INTRA-PELVIC TECHNIC (Manipulative
Surgery of the Pelvic Organs)
PERCY H. WOODHALL, M.D., D.O.
The intra-pelvic examination should, as a general thing be the final
examination. It should have been preceded by the oral examination, the
anamnesis, which through its revelation of history and symptoms will determine
the advisability or the necessity of the intra-pelvic examination.
I wish again to emphasize the fact that all of women's ills do not arise
within the pelvis and that every woman applying for treatment does not
need an intra-pelvic examination, yet at the same time I would remind the
reader of the dominance of the reproductive organs and their function through
some thirty years of a woman’s life.
The question naturally arises, what conditions or symptoms determine
the necessity of an intra-pelvic examination? While this may be left to
individual judgment, and while I still believe that there is a great deal
of meddlesome gynecology, the presence of certain symptoms and conditions
as elicited by the anamnesis demand such an examination unless positive
contraindications for it exist.
1. Disorders of menstruation, amenorrhoea, dysmenorrhoea, menorrhagia
or metrorhagia when not easily controlled. In cases of women other than
virgins the examination may properly be made as soon as the patient presents
Fig. 7. Showing the use of the
unflexed third and fourth fingers in examination and treatment, also the
approximation of the fingers with only the vaginal and abdominal walls
intervening in bi-manual examination before attempting to palpate the separate
2. The presence of abnormal discharges (either in kind or amount) mucous,
pus or blood.
3. The presence of pain in the pelvis or in some sympathetically related
part as the dorsal, lumbar or sacral regions of the spine, hips, thighs,
bladder, rectum, etc.
4. The presence of pain or disturbed function elsewhere in the body
concurrent with the menstrual periods, as headache, backache, indigestion,
etc., occurring immediately before, during or after the menstrual period.
5. Disordered psychic or mental conditions concurrent with menstruation.
6. Obscure cases in which it is necessary to eliminate pelvic pathology
as a causative or contributing factor.
While it may he true that many cases of pelvic trouble can be cured
without an examination, it is a fact that any physician attempting to cure
a pelvic disease without an intra-pelvic examination and a correct diagnosis
is working in a haphazard and unscientific manner. It is just as sensible
to attempt to cure a general disorder without an examination and just as
great an injustice to the patient. It is only in virgins that such an examination
may be dispensed with and in these much can be learned by a recto-abdominal
examination. It sometimes becomes necessary in such cases to make an examination
Every intra-pelvic examination should be preceded by an inspection of
the external genitals. This is first a matter of precaution on the part
of the examiner as by it he or she might be saved an accidental syphilitic
or chancroidal infection. It is further the first step in the diagnosis.
Some disease of the external genitals may be the cause of the symptoms
that are suspected to arise within the pelvis. Ulceration, inflammation,
new growths, deformities or abnormal discharges should he looked for. Especial
attention should, be given to the clitoris and the possibilities of adhesions
or accumulations of smegma about it.
We will assume that the patient to be examined is at least a married
woman and perhaps one who has borne children. She is placed on the examination
table in the dorsal position with the knees flexed and abducted. (Fig.
6.) She is covered with a sheet to minimize exposure. The bladder
and rectum should previously have been emptied. Ordinarily the physician
both for examination and treatment stands at the side of the table and
reaches under the thigh of the patient. In some cases it is better to stand
at the end of the table between the separated knees of the patient. This
position enables the examiner to use his body weight against his elbow
so that more force may be used and the fingers not only passed deeper into
the pelvis by the invagination of the pelvic floor but the examination
made more thorough and less tiresome. The use of sterilized rubber gloves
is always preferable. In their absence the physician's hands should be
thoroughly cleansed with soap and water. While the vagina is lined with
pavement epithelium similar to that of the skin and the ease of infection
here has been exaggerated, still this is no excuse for anything less than
surgical cleanliness. The nails of the index and middle fingers should
be trimmed short and freely anointed with a good lubricant. The following
can be recommended as a good one not only for the hands but for instruments
as well. It is non-greasy and washes off the hands easily. Into one pint
of a saturated solution of Boracic Acid stir one-fourth of an ounce of
Gum Tragacanth. Ten drops of oil of lavender or of carbolic acid may also
be added. Set aside until dissolved, stirring occasionally with any sterile
instrument. If it should be too stiff add water.
