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The physical examination attempts to detect anatomic locations
of tenderness, determine whether the pain bringing the patient to the office
is reproduced when these regions are palpated, and develop a differential diagnosis
(or list of possible problems) that includes the cause of the pain
The examination may include observation of how the patient stands and walks
since a woman’s posture and gait may reveal abnormal curvature of her
spine (lordosis or kyphosis), a limp or a shuffle.
Examination of the patient as she lies down flat can determine dysfunction
or spasm of the psoas muscle (patient flexes one thigh against resistence and
positive result if pain is elicited), the obturator muscle (patient with leg
flexed at hip 90 degrees has ankle immobilized and the knee is gently pulled
laterally and then medially with positive result if pain is elicited), the gallbladder
(apply deep subcostal palpation during inspiration and positive sign if pain
results), the pubic symphysis (palpated for tenderness), or the abdominal viscera
(distention, ascites, palpable masses, guarding, rigidity, or abnormal bowel
sounds).
The gynecological or lithotomy examination can determine abnormalities of the
external genitalia and vaginal vault (redness, ulceration, discharge, trauma,
fissures, pelvic floor defects, tenderness of the underlying musculature, or
urethral tenderness), the cervix (cervical motion tenderness suggests an infection
or trauma), the uterus (tenderness suggests infection, adenomyosis, pelvic congestion
syndrome, endometriosis, or degenerating fibroids and if the uterus is fixed
in place this suggests massive pelvic adhesions or endometriosis), and the adnexae
(excessive ovarian or tubal pain suggests infection, abnormal or hemorrhagic
ovarian cysts, pelvic adhesions or endometriosis). If there are significant
gastrointestinal symptoms a rectal examination should also be performed to look
for underlying muscular tenderness, nodularity suggestive of endometriosis,
abscesses, fissures, or masses that may signify colorectal carcinomas.
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