A bimanual vaginal examination may need to be performed in a number of different clinical scenarios including unexplained pelvic pain, irregular vaginal bleeding, abnormal vaginal discharge and as part of the assessment of a pelvic mass. Bimanual vaginal examination frequently appears in OSCEs and you’ll be required to demonstrate excellent communication and practical skills. This guide demonstrates how to perform a bimanual vaginal examination in an OSCE setting.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain what the examination will involve using patient-friendlylanguage: “Today I need to carry out a vaginal examination. This will involve me using one hand to feel your tummy and the other hand to place two fingers into your vagina. This will allow me to assess the vagina, womb and ovaries. It shouldn’t be painful, but it will feel a little uncomfortable. You can ask me to stop at any point.”
Explain the need for a chaperone: “One of the female ward staff members will be present throughout the examination, acting as a chaperone, would that be ok?”
Gain consent to proceed with the examination: “Do you understand everything I’ve said? Do you have any questions? Are you happy for me to carry out the examination?”
Ask the patient if they have any pain or if they think they may be pregnant before proceeding with the clinical examination.
Provide the patient with the opportunity to passurine before the examination.
Explain to the patient that they’ll need to remove their underwear and lie on the clinical examination couch, covering themselves with the sheet provided. Provide the patient with privacy to undress and check it is ok to re-enter the room before doing so.
Wash your hands.
An abdominal examination should always be performed before moving onto vaginalexamination. This may be less thorough than a full abdominal examination, but should at least include inspection and palpation of the abdomen.
1. Don a pair of non-sterile gloves.
2. Position the patient in the modified lithotomy position: “Bring your heels towards your bottom and then let your knees fall to the sides.”
Position the patient supine
Adequately expose the patient
Inspect the vulva
1. Inspect the vulva for abnormalities:
Ulcers: typically associated with genital herpes.
Abnormal vaginal discharge: causes include candidiasis, bacterial vaginosis, chlamydia and gonorrhoea.
Scarring: may relate to previous surgery (e.g. episiotomy) or lichen sclerosus (destructive scarring with associated adhesions).
Vaginal atrophy: most commonly occurs in postmenopausal women.
White lesions: may be patchy or in a figure of eight distribution around the vulva and anus, associated with lichen sclerosus.
Masses: causes include Bartholin’s cyst and vulval malignancy.
Varicosities: varicose veins secondary to chronic venous disease or obstruction in the pelvis (e.g. pelvic malignancy).
2. Inspect for evidence of vaginal prolapse (a bulge visible protruding from the vagina). Asking the patient to cough as you inspect can exacerbate the lump and help confirm the presence of prolapse.
Inspect the vulva
Inspect the vulva
Ask the patient to cough and inspect for vaginal prolapse
Bartholin's cyst 1
Lichen sclerosus 2
Vaginal candidiasis 3
Uterine prolapse 4
Bartholin’s glands are responsible for producing secretions which maintain vaginal moisture and are typically located at 4 and 8 o’clock in relation to the vaginal introitus. These glands can become blocked and/or infected, resulting in cyst formation. Typical findings on clinical examination include a unilateral, fluctuantmass, which may or may not be tender.
Lichen sclerosus is a chronic inflammatory dermatological condition that can affect the anogenitalregion in women. It presents with pruritis and clinical examination typically reveals white thickened patches. Destructivescarring and adhesions develop causing distortion of the normal vaginal architecture (shrinking of the labia, narrowing of the introitus, obscuration of the clitoris).
Abnormal vaginal discharge
There are several causes of abnormalvaginaldischarge including:
Bacterial vaginosis: typical findings include a thin, profuse fishy-smelling discharge without pruritis or inflammation.
Candidiasis: typical findings include a curd-like, non-offensive discharge with associated pruritis and inflammation.
Chlamydia and gonorrhoea (symptomatic): typical findings include purulent vaginal discharge
Trichomoniasis: typical findings include offensive yellow, frothy vaginal discharge with associated pruritis and inflammation.