It has been my custom to use my right hand as the intra-pelvic hand
not only because the tactile sense is better developed in that hand, but
also because, being right handed, I am more dexterous with it than with
the left. It is advised by some that the right hand be used to explore
the right side of the pelvis, and the left hand for the left side. Personally
I prefer the use of only one hand for intra-pelvic examination and manipulation.
By extending the unflexed third and fourth fingers along the natal cleft
(Fig. 7) instead of flexing them into the palm of the hand the pelvis can
be a little more deeply explored.
The use of rubber gloves is recommended as a routine practice. Emergencies
arise when they are not at hand and soap and water sterilization must be
depended upon. Gloves should always be used when there is any suspicion
of venereal disease.
The examiner is now to have the severest test of his tactile sense and
his manipulative skill. He is to determine the size, shape, position, mobility
and consistence of tissues and organs, as it were, floating in a medium
of almost their own consistence. Patience, practice, a knowledge of location
and the ability to visualize this location are the means to expert diagnosis.
Abnormalities cannot be recognized unless one has a knowledge of the normal.
So no occasion should be lost to acquire this knowledge and to educate
the tactile sense to the feel of the normal pelvic contents. Only after
repeated examinations can this be done but not until then is the examiner
able to detect abnormalities.
As the fingers pass into the vagina the size of its opening, its interior
capaciousness, the tone of the pelvic floor or its resistance to pressure
downward and backward and evidences of lacerations should be carefully
noted. As the fingers are passed backward any swelling, induration, tenderness
or other abnormality of the walls should be carefully looked for. The relation
of any of these to urethra, bladder, vulvo-vaginal glands, rectum or ureteral
location should be noticed and further examination pursued later.
The fingers should now be passed deeper into the pelvis and the cervix,
the chief intra-pelvic landmark, located. It is found about three inches
from the vulva, approximately in the middle of a line connecting the ischial
spines. In the non-parous woman it will be recognized as a firm, somewhat
hard, conical protuberance about one inch in diameter, and projecting at
a right angle, for about three-fourths of an inch into the upper portion
of the vagina. In the center of its end there is a slight depression, the
external os. Childbearing makes certain changes in the cervix. It
becomes softer, broader, and seemingly shorter. The os becomes more patulous,
often admitting the tip of the finger, and instead of being a round depression
it may be felt as a transverse slit or small scars may be felt radiating
from it. If it has been severely lacerated it may be divided into two or
more distinct portions. In some diseased conditions it may become very
much enlarged. Attention should be given to all these changes from the
The cervix should point backward and slightly downward (Fig. 1). Its
position and direction are of some aid in diagnosing displacements of the
uterus, but a diagnosis should never be made from the direction of the
cervix alone. The body of the uterus should always be located.
The cervix should now be tested for mobility. Under normal conditions
with the fingers on either side or front and back, it is freely and painlessly
movable in all directions. If its motion is restricted or painful either
adhesions or inflammation are present. If adhesions they will restrict
motion toward the side opposite their location, i.e., if they are on the
right side of the pelvis they will restrict motion toward the left. If
they are of recent formation stretching them will cause pain. If pain is
caused on the side toward which the cervix is forced it is caused by pressure
upon an inflamed organ or tissue, an ovary, uterine tube, abscess, etc.
The cervix is sometimes immobilized by malignant involvement of the adjacent
tissues. Hypermobility of the cervix less frequently occurs and is the
result of undue laxity or loss of tone of the pelvic floor, often the consequence
of injuries to the Perineum,
The next step in the examination is the palpation of the uterus. For
this both hands are necessary, one on the abdomen to make counter-pressure
and force the uterus down upon the fingers of the other hand, which remains
in the vagina, so that it may be more easily and readily felt by these
fingers. The intra-vaginal fingers are decidedly the more important and
effective element in the examination. It is true that a great deal is learned
through the sense of touch in the external hand, but while it has the thickness
of the abdominal tissues through which to feel, the internal fingers have
only the thinner vaginal wall and upon these most reliance must be placed
for palpatory findings.
