GYNECOLOGICAL EXAMINATION

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GYNECOLOGICAL EXAMINATION

• Doç Dr Asli Somunkiran IS

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Anamnesis

• Name and identity
• Gynecologic Anamnesis anamnez
• Obstetric Anamnesis
• Sexual fonx
• Medical history
• Family history
• Complaints

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Identity

• Age
• Marital status
• Duration of marriage
• Number of marriages
• Educational status-job

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Gynecologic Anamnesis

• Age at Menarche (The first menstrual period)
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• Menstrual cycle anamnesis
• Cyclus length 287 days
• Duration of mns flow 2-7 days
• Amount of bld 2-3 pads/day
• LMP
• Dysmenorrhea
• PMS

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• Polymenorrhea cycles with intervals of 21 days
  or fewer (anovulatory cycles)
• Oligomenorrhea menstrual periods occurring at
  intervals of greater than 35 days, with only four
  to nine periods in a year (anovulatory
  cycles-PCOS)

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• Menorrhagia / hypermenorrhea abnormally heavy
  and/or prolonged menstrual period at regular
  intervals
• End polyps
• Leiomyoma
• End hyperplasia
• Hypomenorrhea?
• Asherman Syndrome
• Genital tb

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• Cryptomenorrhea
• Imperforate hymen
• Cervical stenosis

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Obstetric history

• Gravida
• Parity
• Abortions
• Induced abortions
• Miscarriages

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Sexual history

• Dyspareunia
• Postcoital bleeding
• Contraception (metod duration..)

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Medical history

• Previous ops
• Diseases
• Medications
• Hirsutism
• galactorrhea
• Dysuria
• SUI, urgency

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Complaints

• Present complaints
• Duration
• Location
• Relation to other organic functions (mens flow,
  coitus, bowel movements....)

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Do a Complete Physical Assessment

• HEENT
• CV.. BLOOD PRESSURE
• Lungs
• Breasts
• Abdomen
• Pelvic/rectal
• Neuro
• Musculoskeletal

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Essentials for an Adequate Examination--Relaxation

• Patient should be given an opportunity to empty
  her bladder prior to the exam-- Routine UA
  specimen may be obtained at this time
• Explain what is to take place during the exam
• Drape her appropriately, cover extending at least
  over her knees
• Arms should be at her side or folded across her
  chest.

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Essentials for an Adequate Examination

• Examiner's hands should be warmed, also warm the
  speculum before the exam
• Have eye to eye contact with the patient during
  the exam
• Explain in advance each step in the examination,
  avoiding any sudden or unexpected movements

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Essentials for an Adequate Examination

• Male examiners should always be attended by
  female assistants
• Hx should be taken prior to patient disrobing.
• Do not enter the room with an unclothed patient
  unless you have a female chaperone.

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Correct Examining Position of the Patient

• The Lithotomy Position/or Semi-Sitting Lithotomy
  Position
• Lying in supine position
• Thighs flexed and abducted
• Feet resting in stirrups
• Buttocks extended slightly beyond edge of exam
  table
• Head supported with a pillow

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Correct Examining Position of the Patient
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Sequence of a Pelvic Examination

• Inspect the patient's external genitalia
• Perineal area must be well illuminated
• Both hands are gloved to prevent the spread of
  infection
• Perineum is sensitive and tender, warn the
  patient by touching the neighboring thigh first
  before advancing to the perineum.

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Note

• A patient suffering pain or deformity of the
  joints may be unable to assume a Lithotomy
  position.
• It may be necessary to have the patient abduct
  only one leg or have another person assist in
  separating the patient's thighs.

