36-year-old married woman (P2L2) presents to the gynecology OPD with: Lower abdominal pain for 3 months Progressive abdominal fullness Heavy menstrual bleeding for the last 6 months No fever or weight loss Vital signs: Pulse: 82/min BP: 118/76 mmHg Afebrile General examination: Mild pallor No lymphadenopathy Abdominal examination: Firm pelvic mass corresponding to a 16-week gravid uterus Smooth surface Non-tender Limited mobility Speculum examination: Healthy cervix No discharge Per vaginum examination: Uterus enlarged to approximately 16 weeks Firm consistency Irregular surface Bilateral fornices free Cervical motion not painful Hb: 9.8 g/dL Urine pregnancy test: Negative Ultrasound pelvis: Enlarged uterus Multiple intramural fibroids Largest fibroid: 8 × 7 cm Endometrial thickness: Normal Ovaries: Normal Interpret and explain mass per vaginum

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I now have enough from the textbooks to provide a comprehensive, well-structured answer. Let me compose the full response.

Per Vaginum (PV) Examination - Interpretation & Clinical Explanation

The PV findings in this case are classic for a multiple intramural fibroid uterus (leiomyomatous uterus). Here is a systematic interpretation:

What the PV Examination Found and What Each Finding Means

Finding	Description	Clinical Significance
Uterus enlarged to 16 weeks size	Uterus palpable well above the pubic symphysis, up to approximately the umbilicus	Indicates significant uterine enlargement - normally the uterus is not palpable abdominally
Firm consistency	Hard, rubbery feel on bimanual palpation	Characteristic of fibromuscular tissue (myometrium + leiomyomas); contrasts with the soft/cystic feel of an ovarian cyst or the doughy feel of adenomyosis
Irregular surface	Nodular, bumpy contour felt through the anterior vaginal wall	Each palpable nodule corresponds to an individual leiomyoma distorting the uterine surface
Bilateral fornices free	No masses or tenderness in the lateral sulci	Ovaries and adnexa are not involved; rules out an adnexal origin for the mass
Cervical motion tenderness absent (no CMT)	Moving the cervix does not provoke pain	Excludes peritoneal irritation, PID, and ectopic pregnancy - all causes of CMT

Step-by-Step Bimanual Examination Technique (Context)

In a PV bimanual examination:

Two fingers are placed in the vagina while the other hand depresses the abdomen
The uterus is "caught" between both hands and assessed for size, shape, consistency, mobility, and tenderness
Adnexa are swept laterally to assess ovaries and tubes
Cervical motion tenderness is tested by gently moving the cervix side-to-side

Why "16-Week Uterine Size"?

Uterine size is clinically estimated by comparing its palpable upper limit to known landmarks:

8 weeks - slightly enlarged, not palpable abdominally
10-12 weeks - just at the pubic symphysis
16 weeks - midway between symphysis and umbilicus
20 weeks - at the umbilicus

This patient's uterus reaching "16-week" size implies a uterus enlarged to approximately 14-16 cm, consistent with the ultrasound showing multiple intramural fibroids with the largest being 8 x 7 cm.

Why Is the Surface Irregular?

In a normal uterus the surface is smooth. Multiple intramural fibroids - as seen on her ultrasound - expand asymmetrically from within the myometrium, creating surface lobulations. Each nodule felt on PV corresponds to one fibroid. Robbins Pathology describes leiomyomas as "sharply circumscribed, discrete, round, firm, gray-white tumors" that distort the uterine contour. (Robbins, Cotran & Kumar Pathologic Basis of Disease)

Why Is the Uterus Firm?

Leiomyomas are composed of whorled bundles of smooth muscle cells with dense fibrous stroma, giving them a hard, rubbery consistency on palpation - quite different from:

Adenomyosis: uniformly enlarged, globular, "boggy" or tender
Ovarian cyst: fluctuant or cystic
Pregnancy: softer (Hegar's sign), and the UCG would be positive
Malignancy: often irregular and fixed, but softer, with systemic features

Why Are the Fornices Free?

