Overview of Gynecologic Pelvic Examination
A gynecologic exam is a key part of women’s healthcare. It typically involves a careful look at the external sexual organs, along with an internal check using specific tools and techniques. Sometimes, doctors may also do a rectovaginal exam to further assess the area at the back of the pelvic region. This is useful because it allows medical professionals to detect a variety of health conditions such as abnormal bleeding, pain in the pelvic area, sexually transmitted infections, tumors, cysts, and irregularities in the physical structure. It can also be used for more routine health screenings and during pregnancy.
Additionally, a thorough gynecologic exam is important before doing any medical procedures, like the placement of an intrauterine device (IUD), which is a form of birth control. It is also helpful in following women’s health during their childbearing years.
Doing a gynecologic exam can be challenging for medical professionals. Since these exams deal with very personal health issues, patients may feel uneasy, embarrassed, and uncomfortable. That’s why it’s crucial for healthcare providers to communicate well with patients. They need to thoroughly explain the procedure to the patient, making sure they understand why it’s being done. They also need to respect the patient’s feelings and concerns. Gaining skills in these exams can also be tough, given their sensitive nature.
Anatomy and Physiology of Gynecologic Pelvic Examination
The external parts of a woman’s reproductive system are known as the vulva. This includes the mons pubis, labia majora, labia minora, clitoris, and other features such as the vaginal opening, urethral opening, and the area between the vaginal opening and the anus, known as the perineum.
The mons pubis is the fatty area over the pubic bone. Below it are the labia majora, a pair of fatty folds of skin. Both of these areas naturally have pubic hair. Inside the labia majora are the thinner, hairless labia minora. The space inside the labia minora is called the vestibule. The urethral opening, where urine exits the body, is located in this area in front of the vaginal opening.
The clitoris is a small sensitive organ located at the top of the vulva. It is usually covered by a small piece of skin, called the clitoral hood, which is made from the upper parts of the labia minora. The actual shape of the clitoris inside the body is similar to a “Y”.
Beneath the labia majora are two elongated pieces of erectile tissue known as the vestibular bulbs. They are at the front-middle of the vagina and wrap around the sides of the vaginal opening. Nearby, around the 4 and 8 o’clock positions when a patient is lying back with her legs apart, are the Bartholin glands, which secrete fluid to moisturize the vagina and provide lubrication during sexual intercourse. They are normally about the size of a pea and are neither visible nor can be felt. The Skene glands, which are similar to the prostate in men, are located on both sides of the urinary opening within the vestibule.
The internal parts of a woman’s reproductive system include the vagina, cervix, uterus, fallopian tubes, and ovaries. The bladder, the area between the vagina and rectum called the rectovaginal septum, and the muscles that support the pelvic organs can also be checked during an internal pelvic exam.
The vagina is a stretchy, muscular canal about 8 to 10 cm long that extends from the vulva to the cervix. The inner lining of the vagina has folded ridges known as vaginal rugae, which create friction during intercourse. The environment of the vagina is usually acidic, with a pH level of around 3.5 to 4.0. The acidity is due to bacteria converting sugar in the cells to lactic acid.
The hymen is a thin tissue membrane that partially covers the vaginal opening. Its appearance can vary greatly, and it can also be hard to find after it has broken, which can happen during intercourse, self-stimulation, tampon use, a pelvic examination, injury, or even physical exercise.
The cervix is the lowermost part of the uterus. It is a thick, muscle-rich organ that connects the uterus to the vagina. The cervix is visible when looking inside the vagina with a medical instrument. It projects into the far reach of the vagina, known as the fornix. The cervical canal has an internal and external opening, referred to as the os. When a woman is in labour, the phrase “cervical dilation” refers to the opening of the internal os.
The uterus is a muscular organ shaped like an inverted pear, found in the pelvis. It connects to the vagina through the cervix at its bottom end. The uterus typically measures about 7 cm from the cervix to the top part called the fundus in a woman who is not pregnant. The inside of the uterus is lined with a layer of cells, known as the endometrium. The uterus can be felt during an examination to determine its size, shape, position, and flexibility.
The upper sides of the uterus connect to the fallopian tubes, which are approximately 10 cm long. These tubes link the inside of the uterus to the ovaries. The ovaries, which produce eggs, are almond-shaped organs located on either side of the uterus. They are typically 2 to 3 cm large, although they shrink in size after menopause.
Why do People Need Gynecologic Pelvic Examination
A pelvic exam is a type of check-up where doctors look at a woman’s reproductive organs – both outside and inside. They often also take a look at the bladder, the anus, or the rectum. This check-up is usually needed when a woman is facing certain issues. These can include abnormal bleeding (like problems with periods or bleeding after sex or menopause), pelvic pain, abnormal vaginal discharge, itching, any lumps or growths, visible sores or ulcers, problems getting pregnant, physical injuries, something foreign lodged in the vagina, issues with the shape or development of reproductive organs, neurological conditions, incontinence or conditions that affect the pelvic floor.