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Sequence of a Pelvic Examination

• Mons pubis--note quantity and distribution of
  hair growth
• Labia--usually plump and well-formed in adult
  female
• Perineum--slightly darker than the skin of the
  rest of the body. Mucous membranes appear dark
  pink and moist

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Sequence of a Pelvic Examination

• Separate the labia majora and inspect the labia
  minora
• Labia minora
• Clitoris
• Urethral orifice
• Hymen
• Vaginal orifice

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Sequence of a Pelvic Examination

• Note the following
• Discharge
• Inflammation
• Edema
• Ulceration
• Lesions

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Sequence of a Pelvic Examination

• Note abnormalities such as
• Bulges and swelling of vulva and vagina
• Enlarged clitoris
• Syphilitic chancres
• Sebaceous cyst
• Condylomas

Primary Syphilis
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Sequence of a Pelvic Examination

• Skene's glands
• Near the urethra
• Suspect inflammation check for urethral
  discharge (Dc Infxn Most likely GC)
• Insert index finger with palm facing you into the
  vagina up to the 2d joint. Apply pressure
  upwards and milk the Skene's gland by moving your
  fingers outward
• Do this on both sides and obtain specimen for
  culture in case of discharge.
• Change glove if discharge is found.

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Sequence of a Pelvic Examination

• If there is history or appearance of labial
  swelling check Bartholin's glands
• Insert index finger up to first knuckle
• With your index finger and thumb, palpate the
  posterolateral area of the labia majora noting
  any
• Swelling
• Tenderness
• Masses
• Heat or discharge

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Sequence of a Pelvic Examination

• Bartholin's glands (CONT)
• A painful abscess is pus filled and usually
  staphylococcal or gonococcal in origin and should
  be incised and drained to perform CS.

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Sequence of a Pelvic Examination

• Assess the support of the vaginal outlet
• With the labia separated by middle and index
  finger
• Ask patient to strain down
• Note any bulging of the vaginal walls (cystocele
  and rectocele).

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Sequence of a Pelvic Examination

• Inspect the anus at this time, note presence of
  lesions and hemorrhoids

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Speculum Examination of Internal Genitalia

• Select a speculum of appropriate size, lubricate
  and warm with warm water (Commercially prepared
  lubricants interfere with pap smear studies)
• Small--not sexually active female
• Medium--sexually active
• Large--women who have had children
• Medium to large speculum may be used if female
  has had children.

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Speculum Examination of Internal Genitalia

• Hold speculum in right hand
• Place two fingers just inside or at the introitus
  and gently press down, this will help guide the
  speculum into the vagina opening
• The speculum has to be closed
• Insert closed speculum obliquely into vagina at a
  45 degree angle rotating 50 degrees
  counterclockwise

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Speculum Examination of Internal Genitalia

• Avoid trauma to the urethra
• Care is taken to avoid pulling pubic hair or
  pinching the labia
• Maintaining downward pressure, open blades slowly
  after full insertion and position the speculum so
  that the cervix can be visualized
• When the cervix is in full view, the blades are
  locked in the open position

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Examination/Collection Specimen of the Cervix

• Inspect the cervix
• Color should be uniformly pink
• Erythema around os
• Ectropion--expressed columnar epithelium
• Erosion--term has been used to describe both the
  exposed columnar epithelium and the erythema seen
  with cervicitis
• Pale--anemia
• Bluish--Chadwick's sign, presumptive sign of
  pregnancy.

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Cervical inspection

• Lesions/cysts
• Nabothian cyst--endocervical retention cysts
  usually secondary to cervical infection/inflammati
  on
• Friable, granular, red or white patchy areas--be
  suspicious of dysplasia, needs to be evaluated
  with colposcopy
• Ulcerative lesions--may be herpetic do viral
  culture of lesions and refer for colposcopy
• Polyps--soft, friable mass protruding through os
  may bleed if traumatized refer for
  evaluation/removal

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Cervical inspection

• Discharge
• Endocervical vs. from vaginal vault
• Physiological discharge--odorless, colorless
• Culture any discharge.

