Introduction #
Physical examination of female genitalia
This video will demonstrate how to perform a comprehensive pelvic examination. We will focus on communication skills, preparing for the exam, inspection of external genitalia, speculum examination, and bimanual examination. The video is divided into six learning modules as follows:
1- Introduction and preparation for the examination of the female genitalia
2- Inspection and palpation of external genitalia
3- Speculum examination
4- Preparing a pap smear
5- Evaluation of a patient with pelvic organ prolapse
6- Bimanual Examination
7- Pelvirectal examination
8- Concluding the physical examination of the female genitalia The objectives will be discussed at the beginning of each module.
When to Perform a Pelvic Examination:
A pelvic examination should be part of any woman’s routine physical examination. Women should also undergo a pelvic examination when they have signs or symptoms pelvic disease, or during the first prenatal visit of every pregnancy. Regular annual Pap smears: o Are recommended within two years of onset of sexual intercourse. This includes:
1. genital fondling
2. penile penetration
3. anal sex
4. oral sex
5. use of sex toys
6. other modes of sexual activity that allow for sharing of genital fluids
Preparation for the Examination:
Ideally, the patient should be interviewed in an office setting, fully clothed, prior to being brought into the examination room. The procedures should be completely explained in the office setting with time to address patient’s questions. Often it is helpful to ask if there is anything you can do to make the examination easier for the patient.
In the examination room:
The patient should then be brought to the examination room and given specific instructions on what pieces of clothing to remove, where to put them, and how to put on the sheet or gown provided. Finally show her where to sit when she is ready and tell her approximately how long she can expect to be waiting for you to return. Provide some privacy as the patient changes into a gown. Ensure the patient has emptied her bladder before the exam as a full bladder may compress the vaginal canal and obstruct the view of the cervix.
Before Starting the examination:
You will need to gather the following materials:
1. speculum
2. gloves
3. water-soluble lubricant
4. Auers spatula
5. glass slides and swabs
- Gloves should be worn for the examination of the female genitalia.
- Ensure that the examination light is working.
- Check that the speculum bills approximate where the speculum is closed, and that the screw on the speculum thumb piece is functional .
- Fibro-optic lights can be used for disposable specula.
- It is often helpful to offer a hand mirror to your patient so that they can observe the external genitalia.
- It is an invaluable opportunity for you to educate your patient about their external genitalia and discuss the findings during the examination.
- It is also extremely helpful for many women to feel more in control of what is being done during the examination.
Starting the examination:
- When you are ready to proceed with the examination help your patient into the correct lithotomy position. This is generally with her buttocks slid down the examination table to the point in the table that will swing down, and her feet guided into the foot rests.
- The head of the examination table should be elevated so that eye contact between the physician and the patient can occur.
- She should be draped in such a way that allows for minimal exposure but enables the physician to easily visualize her vulva while still keeping her knees covered.
- The examiner should be seated on a stool between the legs of the patient.
- In patients who are having their first examinations done, or have had difficulties previously, it is important for them to understand that at any time, if they want you to stop, you will.
- Sometimes it is helpful to suggest doing the complete exam over a few visits. It helps your patient feel that she shares in the control of the examination.
- Communication is the key to a successful pelvic examination.
- Eye contact also decreases the patient’s anxiety. A relaxed patient means a more accurate examination.
CyberPatient #
Cyber Patient is an area within a module that combines Flash animation with quiz or diagnostic questions. Its content varies in complexity from module to module.
Physical examination of female genitalia
This video will demonstrate how to perform a comprehensive pelvic examination. We will focus on communication skills, preparing for the exam, inspection of external genitalia, speculum examination, and bimanual examination.
The video is divided into six learning modules as follows:
1- Introduction and preparation for the examination of the female genitalia
2- Inspection and palpation of external genitalia
3- Speculum examination
4- Preparing a pap smear
5- Evaluation of a patient with pelvic organ prolapse
6- Bimanual Examination
7- Pelvirectal examination
8- Concluding the physical examination of the female genitalia
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Video: Physical Examination of Female Genitalia #
Video: Pelvic Exam Introduction #
Video: Pelvic Exam Preparation #
Inspection And Palpation Of External Genitalia #
Introduction #
Inspection of the external genitalia needs a systematic approach, perianal skin to the mons pubis or the other way around. During inspection, it is often useful to touch the patient. Tell the patient that you are going to touch her leg. Use the back of your hand.
