Journal of General Internal Medicine

, Volume 26, Issue 6, pp 651–657 | Cite as

The Challenging Pelvic Examination

Reviews

Abstract

While there is a large body of evidence on the effectiveness of Pap smears for cervical cancer screening and on screening for cervical gonorrhea and Chlamydia, there is sparse evidence to support other portions of the pelvic examination and little guidance on examination logistics. Maximizing comfort should be the goal; lubrication use and careful speculum selection and insertion can ease this intrusive procedure. This is particularly important in adolescent and menopausal women, sexual minorities, obese women, women with disabilities, and women with a history of trauma or prior instrumentation affecting the genitalia. We review the evidence and provide guidance to minimize physical and psychological discomfort with pelvic examination.

References

  1. 1.
    Sandelowski M. ‘This most dangerous instrument’: propriety, power, and the vaginal speculum. JOGNN. 2000;29:73–82.PubMedGoogle Scholar
  2. 2.
    Millstein SG, Adler NE, Irwin CE. Sources of anxiety about pelvic examinations among adolescent females. J Adolesc Health Care. 1984;5:105–11.PubMedCrossRefGoogle Scholar
  3. 3.
    Hoyo C, Yarnall KSH, Moorman KCS, PG SD, Reid L. Pain predicts non-adherence to Pap smear screening among middle-aged African American women. Prev Med. 2005;41:439–45.PubMedCrossRefGoogle Scholar
  4. 4.
    Byrd TL, Chavez R, Wilson KM. Barriers and facilitators of cervical cancer screening among Hispanic women. Ethn Dis. 2007;17:129–34.PubMedGoogle Scholar
  5. 5.
    Wang JH, Sheppard VB, Schwartz MD, Liang W, Mandelblatt JS. Disparities in cervical cancer screening between Asian American and non-Hispanic white women. Cancer Epidemiol Biomark Prev. 2008;17:1968–73.CrossRefGoogle Scholar
  6. 6.
    Diamant AL, Wold C, Spritzer K, Gelberg L. Health behaviors, health status, and access to and use of health care. Arch Fam Med. 2000;9:1043–51.PubMedCrossRefGoogle Scholar
  7. 7.
    Wee CC, McCarthy EP, Davis RB, Phillips RS. Screening for cervical and breast cancer: is obesity an unrecognized barrier to preventive care? Ann Intern Med. 2000;132:697–704.PubMedGoogle Scholar
  8. 8.
    Farley M, Golding JM, Minkoff JR. Is a history of trauma associated with a reduced likelihood of cervical cancer screening? J Fam Pract. 2002;51:827–31.PubMedGoogle Scholar
  9. 9.
    Iezzoni LI, McCarthy EP, Davis RB, Harris-David L. O’Day. Use of screening and preventive services among women with disabilities. Am J Med Qual. 2001;16:135–44.PubMedCrossRefGoogle Scholar
  10. 10.
    U.S. Preventive Services Task Force. Screening for Cervical Cancer, Topic Page. January 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf/uspscerv.htm accessed 11/29/09
  11. 11.
    U.S. Preventive Services Task Force. Screening for Ovarian Cancer: Recommendation Statement. May 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf/uspsovar.htm accessed 11/29/09
  12. 12.
    Practice Bulletin No. 109: Cervical cytology screening. Obstet Gynecol. 2009;113:1409–20.Google Scholar
  13. 13.
    Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society Guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin. 2002;52:342–62.PubMedCrossRefGoogle Scholar
  14. 14.
    Ueland FR, De Priest PD, DeSimone CP, et al. The accuracy of examination under anesthesia and transvaginal sonography in evaluating ovarian size. Gynecol Onc. 2005;99:400–3.CrossRefGoogle Scholar
  15. 15.
    Padilla LA, Radosevich DM, Milad MP. Limitations of the pelvic examination for evaluation of the female pelvic organs. Int J Gynecol Obstet. 2005;88:84–8.CrossRefGoogle Scholar
