Advertisement
JOGC

No. 385-Indications for Pelvic Examination

      Abstract

      Objective

      The primary objective of this document is to clarify the indications for pelvic examination.

      Intended Users

      Physicians, including gynaecologists, obstetricians, family physicians, and emergency physicians; nurses, including registered nurses and nurse practitioners; midwives, including midwives in clinical practice and midwifery trainees; medical trainees, including medical students, residents, and fellows; and all other health care providers who care for women.

      Target Population

      This publication provides evidence and expert-based recommendations for pelvic examination in adult women (18 years and older) both with and without gynaecologic symptoms.

      Outcomes

      This publication clarifies indications for pelvic examination in the context of recently published national task force statements on the utility of pelvic examination. We aim to ensure that women who have clinical indications for examination receive proper clinical investigation with minimal delays to diagnosis of treatable disease.

      Evidence

      For this committee opinion, relevant studies were identified in PubMed and Medline using the following terms, either alone or in combination, with the search limited to English-language materials and human subjects and no publication date cut-off: pelvic examination, bimanual examination, speculum examination, rectovaginal examination, ovarian cancer screening, asymptomatic women, periodic health examination. The search was performed in May and June 2018. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines and national task force statements, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional articles were identified by cross-referencing the identified publications. A formal systematic review was not conducted for all topics discussed due to the paucity of evidence and number of different subtopics discussed. The total number of publications included in this review was 66.

      Validation Methods

      The content and recommendations were drafted and agreed upon by the principal authors. The Boards of the Society of Gynecologic Oncology of Canada (GOC), the College of Family Physicians of Canada (CFPC), and the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication after review by their respective representative committees. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Tables 1 and 2). The Summary of Findings is available upon request.

      Benefits, Harms, and Costs

      This committee opinion should benefit all women with and without gynaecologic symptoms who present to gynaecologists and primary care practitioners. It will help guide practitioners in identifying indications for pelvic examination to reduce unnecessary examination with related potential harm while also increasing indicated examination to reduce delays in diagnosis of treatable gynaecologic conditions.

      Guideline Update

      This SOGC Committee Opinion will be automatically reviewed 5 years after publication to determine if all or part of the committee opinion should be updated. However, this review may be performed earlier if new high-impact research is published in the interim.

      SUMMARY STATEMENTS

      • 1
        National and international statements and guidelines on pelvic examination should not be interpreted to suggest that the pelvic examination is irrelevant or noncontributory to physical assessment or that the pelvic examination in symptomatic women should be omitted.
      • 2
        Pelvic examination may include visual inspection, speculum examination, bimanual examination, single digit examination, and/or rectovaginal examination depending on the indication for examination.
      • 3
        No study published to date has adequately evaluated any component of the pelvic examination as a screening method for any type of malignant gynaecologic disease, except for the speculum examination for cervical cancer cytology screening. As such, any universal recommendations for or against pelvic examinations for other indications can only be made based on expert opinion and low-quality evidence.
      • 4
        In asymptomatic women at average risk for cervical cancer, cervical cytology screening reduces both the incidence of, and mortality from, cervical cancer by detecting pre-invasive, treatable lesions.
      • 5
        In asymptomatic women at average risk of malignancy, a visual and bimanual examination at the time of obtaining cervical cytology samples may add value to this screening manoeuvre: Women might not raise certain gynaecologic concerns until the time of pelvic examination; the examination provides an opportunity for patient education and practitioner skill maintenance; and, although inadequately studied to date, there may be positive effects on ovarian and vulvar malignancy that require further investigation. These potential benefits should be weighed against potential harms like patient discomfort and false positives/negatives that may result in inappropriate reassurance or unnecessary investigations/interventions.

