A normal tube is not palpable. A normal ovary (about 4 × 2 × 3 cm in size, sensitive, firm, and freely movable) is often not palpable. If an adnexal mass is found, evaluate its location relative to the uterus and cervix, architecture, consistency, tenderness, and mobility.
5.
Palpate the left adnexal region, repeating the technique described previously, but place the vaginal fingers in the left fornix and the abdominal hand on the left lower quadrant.
6.
Follow the bimanual examination with a rectovaginal–abdominal examination.
Insert the index finger into the vagina and the middle finger into the rectum very gently. Place the other hand on the infraumbilical region. The use of this technique makes possible higher exploration of the pelvis because the cul-de-sac does not limit the depth of the examining finger.
7.
In patients who have an intact hymen, examine the pelvic organs by the rectal–abdominal technique.
Table 1.6 (Continued )
E. Rectal examination 1. Inspect the perianal and anal area, the pilonidal (sacrococcygeal) region, and the perineum for the following aspects: a.
Color of the region (note that the perianal skin is more pigmented than the surrounding skin of the buttocks and is frequently thrown into radiating folds) b.
1.
The perianal and perineal regions are common sites for itching. Pruritus ani is usually indicated by thickening, excoriations, and eczema of the perianal region and adjacent areas.
2.
The anal opening often is the site of fissures, fistulae, and external hemorrhoids.
3.
The pilonidal area may present a dimple, a sinus, or an inﬂamed pilonidal cyst.
2.
Instruct the patient to “strain down” and note whether this technique brings into view previously concealed internal hemorrhoids, polyps, or a prolapsed rectal mucosa.
3.
Palpate the pilonidal area, the ischiorectal fossa, the perineum, and the perianal region before inserting the gloved finger into the anal canal. Note the presence of any concealed induration or tenderness in any of these areas.
4.
Palpate the anal canal and rectum with a well-lubricated, gloved index finger. Lay the pulp of the index finger against the anal orifice and instruct the subject to strain downward. Concomitant with the patient’s downward straining (which tends to relax the external sphincter muscle), exert upward pressure until the sphincter is felt to yield. Then, with a slight rotary movement, insinuate the finger past the anal canal into the rectum. Examine the anal canal systematically before exploring the rectum.
5.
Evaluate the anal canal for: a.
Tonus of the external sphincter muscle and the anorectal ring at the anorectal junction b.
Tenderness (usually caused by a tight sphincter, anal fissure, or painful hemorrhoids) c.
Tumor or irregularities, especially at the pectinate line d.
Superior aspect: Reach as far as you can. Mild straining by the patient may cause some lesions, which are out of reach of the finger, to descend sufficiently low to be detected by palpation.
e.
Test for occult blood: Examine the finger after it is withdrawn for evidence of gross blood, pus, or other alterations in color or consistency. Smear the stool to test for occult blood (guaiac).
6.
Evaluate the rectum: a. Anterior wall 1.
Cervix: size, shape, symmetry, consistency, and tenderness, especially on manipulation 2.
3.
In patients with an intact hymen, the examination of the anterior wall of the rectum is the usual method of examining the pelvic organs.
b. Right lateral wall, left lateral wall, posterior wall, superior aspect; test for occult blood