Alexandra Duncan, GTA, Praxis Clinical, New Haven, CT
Tiffany Cook, GTA, Praxis Clinical, New Haven, CT
Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
A bimanual exam is a thorough check of a patient's cervix, uterus, and ovaries. It can tell an experienced provider a great deal, as it may lead to the discovery of abnormalities, such as cysts, fibroids, or malignancies. However, it's useful even in the absence of such findings, as it allows the practitioner to establish an understanding of the patient's anatomy for future reference.
Performing the bimanual exam before the speculum exam can help relax patients, mentally and physically, before what is often perceived as the "most invasive" part of the exam. A practitioner already familiar with the patient's anatomy can insert a speculum more smoothly and comfortably. However, lubrication used during the bimanual exam may interfere with processing certain samples obtained during the speculum exam. Providers must be familiar with local laboratory processing requirements before committing to a specific order of examination.
This demonstration begins immediately after the end of the speculum exam; therefore, it assumes the patient has provided a history and is in the modified lithotomy position.
A rectovaginal exam is not always necessary, but it may be performed to fully assess a retroverted uterus and ovaries (this may be the only way to accomplish full assessment depending on uterine position) or to assess the rectum.
1. Bimanual Exam
Figure 1. Bimanual exam. Correct positioning of the examiner's hands for the bimanual exam.
- Prepare the patient by saying, "I will now place two gloved fingers in your vagina and use my other hand to press on your abdomen to assess your uterus and ovaries."
- Fully coat the first two fingers of your dominant hand with lubricant.
- Sit and tell the patient you are placing one, then two fingers in the patient's vagina.
- Insert the dominant index finger, palm down with the other fingers tucked, 1 inch into the vaginal introitus. Apply posterior pressure to open the introitus and insert the middle finger.
- Apply posterior pressure to avoid tugging the labia, and supinate your hand.
- Insert the fingers fully into the patient's vagina, while moving the labia away with your thumb on one side and your fourth and fifth fingers on the other.
- Release the labia, rest your external fingers in the inguinal groove, and stand up.
- Place your dominant foot on the footstool, tuck your dominant elbow into your side, and soften your wrist. If more pressure is needed to insert the fingers farther, stand straight and use your core to press forward without looming over the patient.
- Use your internal fingers to locate the cervix.
- Place the fingers palm up on the posterior (bottom) wall of the vagina.
- Sweep the fingers from side to side, moving upward, until the cervix is located, which should feel moist and firm. Often, it is angled down, which makes it easy to end up in the anterior fornix. If the cervix cannot be located, start again at the posterior vaginal wall.
- Use a sweeping motion with your internal fingers to assess the face of the cervix for masses. Note the cervical os and the direction the os is pointing.
- Check cervical tone by gently squeezing the cervix. A nulliparous patient's cervix should feel firm, like cartilage. It may be softer in a patient who has been pregnant.
- Gently move the cervix up, down, and from side to side, watching the patient's face for any discomfort, which is a positive sign of cervical motion tenderness (CMT).
- Move your fingers so they are underneath the cervix, and gently press upward. If the patient's uterus is retroverted, it may feel like it's protruding into the posterior fornix. Use your fingers to assess as much of the uterus as can be reached.
- Starting at the umbilicus, use the pads of the fingers on your non-dominant hand to press down on the patient's abdomen, and scoop forward.
- Move your external hand 1 inch lower and repeat. Continue until the abdominal hand moves the uterus, causing the cervix to move lightly (tap) against your internal fingers. As you get nearer to the uterus, the cervix taps more intensely. The most intense tapping indicates your external hand is directly on the uterus.
- Note where the most intense movement starts and stops, which indicates, respectively, the upper and lower boundaries of the uterus.
- Move from one side of the patient's abdomen to the other (in line with the uterus), while applying a rocking pressure, to locate the side boundaries of the uterus.
- Use your external hand to pull the uterus toward you, as your internal fingers gently press up on the cervix, until you are palpating the uterus between your hands. Remember that the position of the uterus can range from anteflexed to retroflexed (roughly 10-15% of patients), and this can affect other parts of the exam and the patient's reproductive health. The uterus may also be slightly tilted or off-center.
