How to describe a vaginal examination for an ovarian tumor?

From the Guidelines

A vaginal examination for an ovarian tumor is not recommended as a screening tool due to its low accuracy and potential to cause harm, as evidenced by the lack of studies showing mortality or morbidity benefits in asymptomatic, average-risk women 1. When performing a vaginal examination for ovarian tumor assessment, it is essential to prioritize the patient's comfort and safety. The examination should be conducted in a systematic and gentle manner, using a bimanual palpation technique.

• Begin by having the patient in lithotomy position with an empty bladder.
• Insert two lubricated fingers of one hand into the vagina while placing the other hand on the lower abdomen.
• Apply gentle pressure with both hands to trap the pelvic organs between them.
• For ovarian assessment, direct the vaginal fingers into the lateral fornices on each side of the cervix while the abdominal hand presses downward.
• Note any masses, evaluating their size, shape, consistency, mobility, tenderness, and location. However, it is crucial to note that the USPSTF found inadequate evidence on the accuracy of pelvic examination to detect a range of gynecologic conditions, including ovarian cancer, with limited evidence reporting low positive predictive values (0% to 3.6%) 1. The proximity of the vaginal wall to pelvic organs allows for detailed tactile assessment, but limitations include difficulty examining obese patients or those with significant abdominal guarding.
• Ovarian tumors typically present as firm, smooth, mobile masses lateral to the uterus.
• Also assess if the mass is separate from the uterus, as this helps distinguish ovarian from uterine pathology.
• Document any pain during examination, as malignant tumors are usually painless while benign conditions may cause discomfort. It is essential to weigh the potential benefits and harms of the examination, considering the lack of evidence supporting its use as a screening tool for ovarian cancer in asymptomatic, average-risk women 1.

From the Research

Description of Vaginal Examination for Ovarian Tumor

• A vaginal examination for ovarian tumor typically involves a bimanual examination, where the healthcare provider inserts two fingers into the vagina and uses the other hand to press on the abdomen to feel the ovaries and uterus 2, 3, 4, 5.
• The examination may also include a speculum examination, where a speculum is inserted into the vagina to visualize the cervix and vagina 2, 6.
• The healthcare provider may also perform a rectovaginal examination, where they insert a finger into the rectum and vagina to feel the ovaries and uterus from a different angle 2.

Indications for Vaginal Examination

• Vaginal examination is indicated for women with gynaecologic complaints, such as vulvar complaints, vaginal discharge, abnormal bleeding, pelvic pain, or dyspareunia 2.
• It is also indicated for women who are at high risk of ovarian cancer, such as those with a family history of the disease or a genetic mutation that increases their risk 2, 4, 5.

Limitations of Vaginal Examination

• Vaginal examination has limited sensitivity and specificity for detecting ovarian cancer, especially in asymptomatic women 3, 4, 5.
• The examination may not detect early-stage ovarian cancer, and it may not distinguish between benign and malignant lesions 4, 5.
• The examination can be uncomfortable and may cause false positives or negatives, leading to unnecessary investigations or interventions 6, 3, 4, 5.

Recommendations

• The Society of Obstetricians and Gynaecologists of Canada recommends that vaginal examination be performed in women with gynaecologic symptoms or those who are at high risk of ovarian cancer 2.
• The American College of Obstetricians and Gynecologists recommends that vaginal examination be performed annually in women aged 21-29, and every 3 years in women aged 30-65 who are at average risk of ovarian cancer 6.
• However, other studies suggest that routine vaginal examination may not be necessary for asymptomatic women, and that other screening methods, such as transvaginal ultrasound or CA-125 testing, may be more effective in detecting ovarian cancer 3, 4, 5.