The Bimanual Vaginal Abdominal Rectal Examination happens at the Ob-Gyn visit when the doctors examines your vagina and pelvic organs with both hands.
Bimanual vaginal abdominal examination
If the doctor has an assistant they should help with lubricant. This should be applied to the middle and forefinger of the doctor's hand. The lubricant package should not touch the glove. The doctor should alert you verbally that the bimanual examination is about to begin, again establishing a tactile signal. Take a deep breath and exhale.
The doctor introduces the tips of two fingers into the vagina. Then he/she inserts both fingers into the vagina up to the middle knuckle, then turns the hand palm up and continues inserting, hyper extending the thumb and flexing the 4th and 5th fingers toward the palm. They should keep their hand flexible to keep the outside fingers from agitating the external genitalia during this part of the exam. They should be standing for this part of the exam.
The doctor palpates the vaginal rugae (tissue), checking for depth and noting anything unusual such as cysts, scarring or deformity. Now they locate the cervix. Checking the size direction, consistency and tenderness of the cervix. (The cervix normally is firm, but a hard cervix could indicate cancer.) Now they get their fingers underneath the cervix. Remember to take a deep breath and relax your abdominal muscles. With the inside hand pushing up gently, and their outside hand pushing down on the abdomen, the doctor palpates the uterus. They will note the size, position, consistency (firm vs. soft), direction (anteverted vs. retroverted) and tenderness.
Next they move the vaginal fingers over with the abdominal hand to palpate for each ovary. The ovaries are often difficult to palpate. It's very subtle. They note the thickness of the parametrial tissue and whether there are any pelvic masses. They now remove fingers smoothly, and remove the outer glove, holding hand down and turning glove inside out to prevent any splattering. They should discard the glove in biohazard waste bin or bag. With the help of the assistant, they re-glove and again apply lubricant to middle and forefinger of dominant hand.
Bimanual rectovaginal examination
Now for the the rectovaginal examination.
Some OB-GYN visits exclude this part of the examination entirely. This is not acceptable. Many people would like to avoid this rectal exam due to discomfort and fear but should not, as many polyps are discovered rectally and this small part of the exam could save your life.
In this final part of the exam, the doctor will be inserting their index finger into the vagina, and at the same time, inserting their middle finger into the rectum. Again, they should alert you that the exam is about to begin. Reestablish the tactile signal. They place the forefinger at the entrance to the vagina and middle finger at the entrance to the rectum. While you may feel some discomfort, you should not feel any pain. Take a deep breath as they bear down as if you are having a bowel movement, in order to relax the anal sphincter. They then insert both fingers. Again, they palpate the uterus and ovaries. In a woman with a retroverted uterus, the uterus may be easier to palpate from this position. They then palpate the posterior rectal wall, then in a sweeping motion, palpate the septum between the two fingers and finally remove the fingers smoothly, and again remove gloves, holding hand down and turning glove inside out. Then they discard the gloves and wash their hands again.