Pelvic Exams

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Groove

Groove

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I haven't done a pelvic exam in ages which is a clear change in practice from residency and new attendinghood. I had an interesting case recently that just reinforced my reluctance to do them.

Young female in her 20s who had scheduled a routine wellness exam with pap smear with local NP. NP (female) does exam and I guess was reportedly too rough and did a speculum followed by manual exam and the pt reportedly asked them to "give her a second" or "slow down" and inadvertently got a self reported abrasion from the practitioners "long nails". NP reportedly was very in and out of the room and discharged her. Well, she shows up in my ED in the wee hours and wants to be evaluated and wants to make a police report on "sexual abuse". I kind of rolled my eyes inwardly after hearing the story and thought that sure...it sounded like it was probably a hasty exam that could have been more gentle but I didn't hear anything that sounded like assault and I'm sure there was a chaperone there (hopefully) that could attest. Regardless, it turned into the biggest ordeal where I had to work her up, have the police take a report, who then handed her off to a forensics team and no doubt will be going by the NPs practice to get a report from her. I'm sure nothing probably will come of it but it just reinforces the sensitivity of those types of encounters and in my personal opinion, the less of them we do in ED (unless indicated), the better. It also underscores the importance of constance chaperone vigilance. I feel bad for the NP who probably had a million physicals and pelvics to do that day and was just rushing through the patients and now will have to worry about a police report and no doubt brief internal investigation.

I have no problem telling patients these days that I'm an ER doc, not a gynecologist and I don't do pelvics in the ER unless they are actively delivering or they lost a family heirloom. I'll CT/US all day long to avoid doing them. I think a lot of us who are older did WAY too many of them in residency and I hope things have changed.
 
There’s very few reasons why a pelvic exam needs to be done on an emergent basis. More and more primary care stuff gets punted to the ED that doesn’t need to be done emergently. OB/Gyns tend to disagree but they can do the exam in their office.
 
I agree with you, but this is not a universally shared opinion in EM. We get monthly emails from our quality review team, and one common point that often makes it into their recommendations is that every woman with possibly pelvic complaint (interpreted broadly) needs a pelvic exam. Many colleagues would crucify you for not doing them.
 
I rarely do pelvic exams.

One seasoned attending once told me when I was a fresh residency grad, who’s prior attendings required a pelvic exam for every pelvic complaint, “I don’t do pelvics, and I don’t do rectals.” I was surprised and also realized it wasn’t a cop out, it just really isn’t necessary.

Primarily do pelvic exams for uncommon foreign body removals and rare cases of precipitous labor. Also rarely for severe vaginal bleeding and pain with clot removal from external cervix (unnecessary for majority of vaginal bleeding including menstrual cycles, DUB, and miscarriage).

Vast majority of the time a pelvic exam doesn’t change management. Image with US/CT more often. Ovarian torsion and PID/TOA to a lesser degree are also often clinical diagnoses where your exam from the door gives you half the information.
 
gro2001 said:
I agree with you, but this is not a universally shared opinion in EM. We get monthly emails from our quality review team, and one common point that often makes it into their recommendations is that every woman with possibly pelvic complaint (interpreted broadly) needs a pelvic exam. Many colleagues would crucify you for not doing them.
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How many ED physicians are on this quality review team? Pelvic exams are a quality metric at your hospital now? Ha...that's an email I'd delete before ever opening every time. Colleagues that crucify me are more than welcome to go do pelvic exams on my patients when I don't feel they are indicated.
 
gro2001 said:
I agree with you, but this is not a universally shared opinion in EM. We get monthly emails from our quality review team, and one common point that often makes it into their recommendations is that every woman with possibly pelvic complaint (interpreted broadly) needs a pelvic exam. Many colleagues would crucify you for not doing them.
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But...why?
 
Groove said:
I haven't done a pelvic exam in ages which is a clear change in practice from residency and new attendinghood. I had an interesting case recently that just reinforced my reluctance to do them.

