Genital Examination in Women - A resource for skills development and assessment - Royal College of Nursing
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Genital Examination in Women
A resource for skills development and assessment
CLINICAL PROFESSIONAL RESOURCE
Endorsed byGENITAL EXAMINATION IN WOMEN
Acknowledgements
This document was reviewed and updated in Marie-Therese Massey, RCN Professional Lead
May 2020 with thanks to: for General Practice Nursing
Debby Holloway, RCN Women’s Health Forum Fiona Smith, RCN Professional Lead for Children
Committee Chair, Consultant Nurse and Young People
Deb Panes, RCN Women’s Health Forum
Dr. Kathy French, RCN Public Health Forum and
Committee member
Independent Sexual Health adviser
Ellie Stewart, RCN Women’s Health Forum
Committee member Belinda Loftus, RCN Public Health Forum and
Cluster Manager for Integrated Sexual Health
Nikki Noble, RCN Women’s Health Forum
Services – Spectrum CIC
Committee member
FSRH Clinical Standards Committee
Sally Stacey RCN Women’s Health Forum
Committee member, Wendy Norton, Senior Lecturer, The Leicester
Ruth Bailey, RCN Women’s Health Forum School of Nursing, De Montfort University,
Committee member Leicester
Katharine Gale, RCN Women’s Health Forum Mike Passfield, Head of Clinical Service,
Committee member Integrated Contraception and Sexual Health
Carmel Bagness, RCN Professional Lead for Services (iCaSH) Chair of the Clinical Standards
Midwifery and Women’s Health Committee, Faculty Sexual and Reproductive
Helen Donovan, RCN Professional Lead for Health
Public Health Nikki Mills, RCN Project Co-ordinator
It is recognised that services are provided by nurses and midwives in a range of settings. For ease
of reading, the generic terms ‘nurse’, ‘nursing’ and ‘nurses’ are used throughout this document
to indicate the roles and contributions of nurses, midwives, specialist community public health
nurses and nursing associates including support workers, where appropriate .
This publication will be reviewed in June 2023 to provide feedback on the contents or on your
experience of using the publication. Please email publications.feedback@rcn.org.uk
Publication
This is an RCN practice guidance. Practice guidance are evidence-based consensus documents, used to guide decisions about appropriate
care of an individual, family or population in a specific context.
Description
This publication provides standards and sample assessment tools for training in genital examination in women for registered nurses working
in sexual and reproductive health settings, and related health and social care settings.
Publication date: June 2020. Review date: June 2023
The Nine Quality Standards
This publication has met the nine quality standards of the quality framework for RCN professional publications. For more information, or to
request further details on how the nine quality standards have been met in relation to this particular professional publication, please contact
publications.feedback@rcn.org.uk
Evaluation
The authors would value any feedback you have about this publication. Please contact publications.feedback@rcn.org.uk clearly stating
which publication you are commenting on.
RCN Legal Disclaimer
This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers are
advised that practices may vary in each country and outside the UK.
The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been
made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it
may be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be caused
directly or indirectly by what is contained in or left out of this website information and guidance.
Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN
© 2020 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without
prior permission of the Publishers. This publication may not be lent, resold, hired out or otherwise disposed of by ways of
trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers.
2ROYAL COLLEGE OF NURSING
Contents
1 Introduction 4 Requests for female only practitioners 15
About this document 4 Protecting the practitioner 15
Why are genital examinations performed? 5 Antenatal contraindications 15
Who can undertake genital examinations? 5 Language barriers 15
Professional issues 6 Examinations under anaesthetic 15
Valid consent 6 Capacity issues 15
Confidentiality 7 Children 16
Chaperones 7
3 Learning outcomes framework 17
2 Knowledge and skills 8 Purpose and scope of this learning and
assessment framework 17
The examination environment 8
Learning outcomes 17
Prior to examination 8
4 Training and assessment process 18
The examination 10
Introduction for trainers and assessors 18
Abdominal inspection and examination 10
Standards for learning and competency 19
External genital examination 10
Vaginal examination 11
Appendices 20
Speculum examination 11
Appendix 1: Sample learning contract 20
Sims speculum use 12
Appendix 2: Sample logbook 21
Speculum examination and STI
screening in pregnant women 12 Appendix 3: Sample assessment of learning
outcomes and competence tool 22
Bimanual genital examination 12
Appendix 4: Sample consultation
Following the examination 13 feedback form 23
Specific considerations 13 Appendix 5: Sample evaluation of learning
and assessment form 24
History of trauma 14
Appendix 6: Sample certificate of
Post menopausal atrophic vaginitis 14 competence 25
Vaginismus 14
References and further reading 26
Female genital mutilation 15
Police use of restraints 15
3GENITAL EXAMINATION IN WOMEN
1. Introduction
examination carried out for assessment of people
About this document who are non-binary and trans-gender.
The continuing development and extension of The purpose of this document is to provide
nursing roles benefits both nurses and their standards and sample assessment tools for
client groups. The ability to carry out genital and training in genital examination in women
bimanual examinations is now a key requirement for registered nurses working in sexual and
for many nurses working in primary, secondary reproductive health settings, and related
and community care settings. health and social care settings. It assumes
In order to enhance service delivery, more an extensive knowledge of relevant anatomy,
registered nurses are performing examinations, physiology and pathology. It is envisaged that
procedures, and observations involving this document could be used by registered health
female genitalia (often referred to as intimate care professionals who would require training
internal vaginal or genital examinations). in genital examination in order, for example, to
Genital examinations form part of many undertake the following procedures:
routine assessments of women and are used for
• cervical sampling including liquid based
diagnostic and treatment purposes related to
cytology and colposcopy
gynaecological, obstetric and sexual health care.
