YOU WERE LOOKING FOR: Pelvic Exam Tutorial Video
A pelvic exam often is part of a routine physical exam for women to find possible signs of a variety of disorders, such as ovarian cysts, sexually transmitted infections, uterine fibroids or early Back to Reference. Awarded by the Society of...
All recent searches will be deleted During a pelvic exam, your doctor visually and manually assesses your reproductive organs. A pelvic exam usually is done as part of a woman's regular checkup, or your doctor may recommend a pelvic exam if you're...
A pelvic exam is a relatively short procedure. In the course of a pelvic exam, your doctor checks your vulva, vagina, cervix, uterus, rectum and pelvis For more free medical education and nursing videos, visit our medical education websites at: brooksidepress.
Our program works with second year medical students providing a solid introduction to invasive exam procedures. Students learn relaxation techniques, transition techniques and get extensive information on patient education and communication while receiving instruction on all breast and pelvic examination techniques. Our protocol is based on a patient empowerment model focusing on patient centered care and successfully meets the challenge of integrating the examiner and female patient into a partnership which improves her health care and overall health.
Our Gynecologic Teaching Associate Program provides a standardized, quality controlled learning environment wherein students are provided with a systematic approach for conducting the well-woman gynecologic exam. Each GTA is extensively trained and certified by the Department of Obstetrics, Gynecology and Women's Health and acts as both the instructor and the patient. This provides a unique opportunity to receive immediate feedback while reproducing exam techniques under GTA direction. GTAs guide each participant step by step through the entire exam and each participant gets a chance to practice all the techniques and palpate structures. Evaluation by participating students and program directors is always in the superlative and speaks to the success of this outstanding program.
Additionally, we have exceptional sexual assault forensic evidence collection and domestic violence training programs available. This experience has been provided at a number of Universities across the country and has been received with very high regard as to program success and efficacy. Portions of this training are now being considered for utilization in national certification for those trainees unable to obtain the required number of exams. Training is tailor-made to suit the individual needs of each program for whom we are providing assistance. We have averaged two of these types of trainings per year and the feedback and continued success of the programs that have utilized our consulting services is unsurpassed.
We also have a GTA training curriculum which is available for purchase. The curriculum is extensive and provides a step by step, comprehensive and interactive instructional guide that is an exceptional resource for those programs setting up their own in house GTA programs. The curriculum includes a manual, exam, evaluation sheets, video and audio training discs, a section designed specifically for the new GTA trainer and additional related articles necessary for program success.
Although, bimanual assessment is considered to be the third part of the pelvic exam, you may choose to perform this before the speculum examination. This decision depends on the type of cytology your institution prefers and whether or not the lubricant will interfere with it. In fact, performing bimanual assessment first ensures that the patient is as relaxed as possible before this most physically invasive part of the pelvic examination. This also helps a physician gain more knowledge about the cervical position, before attempting to place the speculum. As the name suggests, the bimanual assessment involves usage of both the hands.
The external or the abdominal hand that exerts gentle pressure on the abdominal wall to gently displace organs inwards, which can then be felt by the finger pads of the internal or the pelvic hand placed inside the vagina. This allows one to evaluate the size, position and consistency of the organs, and to detect the areas of tenderness and pelvic masses. Some patients also need rectovaginal examination for the full assessment of their internal genital organs, rectum, rectovaginal septum, and other pelvic structures. This video will demonstrate the correct technique for both bimanual assessment and rectovaginal examination in detail. Before starting with the exam one needs to have a good understanding of the topographical anatomy of the pelvis for proper interpretation of the findings. The uterus is a pear-shaped, fibromuscular organ that consists of two parts-the body and the cervix. The body receives the openings of the uterine tubes that extend laterally towards the ovaries.
The cervix protrudes into the vagina, creating 4 recesses-namely the anterior fornix, the posterior fornix and the two lateral fornices. The sagittal view of the pelvis reveals that the uterus lies posterior to the urinary bladder, and anterior to the rectum, which is separated from the uterus by the rectouterine pouch. The proximity to the anterior abdominal wall allows evaluation of the uterus and the ovaries by bimanual assessment. One should remember that the uterine position differs amongst individuals. In cases where the uterus is tilted towards the rectum-as in retroflexion-it can be felt by the examiner through the posterior fornix. Whereas in cases where the uterus is anteflexed, normally or severely, because the cervix is pointing downward you cannot feel the uterus protruding into the posterior fornix.