Young female in her 20s who had scheduled a routine wellness exam with pap smear with local NP. NP (female) does exam and I guess was reportedly too rough and did a speculum followed by manual exam and the pt reportedly asked them to "give her a second" or "slow down" and inadvertently got a self reported abrasion from the practitioners "long nails". NP reportedly was very in and out of the room and discharged her. Well, she shows up in my ED in the wee hours and wants to be evaluated and wants to make a police report on "sexual abuse". I kind of rolled my eyes inwardly after hearing the story and thought that sure...it sounded like it was probably a hasty exam that could have been more gentle but I didn't hear anything that sounded like assault and I'm sure there was a chaperone there (hopefully) that could attest. Regardless, it turned into the biggest ordeal where I had to work her up, have the police take a report, who then handed her off to a forensics team and no doubt will be going by the NPs practice to get a report from her. I'm sure nothing probably will come of it but it just reinforces the sensitivity of those types of encounters and in my personal opinion, the less of them we do in ED (unless indicated), the better. It also underscores the importance of constance chaperone vigilance. I feel bad for the NP who probably had a million physicals and pelvics to do that day and was just rushing through the patients and now will have to worry about a police report and no doubt brief internal investigation.

I have no problem telling patients these days that I'm an ER doc, not a gynecologist and I don't do pelvics in the ER unless they are actively delivering or they lost a family heirloom. I'll CT/US all day long to avoid doing them. I think a lot of us who are older did WAY too many of them in residency and I hope things have changed.
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I only do them a few times a year. Most of the time for suspected STD, cervicitis, or any other infection I just have them self swab.
 
gro2001 said:
I agree with you, but this is not a universally shared opinion in EM. We get monthly emails from our quality review team, and one common point that often makes it into their recommendations is that every woman with possibly pelvic complaint (interpreted broadly) needs a pelvic exam. Many colleagues would crucify you for not doing them.
Click to expand...

I suspect it's because those on the quality review team don't know anything about Emergency Medicine. And the usefulness of a pelvic exam in Emergency Medicine. And they are just parroting what they heard in some admin meeting.

At the end of the day if my job depended on it, I would do them more often and tell the patient "I'm just not qualified enough to know about many of the detailed aspects of this exam. Your gynecologist is by far the best person for this complaint."
 
TooMuchResearch said:
But...why?
Click to expand...
PID/cervicitis. No other reason. That’s not a dx that can be made based easily on external exam or ultrasound. Thankfully it’s a an uncommon dx these days, so if you never do an exam you’ll probably be ok.

But it won’t really be defensible if you miss the rare one. At that point just settle since it’s your practice to not routinely do pelvic exams and you will probably just lose. I say that nonsarcastically.

I don’t routinely do pelvics for pelvic pain only. I do it for miscarriages as I may be able to relieve suffering by removing fetal products. I also do it for vaginal discharge as I won’t have patients self swab. (it is perfectly reasonable to do self swabbing, but The first time I ever did this, the patient surprisingly complained and I find complaints annoying). Lastly, I am the same as everyone else in that if someone has something lost in vagina, I will unfortunately have to go grab it.

Those were the only three situations that I ever routinely do internal public exams.
 
Rendar5 said:
PID/cervicitis. No other reason. That’s not a dx that can be made based easily on external exam or ultrasound. Thankfully it’s a an uncommon dx these days, so if you never do an exam you’ll probably be ok.
Click to expand...

but mt. ascepiles said he can diagnose PID by looking at a patient. That's a good trick. Imagine him at a party 😆
 
Re: the original post, at my shop the SANE nurse would do almost all the work on this.

It seems like a rare patient presentation, and perhaps there’s some supratentorial stuff going on - I wouldn’t let it deter me from future pelvic exams or hold it as an example of why not to do one.

As for my practice, I perform them much less commonly than I used to. But still do them to evaluate for PID, or during incomplete AB where I can remove tissue from the os. I will generally offer them for all threatened ABs although I disclose they will likely not change management or outcome, and most patients decline.

I recall a case about ten years ago. A spry elderly woman came in for vaginal bleeding. I suppose I could have just ordered an ultrasound, but I didn’t, and exam revealed a vaginal laceration. She had recently had intercourse (didn’t think it was relevant) and didn’t realize the bleeding could be from atrophic vaginal tissue.
 
Oh, and I am 100% with you on chaperones. I will never ever do any sensitive exam (breast, pelvic, rectal) without one. I trust no one. Anyone can make wild accusations.
 
xaelia said:
How about: "Pt with intractable pain since IUD placement; cannot get in with [whoever], wants it out"
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I feel like the general sentiment on these is negative - and maybe I'm wrong - but I don't mind these at all. They're very quick turnaround and the patient is grateful. There's no pain quite like a low lying IUD that the cervix is trying (and failing) to expel.
 
