Pelvic Exam - When is it really useful?

[Angry Birds]

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As an attending, I've noticed I do way fewer pelvic exams than I did in residency. I am sure a big part of it is that I don't like doing them, but I think it's also because I feel that they are rarely helpful in my clinical decision pathway. Am I in the wrong here? What's your take on this? How often do you do pelvic exams?

 

[bougiecric]

Completely agree - practicing on my own, I find there are only a few specific instances in which a pelvic helps decision making. The dogmatic "all female pain below the umbilicus needs a pelvic," that I was taught in residency, is wrong.

I find it useful in:

• Women who are bleeding heavily (i.e. look sick) to get a sense of how much blood there really is.
• Later first trimester / second trimester miscarriage where I may need to remove products from the vagina or os.
• Suspected PID to check for CMT and to obtain cultures.
• Might be missing another example or two.

I don't find it useful in:

• The VAST majority of early first trimester pregnancies with spotting or vague abdominal pain (i.e. acute ultrasound deficiency).
• Evaluating for ovarian cysts or adnexal masses.
• Vaginal discharge (will simply treat if story is good).
• Differentiating gyn vs non-gyn abdominal complaints.

Maybe I'm going too far, but I also don't generally find pelvic US helpful in the non-pregnant patient. CT can see most cysts, and honestly, if a CT doesn't show surgical pathology, I don't believe that a pelvic US adds much diagnostically. Of course, I use it with doppler to evaluate for (not exclude) torsion, but this is only in patients who I'm already concerned about clinically. As we all know, pelvic US has poor sensitivity and can't rule out torsion.

 

[tsbqb]

http://www.ncbi.nlm.nih.gov/pubmed/21691528

CONCLUSION:
In 94% of women with acute abdominal pain or vaginal bleeding, the results of the pelvic exam were either predictable or had no effect on the clinical plan. This suggests that there may be a subset of women with abdominal pain or vaginal bleeding in whom a pelvic exam may safely be deferred.

 

[Angry Birds]

Completely agree - practicing on my own, I find there are only a few specific instances in which a pelvic helps decision making. The dogmatic "all female pain below the umbilicus needs a pelvic," that I was taught in residency, is wrong.

I find it useful in:

• Women who are bleeding heavily (i.e. look sick) to get a sense of how much blood there really is.
• Later first trimester / second trimester miscarriage where I may need to remove products from the vagina or os.
• Suspected PID to check for CMT and to obtain cultures.
• Might be missing another example or two.

I don't find it useful in:

• The VAST majority of early first trimester pregnancies with spotting or vague abdominal pain (i.e. acute ultrasound deficiency).
• Evaluating for ovarian cysts or adnexal masses.
• Vaginal discharge (will simply treat if story is good).
• Differentiating gyn vs non-gyn abdominal complaints.

Maybe I'm going too far, but I also don't generally find pelvic US helpful in the non-pregnant patient. CT can see most cysts, and honestly, if a CT doesn't show surgical pathology, I don't believe that a pelvic US adds much diagnostically. Of course, I use it with doppler to evaluate for (not exclude) torsion, but this is only in patients who I'm already concerned about clinically. As we all know, pelvic US has poor sensitivity and can't rule out torsion.

Thanks for your post. I do like pelvic ultrasounds ... since I don't have to do them.

 

[e30ftw]

When you have to call OB/GYN for post-op or otherwise high-risk vaginal bleeders and describe a pelvic exam.

When the hx suggests PID and you perform the exam to assess for CMT and medico-legally strengthen the chart.

I do not routinely perform pelvic exams on 1st trimester bleeders who get TV US or on every female with low abd pain as suggested by some in academics. There is always a chance one day I'll be burned though and end up on the stand asking why an exam was not performed to assess for adnexal fullness in a patient with low abd pain and a neg CT who ended up with torsion. This will inevitably occur overnight when U/S is not available and the only option is transfer..

The risks we take..

