When indicated, a rectovaginal examination forms part of the complete pelvic examination on initial and annual examination, as well as at interval examinations whenever clinically indicated.
The rectovaginal examination is begun by changing the glove on the vaginal hand and using a liberal supply of lub-ricant. The examination may be comfortably performed if thenatural inclination of the rectal canal is followed: upward at a 45-degree angle for approximately 1 to 2 cm, then downward (Fig. 1.10). This is accomplished by positioning the fingers of the vaginal hand as for the bimanual examination, except that the index finger is also flexed. The middle finger is then gently inserted through the rectal opening and inserted to the “bend” where the angle turns downward. The index (vaginal) finger is inserted into the vagina, and both fingers are inserted until the vaginal finger rests in the posterior fornix below the cervix, and the rectal finger rests as far as it can go into the rectal canal. Asking the patient to bear down as the rectal finger is inserted is not necessary, and may add to the tension of the patient. Palpation of the pelvic struc-tures is then accomplished, as in their vaginal palpation. The uterosacral ligaments are also palpated to determine if they are symmetrical, smooth, and nontender (as normally), or if they are nodular, slack, or thickened. The rectal canal is eval-uated, as are the integrity and function of the rectal sphinc-ter. After palpation is complete, the fingers are rapidly but steadily removed in a reversal of the sequence of movements used on insertion. Care should be taken to avoid contamina-tion of the vagina with fecal matter. A guaiac determination is routinely made from fecal material collected on the rectal finger in patients 40 years or older.
At the conclusion of the pelvic examination, the patient is asked to move back up on the table and, thereafter, to sit up.
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