Download Chapter 18 Female Genitalia Examination of the female genitalia is

Chapter 18
Female Genitalia
Examination of the female genitalia is typically performed:
When patient has a specific complaint
As part of the newborn examination
With a sexually active adolescent
As part of an overall well woman examination
Examination of the anus and rectum (see Chapter 20) is often performed at the same time.
Physical Examination Preview
External Genitalia
Patient is in the lithotomy position.
Inspect the pubic hair characteristics and distribution.
Inspect and palpate the labia for the following:
Symmetry of color
Caking of discharge
Inflammation
Irritation or excoriation
Swelling
External Genitalia (Cont.)
Inspect the urethral meatus and vaginal opening for the following:
Discharge
Lesions or caruncles
Polyps
Fistulae
Milk the Skene glands.
Palpate the Bartholin glands.
External Genitalia (Cont.)
Inspect and palpate the perineum for the following:
Smoothness
Tenderness, inflammation
Fistulas
Lesions or growths
External Genitalia (Cont.)
Inspect for bulging and urinary incontinence as the patient bears down.
Inspect the perineal area and anus for the following:
Skin characteristics
Lesions
Fissures or excoriation
Inflammation
Internal Genitalia Speculum Examination
Insert the speculum along the path of least resistance.
Inspect the cervix for the following:
Color
Position
Size
Surface characteristics
Discharge
Size and shape of os
Internal Genitalia Speculum Examination (Cont.)
Collect necessary specimens.
Inspect vaginal walls for the following:
Color
Surface characteristics
Secretions
Bimanual Examination
Insert the index and middle fingers of one hand into the vagina and place the other hand on the
abdominal midline.
Palpate the vaginal walls for the following:
Smoothness
Tenderness
Lesions (cysts, nodules, or masses)
Bimanual Examination (Cont.)
Palpate the cervix for the following:
Size, shape, and length
Position
Mobility
Palpate the uterus for the following:
Location
Position
Size, shape, and contour
Mobility
Tenderness
Bimanual Examination (Cont.)
Palpate the ovaries for the following:
Size
Shape
Consistency
Tenderness
Palpate adnexal areas for masses and tenderness.
Rectovaginal Examination
Insert the index finger into the vagina and the middle finger into the anus.
Assess sphincter tone.
Palpate the rectovaginal septum for the following:
Thickness
Tone
Nodules
Rectovaginal Examination (Cont.)
Palpate the posterior aspect of the uterus.
Palpate the anterior and posterior rectal wall for the following:
Masses, polyps, or nodules
Strictures, other irregularities, tenderness
Note characteristics of feces when the gloved finger is removed.
Anatomy and Physiology
External Genitalia
Vulva, or external female genital organs include:
Mons pubis
Labia majora and minora
Clitoris
Vestibular glands: Skene and Bartholin ducts
Vaginal vestibule
Vaginal orifice
Urethral opening
Internal Genitalia
Vagina
Uterus
Corpus
Fundus
Body
Isthmus
Cervix
Fallopian tubes
Ovaries
Menstrual Cycle
Menstrual phase
Postmenstrual phase
Ovulation
Secretory phase
Premenstrual (luteal) phase
Bony Pelvis
Four bones
Two innominate: ilium, ischium, pubis
Sacrum
Coccyx
Four pelvic joints
Symphysis pubis
Sacrococcygeal
Two sacroiliac
Bony Pelvis (Cont.)
Two parts
Upper or false pelvis
Flared-out iliac bones
Lower or true pelvis
Lower curved bony canal
True pelvis
Inlet
Cavity
Outlet
Nullipara vs. Pregnancy
Infants and Children
Vagina is narrow.
Cervix comprises most of uterus.
Ovaries are immature.
Labia majora is hairless.
Hymen is intact.
Genitalia grow incrementally in childhood.
Adolescents
Puberty: functional maturation of reproductive organs is seen.
External genitalia increases.
Clitoris becomes erectile.
Pubic hair develops.
Vagina lengthens and secretions become acidic.
Uterus, ovaries, and tubes increase in size.
Uterine musculature and vascular supply increase.
Endometrial lining thickens.
