Components of a Pelvic Examination Report
A pelvic examination report should document findings from visual inspection of external genitalia, speculum examination of the vagina and cervix, bimanual examination, and when indicated, rectovaginal examination, with specific notation of any abnormalities, tenderness, masses, or anatomical variations identified during each component. 1
Essential Components to Document
External Genitalia Assessment
- Visual inspection findings including appearance of vulva, perineum, and anus 2
- Presence or absence of lesions, masses, discoloration, or anatomical abnormalities 2
- Signs of atrophy, inflammation, or infection 1
Speculum Examination Findings
- Vaginal wall appearance including color, moisture, presence of discharge 1
- Cervical visualization documenting position, appearance, lesions, or discharge 1
- Whether cervical cytology specimens were obtained (if applicable) 2
- Any abnormalities of the vaginal vault or cervix 2
Bimanual Examination Documentation
- Uterine characteristics: size, position (anteverted/retroverted), mobility, tenderness 2
- Adnexal findings: presence or absence of masses, tenderness, fullness 1
- Cervical motion tenderness (present or absent) 2
- Fixation or restriction of pelvic structures 3
Rectovaginal Examination (When Performed)
- Posterior uterine assessment and uterosacral ligament evaluation 1
- Rectovaginal septum integrity 2
- Presence of nodularity or masses 3
Context-Specific Documentation
For Symptomatic Presentations
When examining women with gynecologic complaints (abnormal bleeding, pelvic pain, discharge, dyspareunia), the report must specifically address findings relevant to the presenting symptom 2. For example, with pelvic pain, document site-specific tenderness and any masses or anatomical abnormalities that correlate with symptoms 2, 3.
For Screening Examinations
In asymptomatic women undergoing routine examination, document that the examination was performed for screening purposes and note whether it coincided with cervical cancer screening 4, 2. The report should explicitly state normal findings or any incidental abnormalities discovered 2.
Critical Documentation Elements
Patient Comfort and Examination Quality
- Note if examination was limited by patient discomfort, body habitus, or other factors 5
- Document use of appropriate speculum size and lubrication 5
- Record if any component could not be adequately performed 5
Specific Pathology Assessment
- Pelvic organ prolapse: stage and compartment if present 2
- Masses: size, location, mobility, consistency 1
- Tenderness: specific location and severity 2, 3
Important Clinical Considerations
The documentation should reflect that pelvic examination has limited screening value in asymptomatic women for conditions other than cervical cancer (via cytology), with positive predictive value for ovarian cancer less than 4% 1. However, examination remains essential for symptomatic women to identify treatable benign or malignant disease 2.
For women over age 70 who no longer require cervical cytology screening, reports should still document vulvar inspection findings as this population may not recognize or report vulvar pathology 2.