Transcript Pelvic Examination

Pelvic Examination
Akmal Abbasi, M.D.
Cross Section, Side View
Pelvic Examination

1. Preparation of the patient:
– A. Instruments for pelvic examination:
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1.
2.
3.
4.
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6.
7.
8.
examining gloves
bivalve speculum (plastic or metal) (various sizes)
sponge forceps
cotton balls or GYN “cue tips”
wooden spatula
Cyto brush
2 glass slides or whatever your clinic uses
fixative, liquid or spray
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.
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.
Pelvic examination
• Tips to make the experience tolerable for
the patient
• Don’t 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!).
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 patient’s response.
• Be sensitive.
Examination of External Genitalia
A.
 B.
 C.
 D.
 E.
 F.
 G.

Clitoris
Prepuce
Labia majora
Labia minora
Perineal body
Hymen
Urethral meatus
Examination of External Genitalia
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H. Vestibule
I. Bartholin’s glands (greater vestibular) J. Skene’s glands (paraurethral) K. Lesions, discharge
L. Pubic hair pattern
External Genitalia
• Bartholin’s glands and Skene’s 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.
Note any inflammation,
ulceration of Skene's glands
(e.g., from gonorrhea) is
suspected, insert your index
finger into the vagina and milk
the urethra gently from
the inside outward. Note any
discharge from or about the
urethral orifice. If present, a
culture should be taken.
If there is a history or appearance of
labial swelling, check Bartholin's
glands. Insert your index finger into
the vagina near the posterior end of
the introitus. Place your thumb outside
the posterior part of the labia majora.
On each side in turn palpate between
your finger and thumb for
swelling or tenderness. Note any
discharge exuding from the duct
opening of the gland.
If present, culture it. Note any surgical
scars (episiotomy or other scars) and
other abnormalities.
Inflammation commonly
caused by gonorrhea and may
be acute or chronic. Acutely,
it is a tense, hot, very tender
abscess. Look for pus coming
out of the duct.
Chronically, a non-tender cyst
occupies the posterior labium.
It may large or small.
Assess the support of the vaginal outlet. With the labia
separated by your middle and index finger; ask the pt.
to strain down. Note any bulging of the vaginal walls.
A cystocele is present when the anterior
wall of the vagina, together with the
bladder above it, bulges into the vagina
and sometimes out the introitus.
Look for the bulging vaginal
wall as the client strains down.
A rectocele is formed by the
anterior and downward
bulging of the posterior
vaginal wall together with the
rectum behind it. To identify
it, spread the client's labia
and ask her to strain down.
INTERNAL EXAM INSTRUCTIONS
• Inspect the vagina and cervix next using a
speculum.
• A speculum is placed inside the vagina and
opened.
• The speculum is an instrument that holds the
vaginal walls apart and allows the examiner to
see the cervix and vagina and check for
inflammation, infection, scars or growths.
• There may be some feeling of pressure on the
bladder or rectum with the speculum in place.
INTERNAL EXAM INSTRUCTIONS
• Select a speculum of appropriate size, lubicate
it and warm it with warm water. (Other
lubricants, such as K-Y Jelly, may interfere
with cytological or other studies but they may
be used if no such tests are planned.)
• By having your speculum ready during
assessment of the vaginal outlet, you can ease
speculum insertion and increase your efficiency
by proceeding to the next maneuver while the
pt. is still straining down.
Place two fingers just inside or at the introitus and
gently press down on the perineal body. With your other
hand introduce the closed speculum past your fingers
at a 45-degree angle downward.
The blades should be held
obliquely and the pressure
exerted toward the posterior
vaginal wall in order to avoid
the more sensitive anterior wall
and urethra. Be careful not to
pull on the pubic hair or to
pinch the labia with the
speculum.
After the speculum
has entered the
vagina, remove your
fingers from the
introitus. Rotate the
blades of the speculum
into a horizontal
position maintaining
the pressure
posteriorly.
Open the blades after full insertion and maneuver the
speculum so that the cervix comes into full view.
When the introitus is retroverted, the cervix points more
anteriorly than diagrammed. Position the speculum more
anteriorly, i.e., more horizontally, in order to bring the
cervix into view.
A normal cervix will appear pinkish in color.
The cervix will appear as purplish in color if a woman is
pregnant.
OBTAINING SPECIMEN SAMPLES
Pap smear
• If you are going to obtain specimens for
cervical cytology (Papanicolaou smears, also
known as a pap smear). Take these steps in
order:
• 1. The Endocervical Swab: Moisten the end of a
cotton applicator stick with saline and insert it
into the os of the cervix.
• Roll it between your thumb and index finger,
clockwise and counter clockwise. Remove it.
Pap smear
• Smear a glass slide with the cotton swab, gently
in a painting motion. (Rubbing hard on the
slide will destroy the cells.)
• Place the slide into the ether-alcohol fixative at
once.
• 2. Cervical Scrape: Place the longer end of the
scraper on the os of the
cervix.
• Press, turn and scrape. Smear
on a second slide as before.
Pap smear
• 3. Vaginal Pool: Roll a cotton applicator stick
on the floor of the vagina below the cervix.
• Prepare a third slide as before. If the pt. has an
infection or a discharge from the cervix or the
vagina, this would be a good time to take a
sample with a cotton swab for analysis.
• If the cervix has been removed, do a vaginal
pool and scrape from the cuff of the vagina.
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
BIMANUAL INSPECTION
• Perform a bimanual examination.
• From a standing position, introduce the index
and middle finger of your gloved and
lubricated hand into the vagina, again exerting
pressure primarily posteriorly.
• Your thumb should be abducted, your ring and
little fingers flexed into your palm.
• Note any nodularity or tenderness in the
vaginal wall, including the region of the urethra
and bladder anteriorly.
BIMANUAL INSPECTION
• Identify the cervix, noting its position, shape,
size, consistency, regularity, mobility and
tenderness.
