Exam methods

• External examination
  • Tell the patient that they will feel you touching their genitalia.
  • Examine the mons pubis, labia majora, and perineum for inflammation, indurations, swelling, or any lesions.
  • Separate the labia to expose the labia minora, clitoris, urethral meatus, and introitus observing for inflammation, indurations, swelling, lesions, or discharge.
• Internal visual examination
  • Inform patient a speculum will be inserted for internal visual examination.
  • Warm speculum under water or use water-based lubricants. Certain lubricants that contain carbomers or Carbopol polymers need to be avoided as they may interfere with cytology.
  • Separate the labia minora and introduce the speculum with downward pressure and advance the speculum in the area that is without resistance and opened once vaginal apex is reached. Open the speculum gently once fully inserted.
  • Note the color and position of the cervix, as well as any lesions or discharge.
  • At this time, cervical specimens may be obtained for cervical cytology or sexually transmitted infection testing, as indicted..
  • Once completed, gently close the speculum, and withdraw it slowly, observing the vaginal walls and note any lesions, abnormal discharge, or bleeding.
• Bimanual examination
  • Advise the patient that you will be inserting two fingers into the vagina for the bimanual examination.
  • Use water-soluble lubricant on the index and middle fingers.
  • From a standing position, insert index and middle fingers into the vagina with slight posterior pressure. Your thumb should be abducted and third and fourth fingers folded into the palm.
  • Palpate the cervix, noting position, shape, consistency, mobility, and any tenderness.
  • Palpate the uterus by placing the other hand just above the symphysis pubis and lifting the cervix and uterus with the internal hand, grasping the uterus between the two hands.
  • Palpate each ovary by placing the abdominal hand on the lower quadrant pressing downward toward the pelvic hand, mobilizing the ovary between the fingers of both hands. Note position, consistency, presence of masses, and any tenderness.
    • Ovaries can be difficult to palpate due to the patient’s body habitus and presence of pelvic abnormalities
  • Assess pelvic floor muscles by asking the patient to squeeze down on your fingers for three seconds and then bearing down to observe for urinary leakage.
• Rectovaginal examination
  • A rectovaginal exam is indicated for examination of a retroverted uterus and assessing for pelvic pathology.
  • Change your gloves and lubricate your index and middle fingers.
  • Tell the patient that the index and middle fingers will be inserted simultaneously, one into the vagina and one into the rectum.
  • Insert the index finger into the vagina, and the middle finger into the rectum while asking the patient to bear down to allow sphincter relaxation.
  • Also inform the patient that they may experience a sensation of having a bowel movement but reassure them this will not happen.
  • Apply pressure against the anterior and lateral walls with the pelvic examination fingers, while exerting pressure on the abdomen to palpate the pelvic structures.
  • Palpate the rectal vault and note any masses, blood, tenderness, or hemorrhoids.

PEARLS

• Cervical motion tenderness may be a sign of pelvic inflammatory disease.
• Obesity or posterior position of the uterus may make palpation of the uterus during a bimanual examination difficult or impossible.
• Ovaries atrophy after menopause making them unable to be palpated.
• Full pelvic floor strength is defined by a full three second hold during assessment.
• Provide a soft tissue or towel to the patient to wipe away any excess lubricant at the end of the exam.