| Pelvic examination |
A pelvic examination is the physical examination of the external and internal female pelvic organs.[1] It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma (e.g. sexual assault).[2] [3] It can also be used to assess a woman's anatomy in preparation for procedures.[4] The exam can be done awake in the clinic and emergency department, or under anesthesia in the operating room.[5] The most commonly performed components of the exam are 1) the external exam, to evaluate the vulva 2) the internal exam with palpation (commonly called the bimanual exam) to examine the uterus, ovaries, and structures adjacent to the uterus (adnexae) and 3) the internal exam using a speculum to visualize the vaginal walls and cervix.[6] During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer (the Pap test).[6]
Some clinicians perform a pelvic exam as part of routine preventive care.[3] However, in 2014, the American College of Physicians published guidelines against routine pelvic examination in adult women who are not pregnant and lack symptoms, with the exception of pelvic exams done as part of cervical cancer screening.[7] [8]
Traditionally in the field of gynecology, the benefits of routine pelvic examinations were assumed, and the exam was a recommended part of the initial gynecology visit, annual visits, and as needed for treatment.[9] In 2014, the American College of Physicians (ACP) published a review of the benefits and the risks of the exam and issued a guideline that recommended against performing this examination to screen for conditions in asymptomatic, nonpregnant, adult women, concluding that the potential harms outweighed the demonstrated benefits and that screening pelvic exams in asymptomatic women did not reduce mortality or morbidity rates. The guideline did not consider the necessity or frequency of Pap smears. The ACP guideline concluded that there was no evidence that the exam in asymptomatic adult women reduced morbidity or mortality, and that there were no studies that addressed the exam's diagnostic accuracy for identifying specific gynecologic conditions. The guideline concluded that there was evidence of harm, including fear, embarrassment, pain, discomfort and unnecessary surgery. This was a strong recommendation, based on moderate-quality evidence.[7] In 2018, the American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion that pelvic exams should be performed for 1) symptoms of gynecologic disease, 2) screening for cervical dysplasia, or 3) management of gynecologic disorders or malignancy, using shared decision-making with the patient.[10] ACOG acknowledged that given changes in screening recommendations and an assessment of harms vs benefits as reviewed by the US Preventive Services Task Force, re-evaluation of routine screening pelvic examination for asymptomatic, non-pregnant women with average risk for gynecologic disease was indicated. A 2020 update of the literature by the US Preventive Services Task Force concluded that the evidence remained insufficient to assess the balance of benefits and harms of screening pelvic examinations in asymptomatic women.[11]
Annual "well-woman visits" are an occasion for gynecologists to identify health risks for women; ACOG has noted that these visits may also include clinical breast examinations, immunizations, contraceptive care discussions, and preventive health care counseling.[2] ACOG reinforced the potential value of pelvic examinations in allowing clinicians to explain a patient's anatomy, reassure her of normalcy, and answer specific questions, thus establishing open communication between patient and clinician.
See also: National Center for Trauma-Informed Care. The examination can be emotionally and physically uncomfortable for women. Preparation, good communication, thoughtful technique, and trauma-informed care can help mitigate this discomfort.[12] [13]
Prior to the exam, before the patient is undressed and lying on the examination table or chair, examiners should ask the patient if she has had a pelvic exam in the past and whether she has any questions or concerns about the exam. Women may be concerned about pain, or they may be embarrassed about the examination of sensitive areas of the body. They may have experienced sexual assault or negative experiences with pelvic examination in the past, which may lead to the exam triggering strong emotional and physical symptoms.[14] Additionally, patients may have concern about odor or menstruation during exam, neither of which should impact the examiner's ability to perform a thorough, respectful exam.[15] Patients generally prefer to be asked about past experiences and are often helpful in suggesting ways to mitigate the discomfort of the exam. Prior to the exam, the examiner should offer to show the patient models or diagrams of the pelvic anatomy and any instruments that will be used during the exam.
Careful preparation is helpful for an efficient and comfortable exam. Prior to asking the patient to position herself on the exam table or chair for examination, the examiner should collect all the instruments needed for the exam and any planned procedures, including the speculum, light source, lubricant, gloves, drapes, and specimen collection media. Warming the speculum with warm tap water or keeping the speculum in a warmer will also increase comfort. The patient should be given the opportunity to have a chaperone or support person in the room during the exam. In general, male examiners should always be accompanied by a female chaperone.