      RECOMMENDATIONS

      Symptomatic Women
      • 1
        Any woman with gynaecologic complaints including, but not limited to, vulvar complaints, vaginal discharge, abnormal premenopausal bleeding, postmenopausal bleeding, infertility, pelvic organ prolapse symptoms, urinary incontinence, new and unexplained gastrointestinal symptoms (abdominal pain, increased abdominal size/bloating, and difficulty eating/early satiety), pelvic pain, or dyspareunia should undergo appropriate components of the pelvic examination to identify benign or malignant disease (strong, low).
      • 2
        Health care providers may consider discussing the risks and benefits of performing a baseline pelvic examination including visual and bimanual examination prior to prescribing hormonal replacement therapy/menopausal hormonal treatment (weak, very low).
      Asymptomatic Women
      • 3
        Health care practitioners should perform cervical cytology cancer screening in accordance with provincial/territorial guidelines (strong, strong).
      • 4
        There is insufficient evidence to guide recommendations on screening pelvic examination for noncervical gynaecologic malignancy or any benign gynaecologic disease in healthy, asymptomatic women with average risk of malignancy. However, health care practitioners may consider performing a screening pelvic examination including visual, speculum, and bimanual examinations in concert with cervical cytology sampling intervals as recommended by provincial/territorial guidelines. This practice may identify clinically important benign or malignant disease not recognized or reported by the patient (weak, very low).
      • 5
        In women over age 70 who no longer require screening with cervical cytology, health care practitioners should consider continuing periodic screening of asymptomatic women for vulvar disease with inspection of the vulva, perineum, and anus to identify benign or malignant disease unrecognized by this population. There is insufficient evidence to guide recommendations on frequency of this examination (weak, low).
      • 6
        Women with a personal history of gynaecologic malignancy, a genetic diagnosis that increases gynaecologic malignancy risk, or a history of in utero diethylstilbestrol exposure may benefit from more frequent screening pelvic examinations to identify early primary, recurrent, or metastatic malignancy in the absence of symptoms. Because there is inadequate evidence to define these screening intervals, they should be in accordance with provincial/territorial guidelines and expert opinion (weak, very low).
      • 7
        Non-invasive and self-collection screening options for chlamydia and gonorrhea are acceptable in asymptomatic women, but pelvic examination, including visual inspection, speculum examination, and bimanual examination, is required in the presence of symptoms to rule out pelvic inflammatory disease or tubo-ovarian abscess (strong, low).
      • 8
        No pelvic examination is required prior to prescription of hormonal contraception in a healthy woman with no gynaecologic symptoms (strong, low).

