The Challenging Pelvic Examination

Abstract

While there is a large body of evidence on the effectiveness of Pap smears for cervical cancer screening and on screening for cervical gonorrhea and Chlamydia, there is sparse evidence to support other portions of the pelvic examination and little guidance on examination logistics. Maximizing comfort should be the goal; lubrication use and careful speculum selection and insertion can ease this intrusive procedure. This is particularly important in adolescent and menopausal women, sexual minorities, obese women, women with disabilities, and women with a history of trauma or prior instrumentation affecting the genitalia. We review the evidence and provide guidance to minimize physical and psychological discomfort with pelvic examination. P elvic examinations are performed to evaluate pain, bleeding, and vaginal discharge and to screen for cervical cancer and sexually transmitted infections. Little attention has focused on the mechanics of pelvic examination technique, yet the examination is an intrusive experience for many women who feel exposed and lack control. 1 Emotional distress and fear of pain are cited as reasons for reduced adherence to cervical screening especially among adolescents, 2 racial/ethnic 3-5 and sexual minority groups, 6 obese women, 7 victims of sexual assault and other trauma, 8 and women with disabilities. 9 Therefore, examination should be limited to components with proven utility and should be performed with cultural sensitivity and procedural excellence, especially in clinical situations that require particular finesse. Accordingly, we review the clinical evidence as it exists, and in areas that lack evidence offer our own experience to optimize technical aspects of speculum choice and insertion, and suggest strategies to manage challenging circumstances. When recommendations are not referenced, we are relating our experience in the absence of evidence. Bimanual examination is not useful as a screening test for ovarian cancer because of limited sensitivity and specificity. In one study, ovaries were palpable in 55% of women under 200 lbs during examination under anesthesia, but in only 9% of women over 200 lbs. 14 In another study under similar circumstances, uterine size and contour were correctly assessed in over 50% of patients; however, sensitivity of examination for adnexal masses of 5 cm or greater was only 28% among attending gynecologists and 16% among gynecology residents. 15 The USPFTF acknowledges poor performance characteristics of the bimanual examination in its recommendation about screening for ovarian cancer. 11 In the non-screening setting, bimanual examination is inadequate to evaluate acute abdominal pain or vaginal bleeding, 16 since ultrasound is so much more sensitive and specific. COMPONENTS OF THE FEMALE PELVIC EXAMINATIONThe most evidence-based approach would therefore suggest Pap smear collection alone and the speculum examination required to achieve that goal. We suggest that bimanual and sometimes rectovaginal examinations may be important in evaluating pelvi...

Female-to-Male Patients Have High Prevalence of Unsatisfactory Paps Compared to Non-Transgender Females: Implications for Cervical Cancer Screening

“…17,18 Higher BMI was negatively associated with inadequacy, which is surprising, as performing a Pap on obese patients is often more difficult due to prolapse of the vaginal wall between the speculum bills which can impede visualization of the cervix. 19 Testosterone therapy, used by the majority of transgender patients in this study, alters body composition and waist and hip circumference, though impact on BMI is not clear. 20,21 The relationship between BMI and fat composition is known to vary between males and females, 22 and it may be that BMI, a measure developed without transgender bodies in mind, may not be directly comparable between transgender and non-transgender patients.…”

“…Provider training should focus on acquiring the technical skill to perform adequate cervical sampling in a variety of challenging circumstances, and on facilitating comfort during the pelvic examination for diverse populations of patients, including transgender men. 19 For FTM patients who desire hysterectomy, total hysterectomy is preferable to supracervical hysterectomy, as this procedure obviates the need for Pap tests.…”

Cervical Cancer Screening for Patients on the Female-to-Male Spectrum: a Narrative Review and Guide for Clinicians

“…While use of sedative-hypnotics can be helpful, this practice requires careful consideration when patients have a trauma history, as these agents increase the likelihood of dissociation, may reduce a patient's sense of control, and can interfere with the memory of what actually transpires during an exam, thereby potentially re-traumatizing the patient. 1,44 Therefore, although antianxiety medication may be an important tool for some patients in overcoming barriers to being examined, informed consent should be obtained before using Since minor bleeding is common after cytology sampling, but can be an unpleasant reminder of menstruation or prior trauma for some patients, mention and normalize this possibility using non-gendered language (Table 3). In addition, because FTM patients are more likely to have unsatisfactory Pap results, 27 yet more likely to delay returning for repeated testing, 26 providers should prepare patients for the possible need to repeat a Pap and follow official guidelines that recommend retesting within 2-4 months of an initial inadequate test.…”

Patient preferences for chaperone use during transvaginal sonography

“…Due to existing literature that patients generally prefer chaperones for pelvic physical examinations when their practitioner is a male, and due to medico-legal concerns Correspondence to: Matthew S. Davenport; email: matdaven@med. umich.edu that may arise in the setting of an unobserved intimate examination [12], it has been recommended in the literature [13] and by the American College of Obstetricians and Gynecologists [14] that for gynecological examinations, chaperones be standard for male practitioners and at the discretion of the patient for female practitioners. If this recommendation were to be followed for pelvic ultrasound studies, chaperones would be required to be available at all hours of clinical operation in the event that one was needed.…”