IVMS ICM-Physical diagnosis- FM Pelvic Exam

1. 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
Page 1

2. 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
Page 2

3. 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
Page 3

4. 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.
Examination of the Female Pelvis
Page 4

5. 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.
Examination of the Female Pelvis
Page 5