Pelvic Examinations

In making a digital examination the introduced finger recognizes that in the nullipara the vagina is narrow, admitting only one finger, and rugous on its anterior and posterior walls. In multiparas it is smooth and admits two fingers. As the pulp on the palmar surface of the finger is used and not the side, the finger is to be directed posteriorly into the hollow of the sacrum and then brought anterior (Fig. 462). As the cervix enters the anterior wall and therefore, if normal, points down and back, and is about 6.5 to 7.5 cm. ( 2 1/2 to 3 in.) from the vulvar orifice, it is usually within reach of the tip of the finger. In the nullipara it is felt to be hard, rounded, and projecting distinctly into the vagina with a small os. In multiparae it is larger, softer, not so prominent, its os is wider and often irregular in shape from lacerations. The uterus is often displaced so that the os may look forward or to one side. The normal uterus is not firmly fixed but is movable and can be readily moved up and down by the examining finger. If it is in a normal anteverted position it can be felt between the finger of one hand within and firm pressure with the tips of the fingers of the opposite hand from without just above the symphysis pubis. When the uterus retains its normal almost straight shape and falls either forward or backward it is said to be in a position of anteversion or retroversion. If the uterus is bent on itself in the shape of a curve it is then said to be anteflexed or retroflexed. In anteversion the external os points down and back, and the fundus can be felt with the other hand above the pubes. In retroversion the os looks downward and forward and the body of the uterus cannot readily be made out by bimanual palpation. If anteflexed instead of anteverted it is more difficult to feel the uterus through the abdominal walls but its fundus can be felt through the anterior vaginal wall in front of the anterior lip of the cervix. If retroflexed its projecting rounded fundus can readily be felt in Douglas's sac just behind the cervix. By a digital examination one determines the amount of mobility of the uterus, its size, its position, the condition of the cervix, whether or not it is the seat of indurations such as occur from cicatrices and cancer, whether it is lacerated, etc. Growths like fibroid tumors projecting from the anterior or posterior walls can also be felt. Particularly in thin subjects relaxed by anaesthesia the broad ligaments can be followed to the sides and even normal ovaries be recognized. When prolapsed they fall into Douglas's pouch and can be felt posterior to the cervix. Enlarged Fallopian tubes can be felt as distinct masses either fixed to one side of the uterus or prolapsed into Douglas's pouch. Renal calculi impacted in the ureter at its vesical end can be felt between the middle and upper end of the vagina to one side or the other.

Fig. 462.   Digital vaginal examination. Ovary slightly prolapsed but as yet has not descended entirely into Douglas's pouch.

Fig. 462. - Digital vaginal examination. Ovary slightly prolapsed but as yet has not descended entirely into Douglas's pouch.