• Palpate the fornix around the cervix. Note that
during pregnancy, the cervix will be softer in
consistency (like palpating your lips) as
compared to nonpregnancy (like the end of
your nose).
• Place your abdominal hand about midway
between the umbilicus and symphysis pubis
and press downward toward the pelvic hand.
BIMANUAL INSPECTION
• 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.
• Identify the uterus between your hands and not its size,
shape, consistency, mobility, tenderness and masses.
• This procedure may cause some discomfort for the
client.
• Uterine enlargement suggests pregnancy, benign or
malignant tumors.
Place your abdominal hand on the right lower quadrant,
your pelvic hand in the right lateral fornix.
Maneuver your abdominal hand downward, and using
your pelvic hand for palpation, identify the right ovary
and nay masses in the adnexa. Three to five years after
menopause, the ovaries have usually atrophied and are
no longer palpable. If you can feel an ovary in a
post-menopausal woman, suspect an ovarian tumor.
Note the size, shape, consistency,
mobility and tenderness of any
palpable organs or masses. The
normal ovary is somewhat tender.
Repeat the procedure on the
left side.
Vaginal-Rectal Exam:
• Withdraw your fingers, removing your gloves
and throwing them away.
• Reglove using fresh, clean gloves. Place
lubricant (K-Y Jelly) on internal exam glove.
• Then slowly reintroduce your index finger into
the vagina, your middle finger into the rectum.
• Ask the pt. to strain down as you do this so that
her anal sphincter will relax.
Vaginal-Rectal Exam:
• Tell her that this examination may make her feel as
if she has to move her bowels - but, she won't.
• Repeat the maneuvers of the bimanual
examination, giving special attention to the region
behind the cervix which may be accessible only to
the rectal finger.
• In addition, try to push the uterus backward with
your abdominal hand so that your rectal finger can
explore as much of the posterior uterine surface as
possible.
• Check the rectum itself and other nearby
structures for any abnormalities.
Pelvic Exam Checklist
External Genitalia
Inspect
Palpate
Chart
Hair distribution
X
Pattern, amount
Labia Majora
-Symmetry
-Shape
-Color
-Surface charact eristics
X
X
X
X
X
Stage of development,
abnormal symmetry, color,
surface lesions
Labia Minor
-Symmetry
-Shape
-Color
-Surface charact eristics
X
X
X
X
Same as labia majora
X
Pelvic Exam Checklist
External Genitalia
Inspect
Palpate
Chart
Prepuce
X
Abnormalities
Clitoris
X
Abnormalities in size
Urethra & Meatus
X
X
-discharge, redness
Skenes (paraurethral)
X
X
-discharge, enlargement
Vaginal Orifice (introitus)
X
X
Size--closed, gaping
Bartholins (greater vestibular)
X
X
Enlargement , tenderness
Pelvic Exam Checklist
External Genitalia
Inspect
Palpate
Chart
Cystocele
X
Preset/absent; degree
Rectocele
X
Preset/absent; degree
Uterine Dycensus
X
Preset/absent; degree
Perineal Body
X
Anus
X
X
Tone
-hemmorhoids; tone, occult
bloodtest
Pelvic Exam Checklist
Speculus Exam
Inspect
Vaginal Mucosa
X
Color, lesions, rugation
Cervix
-Size
-Shape
-Color
-Symmetry
-Surface charact eristics
X
X
X
X
X
X
Size, shape, color,
color, symmetry,
surface charact eristics
Eternal Os
X
Eversion, erosion, color
consistency, odor
GC/clamydia/culture/w et
mount
X
Done/not done & w hy
PAP smear
Discharge
Palpate
Chart
Done/not done & w hy
X
Color, consistency,
odor
Pelvic Exam Checklist
Bimanual Exam
Inspect
Palpate
Chart
Vagina
X
Cysts, masses
Cervix
-Consistency
-Mobility
-Tenderness
X
X
X
X
Soft/firm;
mobile/immobile;
tender/nontender
Supra Pubic
X
Masses, tenderness
Posterior Cul de sac
X
Masses, tenderness
Pelvic Exam Checklist
Bimanual Exam
Uterus
-Size
Inspect
Palpate
X
X
-Shape
-Position
X
X
-Consistency
-Mobility
-Tenderness
X
X
X
Andenexa
-Tubes, Ovaries,
Ligaments
X
X
Chart
Small or w eeks
gestation
Smooth/irregular
Anteverted/flexed, mid,
retrovrted/flexed
Soft/firm
Mobile/immobile
Tender/nont ender
Enlargement , masses,
tenderness
Pelvic Exam Checklist
Rectovaginal Exam
Inspect
Palpate
Chart
Rectovaginal Septus
X
Thickness
Posterior Cul de sac
X
Masses, tenderness
Posterior Uterine Wall
X
Same as vaginal
Adenexae
X
Same as vaginal
Rectal tone
X
Tone, occult blood test
results
Pelvic Examination of the
Adolescent Patient
Remember
• The lithotomy position is uncomfortable both
physically and psychologically.
• Be professional, patient, and gentle.
• "Endearing" names for the patient like "honey" or
"darlin", though used by some gynecologists, are
inappropriate, especially for the adolescent.
• Explain ahead of time that the exam, though
uncomfortable and embarrassing, should not hurt,
and you will stop if it does.
Order of Tests
1. External genitalia inspection
2. Insertion of vaginal speculum and identification
of cervix (Stay away from the urethra and
anterior vaginal wall; downward pressure on the
perineal body during insertion is often helpful)
3. Swab cervix clean (if necessary)
4. Endocervical swab for GC culture and
endocervical portion of Gram stain slide
Order of Tests
5. Endocervical brush for Chlamydia FA and for
endocervical component of PAP smear
6. Wooden spatula for ectocervical portion of PAP
smear
7. Cotton tip swab of vaginal secretions in
posterior fornix for NX Prep, KOH Prep and
other portio of Gram stain slide
8. Inspect vaginal wall as you retract the speculum
Bimanual Exam
1. Identify cervix with intravaginal gloved
examining fingers that have been first
covered with sterile lubricant.