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Cervical inspection

• Cervical Os
• Nulliparous--small, round, oval
• Parous/multiparous--linear, irregular, stellate

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Cervical inspection
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Examination/Collection Specimen of the Cervix

• Obtain specimens
• Chlamydia culture--most prevalent STD
• GC culture--gram stain not reliable, done for
  screening, must do Thayer-Martin for confirmation

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Examination/Collection Specimen of the Cervix

• PAP smear for cytology--sites of collection
• Endocervical brush--all patients
• Endocervical scrape with spatula--all patients
• Posterior fornix--all
• Vaginal cuff and area of former posterior fornix
  for post-hysterectomy patient

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PAP Smear
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PAP Smear
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Examination/Collection Specimen of the Cervix

• Obtain specimens
• Wet mount of normal saline
• WBCs--evidence of infection/inflammatory process
• Flagellated trichomonads--trichomonas
• Granulated epithelial cells,"clue
  cells"--Gardnerella

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Examination/Collection Specimen of the Cervix

• Obtain specimens
• KOH prep--budding yeast--candidiasis "whiff"
  (fishy odor)--Gardnerella
• Viral cultures of suspected lesions
• Others
• STS (RPR/VDRL)--if suspected STDs
• Beta HCG--if pregnancy suspected.

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Examination/Collection Specimen of the Cervix

• Obtain specimens
• Collect during routine PAP smear/pelvic exam
• Wet mount if suspicious discharge
• KOH prep if suspicious discharge
• Thayer-Martin of Transgrow cultures
• Chlamydia cultures

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Inspection of the Vagina

• Withdraw the speculum slowly while observing the
  vaginal wall
• Close blades as the speculum emerges from the
  introitus
• Inspect vaginal mucosa as the speculum is
  withdrawn

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Perform a Bimanual Examination
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Bimanual Examination

• From a standing position, introduce the index
  finger and middle finger of your gloved hand into
  the vagina
• Exert pressure posteriorly
• Your thumb should be adducted with the ring
  finger and little finger into your palm to avoid
  touching the clitoris.

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Bimanual Examination

• Palpate the vaginal walls as you insert your
  fingers for tenderness, cysts, nodules, masses or
  growths
• Identify the cervix, noting the following
• Position--anterior or posterior
• Shape--pear-shaped
• Consistency--firm or soft
• Regularity
• Mobility--move from side to side 1-2 cm in each
  direction
• Tenderness

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Bimanual Examination

• Palpate the fornix around the cervix
• The os should admit your fingertip 0.5 cm
• Place your free hand on the patient's abdomen
  midway between the umbilicus and symphysis pubis
  and press downward toward the pelvic hand

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Bimanual Examination

• Many vaginal orifices will readily admit a single
  examining finger. The technique can be modified
  so that the index finger alone is used. Special
  small speculum or nasal speculum may make
  inspection possible also. When the orifice is
  even smaller, a fairly good bimanual examination
  can be performed with one finger in the rectum.

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Bimanual Examination

• Your pelvic hand should be kept in a straight
  line with your forearm and inward pressure
  exerted on the perineum by your flexed fingers.
• Support and stabilize your arm by resting your
  elbow either on your hip or on your knee which is
  elevated by placing your foot on a stool

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Bimanual Examination

• Identify the Uterus Note the Following
• Size--uterine enlargement suggests
• Pregnancy,
• Benign or malignant tumors (leiomyomas)
• The uterus should be 5.5-8.0 cm long
• Shape--pear-shaped
• Consistency--firm or soft.

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Bimanual Examination

• Identify the Uterus Note the Following
• Mobility--should be mobile in the antero-postero
  plane
• Deviation to the left or right is indicative of
  adhesions, pelvic masses of pregnancy
• Tenderness--suggests PID process or ruptured
  tubal pregnancy
• Masses.

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Pelvic Exam
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Bimanual Examination

• Identify Right Ovary and Masses in the Adnexa
• Place your abdominal hand on the right lower
  quadrant
• Place your pelvic hand in the right lateral
  fornix
• Maneuver your abdominal hand downward
• Use your pelvic hand for palpation.

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Bimanual Examination

• Identify Right Ovary and Masses in the Adnexa
• Ovaries and masses are felt with the vaginal
  hand.
• The ovary has the size and consistency of a
  shelled oyster

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Bimanual Examination

• Identify Right Ovary and Masses in the Adnexa
• Size,
• Shape,
• Consistency,
• Mobility
• Tenderness of any palpable organs or
  masses should be noted.