 

[WilcoWorld]

If I suspect a condition that I need a pelvic to diagnose, I do a pelvic.

If I have a female with lower abdominal pain, and I don't have a diagnosis, I explain which conditions I can't rule out without a pelvic (and I include torsion on the list). If the patient wants a pelvic to evaluate for those conditions, I do it. If not, I don't.

 

[canigetawhatwhat]

Completely agree - practicing on my own, I find there are only a few specific instances in which a pelvic helps decision making. The dogmatic "all female pain below the umbilicus needs a pelvic," that I was taught in residency, is wrong.

I find it useful in:

• Women who are bleeding heavily (i.e. look sick) to get a sense of how much blood there really is.
• Later first trimester / second trimester miscarriage where I may need to remove products from the vagina or os.
• Suspected PID to check for CMT and to obtain cultures.
• Might be missing another example or two.

I don't find it useful in:

• The VAST majority of early first trimester pregnancies with spotting or vague abdominal pain (i.e. acute ultrasound deficiency).
• Evaluating for ovarian cysts or adnexal masses.
• Vaginal discharge (will simply treat if story is good).
• Differentiating gyn vs non-gyn abdominal complaints.

Maybe I'm going too far, but I also don't generally find pelvic US helpful in the non-pregnant patient. CT can see most cysts, and honestly, if a CT doesn't show surgical pathology, I don't believe that a pelvic US adds much diagnostically. Of course, I use it with doppler to evaluate for (not exclude) torsion, but this is only in patients who I'm already concerned about clinically. As we all know, pelvic US has poor sensitivity and can't rule out torsion.

Sudden onset 10/10 LLQ pain. Vomiting. Hx of cysts. Neg u/s. What do you do? Moreso curious as opposed to being confrontational.

 

[bougiecric]

Sudden onset 10/10 LLQ pain. Vomiting. Hx of cysts. Neg u/s. What do you do? Moreso curious as opposed to being confrontational.

History of cysts, but negative US, as in no cysts? Admittedly, seeing a large cyst or adnexal mass is usually the red flag for me. No doubt there are strange cases of torsion (I've only picked up a few) which have absolutely no imaging findings.

I guess my hedge is that if a female has intractable LLQ pain, 10/10, persistent over the course of her ED stay, I continue to work her up and get others involved. Sometimes that means phone calls to the surgeon vs gynecologist vs hospitalist depending.

But this is true of all patients... I generally don't send them home if they continue to hurt significantly (without clear cause, such as ureterolithiasis).

Granted, if the patient is a zebra that's torsing then detorsing, has negative imaging studies, and is pain free at discharge, then... I'm screwed.

 

[Angry Birds]

Dang it, this thread is already making me think I need to do more pelvic exams. I guess what I hate the most is the coordination with the nurses. In residency, it was very nice, because I would tell them to call me on my VOCERA when they are ready, legs in the stirrups, and everything ready. I miss VOCERA!

 

[tsbqb]

Dang it, this thread is already making me think I need to do more pelvic exams. I guess what I hate the most is the coordination with the nurses. In residency, it was very nice, because I would tell them to call me on my VOCERA when they are ready, legs in the stirrups, and everything ready. I miss VOCERA!

Really?? Where I am currently doing residency we set up everything ourselves and then often have to search high and low for a chaperone. I always thought in the community things like this get done easily 🙂

 

[dchristismi]

In my community shop, it's pretty easy.

As above, unless it is going to give me data, I don't do them either. I generally offer, but the vast majority decline.

As far as torsion, doppler flow isn't always a slam dunk. I had a lady with a really good story for torsion, as well as a decently large cyst. Good flow, but really intractable pain. CT just showed the cyst but not much else. (And she was peri/postmenopausal if I remember right - in her 40s-50s.) I called her OBGYN who was skeptical to say the least, but ended up scoping her and found the torsion. He called my secretary to pass along that I was right and he thanked me.

Bottom line: High index of suspicion and spidey sense = call OBGYN and hope you get a reasonable doc.