• taking swabs as part of a sexual health
This document has been developed for: examination
• registered nurses, midwives and nursing • inserting, checking or removing intrauterine
associates working in NHS, independent and devices and IUS
private practice arenas
• vaginal ultrasound
• sexual and reproductive health nurses
(including contraceptive advice) • hysteroscopy
• practice nurses • nurses working within early pregnancy and
acute gynaecology settings
• nurses working in gynaecology, fertility
services, early pregnancy assessment • and as part of any extended role in history
units, custody suites, colposcopy, urology, taking and examination for the assessment of
community, sexual assault referral centres, symptomatic women.
forensics, and acute-based services and Training is intended to enable registered health
ultrasound care professionals to demonstrate competence
• health care professionals working in induced at recognising the abnormal or symptomatic
abortion services from the normal or asymptomatic pelvis, and
not necessarily to make a diagnosis of genital
• service providers and managers pathology. If any abnormality is suspected then
• education providers an experienced clinician should be consulted
without delay to review the findings. Health
• clinical risk teams (for review of practice, risk care professionals should aim to make this
assessment and review of individual practice) examination as comfortable and non-threatening
as possible, maintaining sensitivity and respect
• service and education commissioners
for the woman’s dignity.
• health care assistants and support workers,
This guidance will enable suitably qualified
with clarity around their roles.
health care professionals to undertake
The RCN recognises we live in a gender diverse genital examination in a competent and safe
society and that this guidance includes genital manner; to help trainers and assessors in the
4ROYAL COLLEGE OF NURSING
training process; and to ensure safe practice cervical curettage, fitting of ring pessaries,
for women needing a genital examination. insertion of prostaglandin pessaries, post
Genital examination should only be undertaken surgical/radiotherapy follow-up, removal of
following appropriate history taking. a foreign body, vaginal dilatation, fitting of
contraceptive devices, removal of placenta,
All health care professionals should ensure that evacuation of retained products, transvaginal
they work within clearly defined boundaries of chorionic villus sampling, endometrial
clinical competence in relation to assessment, ablation, and assisted reproduction techniques
diagnosis and treatment; making prompt and such as insemination or embryo transfer.
appropriate referral as indicated by the findings
of the procedure.
Who can undertake
Registered nurses, midwives and nursing genital examinations?
associates work to the Nursing and Midwifery
Council Code (NMC, 2018) which includes the Registered nurses and midwives are personally
need to be knowledgeable, as well as caring and accountable for their practice and answerable
respectful, and to observe confidentiality in all for their actions and omissions. All nursing staff
encounters with women as patients and as clients. and midwives have a duty of care to women,
who are entitled to receive safe and competent
It is anticipated that registered nurses, midwives care. Competence is defined as ‘possessing the
and nursing associates would access training, skills and abilities required for lawful, safe and
where a clear need to learn these skills is effective practice without direct supervision’
identified and where, as with other clinicians, (NMC, 2018). There is no single recognised
a sufficient number of women are seen in order training programme required in order to achieve
that competencies are maintained. They should competence to perform vaginal or genital
be working with a relevant post-registration examinations. Some extended roles do have
qualification. All midwives will develop skills recognised training, which would need to be
as part of their pre-registration midwifery completed prior to undertaking a procedure
qualification, and therefore this document unsupervised, for example colposcopy as
is intended as both a refresher and guide for regulated by the British Society for Colposcopy
enhancing practice. and Cervical Pathology (BSCCP). Midwives
are required to perform vaginal examination
Why are genital and nurses undertaking hysteroscopy training
from the The British Society for Gynaecological
examinations performed? Endoscopy (BSGE) as part of routine care
provision, including registered nurses fitting
A genital examination is performed in the three
intrauterine contraceptive devices all must be
main areas of health care below.
competent in genital bimanual examination.
• Assessment or diagnosis – for example,
The role of health care assistants and assistant
of adnexae, vagina, external genitalia, genital
practitioners should be clarified before
infections, colposcopy, cervical biopsy,
engagement in examination procedures. Where
pregnancy and labour, removal of foreign
clinical judgement is required, this is the role of
body, ie, a tampon, uterine and vaginal
the registered practitioner. It is expected that
prolapse, incontinence, vaginal swabs,
the health care assistant/support worker, having
Bartholin’s cyst and abscess, transvaginal
relevant training, will contribute to nursing care,
ultrasound, vaginal bleeding, amenorrhoea,
and their role here will be around preparation of
searching for illegal substances, vaginal
the area and chaperoning.
trauma, hysteroscopy, investigation of alleged
sexual abuse or rape.
Registered nursing associates training
• Screening – for example, cervical cytology, in cervical sample taking (England only)
transvaginal ultrasound, vaginal and cervical
swabs. In 2019, the NHS Screening programme
announced that registered nursing associates
• Treatment – for example, removal of polyps, would be eligible to perform cervical screening.
