1. Inspection

• Site/shape: A visible swelling in the hypogastrium, which may extend up towards the umbilicus (or beyond, if very large), typically in the midline — occasionally asymmetric if a large subserous fibroid projects to one side.
• Surface: May look smooth and uniformly distended (mimics pregnancy, especially with a single intramural/submucous fibroid) or show visible irregular bosselations/lobulations on the abdominal contour (multiple subserous fibroids).
• Movement with respiration: Fibroid masses arising from the pelvis do not move with respiration (unlike an enlarged liver or spleen), since they are pelvic, not sub-diaphragmatic, in origin.
• Skin over the swelling is usually normal; no engorged veins or visible pulsations (helps exclude vascular causes).
• Umbilicus: pushed up but not everted (contrast with ascites where flanks bulge and umbilicus may evert).

2. Palpation

• First rule out a full bladder — the patient must be catheterized/asked to void before palpating, since a distended bladder is one of the classic mimics and can make interpretation unreliable (S Das, A Manual on Clinical Surgery, p. 540-541).
• Consistency: Firm to hard, though a fibroid undergoing cystic or red degeneration can feel softer.
• Surface/margins: Classically irregular and nodular (multiple fibroids) — this irregularity, in a woman above 30 but before menopause, is a strong pointer to fibroid; a smooth uniformly enlarged uterus is more typical of pregnancy or a single submucous fibroid.
• Mobility: Moves from side to side but is restricted in the vertical (up-down) axis because it is tethered in the pelvis — it cannot be pushed below the swelling (you cannot "get below" it), a key sign distinguishing a pelvic mass from a mobile intraperitoneal one.
• Bimanual/pelvic-abdominal palpation: The mass moves with the cervix on bimanual examination, confirming its uterine origin.
• Usually non-tender, unless there is red degeneration, torsion of a pedunculated fibroid, or infection, in which case marked tenderness appears.
• Lower border generally cannot be reached (arises out of the pelvis) unless the fibroid is pedunculated/subserosal and mobile.

3. Percussion

• Central dullness over the mass, with resonant flanks — this pattern (dull centrally, resonant laterally, in a supine patient) is what distinguishes a solid pelvic mass such as fibroid (or ovarian cyst/pregnancy) from ascites, which shows the opposite pattern (dull flanks, resonant center) and shifting dullness.
• No shifting dullness (unlike ascites).
• If there is a large fibroid pushing up the bowel loops, the area over the mass loses its normal resonance (small bowel is normally resonant in this region) and instead becomes dull, which is itself a useful sign that a mass is present.

4. Auscultation

• A fibroid uterus is classically auscultation-silent — no bowel sounds, no bruit, and no fetal heart sounds are heard over it.
• Auscultation is mainly used here to exclude pregnancy (absence of fetal heart sounds, which would be audible from about 18-20 weeks with a Doppler/Pinard) and to exclude a vascular mass (e.g., aortic aneurysm or arteriovenous malformation, which would show a bruit).
• Absence of bowel sounds over the mass also helps differentiate it from a bowel-related swelling.