2. Assess size and position of uterus using
intravaginal examining fingers and
abdominal hand
3. Feel adnexal structures bilaterally
4. Rectal exam only if indicated.
Bimanual Exam
•
•
•
Give the patient tissues or washcloth to
clean away the lubricant.
Examine slides while your patient is
getting dressed.
Then discuss the results, your diagnosis,
and recommended treatment with her
privately after she is dressed.
Special Considerations
with the Geriatric
Patient
Geriatric Patient
• The pelvic examination proceeds
similarly to that of most women.
• Special considerations in examining the
elderly patient include age-related comorbidities that may make postioning
difficult or the examination
uncomfortable.
• Some of the following recommendations
may also apply to younger women with
disabilities.
Geriatric Patient
• Most elderly women can be examined in
the dorsal lithotomy position.
• For some, conditions that limit hip or
knee movement, such as arthritis,
make the left lateral decubitus position
more comfortable.
• With practice, thorough bimanual and
speculum examinations can be done
with the patient in this position.
Geriatric Patient
• For bed-bound women, placing an
inverted bedpan under the sacrum to
elevate the pelvis will facilitate the
examination.
• The effects of estrogen withdrawal
make examination of the vulva
particularly important.
• After menopause the skin of the vulva
loses elasticity and there is
degeneration of underlying fat and
connective tissues.
Geriatric Patient
• Inflammation caused by irritants,
Candida infection, and vulvar
dystrophies are common and treatable
and are easily identified on pelvic
examination.
• Any lesion that is pigmented or does
not respond to topical therapy should
undergo biopsy.
• Atrophic vaginitis is also common and is
indicated by the presence of a urethral
caruncle or by inflamed vulvar and
vaginal tissue.
Geriatric Patient
• In women who are not receiving
estrogen replacement therapy, vaginal
stenosis and atrophy are very common.
• Small speculums should be used to
examine these women.
• Lubricant may be necessary for the
speculum examination but should be
avoided if a Papanicolaou smear is to be
obtained.
Geriatric Patient
• The speculum can be taken apart and
the lower half used to hold down the
floor and roof of the vagina to look for
cystocele and rectocele, respectively,
while the patient coughs or performs
the Valsalva maneuver.
• Urinary leakage with cough or straining
may also be observed, indicating stress
incontinence.
Geriatric Patient
• Bimanual examination is important to
detect pelvic masses or tenderness.
• Any palpable ovarian tissue in a
postmenopausal woman warrants
further investigation, as does any
uterine mass.
• Pelvic floor muscle strength and control
can be assessed for incontinent patients
by having them contract the muscles
during digital examination.
• This technique can also be used to
teach Kegel exercises more effectively.
Cystocele, a hernial protrusion of the urinary bladder
through the anterior wall of the vagina.
Rectocele, a hernial protrusion of part of the rectum
through the posterior wall of the vagina.
Evaluation of menstrual
disorders
I.
A.
1.
2.
3.
4.
5.
6.
7.
History: Components to Document
Menstrual specific
Age at menarche
Frequency and duration of flow
Quantity of pads/tampons per day and number
periods
Last menstrual period
Last normal menstrual period
Symptoms associated with menses
Disruption of normal activities
8.
Past treatment
A.
Past medical history
1.
2.
3.
4.
5.
Hospitalization
Surgery
Serious infections
Congenital problems (hydrocephalus)
Chronic illness (rheumatologic,
endocrinologic, oncologic, gastrointestinal)
Tanner/SMR stage
Bleeding disorders (epistaxis, hematuria,
hematochezia)
Previous gynecologic evaluation and treatment
Growth
Development
Family history of gynecologic problems
6.
7.
8.
9.
10.
A.
10.
A.
1.
2.
3.
4.
5.
6.
7.
8.
Development
Family history of gynecologic problems
Maternal menarche
Dysmenorrhea/PMS
Endometriosis
Malignancy
Virilization
Ovarian cysts
Bleeding disorders
Surgical procedures
9.
A.
1.
2.
3.
4.
5.
6.
7.
A.
1.
2.
3.
4.
Fertility problems
Medications/substance use
Use of contraceptives
Steroids
Alcohol
Others (antianxiety, antidepressants,
antipsychotics)
Tobacco
Marijuana
Cocaine
Related health issues
Weight change
Nutrition history
Exercise, sports
Emotional symptoms
• Physical Examination: Specific Elements to Document
A. Vital signs
1. Weight
2. Height
3. Blood pressure
4. Heart rate
5. Body mass index
A. Tanner stages: B1-B5, P1-P5
B. External signs
1. Acne
2. Acanthosis nigricans
3. Bruising, ecchymosis, petechiae
4. Galactorrhea
5. Hirsutism, virilization
6. Thyroid size
C. External genitalia and pelvic exam
C. External genitalia and pelvic exam
1. Clitoromegaly
a.Clitoral index = transverse diameter (3.4 mm ± 1.0
mm) × longitudinal diameter (5.1 mm ± 1.4 mm) =
mean 18.52 mm2 †
† Data from Verkauf BS, Von Thron J, O'Brien WF:
Clitoral size in normal women. Obstet Gynecol
80:41-44, 1992.
b.Enlarged ≥ 35 mm2
2. Evidence of estrogen effect on external genitalia,
vaginal epithelium (vaginal smears) (Table 1)
3. Vaginal growths, foreign bodies
4. Cervix: erythema, friability, mucopus, shape of os
I.
A.
1.
2.
3.
4.
5.
Laboratory and Radiologic Tests: Menu to
Evaluate Menstrual Disorders
Routine
Complete blood cell count (CBC) with
differential and indices and platelets
Erythrocyte sedimentation rate§
§ Only if history suggests.
Sequential Multiple Analysis 12 (SMA 12)
(liver, renal functions)§
Urinalysis and urine culture*
Serum or urine pregnancy test¶
¶ Only if teen is currently sexually active or has
a past history of sexual activity.
