Examination Vagina By Finger

Inspect the Cervix

The speculum is introduced to full depth. When it is inserted completely, the speculum is rotated to the horizontal position, with the handle now pointing downward, and is opened slowly. With the bills open, the vaginal walls and cervix can be visualized. The cervix should rest within the bills of the speculum. This is demonstrated in Figure 19-21 and diagrammed in Figure 19-22. To keep the speculum open, the set screw can be tightened. If the cervix is not immediately seen, gently turn the bills in various directions to expose the cervix. The most common reason for not visualizing the cervix is failure to insert the speculum far enough before opening it.

Dick Vagina Cross Section View
Figure 19-20 Cross-sectional view of the speculum examination.
Speculum Examination Position

Figure 19-21 Technique for inspecting the cervix. A, Opening of the speculum bills after the speculum has been fully inserted and rotated to the transverse position. B, Internal view of the cervix when the speculum is correctly inserted.

Figure 19-21 Technique for inspecting the cervix. A, Opening of the speculum bills after the speculum has been fully inserted and rotated to the transverse position. B, Internal view of the cervix when the speculum is correctly inserted.

Internal View NoseVulva Inspection

Figure 19-22 Cross-sectional view illustrating the position of the speculum during inspection of the cervix.

Figure 19-23 A normal cervix. Note the round external cervical os in a nulliparous woman.

Figure 19-23 A normal cervix. Note the round external cervical os in a nulliparous woman.

If a discharge is obscuring any part of the vaginal walls or cervix, the discharge should be removed with a cotton-tipped applicator and spread onto a glass microscope slide.

Inspect the cervix for color, discharge, erythema, erosion, ulceration, leukoplakia, scars, and masses. What is the shape of the external cervical os? A bluish discoloration of the cervix may be an indication of pregnancy or a large tumor.

A normal cervix is seen in Figure 19-23. Notice that the external cervical os is round, which is characteristic of the cervix of a woman who has never had a vaginal delivery.

Pap Smear

A Pap* smear is obtained with a wooden Ayres' cervical scraper inserted through the speculum, as demonstrated in Figure 19-24. The longer end of the scraper is inserted into the external cervical os (Fig. 19-25). The scraper is then rotated 360° while it scrapes off cells from the external cervical os. Other specimens are taken with a cotton-tipped applicator from the posterior and lateral vaginal fornices and from the endocervix.

Traditionally, the sample is smeared directly onto a glass microscope slide, fixed, and then sent to the laboratory. The average conventional slide contains 50,000 to 300,000 cells to review. For more than 50 years, all cervical cytology samples were handled this way. This method works quite well and is relatively inexpensive. However, cells smeared onto the slide are sometimes mounded up on each other, so cells at the bottom of the pile cannot be clearly seen. Excessive blood, bacteria, mucus, inflammatory cells, or yeast cells may hide the cervical cells, making review more difficult. A newer method, the liquid-based cytology, or liquid-based Pap, test, can remove most of the blood, mucus, bacteria, yeast, and pus cells in a sample and can spread the cervical cells more evenly on the slide. The cervical/endocervical sample is collected in the same conventional manner with a broom-type or Cytobrush/plastic spatula cervical sampling device. Instead of being directly placed on a slide, the sample is placed into a vial with a special preservative solution. This new method, performed with the ThinPrep or SurePath system, also prevents cells from drying out and becoming distorted.

Studies have revealed that liquid-based testing can slightly improve detection of cancers, greatly improve detection of precancerous conditions, and reduce the number of tests that need to be repeated. This method is, however, more expensive than a usual Pap smear. The liquid-based Pap test has a higher sensitivity and lower specificity than conventional Pap tests; more false-positive results are obtained with this type of Pap test. Women with positive test results must receive a full diagnostic work-up to distinguish the true-positive results from the false-positive results. According to the National Cervical Cancer Coalition, in the United States today, approximately 90% of all Pap tests are performed with the liquid-based technology. Although liquid-based Pap smears demonstrate distinct advantages in slide quality and

*Named for George N. Papanicolaou, the physician who developed this screening technique. When properly performed, the Pap test can accurately diagnose cervical carcinoma in 98% of cases and can detect 80% of cases of endometrial carcinoma.

