3-37
Symptom: GYN Problems: Female Pelvic Examination
MAJ Ann Friedmann, MC, USAWhen: As indicated per differential diagnosis, which primarily is for abdominal and pelvic complaints.
Most females in the U.S. have one pelvic examination per year from the age of 18 to assess for gynecologic
malignancies or benign conditions such as uterine fibroids. The Pap smear, normally a part of this exam,
provides cellular material to screen for cervical carcinoma. However, the Pap smear is not normally done in
the field and will not be discussed here. Rectal evaluation may or may not be a part of each examination.
Rectovaginal or rectal exam can aid in assessing the posterior aspect of the uterus, the uterosacral ligaments
and posterior cul-de-sac. A stool sample can be obtained and tested for occult blood and lower rectal
masses can be palpated. Stool occult blood sampling is recommended with pelvic examination after the
age of 40-50.
For the field medic who will only be performing problem-based pelvic examinations, the exam may be
tailored to the specific problem and need not always include bimanual, rectovaginal and rectal exam. For
example, if the patient complains only of abnormal vaginal discharge without pelvic pain, a vaginal exam,
KOH and wet prep may be all that is necessary
For females this examination is the most sensitive and fraught with concern. Discussion before and after
the exam what will happen and what was found. It is necessary to discuss each part of the exam prior to its
performance – prior to touching or moving any structure the examiner should say, for example, “I am going
to touch the right side of the labia now" or “Now I will move the cervix.” The exam should be performed
expeditiously yet thoroughly. A female chaperone is absolutely necessary for male examiners in the United
States. In field situations, a trusted female friend of the patient, her partner or spouse and a male assistant
to hand you equipment could be an acceptable alternative. Keep the patient as covered as possible. If the
examination targets the vulva ask the patient to undress only from the waist down. Cover the abdomen with a
sheet or drape. As soon as the exam is done, allow the patient to dress.
What You Need:
For all exams: Good light source – preferably a mobile light, non-sterile gloves, water-soluble lubricant,
vaginal speculum of the correct size (small for patients who are virginal, medium Graves are appropriate
for most sexually active females and for parous women. Obesity may necessitate a large Graves due to
redundant tissue in the vagina). A speculum may be improvised out of two spoons joined by a rubber
band, or two bent spoons.
Figure 3-1
On certain exams: Culture medium for gonorrhea and chlamydia testing, large cotton-tipped swabs, pH
paper, screening test for fecal occult blood, set-up for wet mount and KOH prep (see Lab Procedures).
What To Do:
The exam described below will be appropriate for triage screening and diagnosis. It is not necessary that a