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Pelvic Examination Periprocedural Care

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

Equipment

The pelvic examination is usually performed on a flat surface, typically a table with foot supports. Pelvic examination chairs, electronic tables that can tilt the patient, and tables with supports for the entire lower leg are available.

Speculums come in various designs and materials.

The plastic speculum is individually packaged and disposable. Many of the plastic speculums are designed with rechargeable battery-powered lighted channels or cord lighting systems.

Metal speculums are made from various alloys that can be coated for use in surgical procedures.

Pederson speculums (see image below) have a flat narrow design to accommodate a narrower vagina. These speculums are advantageous in younger, virginal, or nulliparous patients, as well as in elderly women. Pederson speculums can minimize some of the discomfort of a pelvic examination while facilitating visualization of internal structures.

Pederson speculum. Pederson speculum.

Graves speculums (see image below) have a wider blade than Pederson speculums, and their sides are also curved. Because the vaginal canal may be wider in parous women, the Graves speculum may aid in visualization.

Graves speculum. Graves speculum.

Some speculums can be used for pediatric purposes. Weighted and open-sided (either left or right) speculums are available for procedures, and vaginal wall retractors are available if better visualization is required.

Room lighting is rarely sufficient for the speculum examination. Once the speculum is inserted, the speculum itself can be lit or lighting can be directed into the vagina (see images below).

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Patient Preparation

Anesthesia

Routine pelvic examinations are performed in the office without any sedation. For an extremely anxious patient, oral anti-anxiety medications in small doses with appropriate monitoring can be used. For patients who are extremely young (children) or who have medical problems, examinations under intravenous sedation or general anesthesia can be performed.

Positioning

Patients are undressed from the waist down and then draped from waist to knees. Relaxation is important, and the patient should be placed in the dorsal lithotomy position. The dorsal supine lithotomy position is best accomplished with the use of supports, which are adjusted to the patient’s leg length and allow the legs to be flexed and abducted.

Most office foot supports require the patient to have adequate muscle control to hold her legs upright. For patients with neurologic conditions or who are anesthetized or sedated, the feet can be placed in candy-cane stirrups, which support the legs in the lithotomy position (see image below).

Candy cane type stirrups for lithotomy examination Candy cane type stirrups for lithotomy examination under anesthesia.

It is also possible for the pelvic examination to be performed with supports that hold the entire leg rather than just the feet. This type of support is almost essential for women with disabilities or poor musculature.

The buttocks should be positioned at or slightly extending past the table to provide the optimal visualization and to allow adequate room for the speculum. The table height can be elevated for the comfort of the gynecologist or can be placed in the Trendelenburg position. Elevation of the head by about 30° helps in abdominal wall relaxation, and further elevation may facilitate communication.

In some cases, the Trendelenburg position can improve visualization. Most examiners sit for the speculum examination and the collection of any specimens, and some then prefer to stand for the bimanual examination. If the uterus is very large, the examiner needs to stand to palpate far enough up on the abdomen to appreciate the top of the uterine fundus.

The knee-chest (see image below) or genupectoral position can be used for rectal evaluations. It is possible to help resolve prolapse with this position, so it can be a helpful alternative.

Knee-chest examination position. Knee-chest examination position.

If a pelvic table cannot be used, such as when the patient is hospitalized, bedridden, or on an x-ray table for procedures, the patient can be placed with the bottoms of her feet together in a "frog-leg" position or with a padded overturned bedpan under her buttocks to facilitate the examination (see image below).

Sims lateral examination position. Sims lateral examination position.
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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
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  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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