Pelvic Exams: A Modern Guide

Hey Scarleteen readers! I’m Caitlyn, and I’m a pelvic health physical therapist. I specialize in helping people of all genders with issues ranging from constipation to painful sex⁠ (sex: Different things people choose to do to actively express or enact sexuality and sexual feelings; often this involves genitals, but not always. ) to recovery after pregnancy⁠ (pregnancy: The state of carrying a developing embryo or fetus within the uterus. Medically, someone is considered to be pregnant when an egg has been fertilized by sperm, cells divide, and the fertilized egg is implanted within the lining of the uterus.) . You might have read some of my other articles on painful peeing, endometriosis, and other topics.

I’m going to dive into pelvic exams here: what they are, why you might need one, and how to make them a comfortable and positive experience. If you’ve never had a pelvic exam from a medical professional, check out⁠ (out: Short for ‘out of the closet’. When someone’s LGBTQ+ identity is known to other people.) Scarleteen’s handy guide to your first gynecology appointment here.

Perhaps you’ve had pelvic exams in the past, and they didn’t go so smoothly. Discomfort and anxiety surrounding medical exams in general, and pelvic exams in particular, are common problems. Fortunately, the medical community is working hard to address these concerns and improve the experience for patients – hence the reason for this article!

We’ll start by learning why a pelvic exam may be necessary, and then we’ll discuss how it can be modified for people experiencing discomfort. We’ll finish by discussing the type of pelvic exam performed by pelvic PTs like me: how it differs from a gynecologist⁠ (gynecologist: (Pronounced guy-na-coll-o-jist) A doctor that specializes in the health of the uterus, ovaries, vagina, and vulva. . They may also be referred to as "OB/GYNs" or, informally, "gynos".) ’s exam, and how it can help improve your next exam at the doctor’s office.

The Whats and Whys of Medical Pelvic Exams

If you have a vagina⁠ (vagina: The internal passage leading from the opening of the vulva to the cervix of the uterus.) , your healthcare provider⁠ (healthcare provider: A qualified person to provide sound physical and/or mental healthcare, such as a doctor, nurse, clinician, counselor, medical assistant, midwife or other healthcare professional.) may need to inspect the inside of it and/or your pelvis to screen for certain medical conditions. Pelvic exams used to be commonplace at yearly check-ups for all people with vaginas after age 21. However, more recent guidelines suggest that a routine pelvic exam isn’t always necessary for a non-pregnant person with no symptoms or risk factors.

If it’s indicated by your medical situation or symptoms, your provider may recommend a bimanual exam. For this exam, the provider will place two fingers of one gloved hand inside the vagina. Their other hand will be outside, on your abdomen, a little below your belly button. They will use both hands to inspect the size, shape and position of the uterus⁠ (uterus: An internal, muscular reproductive organ in the pelvis. During pregnancy, this is where a fetus will develop. The lining of a person’s uterus is also the thing that sheds every menstrual cycle in what we call a period.) , cervix⁠ (cervix: The opening to the uterus, the bottom of which is at the back end of the vagina.) , and other nearby structures.

From time to time, your provider may need to perform a full pelvic exam with a speculum. A speculum is a plastic medical device that looks a bit like a duck’s bill. It is inserted into the vagina to help widen the (flexible) canal. Your physician can then look through the opening in the “bill” to visualize the inside of the vaginal canal.

These exams (bimanual and speculum) are typically used to rule out diseases or problems with your internal organs that could be causing symptoms. For example, your provider may need to use a speculum to check your cervix (at the far end of the vagina) for signs of cervical cancer.

Modifying the Medical Pelvic Exam

If you’ve had pain with pelvic exams in the past, or if you’re nervous about the exam, speak to your provider about it.  Modifications to the exam can make the experience more comfortable and are always okay to ask for – here are some adjustments that may be helpful.

• Your provider can select a smaller speculum size to better fit your anatomy⁠ (anatomy: The body, parts of the body, or physical structure of organisms like people, animals or plants.) .
• Your provider can apply more lubricant⁠ (lubricant: A fluid used in order to make kinds of sex (such as masturbation, vaginal intercourse, anal intercourse or manual sex) more pleasant and comfortable, and/or to help prevent condoms from breaking by decreasing friction.) to your vaginal opening⁠ (vaginal opening: The external opening to the vagina.) and the speculum. (Physicians used to worry that lube would interfere with cell sampling to screen for diseases, but that’s not the case – water-based lubricant doesn’t affect those tests.)
• You may be able to change your body position to increase your comfort. The infamous “stirrups” in which patients commonly place their feet for a pelvic exam help providers visualize the inner pelvis. However, they can feel demeaning or triggering for some people. Here are some alternative positions you may be able to try:
  • The “letter M”: knees bent and feet on the end of the exam table, thighs apart.
  • The “letter V”: on your back with legs straight out on the table, separated in a V shape.
  • The “diamond”: knees bent, soles of feet together with legs open in a diamond shape.
  • Sidelying: lying on one side with hips and knees bent up towards your torso.
• In some cases, providers can recommend anti-spasm medication to help relax the pelvic floor muscles before an exam. This is often placed inside the vagina and allowed to dissolve there to target the muscles directly. In other cases, you can be prescribed one dose of oral medication to take before the exam.