Pregnant Women
Increased estrogen and progesterone
Enlarged elastic uterus
Softened pelvic cartilage
Strengthened pelvic ligaments
Pelvic congestion and edema
Thickened vaginal walls
Increased vaginal secretions
Older Adults
Menopause
External and internal genitalia decrease in size.
Tissue loses elasticity and tone.
Pubic hair turns gray.
Libido decreases.
Vagina narrows and loses lubrication.
Review of Related History
History of Present Illness
Abnormal bleeding
Character
Change in flow
Temporal sequence
Associated symptoms
Medications
History of Present Illness (Cont.)
Pain
Temporal sequence
Character
Associated symptoms
Association with menstrual cycle
Relationship to body functions and activities
Aggravating and relieving factors
Previous medical treatment
Efforts to treat
Medications: analgesics
History of Present Illness (Cont.)
Vaginal discharge
Character
Occurrence
Douching
Clothing habits
Presence of discharge or symptoms in sexual partner
Use of condoms
Associated symptoms
Efforts to treat
Medications: oral contraceptives, antibiotics
History of Present Illness (Cont.)
Premenstrual symptoms complaint
Symptoms
Frequency
Interference with activities of daily living (ADLs)
Relief measures
Aggravating factors
Medications: analgesics, diuretics
History of Present Illness (Cont.)
Menopausal symptoms complaint
Age at menopause or currently experiencing
Symptoms
Postmenopausal bleeding
Feelings about menopause
Mother’s experience with menopause
Birth control measures during menopause
Medications: hormone therapy, serum estrogen receptor modulators
History of Present Illness (Cont.)
Infertility
Length of time attempting pregnancy, sexual activity pattern, knowledge of fertile period
in menstrual cycle, length of cycle
Abnormalities of vagina, cervix, uterus, fallopian tubes, ovaries
Contributing factors: stress, nutrition, chemical substances
Partner factors
Diagnostic evaluation to date
History of Present Illness (Cont.)
Urinary symptoms
Dysuria
Burning on urination
Frequency
Urgency
Character
Urine description
Associated symptoms
Medications: urinary tract analgesics, antispasmodics
Past Medical History
Menstrual history
Menarche
Last menstrual period
Days in cycle
Character of flow
Dysmenorrhea
Intermenstrual bleeding or pain
Premenstrual symptoms
Past Medical History (Cont.)
Obstetric history
Gravidity
Term pregnancies
Preterm pregnancies
Abortions: spontaneous or induced
Living children
Complications of pregnancy, delivery, abortion, or with fetus or neonate
Past Medical History (Cont.)
Menopausal history
Age of menopause
Associated symptoms
Postmenopausal bleeding
Birth control during menopause
Feelings about menopause
Mother’s experience with menopause
Medications
Use of complementary and/or alternative therapies
Past Medical History (Cont.)
Gynecologic history
Prior Pap smears, human papillomavirus (HPV) testing and results
Past and recent gynecologic procedures or surgery
Sexually transmitted infections
Pelvic inflammatory disease
Vaginal infections
Diabetes
Cancer of reproductive organs
Family History
Diabetes
Cancer of reproductive organs
Mother received diethylstilbestrol (DES) while pregnant
Multiple pregnancies
Congenital anomalies
Personal and Social History
Cleansing routines
Contraceptive history
Douching history
Performance of genital self-examination
Date of last pelvic examination and Pap smear
Use of alcohol, drugs
Personal and Social History (Cont.)
Sexual history
Current sexual activity
Contraception
Barrier protection
Prior sexually transmitted infections
Satisfaction with relationship
Problems: pain on penetration (entry or deep); decreased lubrication, lack of orgasm
Infants and Children
Bleeding
Character
Associated symptoms
Parental suspicion about foreign objects
Suspicion about sexual abuse
Pain
Character
Location
Associated symptoms
Contributory problems
Infants and Children (Cont.)
Vaginal discharge
Relation to diapers
Associated symptoms
Contributory problems
Urinary symptoms
Diarrhea, fever, or nausea and vomiting
Infants and Children (Cont.)
