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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