What should be assessed during a pelvic exam in a patient with vaginal bleeding?

Key Elements of Pelvic Examination in Patients with Vaginal Bleeding

A thorough pelvic examination in patients with vaginal bleeding should include visual inspection, speculum examination, bimanual examination, and possibly rectovaginal examination, with specific attention to identifying the source and cause of bleeding. 1

Initial Assessment

• Visual inspection of the external genitalia should assess for:

  • Vulvar lesions, lacerations, or trauma 1
  • Presence of blood at the introitus and determination of whether it's coming from the vagina, urethra, or rectum 2
  • Signs of infection or inflammation 3

• Proper positioning is crucial:

  • For adult women: lithotomy position 1
  • For prepubertal girls: frog-leg or knee-chest position with lateral and downward traction of the vulva to visualize external genitalia and outer third of vagina 2

Speculum Examination

• Assess for:
  • Active bleeding and its source (cervical, vaginal, or from higher in the reproductive tract) 1
  • Cervical lesions, polyps, or inflammation 4
  • Vaginal lacerations, foreign bodies, or masses 3
  • Products of conception in cases of pregnancy-related bleeding 5

Bimanual Examination

• Evaluate:
  • Uterine size, shape, position, and tenderness 1
  • Adnexal masses or tenderness 1
  • Cervical motion tenderness (suggesting PID) 1
  • Uterine contractions or increased tone in pregnancy-related bleeding 4

Important Considerations for Pregnant Patients

• Digital pelvic examination should be avoided until placenta previa, low-lying placenta, and vasa previa have been excluded by ultrasound in pregnant patients with second and third trimester bleeding. 4

• For pregnant patients with vaginal bleeding:

  • Ultrasound is the mainstay for diagnosis before performing digital examination 4
  • Transabdominal and transvaginal ultrasound with Doppler are usually appropriate for evaluation 4
  • In first trimester bleeding, assess for intrauterine pregnancy, ectopic pregnancy, or nonviable pregnancy 4

Special Populations

• For prepubertal patients:

  • If child is reluctant to undergo examination or if extent of injury cannot be determined, examination under anesthesia with vaginoscopy is recommended 3
  • Common causes include trauma, foreign bodies, urethral prolapse, infection, and rarely malignancy 2

• For postpartum patients:

  • Assess for retained products of conception, uterine atony, or lacerations 4
  • Bimanual examination to evaluate uterine tone and size 4

Clinical Pearls and Pitfalls

• In approximately 94% of women with acute abdominal pain or vaginal bleeding, the pelvic exam findings are either predictable or do not change the clinical plan, suggesting there may be a subset of women in whom the exam could be deferred 6

• Common pitfalls:

  • Failure to adequately visualize the entire vagina and cervix 1
  • Performing digital examination in pregnant patients with bleeding before ruling out placenta previa 4
  • Overlooking subtle findings such as small cervical polyps or lesions 4
  • Not considering age-specific causes of bleeding (e.g., prepubertal vs. reproductive age vs. postmenopausal) 3, 2

• When the source of bleeding cannot be identified or adequately visualized, further imaging or examination under anesthesia may be necessary 3, 2