Pelvic Examination 

Updated: Sep 25, 2018
Author: Aurora M Miranda, MD, FACOG; Chief Editor: Christine Isaacs, MD 

Overview

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]

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

  • 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

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.

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. 

 

Contraindications

Contradications to the examination include the following:

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

Periprocedural Care

Patient Education and Consent

Patient autonomy must be respected at all times.

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).

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.
 

Technique

Approach Considerations

The pelvic examination usually consists of a soft-tissue evaluation of the lower and upper genital tract, as well as the urethra, bladder, and rectum. The bony pelvis is not typically part of a standard pelvic examination but may be evaluated in early or late pregnancy or in the case of known trauma or abnormalities.

The pelvic examination typically consists of visual external inspection, insertion of the speculum, performance of any tests or cytology, and then bimanual examination to determine the size and character of the uterus and ovaries. Right-handed individuals generally put their right hand in the vagina and use their left hand abdominally.

Specimen collection and cervical screening is covered in the Cervical Screening topic.

Abdominal examination correlated with radiologic imaging studies can support the findings of larger pelvic masses.

Vulvar Examination

Basic evaluation of the vulvar area includes basic developmental assessment, symmetry, hair quality and growth distribution, skin abnormalities, swelling, ulcerations, growths such as external genital warts (EGW) or tumors, rashes, lacerations, piercings, bruising, and discharge (see image below). Some advocate noting general cleanliness. Most examiners do not document tattoos or scars, but these could also be noted.

External vulvar and vaginal structures for evaluat External vulvar and vaginal structures for evaluation.

Bartholin glands are in the most distal part of the vaginal opening, at approximately the 5 and 7 o'clock positions. The gland opening typically cannot be identified. A mass palpable in this region is typically a Bartholin cyst.

Vulvar varicosities should be palpated and noted, with comment as to location and extent of venous insufficiency. With the thumb on the perineum and the index finger in the vaginal opening, the labia can be palpated for lumps, tumors, pain, or lymphadenopathy. Examination of the labia minora should include inspection of the folds of the labia, their symmetry, changes from prior examinations, and presence of lacerations.

Fusion of the labia majora and minora should be noted in conditions such as lichen sclerosis.

Examination of the mons includes noting hair distribution, moles, swelling or tenderness, and male versus female pattern of hair growth.

Vaginal Examination

The labia minora are gently separated to visualize the hymenal ring. Light pressure on the bulbocavernosus muscle helps to relax the vaginal walls, especially posteriorly, so speculum insertion is easier. The presence of a cystocele, urethrocele, cystourethrocele, or rectocele, with or without vaginal prolapse or vaginal wall defect, can be evaluated. Instructing the patient to bear down can enhance the evaluation of wall descent, and having the patient cough can demonstrate stress incontinence.

The urethral examination includes checking the urethral opening, the Skene glands, any discharge, tenderness or erythema, or any eversion or prolapse of the meatus.

Lubrication can help with speculum insertion, although excessive lubrication can potentially interfere with specimen collection from the cervix or the vagina.

The speculum is inserted by passing the collapsed speculum towards the cervix. A preinsertion single-digit examination can help determine the path (angle) of the vagina and the position of the cervix during difficult examinations. The speculum can be inserted horizontally if the opening is patulous enough, but, for comfort and ease, the insertion is usually done at an oblique angle (45°).

The speculum should be inserted to the full length of the vagina, with the blades in the posterior fornix, before the blades are gently opened to expose the lateral walls. When it is properly placed, the patient should be comfortable and the cervix visible at the distal end of the speculum.

It is relatively easy to teach a patient speculum self-insertion. In a small trial, 91% of participants said they preferred the technique, although few examiners use it.

The walls of the vagina are inspected for discharge, estrogenization (presence or absence of atrophy), erythema, and lesions.

The cervix should be examined for contour, amount of erosion, shape of the os (patulous, scarred, parous, nonparous), discharge, lacerations, polyps, neoplasias, and lesions (eg, warts). In a pregnant female, the cervix may appear to have a purple tone.

Bimanual Examination

The purpose of the bimanual examination is to determine the size and nature of the uterus and the presence or absence of adnexal masses.[5] Uterine mobility and tenderness is assessed, and the presence of any adnexa tenderness should be noted. Ovaries are palpable in many premenopausal females with a normal habitus. Obesity can impair adnexal evaluation. Postmenopausal females have smaller ovaries, which are typically not palpable.

Typically, the index and middle finger of the provider's dominant hand are gently inserted into the vagina (see images below). The opposite hand is placed on the abdomen with the ulnar edge and the tips of the fingers used for palpation. The uterus is usually palpable when the abdominal fingers are just above the symphysis. However, large masses can be missed unless the palpation begins at the umbilicus and moves downward. It is not always possible to palpate the uterus or the ovaries in patients who are obese.

Bimanual examination. Bimanual examination.
Bimanual examination, lateral view. Bimanual examination, lateral view.
Bimanual evaluation of the retroflexed and retrove Bimanual evaluation of the retroflexed and retroverted uterus.

The cervix should be palpated to determine the shape, form, and consistency.

Uterine palpation is typically the next step in the evaluation. Palpation of the cervix helps to determine the location. Palpation of the vaginal fornix above the cervix is used to feel the uterine fundus when the uterus is anteflexed. In cases of retroversion, the fundus is palpable through the posterior fornix. The position, size, shape, consistency, amount of mobility, and any discomfort during the examination should be noted.

By moving the abdominal hand to the lateral lower quadrant and the pelvic hand to each ipsilateral side, each adnexal region can be palpated, feeling for the ovary. The presence of a mass or any adnexal tenderness or lack of mobility can be determined. Factors that interfere with an adequate examination, such as guarding or tenderness, should be noted. The patient can be asked to exhale as the provider presses down to facilitate muscle relaxation.

Cervical mobility and cervical motion tenderness can also be noted. This is generally checked last, as, if present, patient discomfort will limit the remainder of the examination.

Rectal Examination

Rectal examination should be performed using lubrication. A slow, single-digit insertion, allowing the rectal sphincter to relax, decreases the discomfort of the rectal examination. The presence of hemorrhoids, polyps, and growths and the tone of the sphincter itself should be noted. The pararectal and parametrial area can be palpated. Fecal material can be felt, and extensive or impacted material can preclude thorough examination. If bimanual examination cannot be performed, the uterus can be assessed rectally, and large adnexal masses can sometimes be palpated.

Rectovaginal examination is performed by inserting the index finger into the vagina and the third finger in the rectum. The rectovaginal septum and the distal portion of the cul de sac can be evaluated for any anatomic distortions or tenderness. This examination is particularly important in patients who may have infection, endometriosis, or cancer.

 

Medication

Medication Summary

If necessary for the decision-making process, children and patients with physical and psychological limitations may be sedated in order to complete the gynecologic exam.