Learning Objectives #
1- To understand the role and importance of an abdominal exam during a pelvic exam
2- To be aware of the proper positioning and draping of the patient for a pelvic examination
3- To be able to perform a bimanual pelvic examination using proper technique and understand the size, shape , and consistency of the uterus and adnexa
Introduction #
An abdominal examination should be done at the beginning of every pelvic examination. The abdominal examination provides necessary clinical information and allows for the exam to proceed initially on a more neutral and less vulnerable part of the body.
The bimanual pelvic examination is used to palpate the uterus and adnexa. Lower the head of the examination table to 15 degrees or flat, depending on the patient’s preference. In general, the right hand is inserted into the vagina and the left hand palpates the abdomen, but this is a matter of personal preference.
Technique:
The physician should stand between the patient’s legs. To avoid contamination of the patient’s abdomen when switching from the speculum exam to the bimanual exam remove or replace the glove on your nondominant hand. A suitable jelly lubricant is held in the left hand and a small amount is dropped from the tube onto the examiner’s gloved right index and middle fingers. The examiner should not touch the tube of lubricant to the gloves because the lubricant will be contaminated. The patient is told that the internal examination will now begin.
As the bimanual examination is being performed, the examiner should observe the patient’s face. Her expression will quickly reveal whether the examination is painful. The labia are spread and depending on the diameter of the introitus and the patient’s comfort level, the examiner may be able to insert the right index and middle fingers into the vagina for bimanual palpation. If the introitus is small, the examiner should introduce the right middle finger first and gently push downward toward the anus.
It can be helpful to initially apply gentle pressure on the posterior forchette to help relax the interoital pelvic floor muscles. The right fourth and fifth fingers are flexed into the palm of the hand. The right thumb is extended. The area around the clitoris should not be touched. As the finger is introduced you can gently feel over the anterior vaginal wall to rule out any abnormal lesions like nodules, induration, and tenderness. Once again it is important to have a systematic approach.
Once inserted into the vagina, the examiner’s right hand is rotated 90 degrees clockwise so that the palm is facing upward. The cervix is palpated for its position, size, shape, consistency, regularity, mobility, and tenderness. The cervix is normally rounded and firm with a consistency similar to the cartilage at the tip of the nose. The cervix can usually be moved 2-4 cm in any direction. It should be nontender and mobile. Feel the fornix around the cervix.
The left hand is now placed on the abdomen approximately one third of the way to the umbilicus from the pubic symphysis. The wrist of the abdominal hand should not be flexed or supinated. The vaginal hand pushes the pelvic organs up out of the pelvis and stabilizes them while they are palpated by the abdominal hand. It is the abdominal, not the vaginal, hand that performs the palpation. You do not need to palpate deeply with the abdominal hand if the uterus is sufficiently elevated with the vaginal hand.
With an anteverted uterus the body of the uterus can be predominantly felt with the abdominal hand assessing for position, size, shape, consistency, mobility, and tenderness.
A normal uterus is firm and mobile. The most common uterine position is anteverted. A retroverted uterus is directed toward the spine and is not easily felt by bimanual palpation. The bulk of the posterior wall of the uterus might be felt with vaginal fingers.
After the uterus has been palpated, the right and left adnexa are palpated. If the patient has complained of pain on one side, start the examination on the other side. The vaginal hand should move to the left lateral fornix while the abdominal hand moves to the left lower quadrant. The vaginal fingers lift the adnexa toward the abdominal hand, which attempts to palpate the adnexal structures.
The adnexa should be explored for masses. Describe the size, shape, consistency, and mobility, as well as any tenderness, of the structures in the adnexa. The normal ovary is sensitive to pressure when squeezed. After the left side is examined, the right adnexa are palpated by moving the vaginal hand to the right lateral fornix and the abdominal hand to the right lower quadrant of the patient. It is common not to feel the ovaries of a woman in reproductive years. Plapation is often difficult in obese or poorly relaxed women. One is essentially trying to rule out any unusual masses or irregularities in the pelvic structures. If an ovary of a post menopausal woman is felt this will need further investigation. After completion of the examination of the adnexa, the examining vaginal fingers move to the posterior fornix to palpate the uterosacral ligaments and the pouch of Douglas (posterior Cul-de-sac ). Marked tenderness and nodularity suggest endometriosis.
When the vaginal fingers are being removed, palpate the posterior vaginal wall to assess the rectovaginal septum.