How to assess uterine tenderness?

How to Assess Uterine Tenderness

The bimanual examination is the gold standard method for assessing uterine tenderness, performed by inserting 1 or 2 fingers into the vagina with a water-based lubricant on the gloved hand while palpating the uterus for size and tenderness. 1

Proper Bimanual Examination Technique

• Insert 1-2 lubricated, gloved fingers into the vagina while placing the other hand on the lower abdomen to trap the uterus between both hands 1
• First assess the cervix for consistency (firm in non-pregnant state, softer in pregnancy) 1
• Gently move the cervix to assess for cervical motion tenderness, which indicates pelvic infection or inflammation 1
• Palpate the uterus between the vaginal and abdominal hands to assess:
  • Size (small and firm when non-pregnant; larger, softer, and more globular in pregnancy) 1
  • Tenderness (note any pain with palpation) 1
  • Position (anteverted or retroverted) 1

Clinical Significance of Uterine Tenderness

• Uterine tenderness is one of the most common gynecological presentations with diverse etiologies 2
• Primary causes of uterine tenderness include:
  • Pelvic inflammatory disease (PID) - a main cause requiring prompt diagnosis 2
  • Pregnancy complications 3
  • Endometriosis and chronic pelvic pain 4
  • Uterine position abnormalities 5

Important Considerations During Assessment

• Distinguish between true pain and discomfort, as patients (particularly adolescents) commonly mistake movement or pressure for pain 1
• The angle of uterine flexion may impact pain perception - flexion angles ≥210° are associated with more severe menstrual pain 5
• Document any associated findings such as:
  • Cervical discharge or bleeding 3
  • Adnexal tenderness or masses 1
  • Cervical motion tenderness 1

Supplementary Assessment Methods

• Transvaginal ultrasound can provide additional information about:
  • Uterine position and mobility 6
  • Presence of fibroids, adenomyosis, or other pathology 6
  • Relationship between the uterus and surrounding structures 6
• Combined transabdominal and transvaginal ultrasound approaches provide the most comprehensive evaluation 1

When to Refer to a Specialist

• Refer to a gynecologist for:
  • Acute pelvic pain with possible ovarian torsion, ectopic pregnancy, or tubo-ovarian abscess 1
  • Pelvic inflammatory disease (if not comfortable with management) 1
  • Chronic pelvic pain unresponsive to initial management 1
  • Abnormal vaginal bleeding with severe anemia 1

Patient Communication Considerations

• Use therapeutic language: "I'm going to check your uterus now" rather than "I'm going to examine you" 1
• Explain that the patient is in control and can request to pause or stop the examination at any time 1
• Provide clear expectations about potential sensations (pressure, discomfort) during the examination 1
• Consider having a chaperone present during the examination 1