Vaginal examination

1. ANATOMY OF FEMALE REPRODUCTIVE PART
What is a vaginal examination?
A vaginal examination is an internal physical examination done by a doctor or midwife.
In most cases during pregnancy

2. A bimanual vaginal examination may need to be performed in a number of different
clinical scenarios including unexplained pelvic pain, irregular vaginal bleeding,
abnormal vaginal discharge and as part of the assessment of a pelvic mass.
.
Gather the appropriate equipment:
Gloves
Lubricant
Paper towels
Introduction
1.Wash your hands and don PPE if appropriate.
2.Introduce yourself to the patient including your name and role.
3.Confirm the patient’s name and date of birth.

3. 4.Explain what the examination will involve using patient-friendly language: “Today I
need to carry out a vaginal examination. This will involve me using one hand to feel
your tummy and the other hand to place two fingers into your vagina. This will allow
me to assess the vagina, womb and ovaries. It shouldn’t be painful, but it will feel a
little uncomfortable. You can ask me to stop at any point.”
5.Explain the need for a chaperone: “One of the female ward staff members will be
present throughout the examination, acting as a chaperone, would that be ok?”
6.Gain consent to proceed with the examination: “Do you understand everything I’ve
said? Do you have any questions? Are you happy for me to carry out the
examination?”
7.Ask the patient if they have any pain or if they think they may be pregnant before
proceeding with the clinical examination.
8.Provide the patient with the opportunity to pass urine before the examination.
10.Explain to the patient that they’ll need to remove their underwear and lie on the

4. clinical examination couch, covering themselves with the sheet provided. Provide the
patient with privacy to undress and check it is ok to re-enter the room before doing
so.
Vaginal examination
1.Position the patient supine in the modified lithotomy position: “Bring your heels
towards your bottom and then let your knees fall to the sides.”.
2.Adequately expose the patient
3.Don a pair of non-sterile gloves.
4. Inspect the vulva for abnormalities:
Ulcers: typically associated with genital herpes.
Abnormal vaginal discharge: causes include candidiasis, bacterial vaginosis,
chlamydia and gonorrhoea.
Scarring: may relate to previous surgery (e.g. episiotomy) or (destructive
scarring with associated adhesions).
Vaginal atrophy: most commonly occurs in postmenopausal women.
White lesions: may be patchy or in a figure of eight distribution around the

5. vulva and anus, associated with lichen sclerosus.
Masses: causes include Bartholin’s cyst and vulval malignancy.
Varicosities: varicose veins secondary to chronic venous disease or obstruction
in the pelvis (e.g. pelvic malignancy).
Female genital mutilation: total or partial removal of the clitoris and/or labia
and/or narrowing of the vaginal introitus.
5. Inspect for evidence of vaginal prolapse (a bulge visible protruding from the
vagina). Asking the patient to cough as you inspect can exacerbate the lump and
help confirm the presence of prolapse.
Bartholin’s cyst
Bartholin’s glands are responsible for producing secretions which maintain vaginal
moisture and are typically located at 4 and 8 o’clock in relation to the vaginal
introitus. These glands can become blocked and/or infected, resulting in cyst
formation. Typical findings on clinical examination include a unilateral, fluctuant
mass, which may or may not be tender.

6. Lichen sclerosus
Lichen sclerosus is a chronic inflammatory dermatological condition that can affect
the anogenital region in women. It presents with pruritis and clinical examination
typically reveals white thickened patches. Destructive scarring and adhesions develop
causing distortion of the normal vaginal architecture (shrinking of the labia,

7. narrowing of the introitus, obscuration of the clitoris).
Abnormal vaginal discharge
There are several causes of abnormal vaginal discharge including:
Bacterial vaginosis: typical findings include a thin, profuse fishy-smelling
discharge without pruritis or inflammation.
Candidiasis: typical findings include a curd-like, non-offensive discharge with
associated pruritis and inflammation.
Chlamydia and gonorrhoea (symptomatic): typical findings include purulent
vaginal discharge
Trichomoniasis: typical findings include offensive yellow, frothy vaginal
discharge with associated pruritis and inflammation.
Vaginal examination
Warn the patient you are going to examine the vagina and ask if they’re still ok for
you to do so.
If the patient consents to the continuation of the examination:

