Bimanual pelvic examination
6 steps1 video
Feeling the uterus and adnexa between two hands: size, position, mobility, tenderness, masses.
Consent and trauma-informed practice
- Explain what the examination involves, why it is proposed, and what the alternatives are, in plain language, before anyone undresses.
- Ask for permission, and make clear the patient can stop at any point, by saying so or by raising a hand. Stopping is honoured immediately, without persuasion.
- Offer a chaperone and record the offer and the response; a student never examines without the supervising clinician present and the patient's specific agreement to the student's involvement.
- Privacy: a door that locks or a sign, a sheet, undressing only what is needed, time to undress and dress alone.
- Trauma-informed: assume a history you have not been told. Explain each step before it happens, keep talking, avoid sudden touch, ask about pace, and notice dissociation or distress and pause.
- Never examine a patient under anaesthesia for teaching without their specific prior consent to that examination.
The sequence
6 steps- 01
External
Inspect and gently palpate the vulva and introitus.
- 02
One, then two fingers
Insert one lubricated finger, then two if comfortable, along the posterior wall. Feel the cervix: consistency, position, an open or closed os, and whether moving it hurts (cervical motion tenderness).
- 03
The uterus
Lift the cervix with the internal fingers while the abdominal hand presses down above the symphysis: the uterus is caught between them. Note size (weeks-equivalent), shape, contour (fibroids), consistency, position (anteverted or retroverted), mobility and tenderness.
- 04
The adnexa
Move the internal fingers into each lateral fornix and the abdominal hand to the same side: normal ovaries are often not felt; a mass, its size, mobility and tenderness are noted.
- 05
The pouch of Douglas
Nodularity or tenderness of the uterosacral ligaments (endometriosis) is felt posteriorly; a rectovaginal examination is added when deep disease is suspected.
- 06
Withdraw and explain
Withdraw, offer tissues and privacy, then explain the findings dressed and seated.
Indications
- Pelvic pain, pelvic mass, abnormal bleeding
- Before IUD insertion (uterine size and position)
- Suspected pelvic inflammatory disease (cervical motion tenderness)
Preparation
- Consent as below; empty bladder; supine with knees bent, or lithotomy
- Gloves, lubricant; warm hands; explain each step
Complications
- Discomfort; stop if asked
- Limited by body habitus, guarding or pain
Watch for
- A fixed, retroverted, tender uterus with nodularity: endometriosis
- An adnexal mass with a positive pregnancy test: ectopic
- Cervical motion tenderness with fever: pelvic inflammatory disease