Laterally, one can assess the ovaries by sweeping with the abdominal hand over lower lateral quadrant so the ovary is displaced and swept over the pelvic hand in the ipsilateral fornix. The uterine tubes are normally non-palpable. Now let's review the steps and the technique of the bimanual examination. Before beginning the exam, prepare the patient by saying something like, "Dialogue".
Fully coat the first two fingers of your dominant hand with lubricant, and let the patient know that you are placing one, and then two fingers into their vagina Start the exam by placing the back your hand on the patient's thigh. Then, while keeping the palm down, insert the dominant index finger for about one inch into the introitus. Apply slight posterior pressure and introduce the middle finger for about one inch as well. Then slowly supinate your hand and insert both fingers fully, while separating the labia with the thumb, and the fourth and fifth fingers. Now position your hand in the inguinal groove, and stand up. Place your dominant foot on the footstool, tuck your elbow into your side, and relax your wrist.
Place the internal fingers on the posterior vaginal wall and sweep them from side to side, moving upward until you locate the cervix, which should feel moist and firm. On the face of the cervix you will feel the indentation of the os. Often the os will be angled posteriorly, which usually indicates some degree of anteversion of the uterus. An os that is pointing fully downward may indicate severe anteflexion, where the uterus is curved over the bladder. Whereas, a retroverted uterus may have a more midline os, but you will be able to feel the uterus extending below the cervix into the posterior fornix.
Use a sweeping motion with your internal fingers to assess the surface of the cervix for masses. Check cervical tone by gently squeezing the cervix. Gently move the cervix up, down, and from side to side, while watching the patient's face for any discomfort, which is a positive sign of cervical motion tenderness, or CMT. Anchor your fingers on the face of the cervix and gently press up. If you feel like the uterine body is protruding into the posterior fornix, then it confirms the presence of a retroflexed uterus.
Subsequently, place your non-dominant finger pads at the level of umbilicus and press down on the abdominal wall while making a scooping forward motion, moving about an inch lower every time. Repeat this maneuver until you can feel the cervix tap against your fingers. Note where the most intense movement starts and stops, these indicate the upper and lower uterine boundaries. Then, locate the lateral boundaries by palpating across the abdomen with a rocking motion. Use your external hand to pull the uterus toward you, as your internal fingers gently press on the cervix; continue until you can feel the uterus between your hands. Assess the uterus for size, shape, and consistency. It should feel firm, like a muscle, not boggy or hard.
Any palpable protrusions may indicate fibroids. You can estimate size based on either the boundaries of the uterus you estimated earlier, or based on what you feel when holding the uterus between your hands. The uterus of a nulliparous adult is roughly 7 cm by 4 cm; if the patient has been pregnant, it may be larger. Next, place your internal fingers onto the right lateral fornix. Drop your wrist, hook the fingertips up, locate the internal iliac pulse and press your fingers toward it.
Then, locate the right anterior superior iliac spine, position the external finger pads one inch medial to it and sweep slowly and smoothly with light to medium pressure towards the inguinal groove. During this sweeping motion, the ovary can be felt by the internal fingers as a small oval bulge. As the ovaries are sensitive to touch, ensure that you don't stop on top of an ovary or push on it directly. Move your fingers into the left lateral fornix and palpate the left ovary in the same manner. The next part of the video will demonstrate how to conduct the rectovaginal exam, which may be performed for different reasons. For example, to further assess the uterus and ovaries, particularly in patients with a retroverted and retroflexed uterus; in response to rectal symptoms or pelvic pain; to screen for cancer or other non-sympomatic pelvic conditions.
For this exam, one finger is placed into the rectum and the other in the vaginal canal. This allows examination of the rectum itself, the rectovaginal septum and the rectrovaginal pouch, as well as the retroverted uterus, which will protrude posteriorly and be palpable through the septum. Start by changing the gloves to avoid cross-contamination, and then coat the first two dominant fingers from base to the tip with the lubricant. Position your dominant foot on the footstool and place your dominant elbow on your leg for support. Before starting the examination, let the patient know what to expect, "Dialogue".
