The rectovaginal examination: physician attitudes and practice patterns.

Background: The value of screening with the rectovaginal examination (RVE) has not been validated. This study describes physician attitudes and practice patterns regarding the RVE.

Methods: Cross-sectional survey of residents and faculty in general internal medicine and obstetrics/gynecology (OB/GYN) at a university hospital.

Results: Thirty-four percent of physicians surveyed reported routinely performing the RVE. More OB/GYN than internal medicine physicians reported doing the RVE routinely (60% versus 27%, P = 0.02), and felt it provided additional information (80% versus 44%, P = 0.01). More respondents believed that it provides additional information to the routine pelvic examination (53%) than agreed with its routine inclusion (42%) or that reported routinely performing it (34%). (P = 0.0001).

Conclusions: More OB/GYN than internal medicine physicians routinely perform the RVE and believe it adds additional information to the routine pelvic examination. Additional research is indicated to determine if frequent omission of the RVE impacts women's health.

Key Words: women's health, gynecology, ambulatory care, rectovaginal examination, screening

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The rectovaginal examination (RVE) is taught as a routine part of the pelvic examination and is credited by physical diagnosis textbooks as providing better evaluation of the posterior portion of the pelvis and the rectovaginal septum than the bimanual examination alone. (1,2) It is performed by simultaneously inserting the index finger into the vagina and the middle finger into the rectum. (1,2) This type of examination may be uncomfortable to patients. The value of the RVE as part of the periodic health examination for screening purposes has not been established. (3) As with many commonly performed physical examination procedures in asymptomatic patients which have been found to be unproductive, (4) the RVE may be low yield as well as uncomfortable.

The only study of the value of the RVE was done in patients under general anesthesia, comparing the examination findings to the surgical findings. The sensitivity of the RVE for detecting cul-de-sac disease in that study was very low despite the controlled setting of the operating room, suggesting it has limited capacity as a screening test. (5) Although the RVE has not been studied as a screening test in asymptomatic outpatients, a study of the more commonly performed bimanual examination revealed that it is of questionable value as a screening strategy. (6) Even if there is no benefit from the RVE for detecting cul-de-sac disease, there could theoretically be potential benefit from the concomitant digital rectal examination (DRE). (7) However, there is evidence that DRE is not useful in women under the age of 40 during a routine pelvic examination. (8) For patients over the age of 50, in whom fecal occult blood testing is desired as a means of colorectal cancer screening, test cards prepared at home by patients on three consecutive days is preferred over samples obtained by digital rectal examination. (9)

Although the minimal data available indicates that the RVE is unlikely to be valuable in asymptomatic women, it continues to be taught as a standard part of the physical examination. It is suspected that some physicians do not perform the RVE routinely. It is unknown if the use of this part of the examination varies by specialty or gender. We conducted a study to explore physician attitudes and practice patterns regarding the RVE.

Materials and Methods

This study was a cross-sectional survey of internal medicine and obstetrics/gynecology (OB/GYN) physicians at a university hospital to determine the reported routine use of the RVE, attitudes toward it, and potential variations by specialty or gender. This study was approved by the Institutional Review Board for the Protection of Human Research Subjects. The survey was mailed to the workplace mailboxes of all residents and faculty in general internal medicine (79) and OB/GYN (25) at a university hospital. They were asked the four questions which are seen in the Table. If the answer to the fourth question indicated that they do not perform the RVE routinely, they answered an additional question to explain why they do not. The survey results were analyzed by contingency table chi squared and logistic regression with the help of a statistician using JMP software (JMP is a registered trademark of the SAS Institute, Cary, NC).

Results

Fifty-seven percent of the 104 mailed surveys were returned (56% internal medicine and 60% OB/GYN). Overall, 34% of physicians surveyed reported routinely performing the RVE (question number 4 in the Table). There was a significant difference in reported performance rates between specialties with OB/GYN physicians being more likely to report performing the examination (60%) than internal medicine (27%) (P = 0.02). While 80% of OB/GYN physicians indicated that the RVE adds additional information to the routine pelvic examination, only 44% of internal medicine physicians responded affirmatively (P = 0.01). More respondents indicated that the RVE adds additional information to the routine pelvic examination (53%) than agreed with its routine inclusion (42%) or that reported routinely performing it (34%). (P = 0.0001) There were no statistically significant differences between the specialties in regard to past education and belief that the RVE should be part of the routine pelvic examination. (See Table) In addition, gender was not found to be significantly associated with any of the answers to survey questions (data not shown).

