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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 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; Labia minora Clitoris Urethral orifice Hymen Vaginal orifice Sequence of a Pelvic Examination Note the following: 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: 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 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 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 93