During a bimanual examination, one hand is placed externally on the abdomen and two fingers of the other hand (the index and middle finger) are located inside the vagina to palpate the internal reproductive organs. In this manner you will not only gather information about the internal genitalia but also about the region in which they are positioned, namely the pelvis. The vaginal examination is therefore also appropriate when investigating lower abdominal symptoms [see also the ‘The abdominal examination’].
The bimanual examination is conducted with the examiner standing up. With a table which has leg supports or foot stirrups, the best position for the physician is between the stirrups [Figure 41], in other situations you should stand next to the patient’s thighs.
Figure 41
- Put on gloves and apply some lubricant to the fingers of the examining hand.
- Part the labia by moving them in a lateral and ventral direction with thumb and index finger of your non-examining hand. Continue parting until the examining fingers have been inserted deep enough and you are certain that no hairs or skin have been pulled along. In some cases the vaginal introitus is already opened somewhat; parting is then not always necessary.
- First insert one-third of the middle finger along the posterior vaginal wall. Make space for the index finger by exercising pressure onto the perineum and then slide the index finger alongside the middle finger. Avoid pressure on the urethra and always move in the direction of the vaginal axis [Figures 42, 43].
Figure 42
Figure 43
- During the examination, hold the underarm horizontally with the wristheld low and in a relaxed position.
- Keep the thumb away from the clitoris and thighs. Pay attention no to do this throughout the examination! If possible you can hold your thumb inside the palm of your hand when examining. Then you will be sure that it can not touch the clitoris [Figures 44, 45].
Figure 44
Figure 45
- Insert the relaxed fingers into the vagina as far as possible. The bent 4th and 5th finger can be pressed against the perineum if required.
- Place the flat of the other hand on the abdomen, with the fingers closely adjacent to each other. Hold the fingers as parallel to the symphysis as possible. Due to the downward pressure on the abdominal wall and, indirectly, on the uterus it is easier to palpate the cervix as it is moved downwards in the vagina.
Vaginal portion of the cerix
Palpate the cervix and assess:
- Surface of the cervix
- Consistency
- External os
- Position of the vaginal portion of the cervix / position of the cervix in relation to the vaginal axis
- Adnexal tenderness (by moving the cervix sideways between two parted fingers or by tapping it on one side)
- Cervical motion tenderness (with the fingers in the posterior fornix, moving the cervix ventrally)
- The fornices.
Under normal circumstances you can move around the fornices with both fingers. Also determine which fornix is situated most deeply (this depends on the position of the cervix).
Normally the cervix is smooth. The consistency is firm and rubbery, like the tip of your nose. The external os is closed (except during labour). The vaginal portion of the cervix points in a specific direction in the vaginal canal: towards the symphysis, centrally or towards the sacrum. This is also dependent on the cervix and the uterus. If the os points in a sacral direction, the uterus will be tilted forward in relation to the vaginal axis: anteversion [Figure 46a]. If the cervix is pointed towards the symphysis, the uterus will be tilted backwards in relation to the vaginal axis: retroversion [Figure 46b].
Figure 46a
Figure 46b
When moving the cervix from side to side, you also move the uterus and adnexae internally. This is not painful, unless there is the presence of a disorder of the Fallopian tubes or ovaries or peritoneal irritation. During cervical motion with the internal fingers in the posterior fornix, you come within reach of the deepest peritoneum fold of the abdominal space and can push indirectly against the pouch of Douglas. Normally this is not painful, but in the event of acute abdominal complaints this can be extremely painful. This investigation is often used in abdominal examinations.
Uterus
Place the internal fingers in the posterior fornix and move the ectocervix / endocervix transition towards the abdominal wall. Turn the external hand 90 degrees, so that the fingers point towards the navel. Simultaneously, pressure is gradually put on the abdominal wall with the external hand. In this way, try to palpate the uterus between the two hands [Figures 47, 48, 49]. Do not use only your finger tips during this procedure but exert pressure with the whole length of your fingers.
Assess, if possible:
- Position of the uterus
- Mobility of the uterus
- Consistency
- Shape
- Surface
- Size.