  16. 16.
    Brown T, Herbert ME. Medical myth: bimanual pelvic examination is a reliable decision aid in the investigation of acute abdominal pain or vaginal bleeding. Can J Emerg Physicians. 2003;5:120–2.Google Scholar
  17. 17.
    Larsen M, Oldeide DD, Malterud K. Not so bad after all… Women’s experiences of pelvic examinations. Fam Pract. 1997;14:148–52.PubMedCrossRefGoogle Scholar
  18. 18.
    Huber JD, Pukall CF, Boyer SC, Reissing ED, Chamberlain SM. ”Just relax”: Physicians’ experiences with women who are difficult or impossible to examine gynecologically. J Sex Med. 2009;6:791–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Broadmore J, Carr-Gregg M, Hutton JD. Vaginal examinations: women’s experiences and preferences. NZ Med J. 1986;99:8–10.Google Scholar
  20. 20.
    Gawande A. Naked. N Engl J Med. 2005;353:645–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Stagno SJ, Forster H, Belinson J. Medical and osteopathic boards’ positions on chaperones during gynecologic examinations. Obstet Gynecol. 1999;94:352–4.PubMedCrossRefGoogle Scholar
  22. 22.
    Intimate examinations. London: General Medical Council Standards Committee, December 2001.Google Scholar
  23. 23.
    Gynaecological examinations: guidelines for specialist practice. London: Royal College of Obstetricians and Gynaecologists, July 2002.Google Scholar
  24. 24.
    Fiddes P, Scott A, Fletcher J, Glasier A. Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers. Contraception. 2003;67:313–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Santen SA, Seth N, Hemphill RR, Wrenn KD. Chaperones for rectal and genital examinations in the emergency department: what do patients and physicians want? S Med J. 2008;101:9–10.CrossRefGoogle Scholar
  26. 26.
    Haar E, Halitsky V, Stricker G. Patients’ attitudes toward gynecologic examination and to gynecologists. Med Care. 1977;15:787–95.PubMedCrossRefGoogle Scholar
  27. 27.
    Olson BK. Patient comfort during pelvic examination: new foot supports vs metal stirrups. JOGN Nurs. 1981;10:104–7.PubMedGoogle Scholar
  28. 28.
    Seehusen DA, Johnson DR, Earwood JS, et al. Improving women’s experience during speculum examinations at routine gynaecological visits: randomized clinical trial. BMJ doi:10.1136/bmj.38888.588519.55
  29. 29.
    Barr WB. Vaginal speculum examinations without stirrups. BMJ. 2006;333:158–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Richman S. Gynecological care of women with physical disabilities. Obstet Gynecol Surv. 2007;62:421–3.PubMedCrossRefGoogle Scholar
  31. 31.
    Ferreyra S, Hughes K. Table Manners: A Guide to the Pelvic Examination for Disabled Women and Health Care Providers. San Francisco, CA: Sex Education for Disabled People, Planned Parenthood Alameda/San Francisco; 1984 (http://www.bhawd.org/sitefiles/TblMrs/cover.html (accessed 11/29/09).
  32. 32.
    Amies AM, Miller L, Lee SK, Koutsky L. The effect of vaginal speculum lubrication on the rate of unsatisfactory cervical cytology diagnosis. Obstet Gynecol. 2002;100:889–92.PubMedCrossRefGoogle Scholar
  33. 33.
    Griffith WF, Stuart GS, Gluck KL, Heartwell SF. Vaginal speculum lubrication and its effects on cervical cytology and microbiology. Contraception. 2005;72:60–4.PubMedCrossRefGoogle Scholar
  34. 34.
    Harer WB, Valenzuela G, Lebo D. Lubrication of the vaginal introitus and speculum does not affect Papanicolaou smears. Obstet Gynecol. 2002;100:887–8.PubMedCrossRefGoogle Scholar
  35. 35.
  36. 36.
    Brady K, Sizemore KL, Duff P, Aamodt LW. The effect of bacteriostatic lubricant on group B streptococcal cultures of the female genital tract. Obstet Gynecol. 1989;74:848–50.PubMedGoogle Scholar