PELVIC INFLAMMATORY
DISEASE (PID)
Akmal Abbasi, M.D.
PELVIC INFLAMMATORY DISEASE
• Pelvic inflammatory disease (PID) is defined as
a group of disorders that affect the upper
genital tract of women.
• It is thought to occur by the ascending spread
of organisms from the cervix or vagina to the
endometrium, fallopian tubes, and contiguous
structures.
• PID may include any combination of
endometritis, salpingitis, tubo-ovarian abscess
(TOA), or pelvic peritonitis.
Incidence
• More than 1 million women contract PID each
year, resulting in more than 2.5 million
outpatient visits, 200,000 hospitalizations, and
100,000 surgical procedures annually.
• More than 25% of women with a history of PID
suffer at least one sequela, including infertility,
ectopic pregnancy, or chronic abdominal pain.
Incidence
• Increasing number of adolescents develop this
disease.
• Nearly 70% of female patients with PID are
younger than 25 years of age, with ~33%
experiencing their first infection before the age
of 20 years.
• Adolescents aged 15 to 19 years have the
highest incidence of PID compared with all
other age groups.
ETIOLOGY
Chlamydia trachomatis.
Neisseria gonorrhoeae.
Vaginal aerobes anaerobes
Escherichia coli.
Haemophilus influenzae.
Mycoplasma hominis
Ureplasma urealyticum
Pathogenesis
•
•
•
PID develops when:pathogenic microorganisms ascend from an
infected cervix along the endometrial mucosal
surface to the uterus and fallopian tubes.
N. gonorrhoeae and C. trachomatis may initiate
changes in the cervix, endometrium, and tubal
mucosa, causing damage and facilitating
subsequent anaerobic or facultative bacterial
invasion.
Pathogenesis
•
Other mechanisms in the development of
PID may include lymphatic drainage with
spread of the infection parametrially or the
adherence of N. gonorrhoeae, C.
trachomatis, or other bacteria to
spermatozoa that may spread through the
genital tract.
Pathogenesis
•
•
The normal flora of the vagina consists
predominantly of Lactobacillus sp., which are
believed to be responsible for regulating the
growth of the vaginal flora.
Lactobacilli sp. produce hydrogen peroxide and
are also responsible for the presence of a low
vaginal pH level that may inhibit the growth of
other microorganisms
Pathogenesis
• Bacterial vaginosis is a clinical syndrome caused by an
overgrowth of endogenous and anaerobic flora.
• A shift in the vaginal flora occurs from a predominance
of Lactobacillus flora to one characterized by high
concentrations of G. vaginalis, anaerobic bacteria, and
genital mycoplasmas.
• Bacterial vaginosis-associated organisms include G.
vaginalis, Bacteroides sp., anaerobic cocci, Mobiluncus
sp., M. hominis, and U. urealyticum.
Pathogenesis
• The endocervical canal and mucus plug within the
endocervix represent the major barriers that
protect the endometrium and the rest of the upper
genital tract from the vaginal flora.
• Changes in the composition of the normal vaginal
flora and a failure of the barrier function at the
cervical-vaginal interface may allow the
ascendance of lower genital tract flora into the
endometrial cavity and contiguous structures.
Pathogenesis
• Infection may also diminish the clearance
mechanism normally provided by the ciliary
epithelial cells of the uterine and fallopian
tubes.
RISK FACTORS--Age
• Teenagers , especially those who are
sexually active.
• Sexually experienced teenagers are three
times more likely to be diagnosed with PID
than are 25- to 29 year olds.
Menstrual Cycle Influences:
• Symptoms of PID frequently present within
the first 7 days of the menstrual cycle,
especially in association with N.
gonorrhoeae infection.
• This may suggest that organisms are
transmitted from the cervix to the upper
genital tract at the time of menses.
Sexual Behavior:
•
•
Behaviorally, adolescents have more sexual
partners per time period, tend to be inconsistent
in the use of barrier methods of protection, and
have a higher prevalence of STDs in the partner
pool.
A higher frequency of sexual intercourse and an
increased rate of acquiring unprotected, new
partners are also risk factors for PID.
Choice of Contraceptive:
• Barrier methods, including condoms,
spermicides, and diaphragms, reduce the risk
for PID .
• IUD increase the risk for PID, although this
risk seems to be highest in the first 4 months
after IUD placement and not significantly
elevated above baseline at 5 months follow-up
and beyond.
• In these cases, PID is probably caused by the
introduction of vaginal or cervical organisms
into the uterus at the time of intrauterine
device insertion.
Other Risk Factors:
• Women who have had previous episodes of
Gonococcal PID are more likely to have recurrent
PID involving any cause.
• Douching may increase the risk for PID by
altering the vaginal environment to one that is less
protective against pathogenic organisms.
• Another theory is that douching flushes vaginal
and cervical microorganisms into the uterine
cavity, thus increasing the risk for upper genital
tract infection.
SYMPTOMS
Lower abdominal pain (1wk post menses).
Adnormal vaginal discharge.
Poscoital bleeding.
Spotting between menses.
N/V/diarrhea.
Fever/chills.
Dyspareunia.
CLINICAL FINDINGS
Fever,
Lower abd. pain with rebound.
CMT
Adenexal tenderness.
Adenexal fullness/mass.
Lab evaluation
Urine and/or serum
CBC
ESR
Chlamydia and GC.
HCG.
DIAGNOSTIC EVALUATION
Ultrasound.
 To R/O tubo-ovarian abscess.
Laporoscopy gold standard for diagnosis.
Endometrial biopsy to r/o endometritis.
RECOMMENDATIONS FOR CRITERIA USED TO
DIAGNOSE PID
• Minimum criteria:
Lower abdominal tenderness
Adnexal tenderness
Cervical motion tenderness
• Additional criteria
Oral temperature >101°F
Abnormal cervical or vaginal discharge
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
Lab documentation of cervical infection with N.
gonorrhoeae or C. trachomatic
RECOMMENDATIONS FOR CRITERIA USED TO
DIAGNOSE PID
• Elaborate criteria:
Histopathologic evidence of endometritis on endometrial
biopsy
Transvaginal sonography or other imaging techniques
showing thickened, fluid-filled tubes with or without free
pelvic fluid or tubo-ovarian complex
Laparoscopic abnormalities consistent with pelvic
inflammatory disease
DDX
Ectopic pregnancy.
