Bimanual examination

Written by Prashant Bamania

Introduction

Introduce yourself, confirm the patient's name and date of birth.

Ask the patient if they have had a bimanual examination done before and whether they understand what it involves. Explain the purpose of the examination and obtain consent. Inform the patient that the examination may be slightly uncomfortable, but if they feel any pain that they should let you know. Always call for a female chaperone. Ask if the patient would like to empty their bladder before beginning.

Knowing what to say in a bimanual examination is important. Here are a few recommended phrases:

“I have been asked to perform a bimanual examination. Have you had one before? Do you understand what it involves?”

“In this examination, I will be using my gloved hand to insert two lubricated fingers into your vagina. This allows me to check for any abnormalities inside the vagina and around the neck of your womb. I will also be placing my other hand on your tummy at the same time.”

Positioning and exposure

The patient must be exposed below the waist, including removal of any undergarments. Ask the patient to get themselves ready and cover themselves with the sheet provided. Close the curtains to give the patient privacy.

Once the patient is ready ask them to lie supine on the bed, put their feet together, bring their heels towards their bottom and slowly part their knees. This is known as the lithotomy position.

Remember the 7 C's.

Confirm (name and DOB), consent, check understanding, chaperone, behind the curtains, lie down on the couch (bed) and cover to preserve dignity.

Equipment

Whilst the patient is preparing, wash your hands and obtain the following:

General inspection

Before proceeding, ask the patient if they are in any pain or discomfort.

Begin the examination with a general inspection of the perineum and surrounding area.

Ask the patient if they are in any pain and are comfortable. Remove the covering sheet and inspect the vulva. Look for any scarring, which can be from previous surgery, and ulceration, which could be due to an infection with herpes simplex virus. Inspect for masses such as Bartholin’s cyst, and for any varicosities, abnormal bleeding or discharge. Vaginal atrophy may be visible, and this is common in menopause.

Ask the patient to cough. This may reveal a bulge from the vagina, an indication of a prolapse, or exacerbate any discharge or bleeding that was otherwise not visible.

Note that the inspection in the bimanual examination is identical to that of the speculum examination.

Stay alert for subtle signs. For example, an obviously offensive smell is sometimes missed out by students. This, associated with discharge, suggests infective diagnoses such as bacterial vaginosis.

The two Bartholin’s glands are situated behind the labia minora and are responsible for secreting lubricating mucus for coitus. Blockage of these glands can lead to cyst formation which is often visible as a mass on inspection of the vulva.



There are numerous causes of abnormal bleeding on inspection. These include infection (pelvic inflammatory disease), fibroids, cysts, and malignancy.



Bacterial vaginosis: A common infection of the vagina, most commonly caused by Gardnerella vaginalis. It presents with a thin, white homogenous discharge, with an offensive fishy odour.

Trichomoniasis: Trichomonas vaginalis is a motile, flagellated protozoan parasite which causes trichomoniasis. Characteristic features include a yellow/green, offensive, frothy discharge and a strawberry cervix.

Vaginal thrush: Also known as vaginal candidiasis or vaginal yeast infection, vaginal thrush is caused by the fungus Candida. Characteristic features include itchiness and a ‘cottage cheese’ discharge.

Vagina

Inform the patient that you will now examine the internal vagina. Place some lubricant on the index and middle fingers of your dominant hand. Using the other hand, gently part the labia with your thumb and index finger. Ask the patient to take a deep breath in. Gently insert your lubricated index finger and middle finger into the vagina. Your thumb should be pointing upwards with your palm facing laterally.

As you fingers enter the vagina, rotate them 90o such that your palm is pacing upwards. Whilst doing so, assess the vaginal wall for any irregularities or masses. A normal vaginal wall should feel smooth all around.

Cervix

With your palm still facing upwards, assess the cervix. A fertile cervix is usually soft, and after ovulation, can become more hard. Check whether the cervical os is open or closed. The os is usually closed, and an open cervical os is most commonly associated with miscarriages before 24 weeks gestation. Finally palpate the cervix on either side and assess for pain. Pain on stimulation is called cervical excitation and can point to a number of pathologies.

Threatened miscarriage: Painless vaginal bleeding; cervical os is closed.

Missed miscarriage: A gestational sac containing products dead products of conception before 20 weeks without any symptoms of expulsion. There may be light vaginal bleeding or discharge; cervical os is closed.

Inevitable miscarriage: Heavy bleeding which is painful; cervical os is open.

Incomplete miscarriage: Bleeding with pain; not all products have been expelled; cervical os is open.