 

[RustedFox]

When you have to call OB/GYN for post-op or otherwise high-risk vaginal bleeders and describe a pelvic exam.

When the hx suggests PID and you perform the exam to assess for CMT and medico-legally strengthen the chart.

I do not routinely perform pelvic exams on 1st trimester bleeders who get TV US or on every female with low abd pain as suggested by some in academics. There is always a chance one day I'll be burned though and end up on the stand asking why an exam was not performed to assess for adnexal fullness in a patient with low abd pain and a neg CT who ended up with torsion. This will inevitably occur overnight when U/S is not available and the only option is transfer..

The risks we take..

Even this, though. - Adnexal "fullness"? What exactly is that ? No idea what a "full" adnexa feels like as opposed to an unfull (empty?) one, as pelvics are done so infrequently that I seriously have no idea what one is supposed to feel like.

Here's how it works IRL, 99% of the time... female usually declines pelvic, written in the chart as "will not consent to pelvic". For the one percent who do, they usually wince and moan and cry and carry on so much that the exam is uninterpretable.

 

[RustedFox]

Dang it, this thread is already making me think I need to do more pelvic exams. I guess what I hate the most is the coordination with the nurses. In residency, it was very nice, because I would tell them to call me on my VOCERA when they are ready, legs in the stirrups, and everything ready. I miss VOCERA!

What's a .. Vo...cer...aah... ?

 

[Xerxes1729]

Sudden onset 10/10 LLQ pain. Vomiting. Hx of cysts. Neg u/s. What do you do? Moreso curious as opposed to being confrontational.

I often work these people up for renal stone. If they get hung up at the UVJ, folks often complain primarily of lower abdominal pain rather than flank/back pain.

 

[GeneralVeers]

I'm not sure how pelvic exam is useful in diagnosing torsion. Pretty much every one of my histrionic female patients has adnexal tenderness bilaterally on exam along with CMT. For cultural reasons, in South Texas, the yield of a pelvic exam in diagnosis of illness is very limited as everything hurts all the time.

I generally do a pelvic in three situations:

1. Vaginal discharge with pain (discharge alone gets treated)
2. Severe vaginal bleeding. Either unstable vital signs, or they're literally soaking through their clothes as I'm talking to them
3. Vaginal foreign body.

For the first trimesters who are primarily there for their free ultrasounds, I order the test, and move on to other things.

 

[emergentmd]

Residency training. All pelvic pain, hell all abdominal pain = pelvic exam. All abd pain = rectal exam. All worse headache of my life = LP.

Real life for 99% of cases- Unless they are discharging or bleeding pregnant - No pelvic. Unless they are rectally bleeding or have specific rectal complaint- No rectal. Unless they are a legit person who looks like they are in legit pain, who aren't frequent flyers, who are not texting or watching TV, who I am very concerned about a Head bleed, I still don't LP but get a CT/CTA.

 

[Angry Birds]

I'm not sure how pelvic exam is useful in diagnosing torsion. Pretty much every one of my histrionic female patients has adnexal tenderness bilaterally on exam along with CMT. For cultural reasons, in South Texas, the yield of a pelvic exam in diagnosis of illness is very limited as everything hurts all the time.

I generally do a pelvic in three situations:

1. Vaginal discharge with pain (discharge alone gets treated)
2. Severe vaginal bleeding. Either unstable vital signs, or they're literally soaking through their clothes as I'm talking to them
3. Vaginal foreign body.

For the first trimesters who are primarily there for their free ultrasounds, I order the test, and move on to other things.

Leaving aside the racial innuendo, this was an otherwise helpful post. One question for you: for #1 (vaginal discharge with pain), you just treat for yeast infection (i.e. clotrimazole or Fluconazole)? What about gonorrhea and chlamydia?

Thanks!

 

[Doctor Bob]

For cultural reasons, in South Texas, the yield of a pelvic exam in diagnosis of illness is very limited as everything hurts all the time.

Leaving aside the racial innuendo...