5GENITAL EXAMINATION IN WOMEN
The following statement was issued by NHS When a NA has registered with the NMC,
Cervical Screening Programme, Health Education a registered professional listed under the
England and NHS England/NHS Improvement legislation (registered nurse or GP) will need to
Primary Care Nursing team in September 2019: supervise the practice of that NA. The supervisor
must be present at the GP practice when the NA
“Enhancing the skill base of registered nursing is carrying out the procedure. The supervisor can
associates (NAs), with the appropriate competency- undertake indirect supervision of the NA when
based training in cervical screening, will: carrying out this procedure. This is a delegated
activity and the NA would be expected to work
• increase the number of sample takers across
within the remits of their professional code.
the country
• improve access to screening NHS England/Improvement, Health Education
England and PHE are working together to follow
• support screening’s aim to reduce the a test cohort of registered nursing associates to
incidence of cervical cancer and reduce the undertake cervical sample taker training. This
number of women who die from it evaluation will help make sure that the new
profession of registered nursing associates can
Registered NAs working in primary care are
support primary care and health services to
eligible to train to undertake the role of cervical
deliver this aspect of care. Any lessons learnt
sample taker.
from the evaluation will be incorporated into
Governance arrangements: Screening providers the training guidance and communicated to
need to ensure the following governance providers by NHS England’s primary care
arrangements are in place: nursing team and PHE screening.
(Public Health England 2019)
Registered NAs must meet the core clinical
competencies in the Skills for Health competency
framework set out in the HYPERLINK “https:// Professional issues
www.gov.uk/government/publications/cervical-
screening-cervical-sample-taker-training” NHS Valid consent
CSP sample taker training guidance. When any nursing or midwifery procedure takes
place, valid consent must be obtained from the
To undertake cervical screening, NAs must have:
woman. Failure to do so may leave a nurse or
• completed a nursing associate qualification midwife vulnerable to the charge of assault.
and be registered as a NA with the Nursing
The Government and professional bodies (such
and Midwifery Council (NMC)
as the RCN), as well as regulators (such as the
• undertaken initial theory and practical NMC) provide a range of guidance documents
training as required by the NHS CSP, on the issue of consent in a variety of situations,
successfully completed the course and for example, young people, people with learning
assessed as competent disabilities, in research, or people in prison. The
information provided should also include an
• undertaken update training and maintained explanation of the status of the person performing
competency in line with national cervical the examination (for example, ‘learner’).
sample taker training guidance
No one has the right to consent on behalf of
Local governance: The registered NA role is not
another competent adult.
yet a named profession under the Treatment of
Disease, Disorder or Injury (TDDI) legislation Key principles for obtaining consent from a
regulated by the Care Quality Commission woman undergoing the examination procedure
(CQC). However, the CQC expects any provider should ensure that:
to consider safety, quality, competency and TDDI
legislation when deploying a NA. See www.cqc. • she is a legally competent person
org.uk/sites/default/files/20190123_briefing_ • consent is given voluntarily
for_providers_nursing_associates_0.pdf CQC
briefing for providers. • she is informed
6ROYAL COLLEGE OF NURSING
• she is aware and understands she can Chaperones
withdraw her consent at any time.
A chaperone is present as a safeguard for
Consent can be given in writing, spoken, or everyone concerned (woman and practitioners)
implied (by co-operation). Only in emergencies, and is a witness to continuing consent of
where treatment is intended to preserve life the procedure. (NHS Clinical Governance
may care be provided without consent. Usually Support Team, 2005). The General Medical
the nurse or midwife performing the procedure Council (2013) and Care quality Commission
is the person obtaining consent. The consent (2015) provide further information on the use
process should not be hurried. The woman of chaperones. All women should always be
should be given sufficient time to process offered a chaperone* to be present during an
information about the pros and cons of the examination, procedure, treatment or any care,
procedure, and given time to ask questions irrespective of organisational constraints or
before arriving at a decision to accept or refuse the settings in which this is carried out. The
planned care. offer and response should be documented in the
woman’s records.
Children and young people under 16 years of
age are able to consent to treatment, provided When the chaperone is a nurse or another
they are deemed competent. Nurses or midwives member of the health care team, they can act as
working with children and young people should an advocate for the woman to:
be aware of current law with regard to obtaining • explain what will happen during the
consent in each of the four countries of the UK. examination or procedure, and the reasons
For example, the consenting age in Northern why
Ireland and Scotland is now 16 years of age
(Sexual Offences (Northern Ireland) Order 2008) • assess the woman’s understanding of what she
and Scotland has the Age of Legal Capacity Act has been told
(Parliament, 1991). • provide a reassuring presence during the
examination or procedure
Confidentiality
• safeguard against any pain, humiliation,
Patient information is generally held under intimidation or unnecessary discomfort
legal and ethical obligations of confidentiality.
Information provided in confidence should not • observe the woman to ensure she feels safe
be used or disclosed in a manner that might and is comfortable
identify a woman without her consent. • always be sensitive to cultural and religious
issues, as well as the context of the woman’s
“As a nurse, midwife or nursing associate,
circumstances and specific needs.
you owe a duty of confidentiality to all those
who are receiving care. This includes making Although a woman should be offered a
sure that they are informed about their care chaperone, she may find it difficult to have
and that information about them is shared a third party in the room and request that
appropriately.” NMC 2018:8) she is on her own with the person doing the
examination. Her request should be respected
Because of the sensitivity of the consultation and documented, unless the health care
and examination process, a woman must have professional feels that one is needed. Nurses
trust in the nurse or midwife that she discloses and midwives should always consider being
her personal details to. Absolute confidentiality accompanied by a chaperone when undertaking
cannot be promised where information disclosed intimate examinations and procedures to
affects the welfare of others, especially in regard avoid misunderstanding and, in rare cases,
to child protection and criminal offences. In such false accusations of abuse and the name of the
circumstances, women should know that the chaperone should be documented within the
information documented will be made available to records (Griffith, et al., 2010).
other members of the team involved in the delivery
of care.
7GENITAL EXAMINATION IN WOMEN
2. Knowledge and skills
The examination to choose from, to make the examination as
physically comfortable as possible.
environment
• Latex-free products should be available.
Genital examinations are carried out in many
different environments, including hospital • There should be a supply of sanitary products
settings, sexual health clinics, GP surgeries, for after the examination.
