Pelvic Exam
Introduction
The nature of the obstetric history and physical exam requires maturity, sensitvity, and confidence from students. The female physical exam especially may be a source of anxiety or discomfort for women, and should be approached carefully. The patient may find it helpful to learn more about her body, and feedback can be offered. A full physical exam should be considered, especially including:
- vitals
- weight
- abdomen (surgical incisions, palpable masses, hepatosplenomegaly)
- brief neuro exam (clitoral reflex: S2,3,4)
An exam should begin with discussion of a patient's concerns.
The pelvic exam is usually the most difficult aspect of the exam for the patient. Begin with proper positioning and give the patient as much control as possible by seeking feedback. Male examiners should always be accompanied by a female chaperone.
Provide information about each step before proceeding.
Begin with inspection of external genitalia. Note
- vulva: atrophy, cough stress test, valsava prolapse
- perineum
- scars
- normal innervation
Speculum Exam
Proceed with insertion of speculum, properly sized, previously warmed with water and with a small amount of water-soluble lubricant on the outer bottom blade. Examine the vagina and the cervix. Proceed smoothly and gently, with pressure aimed downards to avoid causing pain to the urethra.
speculum exam: cervix/vault
- one blade: anterior, posterior walls
Some women may wish to use a mirror to watch.
The Pap smear may be uncomfortable; warm women.
Bimanual Exam
Bimanual exam should be explained to the patient. Uterus anteflexion may be felt by the woman. Assess for:
- masses
- rectocoele
Rectovaginal and rectal examinations can be done to provide information to the examiner and patient, but should be carefully explained.
Q-tip test (use xylocaine)
- insert until no resistance = in bladder; pull back a bit
- measure resting angle and excursion ar rest and with coughing
- a change in over 30 degrees suggests uretheral hypermobility and could provide information for incontinence
- bimanual: if uterus present, assess size, tenderness, direction (anteverted, retroverted)
- adnexal masses or tenderness
- valsava: UVJ mobility
- pelvic floor muscle strength (Kegels: score our of 5)
Resources and References
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