Pinner Doc said:
I feel like the general sentiment on these is negative - and maybe I'm wrong - but I don't mind these at all. They're very quick turnaround and the patient is grateful. There's no pain quite like a low lying IUD that the cervix is trying (and failing) to expel.
Click to expand...
That and its worth a surprising amount of RVUs for 30-60 seconds of work.
 
I do a few of them a year when I absolutely need to (post-procedure bleeding, FB, something seems unusually wrong, etc) but they otherwise rarely change the management compared to self-swabbing, ultrasound, and/or OBGYN follow-up.

I also never do bimanual exams since they seem like the most rapey thing in medicine given that they never changed the outcome or diagnosis in my mind and have always been ripe for a wild patient complaint. Maybe OB can feel whatever and it makes the difference, but that's just not happening for me.
 
Also, regarding self-swabbing, the evidence seems to indicate that it's just as effective as us doing the test.

Our lab director got uppity about not allowing self-swabbing a few years ago until I pointed out that self-collection is the standard for semen analysis after a vasectomy. If we were going to forbid self-swabbing for females in the ED, then maybe we should have a lab tech facilitate post-vasectomy collections instead of asking guys to provide their own sample ...
 
xaelia said:
How about: "Pt with intractable pain since IUD placement; cannot get in with [whoever], wants it out"
Click to expand...

That depends on my mood, these really need to be done by Gyne. I tell them to go to the Gyne office and just wait in the waiting room and ask every 30 minutes to have it pulled. They will do it.
 
BoardingDoc said:
A want is not a need. I don't remove IUDs.
Click to expand...

You know...half the time I can't grasp the IUD wire with my fingers? It makes it much more laborous. Need to get a speculum, kelly forceps or a ring forceps...sometimes it's hard to see the cervix. You never have a proper gyne bed. Women are never in lithotomy position. It's really a pain in the arse
 
Re: initial story I tried to do every exam possible with a chaperone, had a colleague deal with an insane headache after someone’s boyfriend reported he “felt her up” by listening to the heart. Obviously not always practical, but I still do that even outside em. I also was very conscious of where my phone camera was and where it was facing for same reason.

No longer an EM doc, so I have no stakes here, but I generally made practice decisions on trying not to get burned over 10-20 years of practice.

At one site Where I worked there was a lot of cervicitis and pid, and a lot of the people denied discharge/vaginal symptoms (despite foul smelling discharge practically pouring out) and would only complain about lower belly pain. I found about one toa each year when I worked there (these were all caught on ultrasound), I had seen none prior to working there.

If something is bleeding at a time when it isn’t supposed to bleed I usually felt it was good to try to examine it: history is unreliable, especially with the population I had. Vaginal tissue like most mucosal linings will usually heal well, but I wouldn’t have wanted to bet the headache of a lawsuit (or more likely a quality case, that place was malignant af) for a missed laceration.

Overall I never thought they were a huge deal, and aside from the pain of finding a nurse and waiting for the patient to get undressed, they took about 8 seconds. I usually told nurses based on chief complaint I needed an exam and they’d go in, have them undressed, and have the stuff in the room for me by the time I got there.

I wouldn’t shed a tear or lose sleep if someone declined one, and I don’t judge the folks who don’t do them often. I think a lot of it depends where you work, which is why it’s polarizing. If you live in a community like above, it seems like poor practice not to, but if you live in a “normal” place without much pid (or with patients who are reasonable historians) then it’s probably unnecessarily invasive.
 
thegenius said:
You know...half the time I can't grasp the IUD wire with my fingers? It makes it much more laborous. Need to get a speculum, kelly forceps or a ring forceps...sometimes it's hard to see the cervix. You never have a proper gyne bed. Women are never in lithotomy position. It's really a pain in the arse
Click to expand...

Technically, women can remove these themselves. But often aren't taught or just don't know.
 
I rarely do them and looking around in my large group of ~50 docs I believe that is more or less the norm.

I'm aware of two docs in my group who have had legal/board issues after an insane patient files a complaint following an exam. First doc was a young female who did a GU exam on a homeless patient, who then later called the police stating they had been sexually assaulted. I wasn't present but based on working with this doc I'm sure consent was obtained and a chaperone present.

