Pelvic exams under anesthesia are performed when a patient cannot undergo a pelvic exam without sedation or general anesthesia. These reasons may have physical or psychological explanations. Some patients may prefer to have gynecological exams and procedures done under anesthesia due to an inability to tolerate the exam. However, these exams may be important in the sense that they may, for example, guide a subsequent surgical procedure, so utilizing anesthesia may be preferred to skipping the exam altogether. These exams allow a clinician to fully understand a patient’s anatomy and where their uterus is located. Patients should always be consented prior to a pelvic exam. There are several indications for administering sedation during a pelvic exam. 

Most commonly, pelvic exams are performed under sedation prior to a procedure. There is more relaxation of the abdominal and pelvic muscles under anesthesia which allows for a more informative assessment of a patient’s internal organs. Depending on patient’s body habitus and comfort level, it may be difficult for them to fully relax their muscles during a pelvic exam (Goedken, 2005). It is important that prior to surgery, a clinician has a good understanding of a patient’s anatomy. Outside of the OR, pelvic fracture is a common indication for performing a pelvic exam under sedation. In patients with pelvic fracture, performing a pelvic exam under anesthesia with dynamic stress fluoroscopy may be helpful in providing information regarding instability of the pelvic ring. In these cases, the pelvic exam under anesthesia informs further surgical intervention and the decision to move forward with anterior and/posterior operative reduction and stabilization (Sagni & Coniglione, 2011).  

Examination under anesthesia has also been discussed in the assessment of pediatric and adolescent patients. In a group of pediatric and adolescent females, exam under anesthesia with diagnostic vaginoscopy was performed in assessment for reconstructive surgery, vaginal stenosis, vaginal discharge, vaginal bleeding, and pelvic pain (Nakhal et al., 2012). Physical, behavioral, or developmental disabilities in adolescents may be an indication for sedation for a pelvic exam. Current indications for pelvic examination in the pediatric office setting include persistent vaginal discharge, dysuria or urinary tract symptoms in a sexually active female, dysmenorrhea unresponsive to NSAIDs, amenorrhea, abnormal vaginal bleeding, lower abdominal pain, contraceptive counseling for an IUD or diaphragm, performing a Pap test, suspected/reported sexual abuse, and pregnancy (Braverman & Breech, 2010).  

In all situations, a patient must provide informed consent to a pelvic exam, including pelvic exams under anesthesia. If a pelvic exam is done under sedation, the clinician must provide informed consent explaining what procedure will be performed, who may perform the exam, and what the indications are – why the procedure is needed and why anesthesia will be utilized. This exam is included in the standard consenting process for gynecologic surgery. However, only 19%% of patients undergoing gynecologic surgery were aware that a medical student may do a pelvic exam in the OR. 72% were asked for explicit consent before medical students participated in the pelvic exams under anesthesia. While patients may be open to allowing medical students to perform the pelvic exam, appropriate and explicit consent must be obtained (Wainberg et al., 2010).  

Ultimately, while pelvic exams under anesthesia are indicated in certain cases, patients must always provide informed consent prior to the exam. The pelvic exam under anesthesia allows a clinician to better understand and evaluate a patient’s internal anatomy and make clinical decisions based on their findings. Patients must understand the purpose of the exam under anesthesia and know the personnel who will be performing the exam.  

References  

1. Goedken J. Pelvic examinations under anesthesia: an important teaching tool. J Health Care Law Policy. 2005;8(2):232-239. 
2. Paula K. Braverman, Lesley Breech, The Committee on Adolescence; Gynecologic Examination for Adolescents in the Pediatric Office Setting. Pediatrics September 2010; 126 (3): 583–590. 10.1542/peds.2010-1564 
3. Nakhal RS, Wood D, Creighton SM. The role of examination under anesthesia (EUA) and vaginoscopy in pediatric and adolescent gynecology: a retrospective review. J Pediatr Adolesc Gynecol. 2012;25(1):64-66. doi:10.1016/j.jpag.2011.08.005 
4. Sagi HC, Coniglione FM, Stanford JH. Examination under anesthetic for occult pelvic ring instability. J Orthop Trauma. 2011;25(9):529-536. doi:10.1097/BOT.0b013e31822b02ae 
5. Wainberg S, Wrigley H, Fair J, Ross S. Teaching pelvic examinations under anaesthesia: what do women think?. J Obstet Gynaecol Can. 2010;32(1):49-53. doi:10.1016/S1701-2163(16)34404-8