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Bimanual/Speculum Examination

The purpose of the examination is to look at the size and shape of external and internal reproductive organs.

 

The external examination will involve:

  • examination of anatomy
  • looking for any lesions, ulcers,  discharge or other signs of disease
  • palpation of the abdomen

 

    The internal examination will involve:

    • palpation of the vulva and vaginal walls
    • examination of the cervix
    • assessing the size and position of the uterus
    • palpating for any adnexal tenderness
    • location of the cervix using the speculum
    • performing any appropriate swabs or smears using the speculum

     

    Female pelvic anatomy

    Preparation and Introduction

    1. Introduce yourself and wash your hands
    2. Ask the patient whether they are experiencing any symptoms and explain the purpose of the examination
    3. Explain that it will involve undressing fully from the lower half and the examination may be a bit uncomfortable but should not be painful
    4. Gain consent and offer a chaperone
    5. Before the patient undresses, perform a general examination, looking for signs of hormonal disorders for example hirsutism and acne
    6. Explain to the patient that the position they should be lying in is supine, with knees bent, heels brought up towards bottom, and then letting legs fall to either side of the bed. Let the patient undress in privacy behind the curtain and provide them with a blanket to maintain their dignity.  
    7. Prepare trolley and equipment: flexible light source, gloves, lubricating jelly, speculum.
    8. Allow the patient to become comfortable before starting

    Inspection

    1. Begin with a general abdominal examination
    2. Inspect the external genitalia for hair distribution, sweling, scarring, signs of infection for example warts or ulcers
    3. Ask the patient to cough looking for signs of prolapse

    Speculum Examination

    1. Think about the size of the speculum needed and use lubrication
    2. Explain to the patient what you are going to do before proceeding
    3. Expose the introitus by spreading the labia from below using the index and middle finger
    4. Gently insert the speculum at a 45 degree angle and pointing slightly downward
    5. Gently rotate the speculum to a horizontal position and gently open the blades until the cervix is in view (the blades may not need to be fully opened)
    6. Secure the speculum by turning the thumb nut
    7. Visualise the cervix and vaginal walls for any abnormalities, such as ectopy, cysts or polyps
    8. Comment on whether the cervical os is open or closed? (parous or nulliparous)
    9. Perform any necessary tests, obtaining samples for culture and cytology (below)
    10. Withdraw the speculum slightly to clear the cervix and gently loosen the speculum to close the blades
    11. Continue to withdraw whilst rotating the speculum to 45 degrees, avoiding contact with the vaginal walls

    Swabs and Smear

    A speculum examination should be performed using minimal lubrication if a smear is to be performed.  For this reason, it is recommended the speculum examination is performed before the bimanual examination, to allow for extra lubricant during the bimanual procedure.   

     

    • Smear - this is done to analyse cells for any pre-cancerous changes. Under direct vision using the cervical brush, rotate 5 x 360 degree sweep around the centre of the cervix, then break the sample brush off into the liquid based cytology pot. For further information about smear tests see here.  

     

    • High Vaginal Swab - this will test for any bacterial infection for example bacterial vaginosis. A routine bacteriology swab is used to collect the sample, including any discharge present from the posterior fornix (upper vagina).

     

    • Endocervical Chlamydial Swab - as chlamydia actually resides within cells, PCR is used. First a swab is used to clean away any discharge, then the endocervical swab is gently inserted into the centre of the cervix and gently rotated. The swab is then broken off into the liquid sample pot provided. An endocervical swab is also used for gonorrhoea.  

    Palpation

    1. Explain to the patient what you are going to do before you proceed
    2. Use gloves and lubricant
    3. Gently palpate the labia majora and minora, part the labia and inspect the clitoris
    4. Expose the introitus by parting the labia using your non dominant hand, and gently insert lubricated index and middle finger, placing other hand on patients abdomen
    5. Assess vaginal walls
    6. Locate cervix and assess size, shape and consistency
    7. Gently move the cervix side to side looking for any tenderness assessing for cervical excitation
    8. Examine the anterior uterine fundus by lifting the cervix with the vaginal hand, and pressing downwards with the abdominal hand (bimanual)
    9. Assess uterine size and position (anteverted / retroverted), normally is mobile and non tender
    10. Examine the adnexal structures by sweeping fingers into left and right fornices, palpating over the iliac crests with the abdominal hand to assess the overies and any other masses, any tenderness?
    11. Gently withdraw fingers and look at glove for any blood or discharge
    12. Re-drape the patient and allow to redress in privacy
    13. Summarise findings

     

    Positioning and technique for bimanual examination
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