🩺 Bimanual Pelvic Examination

The bimanual pelvic examination is a diagnostic technique used to palpate the internal female pelvic organs by using both hands—one internally via the vagina and one externally on the abdominal wall. It allows the clinician to assess the uterus and adnexa for size, position, tenderness, and masses. This examination is critical for diagnosing conditions like PID, fibroids, and ectopic pregnancy. Professionalism, consent, and the presence of a chaperone are fundamental to the safe and ethical performance of this exam.

A bimanual pelvic examination is indicated to assess the size, shape, position, and mobility of the uterus and to check for adnexal masses or tenderness. It is a key part of the workup for pelvic pain, suspected pelvic inflammatory disease (PID), endometriosis, or suspected uterine fibroids. It is also used to evaluate the extent of known gynaecological malignancies or to localize pain during a diagnostic workup. In the emergency setting, it is vital for assessing cervical motion tenderness in suspected ectopic pregnancy.

The procedure is contraindicated in patients who have not given informed consent or where a chaperone is not available. It should be avoided in pre-pubertal or non-sexually active patients unless absolutely necessary and performed by an expert. In the context of pregnancy, a bimanual exam is contraindicated if there is suspected placenta praevia or if there has been pre-labour rupture of membranes (due to infection risk). Severe vaginal or pelvic pain that makes the examination intolerable is a relative contraindication.

Basic equipment includes non-sterile (or sterile if indicated) gloves and a significant amount of water-soluble lubricant. A private examination room with a couch and appropriate draping is required. A chaperone is mandatory. Tissues should be available for the patient to clean themselves following the procedure. If the bimanual is followed by a speculum exam, the speculum and light source must also be prepared, though the bimanual is usually performed after the speculum exam to avoid interference with swab results.

Ensure consent, privacy, and a chaperone. With the patient in the supine position (knees up, feet together), lubricate the index and middle fingers of your dominant hand. Gently insert them into the vagina until you reach the cervix. Note its consistency and mobility. Place your non-dominant hand on the patient's lower abdomen, just above the symphysis pubis. Push down with the external hand while lifting the cervix and uterus with the internal fingers to palpate the uterine fundus. Move your internal fingers to the lateral fornices while pressing your external hand into the iliac fossae to palpate the adnexa.

The normal uterus is typically anteverted, firm, non-tender, and about the size of a small pear. A 'fixed' or immobile uterus may suggest adhesions from previous surgery, endometriosis, or malignancy. 'Cervical excitation' (exquisite pain when the cervix is moved) is highly suggestive of pelvic inflammatory disease or an ectopic pregnancy. Palpable adnexal masses may indicate ovarian cysts or tumours. Tenderness in the fornices also points towards inflammatory or infectious processes within the pelvis.

Common errors include not using enough lubricant, which causes patient discomfort, and using too much pressure with the internal fingers. Students often fail to properly coordinate the movement of the external hand with the internal fingers, missing the chance to 'sandwich' the pelvic organs. Another mistake is neglecting to palpate the adnexa (ovaries and tubes) separately from the uterus. Clinicians sometimes forget to check for 'cervical excitation' (pain on movement of the cervix), which is a critical sign in suspected ectopic pregnancy or PID.

Always perform the speculum examination before the bimanual if swabs are needed, as the lubricant from the bimanual can interfere with samples. Warm your hands before starting. Ensure the patient's bladder is empty, as a full bladder can make the exam uncomfortable and interfere with palpation. Use the phrase 'I am now going to press on your tummy from the outside' to keep the patient informed. Always document the findings clearly: 'Uterus anteverted, non-tender, no adnexal masses felt.'

Aligned with MLA 'Obstetrics and Gynaecology' requirements. Students must recognize that the 'bimanual' is the second part of a full pelvic exam (following the speculum). It is essential to understand the clinical triad of ectopic pregnancy (amenorrhoea, abdominal pain, and vaginal bleeding) and the role of the bimanual exam in identifying cervical excitation. Knowledge of the 'Red Flag' signs for ovarian cancer (e.g., bloating, palpable mass) is frequently tested in the AKT.