Overview
A gynecological examination in the Emergency Department is performed to evaluate acute problems affecting the female reproductive tract. Common indications include pelvic pain, abnormal vaginal bleeding, vaginal discharge, suspected pelvic inflammatory disease, early pregnancy complications, and concerns about sexually transmitted infections.
ED priorities are to recognise time-critical conditions such as ectopic pregnancy, ovarian torsion, severe pelvic infection, significant haemorrhage and sexual assault, while maintaining privacy, dignity and clear communication.
Preparation
- Ensure a private space, appropriate draping and a professional chaperone for intimate examinations.
- Introduce yourself, explain the indication for the examination and obtain verbal consent.
- Ask the patient about pain and offer simple analgesia before the exam where appropriate.
- Position the patient comfortably (usually in the lithotomy or semi-recumbent position) and ensure they can stop the examination at any time.
- Confirm pregnancy status in women of reproductive age and consider a urine or serum β-hCG before internal examination if indicated.
Key History & Red Flags
- Bleeding: onset, amount (pads/hour, clots), relation to periods or pregnancy, post-coital bleeding.
- Pain: site (uni/bilateral), character, radiation, timing (sudden vs gradual), relation to cycle or intercourse.
- Discharge: colour, odour, volume, associated pruritus or irritation.
- Menstrual and obstetric history: LMP, cycle pattern, contraception, previous pregnancies and outcomes, prior ectopic pregnancy.
- Sexual history: new partners, protection use, prior STIs, sexual assault concerns.
- Systemic features: fever, nausea, vomiting, syncope, shoulder-tip pain, urinary or bowel symptoms.
Red flags: haemodynamic instability, severe unilateral pelvic pain, heavy PV bleeding with clots, positive pregnancy test with pain or bleeding, peritonism, fever with cervical motion tenderness, and any suspicion of sexual or gender-based violence.
Components of the Examination
Always explain each step as you go and stop if the patient is in distress.
- External inspection: assess vulva, perineum and anus for skin changes, lesions, ulcers, warts, scars, trauma, swelling or active bleeding.
- Speculum examination: gently insert a lubricated speculum (water-based gel if not doing microscopy) to visualise:
- Vaginal walls: discharge, blood, foreign bodies, atrophic changes, lesions.
- Cervix: appearance, ectropion, friability, discharge (mucoid, purulent, blood), lesions or erosions.
- Collect samples for STI testing, pH testing, microscopy or culture as indicated.
- Bimanual examination: with one hand in the vagina and the other on the lower abdomen, assess:
- Cervical motion tenderness (PID/ectopic suspicion).
- Uterine size, position (anteverted/retroverted), tenderness and mobility.
- Adnexal tenderness or masses (cysts, ectopic pregnancy, ovarian torsion).
- Abdominal examination: should be performed before internal exam – look for guarding, rebound, masses or peritonism.
Diagnostic Tests
Depending on symptoms and examination findings, investigations may include:
- Pregnancy test: urine or serum β-hCG in all women of reproductive age with pelvic pain or PV bleeding.
- STI testing: cervical/vaginal swabs for Chlamydia, Gonorrhoea and other infections, as per local protocol.
- Pelvic ultrasound: transabdominal and/or transvaginal to evaluate uterus, adnexa, free fluid and pregnancy location.
- Blood tests: FBC, CRP, U&E, group and save/crossmatch, liver function tests, clotting profile where indicated.
- Urinalysis: for haematuria, infection, proteinuria or pregnancy-related complications.
Differential Diagnosis
Common conditions presenting with gynaecological symptoms in the Emergency Department include:
| Condition | Common Symptoms | Diagnostic Tests | Treatment (Principles) | Danger Signs | Grading / Notes |
|---|---|---|---|---|---|
| Pelvic inflammatory disease (PID) | Lower abdominal/pelvic pain, dyspareunia, abnormal discharge, intermenstrual or post-coital bleeding, fever. | Pelvic exam (cervical motion tenderness), cervical swabs, pregnancy test, ultrasound if abscess suspected. | Broad-spectrum antibiotics according to protocol, analgesia, partner notification and follow-up. | High fever, sepsis, peritonism, adnexal mass, suspected tubo-ovarian abscess or failure to respond to therapy. | Mild, moderate, severe – based on pain, systemic features and imaging (e.g. presence of abscess). |
| Ectopic pregnancy | Pelvic or abdominal pain, PV bleeding, amenorrhoea or missed period, sometimes shoulder-tip pain or dizziness. | Positive pregnancy test, serial β-hCG, transvaginal ultrasound, sometimes diagnostic laparoscopy. | Urgent surgical management for unstable patients or ruptured ectopic; medical (methotrexate) or surgical options for stable patients as per criteria. | Haemodynamic instability, sudden severe pain, syncope, heavy PV bleeding, peritonism, falling Hb. | Classified by size, location and stability; management guided by haemodynamics and imaging. |
| Endometriosis | Chronic pelvic pain, dysmenorrhoea, deep dyspareunia, subfertility; may flare with periods. | Pelvic exam, ultrasound (often normal), laparoscopy is gold standard for diagnosis. | Pain management, hormonal therapy, referral for elective surgical management where indicated. | Severe acute pain, heavy bleeding, signs of acute abdomen may suggest complications or alternative diagnoses. | Stage I–IV based on distribution and severity of lesions (surgical staging, usually non-ED). |
| Urinary tract infection (UTI) | Dysuria, frequency, urgency, suprapubic discomfort; flank pain and fever if pyelonephritis. | Urinalysis, urine culture, blood tests if systemic features; imaging in recurrent/complicated cases. | Oral or IV antibiotics (depending on severity), hydration, analgesia; hospitalisation for pyelonephritis with sepsis or pregnancy. | Fever with rigors, flank pain, hypotension, pregnancy, recurrent or resistant infection. | Mild (uncomplicated cystitis) to severe (pyelonephritis, urosepsis), guided by clinical presentation. |
OBGYN Guidelines
For detailed management pathways, medication regimens and referral criteria, refer to:
Conclusion
Gynecological assessment in the Emergency Department requires a structured history, careful and respectful examination and timely use of investigations. Recognising red flags for ectopic pregnancy, ovarian torsion, severe pelvic infection and significant haemorrhage is critical. Local OBGYN guidelines should be followed for definitive management, admission and follow-up planning.