What is the approach to a pelvic assessment?

Approach to Pelvic Assessment

A comprehensive pelvic assessment should be performed only when clinically indicated by symptoms or specific medical conditions, rather than as a routine screening procedure in asymptomatic women.

Indications for Pelvic Examination

• Pelvic examination is indicated for women with gynecologic complaints including vulvar complaints, vaginal discharge, abnormal bleeding, infertility, pelvic organ prolapse symptoms, urinary incontinence, unexplained gastrointestinal symptoms, pelvic pain, or dyspareunia 1, 2
• Pelvic examination is essential for evaluating suspected or reported rape or sexual abuse, and for evaluating lower abdominal pain 1
• Persistent symptomatic vaginal discharge requires a speculum examination 1
• Suspected pelvic inflammatory disease (PID) requires complete pelvic examination - key symptoms that indicate need for examination include lower abdominal pain and/or dyspareunia 3

Components of Pelvic Assessment

A complete pelvic examination may include several components, depending on the clinical indication:

• External visual inspection of the vulva, perineum, and anus 2
• Speculum examination of the vagina and cervix 1, 2
• Bimanual palpation of the uterus and adnexa 1, 2
• Rectovaginal examination when indicated 1, 2

When Pelvic Examination is NOT Required

• Routine screening pelvic examination in asymptomatic, nonpregnant, adult women is not recommended (strong recommendation, moderate-quality evidence) 1
• No pelvic examination is required prior to prescribing most hormonal contraception in healthy, asymptomatic women 1, 2
• Screening for sexually transmitted infections can be performed using less invasive methods such as urine testing or self-collected vaginal swabs 1, 2

Approach to Pelvic Floor Dysfunction Assessment

For patients with symptoms of pelvic floor dysfunction:

• Initial assessment should include detailed history and physical examination 1
• Physical examination alone may be limited in depicting multicompartment involvement 1
• Consider additional diagnostic tests when indicated:
  • Urodynamic studies for urinary incontinence 1
  • Anal manometry for defecatory dysfunction 1
  • Radiologic tests (fluoroscopy, MRI, ultrasound) provide global information about the pelvic floor and are particularly beneficial in:
    • Severe or recurrent prolapse 1
    • Enteroceles 1
    • Defecatory dysfunction 1
    • Cases where patients cannot tolerate adequate physical examination 1
    • Cases with discordant findings between clinical evaluation and patient symptoms 1

Special Considerations

Adolescents

• First pelvic examination should be performed only when clinically indicated 1
• Adequate preparation is essential - use of anatomic models, pictures, and educational materials can help reduce anxiety 1
• Consider having the patient's mother or another trusted female present if the patient prefers 1

Psychological Aspects

• Pelvic examinations may cause anxiety, discomfort, and pain in 30-35% of women 1
• Women with history of sexual violence, particularly those with PTSD, may experience more pain, discomfort, fear, anxiety, or embarrassment 1
• Ensure adequate time is allotted, particularly for first examinations 1
• Encourage patient feedback during the examination 1
• If the patient does not appear to be tolerating the examination, it should be stopped and tried again later 1

Emergency Setting

• In emergency settings, pelvic ultrasound may be performed to evaluate for conditions such as ectopic pregnancy, ovarian cysts, fibroids, tubo-ovarian abscess, and ovarian torsion 1
• The uterus should be examined in at least two planes (short and long axis) 1
• The cul-de-sac should be evaluated for fluid 1
• The ovaries should be scanned in at least two planes 1

Pitfalls and Caveats

• Routine screening pelvic examinations have not been shown to reduce morbidity or mortality rates in asymptomatic women 1
• False-positive findings from routine screening pelvic examinations can lead to unnecessary procedures, including laparoscopies or laparotomies 1
• Fear of pelvic examination may cause some women to avoid or postpone healthcare visits 1
• The decision to perform a pelvic examination in asymptomatic women should be a shared decision between the patient and her healthcare provider 4, 5
• Proper informed consent is essential, particularly for pelvic examinations performed under anesthesia 6