8. 1. Lubricate the gloved index and middle fingers of your dominant hand.
2. Carefully separate the labia using the thumb and index finger of your non-
dominant hand.
3. Gently insert the gloved index and middle finger of your dominant hand into the
vagina.
4. Enter the vagina with your palm facing laterally and then rotate 90 degrees so
that your palm is facing upwards.
5.Palpate the walls of the vagina for any irregularities or masses.
6.Examine the cervix to assess:
Position (e.g. anterior or posterior)

9. Consistency (e.g. irregular, smooth)
Cervical motion tenderness: involves severe pain on palpation of the cervix and
may suggest pelvic inflammatory disease or ectopic pregnancy.
Fornices
The fornices are the superior portions of the vagina, extending into the recesses
created by the vaginal portion of the cervix.
Gently palpate lateral fornices for any masses.
7.Bimanually palpate the uterus:
Place your non-dominant hand 4cm above the pubis symphysis.
Place two of your dominant hand’s fingers into the posterior fornix.
Push upwards with the internal fingers whilst simultaneously palpating the
lower abdomen with your non-dominant hand. You should be able to feel the
uterus between your hands. You should then assess the various characteristics

10. of the uterus:
Size : the uterus should be approximately orange-sized in an average female.
Shape: may be distorted by masses such as large fibroids.
Position: the uterus may be anteverted or retroverted.
Surface characteristics: note if the uterus feels smooth or nodular.
Tenderness: may suggest inflammation (e.g. pelvic inflammatory disease,
ectopic pregnancy).
The position of the uterus can be described as:
Anteverted: the uterus is orientated forwards towards the bladder. This is the
most common position of the uterus.
Retroverted: the uterus is orientated posteriorly, towards the spine. This is a
less common uterine position present in approximately 1 in 5 women.
Bimanually palpate the adnexa:
The term adnexa refers to the area that includes the ovaries and fallopian tubes
1. Position your internal fingers in the left lateral fornix.

11. 2. Position your external hand onto the left iliac fossa.
3. Perform deep palpation of the left iliac fossa whilst moving your internal fingers
upwards and laterally (towards the left).
4. Feel for any palpable masses, noting their size and shape (e.g. ovarian cyst, ovarian
tumour, fibroid).
5. Repeat adnexal assessment on the right.
6. Withdraw your fingers and inspect the glove for blood or abnormal discharge.
7. Cover the patient with the sheet, explain that the examination is now complete
and provide the patient with privacy so they can get dressed. Provide paper towels
for the patient to clean themselves.
8. Dispose of the used equipment into a clinical waste bin.

12. To complete the examination…
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your findings.
Document the examination in the medical notes including the details of the
chaperone.
Example summary
“Today I examined Mrs mukoso , a 28-year-old female. On general inspection, the
patient appeared comfortable at rest. There were no objects or medical equipment
around the bed of relevance.“
“Abdominal examination was unremarkable and there were no abnormalities noted
on inspection of the vulva. Bimanual examination revealed an anteverted uterus of

13. normal size and shape. There were no masses palpated in the vaginal canal or
adnexa.”
“In summary, these findings are consistent with a normal vaginal examination.”
“For completeness, I would like to perform the following further assessments and
investigations.”
Further assessments and investigations
Urinalysis: including β-HCG to rule out pregnancy (including ectopic pregnancy).
Speculum examination: to visualise the vaginal canal and cervix.
Vaginal swabs/endocervical swabs: if there are concerns about infection (bacterial
and viral).
Ultrasound abdomen and pelvis: to better visualise any masses palpated and to
assess endometrial thickness.
Complete abdominal examination: if there are concerns about intraabdominal
pathology (e.g. appendicitis).

