Performing a Pelvic Examination
Aims and objectives
The aim of this section is to enable the student to undertake a competent pelvic
examination with sensitivity to the needs of the patient.
Gaining permission
A chaperone should always be present. Consider the need for an interpreter
if English is not the patient's first language. Using clear and simple terms
understandable to the patient, explain the need to perform a pelvic examination.
Discuss the procedure with her and obtain her permission to proceed. Ask her
to empty her bladder if appropriate to minimise any discomfort during the examination.
Provide privacy for her to change and provide suitable cover for her.
Preparing the room
Gather equipment and ensure that the area is prepared before commencing the
procedure. Include:
- light source that is placed in an appropriate position
- speculum
Performing the examination
Perform a general gynaecological examination as indicated by the patient's
history. An abdominal examination is essential prior to any pelvic examination.
This allows the patient to relax and is itself necessary to fully evaluate any
pelvic problem.
Uncover the abdomen from xiphisternum to the pubic hairline, ensuring adequate
exposure while allowing for patient modesty. Abdominal wall relaxation is maximised
by the patient resting her arms alongside her abdomen, rather than behind her
head. The abdomen is initially thoroughly inspected. In particular, the presence
of a visible mass, abnormal abdominal contour, distension, scars, pigmemtation
or other skin lesions are noted. Gentle superficial palpation is then performed.
Deep palpation is carried out to detect any tenderness, guarding, organomegaly
(liver or spleen) or abnormal masses (uterine fibroids, ovarian tumour). Any
identified abnormal masses should be described in terms of location, size, consistency,
tenderness and mobility.
In the case of the acute abdomen, rebound tenderness is elicitied to detect
peritonism and auscultation should be performed.
Bi-manual examination of the pelvic organs
Prior to pelvic examination, don examination gloves. A modesty sheet is placed
on the patient’s abdomen. The patient is examined in a supine position, with
her hips and knees flexed, the ankles approximated and the knees allowed to
be a distance apart. Inspect the vulva and peri-anal region. Note skin lesions
of erythema, ulcers, leukoplakia or condylomata and the presence of any vaginal
discharge.
Using the non dominant hand the labia are gently parted. Using the dominant
hand and lubricating gel, gently introduce first the index and then both index
and middle fingers into the vagina. Identify the location of the cervix – the
cervix of an anteverted uterus is directed posteriorly and that of a retroverted
uterus anteriorly. Feel the cervix for the shape of the internal os, and the
presence of any polyps or cervical growths. With the examiner’s non dominant
hand on the lower abdomen the cervix is gently rocked forwards and backwards
to assess uterine mobility. The size of the uterus is then assessed and the
presence of any fibroids noted.
In evaluation of the acutely tender pelvis cervical excitation is elicited
by moving the cervix from side to side, thus disturbing the adnexal organs and
overlying peritoneum. A positive sign is the elicitation of acute sharp pain.
The examiner's non dominant hand is placed in the right lumbar region and the
vaginal examining fingers in the right vaginal fornix. The non dominant hand
is gradually brought down to the right inguinal region to meet the other hand.
The normal ovary should be felt as an almond size mobile structure slipping
between the examining hands as they are approximated. It is important to place
the examining hand initially high in the abdomen, in order to avoid displacing
upwards a mobile ovarian cyst. Any identified abnormal adnexal masses should
be described in terms of size, consistency, tenderness, mobility and separation
from the uterus. The patient's left adnexal area is similarly examined.
Finally the pouch of Douglas is examined for masses and the uterosacral ligaments
palpated. Any nodularity of these ligaments is noted.
Vaginal examination to detect uterovaginal prolapse
The patient should be examined in the left lateral position. A Sim's speculum
is gently introduced into the vagina. Pressure on the posterior vaginal wall
exposes the anterior vaginal wall. The presence and size of any urethrocoele
or cystocoele is noted. The cervix may also be inspected in this position.
Should uterine descent be sought, the examiner should warn the patient, that
she may experience momentary discomfort as an instrument (volsellum) is placed
on the cervix to exert traction. The degree of uterine descent is noted. The
volsellum is then removed.
The vaginal epithelium is examined for erythema, atropic changes, ulceration
or other abnormal findings. The speculum is withdrawn and reinserted, this time
placing gentle pressure on the anterior vaginal wall to expose the posterior
vaginal wall. The presence and size of any rectocoele or enterocoele is noted.
If the uterus is absent, the presence of a vaginal vault prolapse is sought.
Completing the procedure
Allow the patient to dress in privacy. Explain the findings of the examination
and discuss further management with the patient. Arrange follow up.
Dispose of equipment.
Documentation
If swabs for infectious agents, Pap smear or other specimens are taken then
clearly fill the pathology request form as required. Include details of patient’s
name, identifying chart number, date of birth, date of last menstrual period
and clinical condition warranting the specific investigation. Sign the form.
Useful Websites:
See "Royal College of Obstetricians and Gynaecologists - Intimate Examinations
- Report of a Working Party" 22/03/01 for information on vaginal speculum examination
and bimanual palpation of the female internal genitalia. This report is available
on the website of The Royal College of Obstetricians and Gynaecologists
http://www.rcog.org.uk/intimate_examin.html
See also Canadian STD Guidelines: 1998 Edition. This publication has a section
on the collection of specimens including Pap Smear. Go to Health Canada Online:
http://www.hc-sc.gc.ca/
Select English Translation. This will bring up "Health Canada Online" website.
In the fast find section click on Sexuality/STDs. This will take you to a site
for sexually transmitted infections. Choose Canadian STD Guidelines: 1998. Then
select the PDF version of the report. Pages 49 – 56 contain a section on the
collection of specimens including Pap Smear which is on page 52.
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