Exam Order

Just occurred to me to wonder if the order of the various parts of the gyn exam is standardized. Mine's always been breasts, pap, then bimanual (never had a recto-vaginal). Is that the procedure for others, too?

Yes, for me it is the same order. I am not sure why it's done this way.

That's how it is here in the UK for me too

This is pretty standard, though I have seen a number of accounts, particularly outside the U.S., if my memory serves correctly, where the breast exam is done last, or not at all. The Pap is often done before the bimanual because there was concern that the lubricant used in the bimanual could affect the results of the Pap.

Had a girl friend receive her first pelvic exam with the pelvic exam being done first to get it over with. At least that is what she was told

I've been told by friends who are medical professionals that doctors are trained to work top to bottom.

Yep top to bottom the best way to ensure a full exam is done.

For my wife, yes. Breast, pap, bimanual, rectal.

Agree top to bottom is the best....builds anticipation also.....

Mind, Breast, Vaginal, Anal.....

Yes, that is the standard order. As others have stated, doctors do tend to work from "top to bottom" during a physical exam (including gynecologic exams), unless there's a reason to do things in a different order. I think part of that is to give the patient a little time to get used to the idea of being examined and perhaps to build a bit of rapport with the doctor first, rather than just jumping straight to a vaginal or rectal exam.

So that answers the question of why the breast exam is done before the pelvic exam (since the breast exam is less invasive and -- I think most women would agree -- less embarrassing). But for the pelvic, why is the order Pap, bimanual, then rectovaginal (and possibly a separate rectal exam)? Well, the Pap is done before the bimanual because, as previously mentioned, there is some concern that all the lubricant from the bimanual exam could contaminate the cell samples taken during the Pap smear. My guess is that the bimanual is done before the rectovaginal/rectal exam because that way, there is less concern about bacteria from the rectum getting into the vagina. (Granted, they still try to avoid the reverse -- i.e. vaginal flora getting into the rectum -- but I don't think that's quite as big of a concern.)

In a play exam, I tend to follow the same order. As Lexicon said, it helps build anticipation. However, there's no set rule for that; it's totally up to the play doctor and patient. I can see how in some cases, jumping straight to a rectal exam could be a really exciting way to start things off!

I agree with PlayDrChad. If I have a "patient" who will be receiving a rectal, I always change gloves after the bimanual. I do switch the usual clinical order, which is recto-vaginal followed by rectal, though, since the play exam is for stimulation of the patient as much as anything else, and that order tends to work better for that purpose.

I'm just curious in what order does your gynecologists preform the yearly exam? Does your doctor start with the breast exam or the pap/pelvic examination?

Mine starts with Brest exam pelvic next then ending the exam with the rectal. All done while completely naked with gown removed to expose areas to be examined.

Mine starts with BP, temp then peeing. Then weighing. Then nails, then ears, nose, throat, then breast, then pelvic ending with rectal.

My wife and my conjoined visit goes like this, at least the last four. We both get weighed. We both have blood pressure taken by a nurse. My wife starts getting her EKG while another nurse draws blood for labs, then we switch. Our male Dr. comes in and checks me over. I just strip as needed as the exam goes. My wife sits to the side and joins in on all the conversation.

When it comes to the genital and rectal I just drop my pants to the floor with underwear. My wife gets a kick out of this. A couple of times a nurse practitioner was present as well. When I'm finished up, usually 20 minutes or so. My wife is summons to the exam table and the Doc starts checking her over and asking all the questions.Twice she has already been in a gown and twice still dressed in street clothes. This year she was still dressed.

After interview she got gown on and sit on exam table. Dr. left for just a min. while she changed. When he returned he had her sit and drop her gown to her waist while he examined her seated and then had her lay down. After that he placed her feet in the stirrups. He first did the speculum exam, bi-manuel, vaginal-rectal, and then rectal. He finished up with some questions and that was it.

Stethoscope, breasts, tummy, pap, bimanual, recto-vaginal.

During my 1st ever yearly exam, the female NP started from the top and worked downwards like most have stated here. I since relocated from where that NP practiced and switched to a male. The male gynecologist starts at the pelvic exam and works up to breast exam then checks pulse. I always found it weird he'd start with the pelvic and work upwards.

It would appear that most practitioners reserve the most intimate aspects of the exam for last. I don't know of any reason why the exam couldn't be conducted in a different order. It almost seems customary to examine the most private areas at the very end. I personally feel that it builds nervous anticipation waiting for the inevitable.

For as long as I can remember, every one of my yearly physicals ended with genital exam. Even my current doctor who literally goes head to toe order in his exams skips the genitals until last.

