Priority Topic: Abdominal Pain

Key Feature 3c: In a woman with abdominal pain: Do a pelvic examination, if appropriate.
Skill: Clinical Reasoning
Phase: Physical, Diagnosis

​In my last blog post I described my encounter with a 27 year old female patient presenting with abdominal pain. The cause of her pain was ultimately felt to be a combination of a flare-up of ulcerative colitis along with secondary acute opioid withdrawal. But during my first assessment of her, and with pain that she localised to her right lower quadrant, I had to consider that there was a gynecological etiology contributing to her pain. (As a female of childbearing age, this would be indicated regardless, but on top of that, she had significant risk factors including past history of a ruptured ovarian cyst and pelvic inflammatory disease.) A pelvic examination was warranted as part of this patient's workup, and my findings were reassuring in that there were no specific signs of gynecological pathology on exam. 

My approach to a general pelvic examination is as follows: 

1. Explain: Explain what the exam entails and ask if they have any questions. Obtain consent. Document this.
2. Chaperone: Ask the patient if they would like to have a chaperone present and document if this was declined.
3. Gather supplies: If a am doing a speculum exam +/- a Pap smear, this means having all of those supplies ready. 
4. Personal protection: Put on a pair of gloves.
5. Position and drape the patient: For this exam I position the patient in dorsal lithotomy position with a drape overlying the unclothed pelvis.
6. Inspection: Inspect the external pelvic area for any abnormalities (ex: rash or ulceration)
7. Palpation: Bimanual examination
   1. Vagina: Separating the labia with the thumb and index finger of my left hand, I insert the index and middle finger of my right hand facing laterally, and rotate 90º upwards. I feel for any masses or irregularities of the vaginal walls, I feel the cervix and take note of its position, consistency, and whether the cervical os is open or closed, and gently clasping it between my two fingers I palpate for cervical motion tenderness, a sign that would raise the suspicion for pelvic inflammatory disease. I then palpate for tenderness or abnormalities of the fornices.
   2. Uterus: I then move on to assess the uterus. To do this, I place my left hand approximately 4cm above the pubic symphysis, I place the index and middle fingers of my right hand in the posterior fornix, and then I push up on the cervix with my right hand while simultaneously pushing down on the abdomen with my left hand in the direction of my right hand. Now with the uterus between my two hands I can assess by palpation:
      1. Position (anteverted or retroverted)
      2. Size (a normal nonpregnant uterus is about the size of an orange)
      3. Shape (feeling for any irregularities, which could suggest the presence of fibroids)
      4. Surface (smooth vs nodular)
      5. Tenderness (this assessment is not comfortable  per se, but it should not otherwise cause pain)
   3. Adnexa: I then move on to the last component of the bimanual exam, which is to assess the adnexa on each side of the uterus. On each side, I place the fingers of my right hand into that lateral fornix, with the fingers of my left hand pushing into the iliac fossa on the same side, and I direct the force of my fingers toward one another, noting for any masses or tenderness. After finishing this last part of the bimanual exam, as I remove my right fingers from the vagina, I take a look to see if there is any blood or discharge on my glove.
8. +/- Speculum exam: *​In the setting of right lower quadrant pain without any focal genitourinary symptoms, performing a speculum exam is not indicated. This is my approach to performing a speculum exam when indicated.* Separate the labia and gently insert the lubricated speculum sideways (with blades closed and angled down and back), then rotate the speculum 90 degrees once fully inserted, open the blades to find an optimal view of the view of the cervix, and fix the blades there. Inspect the cervical os and note any discharge or cervical masses or lesions. At this point is when swabs and a Pap smear would be obtained. Now I inspect the vaginal mucosa as I remove the speculum, reversing the steps of insertion.

The end!