A rectovaginal examination is a specialized component of a standard pelvic exam used to assess structures located in the deepest part of the female pelvis. This diagnostic technique utilizes two fingers from the clinician’s examining hand—one placed into the vagina and the other into the rectum—to manually evaluate the area. Examining the tissue between these two spaces provides a more complete understanding of the posterior uterus, the rectovaginal septum, and surrounding ligaments. The procedure diagnoses specific conditions that cannot be adequately assessed through a typical bimanual examination alone.
Steps Involved in the Examination
The examination is typically performed after the speculum and bimanual portions of a pelvic exam are complete, with the patient remaining in the lithotomy position. The clinician changes gloves and applies fresh lubricant to their examining fingers for comfort. This prevents material from the preceding vaginal exam from being introduced into the rectum.
The clinician gently inserts one finger, usually the index finger, into the vagina and simultaneously inserts a second finger, often the middle finger, into the rectum. The other hand is placed on the lower abdomen, compressing the pelvic organs between both hands. This creates a bimanual effect that reaches higher into the posterior pelvis than a standard vaginal exam.
The goal is to palpate the rectovaginal septum, checking for thickening, masses, or tender nodules. The clinician also assesses the rectouterine pouch (cul-de-sac) and the uterosacral ligaments. Trapping the posterior structures provides a detailed three-dimensional assessment of otherwise inaccessible areas. The entire procedure is generally quick.
Clinical Scenarios Requiring the Test
The rectovaginal exam is reserved for situations requiring a deeper assessment of the posterior pelvic structures. The dual-finger technique provides superior resolution for structures located deep or high in the pelvis, which a standard bimanual exam cannot fully evaluate.
This examination is required for the thorough evaluation of deep pelvic pain, especially when pain occurs during bowel movements or sexual intercourse. It is used to assess the uterosacral ligaments for nodularity or scarring, a finding associated with endometriosis. The procedure also helps evaluate suspected masses in the adnexa, such as an ovarian tumor or cyst that has shifted toward the back of the uterus.
The rectovaginal exam is useful in the staging of gynecological cancers, such as cervical or uterine cancer, to determine if the disease has spread to the rectovaginal septum or nearby bowel wall. It also assesses the integrity of the pelvic floor and sphincter muscles. This is relevant in cases of suspected pelvic organ prolapse or issues related to fecal incontinence.
Patient Preparation and Comfort
No extensive preparation is required, but patients should empty their bladder immediately before the procedure for comfort. Clinicians may suggest avoiding a large meal beforehand. If the patient is prone to constipation, a laxative may be recommended the day before, as a full rectum can interfere with accuracy. The exam can be performed during menstruation, but some patients prefer to schedule the appointment when their flow is not heavy.
Open communication with the clinician is encouraged, as the prospect of this exam can cause anxiety. Patients should share any history of severe pain, anxiety, or previous difficult examinations. During the procedure, deep breathing and consciously relaxing the pelvic floor muscles can reduce discomfort.
The exam should not cause sharp or debilitating pain; any such sensation must be communicated immediately to the provider. Patients may feel a strong sense of pressure or the urge to have a bowel movement, which is a normal sensation caused by the finger in the rectum. The process is completed quickly, and the clinician will guide the patient through the examination.