The very practical reason is that the genital exam requires a change in position (standing for males, stirrups for females) and gloving/equipment. Doing all the ungloved and stationary portions first saves time and limits interruptions.

The other reason is that by doing the most intimate exam last, the patient can immediately relax afterward rather than have to re-drape and continue being examined.

When I perform a gynecological exam I always do a general medical examination and usually I follow this order

- after the interview, I invite the patient to remove everything (sometimes I allow to keep panties on at the beginning) and go on the scale for weight and height

- then she seats on the normal examination bed and I perform ENT, neck, breast and armpit exam

- then lying down on the back, careful breast, palpation, heart and anterior lung auscultation

- again sitting, posterior lung auscultation and chest percussion, Giordano's sign and tyroid palpation

- then, if already worn, the patient removes the panties and lye down again for a very careful abdominal exam (palpation first superficial and then deeper, percussion and auscultation)

- then the patient moves to the gyno chair and first I do speculum and PAP, then external genitals evaluation and palpation, then bimanual exam, rectovaginal and rectal exam

- sometimes,if needed, in genupectoral position, again a rectal and anoscopic exam (sometimes again a rectovaginal exam, of course changing the gloves in every phase of the exam)

- finally, before dressing, postural and vertebral evaluation and leg's vein control standing ( I use to evaluate peripherical pulses and articularity of the legs at the end of the abdominal exam, before passing to the gyno chair)

Mine is pretty text book, BP, temp, interview questions, heart, eyes, ears, breast, pap, pelvicexam, and every other year double penetration to check the rectal and vaginal wall.

BP, pulse, etc.

Then heart and lungs, while sitting up, then breasts (sitting up and then lying down), then PAP and pelvic.

I think that's pretty much standard, no?

Everyone I have ever witnessed started with a breast exam, followed by the occasional abdominal exam, then the speculum (pap smear) followed by the bimanual and then, on occasion, the rectal exam.

The order of the exam is very interesting, especially in different geographies.

Seeing as "annual" exams are not really the norm in this country, the question is more in the context of what happens in a pap smear appointment.

This seems to vary quite a lot, but my observations and discussions have always been that they get the pap right out of the way first. Then, a pelvic (if done at all), and almost always (depending on time) the medical practitioner will ask the patient if they would like a breast exam done too, which is usually always done last.

This would seem to be almost the reverse of what happens in the US at an "annual".

My wife changed some gyno in her life.

Every doctor has his procedure.

Her first doctor was used to begin with an abdominal exam, then groin palpation follwed by bimanual and speculum. He ended with a breast exam, anal never done. My wife had to be naked under a towel.

Her actual is a woman. She alwyas starts with vitals (weight, heart, pulse, BP). During this first step my wife wears a gown and panties. Then she goes to breast exam (sitted or stand, then lying) and abdominal. After that, wife has to slip off panties for a ultrasound (external and internal), digital pelvic, speculum, and final pap.

But she was examined by other doctors too, some of them made a rectal at the end.

Weight , bp, heart and lungs , breasts, pap, pelvic exam

For my girl yes. Weight, blood pressure, chief co plaint if any, Breast, pap, bimanual, rectal. Make next years appointments.

For my wife it it Starts usually with urine sample. After this the nurse takes her blood Pressure.

When the doctor Enters, he starts with questions. After this she usually undresses lower Part and gets the pelvic exam including pap and perhaps vaginal ultrasound done.

After this she change, get dressed lower part and undresses breasts. The doc does the breast exam with her standing.

Thats it, dress top and done.

The order of my exam goes as follows: I'm called back to the exam room. The nurse weighs me, takes my bp and gets my basic vitals. She then asks me to undress completely and I wait for the doctor. Once the doctor comes in he checks my breasts then my abdomen. Lastly I'm asked to get in the stirrups and he examines me externally and then internally and then I get a pap.

I thought I would raise this very interesting discussion again. As several people in the thread mention, it is the common practice in many real exam settings to perform the speculum exam/pap smear before the bimanual exam out of a concern that lubricant from the bimanual could affect pap results if the bimanual were done first. In my play exams, I sometimes keep this order for the sake of realism. But other times I do the bimanual first, especially to 'ease in' to things with a patient for whom I may be stretching them quite a bit with the speculum. Doing the bimanual before the speculum exam also allows me to make a better estimate of what size speculum will be most appropriate for a given patient. Of course, any left over lubricant from my fingers can also make the speculum insertion go more easily for those who are a bit tense or smaller.

I wonder if other docs or patients have more comments about the order of either real or play exams...