Appendicitis.
Chronic pelvic pain.
Chronic adhesive disease.
Endometriosis.
Ovarian torsion.
Ovarian cyst.
IBS
SEQUELAE
• The sequelae of PID are a major cause of reproductive
morbidity and can occur in as many as 25% of women
with PID.
• Infertility
• Ectopic pregnancy
• Recurrent PID
• Chronic abdominal pain
• Dyspareunia
• Pelvic adhesions
• Pyosalpinx
• Tubo-Ovarian Abscess
RECOMMENDATIONS FOR HOSPITALIZATION
OF PATIENTS WITH SUSPECTED PID
• Uncertain diagnosis (surgical emergencies cannot be
excluded)
• Pregnancy
• Failure to respond clinically to oral antimicrobial
therapy
• Noncompliance (unable to follow outpatient regimen)
• Severe illness, nausea, and vomiting; or high fever
• Unable to tolerate an outpatient oral regimen
• Tubo-ovarian abscess is present
• Immunodeficiency or HIV positivity
RECOMMENDATIONS FOR OUTPATIENT
TREATMENT OF PID
• Regimen A
Ofloxacin, 400 mg PO BID for 14 days
Plus
Metronidazole, 500 mg PO BID for 14 days
RECOMMENDATIONS FOR OUTPATIENT TREATMENT OF
PID
• Regimen B
Ceftriaxone, 250 mg IM QD Or
Cefoxitin, 2 g IM, plus Probenecid, 1 g
orally in a single dose
Or
Other parenteral third-generation
cephalosporin
Plus
Doxycycline, 100 mg PO BID for 14 days
RECOMMENDATIONS FOR INPATIENT TREATMENT OF PID
• Regimen A
Cefotetan, 2 g IV every 12 hours
Or
Cefoxitin, 2 g IV every 6 hours
plus
Doxycycline, 100 mg IV or orally every 12
hours
RECOMMENDATIONS FOR INPATIENT TREATMENT OF PID
• Regimen B
Clindamycin, 900 mg IV every 8 hours
Plus
Gentamicin, 1.5 mg/kg IV every 8 hours
(load 2 mg/kg IV or IM first dose)
ALTERNATIVE PARENTERAL REGIMENS FOR
INPATIENT TREATMENT OFPID
• Regimen A
Ofloxacin, 400 mg IV every 12 hours
Plus
Metronidazole, 500 mg IV every 8 hours
• Regimen B
Ampicillin/Sulbactam, 3 g IV every 6 hours
Plus
Doxycycline, 100 mg IV or orally every 12 hours
ALTERNATIVE PARENTERAL REGIMENS FOR
INPATIENT TREATMENT OFPID
• Regimen C
Ciprofloxacin, 200 mg IV every 12 hours
Plus
Doxycycline, 100 mg IV or orally every 12 hours
Plus
Metronidazole, 500 mg IV every 8 hours
PATIENT COUNSELING
• Counseling should provide an adequate
opportunity to discuss contraception,
especially the use of barrier methods, to
prevent the transmission of STDs.
• Other potentially health-compromising
behaviors, such as douching, should be
addressed.
PATIENT COUNSELING
• Patients should be instructed to avoid
intercourse while ill with symptoms and
while being treated.
• They should be encouraged to discuss
treatment with their partners and to
verify that their partners have been
treated before reinitiating sexual
intercourse.
Puberty
Akmal Abbasi, M.D.
Puberty
• Between 10 and 20 yr of age, children undergo
rapid changes in body size, shape, physiology, and
psychologic and social functioning.
• Hormones set the developmental agenda in
conjunction with social structures designed to
foster the transition from childhood to adulthood.
• Adolescence proceeds across three distinct
periods—early, middle, and late—each marked by
a characteristic set of salient biologic,
psychologic, and social issues.
• Gender and subculture profoundly affect the
developmental course, as do physical and social
stressors such as cerebral palsy or parental
alcoholism.
Puberty
• Levels of luteinizing hormone (LH) and folliclestimulating hormone (FSH) rise progressively
throughout middle childhood without dramatic effect.
• The rapid changes of puberty begin with increased
sensitivity of the pituitary to gonadotropin-releasing
hormone (GnRH), pulsatile release of GnRH, LH,
and FSH during sleep, and corresponding increases in
gonadal androgens and estrogens.
• The triggers for these changes are incompletely
understood, but may involve neuronal development
that is ongoing throughout middle childhood and
adolescence.
Puberty
• Children in the United States may enter puberty
earlier than the published norms (although reports of
dramatically earlier puberty are controversial),
perhaps related to increased weight and adiposity. The
resulting sequence of somatic and physiologic
changes gives rise to the sexual maturity rating
(SMR) or Tanner stages.
Puberty-Girls
• In girls, the first visible sign of puberty is the
appearance of breast buds, between 8 and 13 yr.
• Menses typically begin 2–21/2 yr later (normal
range 9–16 yr), around the peak in height velocity.
• Less obvious changes include enlargement of the
ovaries, uterus, labia, and clitoris; thickening of
endometrium and the vaginal mucosa; and
increased vaginal glycogen, predisposing to yeast
infections.
Puberty-Boys
• In boys, testicular enlargement begins as early as 91/2
yr.
• Peak growth occurs when testis volumes reach
approximately 9–10 cm3 .
• Under the influence of LH and testosterone, the
seminiferous tubules, epididymis, seminal vesicles,
and prostate enlarge.
• The left testis normally is lower than the right; the
opposite may be true in situs inversus.
• Some degree of breast hypertrophy occurs in 40–65%
of pubertal boys as a result of a relative excess of
estrogenic stimulation.