Figure 47
Figure 48
Figure 49
Depending on the position of the uterus (in relation to the cervical axis), the uterus can be completely/partially/barely palpated. If the body of the uterus is tilted forward in relation to the cervical axis (anteflexion), in combination with anteversion (anteversion/flexion) [Figure 46a], it can be assessed reasonably well. With your internal fingers in the anterior fornix, the body of the uterus can be completely palpated and assessed between the fingers of both hands [Figure 48].
If the body of the uterus is tilted backwards in relation to the cervix (retroflexion), often in combination with retroversion (retroversion flexion [Figure 46b]), the uterus cannot be palpated. In anteversion the uterus is palpable, but not the fundus of the uterus.
All these positions are within the range of normal findings.
A normal uterus is mobile with tendons and ligaments anchoring it in the pelvis. You should be able to maneuver it between both hands. The consistency of the uterus should normally be firm and rubbery, and it is normally pear-shaped. The surface should be smooth upon palpation. The size varies, depending on the age of the woman and the number of pregnancies that she has had.
Adnexae and parametria
Place your internal fingers as high as possible in the lateral fornix, on the side where you are planning to palpate the adnexae. Place the palpating fingers of the external hand at the level of the anterior iliac spine and slide the fingers 3 cm in the medial direction. Sometimes it is helpful to first move the abdominal skin upwards a little when applying the fingers of the external hand, before moving the fingers of both hands towards each other. Gradually press the adjacent fingers of the external hand deeper while the patient exhales. Use your entire hand, do not palpate using only your finger tips. Move the internal fingers as close to the external fingers as possible. Now slide both hands in the direction of the symphysis using a sweeping movement.
The external fingers follow the internal fingers [Figures 50, 51].
Figure 50
Figure 51
In this manner, palpate the ovary / tubes / parametrium:
- Size of ovary
- Tenderness
- Fallopian tube palpable?
- Masses.
You can often briefly palpate the ovary or, in fact, feel it slip between your fingers. Palpate carefully, because palpation of the ovary is painful for the patient. Pay attention to the patient’s facial expression. A healthy ovary is not always palpable, even with a good palpation technique. Usually, the fallopian tubes are not palpable; if they are, it indicates a pathology.
With abnormal swellings or masses, palpate for the following: size, shape, position, consistency, surface, relation to surrounding area, pain upon palpation.
Repeat this process on the other side.
Vaginal walls
Palpate the vaginal walls with two adjacent fingers. Start deep in the fornices and make sideways movements via the posterior vaginal wall whilst gradually retracting the examining fingers. During this, keep the wrist low [Figure 52].
Figure 52
Assess the following during palpation:
- Surface of the vaginal walls
- Pain
- Consistency
- Bulges.
The surface of the vaginal walls is slightly rippled. Usually palpation is not painful and should reveal a soft consistency. If any bulges can be felt then this may indicate a prolapse. If a prolapse is suspected, you can ask the patient to bear down while you palpate the walls. This is an unpleasant examination. Carry this out at the end and only if indicated.
Check your gloves for blood and / or mucus. Do this preferably when you are standing with your back to the patient. Pull off the glove (make a fist and pull the cuff over it, making sure not to splash). Assist the patient in getting off the examination table. Allow her to move from the edge of the table first, before getting up and standing slowly.
- If necessary, provide the patient with a sanitary towel.
- Wash your hands.
- Make a note of your findings and consider what they mean for your hypothesis and which likelihood and differential diagnoses you can make on the basis of the findings.
Clear the used materials and instruments and clean the examination table, so that everything is ready for the next examination. Make sure that the instruments and specula are rinsed and cleaned before being sterilised.
The findings described up to now are usual findings in a woman of childbearing age. In a post-menopausal woman there are some noticeable differences. Pubic hair growth gradually decreases, the labia minora become slightly smaller, the folds of the vaginal walls gradually disappear, the mucous membrane becomes less shiny (drier) and lighter in colour. Furthermore, during bimanual examination the uterus is smaller. These are all normal findings in a post-menopausal woman.
Rectal examination
The rectal examination is indicated:
- Upon (suspected) pathological findings in the pelvis that are related to the rectum or pouch of Douglas.
- To confirm the position of the uterus when in doubt.
- With a vaginal introitus that is too narrow (in small children, for example when tracing a foreign object, examine rectally with the little finger).
- When an abnormality of the rectum is suspected.
In the above instances a rectal examination may be indicated as part of a gynaecological examination. For a description of the rectal examination we would like to refer to the ‘The abdominal examination’.