As the patient bears down, introduce the index finger into the vagina, while placing the distal phalanx of the middle finger into the rectum. Pause for a few seconds as the internal sphincter involuntarily contracts and relaxes, and then fully insert both fingers, while the patient continues to bear down. Scissor the fingers to assess the septum, which normally is firm and pliable. Sweep your middle finger side to side against the anterior rectal wall to assess the utero-sacral ligaments, which should feel like rubber bands. Also, examine for the presence of any fixed masses. Next, curve your index finger a little out of the patient's vagina, so that you can locate the cervix through the septum using your middle finger. Then, like the bimanual exam, use your external hand to press on the abdomen to assess the uterus using your middle finger.
If the patient has a retroverted uterus, you would be able to assess the entire uterine surface through the finger in the rectum. You can also repeat the ovarian sweep like before, though you may not feel anything in a patient with no abnormal findings. This concludes the examination. Remove your fingers, re-drape the patient, and discard the gloves out of the patient's sight, unless a stool sample needs to be obtained. Tell the patient they can push back to sit up. If there were no pathological findings, inform the patient that everything appears healthy and normal.
Also, notify them that you are going to send the samples to the lab, and when they should expect to hear back about the results. Lastly, let the patient know you are stepping out so that they can get dressed, and that afterward you will return to answer any questions they have. You've just watched JoVE's video the on bimanual and rectovaginal examination, which conclude the three part series of systematic pelvic examination. In the first video, we learned how to perform the assessment of the external genitals and the digital inspection of the vagina, cervix and the vestibular glands.
In the second part, we discussed the speculum examination and obtaining samples for the Papanicolau test. Finally, in this third presentation we reviewed how to perform bimanual assessment of the pelvic organs and the rectovaginal evaluation. As always, thanks for watching!
Collecting Cervical Cells For gynecologic care, a woman should choose a health care practitioner with whom she can comfortably discuss sensitive topics, such as sex, birth control, pregnancy, and problems related to menopause. The practitioner may be a doctor, a nurse-midwife, a nurse practitioner, or a physician assistant. A gynecologic evaluation includes the gynecologic history and gynecologic examination. The gynecologic examination refers specifically to examination of a woman's reproductive system. It includes a breast examination. A pelvic examination is done if the woman's circumstances warrant it and the woman wishes it. However, the doctor or other health care practitioner may provide more general medical care and do a more general physical examination during the gynecologic visit. If a woman has any questions or fears about the gynecologic examination, she should talk with the doctor beforehand about her concerns. If any part of the examination causes pain, the woman should let the doctor know.
The woman should empty her bladder before the physical examination and may be asked to collect a urine sample for analysis. The doctor may feel the neck and the thyroid gland to check for lumps and abnormalities. An enlarged, overactive thyroid gland hyperthyroidism can cause menstrual abnormalities. The doctor examines the skin for signs of acne, excess body hair that is more typical of men hirsutism , spots, and growths. A breast examination is typically done before the pelvic examination. With the woman sitting, the doctor inspects the breasts for irregularities, dimpling, tightened skin, lumps , and a discharge. The woman then sits or lies down, with her arms above her head, while the doctor feels palpates each breast with a flat hand and examines each armpit for enlarged lymph nodes and for lumps and abnormalities. While doing the examination, the doctor may review the technique for breast self-examination with the woman. The doctor may use a stethoscope to listen for activity of the intestine and to check for abnormal noises made by blood flowing through narrowed blood vessels.
The doctor may tap areas of the abdomen with the fingers. The doctor gently feels the entire abdomen to check for abnormal growths or enlarged organs, especially the liver and spleen. Although the woman may experience some discomfort when the doctor presses deeply, the examination should not be painful. The doctor may also check the groin for a pulse which is normally present , enlarged lymph nodes, and hernias. Pelvic Examination A pelvic examination is done when Women have symptoms, such as pelvic pain. Screening for cervical cancer or another disorder is needed. Women should talk with their health care practitioner about whether pelvic examinations need to be done and how often they need to be done. At age 21, most women should start having tests to screen for cervical cancer , such as a Papanicolaou Pap test. The pelvic examination includes the following: Evaluation and examination of the internal reproductive organs Examination of the rectum sometimes External Female Genital Organs Internal Female Genital Organs During the pelvic examination, the woman lies on her back with her hips and knees bent and her buttocks moved to the edge of the examining table.