Puberty-Boys
• Gynecomastia sufficient to cause embarrassment and
social disability occurs in fewer than 10%. Breast
swelling less than 4 cm in diameter has a 90% chance
of spontaneous resolution within 3 yr.
• For greater degrees of enlargement, hormonal or
surgical treatment may be indicated.
• Obesity may exacerbate gynecomastia and should be
addressed through diet and exercise.
Puberty
• For both sexes, growth acceleration begins in early
adolescence, but peak growth velocities are not reached
until SMR3 or 4.
• Boys typically peak 2–3 yr later than girls and continue
their linear growth for approximately 2–3 yr after girls
have stopped.
• The growth spurt begins distally, with enlargement of
hands and feet followed by the arms and legs and finally
by the trunk and chest.
• This asymmetric growth gives young adolescents a
gawky look.
• Rapid enlargement of the larynx, pharynx, and lungs
leads to changes in vocal quality, often heralded by a
period of vocal instability (voice cracking) or
dysphonation.
Puberty
• Adrenal androgens stimulate the sebaceous glands,
promoting the development of acne.
• Elongation of the optic globe often results in
nearsightedness.
• Dental changes include jaw growth, loss of the final
deciduous teeth, and eruption of the permanent cuspids,
premolars, and finally molars. Orthodontic appliances
may be needed.
Maturity Stages in Girls
SMR
Stage
Pubic Hair
Breasts
1
Preadolescent
Preadolescent
2
Sparse, lightly pigmented,
straight, medial border of labia
Breast and papilla elevated as
small mound; areolar diameter
increased
3
Darker, beginning to curl,
increased amount
Breast and areola enlarged, no
contour separation
4
Coarse, curly, abundant but
amount less than in adult
Areola and papilla form secondary
mound
5
Adult feminine triangle, spread
to medial surface of thighs
Mature, nipple projects, areola
part of general breast contour
Sex maturity ratings of breast changes in
adolescent girls.
Sex maturity ratings of pubic hair changes in adolescent
boys and girls.
Maturity Stages in Boys
SMR
Stage
Pubic Hair
Penis
Testes
1
none
Preadolescent
Preadolescent
2
Scanty, long, slightly Slight enlargement
pigmented
Enlarged scrotum,
pink, texture altered
3
Darker, starts to
curl, small amount
Longer
Longer
4
Resembles adult
type but less in
quantity; coarse,
curly
Larger; glans and
breadth increase in
size
Larger, scrotum dark
5
Adult distribution,
spread to medial
surface of thighs
Adult size
Evaluation of precocious puberty, excluding factitious and iatrogenic causes.
Evaluation of patient with delayed puberty.
Sexual Assault
Akmal Abbasi, M.D.
• Traditionally, rape was defined as the carnal
knowledge of a woman, forcibly and against
her will.
• Most legal reforms have expanded this
definition to include many different types of
sexual assault such as sodomy, oral
copulation, rape with a foreign object, and
sexual battery.
• Emergency personnel must be well prepared to handle the
evaluation and treatment of sexual assault victims.
• Training should emphasize the need to maintain patient
comfort and support, while approaching patients in a
caring and sensitive manner.
• A patronizing, dismissive, or accusatory attitude may so
alienate the
victim that further evaluation or even needed treatment is
refused.
• The patient’s anxieties may be lessened by specifically
acknowledging the assault and by encouraging her
expression of her feelings, concerns, and needs.
• Step-by-step explanations of any necessary procedures
should be provided as the evaluation progresses.
• The procedure should also include informing the patient of
her rights and options and allowing her to participate in
decisions affecting her care.
• Prepackaged sexual assault or rape kits are
available in the ED or can be obtained from the
law enforcement agency where the incident
occurred.
• These kits contain instructions that guide the
examiner, in a stepwise fashion, through the
forensic evaluation process.
• The kit contains instructions and materials needed
to collect, label, and preserve all the required
specimens.
• Kits may also contain forms designed for the
documentation of history and examination
findings, as well as specialized consent forms
required for evidence collection.
Legal Issues
• Although the law may not require victims to personally
report the crime, most states require physicians to report
the alleged sexual assault to the local law enforcement
agency in the jurisdiction where the crime occurred.
• Reporting requirements generally include the victim’s
name and address, the nature and extent of injuries, and the
location of the assault.
• The victim should be informed of this physician
responsibility and told that her decision regarding the
report of the assault does not affect her access to medical
care and other supportive services.
Legal Issues
• Patient’s legal rights regarding any examination, treatment,
or evidence collection must be preserved because she may
refuse or withdraw consent from any or all parts of the
evaluation process at any time.
• To protect both patients and examiners, signed informed
consents must be obtained before the examination.
• This may require obtaining consent from a parent or legal
guardian if the patient is a minor.
• A general consent in accordance with hospital policy is all
that is required for routine medical evaluation and
treatment.
• Special and separate informed written consent must be
obtained for the collection and release of forensic
evidence, including any photographs taken.
Recommended History
•
•
•
•
•
•
•
General medical history
Acute injury or illness
Chronic disease
• Psychiatric disorders
Preexisting injuries
Current medications
Allergies
Immunizations
• Tetanus
• Hepatitis B
Recommended History
•
•
•
•
•
•
•
•
Gynecologic history
Gravidity and parity
Last normal menstrual period
Last voluntary intercourse
Birth control
• Possibility of missed birth control pills
Possible symptoms of pregnancy
Recent gynecologic surgery
Sexually transmitted diseases
Recommended
History
History of the assault
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Date, time, and place
Number and race of assailants
Types of force and threats used
Use of alcohol or drugs
By victim
By assailant(s)
Loss of consciousness
Type of assault
Fondling
Oral penetration
Vaginal penetration
Anal penetration
Foreign bodies used
Ejaculation on or in the body
Recommended History
•
•
•
•
•
•
•
•
•
Type of assault
Fondling
Oral penetration
Vaginal penetration
Anal penetration
Foreign bodies used
Ejaculation on or in the body
Use of condoms
Use of a lubricant
Recommended History
•
•
•
•
•
•
•
•
•
Postassault activity
Medications
Alcohol or drug use
Change of clothing
Urination or defecation
Bathing, washing, douching
Eating, drinking
Brushing teeth, mouthwash
Tampon use
Physical Examination
• The physical examination is done to identify and treat
injuries and to collect forensic evidence for prosecution.