The second case was a board complaint for an inappropriate GU exam when a patient came in with a very GU-centric complaint. Drugs were involved if memory serves. Doc had to defend himself to the medical board. It was predictably dropped.

I have never heard of a bad outcome or significant complaint from not doing a pelvic exam. I'm sure someone can point to an example but in my real world experience performing the exam seems far more risk prone.

Depending on the situation, if appropriate I discuss with the patient that an exam is often uncomfortable and unlikely to assist in actually reaching a diagnosis. If consensus is reached I document that an exam was discussed and deferred, and move on.

Basically, whether you do it or not, document document document. Not only your findings but how you obtained consent and who was present to chaperone.
 
I don't do pelvics. Did a ton of pelvics in residency and not once did it change management. If I miss something at some point so be it. The risk of a false assault allegation is far higher than missing something because you didn't do a pelvic. Just not worth that to me. FB, sure I'll go get it. Severe bleeding, yeah sure.

I don't remove IUDs, I'm not a gynecologist.

I don't do rectals either. If the patient says they're bleeding I believe them. If their hemoglobin is normal, they can follow up. If it's grossly abnormal they can be admitted for serial trending. I'll do them for unexplained severe anemia.
 
WhatJobDoIPick said:
I don't do pelvics. Did a ton of pelvics in residency and not once did it change management. If I miss something at some point so be it. The risk of a false assault allegation is far higher than missing something because you didn't do a pelvic. Just not worth that to me. FB, sure I'll go get it. Severe bleeding, yeah sure.

I don't remove IUDs, I'm not a gynecologist.

I don't do rectals either. If the patient says they're bleeding I believe them. If their hemoglobin is normal, they can follow up. If it's grossly abnormal they can be admitted for serial trending. I'll do them for unexplained severe anemia.
Click to expand...
I won't do them for unexplained severe anemia. The fecal occult blood test is ridiculous so I don't do them when my pre test probability is high, low, or somewhere in between.


Also very rarely do pelvic exams because there just isn't much there that's going to help me make management decisions.
 
WhatJobDoIPick said:
I don't do pelvics. Did a ton of pelvics in residency and not once did it change management. If I miss something at some point so be it. The risk of a false assault allegation is far higher than missing something because you didn't do a pelvic. Just not worth that to me. FB, sure I'll go get it. Severe bleeding, yeah sure.

I don't remove IUDs, I'm not a gynecologist.

I don't do rectals either. If the patient says they're bleeding I believe them. If their hemoglobin is normal, they can follow up. If it's grossly abnormal they can be admitted for serial trending. I'll do them for unexplained severe anemia.
Click to expand...
Same on rectal exams--stopped doing them a few years ago. I'll do an external exam to see if they have a bleeding external hemorrhoid or fissure but after that I'm done. Otherwise, I wait for them to have a BM for the nurse to send a hemocult (since our lab doesn't trust us to do those anymore). If their Hgb is fine and they can't poop, then off to GI they go
 
JacobMcCandles said:
There’s very few reasons why a pelvic exam needs to be done on an emergent basis. More and more primary care stuff gets punted to the ED that doesn’t need to be done emergently. OB/Gyns tend to disagree but they can do the exam in their office.
Click to expand...
quite the opposite. Unless its changed, in the last few years, ACOG has a stance that pelvics should be done in the ED only under the most blatantly obvious and unequivocally required of situations and otherwise suggests that we not even bother because (reading between the lines) our exams are less reliable than ultrasound or CT or just calling them to do it.
 
xaelia said:
How about: "Pt with intractable pain since IUD placement; cannot get in with [whoever], wants it out"
Click to expand...
might be a good question for the am I the dingus thread. I know some docs who will yank out IUDs on anyone who so much as says it itches their canals and then most people I know just are just dropping this face at that request. No middle ground

ahhh-shocked.gif
 
DocEspana said:
quite the opposite. Unless its changed, in the last few years, ACOG has a stance that pelvics should be done in the ED only under the most blatantly obvious and unequivocally required of situations and otherwise suggests that we not even bother because (reading between the lines) our exams are less reliable than ultrasound or CT or just calling them to do it.
Click to expand...
Got a link? That'd be nice to have because that hasn't been my experience with my local OB/Gyns.
 