A&E departments, custodial settings, operating • The provision of a mirror may help during the
theatres, in radiology and in colposcopy or examination; if a woman is able to visualise
hysteroscopy suites. Local procedures, manual her external genitalia during inspection, it
handling and practice, prevention and control may lessen her anxiety.
focused procedures need to be taken into
account in all settings. It is imperative that • If using an examination couch, the couch
genital examination is only carried out following should be situated so that the woman
appropriate history taking. faces away from the doorway during the
examination and if possible should be height
The following recommendations should adjustable, with fitments to enable lithotomy
be followed whenever possible and position, and the light source should be angle
practical, and the dignity of the woman poised. This consideration should also take
and her consent should be ensured at all account of the need for positioning in relation
times. to windows and the need to use a screen.
• The waiting area should be comfortable,
displaying appropriate information. Prior to examination
• Toilet and hand washing facilities should be Review the following considerations
situated close by. before commencing the procedure.
• Private, warm and comfortable changing • What is the reason for performing the
facilities should be available. procedure?
• If possible, a woman should be given the • How will the information obtained be used to
choice to remain in her own clothes. benefit the woman?
• It should be easy for clothing and/or • Are you competent to perform the planned
underwear to be laid aside and for the disposal procedure?
of any sanitary or continence products.
• Has valid consent been obtained and
• If she needs to undress, or if there is a risk documented?
of damage to the woman’s own clothes, then
there should be a clean gown available/offered. • How will the information be recorded, stored
or referred, if necessary?
• There should be no undue delay prior to
examination. Effective communication is a critical skill
required throughout this procedure. Explain to
• The examination should take place in a the woman what is happening, before and during
closed room that cannot be entered while the the examination.
examination is in progress.
Confirm consent:
• The room should be stocked in advance
with the necessary supplies to allow the • offer the woman the opportunity to decline the
examination to proceed as quickly as possible. examination
• A range of speculum sizes should be on hand • confirm that the woman is aware of her right
8ROYAL COLLEGE OF NURSING
to ask or indicate for the procedure to be • emphasise the importance of relaxation of the
stopped at any time genital and/or abdominal muscles during the
• confirm that the woman agrees to the procedure
procedure as described • explain that she may stop the examination at
• record verbal consent and, if local policy any point with a request to do so, and agree
requires, obtain written consent how that request can be made, such as a key
word, or raising of the hand
• consider the need for a chaperone and, if the
woman declines, record this • it is recommended that a woman should be
advised how to take her own low-vaginal swab
• if a learner is undertaking the examination,
explicit consent for this must be obtained. for chlamydia and gonorrhoe (this is common
practice in sexual health services) BEFORE
Check the woman understands the the rest of the examination
purpose of the consultation/examination:
• explain that some women may experience
• ask if she has ever had a genital examination some spotting after swabs and cervical
before sampling, if appropriate
• discuss any concerns regarding her previous
• ensure the woman has privacy if she needs
experience (be alert to the possibility of sexual
to undress and show her where to place her
abuse)
clothing
• explain the reason for the examination
• the woman should be advised that it is usually
• assure the woman that privacy and dignity will only necessary to remove her lower garments
be maintained throughout the procedure
• assistance to remove garments should only
• discuss with the woman if she wishes to have a be given if required, and not in an attempt to
chaperone and/or someone of her choice in the
hurry the woman
room while she is being examined. This will
vary in colposcopy, hysteroscopy and • ensure the woman has enough tissue or a sheet
IUD insertions to cover the genital area when undressed
• take a history and exclude any materials that • ask if she would like you to talk through the
may cause an allergic reaction, eg latex or procedure as it happens
iodine
• ask the woman to let you know when she is
• explain the procedure for the examination,
ready.
using language that the woman will
understand If you are preparing the area, make
• caution should be exercised with language sure the woman is aware of the possible
used; innocent language when used during sounds she might hear and what they
vaginal/genital examination may be represent:
misconstrued, so it is best to avoid the use of
any personal comments • position and check trolley, and the availability
of required equipment
• ensure that the woman has emptied her
bladder (in some cases this may not be • ensure there is good light and that any viewing
appropriate, eg where swabs are required for light is switched on
urethral gonorrhoea or chlamydia, these will
need to be taken before passing urine or prior • light sources should be cold light and should
to ultrasound scanning) not have hot exteriors which may cause
discomfort to the woman
• inform the woman that the examination
should not be painful but may be • wash hands and wear gloves – consider
uncomfortable possible latex allergy.
9GENITAL EXAMINATION IN WOMEN
any other masses refer immediately to a
The examination doctor.
The following is broad guidance for vaginal • Note any areas of tenderness or pain.
and genital examination. The examinations
performed will differ between fields of practice, • Look at the woman’s face whilst performing
depending on the purpose of the examination. the examination.
Assist the woman into the correct position for the • Note any “guarding” – involuntary contraction
examination, ensuring her comfort and taking of abdominal muscles.
into account any problems such as joint and back • Rebound tenderness (usually only performed
problems - it may be appropriate to offer a choice if the woman is extremely tender and
of position. Examinations may be undertaken in there is concern about possible peritonitis/
the prone or left lateral position, depending upon appendicitis) – press your fingers in firmly
the procedure. Ensure that you inform the woman and slowly, and then quickly withdraw them.
of the position she will be in and request that she Watch and listen to the patient for signs of
remains in that position for the anticipated length pain. Ask the patient to compare which hurts
of the examination or procedure. more, the pressing or the releasing. Pain
induced or increased by quick withdrawal
Abdominal inspection and constitutes rebound tenderness. It results from
examination rapid movement of an inflamed peritoneum.