In many cases, you won’t need to worry about getting this kind of exam at all. If you don’t have symptoms or any prior history of any gynecological conditions, the speculum exam might not be very useful. Importantly, an exam with a speculum is NOT necessary to screen for sexually transmitted infections (STIs) or to prescribe birth control⁠ (birth control: Any number of methods people use to intentionally prevent unwanted pregnancy, including the condom, the cervical barrier, the implant, the patch, the pill, the rhythm method, the ring, the shot, the IUD, spermicide and withdrawal.) (unless you’re getting an IUD⁠ (IUD: Intra-uterine device. A long-term birth control method inserted into the uterus by a healthcare provider. Also called an IUS (Intrauterine system) or IUC (Intrauterine contraceptive).) ).

The same is true of bimanual exams: recent research from the American Medical Association showed that many young people have received unnecessary bimanual pelvic exams. The vast majority of providers performing these exams are well-intentioned: they are simply recommending them based on old guidelines and outdated information from their schooling and mentors. However, if you’re under 21 and have no symptoms or complaints, it’s perfectly reasonable to ask your physician for their reasons for recommending a bimanual exam.

Most importantly: the decision to perform (or not to perform) a pelvic exam should always be a shared one between you and your healthcare provider. After your provider has provided you the necessary information on how and why the exam should (or shouldn’t) be performed, you can make a decision together. In the end, the final decision should be yours: your informed consent⁠ (consent: To freely and actively agree to do a specific thing with someone else with all the information about what that thing is, and the right to change your mind.) (or your choice not to provide it) is the end-all-be-all for most forms of healthcare interventions.

Demystifying Manual Exams in Pelvic PT

A medical pelvic exam is only one method for examining the pelvis. If you have certain pelvic conditions, there are also some alternative ways to assess and manage your symptoms – and pelvic floor physical therapy is one of them. Some people come to pelvic PT specifically because medical pelvic exams are difficult or painful, and they’d like improve their tolerance for these exams.¹

I promise that it’s totally normal to be nervous about pelvic PT, especially if you don’t know what to expect, or if you’ve had negative experiences with medical exams in the past.  Let’s remove some of the uncertainty here with a basic outline of what to expect at a first pelvic PT appointment.

1. A thorough medical history – lots of talking!
   1. Understanding your backstory and medical past is a critical part of your pelvic PT’s job. They may ask you about any medical testing you’ve already completed, any other medical conditions you have, your surgical history, etc.
   2. They’ll also want to understand your life better: what you do for work or school, what you enjoy doing in your free time, and the goals you have for treatment.
   3. Due to the sensitive nature of our work, many pelvic PTs will ask specifically if you’ve had a history of trauma⁠ (trauma: A serious or critical physical and/or emotional injury or physically and/or emotionally painful experience.) – and negative experiences from medical care are included here! The more you’re comfortable sharing with your PT, the better they’ll be able to help ensure that their office is a safe, comforting space for you.

1. Movement assessment and a full-body screen
   1. Your pelvic floor is only one piece of a larger whole. Pelvic PTs understand this, so expect your PT to watch how you move and perform certain tasks. This helps them better understand how habitual movements and issues in other body parts may be affecting your pelvic floor.
   2. Your PT will also likely assess the muscles and joints near your pelvis, since issues in these neighboring areas can directly affect the pelvic floor. They may ask you to perform movements, like pulling your knees to your chest, which demonstrate the health of your hips and lower back.
   3. Sometimes body parts far away from the pelvis can still affect it. It might seem surprising if your PT wants to spend time examining your feet or your jaw, for example, but I promise that there’s a method to the madness! The more information your PT has about how your body works, the better they can tailor a treatment plan just for you.

1. Manual (hands-on) assessments
   1. After watching you move, your PT may ask to test certain body parts with their hands. For example, they may need to feel how much flexibility your hip joints have. They may ask to lightly press on various muscles to feel for tightness or tenderness. They may need to place a hand on your belly to feel how you breathe and how your abdominal muscles contract and relax.
   2. Your abdomen is very closely related to your pelvis. Abdominal exams can provide valuable information about the health of this entire body region. Your PT may ask to palpate (gently press on) the tissues of your belly.
   3. Your PT should ask for your permission before beginning any hands-on testing. Remember, you always have the right to say no and/or ask for more information about why they want to assess any area.

