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A bimanual vaginal examination can be performed for a number of different clinical indications including unexplained pelvic pain, irregular vaginal bleeding, vaginal discharge and assessment of a pelvic mass. It frequently appears in OSCEs and you will be required to demonstrate appropriate clinical and communication skills. This guide demonstrates how to perform a bimanual vaginal examination in an OSCE setting.

Check out the vaginal examination OSCE mark scheme here.

Check out our focused speculum examination OSCE guide here.

 


Introduction

  • Wash your hands
  • Introduce yourself
  • Confirm the patient’s details (name/date of birth)
  • Ask if the patient thinks they may be pregnant
  • Explain the examination and gain consent (as shown below)

Explanation

Describe the examination

Assess the patient’s current understanding of the examination:

  • “Today I need to carry out a bimanual vaginal examination. Do you understand what the examination involves?”

 

Provide a detailed explanation of the examination:

  • “What the examination will involve is 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 will be in full control throughout the examination and you can ask me to stop at any point.”
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Explain the need for a chaperone:

  • “For this examination, another staff member will be present, acting as a chaperone.”
  • “Are you happy for a chaperone to be present?”
  • “Do you have any preference on the gender of the chaperone?”

 

Gain verbal consent:

  • “Does everything I’ve said make sense?”
  • “Do you have any questions?”
  • “Are you happy for me to perform the examination?”

 

Ask if the patient would like to empty their bladder before the examination.

 


Gather equipment

  • Gloves
  • Lubricant
  • Paper towels
  • Gather equipment

Abdominal examination

An abdominal examination should always be performed before moving onto vaginal examination.  This may be less thorough than a full abdominal examination, but should at least include inspection and palpation of the abdomen.

 


Position

The patient should be positioned supine on a bed with their underwear removed and their abdomen exposed (a modesty cloth should be provided):

  • “I need you to go behind the curtain and remove your underwear, then please could you get onto the bed. You can cover yourself with the sheet provided.”
 

Position the patient in the modified lithotomy position:

  • “Bring your heels towards your bottom and then let your knees fall to the sides.”
  • Position patient supine

Vulval inspection

1. Don gloves

2. Inspect the vulva:

  • Ulcers (e.g. genital herpes)
  • Abnormal vaginal discharge (e.g. chlamydia or gonorrhoea)
  • Scars from previous surgery (e.g. episiotomy)
  • Vaginal atrophy (secondary to post-menopausal changes)
  • Masses (e.g. Bartholin’s cyst)
  • Varicosities (varicose veins secondary to venous disease/obstruction in the pelvis)

3. 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.

Vaginal examination

Warn the patient you are going to examine the vagina and ask if they’re still happy for you to do so.

Entering the vagina

1. Lubricate the gloved index and middle fingers on your dominant hand

2. Carefully separate the labia using the thumb and index finger of your non-dominant hand

3. Gently insert the gloved index and middle finger of your dominant hand into the vagina

4. Enter the vagina with your palm facing laterally and then rotate 90 degrees so that it is facing upwards

  • Lubricate gloved fingers.

Vagina, Cervix and Fornices

Assess the vagina

Palpate the walls of the vagina for any irregularities or masses.

 

Assess the cervix

  • Position 
  • Consistency (hard/soft)
  • Os (open/closed)
  • Cervical excitation – severe pain on palpation of the cervix (may suggest pelvic inflammatory disease)

 

Assess the fornices 

Gently palpate the fornices either side of the cervix for any masses.

  • Assess the vagina and cervix.

Uterus

Palpate the uterus

1. Place your non-dominant hand 4cm above the pubis symphysis

2. Place your dominant hand’s fingers into the posterior fornix

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 uterus between your hands. You should then assess the various characteristics of the uterus that are shown below.

 

Assess the uterus

  • Size – approximately orange sized in an average female
  • Shape – may be distorted by masses such as fibroids
  • Position  – anteverted vs retroverted
  • Surface characteristics – smooth vs nodular
  • Note any tenderness during palpation
  • Palpate and assess the uterus bimanually.

 

Ovaries and uterine tubes

Assess the adnexa

1. Place your internal fingers into the left lateral fornix

2. Place your external fingers 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 palpable masses, noting their size and shape (e.g. ovarian cyst/ovarian tumour/fibroid)

5. Repeat adnexal assessment on the opposite side

  • Palpate the right adnexa.

To complete the examination…

  • Withdraw your fingers – inspect the glove for blood or abnormal discharge
  • Re-cover the patient – allow the patient time to re-dress in private
  • Thank the patient
  • Dispose of equipment into a clinical waste bin
  • Wash hands
  • Withdraw fingers and inspect for discharge or blood.

Summarise findings

“On examination of Mrs Smith, a 29-year-old female, the abdomen was soft and non-tender. There were no abnormalities noted on inspection of the vagina. Vaginal examination was unremarkable, with no tenderness or masses noted. The uterus was retroverted and normal in size and shape. No masses were noted in the adnexa. These findings are consistent with a normal vaginal examination.”.

 

Suggest further assessments and investigations


REVIEWED BY

Mr Isaac Magani

Consultant Obstetrician 


 

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