The bimanual pelvic examination is a standard component of a comprehensive physical assessment focused on the female reproductive organs. It is a manual technique that allows a healthcare provider to assess internal structures that are otherwise not visible. The procedure is named for the use of two hands, which work together to gather tactile information about the organs located deep within the pelvic cavity. This examination provides an immediate evaluation of reproductive health.
Defining the Bimanual Pelvic Exam
The core purpose of the bimanual exam is to manually assess the size, shape, consistency, and mobility of the internal pelvic organs. These organs include the uterus, the adnexa (which encompasses the fallopian tubes and ovaries), and the cervix. The tactile nature of this assessment provides a three-dimensional sense of structures that cannot be fully evaluated by visual inspection alone.
By placing one hand externally and one hand internally, the provider is able to sandwich the pelvic organs. This technique allows for the palpation of structures like the uterus. Feeling the organs allows the provider to determine if they are firm or soft, smooth or irregular, and fixed or freely movable within the pelvic space.
The Step-by-Step Procedure
The procedure begins after the visual inspection and speculum examination are complete, with the patient lying on the examination table in the dorsal lithotomy position. The healthcare provider will first lubricate their gloved dominant hand, typically inserting the index and middle fingers gently into the vagina. These internal fingers are advanced until they reach the cervix, which is palpated to check its consistency and position.
The provider then places their non-dominant hand flat on the patient’s lower abdomen. The internal and external hands work together, with the internal fingers lifting the pelvic structures upward while the external hand presses downward. This coordinated pressure allows the provider to effectively palpate the uterus, assessing its dimensions and orientation, such as whether it is tilted forward (anteverted) or backward (retroverted).
Following the assessment of the uterus, the provider repositions the hands to evaluate the adnexa. The internal fingers move into the lateral fornices of the vagina while the external hand sweeps across the corresponding lower abdominal quadrant. This movement attempts to feel the ovaries and fallopian tubes, which are often not palpable unless they are enlarged. The provider also checks for cervical motion tenderness, which is pain experienced when the cervix is moved side to side.
Conditions Diagnosed or Assessed
The bimanual exam is instrumental in identifying or assessing a range of gynecologic conditions based on changes in the organs’ physical characteristics. For instance, an enlarged uterus with an irregular, lumpy contour often suggests the presence of uterine fibroids, which are common, non-cancerous growths of muscle tissue. Tenderness or swelling in the adnexal areas can indicate an ovarian cyst or a more serious issue like an abscess.
The exam also helps detect signs of infection and inflammation, most notably Pelvic Inflammatory Disease (PID), where movement of the cervix or palpation of the adnexa may elicit significant pain. Any significant enlargement or a solid, fixed mass in the adnexa could raise concern for a tumor or ectopic pregnancy. Furthermore, the exam can reveal nodularity or thickening in the posterior pelvis, which might be a physical manifestation of endometriosis.
Preparing for and Experiencing the Exam
Proper preparation can help ensure the most accurate results and a better experience during the bimanual examination. Patients are often advised to empty their bladder before the exam, as a full bladder can push the pelvic organs out of their normal position, making them more difficult to assess. Some providers may also suggest avoiding douching or vaginal intercourse for 24 to 48 hours prior to the appointment.
During the procedure, the most common sensation experienced is one of pressure, rather than sharp pain, as the provider presses down on the abdomen and up internally. The entire bimanual portion of the exam is relatively quick, typically lasting only a minute or two. Patients are encouraged to communicate immediately if they experience significant discomfort or pain, allowing the provider to adjust their technique. Relaxation is helpful, as tensing the abdominal muscles can make palpation difficult.