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Bimanual Examination

• Repeat the procedure on the left side
• The normal ovary is somewhat tender when palpated
• Withdraw Fingers from Vagina and Change Gloves

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Rectovaginal Examination

• The rectovaginal exam allows the examiner to
  reach almost 1" higher into the pelvis
• The rectovaginal exam is usually performed after
  the bimanual examination.

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Bimanual Examination
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Rectovaginal Examination
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Rectovaginal Examination

• There is a risk of spreading infection between
  the vagina and rectum.
• Gonorrhea may infect the rectum, as well as the
  female genitalia.
• It is recommended that gloves be changed between
  bimanual and rectovaginal examination, in order
  to avoid spreading gonococcal infection.
• In order to avoid fecal soiling, gloves should
  always be changed, if for some reason the
  practitioner examines the vagina after the rectum.

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Rectovaginal Examination

• Tell the patient that this may be somewhat
  uncomfortable, and will make her feel as if she
  has to move her bowels
• Lubricate dominant gloved hand
• Inspect the perianal area for lesions,
  discoloration, inflammation and hemorrhoids.

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Rectovaginal Examination

• Patient is instructed to bear down as though she
  as having a bowel movement, caution her she will
  feel as though she must pass a bowel movement
• As the anal sphincter relaxes, insert your
  fingertip of the second finger gently into the
  anal canal and the 1st finger into the vagina.
• Sphincter tone is palpated

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Rectovaginal Examination

• Palpate the anorectal junction.
• Tell the woman to bear down, palpate the anterior
  rectal wall and check for sphincter tone.
• A loose sphincter may be present due to
  neurologic deficit or 3rd degree perineal
  laceration after childbirth

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Rectovaginal Examination

• Insert fingers as far as they will go.
• Tell the woman to bear down, and that should
  bring another centimeter of palpation.
• Check the rectal walls, rotating your finger,
  checking for masses, polyps, irregularities or
  tenderness.

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Rectovaginal Examination

• Palpate the rectovaginal septum for tone and
  thickness
• With your vaginal finger in the posterior fornix,
  perform a bimanual exam and palpate the bottom of
  the uterus and adnexa completely.
• Withdraw your fingers and evaluate the posterior
  rectal wall.

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Rectovaginal Examination

• Prepare guaiac of rectal finger
• Give the patient a towel or tissues to cleanse
  herself

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Common Abnormalities

• Vulva
• Bartholin's cyst
• Condyloma acuminatum

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Common Abnormalities

• Cervix
• Polyps
• Discharge
• Discoloration

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Common Abnormalities

• Uterus--enlarged
• Pregnancy
• Fibroids

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Common Abnormalities

• Adnexa
• Ectopic pregnancy
• Ovarian tumor or cyst

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SUMMARY

• PELVIC EXAM
• Inspect Externally
• Palpate Skenes Glands
• Palpate Bartholins Glands
• Assess Outlet
• Speculum Exam
• Bimanual Exam
• Vagina, Cervix, Uterus, Adnexa

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SUMMARY

• RECTOVAGINAL EXAM
• Palpate sphincter tone
• Palpate rectal wall
• Palpate rectovaginal septum
• Palpate Uterus
• Palpate Adnexa
• Guaiac

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Vaginitis Differentiation
Vaginitis Curriculum
Normal Bacterial Vaginosis Candidiasis Trichomoniasis
Symptom presentation Odor, discharge, itch Itch, discomfort, dysuria, thick discharge Itch, discharge, 50 asymptomatic
Vaginal discharge Clear to white Homogenous, adherent, thin, milky white malodorous foul fishy Thick, clumpy, white cottage cheese Frothy, gray or yellow-green malodorous
Clinical findings Inflammation and erythema Cervical petechiae strawberry cervix
Vaginal pH 3.8 - 4.2 gt 4.5 Usually lt 4.5 gt 4.5
KOH whiff test Negative Positive Negative Often positive
NaCl wet mount Lacto-bacilli Clue cells (gt 20), no/few WBCs Few WBCs Motile flagellated protozoa, many WBCs
KOH wet mount Pseudohyphae or spores if non-albicans species