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Obstetrics and Gynaecology Canada
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • Macfarlane C
        The value of the periodic pelvic examination of supposedly well women.
        Med Clin North Am. 1948; 32: 1557-1561
        • Bloomfield HE
        • Olson A
        • Greer N
        • et al.
        Screening pelvic examinations in asymptomatic, average-risk adult women: an evidence report for a clinical practice guideline from the American College of Physicians.
        Ann Intern Med. 2014; 161: 46-53
        • Stormo AR
        • Cooper CP
        • Hawkins NA
        • et al.
        Physician characteristics and beliefs associated with use of pelvic examinations in asymptomatic women.
        Prev Med. 2012; 54: 415-421
        • Saleh N
        • Abu-Gariba M
        • Yehoshua I
        • et al.
        Barriers to implementation of a pelvic examination among family doctors in primary care clinics.
        Postgrad Med. 2018; 130: 341-347
        • MacLaughlin KL
        • Faubion SS
        • Long ME
        • et al.
        Should the annual pelvic examination go the way of annual cervical cytology?.
        Womens Health (Lond). 2014; 10: 373-384
        • Sawaya GF
        • Smith-McCune KK
        • Gregorich SE
        • et al.
        Effect of professional society recommendations on women's desire for a routine pelvic examination.
        Am J Obstet Gynecol. 2017; 217 (e1–7): 338
        • Vandborg MP
        • Christensen RD
        • Kragstrup J
        • et al.
        Reasons for diagnostic delay in gynecological malignancies.
        Int J Gynecol Cancer. 2011; 21: 967-974
        • Qaseem A
        • Humphrey LL
        • Harris R
        • et al.
        Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians.
        Ann Intern Med. 2014; 161: 67-72
        • Tonelli M
        • Connor Gorber S
        • Moore A
        • et al.
        Recommendations on routine screening pelvic examination: Canadian Task Force on Preventive Health Care adoption of the American College of Physicians guideline.
        Can Fam Physician. 2016; 62: 211-214
        • Guirguis-Blake JM
        • Henderson JT
        • Perdue LA
        Periodic screening pelvic examination: evidence report and systematic review for the US Preventive Services Task Force.
        JAMA. 2017; 317: 954-966
        • Bibbins-Domingo K
        • Grossman DC
        • Curry SJ
        • et al.
        Screening for gynecologic conditions with pelvic examination: US Preventive Services Task Force recommendation statement.
        JAMA. 2017; 317: 947-953
      1. Committee on Gynecologic Practice, Committee opinion No. 534: well-woman visit.
        Obstet Gynecol. 2012; 120: 421-424
      2. Schünemann H Brozek J Guyatt G The GRADE Handbook. GRADE Working Group, 2013 (Available at:)
        • Savas JA
        • Pichardo RO
        Female genital itch.
        Dermatol Clin. 2018; 36: 225-243
        • Akhtar-Danesh N
        • Elit L
        • Lytwyn A
        Trends in incidence and survival of women with invasive vulvar cancer in the United States and Canada: a population-based study.
        Gynecol Oncol. 2014; 134: 314-318
        • Lai J
        • Elleray R
        • Nordin A
        • et al.
        Vulval cancer incidence, mortality and survival in England: age-related trends.
        BJOG. 2014; 121 (; discussion 39): 728-738
        • Holleczek B
        • Sehouli J
        • Barinoff J
        Vulvar cancer in Germany: increase in incidence and change in tumour biological characteristics from 1974 to 2013.
        Acta Oncol. 2018; 57: 324-330
        • Singh S
        • Best C
        • Dunn S
        • et al.
        Abnormal uterine bleeding in pre-menopausal women.
        J Obstet Gynaecol Can. 2013; 35: 473-479
        • Reichman DE
        • Laufer MR
        Congenital uterine anomalies affecting reproduction.
        Best Pract Res Clin Ostet Gynaecol. 2010; 24: 193-208
        • Krychman M
        • Graham S
        • Bernick B
        • et al.
        The Women's EMPOWER survey: women's knowledge and awareness of treatment options for vulvar and vaginal atrophy remains inadequate.
        J Sex Med. 2017; 14: 425-433
        • Weiderpass E
        • Tyczynski JE
        Epidemiology of patients with ovarian cancer with and without a BRCA1/2 mutation.
        Mol Diagn Ther. 2015; 19: 351-364
        • Haylen BT
        • Maher CF
        • Barber MD
        • et al.
        An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP).
        Int Urogynecol J. 2016; 27: 655-684
        • Pahwa AK
        • Siegelman ES
        • Arya LA