JacobMcCandles said:
Got a link? That'd be nice to have because that hasn't been my experience with my local OB/Gyns.
Click to expand...
This is the actual hard statement that was put out by ACOG

The Utility of and Indications for Routine Pelvic Examination

www.acog.org www.acog.org

In the strictest of senses it says that routine pelvic exams are unnecessary outside of pregnancy in the "asymptomatic patient". Unfortunately, an OBGYN who wants you to do their work for them is not going to read past that summarized consensus statement and actually read into the bigger discussion that happens in that clinical guidance.

But in the way it's written, its really talking about quite a bit more than asymptomatic patients. It implies that in most acute gynecologic complaints it's probably also unnecessary, unless a pelvic exam would be the only way to evaluate the complaint.

It was a major shift in ACOG's position and contemporaneously quite a number of emergency medicine movers and shakers weighed in with how emergency medicine should interpret this, because the statement was not just about recommendations for OBGYNs, but rather recommendations for anyone taking care of women

I just asked chatgpt to make me a summary of some of those emergency medicine statements.... And it did.... But in the process of trying to get the links to the various opinion papers, I ended up losing the entire answer from chatgpt. So now I'm grumpy and you can ask chat gpt yourself
 
My facility requires written consent and a chaperone….

Probably for cases like this
 
NYEMMED said:
My facility requires written consent and a chaperone….

Probably for cases like this
Click to expand...
I (male MD) always do sensitive female exams with a chaperone of course but might start getting consent for pelvics and rectal exams on the very rare occasions when I still do them. I almost never to those exams anymore though lol. I frankly never cease to be amazed at the number of people who when you tell them you need to do a breast or pelvic exam on them just start taking their clothes off without the RN around. I'm like, please wait, stop.
 
Interpolfanclub said:
I (male MD) always do sensitive female exams with a chaperone of course but might start getting consent for pelvics and rectal exams on the very rare occasions when I still do them. I almost never to those exams anymore though lol. I frankly never cease to be amazed at the number of people who when you tell them you need to do a breast or pelvic exam on them just start taking their clothes off without the RN around. I'm like, please wait, stop.
Click to expand...
That was the thing 10 years ago. Trying to talk women out of the pelvic, and they were unable to be swayed. In my mind, I was thinking, "seriously?"
 
TooMuchResearch said:
I won't do them for unexplained severe anemia. The fecal occult blood test is ridiculous so I don't do them when my pre test probability is high, low, or somewhere in between.


Also very rarely do pelvic exams because there just isn't much there that's going to help me make management decisions.
Click to expand...
I don’t do fecal occults. But a quick finger for unexplained severe anemia is still reasonable to check for active gi bleed on a patient who can’t tell you if they have a gi bleed or not. Active gi bleed, not occult gi bleed (as in who care what’s on the card)

Every year or two I catch Melena or hematochezia on a patient with some degree of cognitive impairment (whether acute or chronic) +hypotension or +anemia.
 
I don’t understand not doing FOBTs. Besides the fact the entire thing takes under a minute, I can’t tell you how many times I’ve had newly anemic patients say they aren’t bleeding when they are, or patients who present for dark black stool and worry they’re bleeding, when they aren’t. So easy to sort out. Am I understanding that those who defer these are going to punt most of these to a PCP who can fit them in sometime next month?
 
FOBTs are non-emergent screening for colon cancer. The evaluation of anemia is an inpatient or outpatient evaluation. Our job in the ED is to resuscitate the obviously bleeding patient. Somehow our field has overcomplicated this and misconstrued FOBT with our role as rescucitationists. Trying to catch people in a lie about whether or not they are bleeding from their butthole isn’t our job.
 
Pinner Doc said:
I don’t understand not doing FOBTs. Besides the fact the entire thing takes under a minute, I can’t tell you how many times I’ve had newly anemic patients say they aren’t bleeding when they are, or patients who present for dark black stool and worry they’re bleeding, when they aren’t. So easy to sort out. Am I understanding that those who defer these are going to punt most of these to a PCP who can fit them in sometime next month?
Click to expand...
Our newly severely anemic patients usually just get scoped, inpatient or outpatient.

The characteristics of the FOBT aren't good enough to rule in or rule out bleeding.
 
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