What should you look for during a pelvic exam?

Components of a Comprehensive Pelvic Examination

During a pelvic examination, you should systematically assess the external genitalia, vagina, cervix, uterus, adnexa, and surrounding structures to detect potential pathology including cancer, infections, and pelvic inflammatory disease.

External Genitalia Assessment

• Inspect pubic hair distribution and note any lesions including:

  • Pubic lice, nits, or folliculitis
  • Inflammatory lesions such as hidradenitis suppurativa
  • Genital piercings and associated complications 1

• Examine external genitalia for:

  • Signs of inflammation (redness or swelling)
  • Pigmentary changes (hypopigmentation seen in lichen sclerosis or vitiligo)
  • Clitoral size (width should be <10 mm; enlarged clitoris may indicate elevated androgens) 1

• Assess the hymen for:

  • Patency and configuration
  • Presence of imperforate, microperforate, or cribriform hymen
  • Hymenal bands that may impair menstrual flow or tampon use 1

Speculum Examination

• Visualize the vaginal walls for:

  • Abnormal discharge
  • Erythema or inflammation
  • Lesions or masses

• Examine the cervix for:

  • Color and appearance
  • Discharge from os
  • Lesions, polyps, or masses
  • Cervical motion tenderness (may indicate PID) 1

Bimanual Examination

• Palpate the cervix for:

  • Position
  • Consistency
  • Mobility
  • Tenderness

• Assess the uterus for:

  • Size
  • Shape
  • Position
  • Mobility
  • Tenderness
  • Masses or irregularities

• Evaluate the adnexa (ovaries and fallopian tubes) for:

  • Masses
  • Tenderness
  • Enlargement 1

Rectovaginal Examination (When Indicated)

• Assess for:
  • Nodularity in the posterior cul-de-sac
  • Uterosacral ligament tenderness
  • Rectal masses or abnormalities

Important Considerations

Patient Preparation

• Explain the procedure thoroughly before beginning
• Reassure the patient that nothing will be done without telling her first
• Encourage feedback during the examination if discomfort occurs
• Allow the patient to empty her bladder before the examination 1

Common Pitfalls to Avoid

1. Unnecessary screening examinations: The American College of Physicians strongly recommends against performing screening pelvic examinations in asymptomatic, nonpregnant adult women (strong recommendation, moderate-quality evidence) 1, 2. This recommendation is based on:

   • Low positive predictive value for detecting conditions like ovarian cancer (<4%)
   • No studies demonstrating morbidity or mortality benefits
   • Potential harms including pain, discomfort, fear, anxiety, and embarrassment in approximately 30% of women 1

2. Overreliance on examination alone: Studies show that pelvic examination without appropriate laboratory testing has limited diagnostic accuracy. For sexually transmitted infections, the sensitivity of history with pelvic examination is only 48.1% 3.

3. Inadequate assessment: Missing components of the examination may lead to missed diagnoses. In one study, 32% of bacterial vaginosis cases, 48% of vulvovaginal candidiasis cases, and 34% of trichomoniasis cases were missed when relying on self-obtained vaginal swabs and history alone without speculum examination 4.

Evidence-Based Indications for Pelvic Examination

• Indicated for symptomatic women: Any woman with gynecologic complaints including vulvar complaints, vaginal discharge, abnormal bleeding, pelvic pain, or dyspareunia should undergo appropriate components of the pelvic examination 5

• Not required for:

  • Prescribing hormonal contraception in healthy asymptomatic women
  • Screening for chlamydia and gonorrhea in asymptomatic women (can use less invasive methods) 5, 6

• Shared decision-making: The American College of Obstetricians and Gynecologists recommends that the decision to perform a pelvic examination in asymptomatic women should be a shared decision between the patient and her healthcare provider 6

By following this systematic approach and understanding the evidence-based indications, you can perform a thorough pelvic examination while minimizing patient discomfort and avoiding unnecessary procedures.