Pelvic Examination

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]

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

• Pre-procedural evaluation

• Preoperative evaluation and planning

• Second opinion/gynecologic consultation

• Pain

• Discharge

• Infection

• Itching

• Swelling

• Bleeding

• Menstrual abnormalities

• Abnormalities of sexual development

• Sexual trauma

• Physical trauma

• Neurologic conditions

• Postoperative complications

• Unexplained vaginal bleeding

• Pelvic floor disorders

• Incontinence

• Desire for transgender surgical procedures

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.

Standard OSHA guidelines regarding sterilization of reusable instrument must be observed.

Colposcopic instruments, laparoscopic instruments, ultrasonography, and office hysteroscopy are additonal tools to complete the comprehensive pelvic examination. The use of new technology (e.g., office hysterscopy) must be approved by the provider's institution based on safety profile and scientific evidence prior to use. The operator must be appropriately credentialed to use the specific instruments. 

Contradications to pelvic examination include the following:

• Critically unstable patient - medically, emotionally, psychologically
• Inavailability of informed consent