PELVIC EXAMINATION

LIEZEL B. CAUILAN MSN,MST

● A pelvic examination is the physical examination of
the external and internal female pelvic organs.
● 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). It can also be used
assess a patient's anatomy in preparation for
procedures.
● The most commonly performed components
of the exam are 1) the external exam, to
evaluate the external genitalia 2) the
internal exam with palpation (commonly
called the bimanual exam) to examine the
uterus, ovaries, and fallopian tubes, and 3)
the internal exam using the speculum to
visualize the vaginal walls and cervix.
Preparation
● Prior to the exam, before the patient is
undressed and lying on the table,
examiners should ask the patient if they
have had a pelvic exam in the past and
whether they have any questions or
concerns about 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. 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.
● If at any point the patient does not want to
continue the exam, the examiner should stop,
speak with the patient about their concerns
and how to mitigate them, and only continue
when the patient is ready to do so.
● Relaxation of the pelvic muscles can reduce discomfort
during the exam.
● Patients can be told to breathe slowly and deeply into
their abdomens, which is a more instructive way of
describing how to relax the pelvic muscles.
● Careful preparation is helpful for an efficient and
comfortable exam. Prior to asking the patient to position
themselves on the exam table, 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 can 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.
EXTERNAL EXAMINATION

● The pelvic exam begins with an explanation of the procedure.

● The woman is asked to put on an examination gown, get on the
examination table, lay on her back with her feet in stirrups.
● Sliding down toward the end of the table is the best position for the
clinician to do a visual examination.
● 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.
● The typical external examination begins with
making sure that a woman is in a comfortable
position and her privacy respected.
● In some instances, different positioning and
assistance may be required to keep tissue
from blocking the view of the perineal area.
The pubic hair is inspected for pubic lice and
hair growth patterns
The labia majora are evaluated.
Their position and symmetry are
assessed. The expected finding
in older women is that the labia
majora can be thinner and
smaller. The examiner is looking
for ulcers, inflammation, warts
and rashes. If drainage is
present from these structures,
its color, location and other
characteristics are noted.
Infection control is accomplished
by frequent glove changes.
● The labia minora are then evaluated. They
should appear moist, smooth in texture and
pink. The presence of tearing, inflammation
and swelling is noted. Thinner and smaller
labia minora are an expected finding in older
women.
● The clitoris is assessed for size, position,
symmetry, and inflammation.
● The urethral opening is inspected. No urine should leak when
the woman is asked to cough. Urine leakage may indicate stress
incontinence and the weakening of pelvic structures. The
opening should be midline, pink, and smooth. The presence of
inflammation, or discharge which may indicate an infection.
Excoriation can be present in obese women due to urinary
incontinence.
● The vaginal opening is inspected for position, presence of the
hymen, and shape. The presence of bruising, tearing,
inflammation and discharge. Pelvic examinations are usually
procedures that are designed to obtain objective, measurable
descriptions of what is observed.
● If sexual abuse is suspected, questions
regarding this is discussed after the examination
and not during it. When the woman is requested
to ‘bear down’, the presence of prolapsed
structures such as the bladder (cystocele),
rectum (rectocele) or uterus are documented.
Prolapsed structures can appear when
abdominal pressure increases or they can
protrude without bearing down.
● The perineum, the space between the vagina
and the anus, is inspected. It should be smooth,
firm, and free of disease. Scars from
episiotomies are visible on women who have
had the procedure during childbirth.
● The anus is assessed for lesions, inflammation
or trauma. It should appear dark, continuous
and moist. In some women, excoriation may be
present, and can be a sign of fecal incontinence
● A swab or cytobrush
will be used to collect
or scrape cervical cells
off of the surface of the
cervix to be evaluated
for changes. Other
vaginal swabs can be
taken at this time to test
for sexually transmitted
diseases.
INTERNAL EXAMINATION

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 woman can
anticipate where she will feel the
palpations.
● The woman is first informed that
the examiner will insert their finger
into the vagina.
● The palpation of the vagina is
done by evaluating the condition of
the vaginal walls. These should
feel smooth, consistent and soft.
The rugae can also be assessed
by palpation. The woman is again
asked to bear down while the
examiner continues the internal
examination. The presence of
bulging is assessed.
● The position of the ● The Bartholin glands
urethra is assessed by
are also assessed
palpation with a finger
internally by gently
through the vaginal wall.
squeezing them with
The Skene's glands,
one finger placed
located on each side of
externally, on the
the urethra are palpated
posterior labia majora
to produce secretion
and the other finger in
from the glands.
the vagina.
● At this point of the pelvic
exam, the examiner will
insert the speculum to
visualize other internal
structures: the cervix,
uterus, and ovaries. If this
is the first pelvic exam of
the woman, the examiner
will show the speculum to
the woman, explain its use
and answer any questions.
● The appropriate sized
speculum is selected. The
speculum is slowly inserted in
its collapsed state at a forty-
five degree angle to match
the slope of the vagina. The
blades are then expanded
until the cervix comes into
view. If the speculum is
transparent, the vaginal walls
can be seen.
● The next part of
the pelvic exam is
the bimanual
palpation and
begins after the
speculum is
removed.
● The cervix is then assessed.
It should look moist, round,
pink, and centered to the
middle. The secretions of the
cervix should be clear or
whitish with no odor. The
presence or absence of
polyps, ulcers, and
inflammation are noted.
● The examiner informs and explains
this part of the exam. ● If the examiner can feel the fallopian
● Two fingers are used to palpate tubes, this is not a normal finding.
the cervix. The cervix and fornices ● If the examiner can feel the fallopian
tubes, this is not a normal finding.
are assessed for mobility and the
● The rectum is assessed by having
presence of lumps.
one finger in the vagina and the
● The uterus is palpated and
other in the rectum. The rectum
evaluated to determine its position should be smooth.
by leaving the fingers of one hand ● The examiner removes their fingers,
in the vagina while pressure to the discards their gloves, washes their
abdomen is applied with the other hands and helps the women get into
hand. If the body tissue is too thick an upright position. Any deviations
due to obesity, an ultrasound may from what is considered normal will
be performed instead. be discussed.