Pelvic Exam

Definition

A pelvic examination is a routine procedure used to assess the well being of the female patients' lower genito-urinary tract. This is done as part of a usual health screening and prevention tool, and is an element of the total health care for the female patient.

Purpose

Pelvic exams are useful as a screening tool for sexually transmitted diseases such as gonorrhea, chlamydia, genital warts, herpes, and syphilis. In addition, exams detect some forms of cancer that may affect the genitalia. By analyzing the cervical region with a Papanicolaou or Pap smear, clinicians are able to look for signs of cervical cancer. The American Cancer Society and the American College of Obstetricians and Gynecologists recommend pelvic exams with Pap tests for women starting at age 18. It is also recommended that exams start earlier if the teenager requests oral contraception. Pap smears should continue once yearly for three years and at the physicians discretion following this time. Various groups differ in opinions on when to discontinue screening for cervical cancer, however, the United States Preventative Services Task Force recommends screening continue until age 65 if the patient has not had previous abnormal results. Women who have undergone a total hysterectomy for reasons other than cervical cancer do not need to be screened.

Precautions

Pelvic examinations are safe procedures, thus no precautions are necessary.

Description

The first part of the examination involves visual inspection and palpation of the external genitalia. The examiner will note the characteristics of the labia majora, labia minora, clitoris, urethral orifice, and the Skene's and Bartholin's glands. In addition, the perineum and anus will be checked. The clinician will be examining these areas for any indication of swelling, inflammation, abnormal discharge, polyps, abnormal odor, or other lesions.

The next part involves examining the internal genitalia. The examiner will first insert a gloved finger into the vagina in order to palpate the cervix. Next an instrument called a speculum is inserted. This device is made of plastic or metal and used to open the vaginal cavity in order for the examiner to be able to view the vaginal walls and cervix. Any lesions, bleeding, or abnormal discharge can be visualized with the speculum in place. If indicated, a Pap smear will then be performed. With the speculum still in place, the examiner gently scrapes the patient's cervix with a wooden or plastic spatula as well as a cylindrical-type brush. The spatula collects cells from the outer surface of the cervix, while the brush is used to collect cells from the inner-cervix. The collected cells are then spread on a glass slide, sprayed with a fixative, and sent to a laboratory for analysis. The examiner may then insert a cotton or Dacron swab into the cervix. This will be held in place for 10-30 seconds and when withdrawn spread on a plastic plate or into a tube containing a reagent for the specimen. This procedure may be repeated again with the anus. Such swab tests are used to check for gonorrhea and chlamydia, or bacterial vaginitis, which is a bacterial infection resulting in inflammation of the vagina.

Following the Pap smear is the bimanual examination during which the examiner will place an index and middle finger into the vagina to first examine the vaginal walls for any irregularities or tenderness. The cervix will then be palpated in order to note its shape, consistency, mobility, and any tenderness. The examiner will then place his or her other hand on the abdomen and gently push down while pushing the cervix up. This is done to assess the size and shape of the uterus, and also to note any tenderness or abnormal lesions. During this time, the ovaries are also checked for any masses, or tenderness.

The last part of the pelvic exam is the rectovaginal examination. This allows the clinician to better examine the pelvic organs and structures. The examiner will place their index finger into the vagina and a lubricated, gloved middle finger against the anus. During this part, the patient may feel an urgency to have a bowel movement. However, this is a natural feeling and a bowel movement will not occur. The patient will then be asked to strain down in order for the anal sphincter to relax. As relaxation occurs the examiner will insert the middle finger into the rectum, enabling the position and shape of the uterus to be better assessed. In addition, any masses or tenderness can be evaluated at this point. The anal canal and rectum can also be examined for any polyps, or other lesions at this time. After the rectovaginal exam, the patient will be allowed clean off any excess lubricant and get dressed. The examiner will then discuss the procedure and any findings with the patient.

Preparation

Pelvic exams require the patient to void prior to starting, as a full bladder can add to discomfort and make palpation difficult for the examiner. Even though some tests cannot be done on a menstruating patient, an examination can still be performed. Any tampons should be removed prior to the exam. Douching is not recommended before an exam due to the hazard of washing away cells that are needed for examination. If a Pap smear is to be done, the patients should also refrain from sexual intercourse or using vaginal suppositories for 24 to 48 hours prior to the exam. The patient will be asked to undress and put on a gown. The examiner will instruct the patient to lie on the examination table on her back and may assist her in putting her feet in stirrups. The buttocks are then slid to the edge of the table in order for a full view of the area to be examined.

