How should a nurse practitioner perform a pelvic examination?

How to Perform a Pelvic Exam as a Nurse Practitioner

As a nurse practitioner, perform the pelvic exam systematically in three phases: external inspection, speculum examination, and bimanual examination, always obtaining informed consent and offering a chaperone before beginning. 1

Pre-Examination Preparation

Patient Communication and Consent

• Obtain informed consent before proceeding, following state laws and institutional policies 1
• Offer a chaperone for patient comfort 1
• Use a trauma-informed care approach, recognizing potential past traumatic exposures to avoid re-traumatization 1
• Explain each step before performing it—reassure the patient that nothing will be done without telling her first 2
• Emphasize that the exam may be uncomfortable but should not be painful in the absence of pathology 2
• Empower the patient by reminding her she controls her body and can say "Wait," "Stop," or "That's not comfortable" at any time 2
• Have the patient empty her bladder before the exam to minimize discomfort 2

Phase 1: External Genitalia Examination

Systematic Inspection

1. Assess pubic hair for Tanner stage and lesions (pubic lice, nits, folliculitis, hidradenitis suppurativa) 2
2. Examine external genitalia for:
   • Signs of inflammation (redness, swelling) 2
   • Pigmentary changes (hypopigmentation in lichen sclerosis or vitiligo) 2
   • Clitoral size after retracting the hood (width should be <10 mm; enlargement suggests elevated androgens) 2
3. Evaluate the hymen for patency and configuration (imperforate, microperforate, cribriform, or bands) 2
4. Inspect for lesions: papules, vesicles, pustules, ulcers, fissures, warts 2
   • Ulcers: most commonly HSV or syphilis—obtain viral culture and serologic tests 2
   • Warts (condylomata acuminata): flat or exophytic, HPV-related 2
5. Check Bartholin glands (4 and 8 o'clock positions in posterior vestibule) for swelling, erythema, tenderness 2
6. Check Skene glands (lateral to urethra) for erythematous areas; insert finger vaginally with anterior pressure to express discharge 2
7. Note vaginal discharge: assess amount, color, odor 2
8. Include perianal area: look for trauma, discharge, warts 2
9. Palpate inguinal nodes for size, tenderness, consistency (enlarged painful nodes suggest STI) 2

Phase 2: Speculum Examination

Insertion Technique

• Optionally insert a single finger along the posterior vaginal wall to locate the cervix first 2
• Lubricate the speculum with warm water to facilitate insertion 2
• Avoid anterior pressure during insertion to prevent urethral pain 2
• Insert the speculum completely BEFORE opening the blades—opening it prematurely causes pain 2
• Once fully inserted, the cervix is usually easily visualized without much manipulation 2

Inspection and Specimen Collection

1. Inspect vaginal walls for discharge and lesions 2

2. Visualize the cervix completely and note:

   • Presence of lesions 2
   • Ectropion (squamocolumnar junction on exocervix—normal in adolescents) 2
   • Friability and hyperemia (suggests STI) 2
   • White plaques that cannot be removed (possible condyloma) 2
   • Red punctate lesions/"strawberry cervix" (trichomoniasis) 2
   • Bluish hue/Chadwick sign (pregnancy) 2

3. Obtain specimens from pooled vaginal secretions:

   • Wet prep: collect with cotton swab, place in 1 mL normal saline or directly smear slide and add saline 2
   • KOH preparation: for yeast identification 2
   • Vaginal pH testing 2
   • Look for: WBCs (infection), clue cells (bacterial vaginosis), trichomonads, hyphae/budding yeast 2
   • Read wet mount immediately after completing the exam 2

Phase 3: Bimanual Examination

While the provided guidelines focus primarily on external and speculum examination techniques, the bimanual examination follows the speculum exam to assess uterine size, position, mobility, and adnexal masses or tenderness.

Key Clinical Pitfalls to Avoid

• Never open the speculum before full insertion—this is the most common cause of unnecessary pain 2
• Don't apply anterior pressure during speculum insertion—this causes urethral discomfort 2
• Don't rush the exam, especially if it's the patient's first or if she has had negative experiences 2
• Stop the exam if the patient is not tolerating it—try again later to avoid creating negative associations 2
• If the patient cannot tolerate the exam, consider having her practice contracting and relaxing perineal muscles before reattempting 2

Documentation

Document all findings systematically: external genitalia appearance, vaginal discharge characteristics, cervical appearance, any lesions or abnormalities, specimens collected, and patient tolerance of the procedure.