The bilateral fornices represent the lateral spaces around the cervix. "Fornices free" means:

No adnexal masses palpable - ovaries are not enlarged or cystic
No tenderness - rules out salpingitis or tubo-ovarian abscess
No "fullness" suggesting parametrial infiltration (which would suggest malignancy)

This finding confirms the mass is uterine in origin, not adnexal.

Why No Cervical Motion Tenderness?

Cervical motion tenderness (CMT) occurs when the inflamed peritoneum is disturbed by moving the cervix. Its absence here, combined with no fever and a negative pregnancy test, confidently excludes:

Ectopic pregnancy
Pelvic inflammatory disease
Tubo-ovarian abscess

Synthesizing the PV Findings

The combination of:

Enlarged uterus (16-week size)
Firm consistency
Irregular/nodular surface
Free bilateral fornices
No CMT

...is the textbook bimanual examination picture of a multiple fibroid uterus. This is confirmed by the ultrasound showing multiple intramural fibroids, the largest 8x7 cm.

Supporting Clinical Correlation

Her presenting symptoms are all explained by the fibroids:

Symptom	Mechanism
Heavy menstrual bleeding (6 months)	Intramural fibroids distort and enlarge the endometrial cavity, increase surface area, and impair uterine contractility during menses
Lower abdominal pain (3 months)	Pressure/mass effect; possible red degeneration
Abdominal fullness	Physical enlargement of uterus to 16-week size
Anemia (Hb 9.8 g/dL)	Consequence of chronic heavy menstrual blood loss (iron deficiency)

Differential Diagnosis of a Large Firm Pelvic Mass (PV perspective)

Condition	Points for	Points against (in this case)
Fibroid uterus	Firm, irregular, enlarged uterus, free fornices, no CMT	-
Adenomyosis	Enlarged uterus, menorrhagia	Usually smooth, not nodular; often tender
Ovarian mass	Can reach large size	Fornix would not be free; uterus separate from mass
Pregnancy	Enlarged uterus	UCG negative; irregular surface unusual
Malignancy (uterine/cervical)	Large mass	No weight loss, no fever, no abnormal cervix; healthy cervix on speculum
PID / TOA	Pelvic mass	No CMT, no fever, no tenderness

Key Teaching Points

A firm, irregular, enlarged uterus with free fornices and no CMT = fibroid uterus until proven otherwise
Uterine size estimation (8-week, 16-week, etc.) is a time-honoured clinical technique to quantify uterine enlargement before ultrasound
The irregular surface differentiates fibroid uterus from adenomyosis (smooth enlargement) and ovarian masses (separate from uterus)
"Fornices free" is critical - it localizes the mass to the uterus and clears the adnexa
Absence of CMT is the key finding that excludes the entire PID spectrum

(Sources: Berek & Novak's Gynecology; Robbins, Cotran & Kumar Pathologic Basis of Disease; Creasy & Resnik's Maternal-Fetal Medicine)

Explain mass per vaginum in complete detail

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Mass Per Vaginum - Complete Detailed Explanation

1. Definition

"Mass per vaginum" (MPV) refers to the detection and systematic characterization of a pelvic or lower abdominal mass through the vaginal route, primarily using the bimanual pelvic examination. The term is both a clinical method and a clinical finding - it describes the information obtained when an examiner assesses a pelvic mass with fingers inside the vagina combined with a hand on the abdomen.

It is one of the most informative physical examination techniques in gynecology. It allows assessment of the uterus, adnexa, cervix, vaginal fornices, pelvic floor, and cul-de-sac, all without any imaging.

