What is the proper technique for performing a bimanual exam on a female patient, particularly those of reproductive age with gynecologic symptoms?

How to Perform a Bimanual Examination

The bimanual examination is performed by inserting 1 or 2 lubricated fingers into the vagina to assess the cervix, uterus, and adnexa, but should only be done when clinically indicated in symptomatic women—not as routine screening in asymptomatic patients. 1, 2

Step-by-Step Technique

Preparation and Patient Positioning

• Ensure the patient has emptied her bladder before the examination to minimize discomfort during palpation 3
• Explain each step before performing it, explicitly stating that the patient controls the pace and can stop at any point by saying "Wait" or "Stop" 3
• Apply water-based lubricant to the gloved examining hand 1
• Critical pitfall: Never perform cell collection for cervical cytology after applying lubricant, as it contaminates specimens—always collect samples before the bimanual examination 2

Insertion and Cervical Assessment

• Insert 1 or 2 fingers into the vagina (use single digit for adolescents or patients with dyspareunia) 1, 3
• Palpate the cervix first to assess its consistency: the normal nonpregnant cervix is firm, while a gravid cervix is softer 1
• At 8-10 weeks' gestation, the cervix becomes noticeably softer; by 10-12 weeks, the uterus is grapefruit-sized, globular, and protruding from the pelvis 1

Assessing for Cervical Motion Tenderness

• Gently move the cervix to assess for cervical motion tenderness, which indicates pelvic infection or inflammation 1
• Critical pitfall: Adolescents and inexperienced patients commonly mistake movement or pressure for pain—distinguishing between discomfort and true pain can be challenging but is essential 1, 2

Uterine Palpation

• Place your other hand on the lower abdomen and palpate the uterus between both hands 1
• Assess the uterus for size, consistency, and tenderness 1
• The normal nonpregnant uterus is small and firm 1

Adnexal Assessment

• Move your internal fingers to each lateral fornix while applying gentle pressure with the abdominal hand to assess the adnexa (ovaries and fallopian tubes) 1
• Palpate for masses or tenderness 1
• Normal ovaries are usually barely palpable—the examination should focus on identifying abnormalities rather than expecting to clearly feel normal ovaries 1, 2
• Any palpable adnexal mass is a reason for referral to a gynecologist 1, 2

When to Perform Bimanual Examination

Clear Indications (Symptomatic Women)

• Pelvic pain or lower abdominal pain requiring evaluation for pelvic inflammatory disease (assess for cervical motion tenderness and adnexal tenderness) 2, 4
• Abnormal vaginal bleeding (premenopausal or postmenopausal) 4
• Persistent symptomatic vaginal discharge 4
• Dyspareunia, pelvic organ prolapse symptoms, or urinary incontinence 4
• New unexplained gastrointestinal symptoms (abdominal pain, bloating, early satiety) 4

When NOT to Perform Bimanual Examination

• Do not perform routine bimanual examination in asymptomatic women—the American College of Physicians recommends against this practice due to harms outweighing benefits with no demonstrated mortality or morbidity reduction 2, 5
• Not required before prescribing hormonal contraception in healthy asymptomatic women 2, 4
• Not required for cervical cancer screening alone (only visual inspection and cervical sampling needed) 2
• Not required for STI screening in asymptomatic women—nucleic acid amplification tests on self-collected vaginal swabs or urine are highly sensitive and specific 2, 4

Critical Limitations and Harms

Poor Diagnostic Performance

• Bimanual examination has extremely poor sensitivity for detecting ovarian pathology—in the PLCO trial of 78,000 women, it was discontinued after 5 years because no ovarian cancers were detected solely by this method 1, 2
• The positive predictive value for detecting ovarian cancer is less than 4%, meaning 96% or more of abnormal findings are false positives 2

Patient Harms

• Approximately one-third of women experience fear, embarrassment, anxiety, pain, or discomfort during pelvic examinations 1, 2, 5
• False-positive findings lead to unnecessary laparoscopies or laparotomies with attendant psychological and physical harms 2
• Women with history of sexual violence, particularly those with PTSD, may experience more pain and anxiety 2
• Screening pelvic examinations in asymptomatic women add $2.6 billion in unnecessary costs to the U.S. healthcare system annually 2

Special Considerations for Difficult Examinations

For Patients with Dyspareunia or Anxiety

• Teach relaxation techniques before beginning: press on the perineal muscle without inserting a finger and have the patient practice contracting and relaxing that area 3
• Ensure adequate time is allotted—the examination should not be rushed 3
• If the patient is not tolerating the examination, stop immediately and reschedule rather than creating a traumatic experience that will worsen avoidance behaviors 3
• Offer a trusted support person to be present if the patient prefers 3