After this part of the exam, your PT may already have enough information to recommend a treatment plan for you. They may start by treating issues they’ve identified in related body parts like your hips or abdominals. They may suggest some behavioral modifications you can make, and teach you some simple exercises to do at home.

However, if they need more information to understand your symptoms, they may ask to perform a more in-depth assessment of your pelvic floor. They should thoroughly explain how they’d like to inspect the area, so that you can make an informed decision to provide consent (or not!).

Techniques for pelvic PT exams vary. It is entirely possible for them to be comfortable, even if you’ve experienced pain with other exams in the past. If you’d like to have another person in the room during the exam, like a family member or friend, you can request that. If you’re a minor (under 18), the presence of a parent or adult guardian in the room is required. However, the therapist will provide for privacy by draping and covering your body appropriately during the exam.

1. External examination of the genitals⁠ (genitals: Body parts that are generally, culturally, scientifically or personally considered to be external sexual or reproductive organs.) and pelvic floor
   1. Your PT can gain a lot of valuable information just by visually inspecting the outermost portion of your pelvic floor – the skin and the muscles directly underneath it. They may begin by visually inspecting the skin of the genitals, looking for redness, irritation, and other signs of problems in the area.
   2. Your PT may ask you to contract and relax your pelvic floor muscles a few times. They’ll the watch your pelvic floor to see how your muscles perform.
   3. They may ask to palpate the outside of the pelvic floor. This helps them identify any tenderness or tension in the outermost tissues.

1. Internal assessment of the pelvic floor
   1. Sometimes your PT may need additional information about your pelvic floor, and they may recommend an internal exam. Before beginning an internal assessment, your PT will thoroughly explain what they would like to check, and how they propose to do so. Again, you always have the right to decline!
   2. Most pelvic PTs perform exams using their hands exclusively – with no speculum use. Internal exams can provide a lot of valuable information, and they can be performed on anyone, regardless of your genital anatomy. However, for minors who’ve never had a pelvic exam from their physician, an internal exam at PT is not typical.
   3. For people with vaginas, most PTs suggest beginning with a vaginal exam. Typically, you’ll be lying in a comfortable position.
      1. Depending on your condition, your PT may start with a Q-tip assessment. They’ll use the tip of cotton swab to gently press on different locations around the vaginal opening, looking for areas of tenderness or other symptoms. This may provide enough information, and the exam will end here.
      2. Depending on your situation, your PT may recommend a manual (one finger) exam. They will put on clean⁠ (clean: In a sexual context, usually a word used to suggest a person doesn’t currently have anysexually transmitted infections. That term, however, stigmatizes people with illness. Less stigmatizing choices are "negative," "clear" or "STI-free.") exam gloves and place lubricant on one finger. They can they gently insert that finger into the vaginal canal, using it to assess all the internal muscles we discussed at the beginning. They may ask you to contract and relax your muscles around their finger to better assess their function.
   4. Rectal exams can be performed regardless of genital type. Rectal exams are often easiest if you are lying on one side.
      1. Your PT will gently insert one gloved, lubricated finger into the anal canal. This should feel like pressure, but it should not hurt! Your PT will use generous amounts of lubricant to ensure your comfort, and they’ll be checking in regularly to make sure you are doing okay.
      2. Your PT may ask you to contract and relax your anal muscles around their finger to better assess their function. They may gently press on the muscles, assessing for any tenderness or other symptoms.
      3. If you feel like you’re having a bowel movement during a rectal exam, don’t worry: the feeling is totally normal, and it usually fades after a minute or so. I promise you aren’t actually pooping!

While internal exams are very informative, they aren’t the end-all, be-all in pelvic PT. They do not have to be performed during your first visit, or ever, if you aren’t comfortable with the idea.

Wrapping It All Up

The point of any pelvic exam—with a gynecologist, a PT, or any other provider—is to better understand your condition and concerns in order to help address them. They can help both you and your provider better understand your situation and develop a plan to address any identified issues.

However, remember: you are in charge of what happens (or doesn’t happen) to your body—it’s always within your rights to say no! If a healthcare provider isn’t willing to respect your preferences and work with you, it’s time to seek out a second opinion.

I hope that this breakdown of pelvic exams has helped reduce some of the mystery and intimidation that surrounds them. May you feel empowered to ask questions of your providers, opening a line of dialogue that will help you make healthcare decisions as a team!