The accuracy of the rectovaginal examination in detecting cul-de-sac disease in patients under general anaesthesia

BACKGROUND: The rectovaginal examination is frequently used as an adjunct to a bimanual examination. The accuracy of rectovaginal examination in detecting cul-de-sac disease under ideal circumstances of the operating room was studied. METHODS: Fifty-two attending physicians and 30 residents were selected on experience and immediate availability to evaluate the presence of uterosacral nodularity and external rectal compression on 140 women undergoing general anaesthesia, followed by laparoscopy or laparotomy, at an academic medical centre. Physicians were masked to the indications for surgery and procedure ranging from diagnostic laparoscopy to laparotomy for suspected malignancy. RESULTS: Mean patient body mass index (BMI) was 26.1 kg/m 2 and nearly one-third had had previous surgery. Based on the surgical findings, cul-de-sac disease was common, including uterosacral nodularity (5.8%) and rectal compression (10.1%). Both sensitivity and positive predictive value of the rectovaginal examination for detecting uterosacral nodularity were zero, whereas specificity approached 95%. Accuracy in detecting rectal compression was somewhat better with a sensitivity of 34%, specificity 96.7% and positive predictive value 55.6%. Neither examiner-years of experience nor the laterality of the dominant or examining hand affected the accuracy of the rectovaginal examination. CONCLUSIONS: The rectovaginal examination has marked limitations despite the controlled circumstances of the operating room including general anaesthesia, an empty bladder and ideal patient positioning. As suspected, the specificity of the rectal examination is high due to the low prevalence of disease. However, the sensitivity of the rectovaginal examination is very low, limiting its capacity as a screening test.