How do I assess adnexal tenderness on pelvic examination?

How to Assess Adnexal Tenderness on Pelvic Examination

Adnexal tenderness is assessed through bimanual pelvic examination by placing two fingers of one hand in the vaginal fornices while the other hand palpates the lower abdomen, systematically palpating each adnexal region (ovaries and fallopian tubes) to elicit pain or detect masses.

Examination Technique

Patient Positioning

• Position the patient in dorsal lithotomy (standard stirrups position) with hips and knees flexed 1
• If the patient has severe obesity and the cervix or adnexa cannot be adequately assessed, reposition to lateral decubitus (side-lying) with the upper leg elevated 45 degrees from horizontal by an assistant 2

Bimanual Palpation Steps

• Insert the index and middle fingers of your dominant hand into the vagina, advancing to the posterior fornix 3
• Place your non-dominant hand on the lower abdomen, approximately halfway between the umbilicus and pubic symphysis 1
• Palpate each adnexal region systematically: sweep the intravaginal fingers laterally to the right fornix while the abdominal hand presses downward and medially to capture the right ovary and tube between both hands 3, 1
• Repeat the same maneuver on the left side 3
• Note any pain response, masses, or fullness during palpation 3, 4

Interpreting Findings

Adnexal Tenderness

• Adnexal tenderness has 87% sensitivity but only 27% specificity for pelvic inflammatory disease, meaning it is present in most cases of PID but also occurs in many other conditions 3
• Tenderness may indicate ovarian torsion, tubo-ovarian abscess, ectopic pregnancy, hemorrhagic cyst, endometrioma, or other adnexal pathology 5, 1

Cervical Motion Tenderness

• Assess by gently moving the cervix side-to-side and anteroposteriorly with the intravaginal fingers 3
• Cervical motion tenderness has 72% sensitivity and 50% specificity for PID 3

Mass Detection

• Normal ovaries measure approximately 3-5 cm in premenopausal women and may not be palpable 1
• Any palpable mass, fullness, or enlargement warrants imaging evaluation 1, 4

Critical Pitfalls to Avoid

• Do not rely on pelvic examination alone to rule out serious pathology: physical examination can be misleading, especially in pregnancy where pain location may be atypical, pain may be muted, and fever/leukocytosis may be absent despite infection 5
• Do not assume absence of tenderness excludes disease: pelvic examination has moderate sensitivity but poor specificity, so negative findings do not exclude conditions like ovarian torsion or PID 3
• Do not delay imaging when clinical suspicion is high: ultrasound (combined transvaginal and transabdominal with Doppler) is the first-line diagnostic modality for any suspected adnexal pathology and should be obtained urgently when ovarian torsion is considered 6, 7, 8

When to Proceed to Imaging

• Order combined transvaginal and transabdominal ultrasound with Doppler immediately for any patient with acute adnexal tenderness, as this achieves 96% overall accuracy for adnexal pathology 6, 7
• Ultrasound is essential because it detects ovarian torsion (100% sensitivity for absent venous flow), tubo-ovarian abscess (100% sensitivity with power Doppler), hemorrhagic cysts (78% sensitivity), and endometriomas (84% sensitivity) 6, 7
• Do not order Doppler as a separate study; it must be performed concurrently with grayscale imaging 6