Vaginal Examination (PV) – OSCE Guide

geekymedics.com/bimanual-vaginal-examination/

Dr Lewis Potter October 8, 2010

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. Bimanual vaginal
examination frequently appears in OSCEs and you’ll be required to demonstrate excellent
communication and practical skills. This guide demonstrates how to perform a bimanual
vaginal examination in an OSCE setting.

Download the vaginal examination PDF OSCE checklist, or use our interactive OSCE
checklist. You may also be interested in our focused speculum examination OSCE guide.

Gather equipment
Gather the appropriate equipment:

Gloves
Lubricant
Paper towels

Gather equipment

Introduction
Wash your hands and don PPE if appropriate.

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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: “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.”

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?”

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?”

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.

You might also be interested in our OSCE Flashcard Collection which contains over
2000 flashcards that cover clinical examination, procedures, communication skills
and data interpretation.

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.

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.”

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 Position the patient supine

Adequately expose the patient

Inspect the vulva

1. 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.

Inspect the vulva

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Inspect the vulva

Ask the patient to cough and inspect for vaginal prolapse

Bartholin's cyst 1

Lichen sclerosus 2

Vaginal candidiasis 3

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 Uterine prolapse 4

Female genital mutilation

Female genital mutilation (FGM) is defined by the WHO as all procedures that involve
partial or total removal of the external female genitalia, or other injury to the female
genital organs for non-medical reasons.5Over 140 million girls and women worldwide
have undergone FGM.6 Women attending maternity, family planning, gynaecology, and
urology clinics (among others) should be asked routinely about the practice of FGM.7
Cases of FGM in girls under the age of 18 should be reported to the police.8

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.

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).

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

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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.

Lubricate gloved fingers

Separate the labia

Gently insert lubricated fingers into the vagina

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 Rotate your hand 90° so your palm faces upwards

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.

Assess the vagina and cervix

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:

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 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).

Bimanually palpate the uterus

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.

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.

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 Palpate the right adnexa

Palpate the left adnexa

Withdraw fingers and inspect for discharge or blood

Re-cover the patient

Wash hands

To complete the examination…

Thank the patient for their time.

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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 Smith, 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 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).

Reviewer

Mr Isaac Magani

Consultant Obstetrician

References
1. Medimage. Adapted by Geeky Medics. Bartholin’s cyst. Licence: CC BY-SA.
2. Mikael Häggström. Adapted by Geeky Medics. Lichen sclerosus. Licence: CC0.
3. Mikael Häggström. Adapted by Geeky Medics. Vaginal candidiasis. Licence: CC0.
4. Mikael Häggström. Adapted by Geeky Medics. Uterine prolapse. Licence: CC0.
5. WHO. Female Genital Mutilation. Key facts. Available from: [LINK].
6. Farage MA, Miller KW, Tzeghai GE, et al; Female genital cutting: confronting
cultural challenges and health complications across the lifespan. Womens Health
(Lond Engl). 2015 Jan11(1):79-94. doi: 10.2217/whe.14.63. Available from: [LINK].

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7. Erskine K; Collecting data on female genital mutilation. BMJ. 2014 May
13348:g3222. doi: 10.1136/bmj.g3222. Available from: [LINK].
8. FGM mandatory reporting duty; Dept of Health and NHS England, 2015. Available
from: [LINK].

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