What are normal findings in a pelvic exam and bimanual exam?

Normal Pelvic and Bimanual Examination Findings

Normal ovaries are usually barely palpable or not palpable at all during a bimanual examination in most women, and the examination should focus on identifying abnormalities rather than expecting to clearly feel normal structures. 1

External Genitalia Inspection

• Normal external genitalia should be examined as part of routine health care, with inspection of the vulva, perineum, and anus being a standard component 2
• The external examination is non-invasive and should be included in comprehensive physical examinations across all age groups 2

Speculum Examination Findings

• The cervix should appear smooth and pink with a small central os in nulliparous women or a transverse slit-like os in parous women 3
• Normal vaginal discharge is typically clear to white, non-malodorous, and varies with the menstrual cycle 3
• The vaginal walls should appear pink and rugated (with folds) 3

Bimanual Examination Findings

• The cervix should be smooth, firm, and mobile without tenderness to motion 3
• The uterus is typically anteverted or retroverted, mobile, smooth, and non-tender, with size varying based on parity and menopausal status 3
• Normal ovaries are usually NOT palpable in most women, particularly in postmenopausal women where they should be even smaller and less detectable 1
• When ovaries are palpable (more common in thin, premenopausal women), they should be smooth, mobile, approximately 3-4 cm in size, and non-tender 1, 3
• The adnexal regions should be free of masses or tenderness 3

Critical Clinical Pitfalls

• Do not expect to clearly palpate normal ovaries - the inability to feel ovaries is normal, not a failed examination 1
• Any clearly palpable adnexal mass warrants referral to gynecology, as this is abnormal and requires further evaluation 1
• Avoid over-interpreting normal anatomical variations as pathology, particularly pressure sensations that are not true pain 1
• The bimanual examination has extremely poor sensitivity for detecting ovarian pathology - in the PLCO trial involving 78,000 women, bimanual examination was discontinued after 5 years because no ovarian cancers were detected solely by this method 2, 1

Important Context on Examination Utility

• The positive predictive value of bimanual examination for detecting ovarian cancer is less than 4%, meaning 96% or more of abnormal findings are false positives 2, 1
• Approximately one-third of women experience pain, discomfort, fear, embarrassment, or anxiety during pelvic examinations 2
• Routine screening pelvic examinations in asymptomatic women have no proven mortality or morbidity benefit according to the American College of Physicians and USPSTF 2

When Bimanual Examination IS Indicated

• Symptomatic women with vaginal discharge, abnormal bleeding, pelvic pain, or lower abdominal pain require appropriate pelvic examination components 2, 3
• Suspected pelvic inflammatory disease requires bimanual examination to assess for cervical motion tenderness and adnexal tenderness 2
• Evaluation of suspected adnexal masses or uterine abnormalities detected by other means 3