Some systematic plan should be pursued and the following is suggested
especially for the inexperienced. To these the intra-pelvic examination
is for a long time unsatisfactory and disappointing in that they are unable
to differentiate or even definitely feel the different pelvic organs. As
one gains in experience and efficiency the organs become more easily palpated
and the examiner may then modify his routine and adopt the method by which
he gets most accurate and quickest results.
First determine the thickness of the tissues between the anterior vaginal
wall and the skin without the presence of any intervening organs. To do
this approximate the fingers of the two hands by placing the external hand
upon the abdominal wall (either bare or at most with only a thin garment
over it) at a point slightly below midway between the umbilicus and the
os pubis and to one side of the median line, about the outer edge of the
rectus muscle. The hand should be placed upon the skin slightly lower down
than the point it is ultimately to rest upon and the skin pushed up to
this point. The most usual mistake is to place the hand too low down; too
close to the os pubis. The fingers should be slightly curved and a gentle
downward pressure made in the direction of the pelvic axis. At the same
time the fingers within the vagina press upward to one side of the cervix
until the fingers of the two hands are brought together, only the vagina
and abdominal walls intervening (Fig. 7.) The thickness of the tissue between
the two hands will vary greatly in different individuals as they are thin,
stout or muscular. It should be carefully estimated as preparation for
the next step.
The intra-vaginal fingers are now placed deeply in the pelvis just in
front of the cervix and without relaxing its pressure the external hand,
and the tissues with it, is moved toward the median line and the uterus
is brought between the fingers (Fig. 10). It will be recognized by the
additional thickness intervening between the fingers and its firmer consistence
as compared to the tissues of the abdominal and vaginal walls.
In making such an examination every effort should be made to secure
relaxation on the part of the patient and nothing should be done by the
examiner to defeat this end. The patient's head, and sometimes the shoulders
as well, should be elevated to secure relaxation of her abdominal muscles;
her hands should be at her sides and she should be instructed to breathe
naturally and easily. It is sometimes well to engage her in conversation
during the examination as this tends to natural respiration. Advantage
may be taken of the relaxation which follows a deep expiration and the
fingers pressed deeper into the pelvis and the examination facilitated.
Continuous firm but gentle pressure should be maintained by the abdominal
hand. Quick, jerky, gouging movements excite muscular resistance and increase
the tension of the abdominal walls. If failure to locate the uterus should
occur repeat the procedure carefully, feeling more deeply into the pelvis
and centering your attention upon the touch perceptions of the internal
Another method, observing all the details heretofore mentioned, is after
locating the cervix, press it upward, and forward with the two fingers
in the vagina and at the same time insinuate the fingers of the abdominal
hand deeply into the pelvis, behind the uterus and bring it forward. Without
relaxing their pressure the fingers in the vagina are passed to the front
of the cervix and the body of the uterus is brought between the two hands.
After the uterus is located it should be determined whether or not it
is in its normal position and location. If it is not the direction of its
deviation should be ascertained. Its size, whether normal or smaller or
larger than it should be, and be determined. Tenderness on pressure;
freedom from growths; consistence whether soft and fluctuating, firm and
regular or hard and nodulated, are of importance as is also the angle formed
by the body and cervix. It should be possible to carry it out of its normal
position to a considerable degree without pain or discomfort. If this is
not possible the motion which is limited, or produces pain, should be carefully
determined and the cause for the limited motion or pain located.
Fig: 8. Recto-abdominal Palpation.
