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Pelvic Examination

  • Author: Aurora M Miranda, MD, FACOG; Chief Editor: Christine Isaacs, MD  more...
 
Updated: Mar 17, 2016
 

Background

The pelvic examination encompasses an examination of the vulva, vagina, and internal pelvic organs. Females typically undergo their first pelvic examination for the evaluation of gynecological complaints or at age 21 years, whichever comes first. Pelvic examinations were once performed for cervical cytology or screening for gonorrhea or chlamydia before age 21 years. However, the availability of urine testing for gonorrhea and chlamydia has reduced the necessity of routine pelvic examination before age 21 years.

The examination is a basic tool of physical diagnosis and can be performed by either physicians or trained allied health professionals. Few studies have addressed patient preference concerning pelvic examinations alone, but about 45% of women reported that they would prefer a female doctor for their gynecologic care, 4.2% reported that they would prefer a male doctor, and the remaining women expressed no preference. Many women anticipate that the nurse assisting the physician will give them additional information about the pelvic examination.[1]

Since the American College of Obstetricians and Gynecologists (ACOG) guidelines changed the frequency of cervical cancer screening based on age and risk factors, many experts have begun to doubt the need for routine pelvic examination. An Agency for Healthcare Research and Quality (AHRQ)–commissioned report found no evidence that these examinations led to earlier detection of ovarian cancer.[2] In addition, no evidence has shown the benefits of a pelvic examination in the early diagnosis of other conditions in asymptomatic women.[2] Speculum and bimanual examinations are uncomfortable and disliked by many women and take up valuable time during a well-woman visit.

Annual pelvic examinations are often equated with the Papanicolaou (Pap) test, but they are separate tests. For women older than 21 years, the pelvic examination is typically performed as part of the well-woman visit, even when cervical screening is not indicated.

Chaperones typically accompany the provider performing the pelvic examination, although, in usual practice, female providers frequently do not have them present.

Fear of the pain associated with a pelvic examination is a barrier to consistent care,[3] and patients need reassurance. The clinician should establish patient rapport. Making the patient feel at ease, maintaining eye contact, being aware of the patient’s involuntary muscle contraction, selecting the appropriate speculum, clearly explaining the steps of the examination (and providing advanced warning of each step as the examination progresses), and explaining the findings are helpful during a pelvic examination.[4]

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Indications

The pelvic examination is used to assess the mons, vulva, vagina, cervix, uterus, ovaries, and fallopian tubes and to note the urethra and bladder region. It is typically conducted annually starting at age 21 years.

Other than cervical cancer screening and sexually transmitted disease (STD) testing, the primary indications for a pelvic examination are for the evaluation of the following pelvic complaints:

  • Pregnancy or postpartum
  • Pain
  • Discharge
  • Itching
  • Swelling
  • Bleeding
  • Menstrual abnormalities
  • Less-common indications include the following:
  • Abnormalities of sexual development
  • Sexual trauma
  • Physical trauma
  • Neurologic conditions
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Technical Considerations

Complication Prevention

Check the temperature of any warming devices or heating pads to avoid inadvertent pain or burn. Use disposable speculums or appropriately cleaned metal instruments.

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Contributor Information and Disclosures
Author

Aurora M Miranda, MD, FACOG Teaching Faculty, PGY 1 Residency Monitor, Residency Training Program, Medical Staff, Department of Obstetrics and Gynecology, West Penn Hospital; Clinical Associate Professor, Obstetrics and Gynecology and Reproductive Health Sciences, Department of Obstetrics and Gynecology, Temple University School of Medicine

Aurora M Miranda, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, AAGL, American Urogynecologic Society, International Urogynaecology Association

Disclosure: Nothing to disclose.

Coauthor(s)

Diego A Vasquez de Bracamonte, MD Resident Physician, Department of Obstetrics and Gynecology, Allegheny Health Network, Western Pennsylvania Hospital

Diego A Vasquez de Bracamonte, MD is a member of the following medical societies: Peruvian American Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine

Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Acknowledgements

Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause Society

Disclosure: Nothing to disclose.

References
  1. Yanikkerem E, Ozdemir M, Bingol H, Tatar A, Karadeniz G. Women's attitudes and expectations regarding gynaecological examination. Midwifery. 2009 Oct. 25(5):500-8. [Medline]. [Full Text].

  2. Hoyo C, Yarnall KSH, Skinner CS, Moorman PG, Sellers D, Reid L. Pain predicts nonadherence to Pap smear screening among middle-aged African American women. Prev Med. 2005. 41:439-45.

  3. American College of Obstetricians and Gynecologists. Cervical Cytology Screening. ACOG Practice Bulletin No. 109. Obstet Gynecol. 2009. 114:1409-20.

  4. Stormo AR, Hawkins NA, Cooper CP, Saraiya M. The pelvic examination as a screening tool: practices of US physicians. Arch Intern Med. 2011 Dec 12. 171(22):2053-4. [Medline].

  5. Henderson JT, Harper CC, Gutin S, Saraiya M, Chapman J, Sawaya GF. Routine bimanual pelvic examinations: practices and beliefs of US obstetrician-gynecologists. Am J Obstet Gynecol. 2013 Feb. 208(2):109.e1-7. [Medline].

  6. Larsen M, Oldeide CC, Malterud K. Not so bad after all...women's experiences of pelvic examinations. Fam Pract. 1997. 14:148-52.

  7. Myers ER, Bastian LA, Havrilesky LJ, Kulasingam SL, Terplan MS, Cline KE, et al. Management of Adnexal Mass. Evidence Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025.) AHRQ Publication No. 06-E004. Rockville, MD: Agency for Healthcare Research and Quality; February 2006. [Full Text].

  8. Wright D, Fenwick J, Stephenson P, Monterosso L. Speculum 'self-insertion': a pilot study. J Clin Nurs. 2005 Oct. 14(9):1098-111. [Medline].

 
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Candy cane type stirrups for lithotomy examination under anesthesia.
External vulvar and vaginal structures for evaluation.
Bimanual examination.
Bimanual examination, lateral view.
Bimanual evaluation of the retroflexed and retroverted uterus.
Diagram of retroverted uterus.
Diagram of retroverted uterus.
Diagram of relative positions of anteverted and retroverted uterine positions.
Sims lateral examination position.
Knee-chest examination position.
Graves speculum.
Pederson speculum.
 
 
 
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