I have worked at different hospitals in four regions of the county and at all of them I've heard this referred to as "status hispanicus"

 

[coachB]

Residency training. All pelvic pain, hell all abdominal pain = pelvic exam. All abd pain = rectal exam. All worse headache of my life = LP.

Real life for 99% of cases- Unless they are discharging or bleeding pregnant - No pelvic. Unless they are rectally bleeding or have specific rectal complaint- No rectal. Unless they are a legit person who looks like they are in legit pain, who aren't frequent flyers, who are not texting or watching TV, who I am very concerned about a Head bleed, I still don't LP but get a CT/CTA.

.

 

[GeneralVeers]

Leaving aside the racial innuendo, this was an otherwise helpful post. One question for you: for #1 (vaginal discharge with pain), you just treat for yeast infection (i.e. clotrimazole or Fluconazole)? What about gonorrhea and chlamydia?

Thanks!

It's cultural not racial. Different cultures around the United States react to, and interpret pain in different ways. Understanding that helps you to not miss things, and to direct your history and physical to the patient in way that's most helpful. Additionally pathology varies. While in the midwest I'd see a lot more fibromyalgia, and chronic pain, down south I see a lot more gallbladder pain and liver/kidney disease.

When I'm treating women with "vaginal drippies" I usually give them Rocephin, Azithromycin, and flagyl.

 

[filhodeinferno]

Even this, though. - Adnexal "fullness"? What exactly is that ? No idea what a "full" adnexa feels like as opposed to an unfull (empty?) one, as pelvics are done so infrequently that I seriously have no idea what one is supposed to feel like.

Here's how it works IRL, 99% of the time... female usually declines pelvic, written in the chart as "will not consent to pelvic". For the one percent who do, they usually wince and moan and cry and carry on so much that the exam is uninterpretable.

I'm surprised to hear that many people refuse pelvics....I probably do like 10-20 a week, and the only refusals I've ever gotten are from Muslim women who request a female doctor. I've even been able to convince some of them to let me do it.

LPs, on the other hand, I have what seems like a 60-70% refusal rate. Must be the difference in the population....or maybe the patients just like what they see, I dunno.

 

[GeneralVeers]

I'm surprised to hear that many people refuse pelvics....I probably do like 10-20 a week, and the only refusals I've ever gotten are from Muslim women who request a female doctor. I've even been able to convince some of them to let me do it.

LPs, on the other hand, I have what seems like a 60-70% refusal rate. Must be the difference in the population....or maybe the patients just like what they see, I dunno.

You will do a lot more pelvics in residency than as an attending. It's time consuming for both you and nurses to set up and perform, so use them sparingly.

 

[EM4life]

Agree with above, do a lot LESS pelvics as an attending - very rarely clinically helpful but I do find that it is generally good form to:

1. always do a pelvic exam before calling an OB/GYN because seriously, you are calling a specialist without doing the exam of the part in question?
2. I sometimes will do a pelvic exam for undifferentiated abdominal pain f I'm going to sign that patient out - it totally sucks getting a sign out that you have to do a rectal/pelvic on, I try to avoid this scenario as much as possible.

 

[Old_Mil]

I would add that I have seen a not insignificant number of patients who had pelvic exam confirmed cervical discharge without a review of systems positive for vaginal discharge...as well as one patient who denied she was sexually active, had a negative CT and ultrasound and had pelvic exam confirmed PID. I do fewer of them than in residency but I am not sure if that is because my practice has changed or if my patient population here is older.

 

[Cheese Whiz]

i've had multiple MLPs I work with tell me that they give the "here for vaginal discharge" patient the swabs and have the patient self swab both the wet prep and GC/Chlam swabs with the nurse present. They're instructed to get "up in there" and get a "good sample like what they've noticed".
I haven't decided how I feel about it.
Anyone else doing this?

 

[Janders]

Certainly do less as an attending than resident.