Figure 19-24 Technique for obtaining a smear for the Papanicolaou (Pap) test.

adjunctive HPV testing, there is no consensus recommendation in favor of abandoning conventional Pap smears.

Because the Pap smear may cause the cervix to bleed slightly, advise the patient that she may have a little spotting, which is normal. Any significant bleeding, however, should be evaluated. The results of the Pap smear are usually available in 2 to 3 weeks.

Inspect the Vaginal Walls

The patient is told that the speculum will now be removed. The set screw is released with the examiner's right index finger, and the speculum is rotated back to the original oblique

Fingers Stroke Portio Vaginal

position. As the speculum is slowly withdrawn and closed, the vaginal walls are inspected for masses, lacerations, leukoplakia, and ulcerations. The walls should be smooth and nontender. A moderate amount of colorless or white mucus is usually present.

Bimanual Palpation

The bimanual examination is used to palpate the uterus and adnexa. Lower the head of the examination table to a 15° angle or flat, depending on the patient's preference. In this examination, the examiner's fingers are placed in the patient's vagina and on the abdomen, and the pelvic structures are palpated between the hands. In general, the right hand is inserted into the vagina and the left hand palpates the abdomen, but this is a matter of personal preference.


The examiner should be positioned between the patient's legs. If the examiner's right hand is to be used vaginally, the examiner places his or her right foot on a small footrest or stool. A suitable jelly lubricant is held in the left hand, and a small amount is dropped from the tube onto the examiner's gloved right index and middle fingers. The examiner should not touch the tube of lubricant to the gloves, because such touching will contaminate the lubricant. The patient is told that the internal examination will now begin.

As the bimanual examination is being performed, the examiner should observe the patient's face. Her expression will quickly reveal whether the examination is painful. The labia are spread, and the examiner's lubricated right index and middle fingers are introduced vertically into the vagina. A downward pressure toward the perineum is applied. The right fourth and fifth fingers are flexed into the palm of the hand. The right thumb is extended. The area around the clitoris should not be touched. The examiner may now rest the right elbow on his or her right knee so that undue pressure is not placed on the patient. There is no need to palpate deeply with the ''abdominal hand'' if the uterus is sufficiently elevated with the ''vaginal hand.''

The correct positions of the examiner, assistant, and patient are demonstrated in Figure 19-26.

The vaginal walls are palpated for nodules, scarring, and induration.

Once inserted into the vagina, the examiner's right (vaginal) hand is rotated 90° clockwise so that the palm is facing upward. Some clinicians prefer not to rotate the vaginal hand because this may decrease the depth of penetration. The left hand is now placed on the abdomen approximately one third of the way to the umbilicus from the pubic symphysis. The wrist of the abdominal hand should not be flexed or supinated. The vaginal hand pushes the pelvic organs up out of the pelvis and stabilizes them while they are palpated by the abdominal hand. It is the abdominal, not the vaginal, hand that performs the palpation. The technique for the bimanual examination is shown in Figure 19-27 and diagrammed in Figure 19-28.

Figure 19-26 Positions of the examiner (right), assistant (left), and patient (bottom) for the bimanual examination.

Figure 19-26 Positions of the examiner (right), assistant (left), and patient (bottom) for the bimanual examination.

Medical Exam TeenagerClito Finger ExamFrog Leg Position
Figure 19-28 Cross-sectional view of the bimanual examination through the pelvic organs. The uterus is positioned between the examining hands. Note the position of the right thumb, held away from the clitoris.

Palpate the Cervix and Uterine Body

The cervix is palpated. What is its consistency (soft, firm, nodular, friable)?

Tell the patient that she will now feel you move her cervix and uterus, but this should not be painful. The cervix can usually be moved 2 to 4 cm in any direction. The cervix is pushed backward and upward toward the abdominal hand as the abdominal hand pushes downward. Any restriction of motion or the development of pain on movement should be noted. Pushing the cervix up and back tends to tip an anteverted, anteflexed uterus forward into a position where it is more easily palpated. The uterus should then be felt between the two hands. Describe its position, size, shape, consistency, mobility, and tenderness. Determine whether the uterus is anteverted or retroverted. Is it enlarged, firm, or mobile? Are any irregularities felt? Is there any tenderness when the uterus is moved?