Undertake a visual inspection of the skin • Patients with suspected peritonitis,
and note hair pattern on the abdomen. Check appendicitis, ruptured ovarian cyst or ectopic
inguinal lymph nodes for enlargement, pain or pregnancy should be immediately referred to a
tenderness. doctor or the emergency department.
Perform an abdominal examination by palpating External genital examination
the woman’s abdomen working from the
umbilicus towards pubic bone to identify the Inspect the external genitalia and note any of the
uterus, and note findings (size, position and following findings:
tenderness of uterus). For the midwife, this
examination will also focus on identifying the lie, • lesions, colour (variance in colour such
position and gestation of a pregnancy. as Lichen Planus/Sclerosis), varicosities,
scarring, infection, ulceration, discharge,
• Palpate the abdomen in a systematic manner. cysts, trauma, tenderness, enlarged glands,
Skene and Bartholin’s glands
• Gloves are not required for this part of the
examination. • assess sexual maturity – hair development and
distribution, and size of the vagina
• Light palpation – feeling the abdomen gently
is especially helpful in identifying tenderness • inspect mons pubis
and muscular resistance. Keep your hand and
• spread the labia – they should be the same
forearm on a horizontal plane, with fingers
colour and plump in adults (atrophied in post-
together and flat on the abdominal surface,
menopausal women)
palpate the abdomen with a light, gentle
dipping motion. When moving your hand from • on touch the labia should be mobile and soft
place to place, raise it off the skin. Moving
smoothly, feel in all quadrants. • in women who have not had a pregnancy the
labia majora may meet midline and cover the
• Deep palpation – if there is no evidence of labia minora; after childbirth they may be
distress during light palpation, palpate the flaccid
abdomen in the same systematic manner but
deeper. • any alteration to the genital area, including
piercing, which may indicate female genital
• It is often possible to palpate a full colon, mutilation needs to be noted and discussed
especially in slender patients, but if you feel (see section on FGM, on page 15).
10ROYAL COLLEGE OF NURSING
Vaginal examination • In the case of prolapsed vaginal walls, sheath
the speculum with a condom or a non-latex
Depending on the reason for the examination, glove finger with the end cut off, or use a wider
digital vaginal examination if necessary may or long-bladed speculum.
occur before or after a speculum examination.
• Check the woman’s comfort – either with eye
Part the labia and insert gloved and lubricated contact, verbally or using a chaperone.
index and middle finger into the vagina. To
assess the genital floor tone, ask the woman to • Open the speculum and look at the cervix (it
‘bear down’ and ‘squeeze’. is not necessary to fully open the speculum).
To do this you may need to ask the woman to
Advise the woman that you will be applying light cough or change position.
pressure to the posterior fourchette and this will
help the muscles to relax. • Fix or hold the Cusco speculum into the
correct position.
Speculum examination • Note the colour, size, position, appearance,
The Cusco bivalve speculum is most commonly used secretions and texture of the cervix.
for routine examination and inspection of the cervix. • Note any polyps or contact bleeding, presence/
There are other specula, including the Sims, which absence of threads if intrauterine device is in
are useful for complex examinations, continence situ.
assessment and during surgical procedures.
• In a woman who has never had a pregnancy,
Follow the guidelines below to insert the the cervical os will be small and round,
speculum correctly. otherwise it will often look like a horizontal
• Ensure that the correct size and type of line and can be irregular.
speculum is selected. • Note any nabothian cysts or follicles, which
• Offer to demonstrate the speculum. are a normal finding and have the appearance
of small yellow nodules.
• Inform the woman about the sounds associated
with the speculum use, if appropriate. • Note that the cervix is usually midline,
extending 2cm into the vagina. More than 3cm
• Ensure the speculum is lubricated a water- could indicate vaginal prolapse.
based lubricant (be aware that lubricant
can obscure cervical cytology tests and • Note that in pregnancy the cervix will look
swab results, so may not be used in some different and may have a bluish/purple tint,
examinations) and warmed, if required. and normal vaginal discharge may also appear
heavier.
• Ensure that the blades of the Cusco speculum
are closed for insertion. • Note that the cervix and os also change
position and appearance at different stages
• Introduce, or instruct the woman to introduce, of the menstrual cycle and pre- and post-
the speculum. The speculum should be menopause.
inserted into the vagina in a slightly downward
motion. If the labia are flaccid, gently opening • Inspection of the vaginal walls - note colour,
them with your other hand limits any dragging odour and presentation of discharge eg, frothy,
or pulling. The insertion should be a slow and curdy or homogenous. Including inspection for
seamless procedure. internal warts.
• Ensure that the speculum points down • If collecting samples for sexual health
towards the posterior of the woman and insert screening or cytology, collect them according
into the vagina until flush with the perineum. to local protocol.
• Ensure no pubic hair is caught, and that there • It is important to remember that the cervical
is no pressure on delicate structures such as smear should be the first specimen collected
the urethral meatus and clitoris. regardless of any others to be collected.
11GENITAL EXAMINATION IN WOMEN
• Remove the speculum carefully ensuring that and Reproductive Health Clinical Standards
you have not trapped the vaginal walls or Committee, 2019).
cervix in the speculum as it closes. Remove
with the speculum slightly open. Bimanual genital examination
• Examine the vagina as the speculum is This examination is used by appropriately
removed assessing the vaginal walls for trained nurses and midwives, mainly for
infection, cysts or foreign bodies. Rugae are a assessment and diagnostic purposes.
normal finding in younger women.
