Vaginal (Bimanual) Exam

10. Vaginal Examination - Withdrawing

1. Warn the patient that you are about to withdraw your fingers. 2. Withdraw your fingers and inspect the glove for blood or abnormal discharge. 3. Cover the patient with the sheet, explain that the examination is now complete and provide the patient with privacy so they can get dressed. Provide paper towels for the patient to clean themselves. 4. Dispose of the used equipment into a clinical waste bin.

4. Vulval inspection

Same as in smear exam

3. Abdominal Examination

An abdominal examination should always be performed before moving onto vaginal examination. This may be less thorough than a full abdominal examination, but should at least include inspection and palpation of the abdomen. I.e ask examiner if abdo exam is needed before

What is an anteverted uterus ?

Anteverted: the uterus is orientated forwards towards the bladder. This is the most common position of the uterus.

9. Vaginal Examination - Ovaries and Uterine tubes

Bimanually palpate the adnexa: 1. Position your internal fingers in the left lateral fornix. 2. Position your external hand onto the left iliac fossa. 3. Perform deep palpation of the left iliac fossa whilst moving your internal fingers upwards and laterally (towards the left). 4. Feel for any palpable masses, noting their size and shape (e.g. ovarian cyst, ovarian tumour, fibroid). 5. Repeat adnexal assessment on the right.

8. Vaginal Examination - The Uterus

Bimanually palpate the uterus: 1. Place your non-dominant hand 4cm above the pubis symphysis. 2. Place two of your dominant hand's fingers into the posterior fornix. 3. Push upwards with the internal fingers whilst simultaneously palpating the lower abdomen with your non-dominant hand. You should be able to feel the uterus between your hands. You should then assess the various characteristics of the uterus.

2. Gather equipment

Gloves Lubricant Paper towels

6. Vaginal Examination - Vaginal walls

Palpate the walls of the vagina for any irregularities or masses.

7. Vaginal Examination - The cervix

Position (e.g. anterior or posterior) Consistency (e.g. irregular, smooth) Cervical motion tenderness: involves severe pain on palpation of the cervix.

What is a retroverted uterus ?

Retroverted: the uterus is orientated posteriorly, towards the spine. This is a less common uterine position present in approximately 1 in 5 women.

What characteristics of the uterus should you assess ?

Size: the uterus should be approximately orange-sized in an average female. Shape: may be distorted by masses such as large fibroids. Position: the uterus may be anteverted or retroverted. Surface characteristics: note if the uterus feels smooth or nodular. Tenderness: may suggest inflammation (e.g. pelvic inflammatory disease, ectopic pregnancy). The Philipines Social Security Service

11. Closing

Thank the patient for their time. Dispose of PPE appropriately and wash your hands. Summarise your findings. Document the examination in the medical notes including the details of the chaperone.

What does the term adnexa refer to ?

The areas incoroporating the fallopian tubes AND ovaries

8. Vaginal Examination - The fornices

The fornices are the superior portions of the vagina, extending into the recesses created by the vaginal portion of the cervix. Gently palpate lateral fornices for any masses.

13. Further assessments and investigations

Urinalysis: including β-HCG to rule out pregnancy (including ectopic pregnancy). Speculum examination: to visualise the vaginal canal and cervix. Vaginal swabs/endocervical swabs: if there are concerns about infection (bacterial and viral). Ultrasound abdomen and pelvis: to better visualise any masses palpated and to assess endometrial thickness. Complete abdominal examination: if there are concerns about intraabdominal pathology (e.g. appendicitis).

5. Vaginal examination - Insertion

Warn the patient you are going to examine the vagina and ask if they're still ok for you to do so. If the patient consents to the continuation of the examination: 1. Lubricate the gloved index and middle fingers of your dominant hand. 2. Carefully separate the labia using the thumb and index finger of your non-dominant hand. 3. Gently insert the gloved index and middle finger of your dominant hand into the vagina. 4. Enter the vagina with your palm facing laterally and then rotate 90 degrees so that your palm is facing upwards.

1. Introduction

Wash your hands and don PPE if appropriate. Introduce yourself to the patient including your name and role. Confirm the patient's name and date of birth. Explain what the examination will involve using patient-friendly language. Explain the need for a chaperone Gain consent to proceed Ask patient if they could pregnant or if they have any pain before proceeding Provide the patient with the opportunity to pass urine before the examination. Explain to the patient that they'll need to remove their underwear and lie on the clinical examination couch, covering themselves with the sheet provided. Provide the patient with privacy to undress and check it is ok to re-enter the room before doing so.

What conditions can cause cervical motion tenderness ?

may suggest pelvic inflammatory disease or ectopic pregnancy.

Indications for a bimanual exam ?

unexplained pelvic pain irregular vaginal bleeding abnormal vaginal discharge part of the assessment of a pelvic mass.

How to gain consent to proceed ?

"Do you understand everything I've said? Do you have any questions? Are you happy for me to carry out the examination?"

How to explain need for a chaperone ?

"One of the female ward staff members will be present throughout the examination, acting as a chaperone, would that be ok?"

12. Summarising

"Today I examined Mrs Smith, a 28-year-old female. On general inspection, the patient appeared comfortable at rest. There were no objects or medical equipment around the bed of relevance." "Abdominal examination was unremarkable and there were no abnormalities noted on inspection of the vulva. Bimanual examination revealed an anteverted uterus of normal size and shape. There were no masses palpated in the vaginal canal or adnexa." "In summary, these findings are consistent with a normal vaginal examination." "For completeness, I would like to perform the following further assessments and investigations."

How to explain the procedure ?

"Today I need to carry out a vaginal examination. This will involve me using one hand to feel your tummy and the other hand to place two fingers into your vagina. This will allow me to assess the vagina, womb and ovaries. It shouldn't be painful, but it will feel a little uncomfortable. You can ask me to stop at any point."