginas in medical literature, yet penis-measuring — for official scientific publication — dates back to the 19th century. There have been studies examining clitoral size or vaginal length, but very little attention has been given to characteristics like labial size, color, or texture.

There is no shortage of “men can’t find the clitoris” jokes, but in fairness to them, the confusion is perhaps more understandable than we give them credit for; clitoral locations in relation to the urethra and vagina are by no means standard.

So while it sounds like something you might find at a bachelor party, the robotic pelvis is actually an important diagnostic tool that has been a long time coming.

The Nuts And Bolts Of The Robotic Vagina

The medical student uses one hand each for the internal and external components of the exam; each hand is attached to a separate robotic arm that recreates the relevant touch interaction — including the internal anatomy and abdomen. The student conducts the exam while seeing the “virtual” patient on a screen which can be modified to show internal anatomy, while the simulation software records the movements made by both hands and measures the pressure applied.

“Together with the three-dimensional anatomy, this data can be used to assess performance as the system knows which anatomical regions and/or abnormalities have been palpated and how,” Bello explains.

To the best of Bello’s knowledge, this is the first robotic pelvis of its kind. There are, however, already several so-called “benchtop” plastic pelvis models, some of which even have electronic (e.g. pressure) sensors integrated, he notes. In addition, there have been other research prototypes for ultrasound, intrauterine devices, or birthing, some of which have made it to commercial products, such as the VirtaMed PelvicSim. ViRGET is, however, the only robotic pelvis capable of supporting bimanual vaginal examination (BVE), Bello explains.

“The traditional way medical students are taught BVE/gynaecological examination is through learning of the pelvic anatomy, then tutored sessions with plastic ‘benchtop’ models and, in some cases, practice on Gynaecological Teaching Assistants (GTAs) — women that in most cases have been trained on the details of the examination and allow themselves to be examined by students,” he says.

While beneficial, GTAs are not widely available and can therefore be expensive. Not surprisingly, it can be difficult to find people willing to be examined by med students down there while conscious — even if a fee is provided.

“Consent tends to be given verbally on the spot,” Bello explains. “A senior clinician/consultant asks the patient if she wouldn’t mind being examined a second time by a trainee doctor. It used to be common that anaesthetised women were examined by junior doctors, but I believe/understand this is rare nowadays and when it does happen, written consent is requested.”

In addition to the technical aspects of the examination — including conducting an adequate and comprehensive internal palpation, and identifying relevant structures — Bello stresses that face-to-face dialogues are equally important.

“The doctor needs to be able to communicate with the patient effectively, allaying any fears or anxieties she might have whilst doing the examination and then communicate the findings,” he continues.

While the communication aspect makes having the human element undeniably necessary, Bello argues that it is possible to first practice and master the technical skills before examining a GTA or patient. That’s where the robotic pelvis comes in — to be used alongside a Simulated Patient (professional actor) who is lying down behind the model and can provide the required training in communication skills.

According to Bello, even if GTAs are used, due to the unsighted nature of the examination, medical students learn how to conduct examinations by touch, with little to no feedback on what they are doing, or the accuracy of it. Although certain plastic models include integrated sensors and interchangeable anatomies — allowing trainees to experience different conditions — they are limited, not particularly realistic, and in some cases, may overemphasize certain medication conditions.

He also says that in addition to feeling more realistic — literally — than existing plastic models, there are numerous benefits to the robotic pelvis. It can cover a wide (infinite in theory) range of anatomical cases; real-time visualization and feedback on performance can be given to trainees (including a summative performance at the end of a training session to allow students to compare performance across sessions); it can be practiced in a safe setting without putting patients at risk or in discomfort; and it can help make trainees less anxious as they learn the necessary skills to adequately perform a BVE.

“Our hypothesis is that [medical students] will be not only be more competent, but also more confident when performing a BVE,” Bello says. “This in turn should result in less discomfort when being examined by a medical student/junior doctor, [as well as a] more accurate examination and perhaps also a faster one.”

Currently, Bello and his team have an initial prototype that he says needs further refinement and development — it is the only one in existence, after all. They are planning to make several improvements and work toward producing a commercial product over the next 24–36 months, pending securing additional funding for the work, he adds.

And just to be clear, the robotic pelvis is not a high-tech sex toy: Bello says it is currently restricted to educational and clinical use. “Exploring its use in a sexual context would require significant, bespoke redesign of both the robotic arm(s), as well as the simulation software,” he notes.

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Lead image: Modified from wikimedia.org