Palpation by the bimanual technique is possible only if the uterus is anteverted and ante-flexed, which is the most common uterine position. A retroverted uterus is directed toward the spine and is not easily felt by bimanual palpation.

Palpate the Adnexa

After the uterus has been evaluated, the right and left adnexa are palpated. If the patient has complained of pain on one side, start the examination on the other side. The right hand should move to the left lateral fornix while the left (abdominal) hand moves to the patient's left lower quadrant. The vaginal fingers lift the adnexa toward the abdominal hand, which attempts to palpate the adnexal structures. This is illustrated in Figure 19-29.

The adnexa should be explored for masses. Describe the size, shape, consistency, and mobility, as well as any tenderness, of the structures in the adnexa. The normal ovary is sensitive to pressure when squeezed. After the left side is examined, the right adnexa are palpated by moving the right (vaginal) hand to the right lateral fornix and the left (abdominal) hand to the patient's right lower quadrant.

In many women, the adnexal structures cannot be palpated. In thin women, the ovaries are frequently palpable. Adnexal tenderness or enlargement is relatively specific for a pathologic state.

After completion of the examination of the adnexa, the examining vaginal fingers move to the posterior fornix to palpate the uterosacral ligaments and the pouch of Douglas. Marked tenderness and nodularity are suggestive of endometriosis.

If the patient has borne children, the examiner should have no difficulty using the right index and middle fingers in the vagina for bimanual palpation. If the introitus is small, the examiner should introduce the right middle finger first and gently push downward toward the anus. By stretching the introitus, the right index finger can be introduced with little discomfort. If the patient is a virgin, only the right middle finger should be used.

Rectovaginal Palpation Palpate the Rectovaginal Septum

Tell the patient that you will now examine the vagina and rectum. The rectovaginal examination allows for better evaluation of the posterior portion of the pelvis and the cul-de-sac than does the bimanual examination alone. You can often reach 1 to 2 cm higher into the pelvis with the rectovaginal examination. Remove your fingers from the vagina, and change your glove. Explain to the patient that the examination will make her feel as if she were going to have a bowel movement but that she will not do so. Lubricate the gloved index and middle fingers. Inspect the anus for hemorrhoids, fissures, polyps, prolapse, or other growths. Insert the index finger back into the vagina while the middle finger is introduced into the anus. The examining right index finger is positioned as far up the posterior surface of the vagina as possible. This technique is shown in Figure 19-30 and diagrammed in Figure 19-31.

The rectovaginal septum is palpated. Is it thickened or tender? Are nodules or masses present? The right middle finger should feel for tenderness, masses, or irregularities in the rectum.

The patient is told that the internal examination is completed and that you are about to remove your fingers. When you withdraw your fingers, inspect them for discharge or blood. Offer the patient tissues to wipe off any excess lubricant.

Test Stool for Occult Blood

Any fecal material on the middle (rectal) finger should be tested with the occult blood testing card and Hemoccult developer.

Position For Finger Sex

Figure 19-29 Technique for palpating the left adnexa. A, Cross-sectional view through the pelvic organs. B, Position of the ovary and fallopian tube between the examining hands. C, Position of examiner's hands.

Figure 19-30 Technique for performing the rectovaginal examination.

Figure 19-30 Technique for performing the rectovaginal examination.

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  • Clare
    How to open the vagina with finger?
    2 years ago
  • katja
    How to do vagina examination using the fingers?
    8 months ago
  • alessandra
    How to do vaginal examination by finger?
    7 months ago
    How can we check oue vaginaby inserting fingre?
    5 months ago
  • hildifons bolger
    Can cul de sac be palpated on vaginal exam?
    4 months ago
  • Gail Abbas
    Is is normal if the cervix is not placed vertically?
    2 months ago

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