The external genitalia should be inspected carefully. The hair is inspected for its pattern and for pubic lice and nits. The skin of the vulva is inspected for any abnormal findings. Any abnormal lesion should be palpated for tenderness.
Inspection of the labia minora need gentle lateral traction with your fingers. The labia minora may show wide variation in size and shape, they may be asymmetrical. Occasionally, yellow-white, asymptomatic papules may be seen over the inner labia minora. These are ectopic sebaceous glands and are called Fordyce’s spots and are normal.
To adequately visualize the vestibule, apply gentle lateral traction of labia minora. In some situations having the woman do this traction herself will reduce or alleviate anxiety.
The clitoris is inspected for size and lesions. The clitoris is normally 3-4 mm in size.
Inspect the urethral meatus for pus or inflammation. A urethral caruncle is a small benign tumor at the urethral orifice and is relatively common in postmenopausal women. It appears as a bright red or flesh-colored mass extending through the urethral orifice. It may be asymptomatic or may cause pain or bleeding. Urethral caruncles must be differentiated from other tumors by biopsy.
Normal Bartholin’s glands can be neither seen nor felt. At times the gland duct becomes obstructed and results in a swollen cyst filled with mucoid secretions. The cyst may turn into an abscess with a superimposed infection. A Bartholin’s abscess is warm, red and extremely tender.
To examine the Bartholin glands tell the patient that you are going to palpate the glands of the labia. With a moistened glove, palpate the area of the right gland ( at 7-8 o’clock position) by grasping the posterior portion of the right labia between the right index finger in the vagina and the right thumb on the outside. Look for tenderness, swelling or pus. Use the left hand to examine the area of the left gland (at the 4-5 o’clock position)
In case of an abscess, the glad is enlarged, warm, red, and extremely tender.
The perineum and anus are inspected for masses, scars, fissures, and fistulas. The anus should be inspected for hemorrhoids, irritation, and fissures.
Video: Inspection and Palpation of Female External Genitalia #
Speculum Examination #
Introduction #
The speculum consists of two bills that are introduced closed into the vagina and are then opened by squeezing the handle mechanism to inspect the vagina and cervix. The vaginal walls are held apart by the bills, and adequate visualization of the vagina and cervix is achieved. There are several types of specula. The plastic disposable speculum is currently becoming more common. Its colorless scheme allows for good visualization of the vaginal walls. In addition, a fibro-optic light source can be attached to the speculum handle directly, allowing the exam to proceed more smoothly. Of the reusable specula, the Graves’ speculum is used more commonly. The bills are wider and are curved on the sides. Pedersens’ speculum has narrower, flat bills and is used for women with small interoitus.
Before using the speculum in a patient, practice opening and closing it. If the patient has never had a speculum examination, show the speculum to her. Put on a clean pair of gloves and warm the speculum with warm water. Ensure the temperature is comfortable for her by touching it to her thigh. Jelly lubricant should not be used because it may interfere with cervical cytologic examinations and gonococcal cultures. Tell the patient that you are now going to perform the speculum part of the internal examination. For some patients gently pushing down on the posterior forchette with a lubricated index finger will help them understand what sensation they can expect. At all times, during the examination, you must tell your patient what to expect next, before proceeding. This again gives them a chance to stop you if needs be.
Technique:
While the examiner’s left index and middle fingers separate the labia and firmly depress the perineum, the closed speculum, held in the examiner’s right hand, is introduced slowly into the interoitus . The bills can be horizontal on entry as long as the labia are held clear. Any turning of the speculum as it first enters the vagina can catch hair or skin. Do not introduce the speculum vertically, because injury to the urethral meatus may occur. Slight downward pressure is usually helpful during complete insertion of speculum.
As the bills enter the full length of the vaginal canal, open them slightly to visualize the cervix. The speculum handle should be approximately 2 cm away from the interoitus before opening the speculum bills. The part of the cervix that comes in to view will determine how to move the speculum to open fully on to the cervix. If the cervix is not visualized close the speculum, back up 1 to 2 cm and then gently insert and turn the blades in various directions, reopen the blades to expose the cervix. This manoeuvre may need to be repeated several times. The cervix often drops down within the bills of the speculum once it is properly positioned. The most common reason for not visualizing the cervix is failure to insert the speculum far enough before opening it. Once the cervix is visualized, open the speculum further to encircle the cervix and then lock the speculum in place by turning down the screw on the speculum thumb piece.