The final question inquired why physicians did not perform the RVE on a routine basis. This question was only asked of those physicians who indicated they do not routinely perform the examination. Of the physicians answering this question, 55% indicated failure to perform the examination based on patient discomfort; while 32% indicated that rectovaginal examinations provide no useful information. Another stated reason for omitting the RVE was the fact that occult blood could be checked with a rectal examination, implying that occult blood testing was the main benefit gained by doing the RVE. Some respondents wrote in what they felt to be indications for rectovaginal examination, which included patients over 50, a retroverted uterus, postmenopausal, women over 40, pelvic pain, endometriosis, bleeding of unknown source, dyspareunia, postpartum, and assessments for rectocele.

Discussion

Only 34% of all physicians surveyed reported routinely performing the RVE. Lack of efficacy was cited as a major reason for failure to perform the examination. Apparently, the RVE is not performed routinely, even by physicians who believe it provides valuable information, as more physicians indicated that it provides additional information than indicated routinely performing it. One reason may be the perception of patient discomfort, as more than half of the respondents who do not perform it cited that as a reason. There is no study documenting patient discomfort with the RVE, but there is data that many women find the pelvic examination in general to be uncomfortable, (10,11) and the authors have anecdotally noted complaints from patients about the RVE. Many survey participants wrote in what they consider to be indications for doing the RVE. The variability of these responses indicates that there is a lack of uniformity regarding the performance of the rectovaginal examination.

Our study reveals that more OB/GYN than internal medicine physicians believe that the RVE adds additional information to the routine pelvic examination. This is not surprising, since pelvic examinations and women's health plays a relatively smaller role in the practice of internal medicine. OB/GYN physicians may have personally found abnormalities on the RVE which may cause them to believe it is valuable. This interpretation could be subject to selection bias, as their patient population is different from that of internists, who are primarily doing screening examinations on patients with no known gynecologic abnormalities. Due to such potential bias, it is important to note that anecdotal evidence by OB/GYN physicians regarding the value of the RVE does not in itself justify it as a screening test in asymptomatic women.

More OB/GYN than internal medicine physicians routinely perform the RVE. The majority of all physicians surveyed (72%) indicated that they were taught to do the RVE with no significant difference between the two specialties. This suggests that RVE skills that were taught uniformly in medical school are reinforced in OB/GYN but not internal medicine training. The reason why internal medicine training is associated with performing the RVE less frequently than OB/GYN training is unknown but is possibly due to a deficiency in gynecologic training or simply to strict adherence to only evidence-based screening practices in internal medicine. If future research supports the practice of doing the RVE in asymptomatic patients, internists will have to perform it if they want to be as competent in women's health as other practitioners. One study has suggested that family practice academic physicians feel more competent at pelvic examinations than general internal medicine academic physicians. (12) Given the recent emphasis by the American Board of Internal Medicine on women's health skills, it is particularly important for internal medicine physicians to be willing to perform or teach these skills. (13)

A limitation of this study is that the sample was limited to only one institution and the generalizability of these results is unclear. In addition, the term RVE was not defined in the survey. It is possible that physicians who are not well trained in women's health may not have been familiar with the term "rectovaginal examination." and may have used the term interchangeably with the practice of doing a rectal examination separately during a pelvic examination. It also would have been more clear if the phrase "routine pelvic examination" had been defined in the survey as a screening pelvic examination which excluded any woman with a specific problem or complaint. As with any survey, the answers may be subject to reporting bias and some physicians may have over reported doing the examination because they felt they should do it. Internal medicine physicians were more heavily represented than OB/GYN physicians in this survey due to the larger number of internal medicine physicians employed at the university hospital where the survey was conducted. However, the percentage of the available physicians in each group who returned the surveys was not significantly different, so it is unlikely that there was a systematic bias due to lack of interest among one group. In general, there is potential response bias because those who returned the survey may be more likely to be interested in women's health and more familiar with the pelvic examination than those who did not.

Conclusion

Overall, this study revealed a lack of uniformity in practice patterns regarding the RVE. Only 34% of all physicians surveyed are routinely doing the RVE and it is being done more commonly by OB/GYN physicians compared with internists. There is little data to help determine if omission of the RVE impacts a woman's health, although the available evidence suggests that it is unlikely to be of benefit in asymptomatic women. The lack of efficacy data and physician perceptions that the RVE is uncomfortable for the patient are major reasons for the failure of physicians to perform the examination. Research should be done to explore patient attitudes toward the RVE to determine if physicians are justified in believing that this part of the examination is uncomfortable for patients. More research should also be done into the value of the RVE to clarify whether physicians' failure to perform it affects the quality of healthcare by women. Furthermore, this would identify whether the more frequent failure to perform the RVE by internists as compared with OB/GYN physicians represents a need for internal medicine to improve its training in women's health skills. If evidence continues to mount that suggests a lack of efficacy of the RVE, particularly if data also confirms that the RVE causes discomfort, it is possible that the performance of this examination can be abandoned as a part of a routine pelvic examination. Future research should also be done to delineate if there are specific indications for the RVE or subgroups of women who would benefit from it, as this is not currently known.

