Bimanual Examination

Original Author: Oliver Jones
Last Updated: 15th February 2017
Revisions: 5

The bimanual examination (also known as a pelvic examination) is an examination of the female genital organs.

In this article, we shall look at how to perform a bimanual examination in an OSCE-style setting.

Introduction

  • Introduce yourself to the patient
  • Wash your hands
  • Explain to the patient what the examination involves and why it is necessary
    • Reassure that it should not be painful but you will stop immediately if it becomes too uncomfortable
  • Obtain verbal consent
  • Request a chaperone

Preparation

  • Patient should have an empty bladder
  • Ask the patient to remove clothing from the waist down and any sanitary protection
    • Cover with a sheet when appropriate
  • When ready, ask the patient to lie on the couch on their back, with knees bent and apart.
    • Note that any abdominal inspection and palpation should be performed before this step.

Abdominal Examination

  • Inspect the abdomen for scars and ascites
  • Palpate the abdomen for masses and tenderness
  • Palpate the groin for inguinal lymphadenopathy

External Examination

  • Put on gloves
  • Inspect the external genitalia and perineum for:
    • Deficiency associated with childbirth
    • Abnormal secondary sexual characteristics – hair distribution, cliteromegaly (associated with hyperandrogenism)
    • Skin abnormalities – lesions, warts, erythema
    • Discharge – colour, consistency
    • Bleeding
    • Swellings of the vulva – tumours, cysts (sebaceous, Bartholin’s)
  • Ask the patient to cough to observe any incontinence or prolapse
  • Palpate the labia majora with the index finger and thumb

Fig 1 – Signs on external inspection during the bimanual examination. A) Uterine prolapse, b) Genital warts, c) Bartholin’s cyst.

Bimanual Examination

  • Use lubricating gel to lubricate the right index finger and middle finger
  • Ensure the patient is still happy to proceed, and gently insert fingers into the vagina
    • Enter with the palm facing sideways, then rotate so the palm is facing upwards
    • In practice, you can use one finger for the whole examination. However, for OSCE/examination purposes, two fingers should be used (unless the presenting complaint is that partner cannot enter / pain during sex).
  • Move along the posterior wall of the vagina and locate the cervix and feel for:
    • Smoothness, clots, mobility and firmness
  • Place fingers in the posterior fornix to lift the uterus whilst simultaneously pushing the fundus down by placing the left hand above the symphysis pubis.
    • Assess uterus size (a normal uterus is approximately the size of a plum)
    • Determine if anteverted or retroverted
    • Note tenderness, mobility and shape
  • Place the fingers in the lateral fornix and press lateral to the umbilicus to feel for any adnexal tenderness or masses (repeat on the other side)
  • Gently move the cervix from side to side to check for cervical tenderness (important sign with ectopic pregnancy or pelvic inflammatory disease).
  • Remove fingers gently and inspect for discharge or blood

Fig 2 – The bimanual examination. One hand lifts the uterus, whilst the other pushes the fundus down.

Completing the Examination

  • Thank the patient and allow them to get dressed in private
  • Remove your gloves and wash your hands
  • Summarise findings and suggest further investigations (usually a pelvic ultrasound +/- bloods depending on the history and findings)

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