        Physical examination of the female internal and external genitalia with and without pelvic organ prolapse: a review.
        Clin Anat. 2015; 28: 305-313
        • Veeraswamy A
        • Lewis M
        • Mann A
        • et al.
        Extragenital endometriosis.
        Clin Obstet Gynecol. 2010; 53: 449-466
        • Goff BA
        • Mandel LS
        • Drescher CW
        • et al.
        Development of an ovarian cancer symptom index: possibilities for earlier detection.
        Cancer. 2007; 109: 221-227
        • Kruszka PS
        • Kruszka SJ
        Evaluation of acute pelvic pain in women.
        Am Fam Physician. 2010; 82: 141-147
        • Brawn J
        • Morotti M
        • Zondervan KT
        • et al.
        Central changes associated with chronic pelvic pain and endometriosis.
        Hum Reprod Update. 2014; 20: 737-747
        • Hersh JE
        Vulvodynia in adolescents: presentation, diagnosis and treatment options.
        Curr Opin Obstet Gynecol. 2018; 30: 293-299
        • Spitznagle TM
        • Robinson CM
        Myofascial pelvic pain.
        Obstet Gynecol Clin North Am. 2014; 41: 409-432
        • Linden JA
        • Grimmnitz B
        • Hagopian L
        • et al.
        Is the pelvic examination still crucial in patients presenting to the emergency department with vaginal bleeding or abdominal pain when an intrauterine pregnancy is identified on ultrasonography? A randomized controlled trial.
        Ann Emerg Med. 2017; 70: 825-834
        • Isoardi K
        Review article: the use of pelvic examination within the emergency department in the assessment of early pregnancy bleeding.
        Emerg Med Australas. 2009; 21: 440-448
        • Hsu WP
        • Hsiao PC
        In response: Review article: The use of pelvic examination within the emergency department in the assessment of early pregnancy bleeding.
        Emerg Med Australas. 2010; 22: 254
        • Andersen MR
        • Drescher CW
        • Zheng Y
        • et al.
        Changes in cancer worry associated with participation in ovarian cancer screening.
        Psychooncology. 2007; 16: 814-820
        • Mehrotra A
        • Zaslavsky AM
        • Ayanian JZ
        Preventive health examinations and preventive gynecological examinations in the United States.
        Arch Intern Med. 2007; 167: 1876-1883
        • Norrell LL
        • Kuppermann M
        • Moghadassi MN
        • et al.
        Women's beliefs about the purpose and value of routine pelvic examinations.
        Am J Obstet Gynecol. 2017; 217 (e1–6): 86
        • Dickinson J
        • Tsakonas E
        • Conner Gorber S
        • et al.
        Recommendations on screening for cervical cancer.
        CMAJ. 2013; 185: 35-45
        • Ladouceur R
        Recommendations for the routine screening pelvic examination: could they have a negative effect on physician competence?.
        Can Fam Physician. 2016; 62: 460
        • Tambouret RH
        The evolution of the Papanicolaou smear.
        Clin Obstet Gynecol. 2013; 56: 3-9
        • Traut HF
        • Papanicolaou GN
        Cancer of the uterus: the vaginal smear in its diagnosis.
        Cal West Med. 1943; 59: 121-122
        • Kingsberg SA
        • Wysocki S
        • Magnus L
        • et al.
        Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey.
        J Sex Med. 2013; 10: 1790-1799
        • Nappi RE
        • Kokot-Kierepa M.
        Vaginal Health: Insights, Views & Attitudes (VIVA) - results from an international survey.
        Climacteric. 2012; 15: 36-44
        • Braun MM
        • Overbeek-Wager EA
        • Grumbo RJ
        Diagnosis and management of endometrial cancer.
        Am Fam Physician. 2016; 93: 468-474
        • Henderson JT
        • Webber EM
        • Sawaya GF
        Screening for ovarian cancer: updated evidence report and systematic review for the US Preventive Services Task Force.
        JAMA. 2018; 319: 595-606
        • Grossman DC
        • Curry SJ
        • Owens DK
        • et al.
        Screening for ovarian cancer: US Preventive Services Task Force recommendation statement.
        JAMA. 2018; 319: 588-594
        • Jacobs IJ
        • Skates SJ
        • MacDonald N
        • et al.
        Screening for ovarian cancer: a pilot randomised controlled trial.
        Lancet. 1999; 353: 1207-1210
        • Buys SS
        • Partridge E
        • Black A
        • et al.
        Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening randomized controlled trial.
        JAMA. 2011; 305: 2295-2303
        • Jacobs IJ
        • Menon U
        • Ryan A
        • et al.
        Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial.
        Lancet. 2016; 387: 945-956