2. Anatomy Relevant to Per Vaginum Examination

Understanding what can be felt vaginally requires knowing the pelvic anatomy:

Structure	Position	What is felt normally
Cervix	At vaginal vault	Smooth, firm, cylindrical; moves freely
Uterus	Anteverted/flexed above bladder	Pear-shaped, smooth, mobile, non-tender; ~7-8 cm
Anterior fornix	Between cervix and bladder	Empty space; reflects bladder
Posterior fornix	Behind cervix, deepest	Pouch of Douglas; normally empty
Lateral fornices (×2)	On either side of cervix	Ovaries palpable in thin women; tubes not normally felt
Broad ligament	Lateral	Not felt normally
Uterosacral ligaments	Posterolateral	Smooth cords; nodularity = endometriosis

3. Technique of Per Vaginum (Bimanual) Examination

The bimanual pelvic examination - two vaginal fingers elevate the uterus while the abdominal hand presses down to trap and assess pelvic structures between both hands

(Berek & Novak's Gynecology, Figure 1-3: The bimanual examination)

Patient Position

Dorsal lithotomy position
Legs in stirrups, hips at edge of table
Bladder emptied beforehand (full bladder distorts findings)

Examiner Position

Standing between the patient's legs
Non-dominant hand on lower abdomen (suprapubic area)

Step-by-Step Technique

Step 1 - Lubrication and insertion Apply lubricant to the gloved index and middle fingers. Insert gently into the vagina with palm upward. Warn the patient at each step.

Step 2 - Vaginal walls and fornices Palpate the vaginal walls systematically - anterior, lateral, posterior. Feel each fornix (anterior, posterior, both lateral) for masses, fullness, tenderness, or nodularity.

Step 3 - Cervix Feel the cervix - its position, consistency, length, surface, os. Then test for cervical motion tenderness (CMT) by gently moving the cervix side to side. Pain = positive CMT (excitation sign).

Step 4 - Uterus (bimanual) Place vaginal fingers in the anterior fornix or behind the cervix. Press the abdominal hand firmly downward just above the pubic symphysis. The uterus is "caught" between both hands. Assess:

Size (in weeks equivalent)
Shape (pear-shaped vs irregular)
Surface (smooth vs nodular)
Consistency (firm vs soft vs hard)
Position (anteverted / retroverted)
Mobility (moves freely or fixed)
Tenderness (any pain on palpation)

Step 5 - Adnexa (bimanual) Move vaginal fingers into each lateral fornix in turn. The abdominal hand sweeps laterally corresponding to the same side. Structures are swept between both hands. In a normal woman, only the ovary may be palpable (almond-shaped, slightly tender). Assess:

Presence of any mass
Size, shape, surface
Consistency (cystic vs solid)
Mobility or fixity
Tenderness

Step 6 - Posterior cul-de-sac (Pouch of Douglas) Place vaginal fingers in the posterior fornix. Feel for any fluid, masses, or nodularity in the Pouch of Douglas. The abdominal hand palpates the suprapubic area simultaneously.

Step 7 - Rectovaginal examination (when indicated) One finger in vagina, one in rectum. Assesses:

Rectovaginal septum (endometriosis, fistula)
Posterior uterine wall
Uterosacral ligaments (nodularity = endometriosis)
Posterior cul-de-sac deposits (ovarian cancer)
Rectal wall

4. Parameters Assessed for a Mass Per Vaginum

When a mass is detected on PV examination, it is described using eight key parameters. Each gives specific diagnostic information.

4.1 Site / Origin of the Mass

This is the most important first determination - is the mass uterine or extra-uterine (adnexal)?

