From Encyclopedia of Sex and Sexuality
The pelvic examination is that part of the medical examination of a woman in which the physician or other practitioner, by inspection (seeing) and palpation (feeling) of the reproductive organs, can determine the condition of the external and internal reproductive structures. During the pelvic examination, other procedures such as obtaining a Pap smear or a culture of the cervix can also be performed.
The pelvic examination is performed with the patient lying on her back on an examining table equipped with supports for the woman’s legs. The patient places her heels or legs in the leg supports, slides down to the edge of the table, and separates her knees. The practitioner generally covers the woman’s legs and abdomen with a drape for reasons of modesty and to decrease the patient’s feeling of vulnerability. An examining lamp is utilized to allow better viewing by the practitioner.
The initial step of the pelvic examination is inspection and palpation of the external genitalia. The practitioner examines the mons, clitoris, labia majora and minora, perineum, and perianal area. Evidence of irritation, growths, or infections can be seen at this point. The examiner may palpate the Bartholin glands at the side of the vaginal opening and the urethra. The vaginal walls are inspected and their supporting structures observed. Prolapse of the walls of the vagina is noted at this stage and the hymen’s condition is observed.
The next part of the examination is with the speculum, an instrument made of either metal or plastic with two rounded blades that can be separated. The speculum is designed to separate the top and bottom walls of the vagina so that the cervix can be seen. After inserting the speculum into the vagina and opening the blades, one can observe the walls of the vagina and see the cervix between the blades of the speculum. The blades of the speculum come in many sizes, designed to fit all vaginal sizes. With a speculum in place, a Pap smear or cultures can be obtained (see pap test).
The speculum examination, like other parts of the pelvic examination, should not produce pain unless there is a condition present that results in pain. This part of the examination can be made more comfortable by coating the blades of the speculum with either a lubricant or water, selecting a blade appropriate to the size of the woman, and warming the otherwise cold metal speculum to body temperature before use.
The next part of the pelvic examination is the bimanual examination, in which both of the practitioner’s hands are used. Two fingers are inserted into the vagina and the opposite hand is placed on the woman’s abdomen so that the uterus and ovaries can be felt through the abdominal wall. During the bimanual examination, the examiner can palpate the cervix to determine its shape, size, and position and can evaluate the uterus for size, shape, position and consistency. The adnexa (tissues next to the uterus, including the fallopian tubes and ovaries) are also palpated. These can usually not be distinguished one from the other during a pelvic examination because the fallopian tubes are usually of the same consistency as surrounding tissues. The ovaries can usually be felt and their size, shape, and consistency determined. Ovaries of postmenopausal women are usually too small to feel on examination.
The final step in a pelvic examination is a recto-vaginal examination. This is to determine if there are abnormalities in the rectum and on the uterosacral ligament, one of the supporting structures of the uterus. Frequently, a recto-vaginal examination will improve palpation of the ovaries as well. During a recto-vaginal examination, a finger is inserted into the rectum and an adjacent finger into the vagina. Abnormalities in the septum between the vagina and rectum can also be felt at this time. When the examining finger is removed from the rectum, it can be observed for the presence of blood, which would signify the need for further evaluation, since finding blood in the rectum may be a sign of a disease of the gastrointestinal tract. The recto-vaginal examination is the most uncomfortable part of the procedure and is not always done at every pelvic examination.
Although there is no general agreement on the age at which a young woman should have her first pelvic examination, whenever there is a problem involving lower abdominal or pelvic pain, discharge, or abnormal bleeding, an examination should be performed. If the young woman has no symptoms, it is usually suggested that a pelvic examination be done before becoming sexually active or when obtaining contraception. The examination can be done without affecting the hymen if there is an ample opening in the center of the tissue. If not, much information can be gleaned by inspection and a rectal examination. A pelvic examination should be performed when obtaining a Pap smear, usually annually in young, sexually active women. While there is no agreed upon frequency for routine pelvic examinations, annual examinations are usual for young, sexually active women.