- Assess the uterus for size, shape, and consistency. The uterus of a nulliparous adult is roughly 7 cm long by 4 cm; if the patient has been pregnant, it may be larger. It should feel muscular, not boggy or hard, and smooth; protrusions may indicate fibroids.
- To assess the right ovary, slide your fingers, palm up, into the right lateral fornix.
- Drop your wrist and hook the fingertips up to find the internal iliac pulse. It may be necessary to back your fingers out of the vagina 1-2 inches to find the pulse. Once located, hook your fingers upward to press firmly against the pulse (there is more space here than people tend to believe). Do not push your hand in deeper; keep your wrist and arm relaxed, and only press upward with your fingertips.
- Using the pads of the index and middle fingers of your non-dominant hand, begin 1 inch medial to the right hip point, the anterior superior iliac spine (ASIS). Then, sweep your external fingers slowly, with light-medium pressure, down to the pubis, parallel to the inguinal groove.
- The ovary should bump gently against the internal fingers and feel very subtle (may feel like a small oval bulge or a wave of muscle). Do not stop or push directly on the ovary - ovaries are roughly equivalent to testes and are very sensitive.
- Move your fingers into the left lateral fornix to assess the left ovary.
2. Rectovaginal Exam
Figure 2. Rectovaginal exam. Correct positioning of the examiner's hands for the rectovaginal exam.
- Change gloves to avoid cross-contamination from the patient's vagina to the anus.
- Coat the first two fingers of your dominant hand with lubricant, base to tip.
- Stand with your dominant foot on the footstool; rest your dominant elbow on your leg.
- Let the patient know what to expect: "You will now feel me placing a finger in your vagina and a finger in your rectum to better assess your uterus and ovaries."
- Ask the patient to bear down, as if having a bowel movement.
- As the patient is bearing down, insert your index finger into the vagina and your middle finger into the rectum to the first knuckle of your middle finger, then pause.
- Wait a few seconds as the second internal sphincter involuntarily contracts.
- When it relaxes (or after a few seconds, if you cannot feel it clearly), insert the rest of the way as the patient continues to bear down.
- Scissor the fingers to assess the septum, checking that it is firm and pliable.
- Sweep your middle finger side to side against the top wall of the rectum to assess the utero-sacral ligaments (should feel like rubber bands), then press your finger deeper into the rectum while sweeping the walls. Expect to feel stool, but no fixed masses.
- With your middle finger, locate the cervix through the septum and examine what you can reach of the uterus. Repeat the bimanual exam with your middle finger.
- Remove your fingers, re-drape the patient, and remove your gloves out of the patient's sight (as there may be visible discharge or stool). Throw the gloves into the trash unless the rectovaginal exam was just finished, and they are needed for a stool sample.
- Tell the patient to push back to sit up, and offer the patient a wipe.
- If there were no pathological findings, tell the patient that everything appears healthy and normal, that you are going to send the samples to the lab, and when they should expect to hear back.
- Let the patient know you are stepping out, so the patient can get dressed. Afterward, answer any questions from the patient.
The bimanual and rectovaginal exams are performed to more thoroughly evaluate the patient's cervix, uterus, ovaries, rectum and other pelvic structures.
Although, bimanual assessment is considered to be the third part of the pelvic exam, you may choose to perform this before the speculum examination. This decision depends on the type of cytology your institution prefers and whether or not the lubricant will interfere with it. In fact, performing bimanual assessment first ensures that the patient is as relaxed as possible before this most physically invasive part of the pelvic examination. This also helps a physician gain more knowledge about the cervical position, before attempting to place the speculum.
As the name suggests, the bimanual assessment involves usage of both the hands. The external or the abdominal hand that exerts gentle pressure on the abdominal wall to gently displace organs inwards, which can then be felt by the finger pads of the internal or the pelvic hand placed inside the vagina. This allows one to evaluate the size, position and consistency of the organs, and to detect the areas of tenderness and pelvic masses. Some patients also need rectovaginal examination for the full assessment of their internal genital organs, rectum, rectovaginal septum, and other pelvic structures. This video will demonstrate the correct technique for both bimanual assessment and rectovaginal examination in detail.
