Differentials
| Presenting Feature | What might it be? | What might I find? | |
|
Pelvic pain |
Endometriosis |
Cyclical pelvic pain, onset before period.
Location may cause cyclical bladder/bowel symptoms. Examination may be normal. Pelvic tenderness, visible endometrial tissue on speculum, fixed cervix and vaginal/cervical/adnexal tenderness. |
|
|
Adenomyosis |
RF: late reproductive years, multip. Eases post menopause.
Dysmenorrhoea, menorrhagia, dyspareunia. Enlarged and soft, tender uterus. |
||
|
Pelvic inflammatory disease (PID) |
RF: UPSI, multiple sexual partners, young, known STI, IUS/D.
Pelvic pain, discharge, dyspareunia, pyrexia, dysuria. Pelvic and cervical motion tenderness, purulent d/c, cervicitis. |
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|
Ovarian torsion |
Increased likelihood if benign mass, cyst >5 cm, pregnancy.
Sudden onset severe unilateral pain, constant, vomiting. Unilateral pelvic tenderness +/- pelvic mass. |
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|
Pelvic mass |
Ovarian cyst |
Mostly benign pre-menopause, ↑ suspicion post-menopause.
Usually asymptomatic and found on USS incidentally. Can give pelvic pain, bloating, abdominal fullness. Palpable pelvic mass on bimanual exam if large. |
|
|
Ovarian cancer |
RF: age (≈60), BRCA+, obesity, increased ovulation, smoking.
Typically presents non-specifically & diagnosed late. Possible findings: bloating, ascites, pelvic mass. |
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|
Polycystic Ovaries |
Part of Polycystic Ovarian Syndrome (PCOS).
Associated oligomenorrhoea and hyperandrogenism. Bulky ovaries on bimanual examination, acne, hirsutism. |
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|
Uterine fibroids |
RF: late reproductive years, black ethnicity.
May be asymptomatic, menorrhagia (commonest symptom), dysmenorrhoea, bloating, elongated menstrual bleed, deep dyspareunia, sub-fertility. Bimanual examination – bulky, non-tender uterus. |
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|
Vaginal mass |
Pelvic Organ Prolapse |
RF: ↑age, post-menopause, obesity, multiparty, cough/strain.
Sensation of dragging or ‘something in vagina’. Uterine prolapse/cystocele/rectocele. Mass at introitus/speculum exam, more prominent w/cough. |
|
|
Bartholin’s cyst |
Blocked Bartholin’s ducts (secrete lubricating mucus).
Unilateral swelling at postero-lateral introitus, tender++. Can become abscess if infected. |
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|
Vaginal cancer |
Rare, associated with older age, HPV, immunocompromise.
Vaginal wall mass, ulceration or skin changes. |
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Checklist
|
Preparation |
Wash – Name – Explain | |
| Chaparone | ||
| Allow to undress | ||
| Position patient lying flat, knees flexed & thighs abducted | ||
| Ask patient to cover with sheet | ||
| External Inspection | Expose patient | |
| Put on gloves | ||
| Skin colour | ||
| Scarring | ||
| Distribution of hair | ||
| Vulval atrophy | ||
| Vulval ulceration | ||
| Vulval lump or swelling | ||
| Signs of female genital mutilation | ||
| Visible bleeding or discharge at introitus | ||
| Prolapse | ||
| Ask patient to cough & reassess for prolapse | ||
| Bimanual Exam | Lubricate index and middle fingers of dominant hand | |
| Part labia | ||
| Insert index and middle fingers into vagina, palm facing you | ||
| Advance fingers into vagina & rotate 90° (palm upwards) | ||
| Palpate cervix | ||
| Cervical tenderness | ||
| Place non-dominant hand on abdomen in suprapubic region | ||
| Palpate uterus | ||
| Place non-dominant hand on abdomen in right ilic fossa | ||
| Palpate right adnexa | ||
| Place non-dominant hand on abdomen in left ilic fossa | ||
| Palpate left adnexa | ||
| Withdraw fingers into vaginal canal | ||
| Palpate vaginal walls | ||
| Ask patient to cough & assess for prolapse | ||
| Gently rotate fingers 90° (palm to you) & withdraw fingers | ||
| Inspect fingers for blood or discharge | ||
| Finishing | Offer tissue to wipe excess lubricating jelly | |
| Re-cover patient | ||
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
- Explain the presence and purpose of the chaperone
“I have been asked carry out a vaginal examination. This involves inserting two gloved fingers into the vagina to assess the vagina and the neck of the womb as well as pressing on your abdomen. You will feel some pressure and cold jelly, but it should not be painful. You can ask me to stop at any time. There will be a chaperone present whilst I carry out this examination. Are you happy for me to do that?”
