Examination of the Female Pelvis

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Physical Diagnosis

Examination of the Female Pelvis

Marc Imhotep Cray, M.D.

For definitive study refer to Bates' Pocket Guide to Physical

Examination and History Taking by Lynn S. Bickley

Contents Outline

Equipment Needed

General Considerations Positioning the Patient

External Exam Internal Exam

Speculum Exam Bimanual Exam

Notes

Equipment Needed

Exam Table Equiped with Stirrups

Flexible Light Source Vaginal Specula in Various Sizes

Warm Running Water Lubricating Jelly

General Considerations

The patient must have an empty bladder. The patient must be appropriately gowned and draped.

Examination of the Female Pelvis

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Use non-sterile gloves on both hands. Double-glove your dominant hand if you intend to perform a rectal or rectovaginal

exam. [1] Properly dispose of soiled equipment and supplies.

Both male and female examiners should be chaperoned by a female assistant.

Always tell the patient what you are about to do before you do it.

The breast exam is usually done just before routine pelvic exams.

Positioning the Patient

1. Start with the patient lying supine on the exam table with the

head elevated 30 to 45 degrees. [2] 2. Assist the patient to place her heels in the stirrups. Adjust the

angle and length to "fit" the patient. 3. Have the patient slide her hips down until she contacts your

hand at the edge of the table. 4. Have the patient relax her knees outward just beyond the angle

of the stirrups.

External Exam

1. Uncover the vulva by moving the center of the drape away from

you. Try to avoid creating a "screen" with the drape pulled tight between the patient's knees.

2. Announce what you are going to do and then touch the patient

on the thigh with the back of your hand before proceeding. 3. Inspect the outer genitalia for redness, swelling, lesions, masses,

or infestations. 4. Gently palpate the labia majora and minora.

5. Inspect the labia, the folds between them, and the clitoris. 6. Note any redness, swelling, lesions, or discharge.

7. Reassure the patient, if the exam is normal so far, say so.

Examination of the Female Pelvis

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Internal Exam

Speculum Exam

1. Warm and lubricate the speculum by holding it

under running tap water. 2. Announce what you are going to do and then touch

the patient on the thigh with the speculum before proceeding.

3. Expose the introitis by spreading the labia from below using the index and middle fingers of the non-dominant

hand (peace sign). 4. Insert the speculum at a 45 degree angle pointing slightly

downward. Avoid contact with the anterior structures. 5. Once past the introitis, rotate the speculum to a horizontal

position and continue insertion until the handle is almost flush with the perineum.

6. Open the "bills" of the speculum 2 or 3 cm using the thumb lever. Position the bills so that the cervix "falls" in between.

7. Secure the speculum by turning the thumb nut (metal speculum)

or clicking the ratchet mechanism (plastic speculum). Do not move the speculum while it is locked open.

8. Observe the cervix and vaginal walls for lesions or discharge. Obtain specimens for culture and cytology as indicated. [3]

9. Withdraw the speculum slightly to clear the cervix. Loosen the speculum and allow the "bills" to fall together. Continue to

withdraw while rotating the speculum to 45 degrees. Again, avoid contact with the anterior structures.

10. Replace the drape while you prepare for the rest of the exam.

11. Reassure the patient, if the exam is normal so far, say so.

Examination of the Female Pelvis

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Bimanual Exam

1. Apply a small amount of lubricant to the index and middle fingers of your dominant hand.

2. Uncover the vulva and lower abdomen by moving the center of the drape away from you.

3. Announce what you are going to do and then touch the patient on the thigh with the back of your hand before proceeding.

4. Spread the labia and insert your lubricated index and middle

fingers into the vagina. Avoid contact with the anterior structures.

5. Place your other hand on the patient's lower abdomen. 6. Examine the cervix:

1. Palpate the cervix with your index finger noting size, shape, and consistency.

2. Gently move the cervix side to side between your fingers and note mobility and tenderness. [4]

3. Gently lift the cervix forward and note mobility and tenderness. [4]

7. Examine the anterior uterine fundus: 1. Continue to lift the cervix with the vaginal hand.

2. Press downward with the abdominal hand and palpate the uterus (if possible). [5]

3. Note consistancy and tenderness. Attempt to estimate

uterine size. 8. Examine the adnexal structures:

1. Pull back vaginal hand to clear cervix. 2. Reposition vaginal hand into the right fornix, palm up.

3. Sweep the right ovary downward with the abdominal hand 3 or 4 cm medial to the iliac crest.

4. Gently "trap" the ovary between the fingers of both hands (if possible). Note its size and shape along with any other

palpable adnexal structures. [5] 5. Pull back and repeat on the left side.

9. Replace the drape and assist the patient to remove her feet from the stirrups and sit up.

10. Reassure the patient, if the exam is normal, say so.

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11. Leave the room and allow the patient to dress before

continuing with the consultation.

Notes

1. The rectal and rectovaginal exam are part of normal pelvic

examinations, but are not covered here. See page 390 in Bates for more information.

2. For more information refer to A Guide to Physical Examination and History Taking, Sixth Edition by Barbara Bates, published by

Lippincott in 1995.

3. You will obtain a Papanicolaou (Pap) smear and other specimens as part of most pelvic exams. Pap smears are analyzed for

cervical cancer cells by a cytology technician under the supervision of a pathologist.

4. Tenderness with cervical motion is an important sign of pelvic disease. You should both observe the patient's face and ask

her if the examination is painful in any way. 5. Your ability to palpate the uterus and ovaries will depend on the

patient's anatomy, the size of your hands, and your level of skill.