Chandelier Sign

Issues of Concern

Pelvic exams are contraindicated in a pregnant patient with rupture of the chorioamniotic membranes before the onset of labor.[1]

Clinical Significance

The pelvic examination serves as part of the procedure to detect abnormalities indicated by the history and physical as well as unforeseen issues not previously known to the patient. Verbally indicating all physical interaction before proceeding helps comfort the patient and avoid surprises. Ensure patient positioning is in front of the examiner, with a sheet draped over the patient’s legs to provide respectful modesty at all times patient is not actively being examined. If possible, place the head of the bed at 30 degrees to make eye contact with the patient while describing each step throughout the examination, and evaluate the patient’s physical response to the examination. This process will also allow the abdominal muscles to relax, which is more conducive to the pelvic exam.

Pelvic examination starts with an exterior examination and progresses to the examination of the introitus, the vagina, and the cervix. Further details of the pelvic examination will be excluded from this activity; however, all components of the pelvic examination are essential for a comprehensive assessment of the patient. Evaluation of cervical motion tenderness occurs during the bimanual examination, performed by inserting the index finger and middle finger into the vagina until they are at the limit of the vaginal vault in the posterior fornix, which is posterior and caudad to the cervix. The examiner then uses their other hand to place pressure on the abdominal wall, over the suprapubic region. Each hand applies pressure towards the opposite hand, which allows for circumferential examination of the cervix for size, position, shape, mobility, and to assess if there is any present tenderness or palpable masses.  After cervical motion testing, it is crucial to continue onto the bimanual examination of the uterus for a complete assessment. This is accomplished by applying anterior pressure towards the patient’s abdominal wall and assessing for the size, position, shape, tenderness, and mobility of the uterus itself. To finish the bimanual assessment examination of the adnexa is performed by placing the fingers to the side of the cervix, deep to the lateral fornix with pressure towards the anterior abdominal wall, and applying pressure with the abdominal hand toward the symphysis overlying the supporting structures including the ovaries. This will allow the examiner to distinguish the location of any acute tenderness, and note if there is any isolated cervical motion tenderness. This technique may vary in patients with different body mass index classes.[2]

Additionally, there is documentation of utilizing sonography to assess for cervical motion tenderness, in which cervical motion undergoes evaluation when performing a transvaginal ultrasound. This also serves the purpose of visualizing the pelvic structures after discovering this exam finding. In the study conducted by Tayal et al., out of the 30 patients enrolled across various body mass index classes, physician confidence was higher in clinical findings of uterine and adnexal tenderness, but there was no increase in confidence of cervical motion tenderness or retrovaginal tenderness.[3] Although further studies are warranted, the expectation is that physical exam skills remain paramount in ascertaining a medical diagnosis, though the use of sonography clearly has a place in the assessment of a patient.

Cervical motion tenderness alone can add to the differential diagnosis of any process that has peritoneal involvement across different organ systems. Gastrointestinal: appendicitis, diverticulitis, inflammatory bowel disease, hernia, perforated abdominal viscus, abdominal wall hematoma. Urinary: ureteral lithiasis, interstitial cystitis. Gynecological: ectopic pregnancy[4], endometriosis, endometritis, PID,[5] tubo-ovarian abscess, ovarian or adnexal torsion,[6] chronic pelvic cellulitis, vaginitis, cervicitis, pelvic thrombophlebitis.[7] Cervical motion tenderness in and of itself can be indicative of peritoneal irritation.  That is why it is essential to distinguish the location of the tenderness and if any additional pelvic structures are involved.

Nursing, Allied Health, and Interprofessional Team Interventions

The nurse should have the pelvic tray ready with the instruments and gloves. Because a pelvic exam is not always comfortable, the nurse plays a vital role in relieving the patient anxiety by answering questions, providing company, and distracting the patient.

No male physician should ever perform a pelvic exam without a nurse present in the room. A chaperone is a must in today's litigious environment. 

Nursing, Allied Health, and Interprofessional Team Monitoring

Even before the patient gets to the examination room, the nurse should explain the procedure and answer questions. The nurse should monitor the patient for comfort, pain, and anxiety.