How to determine site:

If the mass moves with the cervix when it is manipulated → uterine origin
If the mass is felt separate from the uterus with a groove between them → adnexal origin
If the uterus can be palpated separately from the mass → adnexal / extra-uterine
If the mass fills the entire pelvis and the uterus cannot be delineated → clinical judgment + imaging needed

Location	Likely Origin
Central pelvic mass, moves with uterus	Uterus itself (fibroid, adenomyosis, malignancy, pregnancy)
Lateral to uterus, separate groove	Ovarian / adnexal mass
Behind uterus, in posterior fornix	Pouch of Douglas collection, ovarian cyst, endometrioma
Anterior to uterus	Bladder, anterior fibroid
Fixed, bilateral, in fornices	Broad ligament disease, malignancy, TOA

4.2 Size

Size is estimated in clinical terms and reported as:

Centimeters (e.g., 8 × 6 cm mass in right fornix)
Weeks of pregnancy equivalent for uterine enlargement:

Gestational Equivalent	Anatomical Landmark
6-8 weeks	Uterus just palpable, slightly enlarged, at pubic symphysis level
10-12 weeks	Just above pubic symphysis, reaches the brim
16 weeks	Midway between symphysis pubis and umbilicus
20 weeks	At the umbilicus
24 weeks	4 fingerbreadths above umbilicus
28 weeks	Halfway between umbilicus and xiphisternum

This system is used because clinicians are intimately familiar with the landmark positions of the gravid uterus. In this patient's case - "16-week uterine size" means the uterus reaches halfway between the symphysis and umbilicus, indicating it is approximately 14-16 cm in its long axis.

4.3 Surface

This is felt through the vaginal wall as the mass is moved between both hands.

Surface Character	Description	Interpretation
Smooth	Uniform, no irregularities	Simple ovarian cyst, pregnant uterus, adenomyosis, serous cystadenoma
Nodular / Irregular	Bumpy, lobulated contour	Multiple fibroids (each lump = one fibroid), malignancy, endometrioma
Boss-like projection	Single rounded protrusion	Pedunculated fibroid, subserosal fibroid
Papillary / rough	Rough surface with projections	Ovarian malignancy (papillary serous carcinoma)

In this case: Irregular surface → multiple fibroids distorting the uterine contour, as confirmed by USG.

4.4 Consistency

What the mass feels like under pressure:

Consistency	Feel	Interpretation
Cystic	Fluctuant, fluid-filled; "gives way" under pressure	Simple or complex ovarian cyst, hydrosalpinx, chocolate cyst
Soft / doughy	Uniform softness	Pregnant uterus, lipoma, occasionally adenomyosis
Firm / rubbery	Solid feel like an eraser or rubber ball	Fibroid uterus (most characteristic), leiomyoma
Hard	Stony hard, like bone	Calcified fibroid, dermoid (teratoma with calcification), bone-containing teratoma
Mixed / heterogeneous	Variable feel in different areas	Degenerated fibroid, malignant tumor, dermoid cyst
Tense-cystic	Tense fluid but less fluctuant	Large functional cyst, mucinous cystadenoma, full bladder

In this case: Firm consistency → fibroid uterus. The whorled bundles of smooth muscle in leiomyomas give them their characteristic firm, rubbery feel.

4.5 Mobility

Assessed by attempting to move the mass with vaginal fingers while the abdominal hand restrains:

Mobility	Description	Interpretation
Freely mobile	Moves easily in all directions	Benign pedunculated fibroid, simple ovarian cyst (benign)
Limited mobility	Moves partially; some restriction	Large intramural fibroid (limited by its own bulk), Broad ligament fibroid
Fixed / immobile	Cannot be moved	Malignancy (pelvic wall invasion), PID (adhesions), endometriosis (frozen pelvis), TOA

Remember the rule:

Benign masses tend to be mobile
Malignant or inflammatory masses tend to be fixed

In this case: "Limited mobility" - this is not a red flag for malignancy here. A very large multi-fibroid uterus (16-week size) has mechanical restriction of movement due to its sheer bulk filling the pelvis, not due to infiltration of pelvic sidewalls. This must be distinguished from true fixity due to malignancy.

4.6 Tenderness

The examiner notes whether manipulation of the mass causes pain.

