Is bimanual palpation (manual examination using two hands) recommended with a Pap (Papanicolaou) smear?

Bimanual Palpation is NOT Recommended with Pap Smear

Obtaining a Pap smear specimen does not require and is not an indication for bimanual examination. 1

Key Evidence Against Routine Bimanual Examination

The American College of Physicians conducted a comprehensive systematic review and found:

• No data support the use of bimanual examination to reduce morbidity or mortality from any condition in asymptomatic, average-risk women 1
• Cervical cancer screening with Pap smear (obtained during speculum examination) is completely independent of bimanual palpation 1
• The bimanual examination was dropped from the PLCO ovarian cancer screening trial after 5 years because no malignancies were detected solely by this examination 1

Current Guideline Recommendations

The U.S. Preventive Services Task Force (USPSTF) states:

• There is insufficient evidence to assess the balance of benefits and harms of performing screening pelvic examinations (including bimanual palpation) in asymptomatic women 1
• This "I statement" (insufficient evidence) explicitly does not apply to Pap smear collection, which has established benefit for cervical cancer screening 1

Documented Harms of Routine Bimanual Examination

When performed routinely in asymptomatic women, bimanual examination causes:

• Pain or discomfort in 11-60% of women (median 35%) 1
• Fear, embarrassment, or anxiety in 10-80% of women (median 34%) 1
• Potential for false-positive results leading to unnecessary invasive procedures 1
• Increased costs ($38.11 per screening pelvic examination vs. $45.93 for Pap smear collection alone) 1, 2

Clinical Practice Reality vs. Evidence

Despite lack of evidence supporting its use:

• More than 95% of obstetrician-gynecologists surveyed indicated they would perform bimanual examination in asymptomatic women even when not due for a Pap test 1
• Approximately 54.4% of bimanual examinations performed in young women aged 15-20 years were potentially unnecessary 3
• This practice exposes women to preventable harms without demonstrated benefit 3

When Bimanual Examination IS Indicated

Bimanual palpation should be reserved for:

• Symptomatic women with pelvic pain, abnormal bleeding, or other gynecologic complaints 1
• Evaluation for suspected pelvic inflammatory disease when a woman has lower abdominal/pelvic pain 1
• Assessment during pregnancy (where bimanual palpation is part of routine antenatal care) 4
• Investigation of specific clinical concerns identified during speculum examination 1

Practical Algorithm for Pap Smear Collection

For asymptomatic, average-risk women presenting for cervical cancer screening:

1. Perform speculum examination only to visualize the cervix 1
2. Collect Pap smear specimen using appropriate technique 2
3. Omit bimanual examination unless specific symptoms or findings warrant further evaluation 1
4. Reserve bimanual palpation for women with gynecologic symptoms or clinical concerns 1

Common Pitfall to Avoid

Do not conflate "well-woman exam" with mandatory bimanual examination. The tradition of performing routine pelvic examinations as part of annual visits is not evidence-based and may deter women from seeking necessary preventive care due to fear or discomfort 1