Special pelvic examination tables have heel stirrups that help a woman maintain this position. Usually, a drape is provided, and an assistant is asked to be present to chaperone and sometimes to help with the examination. If a woman wants to observe the pelvic examination, she should tell the doctor, who can provide a mirror. The doctor may explain the examination or review the findings before, during, or after the examination. Before the pelvic examination begins, the doctor asks the woman to relax her legs and hips and breathe deeply.
For the examination, the doctor first inspects the external genital area and notes the distribution of hair and any abnormalities, discoloration, discharge, or inflammation. This examination may detect no abnormalities or may give clues to hormonal problems, cancer, infections, injury, or sexual abuse. The doctor spreads the tissues around the opening of the vagina labia and examines the opening. Using a speculum a metal or plastic instrument that spreads the walls of the vagina apart , the doctor examines the deeper areas of the vagina and the cervix the lower part of the uterus.
The cervix is examined closely for signs of irritation or cervical cancer. The doctor may use a small plastic brush to obtain a sample for testing, usually a Papanicolaou Pap test or a variation of it to screen for cervical cancer. A sample may be taken to be tested for sexually transmitted diseases. The doctor asks the woman to bear down as if having a bowel movement to check for protrusion of the bladder, rectum, or intestine into the vagina called pelvic organ prolapse. Collecting Cervical Cells Doctors use a speculum a metal or plastic instrument to spread the walls of the vagina apart. Then they insert a small plastic brush to obtain a sample from the cervix the lower part of the uterus for testing. After removing the speculum from the vagina, the doctor inserts the index and middle fingers of one gloved hand into the vagina and feels the vaginal wall to determine its strength and support. The doctor also feels for growths or tender areas within the vagina.
With the fingers still in the vagina, the doctor then places the fingers of the other hand on the lower abdomen above the pubic bone called a bimanual examination. Between the two hands, the uterus can usually be felt as a pear-shaped, smooth, firm structure, and its position, size, consistency, and degree of tenderness if any can be determined. Then the doctor attempts to feel the ovaries by moving the hand on the abdomen more to the side and exerting slightly more pressure. More pressure is required because the ovaries are small and much more difficult to feel than the uterus.
The woman may find this part of the examination to be slightly uncomfortable, but it should not be painful. The doctor determines how large the ovaries are and whether they are tender. Rectal examination A rectal examination may be done. The doctor inserts the index finger into the vagina and the middle finger into the rectum to examine the back wall of the vagina for abnormal growths or thickness. In addition, the doctor can examine the rectum for hemorrhoids, fissures, polyps, and lumps. A small sample of stool can be obtained with a gloved finger and tested for unseen occult blood. The woman may be given a take-home kit to test for occult blood in the stool.
All rights reserved. Gynecologic examination of the prepubertal girl March 1, A gentle, patient approach is important when examining a prepubertal girl. Pay special attention to anatomic and pathophysiologic differences in the child. Emphasize setting the stage to make the examination a positive experience for your young patient. Gynecologic examination of the prepubertal girl Jump to: Choose article section Jean Emans, MD A gentle, patient approach is important when examininga prepubertal girl.
Pay special attention to anatomic and pathophysiologicdifferences in the child. Emphasize setting the stage to make the examinationa positive experience for your young patient. Gynecologic assessment of the prepubertal girl is an essential componentof preventive and diagnostic pediatric care. Routine gynecologic examinationof infants and children can help prevent future health problems such asvulvovaginitis by giving the clinician the opportunity to educate parentsabout perineal hygiene. A more thorough gynecologic examination is warranted for the evaluationof vaginal bleeding, vaginal discharge, trauma, or pelvic pain. It is importantto be aware that the gynecologic examination can influence her future attitudetoward gynecologic care. Making the examination a positive experience, ifpossible, therefore is critical. Thepediatrician may have the additional advantage of already having built arelationship with the child who requires a gynecologic examination. Thisarticle focuses on setting the stage so that the examination is a positiveexperience for the patient and her family, describes specific techniquesand strategies for performing an appropriate and non-traumatic examination,and reviews diagnosis of disorders commonly found in prepubertal children.