Tenderness	Interpretation
Non-tender	Fibroid, ovarian cyst (functional or benign), malignancy (early), pregnancy
Tender	PID, TOA, twisted ovarian cyst (torsion), ectopic pregnancy, red degeneration of fibroid, endometrioma rupture
Cervical motion tenderness (CMT)	Peritoneal irritation: ectopic pregnancy, PID, TOA, appendicitis
Exquisitely tender	Torsion of ovary/fibroid, ruptured ectopic, ruptured TOA

In this case: Non-tender mass + no CMT → strongly supports a benign, non-inflammatory etiology.

4.7 Relationship to the Uterus

Relationship	Description	Interpretation
Continuous with uterus	Mass and uterus move together, no groove	Uterine fibroid, adenomyosis, uterine malignancy
Separate from uterus	Groove palpable between mass and uterus	Ovarian mass, adnexal mass, broad ligament mass
Bilateral	Both fornices feel full	Bilateral ovarian disease, TOA, malignancy with omental cake
Posterior	Mass in Pouch of Douglas	Ovarian cyst, endometrioma, pelvic abscess, sigmoid mass

4.8 Condition of the Fornices

The fornices are the recesses in the vaginal vault around the cervix.

Fornix Finding	Description	Interpretation
Free	Empty, non-tender, no masses	Ovaries/adnexa normal; uterine origin of mass
Full / obliterated	Fornix feels "doughy" or full	Parametrial involvement, broad ligament mass, pelvic spread
Tender fornix	Pain on palpating a fornix	PID, ovarian torsion, endometrioma, ectopic pregnancy
Nodular posterior fornix	Nodules felt in posterior fornix	Endometriosis (deposits in Pouch of Douglas), ovarian cancer peritoneal seedlings
Cystic lateral fornix	Fluid-filled mass in fornix	Ovarian cyst, paraovarian cyst, hydrosalpinx

In this case: "Bilateral fornices free" → the ovaries and adnexa are not involved. This critically localizes the mass to the uterus itself.

5. Systematic Framework for Characterizing a Pelvic Mass on PV

Use this framework to describe any mass per vaginum systematically - the SCOTMAF mnemonic:

Letter	Parameter	Example (this patient)
S	Site / Origin	Central, continuous with uterus (uterine origin)
C	Consistency	Firm / rubbery
O	cOntour / Surface	Irregular, nodular
T	Tenderness	Non-tender; no CMT
M	Mobility	Limited (mechanical)
A	Adnexa / Fornices	Bilateral fornices free
F	(si)ze in weeks/cm	16-week equivalent

6. What the Individual Findings Mean Diagnostically

"Uterus enlarged to 16 weeks"

Indicates massive uterine enlargement
Normally the non-pregnant uterus is 7-8 cm and non-palpable abdominally
A uterus reaching 16-week size is ~14-16 cm long
Causes of uterine enlargement on PV:

Cause	Features
Multiple fibroids	Firm, irregular, lobulated
Adenomyosis	Smooth, globular, uniformly enlarged, often tender (especially premenstrual)
Intrauterine pregnancy	Soft, smooth; positive UCG
Endometrial carcinoma	May be enlarged; postmenopausal bleeding; irregular cervix sometimes
Uterine sarcoma	Rapidly enlarging; softer; sometimes tender

"Firm consistency"

Due to the whorled fibromuscular architecture of leiomyomas - dense smooth muscle bundles embedded in fibrous stroma
Robbins describes leiomyomas as "sharply circumscribed, discrete, round, firm, gray-white tumors" with a "characteristic whorled pattern"
Firm feel differentiates fibroids from:
- Cysts (fluctuant)
- Adenomyosis (doughy/boggy)
- Pregnancy (soft - Hegar's sign)

"Irregular surface"

Each fibroid nodule protrudes beyond the uterine outline, creating a lobulated, bumpy surface
The number and size of lobulations correlates roughly with the number of fibroids
Smooth uterine surface despite enlargement would suggest adenomyosis or pregnancy

