What a Rectovaginal Exam Involves
A rectovaginal examination involves inserting one finger into the vagina and one finger into the rectum simultaneously to palpate structures between them, including the rectovaginal septum, posterior uterus, uterosacral ligaments, and cul-de-sac. 1
Technique and Anatomical Assessment
The rectovaginal exam is performed as part of the bimanual examination, typically after the standard vaginal bimanual assessment is completed. The examiner uses a water-based lubricant on a gloved hand and inserts:
- One finger into the vagina (typically the index finger)
- One finger into the rectum (typically the middle finger)
This dual-finger positioning allows the examiner to palpate the thin wall of tissue separating the vagina and rectum (rectovaginal septum) and assess structures that cannot be adequately evaluated through vaginal examination alone 1.
What Can Be Assessed
During the rectovaginal examination, the clinician evaluates:
- Uterosacral ligaments - for nodularity or thickening that might indicate endometriosis or malignancy
- Posterior uterine surface and cervix - for masses or irregularities
- Cul-de-sac (pouch of Douglas) - for masses, fluid, or nodularity
- Rectal wall - for masses, compression, or abnormalities
- Rectovaginal septum - for defects, masses, or infiltration
Important Clinical Context
The rectovaginal examination is NOT routinely indicated for asymptomatic women during well-woman visits. 2, 3 Evidence shows this examination has very low sensitivity for detecting pathology even under ideal conditions. One study found zero sensitivity for detecting uterosacral nodularity and only 34% sensitivity for rectal compression, even when performed under general anesthesia in the operating room 4.
When It IS Indicated:
The rectovaginal exam should be reserved for women with specific symptoms:
- Rectovaginal or pelvic complaints
- Suspected endometriosis with posterior compartment involvement
- Evaluation of pelvic masses
- Assessment of suspected colorectal involvement by gynecologic disease
- Evaluation of pelvic pain with posterior compartment concerns 2, 3
Common Misconception:
Many physicians believe the rectovaginal exam should be routine, but only 34% actually perform it routinely, and there is significant discordance between perceived value and actual practice patterns 5. The examination adds minimal diagnostic information in asymptomatic patients and should not be performed as routine screening 6, 7.