• Insert a gloved and lubricated index and/or
• Consider using vaginal lubricants with middle finger into the vagina (depending on
post-menopausal women prior to vaginal the vaginal canal may only be able to insert
examination. one digit).
• In older women you will need to be aware • Assess the vagina and note findings such
that the vaginal walls are thinner and drier as vaginal tone and vaginal wall support –
and be careful not to cause damage with the degree of prolapse, varicosities, tenderness,
speculum. protrusions, foreign bodies etc.
Sims speculum use • Place the other hand on the abdomen and
press towards the fingers inside the vagina.
• A Sim’s speculum can be used to assess vaginal
prolapse. Examination of the cervix:
• locate the cervix and lightly feel this between
• Ask the woman to lie on her left side and bring
two fingers, then assess its size and movement;
her knees to her chest.
it should move freely (if there is an infection
• Insert the blade of the speculum along the present and/or cervical motion tenderness is a
posterior wall of the vagina to hold it back. sign of Pelvic Inflammatory Disease (PID) and
would need further assessment by a doctor
• Ask the woman to cough or bear down whilst immediately
looking for uterine descent and cystocoele.
• palpate the cervix – it should feel smooth and
• Move the speculum to the anterior wall firm (hard and lateral displacement could
and ask the woman to cough or bear down indicate the presence of tumours/fibroids)
observing for uterine decent and rectocele.
• comment on findings such as mobility,
Speculum examination and STI discomfort, size, shape, consistency, depth/
screening in pregnant women projection into vagina, angle, or any masses.
Where clinically indicated, the examination of a Palpation of the uterus:
pregnant woman with a speculum is considered
• the abdominal hand should be midway
low risk and can be performed safely by a nurse
between the umbilicus and the symphysis
who has received training on how to perform pubis
this examination. Swabs for sexually transmitted
infections can be taken from pregnant • the vaginal hand with palmar surface facing
women, without the need for a speculum anteriorly should maintain contact with the
examination, using a self-taken vulvovaginal cervix so that the nurse/midwife examining
swab (BASHH 2019). Routine cervical cytology the woman can use the cervix as a ‘landmark’
is not recommended in pregnant women, as for palpating the uterus
interpretation of the sample can be difficult,
• lightly applying pressure to the posterior
but should be deferred until 12 weeks post-
portion of the cervix with the vaginal hand
partum. Public Health England (2016) Pregnant
will bring the uterus towards the abdomen
women should be reassured that clinically
indicated speculum examinations, and tests for • once the uterus is raised, use the external
sexually transmitted infections, can be safely hand to palpate, taking note of size, shape,
carried out during pregnancy (Faculty of Sexual position and consistency
12ROYAL COLLEGE OF NURSING
• if the uterus is retroverted or retroflexed, discharge and that there is access to washing
it will not come up between the examining facilities and sanitary pads, if needed.
hands – differentiation between an anteverted
and retroverted uterus is vital for certain Ensure a full record is made of the examination
procedures performed, and that any tests taken and
findings observed are recorded clearly and
• assess the uterus, taking note of size, shape, contemporaneously in the woman’s notes. Wash
position, consistency, mobility and tenderness hands and document your findings using local
policy. The following points should be included in
• record findings from the uterine palpation.
your records:
Follow the guidelines below for palpation
and examination of the adnexa: • abdomen
• external genitalia
• move abdominal hand to the lower abdominal
quadrant on the same side as the internal hand • vagina
• move fingers in the vagina to either the right • cervix
or left sides of the lateral fornix
• uterus
• apply firm and steady pressure, beginning
medial to the anterior iliac crest • adnexae.
• note any tenderness or masses And may include reference to:
• palpate the position of the fallopian tubes • size
on either side of the uterus; these are not • position
normally palpable or tender
• consistency
• when palpating the ovaries at the end of the
fallopian tubes, advise the woman that some • mobility
discomfort is likely
• mass
• the ovaries are approximately 2-4 cm in
• tenderness.
length, smooth, firm, mobile, sensitive to
touch but not tender and, if palpable, should Provide correct information about the findings
feel the size of an almond. In post-menopausal and results of the examination. If swabs have
women they are smaller been taken or screening performed this should
include:
• gentle moving of the cervix slightly from side
to side will demonstrate ‘cervical excitation’. • how the results will be communicated
Should there be any adnexal masses or
tenderness, advice should be sought • when to expect results
• if there is a potential diagnosis of ectopic • what to do if she does not get the expected
pregnancy, this procedure should be results
performed by a skilled clinician, following
• possible outcomes
pregnancy testing and ultrasound scanning
and requires immediate referral to a specialist • any further management.
if there is any suspicion of an ectopic
pregnancy.. Specific considerations
Following the examination Special consideration should be given with
vulnerable groups. The examination can be
Switch off the examination light and provide hindered or limited if a woman has had previous
privacy for the woman to get dressed or experiences that may make this examination
rearrange her clothing. Ensure the woman has traumatic, or if the experience itself requires
tissue available to wipe away any lubricant or particular care. Nurses need to be sensitive to
13GENITAL EXAMINATION IN WOMEN
the fact that some women presenting may have to the local sexual assault referral centres
suffered some form of sexual abuse. (SARCs) and the need to protect any potential
‘evidence’. For information on how to protect
Women who experience difficulty with vaginal forensic evidence when sexual assault has been
examination should be given the opportunity to reported, a CD-ROM is available from www.
discuss any underlying sexual, marital or trauma careandevidence.org
related issues. These discussions should take
place when the woman is dressed. Some women A woman’s health and wellbeing exceeds the
may experience distress without any underlying need for forensic evidence collection, for example
history of sexual abuse or difficulties. if a woman needs physical examination due to
bleeding following an assault this would take
If the woman has not had a vaginal or genital president over the forensic medical examination
examination previously, it may be appropriate and should not be delayed because of it.
to discuss the examination/procedure and
rebook an appointment for a later date. It may If a woman discloses that she has been subject to
be appropriate to see the woman more than once domestic violence, it is important to ensure that
before she is comfortable enough to undertake information is available for her to contact a local or
the examination. national helpline. It is also the responsibility of the
nurse or midwife to record any disclosure and any
If the woman refuses or withdraws consent to physical signs of abuse including the completion
the examination at any time, then it should be of a multi-agency referral form in line with local
terminated, or if not already underway, it should policy. The woman may choose not to take further
not be carried out. action but may wish to refer back to her medical
records at a later date for evidence in a court case.
