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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 !"#!$%&'(%)'*+,--./+0122%%%!3 435465*474%%%7*87* 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 Dermatological Nursing, 2010, Vol 9, No 1 !"#!$%&'(%)'*+,--./+0122%%%!! 57 435465*474%%%7*87*