Bimanual and speculum examination

Question 1

How would you explain a bimanual and speculum exam to a patient?

Answer 1

• It is an internal examination from down below
• It will involve placing 2 fingers into the vagina, and also inserting a small plastic tube to look at the cervix
• It shouldn’t be painful, but if at any point you are uncomfortable or want to stop just say so
• One of the nurses will also be present to ensure you are comfortable and act as a chaperone
• Good idea to go to the bathroom and empty your bladder if you need to
• The door will be locked so that no one can come in unexpectedly during the examination

Question 2

How should the patient be ‘exposed’ and positioned?

Answer 2

• Patient should be undressed from the waist down
• Lying flat in the lithotomy position –> heels together and bring them as close to your bottom as possible, and let your knees flop out to the sides
• There will be a sheet that the patients can cover themselves with

Question 3

What questions should you ask before doing a bimanual and speculum examination?

Answer 3

• Last menstrual period
• Abnormal PV bleeding
• Any abnormal discharge
• Contraception
• Last smear
• Whether they have previously given birth and mode of delivery

Question 4

Describe the examination of the external genitalia in a bimanual and speculum examination.

Answer 4

• Basic lower abdominal exam - distension, scars, masses, tenderness, feel for inguinal lymphadenopathy
• Part labia with forefinger and thumb of left hand
• Inspect vulva: tumours, lesions, warts/ulcerations, cysts, erythema, atrophy, labial fusion, whitening, scarring, discharge, bleeding
• Ask the patient to cough - assess for uterovaginal prolapse

Question 5

How should a speculum examination be carried out?

Answer 5

• Prepare equipment
• Inspect speculum to make sure it is not damaged, and is working properly
• Lubricate the side of the speculum and warn the patient prior to insertion
• Part the labia and insert the speculum with the screw facing sideways
• Rotate the speculum as you advance it so that the screw is facing upwards
• Open the speculum and tighten the screw when resistance is met
• Direct light to visualise the cervix
• Take swabs at this point if required
• Close speculum blades (but not fully to avoid pinching the vaginal walls)
• Remove speculum while rotating it back sideways

Question 6

What are you looking for when inspecting the cervix during speculum examination?

Answer 6

• Discharge
• Erosions
• Ulcerations
• Growths
• Cervicitis
• Blood
• Polyps
• Ectropion

Question 7

How do you swab for cervical cancer on speculum examination?

Answer 7

• Gently insert the endocervical brush through the speculum, ensuring it does not touch the speculum walls
• Tip of the brush should come into contact with the cervical os
• Rotate the brush 5 times in a clockwise direction
• Slowly remove the brush and place the tip of the brush into the sample pot container
• Tap the brush against the bottom of the container 10 times and then remove the brush, close the container
• Remove the speculum

Question 8

How do you examine the vagina on bimanual examination?

Answer 8

• Place some lubricant on the index and middle fingers of your dominant hand
• Using the other hand, gently part the labia with your thumb and index finger
• Ask patient to take a deep breath in
• Gently insert your lubricated index finger and middle finger into the vagina
• Rotate fingers 90 degrees so that palm is facing upwards
• Whilst rotating, assess the vaginal wall for any irregularities or masses

Question 9

How do you examine the cervix on bimanual examination?

Answer 9

• With palm still facing upwards, assess the cervix
• Soft cervix = fertile
• Hard cervix = after ovulation
• Cervical os is usually closed
• Cervical os open - usually miscarriage
• Palpate the cervix on either side and assess for pain
• If pain is present = cervical excitation

Question 10

When is cervical excitation present?

Answer 10

PID

Ectopic pregnancy

Question 11

How do you examine the uterus on bimanual examination?

Answer 11

• Place your free hand on the patient’s abdomen, around 3-4 cm superior to pubic symphysis
• Assess if the uterus is anteverted or retroverted
• Feel for the size and shape of the uterus - normal sized uterus is said to be comparable to an orange
• Assess for any masses (fibroids)
• Assess whether palpation is painful; if it is painful this may indicate PID

Question 12

How can you assess the position of the uterus?

Answer 12

• Keep fingers straight and feel for the cervix
• If you can feel the cervix below your fingers (i.e., pointing upwards) this is likely a retroverted uterus
• If the cervix is pointing towards or pointing down towards your fingers, the uterus is likely anteverted

Question 13

How do you examine the ovaries on bimanual examination?

Answer 13

• Place the index and middle fingers of your internal hand in the right lateral fornix
• Place the fingers of external hand on the RIF
• Gently palpate, moving internal fingers up and out, and move external fingers down and out
• Feel for masses (ovarian cysts, tumours, fibroids)
• Repeat on left side

*When removing finger, check discharge for blood or mucous

Question 14

What methods can be used to make the cervix more visible on speculum examination?

Answer 14

1. Ask patient to cough
2. Ask patient to make 2 fists and place underneath their bottom
3. Move the speculum back a little and reposition it
4. Use a larger speculum