Pelvic examination

A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma the external exam, to evaluate the vulva 2) the internal exam with palpation to examine the uterus, ovaries, and structures adjacent to the uterus the internal exam using a speculum to visualize the vaginal walls and cervix. During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer.
Some clinicians perform a pelvic exam as part of routine preventive care. However, in 2014, the American College of Physicians published guidelines against routine pelvic examination in adult women who are not pregnant and lack symptoms, with the exception of pelvic exams done as part of cervical cancer screening.

Medical guidelines

Traditionally in the field of gynecology, the benefits of routine pelvic examinations were assumed, and the exam was a recommended part of the initial gynecology visit, annual visits, and as needed for treatment. In 2014, the American College of Physicians published a review of the benefits and the risks of the exam and issued a guideline that recommended against performing this examination to screen for conditions in asymptomatic, nonpregnant, adult women, concluding that the potential harms outweighed the demonstrated benefits and that screening pelvic exams in asymptomatic women did not reduce mortality or morbidity rates. The guideline did not consider the necessity or frequency of Pap smears. The ACP guideline concluded that there was no evidence that the exam in asymptomatic adult women reduced morbidity or mortality, and that there were no studies that addressed the exam's diagnostic accuracy for identifying specific gynecologic conditions. The guideline concluded that there was evidence of harm, including fear, embarrassment, pain, discomfort and unnecessary surgery. This was a strong recommendation, based on moderate-quality evidence. In 2018, the American College of Obstetricians and Gynecologists symptoms of gynecologic disease, 2) screening for cervical dysplasia, or 3) management of gynecologic disorders or malignancy, using shared decision-making with the patient. ACOG acknowledged that given changes in screening recommendations and an assessment of harms vs benefits as reviewed by the US Preventive Services Task Force, re-evaluation of routine screening pelvic examination for asymptomatic, non-pregnant women with average risk for gynecologic disease was indicated. A 2020 update of the literature by the US Preventive Services Task Force concluded that the evidence remained insufficient to assess the balance of benefits and harms of screening pelvic examinations in asymptomatic women.
Annual "well-woman visits" are an occasion for gynecologists to identify health risks for women; ACOG has noted that these visits may also include clinical breast examinations, immunizations, contraceptive care discussions, and preventive health care counseling. ACOG reinforced the potential value of pelvic examinations in allowing clinicians to explain a patient's anatomy, reassure her of normalcy, and answer specific questions, thus establishing open communication between patient and clinician.

Preparation, communication, and trauma-informed care

The examination can be emotionally and physically uncomfortable for women. Preparation, good communication, thoughtful technique, and trauma-informed care can help mitigate this discomfort.
Prior to the exam, before the patient is undressed and lying on the examination table or chair, examiners should ask the patient if she has had a pelvic exam in the past and whether she has any questions or concerns about the exam. Women may be concerned about pain, or they may be embarrassed about the examination of sensitive areas of the body. They may have experienced sexual assault or negative experiences with pelvic examination in the past, which may lead to the exam triggering strong emotional and physical symptoms. Additionally, patients may have concern about odor or menstruation during exam, neither of which should impact the examiner's ability to perform a thorough, respectful exam. Patients generally prefer to be asked about past experiences and are often helpful in suggesting ways to mitigate the discomfort of the exam. Prior to the exam, the examiner should offer to show the patient models or diagrams of the pelvic anatomy and any instruments that will be used during the exam.
Careful preparation is helpful for an efficient and comfortable exam. Prior to asking the patient to position herself on the exam table or chair for examination, the examiner should collect all the instruments needed for the exam and any planned procedures, including the speculum, light source, lubricant, gloves, drapes, and specimen collection media. Warming the speculum with warm tap water or keeping the speculum in a warmer will also increase comfort. The patient should be given the opportunity to have a chaperone or support person in the room during the exam. In general, male examiners should always be accompanied by a female chaperone.
The examiner should explain each step of the exam and its purpose, should address and normalize any concerns, should assert that the patient has full control over the exam, and should ask permission before each step of the exam. The examiner should keep as much of the patient's body covered as possible during the exam. Relaxation of the pelvic muscles can reduce discomfort during the exam. Rather than telling the patient to "relax", which can trigger strong emotions for women who are survivors of assault, patients can be told to breathe slowly and deeply into their abdomens, or which is a more instructive way of describing how to relax the pelvic muscles.
The patient should be informed that she can stop the procedure at any time. If the patient does not want to continue the exam, the examiner should stop, speak with the patient about her concerns and how to mitigate them, and only continue when the patient is ready to do so. In 2024, the US Department of Health and Human Services banned pelvic exams without written informed consent, when such exams are done by medical students, nurse practitioners, or physician assistants for “educational and training purposes”.

External examination

The pelvic exam begins with a discussion as described above, and an explanation of the procedure. The patient is asked to put on an examination gown, get on the examination table, and lie on her back with her feet in footrests. Sliding down toward the end of the table is the best position for the clinician to do a visual examination. A pelvic exam begins with an assessment of the reproductive organs that can be seen without the use of a speculum. Many women may want to 'prepare' for the procedure. One possible reason for delaying an exam is if it is to be done during menstruation, but this is a preference of some patients and not a requirement of the clinician. The clinician may want to perform pelvic examination and assessment of the vagina because there are unexplained symptoms of vaginal discharge, pelvic pain, unexpected bleeding, or urinary problems.
The typical external examination begins with making sure that the patient is in a comfortable position and her privacy respected.

In some instances, different positioning and assistance may be required to keep tissue from blocking the view of the perineal area.
The pubic hair is inspected for pubic lice and hair growth patterns. Sparse hair patterns can exist in older and in some Asian patients.
The labia majora are evaluated. Their position and symmetry are assessed. The expected finding in older patients is that the labia majora can be thinner and smaller. The examiner is looking for ulcers, inflammation, warts and rashes. If drainage is present from these structures, its color, location and other characteristics are noted. Infection control is accomplished by frequent glove changes.
The labia minora are then evaluated. They should appear moist, smooth in texture and pink. The presence of tearing, inflammation and swelling is noted. Thinner and smaller labia minora are an expected finding in older patients.
The clitoris is assessed for size, position, symmetry, and inflammation.
The urethral opening is inspected. No urine should leak when the patient is asked to cough. Urine leakage may indicate stress incontinence and the weakening of pelvic structures. The opening should be midline, pink, and smooth. The presence of inflammation or discharge may indicate an infection. Excoriation can be present in obese patients due to urinary incontinence.
The vaginal opening is inspected for position, presence of the hymen, and shape. The examiner should look for the presence of bruising, tearing, inflammation and discharge. Pelvic examinations are usually procedures that are designed to obtain objective, measurable descriptions of what is observed. If sexual abuse is suspected, questions regarding this are discussed after the examination and not during it. When the patient is requested to 'bear down', the presence of prolapsed structures such as the bladder, rectum or uterus are documented. Prolapsed structures can appear when abdominal pressure increases or they can protrude without bearing down.
The perineum, the space between the vagina and the anus, is inspected. It should be smooth, firm, and free of disease. Scars from episiotomies are visible on women who have had the procedure during childbirth.
The anus is assessed for lesions, inflammation or trauma. It should appear dark, continuous and moist. In some patients, excoriation may be present, and can be a sign of fecal incontinence.