Before starting with the exam one needs to have a good understanding of the topographical anatomy of the pelvis for proper interpretation of the findings. The uterus is a pear-shaped, fibromuscular organ that consists of two parts-the body and the cervix. The body receives the openings of the uterine tubes that extend laterally towards the ovaries. The cervix protrudes into the vagina, creating 4 recesses-namely the anterior fornix, the posterior fornix and the two lateral fornices.
The sagittal view of the pelvis reveals that the uterus lies posterior to the urinary bladder, and anterior to the rectum, which is separated from the uterus by the rectouterine pouch. The proximity to the anterior abdominal wall allows evaluation of the uterus and the ovaries by bimanual assessment. One should remember that the uterine position differs amongst individuals. In cases where the uterus is tilted towards the rectum-as in retroflexion-it can be felt by the examiner through the posterior fornix. Whereas in cases where the uterus is anteflexed, normally or severely, because the cervix is pointing downward you cannot feel the uterus protruding into the posterior fornix. Laterally, one can assess the ovaries by sweeping with the abdominal hand over lower lateral quadrant so the ovary is displaced and swept over the pelvic hand in the ipsilateral fornix. The uterine tubes are normally non-palpable.
Now let's review the steps and the technique of the bimanual examination. Before beginning the exam, prepare the patient by saying something like, "Dialogue". Fully coat the first two fingers of your dominant hand with lubricant, and let the patient know that you are placing one, and then two fingers into their vagina
Start the exam by placing the back your hand on the patient's thigh. Then, while keeping the palm down, insert the dominant index finger for about one inch into the introitus. Apply slight posterior pressure and introduce the middle finger for about one inch as well. Then slowly supinate your hand and insert both fingers fully, while separating the labia with the thumb, and the fourth and fifth fingers.
Now position your hand in the inguinal groove, and stand up. Place your dominant foot on the footstool, tuck your elbow into your side, and relax your wrist. Place the internal fingers on the posterior vaginal wall and sweep them from side to side, moving upward until you locate the cervix, which should feel moist and firm. On the face of the cervix you will feel the indentation of the os. Often the os will be angled posteriorly, which usually indicates some degree of anteversion of the uterus. An os that is pointing fully downward may indicate severe anteflexion, where the uterus is curved over the bladder. Whereas, a retroverted uterus may have a more midline os, but you will be able to feel the uterus extending below the cervix into the posterior fornix.
Use a sweeping motion with your internal fingers to assess the surface of the cervix for masses.Check cervical tone by gently squeezing the cervix. Gently move the cervix up, down, and from side to side, while watching the patient's face for any discomfort, which is a positive sign of cervical motion tenderness, or CMT. Anchor your fingers on the face of the cervix and gently press up. If you feel like the uterine body is protruding into the posterior fornix, then it confirms the presence of a retroflexed uterus.
Subsequently, place your non-dominant finger pads at the level of umbilicus and press down on the abdominal wall while making a scooping forward motion, moving about an inch lower every time. Repeat this maneuver until you can feel the cervix tap against your fingers. Note where the most intense movement starts and stops, these indicate the upper and lower uterine boundaries. Then, locate the lateral boundaries by palpating across the abdomen with a rocking motion. Use your external hand to pull the uterus toward you, as your internal fingers gently press on the cervix; continue until you can feel the uterus between your hands. Assess the uterus for size, shape, and consistency. It should feel firm, like a muscle, not boggy or hard. Any palpable protrusions may indicate fibroids. You can estimate size based on either the boundaries of the uterus you estimated earlier, or based on what you feel when holding the uterus between your hands. The uterus of a nulliparous adult is roughly 7 cm by 4 cm; if the patient has been pregnant, it may be larger.
Next, place your internal fingers onto the right lateral fornix. Drop your wrist, hook the fingertips up, locate the internal iliac pulse and press your fingers toward it. Then, locate the right anterior superior iliac spine, position the external finger pads one inch medial to it and sweep slowly and smoothly with light to medium pressure towards the inguinal groove. During this sweeping motion, the ovary can be felt by the internal fingers as a small oval bulge. As the ovaries are sensitive to touch, ensure that you don't stop on top of an ovary or push on it directly. Move your fingers into the left lateral fornix and palpate the left ovary in the same manner.
