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.
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)
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.”
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.
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.
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
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.
Inspect the external vaginal orifice.
Ask the patient to cough to look for vaginal prolapse.
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 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 it is facing upwards
Lubricate gloved fingers.
Separate the labia.
Gently insert lubricated fingers into the vagina.
Rotate hand 90 degrees so your palm faces upwards.
Vagina, Cervix and Fornices
Assess the vagina
Palpate the walls of the vagina for any irregularities or masses.
Assess the cervix
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.
Palpate the uterus
1. Place your non-dominant hand 4cm above the pubissymphysis
2.Place your dominanthand’sfingers into the posteriorfornix
3. Pushupwards with the internalfingers whilst simultaneously palpating the lowerabdomen 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 internalfingers into the leftlateralfornix
2.Place your externalfingers onto the leftiliacfossa
3.Perform deeppalpation of the leftiliacfossa whilst moving your internalfingersupwards 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 oppositeside
Palpate the right adnexa.
Palpate the left 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
Withdraw fingers and inspect for discharge or blood.
Re-cover patient and provide paper towels.
“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.”.