Excessive crying that cannot be resolved by typical measures (e.g., feeding, holding)
Loss of appetite
Fever
Nausea and vomiting
Masturbation
Adolescents
Same questions as any adult female
Talk with teen in private
Should not assume that youthful age precludes sexual activity or any of the related concerns
Questions should be posed in a gentle, matter-of-fact, and nonjudgmental manner
Pregnant Women
Expected date of delivery
Obstetric history
Birth history
Previous menstrual history
Surgical history
Family history
Involuntary fluid leakage
Bleeding
Pain
Gastrointestinal symptoms
Older Adults
Menopausal history
Symptoms associated with age
Itching
Dyspareunia
Urinary problems
Sexual changes in self or partner
Desire
Behavior
Examination and Findings
Equipment
Drapes
Speculum
Gloves
Water-soluble lubricant
Lamp
Equipment (Cont.)
Specimen collection equipment such as:
Sterile cotton swabs
Glass slides
Wooden or plastic spatula
Cervical brush devices
Cytologic fixative
Culture plates or media
DNA probe kits for Chlamydia and gonorrhea, if needed
Preparation
Minimize patient apprehension
Comfortable temperature
Privacy
Empty bladder
Warm speculum
Positioning
Assist the patient into the lithotomy position on the examining table.
Help the woman stabilize her feet in the stirrups and slide her buttocks down to the edge of the
examining table.
Draping and Gloving
Drape in such a way that minimizes exposure.
Cover her knees and symphysis, depressing the drape between her knees.
Allows you to see the woman’s face (and she, yours).
Equipment is nearby and in easy reach.
Draping and Gloving
Examining lamp so that the external genitalia are clearly visible
Wash hands and put gloves on both hands
External Examination
Labia majora
Symmetry
Redness, swelling, or tenderness
Excoriation, rashes, or lesions
Discoloration
Varicosities
Stretching
Trauma or scarring
External Examination (Cont.)
Labia minora
Symmetry
Moisture
Color
Soft, homogeneous, and without tenderness
Inflammation
Excoriation
Discharge
Ulcers
External Examination (Cont.)
Clitoris
Size
Atrophy
Adhesions or inflammation
Urethral orifice
Discharge
Polyps, carbuncles, or fistulae
Irritation or inflammation
External Examination (Cont.)
Vaginal introitus
Moisture
Swelling
Discoloration
Discharge
Lesions, fistulae, or fissures
External Examination (Cont.)
Skene glands
Periurethral location
Discharge
External Examination (Cont.)
Bartholin glands
Posterolateral portion of the labia majora
Discharge
Masses
Tenderness or swelling
External Examination (Cont.)
Muscle tone
Observe for urinary incontinence or uterine prolapse.
Perineum
Tenderness
Inflammation
Fistulae
Lesions or growths
External Examination (Cont.)
Anus
Color
Scarring or skin tags
Excoriation
Fissures or lesions
Internal Examination
Cervix
Color
Position
Surface characteristics
Discharge
Size and shape
Common Appearances of the Cervix
Internal Examination: Smears and Cultures
Pap smear
Endocervical cells
Internal Examination: Smears and Cultures (Cont.)
Gonococcal culture
DNA probe
Chlamydia and gonorrhea
Wet mount
Trichomonas, bacterial vaginosis, or candidiasis
Bimanual Examination
Cervix
Size, length, and shape
Position
Consistency
Movement
Nodules
Hardness
Tenderness
Bimanual Examination (Cont.)
Uterus
Position
Size, shape, and contour
Mobility
Tenderness
Bimanual Examination (Cont.)
Ovaries
Size
Shape
Location
Consistency
Tenderness
Nodularity
Adnexa
Masses
Tenderness
Rectovaginal Examination
Anal sphincter
Tone
Rectal walls
Masses, polyps, nodules, or strictures
Irregularities
Tenderness
Rectovaginal septum
Tone and thickness
Nodules
Rectovaginal Examination (Cont.)
Uterus: confirm bimanual examination findings
Location and position
Size, shape, and contour
Consistency
Tenderness
Stool
Color
Blood
Infants
Inspect and palpate external genitalia only.
Expected swelling
Milky discharge
Enlarged clitoris
Ambiguous appearance
Adhesions between
Labia minora
Children
Inspect and palpate external genitalia.
Redness or irritation
Swelling
Discharge or bleeding
Internal examination only if evidence of:
Bleeding
Discharge
Trauma or abuse
Children (Cont.)
