Pelvic examination

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination, why it’s necessary, and obtain consent
• Get a chaperone
• Explain procedure

Tips to help explain procedure

Be impersonal, e.g. ‘It is an internal examination from down below. It will involve placing two fingers into the vagina, and also inserting a small plastic tube to look at the cervix.’

‘It shouldn’t be painful, but if at any point you are uncomfortable or want to stop, just say so. One of the nurses will also be present to ensure you are comfortable and act as a chaperone.’

Patient should be lying flat in lithotomy position but remain covered initially: ‘You will need to undress from the waist down, put your heels together and bring them as close to your bottom as possible, then flop your knees outwards.’

• Allow patient to get undressed and then cover themself with a sheet in privacy – they should call you back in the room/curtained area when ready
• Ask a few questions before starting: last menstrual period, intra-menstrual bleeding, discharge, contraception, last smear
• Ask if patient needs to use the toilet before the procedure

NB: keep talking to and reassuring the patient using their name throughout.

External examination

• Basic lower abdominal exam: inspect for distension/scars; feel for masses/tenderness; feel groin for inguinal lymphadenopathy 
• Put on gloves
• Part labia with forefinger and thumb of left hand
• Inspect vulva: tumours, lesions, warts/ulcerations, cysts (sebaceous/Bartholin’s), erythema, atrophy, labial fusion, whitening, scarring, discharge, bleeding
• Ask patient to cough to assess for uterovaginal prolapse

Speculum examination (± swabs)

• Warm the speculum if necessary with warm water, lubricate the sides, and warn the patient prior to insertion
• Part the labia and insert the speculum with the screw sideways
• Rotate speculum as you advance it so that the screw is facing upwards. Open speculum and tighten screw when resistance is met.
• Direct light to visualise cervix and look for: discharge, erosions, ulcerations, growths, cervicitis, blood, polyps, ectropion
• Take swabs at this point if required (see procedure notes on gynaecological swabs)
• Close speculum blades (but not fully to avoid pinching vaginal wall) 
• Remove speculum while rotating it back sideways

Internal (bimanual / PV) examination

• Explain and reassure patient
• Lubricate fingers
• Part labia with non-dominant hand, and insert your dominant hand’s index finger first, then introduce middle finger. Enter with palm facing sideways then rotate so it is facing up.
• With the two fingers facing upwards, move along posterior wall of vagina. Move up and over cervix (cervical excitation = pelvic inflammatory disease or ectopic pregnancy), and gently palpate it (smoothness, bleeding propensity, mobility, firmness).
• Now place one finger under cervix and push upwards, while simultaneously pushing down on the lower abdomen to depress the fundus with your other hand
  • Assess uterus size (enlargement = pregnancy, fibroids, malignancy, endometrial fluid collection)
  • Determine if anteverted or retroverted (fundus palpable in posterior fornix)
  • Note tenderness, mobility, shape
• Now place fingers in each lateral fornix in turn, while simultaneously pushing down in the ipsilateral iliac fossa with the other hand to feel for adnexal tenderness (salpingitis, ovarian torsion, ectopic pregnancy) and masses
• Remove fingers slowly and inspect for blood or discharge
• Give patient gauze to wipe off lubricant

To complete

• Thank patient and allow them to get dressed in privacy
• Summarise and suggest further investigations you would consider after a full history

Viva questions

Please list some gynaecological causes of pelvic pain

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Please list some causes of abdominal pain in pregnancy

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Which investigations would you consider to investigate pelvic pain?

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Can you name the different types of genitourinary prolapse?

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Try some OSCE stations

1. Pelvic examination
2. Gynaecological swabs
3. Subscribers can find more here