The examiner should explain each step of the exam and its purpose, should address and normalize any concerns, should assert that the patient has full control over the exam, and should ask permission before each step of the exam. The examiner should keep as much of the patient's body covered as possible during the exam. Relaxation of the pelvic muscles can reduce discomfort during the exam. Rather than telling the patient to "relax", which can trigger strong emotions for women who are survivors of assault, patients can be told to breathe slowly and deeply into their abdomens, or which is a more instructive way of describing how to relax the pelvic muscles.[16]
The patient should be informed that she can stop the procedure at any time.[3] If the patient does not want to continue the exam, the examiner should stop, speak with the patient about her concerns and how to mitigate them, and only continue when the patient is ready to do so. However, in all but seven states in the United States, it is legal for pelvic exams to be done under anesthesia without the patient's consent.[17]
The pelvic exam begins with a discussion as described above, and an explanation of the procedure. The patient is asked to put on an examination gown, get on the examination table, and lie on her back with her feet in footrests.[3] Sliding down toward the end of the table is the best position for the clinician to do a visual examination.[18] A pelvic exam begins with an assessment of the reproductive organs that can be seen without the use of a speculum.[19] Many women may want to 'prepare' for the procedure. One possible reason for delaying an exam is if it is to be done during menstruation, but this is a preference of some patients and not a requirement of the clinician. The clinician may want to perform pelvic examination and assessment of the vagina because there are unexplained symptoms of vaginal discharge, pelvic pain, unexpected bleeding, or urinary problems.[20]
The typical external examination begins with making sure that the patient is in a comfortable position and her privacy respected.
Before inserting the speculum, the vaginal wall, urethra, Skene's glands and Bartholin's glands are palpated through the vaginal wall. During the internal exam, the examiner describes the procedure while doing the assessment, making sure that the patient can anticipate where she will feel the palpations.[20]
At this point of the pelvic exam, the examiner will insert the speculum to visualize other internal structures: the cervix, uterus, and ovaries.[21] If this is the first pelvic exam of the patient, the examiner will show the speculum to the patient, explain its use and answer any questions.
The bimanual component of the pelvic examination allows the examiner to feel ("palpate" in medical terms) the structures of the pelvis, including the vagina, cervix, uterus, and adnexae (structures adjacent to the uterus, which include the ovaries and any adnexal masses).[23] [24] The bimanual exam traditionally occurs after the speculum is removed. The examiner explains this part of the exam. From a standing position, the examiner typically applies lubricant to the fingers of the glove of their dominant hand, and the index finger or index finger and middle finger are gently inserted into the vagina. The examiner's opposite hand is place on the patient's abdomen to allow palpation of the pelvic structures; thus the exam is termed a "bimanual: examination". A systematic exam of the pelvic structures allows an assessment of the vaginal introitus (opening), pelvic floor muscles, bladder, rectum, cervix, and the area posterior to the uterus; this portion of the exam is particularly helpful for individuals with pelvic pain, as it allows an assessment of tenderness and an anatomic source of pain. In assessing the uterus, elevation of cervix with the vaginal hand allows palpation of the uterus above the pubic symphysis with the opposite hand, and the size, shape, mobility, contour, consistency, and position of the uterus can be determined. Observing the patient's face during this exam can provide information about the additional characteristic of uterine tenderness, and the patient can also provide verbal feedback. The adnexal structures are similarly palpated, noting any enlargement of the ovaries and if present, the size, shape, mobility, consistency, and tenderness of ovarian/adnexal masses. Normally Fallopian tubes are not palpable.
An additional component of the pelvic examination may include recto-vaginal examination. The examiner puts on a clean glove, and using sufficient lubricant, places the index finger within the vagina and the middle finger within the rectum. This component of the exam assesses rectal tone and lesions such as hemorrhoids, anal fissures, rectal polyps, or masses including carcinoma. It also allows palpation of the recto-vaginal septum, the intra-abdominal area posterior to the uterus (the cul-de-sac or pouch of Douglas), and the adnexal. Nodularity posterior to the uterus along the uterosacral ligaments has been associated with pelvic endometriosis as well as implants of ovarian cancer.
After completion of the exam, the examiner discards their gloves, washes their hands, assists the patient in sitting up, and describes their findings on the examination.
Prenatal care includes pelvic exams during the pregnancy.
The pelvic exam during pregnancy is similar to the exam for non-pregnant women; however, more attention is give to the uterus and cervix. The size of the uterus is assessed at the initial visit, and the growth of the uterus is assessed at subsequent visits. In the first trimester the uterine size can be assessed on bimanual examination. Subsequently, beyond the 12th week of gestation, the uterus can be felt above the pubic bone, and abdominal examinations assess growth.[25] Attention is given to the vulva to assess any perineal abnormalities. A speculum exam is typically performed at the initial visit; the cervix typically appears bluish, which is a sign of increased blood flow. A Pap test may be performed according to guidelines, and testing for Neisseria gonorrhea and Chlamydia trachomatis may be performed as indicated. A bimanual examination during early pregnancy will reveal that the uterus is enlarged, softened and globular; the external os may be dilated, but the internal os is typically closed. The structures adjacent to the uterus will be assessed, along with the size and shape of the bony pelvis. As the due date approaches, assessment of the cervix with bimanual examwill indicate whether the cervix has begun to dilate and soften.