14. ANATOMY OF FEMALE REPRODUCTIVE PART

15. What is a vaginal examination?
A vaginal examination is an internal physical examination done by a doctor or midwife.
In most cases during pregnancy
A bimanual vaginal examination may need to be performed in a number of different

16. clinical scenarios including unexplained pelvic pain, irregular vaginal bleeding,
abnormal vaginal discharge and as part of the assessment of a pelvic mass.
.
Gather the appropriate equipment:
Gloves
Lubricant
Paper towels
Introduction
1.Wash your hands and don PPE if appropriate.
2.Introduce yourself to the patient including your name and role.
3.Confirm the patient’s name and date of birth.
4.Explain what the examination will involve using patient-friendly language: “Today I
need to carry out a vaginal examination. This will involve me using one hand to feel
your tummy and the other hand to place two fingers into your vagina. This will allow

17. me to assess the vagina, womb and ovaries. It shouldn’t be painful, but it will feel a
little uncomfortable. You can ask me to stop at any point.”
5.Explain the need for a chaperone: “One of the female ward staff members will be
present throughout the examination, acting as a chaperone, would that be ok?”
6.Gain consent to proceed with the examination: “Do you understand everything I’ve
said? Do you have any questions? Are you happy for me to carry out the
examination?”
7.Ask the patient if they have any pain or if they think they may be pregnant before
proceeding with the clinical examination.
8.Provide the patient with the opportunity to pass urine before the examination.
10.Explain to the patient that they’ll need to remove their underwear and lie on the
clinical examination couch, covering themselves with the sheet provided. Provide the
patient with privacy to undress and check it is ok to re-enter the room before doing
so.

18. Vaginal examination
1.Position the patient supine in the modified lithotomy position: “Bring your heels
towards your bottom and then let your knees fall to the sides.”.
2.Adequately expose the patient
3.Don a pair of non-sterile gloves.
4. Inspect the vulva for abnormalities:
Ulcers: typically associated with genital herpes.
Abnormal vaginal discharge: causes include candidiasis, bacterial vaginosis,
chlamydia and gonorrhoea.
Scarring: may relate to previous surgery (e.g. episiotomy) or (destructive
scarring with associated adhesions).
Vaginal atrophy: most commonly occurs in postmenopausal women.
White lesions: may be patchy or in a figure of eight distribution around the
vulva and anus, associated with lichen sclerosus.
Masses: causes include Bartholin’s cyst and vulval malignancy.
Varicosities: varicose veins secondary to chronic venous disease or obstruction

19. in the pelvis (e.g. pelvic malignancy).
Female genital mutilation: total or partial removal of the clitoris and/or labia
and/or narrowing of the vaginal introitus.
5. Inspect for evidence of vaginal prolapse (a bulge visible protruding from the
vagina). Asking the patient to cough as you inspect can exacerbate the lump and
help confirm the presence of prolapse.
Bartholin’s cyst
Bartholin’s glands are responsible for producing secretions which maintain vaginal
moisture and are typically located at 4 and 8 o’clock in relation to the vaginal
introitus. These glands can become blocked and/or infected, resulting in cyst
formation. Typical findings on clinical examination include a unilateral, fluctuant
mass, which may or may not be tender.

20. Lichen sclerosus
Lichen sclerosus is a chronic inflammatory dermatological condition that can affect
the anogenital region in women. It presents with pruritis and clinical examination
typically reveals white thickened patches. Destructive scarring and adhesions develop
causing distortion of the normal vaginal architecture (shrinking of the labia,
narrowing of the introitus, obscuration of the clitoris).

