Pelvic Examination

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Pelvic Examination

• Barbara L. Bridges ARNP-C, EdD
• Family Nurse Practitioner-C
• OB-GYN Nurse Practitioner-C
• Associate Professor
• School of Nursing

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PELVIC EXAMINATION

• 1. Preparation of the patient
• A. Instruments for pelvic examination
• 1. examining gloves
• 2. bivalve speculum (plastic or metal) (various
  sizes)
• 3. sponge forceps
• 4. cotton balls or GYN cue tips
• 5. wooden spatula
• 6. Cyto brush
• 7. 2 glass slides or whatever your clinic uses
• 8. fixative, liquid or spray

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Pelvic examination

• B. Positioning the patient
• Raise the patients head so that eye contact is
  possible.
• Put your hand at the end of the table over the
  sheet and have the patient move down until she
  feels your hand.
• Drape the sheet around the legs and arrange so
  that you can see the patient and only the
  perineum is visible.

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Pelvic examination

• Positioning the patient, continued
• Tell the patient you are going to touch her and
  touch her on her leg or thigh
• Ask her to move her legs out to here--and show
  her how wide.

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Pelvic examination

• Tips to make the experience tolerable for the
  patient
• Dont say things like spread your legs or it
  looks good
• Say let your legs relax--out to here and show
  her and everything looks healthy
• Try to avoid talking about the blades or the
  speculum (ouch!). Call them bills like a bird.

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Pelvic examination

• Tips, continued
• Use firm pressure, not a light tickling touch
• Talk to the patient and tell her what you are
  doing.
• Look at the patient when you ask her a question,
  if you can.
• But, maintain eye contact and and stay in touch
  with the patients response.
• Be sensitive.

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Examination of external genitalia

• A. Clitoris
• B. Prepuce
• C. Labia majora
• D. Labia minora
• E. Perineal body
• F. Hymen
• G. Urethral meatus

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Examination of external genitalia, cont.

• H. Vestibule
• I. Bartholins glands (greater vestibular) -
• J. Skenes glands (paraurethral) -
• K. Lesions, discharge
• L. Pubic hair pattern

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External genitalia

• Bartholins glands and Skenes glands are
  normally non-palpable swelling and tenderness
  indicate abnormality (e.g., abscess)
• Test for relaxation of supporting structures
• Palpate perineal tone.
• Patient is told to hold breath and strain
  (Valsalva maneuver) involuntary loss of urine
  or descent of vaginal wall, or cervix to the
  introitus indicates abnormality. Inquire about
  loses of urine with cough or sneeze.

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Speculum examination

• Put pressure on the perineum
• Insert speculum at an oblique angle
• Insert completely
• Allow the patient and her vagina to relax
• Open the bills of the speculum
• If you can not visualize the cervix, adjust the
  speculum.
• Remove the speculum and palpate, if necessary.

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The speculum in position, lateral view
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The speculum in position, lateral view
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The speculum in position, lateral anterior views
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Cytologic (PAP)

• Cytobrush collects endocervical cells from the
  internal os.
• Wooden spatula collects cells from the external
  cervix (SQ junction, if you see it).
• Apply to glass slide. Fix immediately to avoid
  drying artifact.

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Cultures and Wet Mounts

• Obtain cultures for GC/clamydia (Gynprobe)
• Must use dacron Q tip and turn in os and leave in
  os at least 20 seconds.
• Wet mounts
• Trichamonas Saline
• Yeast, Bacterial Vaginosis- KOH
• Determine pH with Nitrazine or pH paper (normal
  is 4.5 and below)
• Whiff test for amine odor characteristic of
  Bacterial Vaginosis

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Speculum examination

• Assess vagina and cervix for color, discharge,
  lesions

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Internal examination

• Insert fingers in to the vagina. Keep pressure
  on the perineum, not urethra.
• Palpate for masses or tenderness.
• Palpate and elevate cervix.
• Palpate for uterus with you other hand.
• If uterus is posterior, will not be able to
  palpate abdominally, but with rectal exam.

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Cervix

• determine color, size, shape, consistency and
  mobility
• 1. Normal 2-3 cm in size.
• pink, smooth epithelium.
• old bilateral scars may be seen.
• squamocolumnar junction
• 2. Abnormal ulceration, growths.
• eversion of cervical lips
• endocervical epithelium may brow out onto vaginal
  portion of cervix.
• Nabothian cysts are of little clinical importance.

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Vaginal mucosa

• 1. Normal pink, rugated, pliable.
• thin, clear fluid (from cervical secretions).
• 2. Abnormal fluid characteristics (odor, color,
  consistency, quantity).

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Internal Pelvic Examination

• With bladder empty, patient in lithotomy
  position, buttocks over the edge of table.
• Bimanual examination is precisely that. It is
  an attempt to pass the uterus and ovaries in
  review between finger in the vagina and a
  palpating hand flat on the lower abdomen.

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Internal Pelvic Examination, cont.

• Whether left or right hand is employed is
  immaterial. Extra length for vaginal reach
  can be gained by depressing the perineum and by
  resting the forearm of the vaginal hand on the
  knee. This necessitates use of a low stool at
  the foot of the table. Relax the wrist.
• Locate the cervix. All pelvic orientation stems
  from the uterus. If you know where the uterus
  is, location of masses is relatively easy. Note
  size, mobility, position and consistency of the
  cervix. Does movement of cervix pain? Pain on
  motion suggests an inflammatory process. Press
  downward with your abdominal hand palm up, put
  one finger on either side of the cervix and
  attempt to outline the uterus. (See
  illustration).

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The Uterus

• In summary
• Separate the labia minora
• Insert the fingers of one hand into the vagina
  depress the perineum to get more room.
• Press external hand gently on the lower abdomen
  (on the anterior of the fundus) and with the
  finger on either side of the cervix, attempt to
  outline the uterus
• Five important characteristics of the uterus
• a. Size (large or small)
• b. Shape (irregular contour, enlarged, nodular)
• c. Position (normal uterus is at right angles
  to long axis of vagina variations retroflex,
  retroverted, ).

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Pelvic Exam Checklist
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Pelvic Exam Checklist
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Pelvic Exam Checklist
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Pelvic Exam Checklist
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Pelvic Exam Checklist
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Pelvic Exam Checklist
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Pelvic Exam Checklist