Ask the patient to undress from the waist down. Position the patient lying on the examination couch with their knees drawn up to their chest and ask the patient to let their legs relax apart so that their thighs are abducted. Cover the patient until you are ready to start the examination.
Gather the equipment you will need for the examination including gloves, lubricating jelly, and tissue paper. Ensure you have a good source of light.
A vaginal examination may be combined with vaginal swab taking in practice, which is covered elsewhere in this book.
External Inspection
Put on gloves before starting the examination. Check the patient is comfortable and then expose the external genitalia. Inspect the labia majora, labia minora, introitus, and perineum. Check for any redness or breakdown of skin integrity, or any excoriation marks, or sore or itchy vulval skin.
Examine the vulval area for:
- Hair distribution
- Ulceration
- Scarring (e.g., lichen sclerosus or previous episiotomy)
- Atrophic changes (e.g., thin, fragile, inflamed skin)
- Lumps or swelling
- Bleeding or discharge
Examine for any prolapse at the vaginal introitus. Ask the patient to bear down and cough, and observe if prolapse appears with increased intra-abdominal pressure.
Be alert for any signs which raise suspicion for female genital mutilation (cut or missing part of genitalia). If suspected, this requires urgent discussion with a senior colleague (ideally your safeguarding lead).
Bimanual Exam
Apply lubricating jelly to the index and middle fingers of your dominant hand. Ensure the patient is ready, then part the labia with your non-dominant hand. Place your fingers at the vaginal introitus, hand rotated so that your palm is facing left or right. Slowly and gently advance your fingers, ensuring the patient is tolerating the examination, and rotating your fingers 90° so that your palm is facing upwards.
Palpate the cervix, assessing:
- Position (e.g., anterior, posterior, lateral)
- Consistency
- Os – is the os open or closed?
- Tenderness – cervical motion tenderness may indicate inflammation or cervicitis
Palpate the uterus by placing your non–dominant hand on the patient’s abdomen in the supra–pubic region. Position the fingers of your dominant hand posterior to the cervix and gently push upwards towards the abdomen. Feel for the uterus moving between your two hands. If the uterus is palpable, assess:
- Size (e.g., bulky uterus if fibroids present)
- Position (e.g., anteverted or retroverted)
- Consistency (e.g., smooth or irregular)
- Tenderness
Palpate the adnexae for any masses or structures between your two hands. Place your non–dominant hand on the patient’s abdomen in the right iliac fossa and the fingers of your dominant hand into the right fornix (the space to the right of the cervix at the top of the vagina). If any masses or structures are felt, asses for size, shape, mobility, consistency and tenderness. Repeat the above on the other side.
Gently withdraw your fingers into the vaginal canal and assess the vaginal walls as you do so, rotating your hand back 90° so that your palm is again facing left or right. Palpate the vaginal walls for any masses or irregularity, or signs of pelvic organ prolapse. You can ask the patient to cough or bear down to assess the origin of any pelvic organ prolapse.
Once you have completed the examination, withdraw your fingers completely and inspect the glove for any blood or discharge present.
Finishing
Thank the patient and allow them to cover themselves. Offer a paper towel to wipe away any excess lubricating jelly. Wash your hands.
Depending on the examination findings you may wish to carry out a speculum examination; or organise investigations including vaginal swabs, blood tests, or referrals for colposcopy or further imaging (e.g., ultrasound scan).
Last updated Dec 2024
Head to members.zerotofinals.com for practice OSCE stations, including an interactive checklist, specific cases and clinical findings.
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