However I agree with some posters above, some patients with deep pelvic pain and NO reported vaginal discharge will have notable +CMT with mild cervical discharge. PID is real and common and a spectrum of disease. So I do pelvics for this type of patient if the rest of the workup is negative.

 

[Angry Birds]

i've had multiple MLPs I work with tell me that they give the "here for vaginal discharge" patient the swabs and have the patient self swab both the wet prep and GC/Chlam swabs with the nurse present. They're instructed to get "up in there" and get a "good sample like what they've noticed".
I haven't decided how I feel about it.
Anyone else doing this?

Fantastic idea.

 

[VA Hopeful Dr]

i've had multiple MLPs I work with tell me that they give the "here for vaginal discharge" patient the swabs and have the patient self swab both the wet prep and GC/Chlam swabs with the nurse present. They're instructed to get "up in there" and get a "good sample like what they've noticed".
I haven't decided how I feel about it.
Anyone else doing this?

For wet prep I could see doing that, although like Janders mentioned I prefer to do it myself so I can poke the cervix and see if there's a reaction (although as always, I'm not EM so its easy for me to do things my way). For GC/C why not just use urine?

 

[deleted109597]

For GC/C why not just use urine?

Two reasons.
#1, urine is the rate limiting step of every patient in the ED, and nobody wants a patient to tie up a chair for 8 hours while they're waiting to pee again.
#2, because the urine is a different kind of urine and requires different instruction from a clean catch. For GC/C, you want a dirty first catch, not a clean catch. So they either have to pee twice if you want both studies, or you get substandard results for one of them (always the ua, as clean catches are, in fact, impossible).

 

[VA Hopeful Dr]

Two reasons.
#1, urine is the rate limiting step of every patient in the ED, and nobody wants a patient to tie up a chair for 8 hours while they're waiting to pee again.
#2, because the urine is a different kind of urine and requires different instruction from a clean catch. For GC/C, you want a dirty first catch, not a clean catch. So they either have to pee twice if you want both studies, or you get substandard results for one of them (always the ua, as clean catches are, in fact, impossible).

Makes sense, thanks

 

[xaelia]

How about pulling IUDs?

Presumably easy. Not interested.

 

[Janders]

I have pulled IUDs... but i do try to avoid that. Pretty easy. Agree better to send to GYN, but at one point my hospital had no affiliated GYN so I had no one to refer to...
I think I pulled 1 or 2 due to "Severe pain". I think with mild/mod PID you can leave in place and treat around... better than an unwanted pregnancy.

heck I pulled a dobhoff last shift b/c the GI fellow downtown told them to go to the closest ER and have it pulled, since it was clogged and a new one couldn't be placed for another 2 days in outpatient land... rather silly but I had them in and out in 20 minutes. Not sure if dobhoff removal is a billable procedure? 🙂

 

[Birdstrike]

How about pulling IUDs?

Presumably easy. Not interested.

Grab string. Pull. Insert in garbage can. Done.

Done it. Very easy. Not much to be interested about.

 

[Apollyon]

Grab string. Pull. Insert in garbage can. Done.

Done it. Very easy. Not much to be interested about.

Yeah, except for "that one time, when this guy I work with, pulled on it, and the uterus everted". It's like surgeons - they're not there for when it is normal and uneventful - they are there for the complications. No thanks. I didn't put it in. I can't deal with the complications.

 

[Janders]

heh... I'm no cowboy, but I think when I have gently removed IUDs I'd be able to stop before causing some massive, inside-out, uterine prolapse through the cervix.
You don't yank on them like you're trying to start an old lawnmower.

 

[Birdstrike]

heh... I'm no cowboy, but I think when I have gently removed IUDs I'd be able to stop before causing some massive, inside-out, uterine prolapse through the cervix.
You don't yank on them like you're trying to start an old lawnmower.

I know, right? Lol

It's not a pressure washer for flarks sake.

 

[Apollyon]

heh... I'm no cowboy, but I think when I have gently removed IUDs I'd be able to stop before causing some massive, inside-out, uterine prolapse through the cervix.
You don't yank on them like you're trying to start an old lawnmower.

