Bimanual Palpation

Principle

1. Gynecologic Pelvic Examination (Most Common Application)

Patient Position

Step-by-Step Technique

1. Insert the vaginal finger(s): Introduce a well-lubricated index finger — and, where accommodated, the middle finger — into the vagina along the posterior wall. The number of fingers used should be adapted to patient comfort; a single-finger technique is preferred for adolescent, slender, or older patients.
   • Before advancing, test perineal strength by pressing downward and asking the patient to bear down — this may unmask a cystocele, rectocele, or uterine descensus.
2. Evaluate the uterus: Rest the abdominal hand on the infraumbilical area and press gently downward, sweeping pelvic structures toward the vaginal fingers. Assess the uterine body for:
   • Position (anteverted, retroverted, mid-position)
   • Architecture — size, shape, symmetry, any tumors
   • Consistency
   • Tenderness
   • Mobility
   • Any tumors found are further characterized for location, consistency, tenderness, mobility, and number.
3. Evaluate the cervix: Assess the cervix for position, architecture, consistency, and — critically — cervical motion tenderness (CMT). Rebound tenderness should also be noted. Systematically explore the anterior, posterior, and lateral fornices.
4. Right adnexa: Place the vaginal fingers in the right lateral fornix; move the abdominal hand to the right lower quadrant. Manipulate both hands toward each other to outline the adnexa.
   • A normal tube is not palpable.
   • A normal ovary (~4 × 2 × 3 cm, firm, sensitive, freely movable) is often not palpable either.
   • Any adnexal mass found should be characterized by location relative to uterus/cervix, architecture, consistency, tenderness, and mobility.
5. Left adnexa: Repeat with vaginal fingers in the left fornix and abdominal hand over the left lower quadrant.
6. Rectovaginal-abdominal examination (Step 6): Insert the index finger into the vagina and the middle finger into the rectum. The abdominal hand is placed on the infraumbilical region. This technique allows higher exploration of the pelvis because the recto-vaginal septum does not limit depth as the cul-de-sac does. This is used to evaluate the rectovaginal septum, parametria, and posterior cul-de-sac.
7. Intact hymen: Use the rectal-abdominal (rather than vaginal-abdominal) approach.

2. Splenic Palpation

Technique

• Patient is supine with knees flexed.
• The examiner's left hand is placed on the lower left rib cage and pulls the skin toward the costal margin.
• The right hand fingertips start in the left lower quadrant and move gradually toward the left costal margin.
• The patient is asked to inspire slowly, smoothly, and deeply — the splenic tip is felt descending on inspiration.
• Findings are recorded as centimeters below the left costal margin.

Bimanual palpation in the right lateral decubitus position adds nothing to the supine examination. Sensitivity of palpation for splenomegaly is 56–71% compared to ultrasonography.

3. Oral/Head and Neck Examination

• Floor of mouth / submandibular region: One gloved finger intraorally and the other hand externally under the chin — used to detect sialolithiasis (submandibular duct stones), ranulas, and potentially malignant lesions of the floor of mouth. (Cummings Otolaryngology; Goldman-Cecil Medicine)
• Cheeks: Bimanual palpation of the cheeks facilitates identification of potentially malignant lesions of the buccal mucosa.

4. Bladder Staging (Urology)

• T2a: Non-palpable mass
• T2b: Induration but no three-dimensional mass
• T3a: Three-dimensional palpable mass that disappears after resection

5. Pancreatic Evaluation (Intraoperative)

Clinical Significance of Findings