How to determine if the uterus is anteverted or retroverted on per vaginal (vaginal) examination?

Determining Uterine Position (Anteverted vs. Retroverted) on Per Vaginal Examination

To determine if the uterus is anteverted or retroverted during a per vaginal examination, perform a proper bimanual examination where you assess the direction of the uterine fundus relative to the cervix and vaginal axis. 1

Proper Bimanual Examination Technique

• Position the patient in lithotomy position with legs flexed or in stirrups for optimal access 1
• 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 2
• First identify and assess the cervix, noting its position and direction 1
• With the vaginal fingers, gently move upward from the cervix to feel for the uterine body 1

Determining Uterine Position

• Anteverted uterus: When the uterine fundus is directed anteriorly toward the bladder and abdominal wall

  • The cervix will point posteriorly toward the sacrum 3
  • You will feel the uterine body anterior to the cervix, between your vaginal fingers and abdominal hand 1
  • This is the most common and considered the natural position of the uterus 3

• Retroverted uterus: When the uterine fundus is directed posteriorly toward the rectum and sacrum

  • The cervix will typically point anteriorly toward the pubic symphysis 3
  • You will feel the uterine body posterior to the cervix, toward the rectum 4, 3
  • Approximately 25% of women have a retroverted uterus 4

Key Assessment Points

• The angle between the axis of the cervix and the axis of the vagina defines the version of the uterus 3
• In anteversion, the cervix forms an angle with the vagina where the cervix points posteriorly 3
• In retroversion, the cervix forms an angle with the vagina where the cervix points anteriorly 3
• Most retroverted uteri insert at the apex of the vagina (89.8%), while most anteverted uteri insert anteriorly (only 4.7% insert at the apex) 5

Clinical Pearls and Pitfalls

• A full bladder can artificially push a retroverted uterus into an anteverted position, leading to misdiagnosis 1
• Ensure the patient has an empty bladder before assessing uterine position 1
• Uterine position can change after pregnancy and delivery, particularly after cesarean section (27% of post-cesarean women have anteverted retroflexed uteri) 6
• Distinguish between version (relationship of cervix to vagina) and flexion (relationship of uterine body to cervix) 3
• Mobile uterine retroversion is associated with higher rates of dyspareunia and dysmenorrhea 4

Supplementary Assessment Methods

• If per vaginal examination is inconclusive, transvaginal ultrasound provides definitive assessment of uterine position 1
• Transabdominal ultrasound can also help determine uterine position, especially with a moderately filled bladder 1, 3
• During ultrasound, the uterine axis is measured in the longitudinal (sagittal) plane 3, 7

By systematically performing this bimanual examination and noting the relationship between the cervix and uterine body, you can accurately determine whether the uterus is anteverted or retroverted.