Pelvic exam is a physical exam of the female pelvic organs.

External examination, including:

• Examination and palpate the vulva, perianal area, vaginal canal, for erythema, swelling, excoriation, rash, lesions, masses, trauma
• Examine for any areas of discomfort, irritation, or pain
• Palpation of stomach area

Internal examination, including:

• Formalities:
  • Informed consent
  • Allow Pt to get undressed behind a curtain
  • Offer a chaperone
  • Wash hands, and wear gloves
• Speculum exam, which involves:
  • Warm the speculum with warm [but not hot] water, test temperature by touching it to her thigh, apply a water-based lubricant to the speculum, and insert the speculum at a slight downward angle. Do not use the rotation method. The speculum handle should be 2cm away, before opening the speculum blade, and locking it in place by turning the screw on the thumb piece
  • At the center of the speculum window, should be the cervical os (aka external orifice of the uterus, i.e. a small, circular aperture on the rounded extremity of the vaginal portion of the cervix)
  • Examination for foreign bodies
  • Cervical swabs taken, including pap smear which is a swab of the epithelial layer of the cervix
  • High vaginal swab (HVS, aka vaginal wet mount, vaginal smear), where a cotton-tipped swab is used to sample vaginal discharge in the fornix of the vagina (i.e. recesses in the vagina), or along the vaginal wall. It is then sent for culture and sensitivity:
    • Placed on pH paper to determine vaginal pH, which should be 4 (yellow), but if more alkalotic (blue) may indicate infection
    • Smear on to a glass slide, apply KOH and saline to opposite sides of the slide, and cover the slide with cover slips. This is then observed by wet mount microscopy. It is used to find the cause of vaginitis and vulvitis, including:
      • Vaginal yeast infection (candidal vulvovaginitis)
      • Bacterial vaginosis (BV)
      • Trichomonas vaginalis (TV)
      • Group B strep
  • Endocervical culture (aka vaginal culture), where a cotton-tipped swab is positioned in the cervical os for 30 seconds, which is placed in the medium provided, and top is secured. It is then cultured to identify infection (including STI's) in the female genital tract, including:
    • Chlamydia
    • Gonorrhea
    • Herpes simplex 
  • Warn the Pt, unscrew, and unlock the speculum. As you are removing the speculum, slowly close the blades. The blader should be completely closed when exiting the introitus. Examine the walls of the vagina as you are retracting the speculum
• Bimanual exam, where 2 fingers (2nd and 3rd fingers of the dominant hand) are inserted into the vagina
  • Palpate for the vagina, cervix, uterus, and adnexa. The abdominal hand should sweep the pelvic organs down, whilst the vaginal hand is simultaneously elevating them. Determine the size, shape, symmetry, mobility, position, and consistency of the uterus. Check the adnexal region for appropriately sized ovaries, about 2x3cm
  • Test for cervical motion tenderness (aka cervical excitation, chandelier sign, i.e. pain being so excruciating upon bimanual pelvic exam, that it is as if the Pt reaches up to motion the grabbing of a ceiling-mounted chandelier), as seen in PID, ectopic pregnancy, and used to differentiate from appendicitis
• Rectovaginal exam, placing the index finger of the dominant hand into the vagina, and concurrently place the middle finger into the rectum. Apply pressure laterally and anteriorly to palpate structures. Use the other hand to apply downward pressure on the abdomen

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In obese Pt's, the cervix can be difficult to visualize due to excess vaginal wall tissue. Cut off the distal thumb tip of a large latex-free examination glove to create a sleeve, and place this around the speculum. As the speculum is opened in the vaginal canal, the excess vaginal tissue will be kept out of the speculum by the sleeve.

Consider anesthesia for:

• Physical or mental disability
• Abnormal anatomy
• Physical immaturity, with an intact hymen

• The exam shouldn't be excessively uncomfortable, but:
  • Women with vaginal infections may feel pain when the speculum is inserted
  • Palpation of the ovaries during the bimanual exam may be mildly discomfort, or even painful
  • The pap test may cause some cramping, or a small amount of bleeding
• Trainee doctors use to perform pelvic exams on unconscious women, about to undergo surgery for unrelated causes, and were rarely informed. This practice is now forbidden, and informed consent in advance is now required

• Pelvic exam for screening in asymptomatic, nonpregnant, adult women is controversial. Physicians (ACP) issued a guideline recommending AGAINST it because there is little benefit in support of the exam, but there is evidence of harm, including distress and unnecessary surgery. OBGYN's (ACOG) disagreed, whilst although acknowledging routine annual pelvic exam was unsupported by scientific evidence, it is supported by anecdotal clinical experience of gyencologists, permitting recognition of issues like incontinence and sexual dysfunction, and other Pt concerns

• Speculum (device used in the internal pelvic exam)
• Papsmear (often performed)