Pelvic Examination

September 21, 2011

The pelvic examination is the most important part of the overall gynecologic exam. While the examiner must think about the whole patient, the purpose of the pelvic exam is to screen for abnormalities of the cervix, pelvic masses, including abnormalities of the patient’s uterus, fallopian tubes, and ovaries as well as observing any abnormalities in pelvic support structures. At its best, the pelvic exam should be performed in a thoughtful, compassionate manner, instilling in the patient a sense of trust, which should never be violated. At its worst, the thoughtless, hurried examiner can traumatize the patient and cause anxiety about the examination that will never be overcome. This trust should weigh heavy on the examiner’s thoughts while performing this important aspect of the gynecologic exam.

With the woman fully clothed, the examiner should first describe what will happen during the examination, since people tend to retain more information in this setting. once the patient has been examined in the sitting and lying position from the head to the abdomen, the patient places her feet in the exam table’s stirrups, which are ideally covered with stirrup warmers (this is termed the lithotomy position).

Figure 1. Various sizes of the speculum.

The examiner now sits in front of the patient with a suitable flexible light source and appropriately drapes the patient, covering her except for her vaginal area. Prior to introducing the previously warmed speculum (which comes in a variety of sizes, see Figure 1), the examiner should inspect the external anatomy for any abnormality, including the lower abdomen, the external genitalia including the folds of the vaginal opening, the hymen, and the pubic hair area.

The examiner should explain to the patient during and prior to each step what he or she is doing and why. Separating the opening of the vagina, the examiner should continue to inspect the anatomy including the urethral opening, the area between the bottom of the vagina and anus (the perineal body) for abnormal hair distribution, skin color changes, skin lesions or any generalized abnormalities (irritation, ulcers, dryness, etc.), abnormal positions of anatomy, and/or pelvic relaxation. The patient should be asked to cough to inspect for any evidence of pelvic relaxation (lack of muscular support), cystocele (bulging of the bladder into the vagina), or urinary leaking. While separating the opening of the vagina and depressing the perineal body, the speculum should be inserted into the vagina, usually in a vertical fashion keeping continuous pressure on the bottom part of the vagina so as to avoid the more sensitive structures above (urethra, bladder).

Figure 2. The slightly rotating technique followed during the insertion of the speculum into the vagina.

The speculum should be carefully turned as it is introduced, always mindful of the patient’s labia (opening of the vagina) to avoid inadvertent discomfort. This is accomplished best with the insertion at the proper angle, downward pressure on the vagina, and the slightly rotating technique (Figure 2). Once the speculum is inserted to its full length, the speculum blades are then opened exposing the cervix at the top (apex) of the vagina.

One should open the blades only enough to clearly visualize the cervix without undue discomfort to the patient (Figure 3). The Pap smear may then be performed with the thin prep technique (using a small brush and placing the cells in a small container of liquid for computer evaluation) or using the time-honored microscopic slides. A cotton swab may be used to help further expose the cervix if needed. Cultures for gonorrhea and chlamydia may be obtained with small swabs placed in the opening of the cervix. The inspection of the vaginal side walls may be accomplished at this time. Any abnormalities of the cervix should be biopsied, as the Pap smear is only a screening test for use when the cervix appears normal. Any discharge may then be examined for evidence of vaginitis (discharge with inflammation), vaginosis (discharge without inflammation), or other abnormalities. As the speculum is withdrawn (repeating the careful rotation), the anterior and posterior fornix (the area of the vagina around the top and bottom of the cervix) may be inspected.

Figure 3. Opening the blades of the speculum to clearly visualize the cervix.

Attention should be turned to the bimanual aspect of the pelvic exam. This is accomplished by placing one or two fingers of the physician’s dominant hand (which should feel most comfortable and proficient in examining any body part) into the hymenal/vaginal opening while using the opposite hand on the external lower abdomen (Figure 4).

The fingers should be inserted at the proper angle (similar to the speculum) while depressing the perineum, which will further expose any weakness in the pelvic muscle support (pubococcygeal muscles) or confirm the muscles’ strength. The physician should now be examining the length of the vagina, the vaginal wall, and external aspect of the cervix at the top of the vagina. The cervix is gently examined and lifted while the external hand gently examines the top of the uterus as it is lifted up by the internal exam. The examiner should then begin to outline the size, firmness, mobility, shape, and position of the uterus, ovaries, and any palpable pelvic masses.

Figure 4. Bimanual pelvic exam.

The vaginal canal, ovaries, and fallopian tubes are then examined in a similar fashion. The vaginal fingers are then turned laterally to feel the pelvic walls (Figure 5). It should be noted that normal adnexa (ovaries and fallopian tubes) are frequently not detectable even under the best of conditions because normal ovaries and tubes are so small. In the obese patient even enlarged adnexa may be missed (thus vaginal ultrasound is frequently used). Normal-sized ovaries (approximately 3 X 2 X 2 cm or 1.3 X 0.8 X 0.8 in.) may be felt in the premenopausal woman with active ovarian function. However, if the ovaries are felt in the postmenopausal woman, this may be abnormal, as the ovaries should be too small to be felt when they are not ovulating (making eggs). In this case, further investigation is required.

Figure 5. Examining the ovary and the pelvic wall with the examiner's fingers.




Finally, the rectal-abdominal bimanual exam is performed. This portion of the exam is to look for external and internal hemorrhoids, fissures (cracks in the skin), fistulas (small connections between the vagina and rectum, which are not normal), polyps in the rectum near the anal opening, or tumors. The uterus is palpated bimanually with the index finger in the vaginal opening and the middle finger in the rectum. With a posterior uterus (a uterus that is tipped backward, which is completely normal), only now will the top of the uterus be felt. The ovaries and particularly the space behind the uterus and uterine support structures (the uterosacral ligaments) and the internal areas alongside the vagina and cervix are palpated. These areas are best examined rectally and here the diagnostic findings of endometriosis or the spread of cervical cancer may be found. With one finger in the vagina and another in the rectum the rectovaginal septum (the structure separating the vagina from the rectum) can be examined. Having the patient strain may further discover any pelvic support weaknesses including the presence of an enterocele (bulging of small bowel into the vagina) or rectocele (bulging of rectum or large bowel into the vagina). When the bimanual exam is completed the examiner may use his or her rectal finger to place a stool specimen on a hemoccult card to check for blood, which screens for colon cancer in the older patient. The examiner should not perform this blood test if the patient is menstruating or if the cervix had some blood on it without changing gloves. The physician can also give the patient a set of three stool cards to take home with instructions to bring them back to be tested for blood.

Once the pelvic examination has been completed, the examiner should assist the patient to return to the sitting position. The examiner should then talk with the fully clothed patient to discuss the findings of the examination and answer any questions that she may have. Thus the pelvic examination, which screens for cervical cancer and pelvic disease, has been completed. Giving the patient some time to collect her thoughts and to discuss the findings, we think, is the optimal way to complete this very important medical exam.

SEE ALSO: Pap test, Pelvic examination, Pelvic pain


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