• If the patient refuses consent for evidence collection, it is
still important to do a complete medical examination and
to document physical findings.
• This documentation may be used later as evidence.
• If the assault occurred within 72 hours, a complete
evidentiary examination should be done. If more than 72
hours have passed, a full physical examination and a
modified evidentiary examination are indicated because
there may still be value in obtaining cervical samples for
the presence of sperm.
• It is imperative to maintain patient comfort and avoid
further psychological pain throughout the examination.
Physical Examination
• The physical examination is done to identify and treat
injuries and to collect forensic evidence for prosecution.
• If the patient refuses consent for evidence collection, it is
still important to do a complete medical examination and
to document physical findings.
• This documentation may be used later as evidence.
• If the assault occurred within 72 hours, a complete
evidentiary examination should be done. If more than 72
hours have passed, a full physical examination and a
modified evidentiary examination are indicated because
there may still be value in obtaining cervical samples for
the presence of sperm.
• It is imperative to maintain patient comfort and avoid
further psychological pain throughout the examination.
Physical Examination
• It is recommended that patients remain clothed until the actual
examination begins. If possible, the victim should be
photographed in the clothing worn during the assault.
• The patient should remove her own clothing while standing on
clean paper provided in the sexual assault kit, all of which
must be submitted to the crime laboratory in paper bags.
• If she needs assistance to remove her clothing, gloves should
be worn by medical personnel. Approximately 80% of the
population secrete ABO blood group antigens in their other
body fluids including perspiration, saliva, semen, and vaginal
fluid.
• Gloves prevent cross-contamination from any perspiration on
the hands of medical personnel to the clothes of the victim.
• Next, a thorough head-to-toe scan of the victim should be performed to
look for any signs of injury or foreign material.
• Nongenital injuries occur between 20% and 50% of the time in sexual
assaults, more than 80% of these are minor abrasions or contusions.
• The most common areas of injury are the head, neck, and upper
extremities.
• Samples of any foreign material should be gathered on clean paper and
properly placed in collection envelopes.
• Dried stains (possibly secretions or semen from the assailant) should be
collected using water-moistened swabs and the swabs air dried for 60
minutes before placement in collection envelopes.
• Visual examination can be aided by using long-wave ultraviolet light
(Wood’s lamp) in a darkened room.
• Most semen stains will fluoresce under ultravioletlight, but fluorescent
stains are not specific to seminal fluid and can be caused by many
substances including urine.
• Rope marks, recent contusions, and other subtle injuries may also be more
visible with the aid of a Wood’s lamp.
• The pelvic examination should be performed with the
patient in the lithotomy position.
• A Wood’s lamp may be used again to examine the inner
thighs and perineum.
• The condition of the hymen and any signs of trauma to the
introitus should be documented.
• Evaluations of women without prior sexual experience
have revealed significantly more sites of genital injury than
those with prior experience.
• The posterior commissure is a common site of injury with
forced penetration in both groups.
• Lower vaginal lacerations are most common in virgin
women.
• If a tampon is in place, it should be removed, air dried for
60 minutes, and saved in a paper bag or collection
envelope because it may contain seminal fluid, blood, or
other foreign substances.
• To avoid the loss of evidence from the perineal area by
voiding, wiping, or washing, an attempt should be made to
have the patient delay voiding until the examination is
completed.
• If the patient is too uncomfortable to undergo an adequate
examination before voiding, the patient can void but the
urine should be collected so that it may be analyzed for
sperm.
• Also save any tissue used for wiping so that it may be
submitted and analyzed with the other evidence.
• Any visible bite marks should be photographed
and then swabbed using only distilled water for
moistening.
• If indicated by the history or examination,
fingernail scrapings should be collected at this
time.
• Saliva samples can be obtained while examining
the oral cavity for injuries. Swabs of the mouth
may be indicated for seminal fluid up to 6 hours
after assault.
• A nonlubricated speculum moistened only with water
should be used for the vaginal examination because
lubricants interfere with specimen drying and analysis.
• The vaginal walls should be examined for lacerations and
any evidence of foreign body penetration.
• More subtle signs of recent sexual activity include
erythema of the posterior fourchette and superficial
abrasions of the vagina.
• After the visual examination, vaginal secretions must be
aspirated or collected on swabs from the posterior fornix.
• If no secretions are seen, normal saline can be instilled and
then aspirated to help collect any seminal fluid.
• This fluid can then be examined for sperm, acid phosphatase,
and ABO blood group antigens.
• Depending on local protocol, a wet mount slide may be studied
for motile sperm; however, it is preferable to have this
performed by forensic specialists rather than the clinician to
improve diagnostic accuracy.
• Failure to demonstrate sperm does not exclude the possibility
of sexual assault.
• The absence of sperm may be due to several factors, including
poor evidence collection or examination skills, condom use,
and a vasectomy or sexual dysfunction in the assailant.
• It is unnecessary to obtain samples from the cervix unless the
assault occurred more than 24 hours from the time the patient
is examined in the ED.
• A standard bimanual pelvic examination should follow to evaluate uterine
size, adnexal tenderness, or masses.
• The rectal area must also be carefully examined. Any signs of trauma to the
buttocks, perianal skin, and anal folds should be documented.
• Semen stains, lubricant, or other foreign material are scanned for and
samples collected as indicated. If the patient reports anal penetration during
the attack, rectal swabs should also be obtained.
• The swabs must be collected by a method that does not allow
contamination with any material present on the perianal area.
• This is best accomplished by swabbing through a nonlubricated anal
speculum moistened with water.
