pelvic examination, a diagnostic procedure in which the external and internal genitalia are physically examined by inspection, palpation, percussion, and auscultation. It should be performed regularly throughout a woman’s life. See also female reproductive system assessment. ▪ METHOD: The woman empties her bladder, disrobes, and puts on an examining gown. Breast examination is often carried out before the pelvic examination. The woman is made as comfortable as possible in the dorsal lithotomy position, her feet in stirrups and her buttocks at the very edge of the foot of the examining table, and is then draped. Particular attention is paid to the suprapubic area to detect any masses extending from the pelvis above the symphysis and to the groin to detect inguinal lymphadenopathy or hernia. If a mass is felt, percussion may be performed to delineate it. If pregnancy is suspected, palpation and percussion of the uterus and auscultation of fetal heart tones are attempted. The examiner then moves to the stool at the foot of the table between the patient’s legs. The labia majora are spread apart to permit inspection of the clitoris, the urethral meatus, the labia minora, and the vaginal vestibule. Any swelling, discoloration, lesion, scar, cyst, discharge, or bleeding is noted. Skene’s and Bartholin’s glands and ducts are palpated and milked, and any secretions expressed are evaluated and a specimen is spread on culture medium. The urethra is assessed for color and shape. The tone of the perineal and paravaginal musculature is assessed. Cystocele, rectocele, or varying degrees of uterine descensus may be observed as the woman is asked to bear down. The speculum is warmed, lubricated with warm water, and introduced gradually. The examiner is careful to direct the speculum along the axis of the vagina, which is at an angle of approximately 45 degrees to the axis of the table if the woman is lying flat. The speculum may need to be moved lightly from side to side to slip it over the vaginal rugae. The woman is advised that she may feel a stretching sensation. The speculum is gently opened and its position is adjusted to hold the vaginal folds out of the way to reveal the cervix. The color and condition of the vaginal epithelium are observed, and the position, size, and quality of the superficial epithelium are evaluated. Specimens for bacteriological study are obtained before the Papanicolaou (Pap) test. For the Pap test, scrapings of the endocervix and the cervix and a sample of the vaginal secretions may be secured on a Pap stick and an applicator and lightly spread on labeled glass slides. The slides are immediately sprayed or dipped into a fixative. Another method is a liquid-based Pap test, in which the endocervical and cervical secretions are sampled with a collection device and then deposited into a solution. The slide is made at the laboratory. This liquid may also be tested for human papillomavirus, which is known to be a causative factor for cervical cancer. The speculum is then closed, rotated slightly, removed from the vagina, and, if not disposable, rinsed or placed directly into a germicidal solution. In the bimanual part of the examination, two gloved fingers are well lubricated and inserted slowly and gently into the vagina. The examiner uses the opposite hand to apply pressure to the lower abdomen in several positions and directions to move the uterus, tubes, and ovaries into positions in which they may be felt. The size, shape, position, mobility, and consistency of the organs and tissues are evaluated, and any tenderness or discomfort is noted. Rectal or rectovaginal examination is then performed. Before the insertion of a finger in the anus, lateral pressure is applied to the sphincter, and the woman is urged to bear down lightly to relax the muscle and minimize discomfort. ▪ INTERVENTIONS: Minor thoughtlessness or inadvertent movement may cause tension and make the examination more difficult for the woman and for the examiner. Instruments, culture materials, a light, drapes, and a gown are all made ready beforehand. The table, instruments, and drapes are clean and warm. Materials from previous examinations are not in evidence. The woman is forewarned of what to expect at each step of the examination. Gentleness and quietness are exercised at all times. On completion of the examination the woman is helped to slide well back on the table before sitting up. Syncope after pelvic examination is uncommon but not rare; there is risk of injury should the patient faint and fall from the examining table. The woman is observed briefly after sitting up before being left alone. She is then given tissues, a sanitary napkin or tampon, and a private area in which to dress. ▪ OUTCOME CRITERIA: Pelvic examination may demonstrate many pelvic abnormalities and diseases. Cytological and bacteriological specimens are conveniently obtained. A pelvic examination cannot be satisfactorily performed without the cooperation of the woman being examined. Inadequate relaxation, obesity, extensive scarring, pelvic tenderness, and heavy vaginal discharge also may preclude an adequate examination.