In palpating the ovaries it must be remembered that normally they are
lateral to the uterus, slightly posterior and higher in the pelvis than
its body. They are opposite a point on the abdominal wall about two inches
medial to the anterior superior spines of the ilium and an inch and a half
below this point. (Fig. 3.) It requires considerable practice to examine
the normal ovary, especially if the patient has thick or unyielding abdominal
walls. Sometimes one is forced to the conclusion that the ovaries are normal
even though they cannot be found after a careful examination, if there
is no tenderness about their normal location. In examining for them the
intra-vaginal fingers are pressed backward, upward and outward by the side
of the cervix while the abdominal hand over the site of the ovary is pressed
backward and downward in the axis of the pelvis. The fingers of the
two hands are now approximated, the internal hand being relied upon for
palpatory findings. It is sometimes well to first approximate the fingers
of the two hands with only the abdominal and vaginal walls between them
to determine their thickness before attempting to palpate the ovary.
If the ovary is not found at the first attempt, while still maintaining
the external pressure, press the vaginal fingers deeper into the pelvis,
change them a finger's breadth either outward or toward the median line
and repeat the attempt until the ovary if found. Gentleness and relaxation
as suggested in palpating the uterus are of great assistance. If not found
in their usual location the ovaries when displaced tend to fall downward
and backward into the recto-uterine excavation. To examine this region
press the intra-vaginal fingers into the pelvis posterior to the cervix
and the abdominal hand downward and backward in the median line as in the
palpation of the uterus. Approximate the fingers of the two hands behind
the uterus, slightly outward from the median line and if prolapsed the
ovaries can usually be felt.
Pressure upon the normal ovary gives rise to a peculiar sickening pain.
When they are located their size, tenderness and mobility should be determined.
The uterine tubes in their normal condition are even more difficult
of palpation than the ovaries. The method given for palpating the
ovaries will locate them if they are swollen or filled with fluid. Under
these conditions they are recognized by their tortuous course and the irregular
bulgings which occur along them. In severe cases the tube may be so enlarged
as to fill the entire side of the pelvis. In cases of thin and relaxed
abdomens the normal tube may be felt as a small soft cord by palpating
out from the angle of the uterus in the direction of its course. Even under
the most favorable conditions it is the firmer isthmus and not the ampulla
that can be felt. In severe tubal inflammation the tube and ovary may be
so agglutinated as to form a single mass in which neither organ is separately
The normal ureters can only occasionally be palpated. They run from
the base of the bladder backward and outward and upward through the pelvic
connective tissue, about one-half to three-quarters of an inch on either
side of the cervix. When they are inflamed or thickened they can be felt
as tender cords. Occasionally a stone impacted in their pelvic portion
can be palpated through the vagina or rectum. An attempt to palpate them
should be a routine part of every examination. Tenderness or induration
along their course would be suggestive of inflammation, an impacted stone
Recto-abdominal palpation (Fig. 8) as has heretofore been suggested
is sometimes advisable in the case of virgins. The information secured
is limited but at times valuable. Only one finger can be used in the rectum
without anesthesia, as a rule, and only the structure lying low in the
pelvis can be reached with this. The cervix can easily be felt through
the anterior rectal wall. Retrodisplacements are as a rule easily detected
by this method. Often when a mass is found low in the posterior part of
the pelvis by vagino-abdominal palpation it is well to further examine
it through the rectum. Its value is frequently of a negative character.
If there is the absence of tenderness, induration or a mass in the recto-uterine
excavation one is fairly safe in assuming that there is no serious disorder
there. Should any of these he present when an attempt is made to approximate
the abdominal hand and the finger in the rectum their nature and relationship
to the pelvic organs should he determined.
In this examination the gloved or cotted index finger should be used
and it should be pased as high into the rectum as possible. If is turned
forward and while counter pressure is made with the hand on the abdomen
an effort is made to differentiate the organs and conditions, that may
Recto-vagino-abdominal palpation is sometimes perforrned. With one hand
on the abdomen making counter pressure the index finger of the other hand
is introduced into the rectum and the thumb into the vagina. Occasionally
a case may be seen in which some additional information can be secured
by this method.
Figure 9. Erect Position
Examination in the erect posture (Fig. 9) becomes necessary in
extremely rare cases. Occasionally it may be impossible to determine
the amount of descent of the uterus in a case of suspected prolapse
unless the patient is examined while standing. For this the examiner
sits in a chair and the patient stands in front of him with one
foot upon a stool and the vaginal examination is made in this position.