Aftercare

Even with the invasiveness of this procedure, the patient should be able to immediately resume normal daily activities.

Risks

Other than minor discomfort, there are no risks associated with a routine pelvic examination.

Normal results

No significant findings by the examiner indicate a normal pelvic examination. The external and internal genitalia will be free of any lesions or abnormal discharge. The Pap smear will not reveal cervical dysplasia or abnormal tissue development, and there will not be any abnormal masses or tenderness upon palpation.

Abnormal results

The examiner may discover abnormal lesions during the course of the exam that may require additional tests. Ulcerations, bumps, sores, blisters, or vesicles on the external genitalia may be signs of a sexually transmitted disease. Some of the sexually transmitted diseases that may cause lesions to the external genitalia include venereal warts, syphilis, and genital herpes. Gonorrhea or chlamydia may also cause inflammation to the urethral meatus or the external opening of the urethra. These, in addition to bacterial infections, can also cause inflammation of the Skene's glands, Bartholin's glands, and vulva. Infections may result in an irritating discharge. Discharge may also be noted in yeast infections. Other abnormal findings of the external genitalia include carcinomas, vulvar tumors, or hematomas. Hematomas are masses of accumulated blood that appears as a bluish swelling of the labium that may occur following trauma to this area. Examination of the internal genitalia may reveal similar findings in regards to sexually transmitted diseases and carcinomas. Cervical abnormalities can also be found and may include lacerations, infections, ulcers, cysts, and polyps. All of these will require further evaluation in order to determine the underlying cause.

Since Pap smears screen for cervical cancer, abnormal results require special attention. Due to the incidence of false-positives or false-negatives, the test may be repeated or the physician may choose to have the patient undergo a colposcopy. This procedure uses an endoscope and will examine the vagina and cervix in more depth. This will identify 100% of lesions present. A biopsy may then be taken of the lesion in order to determine the exact type of abnormality. Several new techniques are now available that improve the accuracy of the Pap smear including automated analysis machines. Bimanual and rectovaginal exams may reveal abnormalities of the uterus or other pelvic structures. One commonly encountered finding is a myoma, which is a benign uterine tumor. In addition, the uterus may be positioned abnormally by being angled too far forward or backward. Ovarian cysts and tumors, as well as some disorders of the fallopian tubes, can be findings of these two exams.

KEY TERMS

Bacterial vaginitis— This is the term for inflammation of the vagina due to a bacterial infection.

Bartholin's glands— These glands are embedded in the vestibule of the vagina and function to maintain moisture.

Cervical dysplasia— Dysplasia is the abnormal growth of the epithelial cells. This is what a Pap smear will detect in the cervix.

Colposcopy— This procedure is done when a Pap smear reveals abnormal results. With an endoscope placed through the vagina and into the cervix, a physician can determine exactly where lesions of the cervix are.

Hematoma— Hematomas are masses of blood (or clotted blood) that accumulate in tissues and may result from trauma.

Myoma— These are benign (non-malignant) tumors of the uterus.

Papanicolaou or Pap smear— This is a screening test for cancer of the cervix. Cells are scraped from the cervix, smeared on a glass plate, and sent to a laboratory to examine for any abnormal cells or dysplasia. This test may also detect other cells seen in certain vaginal infections.

Skene's glands— These are the glands of the female urethra.

Speculum— A speculum is an instrument that is used during the internal genitalia examination. It can be made of plastic or metal and is used to open up the vaginal cavity in order for the examiner to view the walls of the vagina and the cervix.

Urethral meatus— This is the external opening of the urethra.

Resources

BOOKS

DeGowin, Richard L., and Donald D. Brown. DeGowin's Diagnostic Examination. 7th ed. New York: McGraw-Hill, 2000.

Johnson, Bruce E., et al. Women's Health Care Handbook. 2nd ed. Philadelphia: Hanley and Belfus, Inc., 2000.

Seidel, Henry M., et al. Mosby's Guide to Physical Examination. 4th ed. St. Louis: Mosby Inc., 1999.

PERIODICALS

Russo, Joseph F. "Controversies in the Management of Abnormal Pap Smears." Current Opinion in Obstetrics and Gynecology 12 (Oct. 2000): 339.

Sawya, George F., et al. "Current Approaches to CervicalCancer Screening." New England Journal of Medicine 344 (May 2001): 1603.

Stewart, Felicia H., et al. "Clinical Breast and Pelvic Examination Requirements for Hormonal Contraception: Current Practice vs. Evidence." Journal of the American Medical Association 285 (May 2001): 2232.