Pelvic Examination Periprocedural Care

Updated: Sep 25, 2018
  • Author: Aurora M Miranda, MD, FACOG; Chief Editor: Christine Isaacs, MD  more...
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Periprocedural Care

Patient Education and Consent

Patient autonomy must be respected at all times.

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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. Occasionally, children or physically or mentally disabled women may require examination under intravenous sedation or general anesthesia, with appropriate consent and/or legal counsel.

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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