Pelvic Examination Technique

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.

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.

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.

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.

The purpose of the bimanual examination is to determine the size and nature of the uterus and the presence or absence of adnexal masses. ^[7] 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.

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 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.