Correspondence
Pelvic Examination
N Engl J Med 2007; 357:1778-1779October 25, 2007
- Article
To the Editor:
Edelman and colleagues (June 28 issue)1 describe the standard American method of performing a pelvic examination in their Videos in Clinical Medicine. The dorsal lithotomy position with stirrups is not the only possible method. In Europe, many providers use a lateral position with one leg abducted, and stirrups are usually not used.
Many women are anxious about the pelvic examination because of potential pain, embarrassment, or other reasons. Alternative methods have been suggested, and it has been reported that some of them improve the examination experience for the patient. My colleagues and I recently reported that the use of a no-stirrup technique reduced patients' physical discomfort and sense of vulnerability.2 Self-insertion of the speculum has been found to be a good alternative for some women.3 A semi-sitting position may be preferable for adolescent patients.4
A crucial aspect of the pelvic examination is maximization of the patient's sense of dignity and control. Edelman et al. stress proper gowning of the patient, good eye contact, and continuous communication. Inexpensive and easy methods that reduce stress and discomfort (e.g., self-insertion of the speculum, a sitting position, or an examination without stirrups) should be offered as ways of improving the experience of patients.
Dean A. Seehusen, M.D., M.P.H.
Eisenhower Army Medical Center, Evans, GA 30809
dseehusen@msn.com (The opinions expressed in this letter are those of the author and do not necessarily represent official policies or views of the Department of Defense.)
4 References1
Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination. N Engl J Med 2007;356(26):e26.
2
Seehusen DA ,Johnson DR ,Earwood JS , et al. Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial. BMJ 2006;333:171-171
CrossRef | Web of Science | Medline3
Wright D ,Fenwick J ,Stephenson P ,Monterosso L . Speculum `self-insertion': a pilot study. J Clin Nurs 2005;14:1098-1111
CrossRef | Web of Science | Medline4
Seymore C ,DuRant RH ,Jay MS , et al. Influence of position during examination, and sex of examiner on patient anxiety during pelvic examination. J Pediatr 1986;108:312-317
CrossRef | Web of Science | Medline
To the Editor:
The majority of physically and mentally disabled women can successfully undergo a pelvic examination in the office setting without being subjected to the risks of general anesthesia, which are increased for these women.1 According to the 2000 U.S. Census, persons with disabilities represent 19.3% of the 257.2 million people who are 5 years of age or older in the civilian noninstitutionalized population in the United States.2 A combination of mild sedation, alternative positioning, and previous visits devoted to accommodating the patient to the office setting and to providers goes a long way.
2 ReferencesSusan M. Richman, M.D.
Yale University School of Medicine, New Haven, CT 06520
susan.richman@yale. edu 1
Vadivelu N ,Harkness P ,Richman S ,Shelley KH . Special anesthetic concerns in mentally handicapped institutionalized patients undergoing gynecological procedures in an outpatient setting. Conn Med 2004;68:359-362
Medline2
Richman S . Gynecologic care of women with physical disabilities. Obstet Gynecol Surv 2007;62:421-423
CrossRef | Web of Science | Medline
To the Editor:
The video by Edelman et al. states that rectovaginal examination can be used to screen for colorectal cancer in women over the age of 50 years. This is not actually the case. Acceptable methods for colorectal-cancer screening include the use of an annual home fecal occult-blood test, periodic colonoscopy (every 10 years), flexible sigmoidoscopy (every 5 years) with or without an annual home fecal occult-blood test, and a double-contrast barium enema (every 5 years).1
The U.S. Preventive Services Task Force, the American Cancer Society, and a number of other professional organizations state that a single fecal occult-blood test performed at the time of a digital rectovaginal or rectal examination is not an acceptable method of screening for colorectal cancer. Most colorectal cancers develop in areas not palpable by the examining finger, and the sensitivity of a single digitally collected fecal occult-blood test is poor. Collection of three stool samples at home on guaiac-based cards is more effective. Colorectal-cancer screening remains underused, despite the availability of effective screening strategies.
1 ReferencesLeila C. Kahwati, M.D., M.P.H.
Veterans Affairs National Center for Health Promotion, and Disease Prevention, Durham, NC 277051
U.S. Preventive Services Task Force. Screening for colorectal cancer: recommendations and rationale. Rockville, MD: Agency for Healthcare Research and Quality, July 2002. (Accessed October 4, 2007, at http://www.ahrq.gov/clinic/3rduspstf/colorectal/colorr.htm.)
Author/Editor Response
Fear on both ends of the examination table never serves anyone well, since the patient comes away with a bad experience and the provider is unable to elicit sufficiently helpful findings. Our video was developed as a teaching tool to help those in the process of learning the basic techniques of the pelvic examination and the Papanicolaou smear. The video was designed to help such learners so that they can, with additional, live instruction, provide a comfortable, safe environment for patients while confidently performing a basic, comprehensive pelvic examination.
Seehusen and Richman separately point out that there may be alternative techniques for the standard pelvic examination illustrated in the video. We agree that such alternative techniques can be extremely helpful in more challenging situations — for examination of pediatric and adolescent patients; sexual-assault victims; women with pelvic pain, vulvodynia, or vaginismus; or women with physical or mental disabilities. These patients and the techniques noted by Seehusen and Richman require providers who have advanced skills that are beyond the scope of this introductory video.
With respect to Kahwati's comments: the primary goal of the video is to show the basics of the pelvic examination, not to address comprehensively the acceptable approaches for colorectal-cancer screening. However, we could have been more specific regarding the use of digital rectal examination with fecal occult-blood testing. The addition of in-office fecal occult-blood testing may improve the detection of colorectal cancer, since less than 10% of cancers occur within reach of a digital rectal examination. However, as Kahwati notes, the sensitivity of the test is low.1-3 The additional use of annual in-home fecal occult-blood testing (three samples) may increase detection, as compared with one sample,2 although many patients do not complete such testing. In-office testing may help with adherence and provide an opportunity to discuss colorectal-cancer screening. In any case, whether the result of a digital rectal examination with office fecal occult-blood testing is positive or negative, patients should be encouraged to have one of the additional recommended screening techniques listed by Kahwati.
3 ReferencesAlison Edelman, M.D., M.P.H.
JoDee Anderson, M.D.
Ken Tegtmeyer, M.D.
Oregon Health and Science University, Portland, OR 97239-30981
Winawer SJ ,Fletcher RH ,Miller L , et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594-642[Erratum, Gastroenterology 1997;112:1060, 1998;114:625.]
CrossRef | Web of Science | Medline2
Bini EJ ,Rajapaksa RC ,Weinshel EH . The findings and impact of nonrehydrated guaiac examination of the rectum (FINGER) study: a comparison of 2 methods of screening for colorectal cancer in asymptomatic average-risk patients. Arch Intern Med 1999;159:2022-2026
CrossRef | Web of Science | Medline3
Burke CA ,Tadikonda L ,Machicao V . Fecal occult blood testing for colorectal cancer screening: use the finger. Am J Gastroenterol 2001;96:3175-3177
CrossRef | Web of Science | Medline