21. Abnormal vaginal discharge
There are several causes of abnormal vaginal discharge including:
Bacterial vaginosis: typical findings include a thin, profuse fishy-smelling
discharge without pruritis or inflammation.
Candidiasis: typical findings include a curd-like, non-offensive discharge with
associated pruritis and inflammation.
Chlamydia and gonorrhoea (symptomatic): typical findings include purulent
vaginal discharge
Trichomoniasis: typical findings include offensive yellow, frothy vaginal
discharge with associated pruritis and inflammation.
Vaginal examination
Warn the patient you are going to examine the vagina and ask if they’re still ok for
you to do so.
If the patient consents to the continuation of the examination:

22. 1. Lubricate the gloved index and middle fingers of your dominant hand.
2. Carefully separate the labia using the thumb and index finger of your non-
dominant hand.
3. Gently insert the gloved index and middle finger of your dominant hand into the
vagina.
4. Enter the vagina with your palm facing laterally and then rotate 90 degrees so
that your palm is facing upwards.
5.Palpate the walls of the vagina for any irregularities or masses.
6.Examine the cervix to assess:
Position (e.g. anterior or posterior)
Consistency (e.g. irregular, smooth)

23. Cervical motion tenderness: involves severe pain on palpation of the cervix and
may suggest pelvic inflammatory disease or ectopic pregnancy.
Fornices
The fornices are the superior portions of the vagina, extending into the recesses
created by the vaginal portion of the cervix.
Gently palpate lateral fornices for any masses.
7.Bimanually palpate the uterus:
Place your non-dominant hand 4cm above the pubis symphysis.
Place two of your dominant hand’s fingers into the posterior fornix.
Push upwards with the internal fingers whilst simultaneously palpating the
lower abdomen with your non-dominant hand. You should be able to feel the
uterus between your hands. You should then assess the various characteristics
of the uterus:

24. Size : the uterus should be approximately orange-sized in an average female.
Shape: may be distorted by masses such as large fibroids.
Position: the uterus may be anteverted or retroverted.
Surface characteristics: note if the uterus feels smooth or nodular.
Tenderness: may suggest inflammation (e.g. pelvic inflammatory disease,
ectopic pregnancy).
The position of the uterus can be described as:
Anteverted: the uterus is orientated forwards towards the bladder. This is the
most common position of the uterus.
Retroverted: the uterus is orientated posteriorly, towards the spine. This is a
less common uterine position present in approximately 1 in 5 women.
Bimanually palpate the adnexa:
The term adnexa refers to the area that includes the ovaries and fallopian tubes
1. Position your internal fingers in the left lateral fornix.

25. 2. Position your external hand onto the left iliac fossa.
3. Perform deep palpation of the left iliac fossa whilst moving your internal fingers
upwards and laterally (towards the left).
4. Feel for any palpable masses, noting their size and shape (e.g. ovarian cyst, ovarian
tumour, fibroid).
5. Repeat adnexal assessment on the right.
6. Withdraw your fingers and inspect the glove for blood or abnormal discharge.
7. Cover the patient with the sheet, explain that the examination is now complete
and provide the patient with privacy so they can get dressed. Provide paper towels
for the patient to clean themselves.
8. Dispose of the used equipment into a clinical waste bin.

26. To complete the examination…
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your findings.
Document the examination in the medical notes including the details of the
chaperone.
Example summary
“Today I examined Mrs mukoso , a 28-year-old female. On general inspection, the
patient appeared comfortable at rest. There were no objects or medical equipment
around the bed of relevance.“
“Abdominal examination was unremarkable and there were no abnormalities noted
on inspection of the vulva. Bimanual examination revealed an anteverted uterus of
normal size and shape. There were no masses palpated in the vaginal canal or

27. adnexa.”
“In summary, these findings are consistent with a normal vaginal examination.”
“For completeness, I would like to perform the following further assessments and
investigations.”
Further assessments and investigations
Urinalysis: including β-HCG to rule out pregnancy (including ectopic pregnancy).
Speculum examination: to visualise the vaginal canal and cervix.
Vaginal swabs/endocervical swabs: if there are concerns about infection (bacterial
and viral).
Ultrasound abdomen and pelvis: to better visualise any masses palpated and to
assess endometrial thickness.
Complete abdominal examination: if there are concerns about intraabdominal
pathology (e.g. appendicitis).