Ectopic pregnancy: This is the implantation of a fertilised ovum outside the uterus, most commonly in the fallopian tubes. Patients experience lower abdominal pain and there may be vaginal bleeding. On examination, abdominal tenderness and cervical excitation are present. That being said however, it is advised to not perform a bimanual if an ectopic is suspected, as this can lead to rupture.

Pelvic inflammatory disease: This is an umbrella term used to describe infection and inflammation of the pelvic organs. Common causative organisms include: Chlamydia trachomatis, Neisseria gonnorheae, Mycoplasma genitalium and Mycoplasma hominis. The most common symptoms and signs include lower abdominal pain, fever, deep dyspareunia, vaginal or cervical discharge, and cervical excitation.

Uterus

Place your free hand on the patients abdomen, around 3-4cm superior to the pubic symphysis. Examine to feel for the position of the uterus. It may be anteverted or retroverted.

Next feel for the size and shape of the uterus. Using your dominant hand place your fingers below the posterior fornix and with both hands, gently palpate the uterus. The uterus should be felt between your hands. The size of a normal uterus is said to be usually comparable to that of an orange. The shape may be abnormal if masses are present. This can be due to pathologies such as fibroids. Assess whether the uterus feels smooth and ask the patient if the palpation is painful. Pain may suggest the presence of pelvic inflammatory disease.

The best way to feel for the position of the uterus is to keep your fingers straight and to feel for the cervix. If you can feel the cervix below your fingers (i.e. pointing upwards) this is likely a retroverted uterus. If the uterus is directly ahead (i.e. pointing towards your fingers) or above (i.e. pointing down), this is likely an anteverted uterus.

The majority of women have an anteverted uterus. A retroverted uterus, whilst less common, can still be a normal finding. However it can also be due to pelvic surgery, pelvic adhesions, endometriosis, fibroids, pelvic inflammatory disease, and childbirth.



These are benign smooth muscle tumours of the uterus, and are more common in those of Afro-Caribbean ethnicity. They develop in response to oestrogen, and are therefore rare before puberty. Fibroids may be asymptomatic but can cause lower abdominal cramping pains, menorrhagia, bloating, subfertility, and urinary symptoms.

Ovaries

Next, assess the adnexal area. Place the index and middle fingers of your interal (dominant) hand in the right lateral fornix, and the fingers of your external (free) hand on the abdomen in the right iliac fossa. Gently, palpate moving your internal fingers upwards and laterally, and your external fingers downwards and laterally. Feel for any masses which could indicate ovarian cysts, tumours, or fibroids. Repeat the same on the left side.

Completing the examination

Gently withdraw your fingers. Check for discharge and assess your fingers for any signs of blood or mucus.

Provide the patient with paper towels and allow them to re-dress behind the curtains. Thank the patient, remove your gloves and dispose of them into a clinical waste bin. Wash hands.

Complete your examination by offering to perform urinalysis, speculum examination, vaginal swabs (endocervical and high vaginal), imaging modalities (trans-vaginal ultrasound scan), and a full abdominal examination.

Interactive markscheme


When assessing each other, click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:

  1. Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I have been asked to perform an internal examination of your vagina to check for any abnormalities. Can I confirm your name and DOB? Thank you.”
  2. Explain the examination and obtain consent.
  3. "For the purpose of this examination the examiner will act as a chaperone." Ideally a female chaperone should be asked for.
  4. Position the bed flat and ensure adequate exposure.
  5. Correctly place the patient in the lithotomy position.
  6. Gather the appropriate equipment (gloves, lubricant and paper towels).
  7. Wash your hands.
  8. Ask about pain and discomfort.
  9. Inspect the patient and their surroundings.
  10. Inspect the vulva for scarring, masses, cysts, discharge.
  11. Insert a gloved lubricated finger gently into the vagina and assess the vaginal walls.
  12. Assess the patency of the cervical os.
  13. Check for cervical excitation.
  14. Examine and identify the uterine shape.
  15. Examine and identify the uterine size.
  16. Examine and identify the uterine position (anteverted or retroverted).
  17. Palpate both adnexal regions.
  18. Check for discharge, blood and mucus on withdrawal of fingers.
  19. Thank and cover up the patient.
  20. Give the patient privacy to re-dress and wash hands.
  21. "To conclude, I would like to take a full history, perform an abdominal examination, urinalysis, trans-vaginal ultrasound scan and take vaginal swabs.”
  22. Present findings.
Overall: 0/20