Inspect the cervix for color, discharge, erythema, erosion, ulceration, leukoplakia, scars, and masses. A bluish discoloration of the cervix may be an indication of pregnancy or a large pelvic tumor. I n a woman who has never had a vaginal delivery the external cervical os is usually round. The external os becomes irregular and oval shaped after vaginal birth. A Pap smear should be performed at this stage, if needed.
The patient is told that the speculum will now be removed. The set screw is released with the examiner’s right index finger. When the speculum is removed it is very important to slightly open the bills to loosen the cervix so the speculum can be brought out without pulling down on the cervix. Then with control, slowly withdraw the speculum visualizing the vaginal canal as you go. The bills should be completely closed when exiting the introitus. A moderate amount of colorless or white mucus is usually present
Video: Pelvic Speculum Examination #
Performing A Pap Smear #
Introduction #
The Pap smear is a screening test and is used to evaluate an asymptomatic woman who has a clinically normal appearing cervix. If a clinically suspicious lesion is seen immediate biopsy should be done and the patient referred for further investigation.
The use of a lubricant on the speculum is not recommended as it can obscure cellular detail, interfere with cellular adherence and cause bacterial over-growth on the slide. If the patient is menstruating or infection is present the exam should be rescheduled.
The sample should be taken from squamocolumnar junction which is the area between the columnar epithelium of the endocervix and the mature epithelium of the ectocervix. If the cervix is obscured with discharge or secretions a cotton pledget should be used to gently cleanse the cervix.
The location of squamocolumnar junction is dependent on the patient’s age, parity, hormonal status and any previous surgery on the cervix. In the reproductive age group the junction is often visible, but in post menopausal women the junction is often in the canal.
If the squamocolumnar junction is visible a spatula is used to obtain a single specimen by scraping the cervix circumferentially through 360. Fixation is not necessary in this case.
If the squamocolumnar junction is not visible a spatula should first be used for the exocervical specimen followed by a cytobrush for the endocervical specimen. The brush is inserted into the endocervix until only the bottom-most fibers are exposed. The brush is then slowly rotated 180 degrees in one direction to obtain a sample. Do not over-rotate. Both specimens should be placed on a single slide and fixed immediately. The specimen should be smeared for the spatula and rolled for the brush. The spray should be held at least 10 inches away from the slide to prevent disruption of cells by the propellant. The use of cytobrush is not recommended in pregnant patients.
Alternatively, specimens may be collected using a cervical broom. The central bristles sample the endocervix while the outer bristles sample the transformation zone. The broom should be rotated in the same direction for five turns.
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Video: Performing a Pap Smear #
Evaluation Of A Patient With A Pelvic Organ Prolapse #
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Introduction #
To evaluate the pelvic organ prolapsed, gently separate the labia widely and depress the perineum. Ask the patient to bear down or cough. If vaginal relaxation is present, ballooning of the anterior or posterior walls may be seen. Bulging of the anterior wall is associated with a cystocele, bulging of the posterior wall indicates a rectocele. If stress incontinence is present, the coughing or bearing down may trigger a spurt of urine from the urethral orifice.
To confirm the initial findings the univalve speculum is placed posteriorly to retract the posterior wall downward when examining the anterior compartment and the patient is encouraged to perform the Valsalva so the full extent of the prolapse can be ascertained. The speculum is then placed anteriorly to retract the anterior wall upward when examining the posterior compartment.
If the findings determined with Valsalva are inconsistent with the patient’s description of her symptoms, it may be helpful to perform a standing straining examination with the bladder empty.
Video: Evaluation of a Patient with a Pelvic Organ Prolapse #
Bimanual Examination #
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Introduction #
An abdominal examination should be done at the beginning of every pelvic examination. The abdominal examination provides necessary clinical information and allows for the exam to proceed initially on a more neutral and less vulnerable part of the body.The bimanual pelvic examination is used to palpate the uterus and adnexa. Lower the head of the examination table to 15 degrees or flat, depending on the patient’s preference. In general, the right hand is inserted into the vagina and the left hand palpates the abdomen, but this is a matter of personal preference.
Technique:
The physician should stand between the patient’s legs. To avoid contamination of the patient’s abdomen when switching from the speculum exam to the bimanual exam remove or replace the glove on your nondominant hand. A suitable jelly lubricant is held in the left hand and a small amount is dropped from the tube onto the examiner’s gloved right index and middle fingers. The examiner should not touch the tube of lubricant to the gloves because the lubricant will be contaminated. The patient is told that the internal examination will now begin.
