User:Gyno.Janine/Pelvic Examination

Original Paragraphs A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma (e.g. sexual assault). It can also be used to assess a woman's anatomy in preparation for procedures. The exam can be done awake in the clinic and emergency department, or under anesthesia in the operating room. The most commonly performed components of the exam are 1) the external exam, to evaluate the external genitalia 2) the internal exam with palpation (commonly called the bimanual exam) to examine the uterus, ovaries, and structures adjacent to the uterus (adnexae) and 3) the internal exam using a speculum to visualize the vaginal walls and cervix. During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer.

Some clinicians perform a pelvic exam as part of routine preventive care. However, in 2014, the American College of Physicians published guidelines against routine pelvic examination in adult women who are not pregnant and lack symptoms, with the exception of pelvic exams done as part of cervical cancer screening.

Medical guidelines
Previous to July 2014, the benefits of routine pelvic examinations were not clear and there was no consensus. Since then, American College of Physicians (ACP) issued a guideline that recommended against performing this examination to screen for conditions in asymptomatic, nonpregnant, adult women. (The guideline did not consider Pap smears.) The ACP said that there was no evidence of benefit in support of the examination, but there was evidence of harm, including distress and unnecessary surgery. This was a strong recommendation, based on moderate-quality evidence. In 2018, the American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion that pelvic exams should be performed for 1) symptoms of gynecologic disease, 2) screening for cervical dysplasia, or 3) management of gynecologic disorders or malignancy, using shared decision-making with the patient. ACOG concluded there is inadequate data to support recommendations for or against routine screening pelvic examination for asymptomatic, non-pregnant women with average risk for gynecologic disease.

Annual "well-woman exams" are an occasion for gynecologists to recognize issues like incontinence and sexual dysfunction, and discuss patient concerns, and an exam can be done if indicated by the clinical history.

Lead
A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma (e.g. sexual assault). It can also be used to assess a woman's anatomy in preparation for procedures. The exam can be done awake in the clinic and emergency department, or under anesthesia in the operating room. The most commonly performed components of the exam are 1) the external exam, to evaluate the external genitalia 2) the internal exam with palpation (commonly called the bimanual exam) to examine the uterus, ovaries, and structures adjacent to the uterus (adnexae) and 3) the internal exam using a speculum to visualize the vaginal walls and cervix. During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer.

A pelvic exam may be performed as part of routine preventive care. However, in 2014, the American College of Physicians published guidelines against routine pelvic examination in adult women who are not pregnant and lack symptoms, with the exception of pelvic exams done as part of cervical cancer screening (Pap test).

Medical guidelines
Traditionally in the field  of   gynecology, the benefits of routine pelvic examinations were assumed, and were a recommended part of the initial gynecology visit, annual visits, and as needed for treatment. In 2014, the American College of Physicians (ACP) published a review of the benefits and the risks of the exam and issued a guideline that recommended against performing this examination to screen for conditions in asymptomatic, nonpregnant, adult women, concluding that the potential harms outweighed the demonstrated benefits and that screening pelvic exams in asymptomatic women did not reduce mortality or morbidity rates. The guideline did not consider the necessity of frequency of Pap smears. This was a strong recommendation, based on moderate-quality evidence. In 2018, the American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion that pelvic exams should be performed for 1) symptoms of gynecologic disease, 2) screening for cervical dysplasia, or 3) management of gynecologic disorders or malignancy, using shared decision-making with the patient. ACOG acknowledged that given changes in screening recommendations and an assessment of harms vs benefits as reviewed by the US Preventive Services  Task Force, re-evaluation of routine screening pelvic examination for asymptomatic, non-pregnant women with average risk for gynecologic disease was indicated.

Annual "well-woman visits" are an occasion for gynecologists to identify health risks for women. ACOG has noted that these visits can also include clinical breast examinations, immunizations, contraceptive care discussions, and health care counseling.(Ref #2 original)  Pelvic exams can help to  recognize issues like incontinence and sexual dysfunction. ACOG reinforced the potential value of pelvic examinations in allowing clinicians to explain a patient’s anatomy, reassure her of normalcy, and answer specific questions, thus establishing open communication between patient and clinician.(Ref--ACOG Committee Opinion)

PLAN to Review Lead, and to add paragraph on  Pelvic examination in individuals with physical and other disabilities

Needs a Section on Bimanual Examination (possibly R/V exam)--size, shape,  consistency,  position,  mobility, tenderness--Berek and Novak's Chapter 1, p 13--

Bimanual Examination
The bimanual component of the pelvic examination allows the examiner to feel ("palpate" in medical terms) the structures of the pelvis, including the vagina, cervix, uterus, and  adnexae (structures adjacent to the uterus, which include the ovaries and any adnexal masses). The bimanual exam traditionally occurs after the speculum exam. The examiner typically applies lubricant to the fingers of the glove of their dominant hand, and the index finger or index finger and middle finger are gently inserted into the vagina. The examiner's opposite hand is place on  the patient's abdomen to allow  palpation of the pelvic structures; thus the exam is termed a "bimanual: examination". A systematic exam of the pelvic structures allows an assessment of the vaginal introitus (opening), pelvic floor muscles, bladder, rectum, cervix, and the area posterior to the uterus; this portion of the exam is particularly helpful for individuals with pelvic pain, as it allows an assessment of tenderness and an anatomic source of pain. In assessing the uterus, elevation of cervix with the vaginal hand allows palpation of the uterus above the pubic symphysis with the opposite hand, and the size, shape, mobility, contour, consistency, and position of the uterus can be determined. Observing the patient's face during this exam can provide information about the additional characteristic of uterine tenderness, and the patient can also provide verbal feedback. The adnexal structures are similarly palpated, noting any enlargement of the ovaries and if present, the size, shape, mobility, and consistency of ovarian/adnexal masses.

Pelvic Examination for Individuals with Physical Disabilities
Schedule extra time

Choose exam room with room for accomodations--(table adjustable in height, knee stirrups, room for wheelchair)

Discuss with staff--need for assistance with transfer (patient will provide guidance re what assistance is needed)--what modifications to exam (type of speculum) safe transfer

Flag chart of need for accomodations