PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
This should be handled with sensitivity and preservation of dignity for the patient.
NB: always consider the possibility of pregnancy when presented with abnormal bleeding or pain.
Allow the patient to tell you her problem. She may need prompting over more delicate issues, especially if you are a man.
- Menstrual history:
- Last menstrual period (LMP) - date of first day of bleeding.
- Cycle length and frequency, eg 5/28, 5 days of bleeding every 28 days.
- How heavy is the bleeding? Number of tampons per day/clots/flooding/double protection.
- Any intermenstrual bleeding (IMB).
- Any postcoital bleeding (PCB).
- Age of menarche/menopause.
- Any postmenopausal bleeding (PMB).
- Any symptoms in a partner.
- Pain or discomfort:
- Urinary symptoms:
- Obstetric history:
- Contraceptive history.
- Any recent unprotected intercourse.
- Reliability of method and user.
- Potential contra-indications to different methods, eg combined pill.
- Permanent or temporary method required.
- Sexually active.
- Sexual orientation.
- Relationship difficulties - ask open-ended questions, eg "How are things between you?"
- General health:
- Gynaecological operations.
- Date and result of last cervical smear.
Allow privacy to undress. Offer a chaperone for the examination, and record its offer in notes (together with whether the offer was taken up or declined). Always use a chaperone if requested and especially if your sixth sense tells you to. Provide a blanket or other clean cover. Explain what you are doing and why before you do it, rather than as you do it.
- General appearance:
- Smoke-stained fingers.
- Extreme thinness.
- Swollen abdomen.
- Ankle swelling.
- Look for pyrexia, shock, swelling.
- Blood pressure, breast examination (if appropriate).
- Abdomen palpation feeling for:
- Abnormal lumps including enlarged uterus, liver, spleen, nodes in the groin and umbilicus.
- Ascites, distended veins - peritoneal secondaries can show with an umbilical secondary.
- Percuss the bladder if palpably enlarged, or indicated from history.
- Usually done with the patient on her back.
- Look at the vulva for any abnormalities of skin texture, lumps, excoriation, lichenification and whitening.
- Choose an appropriately sized speculum - usually Cusco's bivalve speculum - for the patient.
- Warm the speculum before use.
- Part the labia with your hand from above and introduce the speculum at a slight tilt to the vertical and twist it gently to the horizontal.
- Point the speculum downwards, at about 45°; open, making sure that the handle is not impinging on the clitoris.
- Look at the vaginal mucosa and locate the cervix.
- Take a vaginal swab if there is discharge.
- Check for any retained tampon.
- Look for warts/herpes (the rash may give symptoms for a week or so before the vesicles appear).
- If no cervix visualised:
- Try partially withdrawing and try again.
- Perform a bimanual examination to establish the position of the cervix.
- Ask the patient to hold on to her knees or put hands under the sacrum to tilt the pelvis. A pillow could also be used.
- The left lateral position may be more successful.
- If you are still unsuccessful, try on a different occasion.
Taking a smear
- Ideally, this should take place mid-cycle.
- Visualise the cervix, clear excess mucus/discharge, unless using liquid-based cytology (LBC).
- If using a spatula, make two full 360° sweeps of the cervix to sample the transformation zone. Fix the slide immediately, as drying before fixing spoils the smear.
- If there is an obviously abnormal area on the cervix, note the position on the form/notes and include the area in your smear sweep.
- If using a brush and LBC, take 5 anticlockwise sweeps of the transformation zone. Then (depending on the brush type) either push the end of the brush into the liquid, or agitate the brush in the liquid for 15-20 seconds to ensure there are adequate cells in the specimen. LBC has reduced the rate of inadequate smears. Training is provided locally.
- Take care not to pinch the vaginal wall or even the cervix when withdrawing the speculum.
- Remember to note your findings on the request form.
- Results are sent directly to the patient's address. Colposcopy may be arranged directly if necessary.
- Mention the possibility of needing to redo the smear or examine more closely (colposcopy).
- Use your left hand to palpate abdomen and your right for internal (if examining from the right).
- Feel for any abnormalities of the vagina.
- Feel the cervix for areas of roughness, hardness, lumps. Note any cervical excitation.
- Assess the uterine position, size, mobility, lumpiness, tenderness.
- Feel the adnexae bimanually for any swelling or tenderness.
NB: an ectopic pregnancy can be ruptured by bimanual examination, so be gentle.
- Within the pelvis (size of an orange) = 8 weeks.
- Suprapubic = 12 weeks.
- Mid-suprapubic umbilicus = 16 weeks.
- To umbilicus = 20 weeks.
- To xiphisternum = 36 weeks.
Confirmation of leakage can be done by asking the patient to cough whilst holding a tissue over the urethral opening, either lying or standing with the feet slightly apart. However, if there is a history of urinary incontinence then refer for urodynamics.
- Vaginal examination needs to be performed with a Sims' speculum in the left lateral position looking for a cystocele or rectocele.
- An assistant can hold the leg at 30° (useful if the patient is obese).
- You need to have a good light and look for uterine or vaginal prolapse whilst withdrawing the Sims' speculum.
Further reading & references
- Samraj GP, Kuritzky L, Curry RW; Chronic pelvic pain in women: evaluation and management in primary care. Compr Ther. 2005 Spring;31(1):28-39.
- Carter JE; A systematic history for the patient with chronic pelvic pain. JSLS. 1999 Oct-Dec;3(4):245-52.
- Daley AM, Cromwell PF; How to perform a pelvic exam for the sexually active adolescent. Nurse Pract. 2002 Sep;27(9):28, 31-2, 34, 37-9, 43; quiz 44-5.
- Mavis B, Vasilenko P, Schnuth R, et al; Medical students' involvement in outpatient clinical encounters: a survey of patients and their obstetricians-gynecologists. Acad Med. 2006 Mar;81(3):290-6.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Hayley Willacy
Dr Hayley Willacy