"Limited mobility"

This is mechanical restriction, not true fixation
A 16-week sized uterus physically occupies most of the pelvic cavity and cannot move freely
True fixation (from pelvic wall infiltration) = malignancy / endometriosis / post-inflammatory adhesions

"Bilateral fornices free"

Confirms the adnexa (ovaries, tubes) are uninvolved
The mass is entirely of uterine origin
Rules out: ovarian cyst, TOA, ectopic pregnancy, ovarian malignancy

"No cervical motion tenderness"

Absence of CMT = no peritoneal irritation
Rules out the entire PID spectrum (salpingitis, TOA)
Rules out ectopic pregnancy
Combined with negative UCG = ectopic definitively excluded

7. Differential Diagnosis of Pelvic Mass on PV Examination

Condition	Site	Size	Surface	Consistency	Mobility	Tenderness	Fornices	Other clues
Fibroid uterus	Uterine	Variable (often large)	Irregular, nodular	Firm/rubbery	Variable (limited if large)	Non-tender	Free	Menorrhagia, parity
Adenomyosis	Uterine	Moderate (12-14 wks)	Smooth, globular	Doughy/boggy	Mobile	Tender (esp. premenstrual)	Free	Dysmenorrhea, multipara
Pregnancy	Uterine	Corresponds to dates	Smooth	Soft (Hegar's sign)	Mobile	Non-tender	Free	UCG positive, amenorrhea
Endometrial carcinoma	Uterine	Slightly enlarged	Smooth-irregular	Firm-soft	Mobile to fixed	Usually non-tender	Free or involved	Post-menopausal bleeding
Ovarian cyst (simple)	Adnexal	Variable	Smooth	Cystic/tense	Freely mobile	Non-tender	Filled (unilateral)	Separate from uterus
Endometrioma	Adnexal	5-10 cm typically	Smooth-nodular	Tense-cystic	Restricted mobility	Tender	Tender fornix	Dysmenorrhea, chocolate cyst
Ovarian malignancy	Adnexal	Large	Irregular, nodular	Solid-mixed	Fixed	Non-tender to tender	Nodular / obliterated	Older age, ascites, weight loss
Tubo-ovarian abscess	Adnexal	Variable	Ill-defined	Doughy-cystic	Fixed	Exquisitely tender	Bilateral, tender, full	Fever, positive CMT, discharge
Ectopic pregnancy	Adnexal	Small-moderate	Ill-defined	Soft-cystic	Variable	Very tender	Tender	UCG positive, CMT positive
Dermoid cyst (Teratoma)	Adnexal	Variable	Smooth	Mixed (may feel hard)	Freely mobile (tends to be anterior)	Non-tender	Filled	Younger women
Pedunculated fibroid	Uterine/free	Variable	Smooth to irregular	Firm	Mobile	Non-tender	May appear separate	Stalk connecting to uterus
Broad ligament fibroid	Lateral	Large	Smooth	Firm	Very limited	Non-tender	Unilateral fullness	Displaced uterus

8. Special Variant: Rectovaginal (RV) Examination

When indicated (suspected endometriosis, malignancy, RV fistula):

One gloved finger in vagina, one in rectum simultaneously
Assesses the rectovaginal septum, posterior uterine wall, uterosacral ligaments
Nodularity or thickening of uterosacral ligaments = endometriosis (very specific finding)
Fixed retroflexed uterus = pelvic adhesions or endometriosis
Shelf-like mass felt anteriorly in rectum = Blumer's shelf sign = peritoneal metastases from ovarian/GI cancer
Posterior cul-de-sac nodularity = Pouch of Douglas implants (ovarian malignancy, endometriosis)