You should not proceed with an examination
if you feel that the woman is not physically or It may be prudent to consider seeing the woman
mentally able to cope with the procedure, for alone if they are accompanied by a partner?
example if the woman: This should also include consideration of women
who may have been subject to trafficking and/or
• is unduly stressed or upset
modern slavery.
• has had previous vasovagal reactions
Post menopausal atrophic vaginitis
• has an imperforate hymen
In women who are menopausal the vaginal
• has a full rectum tissues becomes thin and atrophic. This can lead
• has a clinical condition which prevents to pain and trauma when undertaking vaginal
examination. and speculum examinations. If the examination
can be rescheduled then women may be advised
In certain situations, the woman can be referred to use vaginal oestrogens for six weeks before the
for counselling, surgery or investigations. The subsequent examinations.
vaginal and/or genital examination can be
carried out at a later date when the situation has Vaginismus
been rectified.
Vaginismus can make vaginal and genital
History of trauma examination extremely difficult. This could
be related to a previous vaginal examination,
Some women will have a history of traumatic previous sexual abuse or reasons of unknown
experiences with previous examinations or may origin. Referral to a psycho-sexual counsellor
have experienced sexual abuse, physical abuse may be necessary but the examination should
or rape in the past. This may be evident within not proceed if it will cause further distress to
the history taking. The woman should be given the woman.
an opportunity to discuss this, if she wishes.
Referral for counselling may be appropriate. Female genital mutilation (FGM)
In the case of an unreported rape the nurse or Nurses, midwives and nursing associates should
midwife should be aware of the referral pathway be aware that women from African countries,
14ROYAL COLLEGE OF NURSING
parts of the Middle East and South East Asia Protecting the practitioner
may have undergone FGM. It may be appropriate
to ask if they have been circumcised or closed. If the woman gains sexual satisfaction from
For more information see the RCN publication the examination the need for a chaperone is
Female Genital Mutilation: An RCN resource for paramount. This should be clearly documented.
nursing and midwifery practice (RCN, 2019).
Antenatal contraindications
FGM is illegal in the UK, and widely recognised
If a pregnant woman has had an antepartum
as a form of abuse. The legislation relating to
haemorrhage or is known to have placenta
FGM has changed in 2015, and all health care
praevia then an examination should not be
practitioners should be aware of their role and
carried out.
responsibility with regard to reporting and
recording, as well as how to best care for any girl
Language barriers
or woman affected by FGM.
Women with a limited command of or no English
If a girl under 18 years of age has or is suspected will require a recognised translator. Due to the
of having had FGM carried out, then local intimacy of the examination and the sensitivity of
safeguarding procedures should be implemented, the consultation, a family member or friend may
including informing the police via the 101 non- not be appropriate to assist with the translation
emergency number (DH, 2015). The general advise is that family members
should not be used for translation purposes.
There is now a mandatory duty for all regulated
If translated forms of written information are
health care professionals to report any concerns
available they should be provided prior to the
they may have about a female under 18 years and
examination.
record when FGM is disclosed or identified as
part of NHS health care.
Examination under anaesthetic
If over 18 years of age recording of the case A woman should give consent to “examination
should be carried out in line with Department of under anaesthesia” and be made aware of, as
Health requirement under the Enhanced Dataset well as have the right to refuse any teaching
requirement (HSCIC, 2018). Further information or training of medical, nursing or midwifery
is availably from the Department of Health (DH, learners whilst anaesthetised. Women can
2019). The priority for the woman should always feel particularly vulnerable about being under
be proving the best care possible to support any anaesthetic and not having any control over the
physical or psychological, or psycho sexual needs situation. It is therefore necessary that nothing
she may have (RCN, 2019). additional is performed other than what is
consented for. The nurse or midwife should act as
Police use of restraints the woman’s advocate.
This is a contentious issue but should a woman Examination under anaesthetic by medical
be restrained, for example, in a custodial setting, students/student nurses or other learners should
then the nurse is still responsible for ensuring have separate written consent.
consent is given for the procedure to be carried
out and that the woman’s dignity is maintained. Capacity issues
Requests for female only practitioners Where a woman has a temporary or permanent
learning or physical disability, careful
Some women will request to only be examined consideration should be given as to whether the
by a female and this should be respected. If a proposed examination is necessary (ie, screening
female health professional has been requested or diagnosis may make the requirement more
but is unavailable, alternative arrangements may urgent). Any resistance to the examination should
have to be made. In emergency situations, where be interpreted as refusal. If the woman does not
no female health professionals are available, have capacity then further guidance should be
sensible and practicable measures must be taken. sought before proceeding. If the examination is
15GENITAL EXAMINATION IN WOMEN
abandoned, alternative measures should be taken
as necessary for the woman’s health.
