Pelvic examination under anesthesia

INTRODUCTION — Pelvic examination under anesthesia (EUA) is performed when a patient cannot be adequately examined without sedation or general anesthesia (eg, for reasons of physical or psychological discomfort) or to provide information that will help guide a subsequent surgical procedure. In addition, clinical staging of cervical or vaginal cancer is performed under anesthesia.

Pelvic EUA in adults is reviewed here. General principles of the gynecologic history and physical examination in adults and children, and of cervical cancer staging, are discussed separately. (See "The gynecologic history and pelvic examination" and "Gynecologic examination of the newborn and child" and "Invasive cervical cancer: Staging and evaluation of lymph nodes" and "Vaginal cancer".)

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. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

INFORMED CONSENT — Informed consent is required prior to performing a pelvic EUA [1-3]. The surgeon should discuss with the patient the purpose of the EUA, as well as the personnel who will perform the examination (eg, surgeon, assisting surgeon, residents, medical students) [4]. This discussion should be documented on the surgical consent form and in the medical record. This applies whether the EUA is used solely or in part for the purpose of teaching medical students or trainees.

In addition, 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.

GOALS OF THE EXAMINATION — Determination of the axis and length of the cervix and the size, position, mobility, and descent of the uterus just prior to a procedure provides the following benefits:

●Confirms feasibility of vaginal route of surgery.

●Informs decision regarding vertical or transverse abdominal incision.

●Helps to avoid perforation of the uterus when intrauterine instruments are placed.

●Confirms size and location of a pelvic mass or other findings. Often due to the muscle relaxation induced by anesthesia, the EUA may reveal findings that were not appreciated during ambulatory evaluation (eg, pelvic or abdominal mass, parametrial nodularity) [5].

●Gives information regarding potential adhesive disease.

●Allows examination of patients and use of examination techniques (eg, palpation of the uterosacral ligaments) that were not previously possible due to patient discomfort.

In addition, clinical experience for surgeons, trainees, and students is enhanced by comparing the results obtained preoperatively from pelvic examination, laboratory evaluation, and imaging studies and then correlating these findings with the pathology noted during surgery.

Some, but not all pelvic findings are not identified during an EUA. In a prospective study, for example, 84 women consented to an EUA prior to laparoscopy or laparotomy [6]. 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) [6,7]. There are no data comparing the accuracy of pelvic examination performed with and without anesthesia.

TECHNIQUE — EUA prior to gynecologic surgery usually consists of examination of the abdomen and pelvis. The components of the examination will vary according to the indication for the surgery or if a routine examination is performed in a women who cannot tolerate an ambulatory examination. In women with suspected metastases from a gynecologic malignancy, additional examination may be performed.

One limitation of the EUA is that it is not possible to assess tenderness of any structure. As with ambulatory pelvic examination, patient characteristics such as obesity, uterine size, and abdominal scars may limit the findings of EUA [6].

An overview of the EUA is presented below. General principles of performing a pelvic examination are discussed separately. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)

Timing — The examination is best done after anesthesia has been administered, and prior to sterile preparation or draping of the patient.

Abdominal examination — The examiner should visually inspect the abdomen. With loss of muscle tone due to anesthesia, unexpected bulges or depressions may also be observed in the abdomen or pelvis.

Abdominal palpation is performed to exclude umbilical or incisional hernias, hepatomegaly, splenomegaly, masses, and ascites. Unsuspected hepatomegaly or splenomegaly is a concern when upper abdominal laparoscopy ports are planned; occasionally, an enlarged liver may extend to the level of the umbilical port. A broad mass just deep to the abdominal wall may represent an omental cake; this and/or fixation of the umbilicus are potential signs of advanced intraperitoneal disease. (See "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites".)

Pelvic examination

Vulva and surrounding structures — The skin of the vulva is inspected and palpated. Palpable vulvar lesions may be lifted to assess depth of involvement, and mobility. In particular, areas which were tender due to ulceration or inflammation can be palpated and visualized by stretching the skin taught across the vulva. Lesions can also be moved relative to the urethra or anus, to assess whether these orifices have been involved by an inflammatory or malignant process. Enlarged nodes may be seen in the inguinal areas.

Speculum examination — Visual examination of the vagina and cervix is performed in women with suspected vaginal or cervical lesions or pelvic organ prolapse. This examination can be performed using a speculum or retractors. The vaginal speculum can typically be opened more widely than when the patient is awake, allowing the fornices to be thoroughly inspected. The cervix can also be moved to aid in visualizing upper vaginal lesions. Any abnormalities of the vagina or cervix should be examined with a bright light or colposcope. Biopsy may be indicated.

For women who cannot tolerate an ambulatory pelvic examination, anesthesia allows the only opportunity to visualize the vagina and cervix and obtain cytology and cultures.

Bimanual examination — A bimanual examination is performed in the same manner as for other pelvic examinations. The vagina and cervix are assessed for palpable lesions, and the cervix and uterus are assessed for axis, size, position, mobility, and descent. The adnexae are palpated. The author concludes the EUA by performing a rectovaginal examination.

Palpable abnormalities on bimanual examination are assessed for 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).

Findings of a large or fixed pelvic mass may lead the surgeon to choose an abdominal rather than a vaginal surgical route.

Assessment for metastatic disease — For women with potential metastatic disease, an examination of lymph nodes and a breast examination may be performed. The examiner should note whether nodes are enlarged, and assess for resectability or fixation. Biopsy or aspiration may be appropriate.

A breast examination may be performed, if appropriate. (See "Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass", section on 'Physical examination'.)

SUMMARY AND RECOMMENDATIONS

●Indication – Pelvic examination under anesthesia (EUA) is performed when a patient cannot be adequately examined without sedation or general anesthesia (eg, for reasons of physical or psychological discomfort) or to provide information that will help guide a subsequent surgical procedure. (See 'Introduction' above.)

●Use for clinical cancer staging – Clinical staging of cervical or vaginal cancer is performed under anesthesia. (See 'Introduction' above.)

●Informed consent – Informed consent is required prior to performing an EUA. The surgeon should discuss with the patient the purpose of the EUA, as well as the personnel who will perform the examination. (See 'Informed consent' above.)

●Examination beyond abdomen – EUA prior to gynecologic surgery usually consists of examination of the abdomen and pelvis. In women with suspected metastases from a gynecologic malignancy, additional examination may be performed. (See 'Technique' above.)