A bimanual vaginal examination involves inspecting and palpating the external genitalia, vagina, uterus, and adnexa. The provider explains the procedure to the patient, ensures consent, and positions the patient with their knees fallen to the sides. Using lubricant, the provider inserts two fingers to palpate the vaginal walls, cervix, fornices, and performs a bimanual exam to assess the size, shape, position, and tenderness of the uterus. Both adnexa are also palpated for masses before completing the exam.

1. Bimanual examination-PV
Lecture N7

4. • 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.

6. • Gather equipment
• Gather the
appropriate equipment:
• Gloves
• Lubricant
• Paper towels

7. Introduction:
• Wash your hands and don PPE if appropriate.
• Introduce yourself to the patient including your name and role.
• Confirm the patient’s name and date of birth.
• Explain what the examination will involve using patient-friendly language.
• Ask the patient if they have any pain or if they think they may
be pregnant before proceeding with the clinical examination.
• Provide the patient with the opportunity to pass urine before the examination.
• 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.

8. Abdominal examination
• An abdominal examination should always be performed
before moving onto vaginal examination. This may be less
thorough than a full abdominal examination, but should at least
include inspection and palpation of the abdomen.

9. Vulval inspection
Position
• 1. Don a pair of non-sterile gloves.
• 2. Position the patient in the modified lithotomy
position: “Bring your heels towards your bottom and then let
your knees fall to the sides.”

12. Inspect the vulva
• . 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 lichen sclerosus (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 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.
• 2. 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.

18. 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:
• 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.

19. Equipment
• Non sterile gloves

20. Equipment
Water-soluble lubricant

21. Equipment
• Two drape

22. Equipment
• Kidney shape dish

23. Equipment
• Forceps

24. Equipment
• 3 cotton ball

25. Equipment
• Antiseptic solution

30. • Vaginal walls
• Palpate the walls of the vagina for any irregularities or masses.
• Cervix
• Examine the cervix to assess:
• Position (e.g. anterior or posterior)
• 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.

32. Uterus
• Bimanually palpate the uterus:
• 1. Place your non-dominant hand 4cm above the pubis symphysis.
• 2. Place two of your dominant hand’s fingers into the posterior fornix.
• 3. 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:
• 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).

34. • Uterine position
• 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.

35. Ovaries and uterine tubes
• The term adnexa refers to the area that includes the ovaries and fallopian tubes.
• Bimanually palpate the adnexa:
• 1. Position your internal fingers in the left lateral fornix.
• 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.

41. • Thank you for attention….