Children
This guidance does not include information on
the examination of a child, which should only
be carried out by specialist staff. The age of the
child and the reason for the examination should
be considered. It may be necessary to carry out
the examination under anaesthetic, particularly
in young children.
Where there is an indication that a child or young
person may have been abused, practitioners
should follow local safeguarding procedures and
refer immediately. Please also see above section
on mandatory reporting of suspected abuse,
including FGM.
In contraception, sexual health and termination
of pregnancy services, appropriately trained
nurses and midwives may examine young women
under 16 but must do so under the requirements
of the Fraser Guidelines (DH, 2001) and be fully
aware of the laws regarding consent.
16ROYAL COLLEGE OF NURSING
3. Learning outcomes framework
Purpose and scope of this Learning outcomes
learning and assessment 1. Demonstrate an understanding of how to
framework prepare the environment and equipment
for undertaking vaginal, speculum and
Having recognised learning outcomes ensures genital bimanual examination and specimen
that women requiring a genital examination are collection.
cared for safely, and that training and assessment
processes are congruent with local guidance. 2. Demonstrate how to effectively prepare
the woman physically and psychologically
This framework can be used to: for vaginal, speculum or genital bimanual
examination.
• help professionals to identify their individual
training needs 3. Demonstrate the knowledge and skills
required to safely and effectively perform
• ensure nurses/midwives have the skills and
genital examination.
knowledge to undertake bimanual genital
examination competently and safely 4. Demonstrate the knowledge and skills
required to safely and effectively perform
• provide a basis for assessing individual
speculum examination with or without
competence to successfully and safely
specimen collection appropriate to clinical
complete key skills
indication/request.
• inform the commissioning, development and
5. Demonstrate the knowledge and skills
delivery of education and training.
required to safely and effectively perform
It is acknowledged that the practitioners coming genital bimanual examination.
to these assessments are well established
6. Demonstrate the knowledge and skills
registrants, and have an assumed level of basic
required to interpret findings of examination
knowledge and skills, including adhering to
to identify the woman’s needs.
regulatory requirements (in particular, codes of
practice). 7. Demonstrate the knowledge and skills
required to provide clear and accurate results
Proceeding with these competences also assumes to the woman.
an extensive knowledge of relevant anatomy,
physiology and pathology. 8. Demonstrate the ability to provide holistic
information advice and support to meet the
The following learning outcomes should be woman’s needs.
achieved to demonstrate that consistent and
appropriate training has been successful. The 9. Demonstrate understanding and knowledge
assessment should be set against the content of local referral pathways for ie, psycho-
in the knowledge and skills section of this sexual/SARC/TOP/SRH.
document, and an example is provided in the
10. Maintain accurate records of interventions
sample learning contract in Appendix 1.
and outcomes.
The assessor needs to reassure themselves that
the learner is already working at the higher level
of practice; has an adequate understanding of
relevant anatomy, physiology and pathology;
demonstrates commitment to attaining a
respectful and caring attitude, congruent
with being a professional practitioner; and
demonstrates a level of knowledge that would
be acceptable in order to meet the standards
outlined within this document.
17GENITAL EXAMINATION IN WOMEN
4. Training and assessment
process
A sample assessment of learning outcomes and
Introduction for trainers competence tool can be found in Appendix 3.
and assessors
A learner may be working in a setting where they
This section will focus on the expected skills of would not undertake bimanual examination.
those health professionals who agree to train Therefore, the training is divided into two parts.
and assess the competence of nurses to perform
genital examinations. • Part 1 must be completed by all learners
and covers knowledge, attitude and skills
The learner must identify a practice supervisor in relation to the observation and speculum
and practice assessor, in line with with NMC examination and excludes bimanual
guidance (NMC, 2006) (ideally more than one) examination.
and an assessor, who should be a different person
from the trainer. • Part 2 covers bimanual examination for those
who are required to learn this procedure.
A learning contract (Appendix 1) and logbook
The assessor must make it clear in the certificate
(Appendix 2) should be agreed between the
of competence which elements of genital
learner and the assessor.
examination have been assessed, and the learner
The learner should also keep a reflective diary must agree to undergo further training should
which can be used to good effect to demonstrate they need to undertake bimanual examination
learning and development. training in the future.
Training and assessment can be obtained from The learner should keep a logbook (Appendix 2)
any registered professional (doctor/nurse/ of any supervised practice they have undertaken
midwife working in obstetrics, gynaecology, in a clinical setting. The learner should ask the
sexual health or contraception services) patient to complete a consultation feedback
who holds a recognised teaching/mentoring form (Appendix 4). The learner may also wish
qualification and who is competent in genital to explore electronic feedback mechanisms such
examination. as an online survey tool. The learner also should
complete an evaluation of their training and
Some trainers may choose to develop a more return to the assessor for feedback on the process
formal checklist covering the topics to be (Appendix 5).
assessed, and may use the knowledge and skills
section as a guide. Consideration should be given The logbook may be used as preparatory
to initial practical training on a genital model. training in conjunction with specialist training
It is envisaged that the majority of training will in female examination such as in intrauterine
be on conscious women, but in some instances, contraceptive device insertion where knowing
genital examination of a woman undergoing a the position of the uterus is critical.
procedure under general anaesthesia may be
Trainers may wish to set a timeframe over
undertaken with prior written consent.
which training should be undertaken. The
Some learners may find that there is no suitably recommendation is that this training period
qualified person in their usual place of work to should be no longer than six months.
provide training and assessment. In this case
There is a suggested template for a certificate
the learner would need to find a local training
of competence in Appendix 6 on page 25.
service to help.
Assessment must be objective and be undertaken
by a recognised assessor. It should cover
knowledge, skills and attitudes.
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