The next part of the video will demonstrate how to conduct the rectovaginal exam, which may be performed for different reasons. For example, to further assess the uterus and ovaries, particularly in patients with a retroverted and retroflexed uterus; in response to rectal symptoms or pelvic pain; to screen for cancer or other non-sympomatic pelvic conditions.
For this exam, one finger is placed into the rectum and the other in the vaginal canal. This allows examination of the rectum itself, the rectovaginal septum and the rectrovaginal pouch, as well as the retroverted uterus, which will protrude posteriorly and be palpable through the septum.
Start by changing the gloves to avoid cross-contamination, and then coat the first two dominant fingers from base to the tip with the lubricant. Position your dominant foot on the footstool and place your dominant elbow on your leg for support. Before starting the examination, let the patient know what to expect, "Dialogue". As the patient bears down, introduce the index finger into the vagina, while placing the distal phalanx of the middle finger into the rectum. Pause for a few seconds as the internal sphincter involuntarily contracts and relaxes, and then fully insert both fingers, while the patient continues to bear down. Scissor the fingers to assess the septum, which normally is firm and pliable. Sweep your middle finger side to side against the anterior rectal wall to assess the utero-sacral ligaments, which should feel like rubber bands. Also, examine for the presence of any fixed masses.
Next, curve your index finger a little out of the patient's vagina, so that you can locate the cervix through the septum using your middle finger. Then, like the bimanual exam, use your external hand to press on the abdomen to assess the uterus using your middle finger. If the patient has a retroverted uterus, you would be able to assess the entire uterine surface through the finger in the rectum. You can also repeat the ovarian sweep like before, though you may not feel anything in a patient with no abnormal findings.
This concludes the examination. Remove your fingers, re-drape the patient, and discard the gloves out of the patient's sight, unless a stool sample needs to be obtained. Tell the patient they can push back to sit up. If there were no pathological findings, inform the patient that everything appears healthy and normal. Also, notify them that you are going to send the samples to the lab, and when they should expect to hear back about the results. Lastly, let the patient know you are stepping out so that they can get dressed, and that afterward you will return to answer any questions they have.
You've just watched JoVE's video the on bimanual and rectovaginal examination, which conclude the three part series of systematic pelvic examination. In the first video, we learned how to perform the assessment of the external genitals and the digital inspection of the vagina, cervix and the vestibular glands. In the second part, we discussed the speculum examination and obtaining samples for the Papanicolau test. Finally, in this third presentation we reviewed how to perform bimanual assessment of the pelvic organs and the rectovaginal evaluation. As always, thanks for watching!
Applications and Summary
This video reviewed the techniques for performing a comfortable bimanual and rectovaginal exam. When first performing the exam, it can be hard to know what both normal structures and abnormalities should feel like, but familiarity develops with practice. Experienced practitioners can determine the structure and location of the patient's anatomy and discover polyps, cysts, and malignancies; the potential of pelvic inflammatory disease; and more. The rectovaginal exam can be a good way to gather information about a retroverted uterus and ovaries, as well as other information about the patient's health.
People new to the exam should be aware that the inside of the vagina feels moist and fairly yielding, while the cervix is moist and firm. Depending on whether a patient has had children or not, and whether the patient is in a menstrual cycle, the cervix may feel firmer (like the cartilage of the nose) or softer (like pursed lips). A healthy ovary is soft, subtle, roughly 2 cm by 2 cm, and shaped like an almond. An ovary that is large, hard, and very easily palpable is a concerning finding. Ovaries shrink after menopause and may not be palpable in post-menopausal patients. They may also be challenging to locate in patients who are obese.
It is important to be aware that different patients' anatomy may vary greatly. When concluding an exam, the clinician should inform the patient that "everything appears healthy and normal" as long as there were no concerning findings that required follow-up; in this case, "normal" does not mean statistically average, but normal for the patient. It is important that patients understand the baseline for health in their own bodies, and that, however their anatomy appears, what is healthy and normal for them.