As the bimanual examination is being performed, the examiner should observe the patient’s face. Her expression will quickly reveal whether the examination is painful. The labia are spread and depending on the diameter of the introitus and the patient’s comfort level, the examiner may be able to insert the right index and middle fingers into the vagina for bimanual palpation. If the introitus is small, the examiner should introduce the right middle finger first and gently push downward toward the anus.
It can be helpful to initially apply gentle pressure on the posterior forchette to help relax the interoital pelvic floor muscles. The right fourth and fifth fingers are flexed into the palm of the hand. The right thumb is extended. The area around the clitoris should not be touched. As the finger is introduced you can gently feel over the anterior vaginal wall to rule out any abnormal lesions like nodules, induration, and tenderness. Once again it is important to have a systematic approach.
Once inserted into the vagina, the examiner’s right hand is rotated 90 degrees clockwise so that the palm is facing upward. The cervix is palpated for its position, size, shape, consistency, regularity, mobility, and tenderness. The cervix is normally rounded and firm with a consistency similar to the cartilage at the tip of the nose. The cervix can usually be moved 2-4 cm in any direction. It should be nontender and mobile. Feel the fornix around the cervix.
The left hand is now placed on the abdomen approximately one third of the way to the umbilicus from the pubic symphysis. The wrist of the abdominal hand should not be flexed or supinated. The vaginal hand pushes the pelvic organs up out of the pelvis and stabilizes them while they are palpated by the abdominal hand. It is the abdominal, not the vaginal, hand that performs the palpation. You do not need to palpate deeply with the abdominal hand if the uterus is sufficiently elevated with the vaginal hand.
With an anteverted uterus the body of the uterus can be predominantly felt with the abdominal hand assessing for position, size, shape, consistency, mobility, and tenderness.
A normal uterus is firm and mobile. The most common uterine position is anteverted. A retroverted uterus is directed toward the spine and is not easily felt by bimanual palpation. The bulk of the posterior wall of the uterus might be felt with vaginal fingers.
After the uterus has been palpated, the right and left adnexa are palpated. If the patient has complained of pain on one side, start the examination on the other side. The vaginal hand should move to the left lateral fornix while the abdominal hand moves to the left lower quadrant. The vaginal fingers lift the adnexa toward the abdominal hand, which attempts to palpate the adnexal structures.
The adnexa should be explored for masses. Describe the size, shape, consistency, and mobility, as well as any tenderness, of the structures in the adnexa. The normal ovary is sensitive to pressure when squeezed. After the left side is examined, the right adnexa are palpated by moving the vaginal hand to the right lateral fornix and the abdominal hand to the right lower quadrant of the patient. It is common not to feel the ovaries of a woman in reproductive years. Plapation is often difficult in obese or poorly relaxed women. One is essentially trying to rule out any unusual masses or irregularities in the pelvic structures. If an ovary of a post menopausal woman is felt this will need further investigation. After completion of the examination of the adnexa, the examining vaginal fingers move to the posterior fornix to palpate the uterosacral ligaments and the pouch of Douglas (posterior Cul-de-sac ). Marked tenderness and nodularity suggest endometriosis.
When the vaginal fingers are being removed, palpate the posterior vaginal wall to assess the rectovaginal septum.
Video: Bimanual Examination #
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Pelvirectal Examination #
Introduction #
A pelvirectal examination is not usually done in a routine Gynecologic assessment. This exam can be helpful in assessing suspected pathology in the posterior cul-de-sac and rectovaginal septum. One can often reach 1-2 cm higher into the pelvis with the rectal finger.
Tell the patient that you will now examine the vagina and rectum. Explain to the patient that the examination will make her feel as if she was going to have a bowel movement, but she will not do so. Lubricate the gloved index and middle fingers. As you ask the patient to bear down, introduce your index finger into the vagina and your middle finger into the rectum. The examining right index finger is positioned as far up the posterior surface of the vagina as possible. If the uterus is retroverted or retroflexed it may be palpable only by the rectal finger. The rectovaginal septum is palpated for nodules or tenderness.
The patient is told that the internal examination is completed and that you are about to remove your fingers. Withdraw your fingers gently. When you withdraw your fingers, inspect them for discharge or blood.
The physician must then help their patient back into a comfortable sitting position. Make sure the patient is ok and words of encouragement upon completing the examination successfully are helpful. Once again clear instructions for dressing are needed. The physician must be sure there is adequate tissues present to wipe off any excess lubricant. Make sure the patient knows to get fully dressed and where she is to wait.
Finally the physician must finish the examination with a clean technique by removing their gloves and washing their hands.