9. Common Pitfalls in Per Vaginum Examination

Pitfall	How to Avoid
Full bladder masking findings / creating a false mass	Always ask patient to empty bladder before examination
Missing a retroverted uterus	Fingers in posterior fornix; mass may be felt posteriorly
Confusing a pedunculated fibroid for an adnexal mass	Trace the stalk; it moves with the uterus
Missing a fixed retroflexed uterus as "adnexal mass"	Systematic bimanual on both sides; RV examination
Inadequate relaxation of patient causing false tenderness	Proper patient positioning, communication, and rapport
Obesity limiting examination quality	Deeper abdominal pressure; may be unreliable - proceed to imaging
Missing posterior cul-de-sac disease	Always perform posterior fornix palpation and RV if indicated

10. Summary Table: PV Findings in This Patient

Parameter	Finding	Interpretation
Site	Central, moves with cervix	Uterine origin confirmed
Size	16-week equivalent	Massively enlarged uterus
Surface	Irregular, nodular	Multiple fibroids creating lobulations
Consistency	Firm/rubbery	Fibromuscular leiomyoma tissue
Mobility	Limited	Mechanical, due to large bulk - not malignant fixation
Tenderness	Non-tender	Benign process; no inflammation/torsion
CMT	Absent	No peritoneal irritation; excludes ectopic, PID
Fornices	Bilateral free	Adnexa uninvolved; purely uterine mass
Diagnosis	Multiple fibroid uterus	Confirmed by USG

(Sources: Berek & Novak's Gynecology; Robbins, Cotran & Kumar Pathologic Basis of Disease; Creasy & Resnik's Maternal-Fetal Medicine)

Explain mass per vaginum

I've already covered this in detail in my previous response. Here is a clean, organized summary of everything covered:

Mass Per Vaginum - Complete Explanation

What It Is

Mass per vaginum (MPV) means detecting and characterizing a pelvic mass through the vaginal route using the bimanual pelvic examination - the single most informative clinical technique in gynecology. One or two fingers are placed inside the vagina while the other hand presses down on the lower abdomen, trapping pelvic structures between both hands.

The Bimanual Technique (Step by Step)

Bimanual pelvic examination - vaginal fingers elevate the uterus while the abdominal hand presses down to assess pelvic structures between both hands

(Berek & Novak's Gynecology, Figure 1-3)

Patient in lithotomy position - bladder emptied
Lubricated gloved fingers inserted into vagina (index + middle), palm upward
Vaginal walls and fornices palpated - anterior, posterior, both lateral
Cervix assessed - position, consistency, surface, then cervical motion tenderness (CMT) tested
Uterus assessed bimanually - fingers in anterior fornix, abdominal hand suprapubic; uterus caught between both hands
Adnexa assessed - fingers swept into each lateral fornix; adnexal structures palpated bilaterally
Posterior fornix / Pouch of Douglas - checked for fluid, nodularity, masses
Rectovaginal examination when indicated (endometriosis, malignancy)

The 8 Parameters of a Mass Per Vaginum

Use the mnemonic SCOTMAF (+ Fornices):

1. Site / Origin

The most critical determination - is the mass uterine or extra-uterine (adnexal)?

How to Determine	Implication
Mass moves with cervix on manipulation	Uterine origin
Uterus palpated separately with groove between	Adnexal / extra-uterine
Mass in lateral fornix, separate from uterus	Ovarian / broad ligament
Mass in posterior fornix	Pouch of Douglas, ovarian, rectosigmoid

2. Size

For uterine enlargement, reported as gestational week equivalent:

Weeks Equivalent	Palpable Level
10-12 weeks	At pubic symphysis
16 weeks	Midway between symphysis and umbilicus
20 weeks	At umbilicus
28 weeks	Halfway between umbilicus and xiphisternum

For adnexal masses, reported in centimeters (3D measurement).

