Nuances to Consider for Pelvic Exam

Indication and intent

• • In suspected pelvic inflammatory disease (PID), the goal is to assess for the presence of cervical motion tenderness, uterine/adnexal tenderness, and abnormal discharge, – none of which require a speculum
  • Perform only when findings will change management
  • Weigh the benefits of the exam against the potential emotional and physical harms

Informed consent

• • Clearly explain the steps and value of the exam
  • Use developmentally appropriate language

General Principles

• •  Minimize discomfort and anxiety
    •  Offer Child Life support
  •  Allow a support person at the patient’s discretion
    (If the patient declines a support person of choice, a CMH employee will act as chaperone during the examination – policy 5014)
  •   Explain each step before proceeding 
  • Position patient low on the bed in lithotomy position (knees flexed and hips externally rotated, relaxing pelvic and gluteal muscles)

Exam technique

Bi-manual exam:

• • A lubricated and gloved, single-digit exam is usually sufficient
  • The exam should be done in a systematic fashion
    • Anterior vaginal wall
    • Posterior vaginal wall
    • Cervix should be palpated last to assess for motion tenderness
    • Fundal and adnexal tenderness can be assessed by placing your other hand on the abdomen where the fundus and adnexa are
    • Assess for discharge on the glove

Speculum:

• •  In most cases, labial traction and a digital exam provide adequate information
    • Indications for speculum exam:
      • Unable to assess discharge or cervix on the digital exam
      • Concerns for foreign body or cervical mass

• Special considerations

• Obesity:

  • Redundant vaginal or labial tissue may obscure the cervix on the speculum.
  • Optimize positioning by having the patient move further down on the bed until the sacrum is at the edge of the bed
  • Use the non-examining hand to move the labia to obtain the needed visual field

Anxiety/Trauma history:

• • Use extra sensitivity
  • Consider deferring if non-urgent

These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.