Introduction

The bimanual exam¹ is a key part of any gynecological exam, yielding information about the vaginal opening, the cervix, the uterus, and the adnexa. Every clinician who takes care of women of any age must be able to perform a bimanual exam accurately to ascertain normalcy and assess for pathology. The bimanual exam is often the determining factor in deciding whether further testing should take place.

In a busy office setting where an established patient is coming in to be evaluated quickly for “vaginitis,” it is sometimes acceptable to limit evaluation to the vulva and vagina, deferring the bimanual exam. However, if the patient has an appointment for a chronic or recurrent problem, for an issue that has not been previously well diagnosed, or for a problem that might relate to upper genital tract disease, a bimanual exam must be performed. In our vulvovaginal specialty practice, we perform the bimanual exam at the patient’s initial visit, if she is able to tolerate it, and subsequently only if necessary to further elucidate her situation.

How to perform a bimanual exam

Preparation for the examination

The bimanual examination is the last step of the vulvovaginal evaluation. Prior to performing it, a clinician will:

Arrange for gloves, Q-tips and larger swabs for menstrual flow or excess secretions, pH strips, lubricant, range of speculae from pediatric to large, culture media, saline and slide or container for wet mount. We do not usually perform a Pap smear/HPV screen at the initial vulvovaginal consultation because the vaginal speculum is often not tolerated initially, and undiagnosed inflammation or marked atrophy may result in atypia. It is important to be clear whether the referring clinician or the vulvovaginal clinician is responsible for following HPV and Pap testing.

Obtain the woman’s permission to do the exam. (Annotation D: Patient tolerance for genital exam), and requested that she undress from the waist down, providing a gown or drape, although some women do not wish to use one.

If indicated, complete the abdominal exam with the woman in the recumbent position.

Request that she bring her hips to the edge of the examining table, (the words “scoot down” are childish and demeaning to many women) providing guidance to her as she may be concerned that she will fall off the table.

Position the patient in stirrups, with back of the table comfortably adjusted.

Explain to the the patient about looking at and touching the vulva.

Learn if there is allergy or irritation from office lubricant to obtain an alternative if necessary.

Uncover the vulva and lower abdomen by moving the center of the drape up over the mons, flattening the drape on the abdomen

Evaluations before the bimanual exam

Complete these crucial steps prior to the bimanual examination

• Careful scrutiny of the vulvar architecture, skin color, and texture. (Annotation E: Detailed, systematic vulvar examination) Be sure to gently separate folds and separate tissues for adequate inspection.
• Location of any reported symptoms. (Annotation I: Pain and and symptom mapping and the Q-tip test). Insert the plain Q-tip for pH before use of water, saline, or lubricant that may alter pH. It is possible that there is enough pain with symptom and pain mapping that the examination must be terminated for the present.
• If the initial evaluation has been tolerated, the next step includes application of a small amount of lubricant to the index and middle fingers of your dominant hand to perform
• Single lubricated digit evaluation of the pelvic floor (Annotation L :Exam of the hymenal ring and the Pelvic floor). Once again, the examination may need termination at this point. If the evaluation has been tolerated, the next step includes:
• Speculum examination and examination of the cervix (Annotation M: Speculum examination and examination of the cervix)
• Evaluation of the vaginal architecture (Annotation N: The vaginal architecture)
• Evaluation of the vaginal epithelium  (Annotation O: The vaginal epithelium)
• Inspection of amount and characteristics of cervical and vaginal secretions with samples for microscopy and cultures (Annotation P: Vaginal secretions) and removal of the speculum.
• Digital evaluation of the hymenal ring: The hymenal ring should be visually inspected, gently moving tags and flaps of tissue with around with a Q-tip prior to insertion of the speculum exam, evaluation of the pelvic floor, or bimanual exam. Provoked or spontaneous vulvodynia may manifest as pain in the vestibule near the hymenal ring or underneath a hymenal tag necessitating cautious assessment in this area. See more about the hymen in Annotation L: Exam of the hymenal ring and the pelvic floor.

The actual bimanual exam

• To begin the bimanual exam, spread the labia and insert your lubricated index and middle fingers into the vagina, down and back, trying to avoid contact with the anterior structures of urethra and bladder.
• Place your other hand on the patient’s lower abdomen. Examine the cervix: palpate the cervix with your index finger noting size, shape, and consistency.
• Gently move the cervix side to side between your fingers and note mobility and tenderness.
• Tilt the cervix gently up and forward and note mobility and tenderness. Cervical motion tenderness is an important sign of pelvic disease.
• Examine the body of the uterus by continuing to lift the cervix with the vaginal hand. Press downward with the abdominal hand and palpate the uterus between the upper and lower hands (if possible). Estimate uterine size and note consistency and tenderness.
• Examine the adnexal structures: Pull back vaginal hand to clear cervix. Reposition vaginal hand into the right fornix, palm up. Sweep the right ovary downward with the abdominal hand 3 or 4 cm medial to the iliac crest to encircle the ovary gently between the fingers of both hands (if possible). Note its size and shape along with any other palpable adnexal structures. Pull back and repeat on the left side.
• Cover the vulva with the drape and assist the patient to remove her feet from the stirrups and sit up. Commend the patient on a job well done and tell her if the exam is normal or if you have any concerns. Leave the room and allow the patient to dress before continuing with the consultation.

The bimanual examination is normal if

• Vagina is without masses or tenderness.
• Cervix is smooth, without lesions. Motion of the cervix causes no pain.
• Uterus is normal size, shape, and contour. It is non-tender.
• The adnexa (tubes and ovaries) are neither tender nor enlarged.