Bimanual vaginal examination is 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, most often with a mannequin, however, you will still be required to demonstrate appropriate communication skills. This guide demonstrates how to perform a bimanual vaginal examination in your OSCE. Check out the vaginal examination OSCE mark scheme here.
Confirm patient details – name / DOB
Ask if the patient thinks they may be pregnant
Explain the examination and gain consent (as shown below)
Describe the examination
Assess current understanding of the examination:
“I’ve been asked to carry out a bimanual 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. Let me know at any point if you would like me to stop.”.
Explain the need for a chaperone:
“For this examination one of the female ward staff will be present acting as a 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.
- Paper towels
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.
The patient should be positioned supine on a bed with their underwear removed and their abdomen exposed (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.”
1. Don gloves
2. Inspect the vulva:
- Ulcers – e.g. genital herpes
- Scars – previous surgery e.g. episiotomy
- Abnormal discharge / bleeding
- Atrophy – postmenopausal
- Masses – e.g. Bartholin’s cyst
- Varicosities – varicose veins
- Abnormal hair distribution
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.
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 gloved fingers
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 palm facing laterally and then rotate 90 degrees so that it faces upwards
Vagina, Cervix and Fornices
Assess the vagina
Palpate the walls of the vagina for any irregularities or masses.
Assess the cervix
- Consistency (hard/soft)
- Os (open/closed)
- Cervical excitation – severe pain on palpation of cervix – e.g. PID
Assess the fornices
Gently palpate the fornices either side of the cervix for any masses.
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
- Any tenderness during palpation?
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 whilst moving your internal fingers upwards and laterally (towards the left)
4. Feel for any palpable masses, noting their size and shape (ovarian cyst / ovarian tumour/ fibroid)
5. Repeat adnexal assessment on the other side of the patient
To complete the examination…
Withdraw your fingers – inspect glove for blood or discharge
Re-cover the patient – allow patient time to re-dress in private
Dispose of equipment into clinical waste bin
“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
- Urinalysis – including β-HCG (pregnancy test)
- Speculum examination
- Vaginal swabs / endocervical swabs – microbiology / virology
- Further imaging – e.g. ultrasound scan
- Full abdominal examination
Mr Isaac Magani