Pelvic examination under anesthesia

INTRODUCTION — 

A pelvic examination under anesthesia (EUA) is a complete pelvic examination that is performed with sedation or analgesia. EUA is indicated when a pelvic examination cannot be adequately performed without sedation/analgesia (eg, for reasons of physical or psychological discomfort) or as part of intraoperative surgical planning (eg, severity of uterovaginal prolapse, determination of route of hysterectomy, staging of cervical or vaginal cancer). Shared decision-making is used to understand the need for pelvic EUA and informed consent is required prior.

This topic reviews pelvic EUA in adults. Detailed discussions of gynecologic history and physical examination in adults and children are presented separately.

●(See "The gynecologic history and pelvic examination".)

●(See "Gynecologic examination of the newborn and child".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

INDICATIONS — 

EUA is indicated when a pelvic examination cannot be adequately performed without sedation/analgesia or as part of intraoperative surgical planning. The decision to proceed with EUA involves shared decision-making between the patient and provider. Typical indications for EUA include:

●Difficulty tolerating an examination while awake

●History of sexual assault with or without subsequent posttraumatic stress disorder

●Developmental or intellectual disability and/or delay

●Patient request in situations where benefits of sedation or anesthesia outweigh potential risks

●Assessment of pelvic anatomy (eg, uterus, cervix, ovaries, and adnexa)

•Surgical planning – Sedation relaxes the pelvic and abdominal muscles, allowing for more accurate assessment of the pelvic organs and their support structures.

-Surgical route (eg, assess if hysterectomy can reasonably be performed by vaginal route)

-Pelvic organ prolapse quantification (eg, POP-Q (figure 1A-B)) and intraoperative planning of repair (see "Pelvic organ prolapse in women: Choosing a primary surgical procedure")

•Surgical staging for confirmed or presumed vaginal (table 1) or cervical cancer (table 2)

-(See "Vaginal cancer", section on 'Staging'.)

-(See "Invasive cervical cancer: Staging and evaluation of lymph nodes".)

•Assessment of other disorders that impact the pelvic organs (eg, Crohn disease, Behçet syndrome, necrotizing fasciitis (algorithm 1))

●Assessment of a pelvic fracture and/or extent of pelvic instability or trauma [1,2] (see "Pelvic trauma: Initial evaluation and management")

PREPARATION — 

Preparation for pelvic EUA involves shared decision-making with the patient, discussion of the medical indication, informed consent with review of any trainee involvement, and discussion of the anticipated benefits and risks [3].

Informed consent

Components — Pelvic examinations are performed as indicated by the patient's symptoms and medical history; the decision to perform the examination under sedation or anesthesia requires shared decision-making between the patient and clinician [3].

●Points for discussion – Informed consent is required prior to performing a pelvic EUA [4-6]. The surgeon should discuss with the patient the purpose of the EUA, the personnel who will perform the examination (eg, surgeon, assisting surgeon, residents, medical students), the indication for performing the pelvic EUA, the risks and benefits of a pelvic EUA, and alternatives to a pelvic EUA [7]. The patient should have the capacity to consent and be free of coercion [8]. This discussion should be documented on the surgical consent form and in the medical record [9]; this applies whether the EUA is used solely or in part for the purpose of teaching medical students or trainees.

●Inclusion of likely surgical procedures – The surgeon should discuss the possibility that a finding on examination may change the surgical approach or the extent of the procedure. The patient should be counseled about potential changes and consent or decline preoperatively to changes in the procedure. For example, a patient undergoing vaginal hysterectomy is also consented for abdominal hysterectomy in case the choice of surgical approach changes based on the examination findings. The patient should also explicitly provide consent for photographs and/or biopsies that may reasonably be taken during the procedure, such as photographs of skin lesions or biopsies of lymph nodes.

Discussion of trainee involvement — To ensure clinicians have adequate skill in performing breast and pelvic examinations, trainees (eg, medical students, resident physicians) who are part of the patient's care team may perform a pelvic EUA if the patient has been educated about the practice and the patient has explicitly provided written and verbal consent [9,10]. Informed consent should be obtained by the senior clinician treating the patient, be documented in the patient's medical record (often as a separate consent), and be listed as part of the surgical plan [9,11]. Clinicians should understand and follow their local laws for obtaining and documenting consent for EUA by trainees.

Patients who have consented to EUA by trainees should meet the trainees before the procedure and before receiving any medication that could alter mental status [11]. The trainees should review the plan, confirm patient consent, and answer any questions. Students who do not meet the patient prior to the procedure should not perform an EUA. When EUA is performed with trainees, the senior clinician commonly performs the examination first, followed by the trainee, who then receives active feedback from the supervisor on their technique.

Chaperone — Chaperones are trained licensed or unlicensed members of the care team whose primary role is to serve as a witness and monitor a sensitive examination or procedure. A chaperone is an advocate for the patient during an examination or procedure. In the operating room setting a circulating nurse is often the chaperone.