        • Adonakis GL
        • Paraskevaidis E
        • Tsiga S
        • et al.
        A combined approach for the early detection of ovarian cancer in asymptomatic women.
        Eur J Obstet Gynecol Reprod Biol. 1996; 65: 221-225
        • Grover SR
        • Quinn MA
        Is there any value in bimanual pelvic examination as a screening test.
        Med J Aust. 1995; 162: 408-410
        • Jacobs I
        • Stabile I
        • Bridges J
        • et al.
        Multimodal approach to screening for ovarian cancer.
        Lancet. 1988; 1: 268-271
        • Doroudi M
        • Kramer BS
        • Pinsky PF
        The bimanual ovarian palpation examination in the Prostate, Lung, Colorectal and Ovarian cancer screening trial: performance and complications.
        J Med Screen. 2017; 24: 220-222
        • Altman AD
        • Lambert P
        • Love AJ
        • et al.
        Examining the effects of time to diagnosis, income, symptoms, and incidental detection on overall survival in epithelial ovarian cancer: Manitoba Ovarian Cancer Outcomes (MOCO) Study Group.
        Int J Gynecol Cancer. 2017; 27: 1637-1644
        • Padilla LA
        • Radosevich DM
        • Milad MP
        Accuracy of the pelvic examination in detecting adnexal masses.
        Obstet Gynecol. 2000; 96: 593-598
        • Padilla LA
        • Radosevich DM
        • Milad MP
        Limitations of the pelvic examination for evaluation of the female pelvic organs.
        Int J Gynaecol Obstet. 2005; 88: 84-88
        • Salani R
        • Backes FJ
        • Fung MF
        • et al.
        Posttreatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncologists recommendations.
        Am J Obstet Gynecol. 2011; 204: 466-478
        • National Cancer Institute (NCI)
        Diethylstilbestrol (DES) and Cancer.
        NIH, Bethesda, MD2011 (Available at:)
        • Rubin MM
        Antenatal exposure to DES: lessons learned...future concerns.
        Obstet Gynecol Surv. 2007; 62: 548-555
        • World Health Organization (WHO)
        Sexually Transmitted Infections.
        WHO, Geneva2016 (Available at:)
        • Zakher B
        • Cantor AG
        • Pappas M
        • et al.
        Screening for gonorrhea and Chlamydia: a systematic review for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2014; 161: 884-893
        • Fajardo-Bernal L
        • Aponte-Gonzalez J
        • Vigil P
        • et al.
        Home-based versus clinic-based specimen collection in the management of Chlamydia trachomatis and Neisseria gonorrhoeae infections.
        Cochrane Database Sys Rev. 2015; CD011317
        • Blake DR
        • Maldeis N
        • Barnes MR
        • et al.
        Cost-effectiveness of screening strategies for Chlamydia trachomatis using cervical swabs, urine, and self-obtained vaginal swabs in a sexually transmitted disease clinic setting.
        Sex Transm Dis. 2008; 35: 649-655
        • Bogler T
        • Farber A
        • Stall N
        • et al.
        Missed connections: unintended consequences of updated cervical cancer screening guidelines on screening rates for sexually transmitted infections.
        Can Fam Physician. 2015; 61: e459-e466
        • Davies HD
        • Wang EE
        Periodic health examination, 1996 update: 2. Screening for chlamydial infections. Canadian Task Force on the Periodic Health Examination.
        CMAJ. 1996; 154: 1631-1644
        • Centers for Disease Control and Prevention (CDC)
        STD & HIV Screening Recommendations.
        Centers for Disease Control and Prevention, Atlanta, GA2018 (Available at:)
        • LeFevre ML
        Screening for Chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2014; 161: 902-910
        • Scholes D
        • Stergachis A
        • Heidrich FE
        • et al.
        Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection.
        N Engl J Med. 1996; 334: 1362-1366
        • Low N
        • Redmond S
        • Uuskula A
        • et al.
        Screening for genital chlamydia infection.
        Cochrane Database Sys Rev. 2016; CD010866
        • American College of Obstetricians and Gynecologists (ACOG)
        Guidelines for women's healthcare: a resource manual.
        4th ed. ACOG, Washington, DC2014
        • Black A
        • Guilbert E
        • Costescu D
        • et al.
        No. 329-Canadian contraception consensus part 4 of 4 chapter 9: combined hormonal contraception.
        J Obstet Gynaecol Can. 2017; 39 (e5): 229-268
        • Curtis KM
        • Jatlaoui TC
        • Tepper NK
        • et al.
        U.S. selected practice recommen-dations for contraceptive use, 2016.
        MMWR Recomm Rep. 2016; 65: 1-66