Sexual abuse signs: medical complaints
Evidence of general physical abuse or neglect
Evidence of trauma and/or scarring in genital, anal, and perianal areas
Unusual changes in skin color or pigmentation in genital or anal area
Presence of sexually transmitted infection
Anorectal problems such as itching, bleeding, pain, fecal incontinence, poor anal
sphincter tone
Genitourinary problems (e.g., rash or sores in genital area, vaginal odor, pain)
Children (Cont.)
Sexual abuse signs: behavioral manifestations
Problems with school
Dramatic weight changes or eating disturbances
Depression
Sleep problems or nightmares
Sudden change in personality or behavior
Aggression or destructiveness
Sudden avoidance of certain people or places
Use of sexually provocative mannerisms
Children (Cont.)
Sexual abuse signs: behavioral manifestations
Excessive masturbation or sexual behavior
Age-inappropriate sexual knowledge or experience
Repeated object insertion into vagina and/or anus
Child asking to be touched/kissed in genital area
Sex play between children with 4 years or more age difference
Sex play that involves the use of force, threats, or bribes
Adolescents
All adolescent females should have a pelvic examination within 3 years of initiating sexual
intercourse.
Pap smear with cervical cytology evaluation and sexually transmitted infection evaluation
should also be included.
Young women who are not sexually active should have their first examination by age 21 years.
Adolescents (Cont.)
Allay anxiety for what may be first examination
Same examination and positioning as for adult
Appropriate-size speculum
Maturational changes of sexual development
Just before menarche, there is a physiologic increase in vaginal secretions.
Hymen may or may not be stretched across the vaginal opening.
By menarche, the vaginal opening should be at least 1 cm wide.
Pregnant Women
Same procedure as that for the nonpregnant adult woman
Additional considerations:
Gestational age estimation
Uterine size and contour
Pelvic size estimates
Cervical dilation and length
Pregnant Women (Cont.)
Fetal assessment
Growth
Position
Well-being
Fetal heart rate (FHR)
Fetal movement (FM)
Pregnant Women (Cont.)
Fundal height
Leopold Maneuvers
Pregnant Women (Cont.)
Twin pregnancy
Pregnant Women (Cont.)
During labor
Fetal station
Station is the relationship of the presenting part to the ischial spines of the
mother’s pelvis.
Head position
Older Adults
Examination procedure for the older adult is the same as that for the adult of childbearing age.
Modifications for comfort
Inspect and palpate for age-related changes.
Labia appear flatter and smaller.
Skin is drier and shinier.
Gray and sparse pubic hair.
Clitoris is smaller.
Urinary meatus may appear as an irregular opening or slit.
Older Adults (Cont.)
Age-related changes
Vaginal introitus may be constricted.
Multiparous older women, the introitus may gape
Vagina is narrower and shorter.
Absence of rugation
Less-mobile cervix
Smaller uterus
Nonpalpable ovaries
Rectovaginal septum will feel thin, smooth, and pliable.
Diminished rectal tone
Women with Disabilities
Alternative positions for pelvic examination
Knee-chest position
Women with Disabilities (Cont.)
Alternative positions for pelvic examination
Obstetric stirrups position
M-shaped position
Women with Disabilities (Cont.)
Alternative positions for pelvic examination
V-shaped position
Women with Disabilities (Cont.)
Transfer methods to examination table
Special concerns
Spasticity
Hyperreflexia
Bowel and bladder functional alterations
Abnormalities
Abnormalities
Premenstrual syndrome (PMS)
Collection of physical, psychological, and mood symptoms related to a woman’s
menstrual cycle
Infertility
Inability to conceive over a period of 1 year of unprotected sexual intercourse
Abnormalities (Cont.)
Endometriosis
Presence and growth of endometrial tissue outside the uterus
Lesions from Sexually Transmitted Infections
Condyloma acuminatum (genital warts)
Warty lesions due to sexually transmitted infection with human papillomavirus (HPV)
Lesions from Sexually Transmitted Infections (Cont.)
Molluscum contagiosum
Viral infection of the skin and mucous membranes in the genital area
Considered an STI in adults, in contrast to the common nonsexually transmitted infection
occurring in young children
Lesions from Sexually Transmitted Infections (Cont.)
Syphilitic chancre
Skin lesion associated with primary syphilis
Lesions from Sexually Transmitted Infections (Cont.)
