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.It is performed by simultaneously inserting the index finger into the vagina and the middle finger into the rectum.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. As with many commonly performed physical examination procedures in asymptomatic patients which have been found to be unproductive, the RVE may be low yield as well as uncomfortable. rnrnThe 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. 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. 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). 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. rnrnAlthough 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. rnrnMaterials and Methods rnrnThis 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 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). rnrnResults rnrnFifty-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). rnrnThe 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. rnrnDiscussion rnrnOnly 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. rnrnOur 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. Less