What are the normal findings of an internal examination in OBGYN (Obstetrics and Gynecology) for a healthy adult female with a history of normal Pap (Papanicolaou) smears and no symptoms of pelvic disease?

Normal Internal Examination Findings in OBGYN

In a healthy, asymptomatic adult female with normal Pap smears and no pelvic symptoms, a normal internal examination should document specific anatomical findings when clinically indicated, but routine screening pelvic examinations are not recommended and provide no mortality or morbidity benefit. 1

Key Principle: When to Perform Internal Examination

Internal pelvic examination should be reserved for symptomatic women or those with specific clinical indications—not performed routinely in asymptomatic patients. 2, 3

• The American College of Physicians strongly recommends against performing screening pelvic examinations in asymptomatic, nonpregnant adult women 1
• The American College of Obstetricians and Gynecologists states that pelvic examinations should be performed when indicated by medical history or symptoms, not routinely 4, 5
• Only 1.2% of asymptomatic patients have abnormal findings on pelvic examination, compared to 32.4% of symptomatic patients 6

Normal Findings When Examination IS Indicated

External Genitalia

• Normal appearance: Pink, moist mucosa without lesions, ulcerations, or masses 3
• No evidence of inflammation, discharge, or trauma 3

Speculum Examination of Cervix

• Normal cervix: Pink, smooth, uniform in color and texture 3
• Position: Anterior, mid-position, or posterior (all normal variants) 3
• Consistency: Soft, medium, or firm depending on hormonal status 3
• Os: Nulliparous women have a small, circular os; parous women have a transverse slit 3
• Discharge: Minimal clear or white discharge is normal 3
• No friability, hyperemia, or bleeding on contact 3

Important normal variant: Ectropion (cervical eversion) where the squamocolumnar junction is visible on the exocervix is a normal developmental finding, especially in adolescents and young women 3

Bimanual Examination (When Performed for Symptoms)

• Uterus:

  • Size: 7-9 cm in length (approximately 6-8 weeks size) 3
  • Position: Anteverted, retroverted, or midposition (all normal) 3
  • Contour: Smooth, regular 3
  • Mobility: Mobile, non-tender 3

• Adnexa:

  • Ovaries: May be palpable in thin women, approximately 3-5 cm 3
  • No masses, tenderness, or enlargement 3
  • Fallopian tubes: Not normally palpable 3

• Cul-de-sac: No masses, nodularity, or excessive fluid 3

Critical Clinical Context

Why Routine Screening Examination Is Not Recommended

The evidence is clear that screening pelvic examinations in asymptomatic women cause harm without benefit:

• No mortality or morbidity reduction: Screening pelvic examination does not reduce death or disease from ovarian cancer, pelvic inflammatory disease, or other gynecologic conditions 1
• The bimanual examination was dropped from the PLCO ovarian cancer screening trial after 5 years because no cancers were detected solely by this examination 2
• Documented harms: Pain/discomfort in 11-60% of women, fear/anxiety/embarrassment in 10-80% of women 2
• False positives: Lead to unnecessary laparoscopies and laparotomies 1

When Internal Examination IS Indicated

Perform pelvic examination for:

• Pelvic pain or dyspareunia 3
• Abnormal vaginal bleeding 3
• Vaginal discharge with symptoms 3
• Suspected pelvic inflammatory disease 2, 3
• Evaluation of pelvic organ prolapse or urinary incontinence 3
• History of cervical dysplasia or gynecologic malignancy requiring surveillance 4, 5

Cervical Cancer Screening Without Full Pelvic Examination

For cervical cancer screening, limit the examination to:

• Visual inspection of the cervix 1
• Cervical swabs for cytology and HPV testing 1
• Do not perform bimanual examination unless symptoms warrant it 2

Common Pitfalls to Avoid

• Do not confuse cervical cancer screening with pelvic examination: Pap smear collection ($45.93) does not require bimanual palpation ($38.11 separately) 7
• Do not misinterpret normal variants as pathology: Ectropion in young women is normal, not a sign of infection 3
• Do not require pelvic examination before prescribing hormonal contraception in healthy, asymptomatic women 1, 3
• Do not perform routine screening in women with history of sexual violence without careful consideration, as they experience significantly more distress during examination 1

Special Populations

Women with History of Sexual Violence

• Those with PTSD experience more pain, discomfort, fear, and anxiety during pelvic examination 1
• Avoid routine screening examinations; only perform when clinically necessary 1

Obese Women

• May receive fewer examinations due to embarrassment 1
• More likely to experience embarrassment and disrespect during visits 1