Sometimes, when a woman is having problems with digestion (like difficulty eating, feeling full quickly after eating, stomach pain or bloating), a pelvic exam can be useful too. In addition, throughout pregnancy, pelvic exams can help monitor for issues like bleeding, cramping, contractions, or leaking amniotic fluid (the liquid that surrounds and protects the baby in the womb).
Traditionally, doctors have used pelvic exams during routine check-ups for women who don’t have any symptoms, to check for cancer or infections in the reproductive organs. However, recent research has suggested that these exams might not be very useful for this purpose. There’s limited evidence to suggest that these routine exams actually help improve outcomes for non-cancerous gynecological conditions or cancers that aren’t related to the cervix, including ovarian cancer. This might be because these exams don’t accurately detect ovarian cancer or benign conditions if a patient doesn’t have any symptoms.
Different health organizations provide various guidelines concerning routine pelvic exams. The American College of Obstetricians and Gynecologists suggests that doctors and patients discuss the pros and cons of routine pelvic exams during a regular check-up and decide together if it’s needed. Other bodies like the American College of Physicians and the US Preventative Services Task Force don’t recommend routine pelvic exams for women without symptoms.
However, a routine pelvic exam may be useful in some cases. It can potentially lead to the early detection of cancer in the vulva or vagina before any symptoms appear, or find any abnormal anatomy or foreign bodies. It also allows patients to bring up any concerns about their reproductive health, and the doctor to ask about any abnormal signs the patient may not have noticed. Also, even though pelvic exams can be uncomfortable, one study found that 82% of people felt reassured about their health after the exam.
Although the likelihood is low, pelvic exams may cause some harm, such as pain, discomfort, anxiety, embarrassment, especially for people who have experienced sexual violence in the past. Lastly, it’s important to note that a pelvic exam isn’t necessary before a healthy woman with no symptoms can be prescribed birth control medication.
When a Person Should Avoid Gynecologic Pelvic Examination
The one definite reason a procedure can’t happen is if the person for whom it’s intended doesn’t agree to it.
Equipment used for Gynecologic Pelvic Examination
The pelvic exam is usually carried out on a flat surface like an examination table. This table should ideally have supports for the patient’s feet called stirrups. To maintain the patient’s privacy, a curtain or drape is used to cover the area below the patient’s waist. Also, an absorbent pad is usually placed under the patient’s lower body.
The doctor wears exam gloves for the procedure and uses a device called a speculum. This speculum, along with a light source and a type of lubricant that can be mixed with water, are necessary to complete the internal portion of the examination. If there are unexpected findings like a pus-filled discharge, the doctor should have the necessary supplies ready to take samples for further testing.
Speculums come in different sizes and designs. The Pedersen and Graves specula are the two most commonly used. The Graves speculum can stay in place by itself once it is inserted and is usually wider than the Pedersen speculum. It is often used for women who have given birth. The Pedersen speculum is more narrow and is usually more comfortable for women. However, this speculum needs to be held in place during the exam. There are also pediatric specula which are smaller sized specula used for children.
There are two main types of specula – metal and plastic. Metal specula can be reused but need to be sterilized each time before use. Plastic specula on the other hand are meant for one-time use and are then disposed of. Many plastic specula have a feature that allows them to be used with a fiberoptic light source which aids visibility. However, metal specula need an adjustable lamp instead. Regular room lighting is not sufficient for this examination.
Who is needed to perform Gynecologic Pelvic Examination?
For your comfort and safety, it’s usually a good idea to have another person, called a ‘chaperone’, present during a gynecologic exam (a health check specific to women). This also gives the doctor some security. There isn’t much research to suggest that having a chaperone lowers the chance of legal issues, but it’s still a common practice. The chaperone is usually a trained person like a medical assistant or nurse, and they actively help the doctor carry out the exam.
Preparing for Gynecologic Pelvic Examination
Before any medical examination, the doctor needs to have a detailed discussion with the patient. Here, the doctor will present why an examination is needed and explain the steps it involves. This is called obtaining ‘informed consent’ and it’s an essential process to ensure the patient understands and agrees to the examination.
When it’s time for the examination, the patient will be asked to undress from the waist down while keeping covered with a sheet for privacy. The sheet will only be moved during the examination and the patient will be guided on when and how to position themselves for maximum comfort and effectiveness of the exam.
