Download Undertake vulval assessment

HOW TO
Undertake
vulval
assessment
A
s there are a number of skin
conditions that can affect
the vulval area, dermatology
nurses should be able to undertake an
assessment of the vulval area and should
have a good understanding of its normal
anatomy and physiology.
Figure 1. Lighting, gloves,
modesty sheet.
Patient history
An accurate and thorough history is
essential to any patient assessment. It
is important that the initial dialogue
takes place in a sympathetic and relaxed
atmosphere, as creating a good rapport
is fundamental to the consultation (Lewis,
Neill, 2009). The aim of the assessment
is to plan appropriate care by obtaining
the relevant physical, medical and
psychological information. The effect of
the condition and how any treatments
prescribed may impact on sexual function
should also be considered (Jolley, 2002).
Areas covered during history taking
should include:
!"Presenting complaint, duration,
initiating/provoking/alleviating factors
!"General medical history, including
medication, allergies, previous
treatments both prescribed and
OTC (over the counter), other skin
conditions
!"Physical/psychosocial/relationship/
sexual function impact.
Patient privacy
The examination should always take place
in a private room that cannot be entered
while the examination is in progress. The
privacy and dignity of the patient should
Diane Hamdy is Dermatology Specialist
Nurse, Surrey Community Health,
East Locality
56
Figure 2. Ensure adequate
lighting and gloves.
Figure 3. Ensure patient
positioned correctly on her
back in the dorsal position,
with the thighs abducted
and knees flexed.
be maintained at all times, with a modesty
sheet or clothing used to cover the
abdomen and thighs.
Units will have their own local policy
regarding chaperoning, however the
following points need to be considered.
The Royal College of Obstetricians
and Gynaecologists (RCOG, 2002)
recommends that it is good practice
for a woman to have someone with
her during physical examination. This
may be another healthcare professional,
or a companion of the woman, or
both. Nurses should consider being
accompanied by a chaperone when
undertaking an individual examination or
procedure. This is to reassure the patient,
avoid misunderstanding and, in rare cases,
protect against allegations of improper
behaviour (Royal College of Nursing
(RCN), 2009). The patient’s personal
preference should be documented in
their clinical records. If they prefer to
undergo a consultation, examination
or procedure without the presence of
a chaperone, their decision should be
respected and documented (RCN, 2009).
Dermatological Nursing, 2010, Vol 9, No 1
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HOW TO
Mons Pubis — Prominent pad of subcutaneous fat covered with hair-bearing skin and
overlying the bony symphisis pubis.
Labia Majora — Large outer lips laterally bounded by and merging with the inguinal gluteal
folds. Contain sweat and sebaceous glands.
Labia Minora — Anteriorly divide to fuse beneath clitoris, forming the frenulum and above
the clitoris as the prepuce. These are the thin, inner lips of the vulva, made of loose connective
tissue.
Clitoris — Highly sensitive erectile tissue analogous with penile tissue. Connected to the pubic
bone and covered by a small hood (prepuce). It is packed with thousands of nerve fibres and is
vital for sexual arousal.
Urethra — External opening for passage of urine. May appear as star-shaped or slit-like (Lewis,
Neill, 2009, Wilkinson, Stone, 2008, Bikoo, 2007).
Openings of paraurethral (Skene) ducts
Vestibule of vagina
Vaginal opening
Hymenal caruncle
Opening of greater vestibular (Bartholin) gland
Vestibular (navicular) fossa
Anus
Vestibule and Hymen — Inner area around vaginal opening. Extends anteroposteriorly from frenulum of clitoris to fourchette. Contains the
urethra, minor vestibular glands and Bartholin’s gland duct openings. The hymen surrounds the edge of the vestibule; when ruptured leaves
irregular edge — the hymenal curunculae.
Major Vestibular Glands -—The mucous secreting Bartholin’s Glands may be visible with the naked eye on either side of the lateral part of
the vestibule. The Skene’s Glands open onto the vestibule either side of the urethral opening.
Perineum — lies between the posterior fourcette and the anal orifice and is smooth and hairless (Ridley et al, 2000).
During examination of a woman with
particular religious or cultural needs,
practitioners should be aware of, and
sensitive to, factors that may make the
examination more difficult.
Consent
Full explanation should be given and
verbal consent obtained. The patient must
have understood what examination is to
be undertaken, and why, for consent to
be valid (Department of Health (DH),
2009).
The examination: positioning the patient
The patient should be positioned on
her back in the dorsal position, with
the thighs abducted and knees flexed.
Inspection of the perianal area can then
be undertaken with the patient in the
left lateral position.
During simple visual inspection,
the vulva, the mons pubis, labia majora,
perineum and anus will be seen.
More detailed examination of the
vulva requires separation of the labia
majora and minora. Inspection of the
interlabial and inguinal folds need to
be included.
Good lighting is essential and, if possible,
a means of magnification. Clean, but non
sterile gloves should be worn (Lewis,
Neill, 2009).
By examining the vulva in a
methodical way, assessment can
determine if there are any abnormalities
(Ridley et al, 2000).
Normal anatomy — structures and functions
of the vulva
Situated within the perineum, a muscle
forming part of the pelvic floor, the
vulva includes all the external female
genitalia. The main functions of the vulva
can be considered as protection for
the sexual organs and urinary opening
from trauma and infection. It is vital
for sexual response, with the clitoris
being the main organ of sexual arousal
and orgasm in most women. The vulva
and the perineum can also stretch to
accommodate childbirth.
For further information on
dermatological conditions of the
vulva, please refer to Sherley-Dale,
Humphreys (2008) Dermatological
aspects of female genitalia. Dermatol
Nurs 7(4:) 10-16. DN
References
Bikoo M (2007) Female Genital Mutilation:
classification and management. Nurs Stand
22(7): 43-49
Department of Health (2009) Reference guide
to consent for examination or Treatment,
2nd ed. Produced by COI for the DoH. www.
dh.gov.uk/publications
Jolley S (2002) Taking a sexual history: the
role of the nurse. Nurs Times 98(18): 39
Lewis F, Neill S (2009) Ridley’s The Vulva,
3rd ed. Blackwell, Chichester
Ridley C, Robinson A, Oriel J (2000) Vulval
Disease: A practical guide to diagnosis and
management. Arnold, London
Royal College of Obstetricians and
Gynaecologists (2002) Gynaecological
Examinations: guidelines for specialist
practice. RCOG Press http://www.rcog.
org.uk/files/rcog-corp/uploaded-files/
WPRGynaeExams2002.pdf. Accessed
23.11.09
Royal College of Nursing (2009)
Chaperoning http://www.rcn.org.uk/support/
rcn_direct_online_advice/professional_issues/
chaperoning/should_a_nurse_have_a_
chaperone_when_undertaking_intimate_
examinations_and_procedures?SQ_
ACTION=login& Accessed 22.11.09
Wilkinson E, Stone K (2008) Atlas of Vulvar
Disease 2nd edn. Lippincott,Williams and
Wilkins. Philadelphia
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