Physical Examination

The equipment necessary for the examination of the female genitalia and rectum consists of a vaginal speculum, lubricant, cervical scrapers, cotton-tipped applicators, gloves, glass slides, occult blood testing card and Hemoccult developer, culture media (as appropriate), fixative, tissues, and a light source.

General Considerations

Unlike most other parts of the physical examination, the pelvic examination is often viewed with apprehension by the patient. This is frequently related to a previous bad experience. An examination performed slowly and gently with adequate explanations goes a long way in developing a good doctor-patient relationship. Communication is the key to a successful pelvic examination. The examiner should talk to the patient and tell her exactly what is going to be done. Eye contact is also necessary to decrease the patient's anxiety. The patient's ability to relax enables a more accurate and less traumatic examination.

*In general, fallopian tubal patency or ovulation problems.

{Vas deferens obstruction, varicocele, chromosomal defects, testicular infection, autoimmune states, and decreased sperm count are the most important.

If the examiner is a man, he should examine the patient's genitalia in the presence of a female attendant. Although not required by law, the presence of a female attendant is important for assistance, as well as for medicolegal considerations, especially when the patient appears overly upset or seductive. At times, the patient may request that a family member be present. The examiner should grant such a request if no other attendant is available.

Throughout the world, various patient positions are preferred to facilitate the pelvic examination. These include the woman's lying on her back on an examining table, lying in bed on her left side, lying on her back in bed with her legs abducted, and sitting upright in a chair with her legs abducted. In the United States, the woman usually lies on her back on an examination table with her feet in heel rests. This position can be uncomfortable and demeaning.

Preparation for the Examination

The patient should be instructed to empty her bladder and bowels before the examination. The patient is assisted onto an examination table with her buttocks placed near its edge. The heel rests of the table are extended, and the patient is instructed to place her heels in them. If possible, some cloth should be placed over the rests. Alternatively, the patient can be given plastic foam booties to protect her feet from cold metal heel rests. Shortening the heel rest brackets helps the woman bend her knees to lower the position of the cervix. An older patient with osteoarthritis may need the heel rests to be longer because she may have limited hip and knee motion. Offer the patient a mirror that she can use to observe the examination.

The head of the examination table should be elevated so that eye contact between the physician and the patient can occur. A sheet is usually draped over the lower abdomen and knees of the patient. Some patients prefer not to have the sheet used. The patient should be asked her preference.

The knees are drawn up sufficiently to relax the abdominal muscles as the thighs are abducted. Ask the patient to let her legs relax to the sides or to drop her knees to each side. Never tell a patient to ''spread her legs.''

Gloves should be worn for the examination of the female genitalia. The examiner should be seated on a stool between the legs of the patient. Good lighting, including a light source directed into the vagina, is essential.

The examination of the female genitalia consists of the following:

Inspection and palpation of external genitalia Examination with speculum Bimanual palpation Rectovaginal palpation

Inspection and Palpation of External Genitalia

Inspect the External Genitalia and Hair

To make the woman more comfortable during inspection of the external genitalia, it is often useful to touch the patient. Tell the patient that you are going to touch her leg. Use the back of your hand.

The external genitalia should be inspected carefully. The mons veneris is inspected for lesions and swelling. The hair is inspected for its pattern and for pubic lice and nits. The skin of the vulva is inspected for redness, excoriation, masses, leukoplakia, and changes in pigmentation. Lesions should be palpated for tenderness.

Lichen sclerosus, previously known as kraurosis vulvae, is a relatively common condition in which the genital skin shows a uniform reddened, smooth, shiny, almost transparent appearance. It is a destructive inflammatory condition with a predilection for genital skin. It is much more common in women, although it can be seen in men with involvement of the glans penis and foreskin. Whitish atrophic patches of thin skin are typical, as is fine crinkling of the skin. Pruritus is a common symptom, and the fragile skin is susceptible to secondary infection. Although most common in white and Latino postmenopausal women, lichen sclerosus may be seen in patients of all ages. It is rare in African-American women. Lichen sclerosus should be thought of as a premalignant lesion because one complication is the development of squamous cell carcinoma. Figure 19-9 shows an early stage of lichen sclerosus in a female patient. Notice the resorption of the labia minora;the clitoris is preserved. Figure 19-10 shows a later stage in

Labial Resorption
Figure 19-9 Lichen sclerosus, early stage.