Review benefits and risks

●Benefits – Bimanual and speculum examinations under anesthesia allow the clinician to fully assess the cervix (lesions, axis, and length), uterus (size, position, mobility, and descent), the adnexa (masses, mobility), rectovaginal septum (adhesions or nodules), and pelvic support and structures (cystocele, rectocele, enterocele, uterosacral ligaments).

Benefits of pelvic EUA include:

•Complete routine screening that could not otherwise be performed [3]

•Confirm the feasibility of a planned surgical route (vaginal or laparoscopic approaches versus open abdominal)

•Inform decision regarding need for vertical or transverse abdominal incision

•Reduce the risk of uterus perforation with the placement of intracervical or related instruments (eg, uterine manipulator for laparoscopy)

•Confirm the size and location of a pelvic mass or other findings

•Identify findings that were not recognized during initial evaluation (eg, pelvic or abdominal mass, parametrial nodularity, evidence of adhesions) [12]

While not a direct benefit to the patient, surgeons, trainees, and students gain clinical knowledge by comparing the preoperative pelvic examination findings, laboratory evaluation, and imaging studies with the findings and pathology at the time of surgery.

In a prospective study, for example, 84 women consented to an EUA prior to laparoscopy or laparotomy [13]. For an EUA performed by an attending surgeon, the sensitivity and specificity for detecting abnormalities were: adnexal mass (28 and 93 percent) and uterine enlargement (≥8 weeks' size; 36 and 68 percent) [13,14]. There are no data comparing the accuracy of pelvic examination performed with and without anesthesia.

●Risks – There are minimal risks associated with a pelvic EUA.

•Specific to EUA – The main risk is associated with the known risks of sedation/anesthesia (See "Overview of anesthesia".)

•Minor risks associated with pelvic examination – Minor risks include bleeding, postprocedural discomfort, potential injury to an intact hymen, and, rarely, infection.

EUA limitations — While sedation or anesthesia may enable performing a pelvic examination, it also limits the clinician's ability to assess the tenderness of any structure. As with awake pelvic examination, patient characteristics such as body size, uterine size, and abdominal scars or adhesions may also limit the findings of EUA [13]

TECHNIQUE — 

Pelvic EUA includes a complete examination of the abdomen and pelvis, including external visualization, bimanual examination, speculum examination, and rectovaginal examination. Additional procedures may include photographs (eg, skin lesions) and/or tissue biopsy (eg, enlarged lymph nodes).  

An overview of the pelvic EUA is presented below. Detailed discussions of the gynecologic history, common problems for focus, and examination equipment and components are available separately. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)

Timing — Pelvic EUA is performed after sedation or anesthesia has been administered and prior to sterile preparation or draping of the patient. Nonsterile gloves should always be worn during the examination.

Positioning — In gynecologic cases, the patient is typically placed in the dorsal lithotomy position (supine with feet in stirrups), with arms tucked as needed. In obstetric cases, patients are generally placed in dorsal lithotomy position but may alternatively be placed in a frog-legged position for examination of the pelvis.

Abdominal examination — The clinician performs visual and manual abdominal exams.

●Visual inspection – The examiner first visually inspects the abdomen. Any scars, lesions, skin changes, lacerations, or otherwise abnormal findings are documented. With loss of muscle tone due to anesthesia, previously unseen bulges (eg, hernias) or depressions may be observed.

●Abdominal palpation – Abdominal palpation is performed to identify hernias (eg, umbilical, incisional, other), hepatomegaly, splenomegaly, masses, and ascites. Unsuspected hepatomegaly or splenomegaly should be excluded if upper abdominal laparoscopy ports are planned; occasionally, an enlarged liver may extend to the level of the umbilical port. (See "Overview of gynecologic laparoscopic surgery and nonumbilical entry sites".)

Pelvic examination

Vulvar examination — The external genitalia are visually inspected and palpated. (See "The gynecologic history and pelvic examination", section on 'External genitalia'.)

●Visual inspection – Visual inspection of the vulva is done in a systematic fashion: mons pubis, labia majora, labia minora, clitoral hood, clitoris, vestibule, including paraurethral and Bartholin gland ducts, urethra, and vaginal introitus (vaginal opening) (figure 2). Particular attention should be paid to any abnormalities of the skin or anatomy. If pubic hair prevents adequate evaluation of a key portion of skin, it may be cut using an electric trimmer.

●Palpation – Palpation of the vulva is indicated to assess a visible/known lesion or mass, evaluate a suspected/confirmed infection, or stage a pelvic malignancy.

Begin with superficial and deep palpation in a systematic fashion as listed above (eg, visual inspection). Palpable vulvar lesions may be lifted and moved to assess depth of involvement, mobility, shape, size, regularity, and involvement of surrounding structures (eg, urethra, anus). While the ability to assess tenderness to palpation is lost during an EUA, abnormal areas that limited the examination preoperatively can be palpated and visualized by stretching the skin taught across the vulva when the patient is sedated. Lesions may be palpated with gloved fingers or using an instrument to assess for friability or the expression of discharge. Lastly, assessment of lymph nodes should be routinely performed in the setting of an infections or malignancy. Enlarged nodes may be seen or palpated in the inguinal areas.