  37. 37.
    Kozakis L, Vuddamalay J, Munday P. Plastic specula: can we ease the passage? Sex Transm Infect. 2006;82:263–4.PubMedCrossRefGoogle Scholar
  38. 38.
    Harmanli O, Jones KA. Using lubricant for speculum insertion. Obstet Gynecol. 2010;116:415–7.PubMedCrossRefGoogle Scholar
  39. 39.
    Pendergrass PB, Reeves CA, Belovicz MW, Molter DJ, White JH. Comparison of vaginal shapes in Afro-American, Caucasian, and Hispanic women as seen with vinyl polysiloxane casting. Gynecol Obstet Invest. 2000;50(1):54–9.PubMedCrossRefGoogle Scholar
  40. 40.
    Barnhard KT, Izquierdo A, Pretorius ES, Shera EM, Shabbout M, Shaunik A. Baseline dimensions of the human vagina. Hum Reprod. 2006;21(6):1618–22.CrossRefGoogle Scholar
  41. 41.
    Edelman A, Anderson J, Lai S, Braner D, Tegtmeyer K. Pelvic examination video. N Engl J Med. 2007;356:e26.PubMedCrossRefGoogle Scholar
  42. 42.
    Potter J, Huang G. Web-Based Video Tutorials of the Pelvic Examination [website]. MedEdPORTAL; 2005. Available at: http://www.aamc.org/mededportal, ID = 142.
  43. 43.
    American College of Physicians. The Pelvic Examination: A Patient-Centered Approach Clinical Skills Series DVDGoogle Scholar
  44. 44.
    Bergmark K, Avall-Lundqvist E, Dickman PW, Henningsohn L, Steineck G. Vaginal changes and sexuality in women with a history of cervical cancer. N Engl Med. 1999;340(18):1383–9.CrossRefGoogle Scholar
  45. 45.
    Monsonego J, Semaille C. Local anesthesia of genital mucosa with a lidocaine/prilocaine combination cream before laser therapy of human papillomavirus lesions. Eur J Dermatol. 2000;10:607–10.PubMedGoogle Scholar
  46. 46.
    Chung C, Chu M, Paoloni R, O'Brien MJ, Demel T. Comparison of lignocaine and water-based lubricating gels for female urethral catheterization: a randomized controlled trial. Emerg Med Australas. 2007;19(4):315–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Bachmann G, Lobo RA, Gut R, Nachtigall L, Notelovitz M. Efficacy of low-dose estradiol vaginal tablets in the treatment of atrophic vaginitis. Obstet Gynecol. 2008;111:67–76.PubMedCrossRefGoogle Scholar
  48. 48.
    Badura AS, Reiter RC, Altmaier EM, Rhomberg A, Elas A. Dissociation, somatization, sexual abuse,and coping in women with chronic pelvic pain. Obstet Gynecol. 1997;90(3):405–10.PubMedCrossRefGoogle Scholar
  49. 49.
    Seo JT, Choe JH, Lee WS, Kim KH. Efficacy of functional electrical stimulation-biofeedback with sexual cognitive-behavioral therapy as treatment of vaginismus. Urology. 2005;66:77–81.PubMedCrossRefGoogle Scholar
  50. 50.
    Robohm JS, Buttenheim M. The gynecological care experience of adult survivors of childhood sexual abuse: a preliminary investigation. Women’s Health. 1996;24:59.CrossRefGoogle Scholar
  51. 51.
    Lee TT, Westrup DA, Ruzek JI, Keller J, Weitlauf JC. Impact of clinician gender on examination anxiety among female veterans with sexual trauma: a pilot study. J Women’s Health. 2007;16:1291–9.CrossRefGoogle Scholar
  52. 52.
    Weitlauf JC, Finney JW, Ruzek JI, et al. Distress and pain during pelvic examinations: effect of sexual violence. Obstet Gynecol. 2008;112:1343–50.PubMedCrossRefGoogle Scholar
  53. 53.
    Golding JM, Wilisnack SC, Learman LA. Prevalence of sexual assault history among women with common gynecologic symptoms. Am J Obstet Gynecol. 1998;179:1013.PubMedCrossRefGoogle Scholar
  54. 54.
    Friedman LS, Samet JH, Roberts MS, Hudlin M, Hans P. Inquiry about victimization experiences. A survey of patient preferences and physician practices. Arch Intern Med. 1992;152:1186.PubMedCrossRefGoogle Scholar
  55. 55.
