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Sequence of Pelvic Examination Affects Patient-Reported Pain

Rinko, Rebecca, DO*; Yu, Ian; Bakillah, Emna; Alper, Lauren; Delaney, Colleen; Su, Marisa; Dawson, Melissa, DO, MS*; Gracely, Edward, J., PhD; Whitmore, Kristene, E., MD§

Female Pelvic Medicine & Reconstructive Surgery: March/April 2018 - Volume 24 - Issue 2 - p 150–154
doi: 10.1097/SPV.0000000000000515
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Objective The purpose of this trial is to compare patient-reported pain based on the sequence of the pelvic examination and to assess the relationship between pain during the examination and quality of life, self-esteem, and sexual function.

Methods A randomized controlled trial of women presenting for annual gynecologic examinations. Women were assigned to either group A: a Q-tip touch test, speculum examination, then bimanual examination or group B: Q-tip touch test, bimanual examination, then speculum examination. The primary outcome was visual analog scales to assess pain at baseline and after each portion of the examination. Secondary outcomes were responses to questionnaires for self-esteem, quality of life, and sexual function.

Results Of 200 women who enrolled, 192 (96%) completed all visual analog scale data points. Each portion of the examination caused minimal pain over baseline in each group. Pain during the speculum examination was higher than pain during the bimanual examination in both groups (P = 0.007 and P < 0.001). Group B, however, had significantly higher pain scores after the speculum examination than group A (P = 0.044). The groups did not differ on bimanual pain scores (P = 0.76). Pain scores were not statistically different when analyzed by age, parity, sexual activity, sexual orientation, education, or previous hysterectomy. Within both groups, patients who documented having any pain after the speculum examination or the bimanual examination were also more likely to have lower quality of life scores (P < 0.001 and P < 0.001).

Conclusions Pain associated with the speculum examination was lower in those undergoing speculum before bimanual examination. Speculum pain was greater than bimanual pain in both groups. Most patients reported minimal or no pain during the different portions of the examination.

The sequence of pelvic examinations affects patient-reported pain.

From the *Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine; †Drexel University College of Medicine; ‡Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University; and §Division of Female Pelvic Medicine and Reconstructive Surgery and Urology, Drexel University College of Medicine, Philadelphia, PA.

Correspondence: Rebecca Rinko, DO, 207 N. Broad St, 4th Floor, Philadelphia, PA 19107. E-mail:

The authors have declared they have no conflicts of interest. identifier: NCT02913027.

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