• The swabs may be analyzed for the presence of sperm and acid
phosphatase.
• An alternative method is to instill 5 to 10 ml of normal saline into the
rectum, allow it to equilibrate for 5 minutes, and then aspirate.
• A proctoscopic examination is recommended when significant rectal
trauma is suspected.
Psychological Effects of Sexual
Assault
• The rape trauma syndrome is a two-phase
syndrome of behavioral, somatic, and
psychological reactions that occur as a
result of being exposed to an act of
violence, in this case sexual assault.
• Many symptoms of the rape trauma
syndrome also fit the diagnostic criteria for
posttraumatic stress disorder.
•
•
•
•
•
•
•
Psychological Effects of Sexual
TheAssault
acute phase, which is one of disorganization, begins
immediately and may last for several months.
In this phase patients may initially react in either an expressive
or a controlled manner.
Expressive patients may demonstrate feelings of fear, anger,
and anxiety through such behavior as crying, tenseness, or
restlessness.
In the controlled style, the patient masks her feelings and
appears calm and composed.
During the acute phase it is essential that the victim be
accepted, believed, understood, and made to feel safe, while
regaining a sense of control over her life.
Victims in this phase may demonstrate a wide range of
emotions from humiliation and self-blame to anger and
revenge.
Psychosomatic reactions commonly occur in this phase as
well.
Psychological Effects of Sexual
Assault
• The long-term reorganizational phase begins in approximately 2 to 3
weeks and may last indefinitely.
• It is the phase in which victims develop coping mechanisms and
eventual recovery.
• Many victims attempt lifestyle changes by altering daily routines,
residences, or telephone numbers, and some turn to alcohol or drugs.
• Nightmares and phobias commonly occur, and sexual dysfunction,
which may become chronic, is common.
• It is reported that 50% to 80% of women who have been raped lose
their husbands or boyfriends after the assault.
• Because family members are also victimized by the assault, they
may experience some of the same psychological effects as the
patient.
• Appropriate referrals for support services should be given to them as
well.
Menopause
Akmal Abbasi
Definition
• Menopause is the transition period in a
woman's life when the ovaries stop
producing eggs, the body decreases the
production of the female hormones estrogen
and progesterone, and menstrual activity
diminishes and eventually ceases.
Causes, incidence, and risk
factors
• Menopause is a natural event which normally
occurs between the ages of 45 and 55, beginning,
on average, at age 51.
• During menopause, ovulation (egg production)
stops and menstruation becomes less frequent,
eventually stopping altogether.
• The symptoms of menopause are caused by
changes in estrogen and progesterone levels.
• As the ovaries become less functional, they
produce less of these hormones and the body
responds accordingly.
Causes, incidence, and risk
factors
• In some women, menstrual flow comes to a
sudden halt.
• More commonly, however, it tapers off, both in
amount and duration of flow.
• During this time, often called perimenopause,
menstrual periods generally become either more
closely or more widely spaced.
• This irregularity may last for 1 to 3 years before
menstruation finally ends completely.
Symptoms
• The potential symptoms of menopause, which can
last from 1 to 3 years, include:
• Hot flashes and skin flushing
• Night sweats
• Insomnia
• Mood changes including frequent swings of
irritability, depression, and anxiety
• Irregular menstrual periods
• Spotting of blood in between periods
Symptoms
•
•
•
•
•
Vaginal dryness and painful sexual intercourse
Decreased sex drive
Vaginal infections
Urinary tract infections
In addition, the long-term risks of menopause
include:
• Bone loss and eventual osteoporosis
• Changes in cholesterol levels and heart disease
Signs and tests
• Blood and urine tests can be used to measure
hormone levels that may indicate when a woman
is close to menopause or has already gone through
menopause, for e.g.
• Estradiol
• FSH, LH
• A Pap smear may indicate changes in the vaginal
lining caused by changes in estrogen levels.
• A bone density test may be performed to screen
for low bone density levels seen with osteoporosis.
Treatment
• Menopause is a natural process. It does not
necessarily require treatment unless menopausal
symptoms, such as hot flashes or vaginal dryness,
are particularly bothersome.
• HORMONE REPLACEMENT THERAPY
• For years, hormone replacement therapy (HRT)
was the main treatment for menopause symptoms.
• Many physicians believed that HRT was not only
the best treatment available for reducing
menopausal symptoms, but also reduced the risk
of heart disease and bone fractures from
osteoporosis.
Treatment
• However, the results of a major study -- called the
Women's Health Initiative (WHI) -- has led
physicians to revise their recommendations
regarding HRT.
• In fact, one part of this important study was
stopped early because the health risks outweighed
the health benefits for women taking both estrogen
and progesterone.
• Women taking both of these hormones did see
benefit as far as their bones were concerned.
Treatment
• However, they greatly increased their risk for
breast cancer, heart attacks, strokes, and blood
clots.
• If the symptoms are severe, may still want to
consider HRT for short-term use (two to four
years) to reduce vaginal dryness, hot flashes, and
other symptoms.
• To reduce the risks of estrogen replacement
therapy and still gain the benefits of the treatment,
may use estrogen/progesterone regimens that do
not contain the form of progesterone used in this
arm of the study.
Treatment
• Using a lower dose of estrogen or a different
estrogen preparation (for instance, a vaginal cream
rather than a pill).
• There are also some medications available to help
with mood swings, hot flashes and other
symptoms. These include low doses of
antidepressants such as paroxetine (Paxil),
venlafaxine (Effexor) and fluoxetine (Prozac), or
clonidine, which normally used to control high
blood pressure.
Prevention
• Menopause is a natural and expected part of a
woman's development and does not need to be
prevented. However, there are ways to reduce or
eliminate some of the symptoms that accompany
menopause.
• NO SMOKING.
• Exercise regularly, including activity against the
resistance of gravity, to strengthen your bones.
• Low-fat diet, calcium and vitamin D.
• Control blood pressure, cholesterol, and other risk
factors for heart disease.