The gynecologic bimanual ( two-handed ) palpation of the uterine corpus ( the main part of the womb ), Fallopian tubes, ovaries and surrounding tissues is possibly one of the most difficult kinds of clinical examination performed only with the hands in all Medicine. The difficulty is due to a complicated blend of many objective anatomical facts aggravated by some psychological attitudes and reactions of the patients.

Among them, we first must mention the main anatomical reasons. They are: 1) the deep intrapelvic location of the uterus, Fallopian tubes, ovaries and respective ligaments; 2) the fact that some of the anatomical peculiarities and positions of these organs often vary considerably from woman to woman; 3) the fact that the palpation ( touching ) is performed by trying to touch the uterine corpus, Fallopian tubes and ovaries between our intravaginal and abdominal hands with several other organs and tissues in between; 4) the degree of contraction and thickness of the patient's abdominal wall.

The frequent resistance on the part of many patients caused by nervousness and anxiety due to psychological factors, the variations in each woman's own sensitivity to the palpation and the resulting variable degrees of discomfort that may give rise to contractions of the abdominal muscles, all of these are factors that add considerable difficulties to the anatomical ones. While some patients become almost totally relaxed and calm during the palpation of their inner genitals, others show nervousness, discomfort and pain. Some of the latter even react with strong abdominal contractions, and the examination becomes very difficult, sometimes even impossible.

And here I would like to remark that the observations above concern women without pelvic and genital painful pathologies. The presence of any painful gynecologic condition will obviously and naturally result in pain and discomfort at any deep genital palpation, accompanied by several patient's "defensive" reactions. Nevertheless, I also would like to emphasize that, in the absence of painful pelvic pathologies, many typical women's negative attitudes regarding gynecologic palpation are mostly psychological - though always allied and reinforced by the natural slight discomfort caused by pressing their inner genitals through the vagina and the abdominal wall.

Considering the very rich, intricate, mysterious and often problematic archetypal symbolism of the woman's inner genitals and intrapelvic content, it is probable that those especially anxious patients being examined experience the intimacy of these organs ( and their own physical intimacy as women ) as being "invaded" by the physician's fingers and hands. And, in a way, we must recognize that, to some extent, they are right. Even so, hand examination should not be thought of as something negative. On the contrary, it should be regarded as positive and beneficial, since the gynecologic touch is one of the simple ways we have, in the daily clinical practice, for evaluating the anatomical health of the woman's inner genitals - even considering its considerable degree of inaccuracy when compared to a detailed high-technology evaluation. ( Read below a comparative analysis of palpation and ultrasound, demonstrating the importance of both methods. )

As to the physical details of the gynecologic palpation, the vaginal touch is anatomically very easy, allowing us to feel the entire vaginal walls, the uterine cervix and surrounding structures and, as everybody knows, it is performed with two fingers of only one hand. Conversely, the examination of the uterine corpus, Fallopian tubes, ovaries and surrounding tissues requires the use of both hands: the two fingers of the intravaginal hand and the abdominal one.

In a relaxed and calm patient whose uterus is in anteversion ( bent forward towards the urinary bladder ), the uterine corpus is easily touched between both hands, and we truly may say that we "hold it" almost entirely. ( Anteversion is the most frequent and typical uterine position. ) When the uterine corpus is in intermediate position ( see Note 1, below ) and the uterine size is normal, our hands cannot reach it entirely and its palpation becomes difficult - unless we succeed in moving it to the anteversion position ( the degree of mobility of the uterine corpus is usually considerable and varies from woman to woman ). A backward-placed uterine corpus ( uterine retroversion ) is a very frequent condition and, in it, the corporal part of the organ is bent backwards towards the rectum. In such position the entire palpation of a normal-sized uterus is also difficult, because our hands are only able to touch the cervix and reach a very small part of the posterior uterine wall.

Fibroids ( uterine leiomyomata ) are very easy to touch when they grow close to the uterine external wall ( protruding on the uterine surface ) or enlarge the entire organ. The presence of multiple diffuse small fibroids usually cause a slight or moderate uterine enlargement sometimes associated with an increase in the uterine consistency.

Palpation of normal ovaries and normal Fallopian tubes is usually difficult due to their dimensions. Even so, with some frequency and also depending on the phase of the cycle, we are able to feel normal ovaries - although, as I said, normal-sized ovaries usually are not touched. ( Sometimes we only feel them slightly, because they tend to "slip" from our fingers. ) On the other hand, enlarged ovaries are easily palpable. Normal Fallopian tubes are so thin and soft that usually they are very difficult although not always impossible to feel. Conversely, enlarged and/or thickened tubes, usually due to salpingitis, are very easy to detect.

As I already said, the gynecologic bimanual palpation is one of the most difficult medical examinations performed only with our hands. It is also very "tricky" ( see Note 2, below ) and, in order to be well performed, requires meticulous, careful and intensive training and great skill on the part of the gynecologist, and also - why not say it ? - considerable collaboration and "patience" on the part of the patients due to the slightly or moderately uncomfortable sensations produced by our hands during the examination.

I also would like to emphasize that, contrary to what some people believe, ultrasound has not replaced the traditional gynecological touch, which continues being an essential part of all gynecological routine. In spite of all the enormous and amazing accuracy of the modern transvaginal ultrasound techniques in revealing details of the uterus and ovaries that are absolutely impossible to reveal with our hands, there are also several very important features and details of the female inner genitals that cannot be detected by sonography. Usual ultrasound, for instance, does not visualize the Fallopian tubes, except when they are excessively enlarged and thickened due to very serious salpingitis or by tubal pregnancy. Areas of altered sensitivity or pain in the woman's pelvic organs, as well as their degree of firmness, thickness or softness, only can be detected through the traditional gynecological palpation. Therefore, the gynecological touch and pelvic sonography actually complement each other, and the correct medical assistance to women must include both methods.

Note 1: The uterus is in intermediate position when between anteversion and retroversion.

Note 2: Some of the "tricky" aspects of the gynecological bimanual palpation are: 1) some ovarian enlargements due to cysts or tumors that may be confused with uterine fibroids; 2) uterine fibroids that, in a similar way, may be confused with various ovarian pathologies; 3) tubal pregnancies that can be wrongly taken as ovaries; 4) some ovarian enlargements that, even so, also "slip" from our fingers. Fortunately, in almost all cases like these, a simple transvaginal ultrasound will clearly and safely establish the correct diagnosis. Undoubtedly, the advent and great development of sonography ( together with the modern mammography ) has been one of the greatest achievements of Gynecology in the last decades.

Note 3: The illustration at the top is based on a drawing by Weibel ( reproduced by Botella Llusiá ), and modified by Nelson Soucasaux.

Nelson Soucasaux is a gynecologist dedicated to Clinical, Preventive and Psychosomatic Gynecology. Graduated in 1974 by Faculdade de Medicina da Universidade Federal do Rio de Janeiro, he is the author of several articles published in medical journals and of the books "Novas Perspectivas em Ginecologia" ("New Perspectives in Gynecology") and "Os Órgãos Sexuais Femininos: Forma, Função, Símbolo e Arquétipo" ("The Female Sexual Organs: Shape, Function, Symbol and Archetype"), published by Imago Editora, Rio de Janeiro, 1990, 1993.

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Email: nelsons@nelsonginecologia.med.br