Chandelier Sign

Issues of Concern

Pelvic examinations 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 evaluation to detect abnormalities indicated by the history and physical as well as unforeseen issues not previously known to the patient.[2] Explicit consent for the pelvic examination should be obtained, respecting the patient's autonomy and decision-making. 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 when the 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 evaluating the patient’s physical response to the examination. This process will also allow the patient's abdominal muscles to relax, which is more conducive to a thorough pelvic examination.

Pelvic examination starts with an exterior genital assessment and progresses to the examination of the introitus, the vagina, and the cervix. Evaluation of CMT occurs during the initial 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 the other hand to place pressure on the patient's 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, and mobility and to assess if there is any present tenderness or palpable masses.  After the CMT evaluation, it is crucial to continue with the bimanual examination of the uterus for a complete assessment. This is accomplished by applying anterior pressure toward the patient’s abdominal wall and assessing for the size, position, shape, tenderness, and mobility of the uterus itself. To complete the bimanual assessment, an 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 CMT. This technique may vary in patients with different body mass index classes.[3] All components of the pelvic examination are essential for a comprehensive patient assessment.

Additionally, there is evidence of utilizing sonography to assess for CMT, in which the presence or absence of CMT is evaluated when performing a transvaginal ultrasound. This also serves the purpose of visualizing the pelvic structures after discovering the CMT. In a study by Tayal et al involving 30 patients across various body mass index categories, physician confidence was higher in assessing clinical findings of uterine and adnexal tenderness; however, there was no increased confidence in identifying CMT or retrovaginal tenderness.[4] Although further studies are warranted, the expectation is that physical examination skills remain paramount in ascertaining a clinical diagnosis, though the use of sonography clearly has a place in further assessing a patient.[2]

CMT alone can add to the differential diagnosis of any process with peritoneal involvement across different organ systems. Gastrointestinal diagnoses may include appendicitis, diverticulitis, inflammatory bowel disease, hernia, perforated abdominal viscus, and abdominal wall hematoma. Urinary conditions encompass ureteral lithiasis and interstitial cystitis. Gynecologic pathology may include ectopic pregnancy, endometriosis, endometritis, pelvic inflammatory disease, tubo-ovarian abscess, ovarian or adnexal torsion, chronic pelvic cellulitis, vaginitis, cervicitis, and pelvic thrombophlebitis.[5][6][7][8] CMT, in and of itself, can indicate peritoneal irritation, so it is essential to distinguish the location of the tenderness and determine if any additional pelvic structures are involved.

Nursing, Allied Health, and Interprofessional Team Interventions

The nurse should prepare the pelvic examination tray with the necessary instruments, specimen collection materials, and gloves. Given that a pelvic examination is not comfortable, the nurse plays a vital role in relieving the patient's anxiety by answering questions and providing emotional support.[9] Given the litigious nature of today's society, it is ideal and advisable to have a chaperone present in the room when performing a pelvic examination.

Nursing, Allied Health, and Interprofessional Team Monitoring

Even before the patient gets to the examination room, the nurse should explain the examination procedure and answer questions. The nurse should monitor the patient for comfort, pain, and anxiety.[10] A team-based mindset encourages a collaborative culture, while structured feedback can improve clinical techniques, patient communication, and workflow efficiency.