Skip to main content

Advertisement

SpringerLink
Log in

The Challenging Pelvic Examination

  • Reviews
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Explore related subjects

Discover the latest articles, news and stories from top researchers in related subjects.

References

  1. Sandelowski M. ‘This most dangerous instrument’: propriety, power, and the vaginal speculum. JOGNN. 2000;29:73–82.

    PubMed  CAS  Google Scholar 

  2. Millstein SG, Adler NE, Irwin CE. Sources of anxiety about pelvic examinations among adolescent females. J Adolesc Health Care. 1984;5:105–11.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  4. Byrd TL, Chavez R, Wilson KM. Barriers and facilitators of cervical cancer screening among Hispanic women. Ethn Dis. 2007;17:129–34.

    PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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. 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. Practice Bulletin No. 109: Cervical cytology screening. Obstet Gynecol. 2009;113:1409–20.

    Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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. Larsen M, Oldeide DD, Malterud K. Not so bad after all… Women’s experiences of pelvic examinations. Fam Pract. 1997;14:148–52.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  19. Broadmore J, Carr-Gregg M, Hutton JD. Vaginal examinations: women’s experiences and preferences. NZ Med J. 1986;99:8–10.

    CAS  Google Scholar 

  20. Gawande A. Naked. N Engl J Med. 2005;353:645–8.

    Article  PubMed  CAS  Google Scholar 

  21. Stagno SJ, Forster H, Belinson J. Medical and osteopathic boards’ positions on chaperones during gynecologic examinations. Obstet Gynecol. 1999;94:352–4.

    Article  PubMed  CAS  Google Scholar 

  22. Intimate examinations. London: General Medical Council Standards Committee, December 2001.

  23. Gynaecological examinations: guidelines for specialist practice. London: Royal College of Obstetricians and Gynaecologists, July 2002.

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  26. Haar E, Halitsky V, Stricker G. Patients’ attitudes toward gynecologic examination and to gynecologists. Med Care. 1977;15:787–95.

    Article  PubMed  CAS  Google Scholar 

  27. Olson BK. Patient comfort during pelvic examination: new foot supports vs metal stirrups. JOGN Nurs. 1981;10:104–7.

    PubMed  CAS  Google Scholar 

  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. Barr WB. Vaginal speculum examinations without stirrups. BMJ. 2006;333:158–9.

    Article  PubMed  Google Scholar 

  30. Richman S. Gynecological care of women with physical disabilities. Obstet Gynecol Surv. 2007;62:421–3.

    Article  PubMed  Google Scholar 

  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. 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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  35. http://www.thinprep.com/hcp/utilities/common_technical_questions.html accessed 11/14/10)

  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.

    PubMed  CAS  Google Scholar 

  37. Kozakis L, Vuddamalay J, Munday P. Plastic specula: can we ease the passage? Sex Transm Infect. 2006;82:263–4.

    Article  PubMed  CAS  Google Scholar 

  38. Harmanli O, Jones KA. Using lubricant for speculum insertion. Obstet Gynecol. 2010;116:415–7.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  41. Edelman A, Anderson J, Lai S, Braner D, Tegtmeyer K. Pelvic examination video. N Engl J Med. 2007;356:e26.

    Article  PubMed  Google Scholar 

  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. American College of Physicians. The Pelvic Examination: A Patient-Centered Approach Clinical Skills Series DVD

  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.

    Article  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  55. Wright D, Fenwick J, Stephenson P, Monterosso L. Speculum ‘self-insertion’: a pilot study. J Clin Nurs. 2005;14:1098–111.

    Article  PubMed  Google Scholar 

  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.

  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. Carroll NM. Optimal gynecologic and obstetric care for lesbians. Obstet Gynecol. 1999;93:611–3.

    Article  PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  62. Women with Disabilities Education Task Force. Women with Disabilities Education Program: Communication Modules 2008. http://www.womenwithdisabilities.org. accessed 11/29/09.

  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. 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.

    Article  CAS  Google Scholar 

  65. Wingfield M, et al. Gynaecological care for women with intellectual disability. Med J Aust. 1994;160:536–8.

    PubMed  CAS  Google Scholar 

  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.

    PubMed  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  68. Bycroft J, Shergill IS, Choong EAL, Arya N, Shah PJR. Autonomic dysreflexia: a medical emergency. Postgrad Med J. 2005;81:232–5.

    Article  PubMed  CAS  Google Scholar 

  69. Strickland JL. Female circumcision/female genital mutilation. J Pediatr Adolesc Gynecol. 2001;14:109–12.

    Article  PubMed  CAS  Google Scholar 

  70. Nour NM. Female circumcision and genital mutilation: a practical and sensitive approach. Contemp Ob Gyn. 2000;45:50–5.

    Google Scholar 

  71. Nour NM. Female genital cutting: A persistent practice. Rev Obstet Gynecol. 2008;1:135–9.

    PubMed  Google Scholar 

  72. Braddy CM, Files JA. Female genital mutilation: cultural awareness and clinical considerations. J Midwifery Womens Health. 2007;52:158–63.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank Lisa Iezzoni, MD, for her comments on our text on disabilities and Kim Ariyabuddhiphongs, MD, Diane Brockmeyer, MD, Jill Catalonotti, MD, and Amy Weinstein, MD, who worked with the authors on a 2008 SGIM workshop entitled “Teaching the Pelvic Exam: A Patient-Centered and Evidence-Based Approach to Training Medical Residents.”

Conflict of Interest

None disclosed.

Author information

Authors and Affiliations

  1. Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Carol K. Bates MD & Jennifer Potter MD

  2. Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Nina Carroll MD

Authors
  1. Carol K. Bates MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nina Carroll MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jennifer Potter MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Carol K. Bates MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bates, C.K., Carroll, N. & Potter, J. The Challenging Pelvic Examination. J GEN INTERN MED 26, 651–657 (2011). https://doi.org/10.1007/s11606-010-1610-8

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-010-1610-8

Keywords

Search

Navigation