References

1. Swartz MH. Textbook of Physical Diagnosis: History and Physical Examination. Second Edition. Philadelphia, WB Saunders, 1994, pp 375-391.

2. Stenchever MA, Droegemueller W, Herbst AL, Mishell DR. Comprehensive Gynecology. 4th ed. St Louis, Mosby, 2001, pp 150-151.

3. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Williams & Wilkins, 1996, pp lvii-lxix.

4. Oboler SK, LaForce FM. The periodic physical examination in asymptomatic adults. Ann Intern Med 1989;110:214-226.

5. Dragisic KG, Padilla LA, Milad MP. The accuracy of the rectovaginal examination in detecting cul-de-sac disease in patients under general anaesthesia. Hum Reprod 2003;18:1712-1715.

6. Grover SR, Quinn MA. Is there any value in bimanual pelvic examination as a screening test? Med J Aust 1995;162:408-10.

7. Willis FL, Fanning J. Digital rectal fecal occult blood screening during gynecologic examination. Am J Obstet Gynecol 2004;190:1422-1423.

8. Campbell KA, Shaughnessy AF. Diagnostic utility of the digital rectal examination as part of the routine pelvic examination. J Fam Pract 1998;46:165-167.

9. Pignone M, Rich M, Teutsch SM, et al. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2002;137:132-141.

10. Vondruska-Benkert K, Steiner RA, Buddeberg G, Haller U. Gynecologic examination: perceptions, fears and expectations of polyclinic patients [in German]. Gynakol Geburtshilfliche Rundsch 1995; 35:20-25.

11. Vella PV. A survey of women undergoing a pelvic examination. Aust N Z J Obstet Gynaecol 1991;31:355-357.

12. Dixon JG, Bognar BA, Keyserling TC, et al. Teaching women's health skills: confidence, attitudes, and practice patterns of academic generalist physicians. J Gen Intern Med 2003;18:411-418.

13. Cassel C, Blank L, Braunstein G, et al. What internists need to know: core competencies in women's health: ABIM Subcommittee on Clinical Competence in Women's Health. Am J Med 1997;102:507-12.</p> <pre> If the head and body are to be well, you must begin by curing the soul. --Plato </pre> <p>Laura Davisson, MD, Karen Clark, MD, Roxann Powers, MD, and Gerald Hobbs, PHD

From the Departments of Medicine, Community Medicine, and Statistics, and from the National Center of Excellence in Women's Health, and University Health Service, West Virginia University, Morgantown, WV.

Reprint requests to Laura Davisson, MD, Department of Medicine, PO Box 9160, Robert C. Byrd Health Sciences Center, Morgantown, WV, 26506. Email: [e-mail]

Accepted November 23, 2005.

RELATED ARTICLE: Key points:

* This study revealed a lack of uniformity in practice patterns regarding the RVE.

* Only 34% of all physicians surveyed routinely perform a RVE and it is done more frequently by OB-GYN physicians than internists.

* Research is needed to explore patient attitudes, as well as the diagnostic necessity of the RVE, in order to determine its value in routine pelvic examination screening.

* Researching the value of the RVE will help determine whether the more frequent failure to perform the RVE by internists as compared to OB/GYN physicians represents a need for improved training in internal medicine programs.

* If evidence continues to mount that suggests a lack of efficacy of the RVE, particularly if data confirms that the RVE causes discomfort, it is possible that the performance of this examination can be abandoned as part of the routine pelvic exam.

Table. First four survey questions analyzed by specialty

                                  Answered  Answered
                                  yes (%)   yes (%)
Question                          OB/GYN    IM        P value

1. I was taught the rectovaginal  86.67     68.18     0.14
   examination was part of the
   routine pelvic examination.
2. Rectovaginal examinations      53.33     39.53     0.35
   should be part of all routine
   pelvic examinations.
3. Rectovaginal examinations add  80.00     44.19     0.01
   additional information
   to the routine pelvic
   examination.
4. I routinely perform            60.00     27.27     0.02
   rectovaginal examinations.