For gynecologic exams, doctors usually ask patients to be in a position called the ‘dorsal lithotomy position’. In simpler terms, the patient lies on her back with her feet elevated and placed in foot supports, reminiscent of a birthing position. The doctor will assist the patient in positioning themselves on the table such that their buttocks are slightly over the edge. This positioning allows the doctor to well examine the vaginal area without any obstructions.
In case foot supports are not available, substituting it with something like a padded, upside-down bedpan could work. Legs can also be bent at the hips and knees, or arranged in a ‘frog-leg’ position whereby the soles of her feet are put together. The ‘frog-leg’ position could also be used when a speculum – a tool used for gynecological exams – is not required. For example, when only the outside genital area of a pediatric or postpartum patient is to be examined.
How is Gynecologic Pelvic Examination performed
The gynecological exam is a routine check-up that looks at the female reproductive system. This exam usually includes looking at the outer sex organs, using a tool to look inside the vagina and uterus, and feeling the uterus and surrounding areas. Sometimes, an exam of the rectum and vagina may be included too.
Firstly, the healthcare provider will visually examine the outer sex organs, which include the mons pubis (fatty area over the pubic bone), labia (outer and inner lips of the vagina), clitoris, and perineum (area between the vagina and the anus). They will look for normal development, symmetry, hair distribution, and signs of any swelling, bruising, redness, rashes, lesions, bumps, lumps, or discharge. Touching any visual abnormalities can provide more information about their characteristics such as size, movement, and consistency. To do this, the provider may place their thumb on the labia with the index finger in the vagina, moving the mass between their fingers. They may also ask the patient to push down as if having a bowel movement and observe the movement of the vaginal walls and uterus, to check for a condition called pelvic organ prolapse where organs fall down into or out of the vagina.
Next, the healthcare provider will insert a speculum (a tool that can open up) into the vagina, in order to look at the vagina and the cervix (lower part of the uterus). This tool should be lubricated before insertion. The speculum is gently inserted into the vagina and then opened so the healthcare provider can check the cervix. The cervix should appear smooth and firmer compared to the surrounding vagina. If necessary, samples can be taken for testing at this time. Any unusual findings such as inflammation, ulcers, bumps, or foreign objects are also noted during this step. The provider will then close and remove the speculum carefully.
Following this, the healthcare provider will conduct a bimanual examination. This involves inserting their fingers into the vagina to feel the patient’s uterus and surrounding structures. The healthcare provider will make note of the position, size, shape, movement, and tenderness of the cervix and uterus to detect issues like inflammation or adhesions (where tissues stick together). After performing these checks on one side, they will then repeat the process on the other side.
In some cases, a rectovaginal examination may be done too. This is where the healthcare provider inserts a finger into the rectum and vagina to feel for the tissue structure between these two organs and other pelvic structures. The patient’s comfort is priority and this step is usually discussed in advance.
Possible Complications of Gynecologic Pelvic Examination
It is not common, but sometimes there can be complications during a woman’s gynecologic exam.
For instance, in women suffering from a condition called atrophic vaginitis, which involves the thinning, drying and inflammation of the vaginal walls, the speculum exam (a procedure that involves the insertion of a medical instrument called a speculum into the vagina to observe the vagina and cervix) could be painful and may cause tears in the mucus membrane lining the vagina. To make the examination more comfortable, doctors highly recommend the use of more lubrication and a smaller speculum for these patients.
Also, a pelvic exam could make symptoms worse in women who are suffering from chronic pelvic pain.
Women who have a history of sexual trauma might feel anxious or experience posttraumatic stress disorder during a pelvic examination. Communication is crucial, and doctors strive to make sure to get the patient’s consent before and during each step of the exam to help lessen any anxiety that might arise. Doctors can also utilize mental health counseling, anxiety medications, and different modifications to the exam, such as allowing the patient to insert the speculum herself, giving the option of having only female healthcare professionals present, or allowing a friend or family member to be in the room for support. It’s essential to remember that the patient can ask the examiner to stop the exam at any time.
What Else Should I Know About Gynecologic Pelvic Examination?
The gynecological examination is a valuable tool used by doctors to check the health of female reproductive organs, like the vulva, vagina, uterus, and parts of the pelvis. This check-up is essential to investigate a variety of women’s health concerns, such as abnormal bleeding, unusual discharge, discomfort, unusual growths, lesions, bladder control problems, uterine prolapse, and others.
This examination allows doctors to collect samples that can be tested for various purposes. These can include testing for sexually transmitted infections (STIs), screening for cervical cancer, examining discharge under a microscope, or taking biopsies (small tissue samples) for further testing. This exam helps ensure your reproductive health is in the best possible condition, and it plays a crucial role in early diagnosis of possible health issues.