Warn the patient you are going to examine the vagina and ask if they’re still ok for you to do so.
If the patient consents to the continuation of the examination:
1. Lubricate the gloved index and middle fingers of your dominant hand.
2. Carefully separatethelabia using the thumb and index finger of your non-dominant hand.
3. Gently insert the glovedindex and middlefinger of your dominant hand into the vagina.
4. Enter the vagina with your palmfacinglaterally and then rotate90degrees so that your palm is facing upwards.
Lubricate gloved fingers
Separate the labia
Gently insert lubricated fingers into the vagina
Rotate your hand 90° so your palm faces upwards
Palpate the walls of the vagina for any irregularities or masses.
Examine the cervix to assess:
Position (e.g. anterior or posterior)
Consistency (e.g. irregular, smooth)
Cervical motion tenderness: involves severe pain on palpation of the cervix and may suggest pelvic inflammatory disease or ectopic pregnancy.
The fornices are the superior portions of the vagina, extending into the recesses created by the vaginal portion of the cervix.
Gently palpate lateral fornices for any masses.
Assess the vagina and cervix
Bimanuallypalpate the uterus:
1. Place your non-dominant hand 4cm above the pubis symphysis.
2. Place two of your dominant hand’s fingers into the posteriorfornix.
3.Push upwards with the internal fingers whilst simultaneously palpating the lower abdomen with your non-dominant hand. You should be able to feel the uterusbetween your hands. You should then assess the various characteristics of the uterus:
Size: the uterus should be approximately orange-sized in an average female.
Shape: may be distorted by masses such as large fibroids.
Position: the uterus may be anteverted or retroverted.
Surface characteristics: note if the uterus feels smooth or nodular.
Tenderness: may suggest inflammation (e.g. pelvic inflammatory disease, ectopic pregnancy).
Bimanually palpate the uterus
The position of the uterus can be described as:
Anteverted: the uterus is orientated forwards towards the bladder. This is the most common position of the uterus.
Retroverted: the uterus is orientated posteriorly, towards the spine. This is a less common uterine position present in approximately 1 in 5 women.
Ovaries and uterine tubes
The term adnexa refers to the area that includes the ovaries and fallopiantubes.
Bimanuallypalpate the adnexa:
1. Position your internal fingers in the left lateral fornix.
2. Position your external hand onto the left iliac fossa.
3. Perform deep palpation of the left iliac fossa whilst moving your internal fingers upwards and laterally (towards the left).
4. Feel for any palpablemasses, noting their size and shape (e.g. ovarian cyst, ovarian tumour, fibroid).
5.Repeatadnexalassessment on the right.
6. Withdraw your fingers and inspect the glove for blood or abnormaldischarge.
7. Cover the patient with the sheet, explain that the examination is now complete and provide the patient with privacy so they can get dressed. Provide paper towels for the patient to clean themselves.
8. Dispose of the used equipment into a clinicalwastebin.
9. Wash your hands.
Palpate the right adnexa
Palpate the left adnexa
Withdraw fingers and inspect for discharge or blood
Re-cover the patient
To complete the examination…
Thank the patient for their time.
Summarise your findings.
Document the examination in the medical notes including the details of the chaperone.
“Today I examined Mrs Smith, a 28-year-old female. On general inspection, the patient appeared comfortable at rest. There were no objects or medical equipment around the bed of relevance.“
“Abdominal examination was unremarkable and there were no abnormalities noted on inspection of the vulva. Bimanual examination revealed an anteverted uterus of normal size and shape. There were no masses palpated in the vaginal canal or adnexa.”
“In summary, these findings are consistent with a normalvaginalexamination.”
“For completeness, I would like to perform the following further assessments and investigations.”
Further assessments and investigations
Urinalysis: including β-HCG to rule out pregnancy (including ectopic pregnancy).