3. Surface (Contour)

Surface	Interpretation
Smooth	Simple ovarian cyst, pregnant uterus, adenomyosis, serous cystadenoma
Irregular / nodular	Multiple fibroids (each lump = one fibroid), malignancy
Boss-like projection	Single pedunculated/subserosal fibroid
Papillary / rough	Papillary serous carcinoma of ovary

4. Consistency

Feel	Interpretation
Cystic / fluctuant	Ovarian cyst, hydrosalpinx, chocolate cyst
Soft / doughy	Pregnant uterus, adenomyosis
Firm / rubbery	Fibroid uterus (most characteristic)
Stony hard	Calcified fibroid, dermoid teratoma
Mixed / heterogeneous	Degenerated fibroid, malignancy, dermoid

5. Mobility

Mobility	Interpretation
Freely mobile	Benign cyst, pedunculated fibroid
Limited mobility	Large fibroid (mechanical bulk), broad ligament fibroid
Fixed / immobile	Malignancy (pelvic wall invasion), PID adhesions, endometriosis ("frozen pelvis"), TOA

Rule of thumb: Benign = mobile. Fixed = suspect malignancy or inflammation.

6. Tenderness

Finding	Interpretation
Non-tender	Fibroid, benign cyst, early malignancy
Tender mass	PID, TOA, torsion, red degeneration of fibroid
CMT positive	Ectopic pregnancy, PID, peritoneal irritation
Exquisitely tender	Torsion, ruptured ectopic, ruptured TOA

7. Fornices

Fornix Finding	Interpretation
Free (empty, non-tender)	Adnexa normal; mass is uterine in origin
Filled / cystic (unilateral)	Ovarian cyst, paraovarian cyst, hydrosalpinx
Tender	PID, torsion, endometrioma
Nodular (posterior)	Endometriosis deposits, ovarian cancer peritoneal seedlings
Obliterated bilateral fornices	Malignancy, frozen pelvis, advanced endometriosis

8. Relationship to Uterus

Finding	Interpretation
Continuous, moves with uterus	Fibroid, adenomyosis, uterine malignancy
Separate, groove palpable	Adnexal mass (ovarian, paraovarian)
Cannot delineate uterus from mass	Very large mass - needs imaging

Differential Diagnosis at a Glance

Condition	Consistency	Surface	Mobility	Tenderness	Fornices
Multiple fibroids	Firm	Irregular	Limited	Non-tender	Free
Adenomyosis	Doughy	Smooth	Mobile	Tender (premenstrual)	Free
Ovarian cyst (simple)	Cystic	Smooth	Freely mobile	Non-tender	Filled (unilateral)
Endometrioma	Tense-cystic	Smooth-nodular	Restricted	Tender	Tender
Ovarian malignancy	Solid-mixed	Irregular	Fixed	Variable	Nodular/obliterated
TOA	Doughy-cystic	Ill-defined	Fixed	Exquisitely tender	Bilateral, full, tender
Ectopic pregnancy	Soft-cystic	Ill-defined	Variable	Very tender	Tender + CMT positive
Dermoid (teratoma)	Mixed-hard	Smooth	Freely mobile	Non-tender	Filled (often anterior)

Rectovaginal Examination - When to Do It

Suspected endometriosis (nodular uterosacral ligaments)
Suspected posterior spread of ovarian/uterine malignancy
Fixed retroflexed uterus
Rectovaginal fistula

Blumer's shelf sign - a shelf-like firm mass felt anteriorly in the rectum = peritoneal metastases (ovarian or GI cancer dropping into Pouch of Douglas).

Key Pitfalls

Pitfall	How to Avoid
Full bladder creating a false mass	Always empty bladder first
Retroverted uterus missed	Fingers in posterior fornix
Pedunculated fibroid confused with adnexal mass	Trace the stalk - it moves with uterus
Obesity limiting examination	Proceed to imaging; do not over-interpret
Patient tension causing false tenderness	Adequate communication and relaxation

(Berek & Novak's Gynecology; Robbins, Cotran & Kumar Pathologic Basis of Disease; Creasy & Resnik's Maternal-Fetal Medicine)

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