Pelvic examination


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 the external exam, to evaluate the external genitalia 2) the internal exam with palpation the internal exam using the speculum to visualize the vaginal walls and cervix. During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer.
The examination can be emotionally and physically uncomfortable for patients. Good communication, thoughtful technique, and trauma-informed care can help mitigate this discomfort.
Some clinicians perform a pelvic exam as part of routine preventive care. However, in 2014, the American College of Physicians published guidelines against routine pelvic examination in adult women who are not pregnant and lack symptoms, with the exception of pelvic exams done as part of cervical cancer screening.

Medical uses

Previous to July 2014 the benefits of routine pelvic examinations were not clear and there was no consensus. Since then, American College of Physicians issued a guideline recommending against performing this examination to screen for conditions in asymptomatic, nonpregnant, adult women. The ACP said that there was no evidence of benefit in support of the examination, but there was evidence of harm, including distress and unnecessary surgery. This was a strong recommendation, based on moderate-quality evidence. In 2018, the American College of Obstetricians and Gynecologists symptoms of gynecologic disease, 2) screening for cervical dysplasia, or 3) management of gynecologic disorders or malignancy, using shared decision-making with the patient. ACOG concluded there is inadequate data to support recommendations for or against routine screening pelvic examination for asymptomatic, non-pregnant women with average risk for gynecologic disease.
Annual well-woman exams are an occasion for gynecologists to recognize issues like incontinence and sexual dysfunction, and discuss patient concerns, and an exam can be done if indicated by the clinical history

Preparation, communication, and trauma-informed care

The examination can be emotionally and physically uncomfortable for patients. Preparation, good communication, thoughtful technique, and trauma-informed care can help mitigate this discomfort.
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. Patients may be concerned about pain, or they may be embarrassed about the examination of sensitive areas of the body. They may have experienced sexual assault or negative experiences with pelvic examination in the past, which may lead to the exam triggering strong emotional and physical symptoms. Additionally, patients may have concern about odor or menstruation during exam, neither of which should impact the examiner's ability to perform a thorough, respectful exam. Patients generally prefer to be asked about past experiences and are often helpful in suggesting ways to mitigate the discomfort of 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. Rather than telling the patient to "relax," which can trigger strong emotions for patients who are survivors of assault, patients can be told to breath 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. A pelvic exam begins with an assessment of the reproductive organs that can be seen without the use of a speculum. Many women may want to 'prepare' for the procedure. One possible reason for delaying an exam is if it is to be done during menstruation, but this is a preference of some women and not a requirement of the clinician. 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.
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.
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 next part of the pelvic exam is the Bimanual palpation and begins after the speculum is removed.
The examiner removes their fingers, discards their gloves, washes their hands and helps the women get into an upright position. Any deviations from what is considered normal will be discussed.

During pregnancy

Prenatal care includes pelvic exams during the pregnancy. Women with high risk pregnancies see their obstetrician more often. These are:
The pelvic exam during pregnancy is similar to the exam for non-pregnant women. One difference is that more attention is give to the uterus and cervix. The growth of the uterus is measured each visit, although this does not require a pelvic exam. As the due date approaches, the assessment of the cervix will indicate whether labor has begun or is progressing. Much time is spent determining the health of the fetus. A normal finding during the exam on the pregnant woman is that the cervix has a bluish tinge in early pregnancy. If a bluish tinge is observed in the non-pregnant women, this is a sign of hypoxia.

Informed consent

Part of the procedure is to inform the woman that she can stop the exam at any time.
However in all but seven states in America it is legal for pelvic exams to be done under anesthesia without the patient's consent.