Speculum examination — The vagina and cervix are examined using a speculum or retractors. Use of sedation or anesthesia allows the clinician to open the speculum more widely for improved visualization compared with awake examination. (See "The gynecologic history and pelvic examination", section on 'Speculum examination'.)

●The vaginal walls, fornices, and cervix are visually inspected.

•Evaluate for, and note, any abnormal discharge, bleeding, lesions/ulcerations, and pelvic organ prolapse.

•Cervical cytology, HPV testing, colposcopic examination, and/or tissue biopsy are performed as indicated.

●Pelvic organ prolapse is documented, typically using the POP-Q system (figure 1A), although other systems are available. A tenaculum is placed on the cervix and gentle traction is applied. This allows the clinician to evaluate for descent and the position of the cervix relative to the hymen. The route of hysterectomy and planned reconstructive or obliterative procedure may change based on the descent of the cervix.

Bimanual examination — A bimanual examination is performed in the same manner as for other gynecologic pelvic examinations. (See "The gynecologic history and pelvic examination", section on 'Bimanual examination'.)

●The vagina and cervix are evaluated for palpable lesions, and the cervix and uterus are assessed for axis, size, position (figure 3), mobility, and descent. The adnexa are palpated to evaluate for masses and mobility.

●Palpable abnormalities on bimanual examination are assessed for their consistency, mobility, and relation to adjacent structures (ie, anterior or posterior to the uterus or vagina, attached or separate from the uterus, fixed to the side wall or mobile). Finding a large or fixed pelvic mass may change the route of surgery (eg, abdominal rather than vaginal route of hysterectomy).

Rectovaginal examination — The author concludes the EUA by performing a rectovaginal examination. A rectovaginal examination is indicated for surgical planning or investigation of pathology with rectal involvement. Severity of pelvic organ prolapse, obliteration of the posterior cul de sac from adhesive disease or endometriosis, malignancy involving the rectum and/or vagina, and large fistulas may be assessed with a rectovaginal examination.

Begin by applying lubricant to a gloved finger on the nondominant and dominant hand. Place a finger from your dominant hand into the rectum and a finger from your nondominant hand into the vagina. Pressing the two fingers together and sliding the fingers from left to right will allow for evaluation of the anatomy. Make note of masses, deformities, and fluids (eg, blood) encountered during the examination.

Additional focused examination — Some patients may require additional components to complete the examination. These include patients with:

●Skin lesions or other dermatologic findings – Suspicious skin lesions are evaluated and documented. If included as part of the general surgical consent, intraoperative photographs and possibly biopsy may be performed. These may aid referrals and care planning. Lesions concerning for vulvar cancer may warrant intraoperative consultation by gynecologic oncology.

●Obstetric laceration or vulvar hematoma – Pelvic EUA may be needed to fully evaluate and treat patients who have sustained complex obstetric lacerations, obstetric anal sphincter injuries, and/or vulvar hematomas. These are addressed in detail separately.

•(See "Repair of perineal lacerations associated with childbirth".)

•(See "Obstetric anal sphincter injury (OASIS)".)

•(See "Management of hematomas incurred as a result of obstetric delivery".)

●Pelvic trauma – Patients who sustain pelvic trauma may require a pelvic EUA to evaluate for pelvic fracture, instability of identified fractures, and/or soft tissue injury after pelvic trauma.

•(See "Pelvic trauma: Initial evaluation and management".)

•(See "Blunt genitourinary trauma: Initial evaluation and management".)

•(See "Evaluation and management of female lower genital tract trauma".).

●Lymphadenopathy – We examine the lymph nodes of patients with potential metastatic disease. Enlarged nodes are examined for mobility and potential access for biopsy or resection, as appropriate.

SUMMARY AND RECOMMENDATIONS

●Indications – Pelvic examination under anesthesia (EUA) is performed when a patient cannot be adequately examined without sedation or general anesthesia (eg, reasons of discomfort, pelvic trauma), to guide a subsequent surgical procedure (eg, route of hysterectomy), or to clinically stage a patient at the time of cancer surgery (eg, vaginal or cervical cancer). (See 'Indications' above.)

●Preparation – Preparation for pelvic EUA involves shared decision-making with the patient; discussion of the medical indication; informed consent, including explicit discussion of any trainee involvement; and review of the anticipated benefits and risks. (See 'Preparation' above.)

●Technique – Pelvic EUA includes a complete examination of the abdomen and pelvis, including evaluation of the vulva and speculum, bimanual, and rectovaginal examination. Additional procedures may include photographs (eg, skin lesions) and/or tissue biopsy (eg, enlarged lymph nodes). (See 'Technique' above.)

●Additional focused examination – Some patients may require additional components to complete the examination. These include patients with lymphadenopathy, skin lesions or other dermatologic findings, obstetric laceration or vulvar hematoma, and pelvic trauma or fracture. (See 'Additional focused examination' above.)