Pelvic examination
The speculum examination is followed
by the examination of the vagina,
cervix and uterus.
Learning Outcomes
Able to perform a pelvic examination in a
methodical way
Procedure before examination.
GRIP
Obtain her verbal consent
Explain that you are about to perform an
internal examination of the vagina and the
uterus using fingers.
Explain to her that it shouldn't be painful
and ask her to let you know if there's any
pain
Procedures before examination
Ask her to empty bladder beforehand.
Assure privacy and ask for a chaperone.
Draw the curtains
Ask to lie on the couch and undress, waist down
Sheet for dignity
Position her on back, hips and knees flexed and
thighs abducted.
Examine abdomen for any mass and be sure
bladder is empty.
Examination.
Inspect external genitalia
warts
rashes
ulcers
lumps
vesicles
excoriation
Bartholin’s abscess
Bartholin’s Cyst
Candida
excoriation
Lichen sclerosus
Condylomata accuminata (genital
warts)
Vulval intraepithelial neoplasia
(VIN)
Vulval carcinoma
Vulval carcinoma
Lubricate the right index and middle fingers.
Expose introitus by separating labia with thumb
and forefinger of gloved left hand.
Gently introduce gloved lubricated right index
and middle fingers into vagina.
Thumb abducted to allow maximum use of
length of the index & middle fingers; ring & little
fingers flexed into palm.
Introitus
Clitoris
Labium minus
Labium majus
External urethral orifice
Vagina
Anus
Examination.
Ask the patient to cough - urinary
incontinence
Ask the patient to bear down - uterine
prolapse.
Palpate the vaginal wall as you
introduce the fingers
mass, cyst or foreign bodies.
the vaginal walls are rugose and moist.
Examination
Palpate anterior
posterior
both lateral walls of vagina
fornices ? obliterated or bulging
due to a pelvic swelling
Examination of the cervix.
Locate the cervix with pulps of your fingers
Normally points downwards and slightly
backwards.
Cervix should feel firm, rounded and smooth.
Assess mobility - move cervix gently
Palpate the fornices.
This procedure is painless.
Tenderness is called “cervical excitation.”
Anatomical relations
Sigmoid colon
Uterine tube
Ovary
Uterus
Cervix
Urinary bladder
Pubic symphysis
Vagina
Rectum
Bimanual examination
Uterus
Place palmar surface of your free hand on the anterior
abdominal wall ~ 4cm above pubic symphysis.
Attempt to capture the uterus between your opposing
fingers
Use inner fingers to elevate cervix and uterus in direction
of external hand while simultaneously pressing the
fingers of the external hand in the direction of the internal
fingers.
Bimanual examination
Assess:
Size
Position
Consistency
Mobility
Mass
Tenderness.
Bimanual examination.
Palpate the adnexae.
Difficult to palpate in obese women.
Place the fingers of your free hand on the
iliac fossa while readjusting the vaginal
fingers, into the lateral fornix
Feel for the adnexal structures as they slip
between your fingers.
Bimanual examination.
Should not be painful
Palpation of ovaries may elicit discomfort
If you feel an adnexal structure, assess:
Size
Shape
Mobility
Tenderness.
Ovaries are firm, ovoid and often palpable
Normal fallopian tubes are impalpable.
Bimanual examination.
Withdraw your fingers.
Consider a rectal examination.
Rectovaginal examination sometimes
better for palpating ovaries
Give her a towel or tissue to wipe herself.
Replace sheet and leave to dress.
Explain findings once dressed.
Summary
GRIP
Consent and chaperone
Inspect
Palpate vagina, cervix and fornices
Bimanual palpation
Uterus
Adnexae
Inspect glove
Offer patient tissue
Cover patient
Report findings to patient when dressed
