How to Do a Pelvic Exam
New England Journal of Medicine has just added a video on pelvic examination* to its instructional series, “Video in Clinical Medicine” – unfortunately, it’s behind their subscription wall, but I wish you could see it. It’s not often that women get to see a pelvic exam from the other side of the thin paper drape, so if you have access to a NEJM electronic subscription through your library, I recommend checking it out. However, I’m going to try to describe some of the information presented (blogging as I watch), so you have a better idea of what exactly is going on during an exam.
Section 2, Indications, states that women should have a pelvic examination when they have:
-Vulvar or vaginal complaints, such as pain, discharge, abnormal bleeding, itching, and/or a mass;
-When pregnancy is suspected or proven;
-In women who have been exposed to sexually transmitted infections.
It also highlights the American Cancer Society’s recommendations for pap screening, listed here (scroll down to section on cervical cancer). The ACS guidelines mention that women who are older than 30 and have had 3 normal paps in a row can switch to every-three-year screening unless they have risk factors such as HIV infection; the NEJM video adds new sexual partners as another risk factor for screening more frequently.
Section 2: Preparation
Regarding patient history, viewers are instructed to ask women about their total number of sexual partners and sexual orientation. I have never, ever been asked by a physician about my sexual orientation, and am curious as to whether any of you have.**
I was pleased to see the instruction to ask women about prior discomfort during a pelvic exam, although I don’t think I’ve ever been asked that, either.
The preparation section also includes an equipment list – they forgot the instruction about “find the coldest piece of metal known to humankind.”
Section 3, Procedure:
Did you know that one reason you should urinate prior to the exam is that “a full bladder may compress the vaginal canal and obstruct the view of the cervix?”
This section also provides the instruction to make sure the patient has been offered the opportunity to have a chaperone in the room during the examination. Are you generally offered this option? Do you want this option? I’ve had “chaperones” in the room without being asked, which I find disturbing.
On patient positioning – “You should be able to easily visualize her vulva, but still keep her knees covered.” Sweethearts, when you’re feeling up my boobs and poking around my vagina, the privacy of my knees is the least of my worries.
One qualm with this – the model patient is completely shaved. I’m sure that’s for video purposes, so it’s easier to see the woman’s anatomy while learning about the procedure. However, in the real world, this is not what many women are going to look like. How does that change how well the woman can be “visualized” on exam? How does presenting models in this manner shape those learning to perform the exams?
So, what are they looking at down there? According to the video, it’s the “entire vulva, perianal area, vaginal canal, and Bartholin glands.” I thought this was interesting, because I don’t think I’ve ever, ever heard the words “Bartholin glands” in an exam. [See the vulvar anatomy] Among the things they’re looking for are rashes, lesions, swelling, and trauma, as well as areas of irritation, discomfort, or pain.
The video then informs us that some of the more common findings include:
-Vaginal varicosities (none of you mommy bloggers told me about this!)
[See list and description of "benign vulvar lesions," "vulvar problems," and "self-help tips for vulvar skin care."]
Hey! Wait! They just said to warm the speculum with warm water! C’mon, people, follow the instructions! Speculum goes in to a “depth of 4-5 centimeters,” in case you were wondering. Sure seems like more.
Oh! I wish you could see what the pap part of the exam looks like! There’s the cervix! Okay, so if you get one kind of pap test, it’s a wide brush that looks like a push broom that they sweep over the cervix. If you get the other kind, it’s a “spatula” (seriously, they call it that), followed by a small brush that looks more like something you would clean out an instrument with.
“A healthy adult vaginal pH is 4.”
“Trichomonads will appear to vibrate on the slide.”
“Let the patient know she may have a small amount of bleeding after pap smear sampling.” – Nope, don’t think I’ve ever been told that, either.
Next, the part where one hand goes in the vagina and the other goes on your belly – “The abdominal hand should be used to sweep the pelvic organs downward, while the vaginal hand is simultaneously elevating them.” This is for size, shape, and symmetry, mobility(!), position, and consistency(!!) of the uterus, and checking for appropriately sized, mobile ovaries. (Is “mobile ovaries” taken as a band name?) They’re also looking for “adnexal masses” (that would be a mass on the ovary).
Reasons for rectovaginal examination: assess retroverted uterus; screen for colorectal cancer; evaluate for pelvic pathology. The animation (used for the internal bits) for this is priceless, especially given the purple disembodied hands.
Section 4 is called “Troubleshooting.” What is there to troubleshoot about a pelvic exam? According to the video, “In obese patients, the cervix can be difficult to visualize, due to excess vaginal tissue.” The solution? Cut off the thumb tip of an exam glove, and slide it over the speculum like a sleeve. This gives the speculum two extra “sides” to hold the tissue out of the way.
Yep, apparently that’s the only troubleshooting that is needed. Hmm.
Section 5: Contraindications
Apparently, there are “relatively few,” including physical or mental disability, abnormal anatomy, or physical immaturity. Consider examination under anesthesia in the case of physical immaturity with an intact hymen. Delay if liquid-based pap is not available and the patient is “menstruating heavily.”
And that’s a wrap!
*Obviously you shouldn’t go running around performing pelvics on strangers just based on this blog post.
**None of my observations apply to my current pelvic exam provider, who is awesome.