Transcript 1. gynecological examination

GYNECOLOGICAL
EXAMINATION
Doç Dr Aslı Somunkıran İŞ
Anamnesis
 Name and identity
 Gynecologic Anamnesis anamnez
 Obstetric Anamnesis
 Sexual fonx
 Medical history
 Family history
 Complaints
Identity
 Age
 Marital status
 Duration of marriage
 Number of marriages
 Educational status-job
Gynecologic Anamnesis
 Age at Menarche (The first menstrual
period); 13±2
 Menstrual cycle anamnesis
 Cyclus length; 28±7 days
 Duration of mns flow; 2-7 days
 Amount of bld; 2-3 pads/day
 LMP
 Dysmenorrhea
 PMS
 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)
 Menorrhagia / hypermenorrhea;
abnormally heavy and/or prolonged
menstrual period at regular intervals
 End polyps
 Leiomyoma
 End hyperplasia
 Hypomenorrhea;
 Asherman Syndrome
 Genital tb
 Cryptomenorrhea
 Imperforate hymen
 Cervical stenosis
Obstetric history
 Gravida
 Parity
 Abortions;
 Induced abortions
 Miscarriages
Sexual history
 Dyspareunia
 Postcoital bleeding
 Contraception (metod; duration..)
Medical history
 Previous ops
 Diseases
 Medications
 Hirsutism
 galactorrhea
 Dysuria
 SUI, urgency
Complaints
Present complaints;
 Duration
 Location
 Relation to other organic functions (mens
flow, coitus, bowel movements....)
Do a Complete Physical
Assessment
 HEENT
 CV.. BLOOD PRESSURE
 Lungs
 Breasts
 Abdomen
 Pelvic/rectal
 Neuro
 Musculoskeletal
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.
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
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.
Correct Examining Position of
the Patient
 The Lithotomy Position/or Semi-Sitting
Lithotomy Position
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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
Correct Examining Position of the
Patient
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.
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.
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
Sequence of a Pelvic
Examination
 Separate the labia majora and inspect
the labia minora;
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Labia minora
Clitoris
Urethral orifice
Hymen
Vaginal orifice
Sequence of a Pelvic
Examination
 Note the following:
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Discharge
Inflammation
Edema
Ulceration
Lesions
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
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.
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
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
C+S.
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).
Sequence of a Pelvic
Examination
 Inspect the anus at this time, note
presence of lesions and hemorrhoids
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.
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
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
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.
Cervical inspection
Lesions/cysts:
 Nabothian cyst--endocervical retention cysts
usually secondary to cervical
infection/inflammation
 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
Cervical inspection
Discharge:
 Endocervical vs. from vaginal vault
 Physiological discharge--odorless,
colorless
 Culture any discharge.
Cervical inspection
Cervical Os:
 Nulliparous--small,
round, oval
 Parous/multiparous
--linear, irregular,
stellate
Cervical inspection
Examination/Collection Specimen
of the Cervix
 Obtain specimens
 Chlamydia culture--most prevalent STD
 GC culture--gram stain not reliable,
done for screening, must do ThayerMartin for confirmation
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
PAP Smear
PAP Smear
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
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.
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
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
Perform a Bimanual
Examination
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.
Bimanual Examination
 Palpate the vaginal walls as you insert
your fingers for tenderness, cysts,
nodules, masses or growths
 Identify the cervix, noting the following:
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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
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
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.
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
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.
Bimanual Examination
 Identify the Uterus; Note the Following
 Mobility--should be mobile in the anteropostero plane
 Deviation to the left or right is indicative of
adhesions, pelvic masses of pregnancy
 Tenderness--suggests PID process or
ruptured tubal pregnancy
 Masses.
Pelvic Exam
Bimanual Examination
 Identify Right Ovary and Masses in the
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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.
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
Bimanual Examination
 Identify Right Ovary and Masses in the
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Adnexa
Size,
Shape,
Consistency,
Mobility
Tenderness of any palpable organs or
masses
should be noted.
Bimanual Examination
 Repeat the procedure on the left side
 The normal ovary is somewhat tender
when palpated
 Withdraw Fingers from Vagina and
Change Gloves
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.
Bimanual Examination
Rectovaginal Examination
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.
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.
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
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
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.
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.
Rectovaginal Examination
 Prepare guaiac of rectal finger
 Give the patient a towel or tissues to
cleanse herself
Common Abnormalities
 Vulva
 Bartholin's cyst
 Condyloma acuminatum
Common Abnormalities
 Cervix
 Polyps
 Discharge
 Discoloration
Common Abnormalities
 Uterus--enlarged
 Pregnancy
 Fibroids
Common Abnormalities
 Adnexa
 Ectopic pregnancy
 Ovarian tumor or cyst
SUMMARY
 PELVIC EXAM
 Inspect Externally
 Palpate Skene’s Glands
 Palpate Bartholin’s Glands
 Assess Outlet
 Speculum Exam
 Bimanual Exam
 Vagina, Cervix, Uterus, Adnexa
SUMMARY
 RECTOVAGINAL EXAM
 Palpate sphincter tone
 Palpate rectal wall
 Palpate rectovaginal septum
 Palpate Uterus
 Palpate Adnexa
 Guaiac
Vaginitis Curriculum
Vaginitis Differentiation
Normal
Bacterial Vaginosis
Candidiasis
Trichomoniasis
Symptom
presentation
Odor, discharge, itch
Itch, discomfort,
dysuria, thick
discharge
Itch, discharge, 50%
asymptomatic
Vaginal discharge
Homogenous,
adherent, thin, milky
white; malodorous
“foul fishy”
Thick, clumpy, white
“cottage cheese”
Frothy, gray or yellowgreen; malodorous
Inflammation and
erythema
Cervical petechiae
“strawberry cervix”
Clear to
white
Clinical findings
Vaginal pH
3.8 - 4.2
> 4.5
Usually < 4.5
> 4.5
KOH “whiff” test
Negative
Positive
Negative
Often positive
Lacto-bacilli
Clue cells (> 20%),
no/few WBCs
Few WBCs
Motile flagellated
protozoa, many
WBCs
NaCl wet mount
KOH wet mount
Pseudohyphae or
spores if non-albicans
species
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