Principles of gynecologic assessment One of the most important principles to keep in mind when examining ayoung girl is to maintain her sense of control over the process. This canbe accomplished by establishing rapport with the child, keeping the paceunhurried, proceeding from less to more intrusive examinations and askingfor consent before proceeding, and allowing the child to be an active participantin the process as much as possible. You canmodel for parents appropriate ways to discuss gynecologic issues with theirchild, and help parents and children understand the importance of discussingissues related to reproductive healthand sexuality during the prepubertalyears. Most young children will prefer to have aparent--usually their mother--in the room at all times. In some cases, however,it is helpful to spend time alone with the child during the interview, andto ask whether she prefers to be alone for the examination.
Opening questions can include inquiriesabout the family structure and recent changes, school, friends such aswhether she has a best friend , and the types of activities she enjoys. It is important to assess who cares for the child and to uncover--both fromthe parent and from the child--information about any history of sexual abuseor current concerns in that regard. Asking the child whether anyone hasever touched her in a way that made her feel uncomfortable often is helpfulin drawing out this information. The medical history should be guided by the presenting complaint anddifferential diagnosis. If the issue is vaginal discomfort, pruritus, ordischarge, the differential diagnosis includes nonspecific or infectiousvulvovaginitis, vulvar skin disease, lichen sclerosis, and presence of aforeign body.
Your questions should address the onset of symptoms; the type,frequency and timing of discharge; associated bleeding, pain, or pruritus;foreign body insertion; perineal hygiene; recent infections in the patientor her family such as streptococcal pharyngitis or pinworms ; recent antibiotictherapy; masturbation; and a history of sexual abuse. If the issue is "vaginal" bleeding, the differential diagnosisincludes condyloma acuminatum, urethral prolapse, vascular lesions, precociouspuberty, hormonal medications, and rarely sarcoma botryoides, in additionto vulvovaginitis, foreign body, and lichen sclerosus. The history shouldassess the child's growth and development; signs of puberty such as breastdevelopment, axillary hair, pubic hair, growth spurt, and leukorrhea; genitaltrauma; vaginal discharge; and a history of foreign body insertion.
A historyof behavioral changes and somatic symptoms, including recurrent or chronicabdominal pain, headaches, and enuresis, may signal abuse. Finally, it isimportant to remember that urethritis can cause dysuria or hematuria, whichmay be mistaken for vaginal bleeding. Urethritis can be caused by an infectiousagent, irritation, or trauma. Past medical history should include information about congenital anomalies,systemic disorders with dermatologic manifestations, and growth and development. Congenital anomalies, and particularly renal anomalies, may be associatedwith gynecologic anatomic abnormalities. Many dermatologic disorders, suchas atopic dermatitis, seborrhea, and psoriasis, can manifest as vulvitisor vulvovaginitis. Abnormalities of growth and development can be essentialclues to precocious puberty or other systemic or congenital disorders.
Beginning the examination After you have established a rapport with the child and taken her history,you should explain the gynecologic examination to both the child and herparent. This is an important step toward reinforcing the child's sense ofcontrol over the examination. Explain to the child that the most important part of the examinationis "looking," and that it is important for her to communicatewith you during the examination. Tell the child that the examination willnot hurt, and if you are going to use instruments, that these tools areall specially designed for little girls.
When talking with parents, it is important to carefully explain that thechild's hymen will not be altered in any way by the examination, becausemany parents do not fully understand the anatomy of the vagina and hymen. Basic diagrams of the anatomy may be helpful. A parent or caretaker is usually present during the examination of ayoung child, and most children are comfortable with the parent sitting closeby or holding their hand. An older child should be asked whom she prefersto have in the room during the examination. Using a hand mirror can be usefulto promote education, distract a child, and allow her to participate moreactivelyin the examination.
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