I'm at work, and busy, and salty, so I'll not tell you where to stick your condescension. Go nuts. Pull all of them out. I'm not.

 

[Janders]

I'm at work, and busy, and salty, so I'll not tell you where to stick your condescension. Go nuts. Pull all of them out. I'm not.

Seriously, sorry if I offended you. Not trying to be a jerk, just trying to have a little levity in the discussion. Failed that.

You really think ED IUD removal is dangerous? I know its not our job, and there are better places for it, but I also think its a darned low risk procedure that I am equipped to do. Wouldn't fault you for saying wrong place / wrong time / wrong person but I tend to err towards pragmatism when the patient is already registered / undressed / stirrups are in the room. Dangerous complications were low on my list for reasons to avoid pulling an IUD. Typically my reason is "you need / want to be on some type of birth control, so you need to see your OB to discuss that before we randomly pull your IUD at midnight on Tuesday!"

 

[Apollyon]

Fair enough. I've just never done it, so I just don't. And, is that a foreign body? I am not even sure if I am credentialed to do it!

 

[Petypet]

Unless its infected and purulent if they have an IUD why can't they have an outpatient appointment for removal?

 

[e30ftw]

I've pulled IUDs.

Super easy and helps the patient out.

Would agree that considering all the things we do, pulling an IUD is low risk. I could say, "See your Gyn." But thats just giving the patient the runaround. Of course i strongly advise them to see their gyn for contraception etc but ill pull that iud in the ED.

 

[winkleweizen]

Em rap just did a lecture on ovarian torsion. Even under anesthesia and with a board certified obgyn doing the exam, the sensitivity of feeling an adnexal mass is only 15-35%.

If they can't feel it, no way in hell I'll be able to feel them on my histrionic patients, propped up on a bedpan with a clueless tech there helping.

 

[RustedFox]

The physical exam is dead. Long live the ultrasound.

 

[Birdstrike]

The physical exam is dead. Long live the ultrasound.

How in God's name did this only get 1 like?

I mean...you guys are actually touching people, still?

 

[DeadCactus]

i've had multiple MLPs I work with tell me that they give the "here for vaginal discharge" patient the swabs and have the patient self swab both the wet prep and GC/Chlam swabs with the nurse present. They're instructed to get "up in there" and get a "good sample like what they've noticed".
I haven't decided how I feel about it.
Anyone else doing this?

I'll try to post the studies when I'm not on a cellphone but blind swab has been shown equivalent if not better than cervical swab. Perfectly reasonably to blind swab and do a bimanual if you're worried about PID without bothering with the full pelvic set-up. No stirrups, no speculum. Just gloves, swabs, and a frog leg position.

There's also a study showing that a clean catch is no better than a dirty catch for UTI evaluation so you could reasonably send the same Irvine for UTI and STI, but good luck getting your lab to play along.




Sent from my iPhone using Tapatalk

 

[Angry Birds]

I also support patients doing self-rectals. Study forthcoming.

 

[pinipig523]

My main thing is I don't let my lack of wanting to do something dictate what I do.

If that means I do a pelvic, I'm doing it.

 

[deleted77919]

…

 

[gman33]

The physical exam is dead. Long live the ultrasound.

The same EMRAP discussed that CT is just as good as u/s for looking for torsion.
That was new to me.
Gone is the serial workup of u/s and CT for the vague lower and pain.
CT if neg, gone.
Now if you want to save radiation, that is a different discussion.

And physical exam, in general it plays almost no part in my practice.
With all the EBM stuff we try to practice, using tests with such low sensitivity and specificity is kind of a joke.

 

[Angry Birds]

My main thing is I don't let my lack of wanting to do something dictate what I do.

If that means I do a pelvic, I'm doing it.

I get what you are saying, but it is equally unpleasant for the patients. So, I think we should have a high threshold for poking fingers in orifices, especially in the current climate.