Questionnaire/history: Pain? Abnormal vaginal discharge? Irregular abnormal vaginal bleeding? Pelvic mass? Pregnant? Past medical history? Current medication? Drug allergies? Examination: Examination explained? 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. One of the female ward staff members will be present throughout the examination, acting as a chaperone, would that be ok? Consent obtained? Do you understand everything I’ve said? Do you have any questions? Are you happy for me to carry out the examination? Instructions given? Would you like to empty the bladder before the examination? 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. Abdominal examination Inspection? Palpitation? Vulval inspection Instructions given? Bring your heels towards your bottom and then let your knees fall to the sides. - Ulcers (typically associated with genital herpes)? - Abnormal vaginal discharge?- Scarring (eg from previous surgery (eg episiotomy) or lichen sclerosis)? - Vaginal atrophy (secondary to post-menopausal changes)? - White lesions (associated with lichen sclerosis)? - Masses (eg Bartholin’s cyst or vuval malignancy)? - Varicosities (varicose veins secondary to venous disease/obstruction in the pelvis (eg malignancy))? - Genital mutilation? - Evidence of vaginal prolapse (a bulge visible protruding from the vagina) (Asking to cough can exacerbate the lump and help confirm the presence of prolapse)? Vaginal examination Warned patient that going to examine the vagina and asked if still happy to do so? Lubricated gloved index and middle fingers on dominant hand, carefully separated the labia using the thumb and index finger of your non-dominant hand, gently inserted the gloved index and middle finger of dominant hand into the vagina and entered the vagina with palm facing laterally and then rotated 90 degrees so that it was facing upwards. Vaginal walls Palpation of walls of the vagina (eg irregularities or masses)? Cervix - Position (eg anterior or posterior)? - Consistency (eg irregular or smooth)? - Cervical excitation (severe pain on palpation of the cervix (may suggest pelvic inflammatory disease))? Fornices Gentle palpation of the fornices either side of the cervix (eg masses)? Uterus Placed non-dominant hand 4 cm above the pubis symphysis and dominant hand’s fingers into the posterior fornix, pushed upwards with the internal fingers whilst simultaneously palpating the lower abdomen with non-dominant hand to feel the uterus between the hands and to assess the various characteristics of the uterus. - Size (eg approximately orange sized)? - Shape (eg distorted by masses such as fibroids)? - Position (eg anteverted or retroverted)? - Surface characteristics (eg smooth or nodular)? - Tenderness suggesting possible inflammation (eg pelvic inflammatory disease, ectopic pregnancy)? Ovaries and uterine tubes (Fallopian tubes) Placed internal fingers into the left lateral fornix and external fingers onto the left iliac fossa, performed deep palpation of the left iliac fossa whilst moving internal fingers upwards and laterally (towards the left) and repeated adnexal assessment on the opposite side. - Size - Shape - Masses (eg ovarian cyst, ovarian tumour, fibroid)? Summary: Bimanual examination for eg unexplained pelvic pain, irregular vaginal bleeding, abnormal vaginal discharge or as part of the assessment of a pelvic mass, exam explained, consent of exam obtained, chaperone offered and present (): abdominal examination normal, inspection of vagina normal, bimanual examination revealed anteverted uterus of normal size and shape, no masses in the vaginal canal or adnexa Resource(s): Geeky Medics: Vaginal Examination (PV) – OSCE Guide