    Wright D, Fenwick J, Stephenson P, Monterosso L. Speculum ‘self-insertion’: a pilot study. J Clin Nurs. 2005;14:1098–111.PubMedCrossRefGoogle Scholar
  56. 56.
    Makadon H, Mayer K, Potter J, Goldhammer H, eds. The Fenway Guide to Lesbian, Gay, Bisexual and Transgender Health. Philadelphia; American College of Physicians: 2007.Google Scholar
  57. 57.
    Feldman J. Medical and surgical management of the transgender patient: what the primary care clinician needs to know. In: Makadon H, Mayer K, Potter J, Goldhammer H, eds. The Fenway Guide to Lesbian, Gay, Bisexual and Transgender Health. Philadelphia: American College of Physicians; 2007:365–92.Google Scholar
  58. 58.
    Carroll NM. Optimal gynecologic and obstetric care for lesbians. Obstet Gynecol. 1999;93:611–3.PubMedCrossRefGoogle Scholar
  59. 59.
    Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, Landers S. Sexual and gender minority health: what we know and what needs to be done. Am J Public Health. 2008;98:989–95.PubMedCrossRefGoogle Scholar
  60. 60.
    Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrin Metab. 2009;94:3132–54.CrossRefGoogle Scholar
  61. 61.
    Nosek MA, Howland CA, Rintala DH, Young ME, Chanpong GF. National Study of Women with Physical Disabilities: Final Report. Sex Disabil. 2001;19:5–39.CrossRefGoogle Scholar
  62. 62.
    Women with Disabilities Education Task Force. Women with Disabilities Education Program: Communication Modules 2008. http://www.womenwithdisabilities.org. accessed 11/29/09.
  63. 63.
    Reproductive Care for Women with Disabilities: An interactive site for clinicians serving women with disabilities. American College of Obstetrics and Gynecology. http://www.acog.org/departments/dept_notice.cfm?recno=38&bulletin=4526 accessed 10/14/10.
  64. 64.
    Young ME, Nosek MA, Howland CA, Chanpong G, Rintala DH. Prevalence of abuse of women with disabilities. Arch Phys Med Rehab. 1997;78(Suppl):S34–8.CrossRefGoogle Scholar
  65. 65.
    Wingfield M, et al. Gynaecological care for women with intellectual disability. Med J Aust. 1994;160:536–8.PubMedGoogle Scholar
  66. 66.
    Vadivelu N, Harkness P, Richman S, Shelley K. Special anesthetic concerns in mentally handicapped institutionalized patients undergoing gynecological procedures in an outpatient setting. Conn Med. 2004;68:359–62.PubMedGoogle Scholar
  67. 67.
    Brown D, Rosen D, Elkins TE. Sedating women with mental retardation for routine gynecologic examination: an ethical analysis. J Clin Ethics. 1992;3:68–75. discussion 76-77.PubMedGoogle Scholar
  68. 68.
    Bycroft J, Shergill IS, Choong EAL, Arya N, Shah PJR. Autonomic dysreflexia: a medical emergency. Postgrad Med J. 2005;81:232–5.PubMedCrossRefGoogle Scholar
  69. 69.
    Strickland JL. Female circumcision/female genital mutilation. J Pediatr Adolesc Gynecol. 2001;14:109–12.PubMedCrossRefGoogle Scholar
  70. 70.
    Nour NM. Female circumcision and genital mutilation: a practical and sensitive approach. Contemp Ob Gyn. 2000;45:50–5.Google Scholar
  71. 71.
    Nour NM. Female genital cutting: A persistent practice. Rev Obstet Gynecol. 2008;1:135–9.PubMedGoogle Scholar
  72. 72.
    Braddy CM, Files JA. Female genital mutilation: cultural awareness and clinical considerations. J Midwifery Womens Health. 2007;52:158–63.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Carol K. Bates
    • 1
  • Nina Carroll
    • 2
  • Jennifer Potter
    • 1
  1. 1.Division of General Medicine and Primary CareBeth Israel Deaconess Medical CenterBostonUSA
  2. 2.Department of Obstetrics and GynecologyBeth Israel Deaconess Medical CenterBostonUSA

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