Condyloma latum
Lesions of secondary syphilis
Lesions from Sexually Transmitted Infections (Cont.)
Genital herpes
Most commonly caused by the herpes simplex virus 2 virus (HSV-2)
Vulva and Vagina
Inflammation of Bartholin gland
Commonly, but not always, caused by Neisseria gonorrhoeae
Vulva and Vagina (Cont.)
Vaginal cancer
Classified by the type of tissue from which the cancer arises:
Squamous cell
Adenocarcinoma
Melanoma
Sarcoma
Vulva and Vagina (Cont.)
Vulvar cancer
Classified by the type of tissue from which it arises:
Squamous cell
Adenocarcinoma
Melanoma
Basal cell
Vulva and Vagina (Cont.)
Vaginal infections
Bacterial vaginosis (Gardnerella vaginalis)
Candida vulvovaginitis (Candida albicans)
Trichomoniasis (Trichomonas vaginalis)
Vulva and Vagina (Cont.)
Vaginal infections (Cont.)
Gonorrhea (Neisseria gonorrhoeae)
Chlamydia (Chlamydia trachomatis)
Foreign body
Cervix
Cervical cancer
Two main types of cervical cancer, named for the cell type from which the cancer arises:
Squamous cell carcinoma
Adenocarcinoma
Uterus
Uterine prolapse
Descent or herniation of the uterus into or beyond the vagina
Uterus (Cont.)
Uterine bleeding
Midcycle spotting
Delayed menstruation
Frequent bleeding
Profuse menstrual bleeding
Intermenstrual or irregular bleeding
Postmenopausal bleeding
Uterus (Cont.)
Myomas (leiomyomas, fibroids)
Common, benign, uterine tumors
Endometrial cancer
Cancers of the glandular cells found in the lining of the uterus
Adnexa
Ovarian cysts
Fluid-filled sac in an ovary
Adnexa (Cont.)
Ovarian cancer
Classified by the cells from which the cancer arises
Epithelial
Stromal
Germ cell
Tubal (ectopic) pregnancy
Pregnancy occurring outside the uterus
Adnexa (Cont.)
Pelvic inflammatory disease (PID)
Infection of the uterus, fallopian tubes, and other reproductive organs
Common and serious complication of some sexually transmitted infections
Adnexa (Cont.)
Salpingitis
Inflammation or infection of the fallopian tubes
Often associated with PID
Infants and Children
Ambiguous genitalia
Newborns’ genitalia are not clearly either male or female
Infants and Children (Cont.)
Vulvovaginitis
Inflammation of the vulvar and vaginal tissues
Pregnant Women
Premature rupture of membranes (PROM)
Spontaneous PROM in a preterm pregnancy carries a high risk of:
Infant morbidity and mortality
Maternal morbidity and mortality
Cause unknown
Infection and hydramnios (excessive amniotic fluid) have been implicated.
Pregnant Women (Cont.)
Bleeding
Early pregnancy
Ectopic pregnancy
Late pregnancy
Abruptio placentae: separation of the placenta from the site of uterine
implantation before delivery of the fetus
Older Adults
Atrophic vaginitis
Inflammation of the vagina due to the thinning and shrinking of the tissues, as well as
decreased lubrication
Urinary incontinence
Stress
Urge
Overflow
Functional
Question 1
The Fundus flexing easily on the cervix is called:
A. Goodell sign
B. Hegar sign
C. McDonald sign
D. Chadwick sign
Question 2
During a pelvic examination for a postmenopausal woman, you would expect to assess:
A. A wider and longer vaginal vault
B. Absence of vaginal wall rugation
C. A nonpalpable cervical os
D. A more mobile cervix
Question 3
An irregular interval between menstrual periods with excessive flow and duration is called:
A. Polymenorrhea
B. Menorrhagia
C. Metrorrhagia
D. Menometrorrhagia
Question 4
The female patient should ideally be in which position for the pelvic examination?
A. Fowler
B. Prone
C. Lateral-supine
D. Lithotomy
Question 5
You are completing a pelvic examination on a 38-year-old patient and note the presence of small,
white and yellow, raised, round areas on the cervix. You determine these are:
A. Nabothian cysts
B. Herpes virus
C. Squamocolumnar epithelium
D. Cervical polyps