Figure 19-10 Lichen sclerosus, later stage. Note the classic whitish crinkling of the skin and resorption of the labia and clitoris.

another patient. Notice the classic whitish crinkling of the skin and the resorption of the labia and clitoris. Figure 19-11 shows vulvar squamous cell carcinoma with the background of lichen sclerosus in another patient.

Inspect the Labia

Tell the patient that you are now going to touch and spread the labia, as demonstrated in Figure 19-12. Inspect the vaginal introitus.

The labia minora may show wide variation in size and shape;they may be asymmetric. On occasion, yellowish-white, asymptomatic papules may be seen over the inner labia minora. These are called Fordyce's spots and are normal;they represent ectopic sebaceous glands. Figure 19-13 shows Fordyce's spots. Ectopic sebaceous glands are also common in the mouth (see Fig. 12-18) and on the shaft of the penis (see Fig. 18-11).

Inflammatory lesions, ulceration, discharge, scarring, warts, trauma, swelling, atrophic changes, and masses are noted. Figures 19-14 and 19-15 show condylomata acuminata of the labia.

Inspect the Clitoris

Inspect the clitoris for size and lesions. The clitoris is normally 3 to 4 mm in size. Inspect the Urethral Meatus

Is pus or inflammation present? If pus is present, determine its source. Dip a cotton-tipped applicator into the discharge, and spread the sample on a microscope slide for later evaluation. Are any masses present?

White Patch Mons Pubis
Figure 19-13 Fordyce's spots of the labia.

Figure 19-14 Condylomata acuminata.

Caruncle Urethral

A urethral caruncle is a small benign tumor at the urethral orifice and is relatively common in postmenopausal women. It appears as a bright red or flesh-colored mass extending through the urethral orifice. It may be asymptomatic or may cause pain or bleeding. Urethral caruncles must be differentiated from other tumors by biopsy.

Inspect the Area of Bartholin's Glands

Tell the patient that you are going to palpate the glands of the labia. With a moistened glove, palpate the area of the right gland (at the 7 to 8 o'clock position) by grasping the posterior portion of the right labia between your right index finger in the vagina and your right thumb on the outside, as demonstrated in Figure 19-16. Is any tenderness, swelling, or pus present? Normally, Bartholin's glands can be neither seen nor felt. Use your left hand to examine the area of the left gland (at the 4 to 5 o'clock position).

Figure 19-17 shows an abscess in the left Bartholin's gland.

Vaginal Palpation
Figure 19-16 Technique for palpation of Bartholin's glands.

Figure 19-17 Bartholin's gland abscess.

Inspect the Perineum

The perineum and anus are inspected for masses, scars, fissures, and fistulas. Is the perineal skin reddened? The anus should be inspected for hemorrhoids, irritation, and fissures.

Test for Pelvic Relaxation

While you gently separate the labia widely and depress the perineum, ask the patient to bear down or cough. If vaginal relaxation is present, ballooning of the anterior or posterior walls may be seen. Bulging of the anterior wall is associated with a cystocele;bulging of the posterior wall is indicative of a rectocele. If stress incontinence is present, the coughing or bearing down may trigger a spurt of urine from the urethral orifice.

Examination with Speculum Preparation

The speculum examination entails inspecting the vagina and cervix. There are several types of specula. The metal Cusco, or bivalve, speculum is the most popular. This speculum consists of two blades or bills that are introduced closed into the vagina and are then opened by squeezing the handle mechanism. The vaginal walls are held apart by the bills, and adequate visualization of the vagina and cervix is achieved. There are basically two types of bivalve specula: Graves' and Pedersen's. Graves' speculum is more common and is used for most adult women. The bills are wider and are curved on the sides. Pedersen's speculum has narrower, flat bills and is used for women with a small introitus. The plastic, disposable bivalve speculum is becoming more common. A disadvantage to its use is the loud click made as the lower bill is disengaged during removal from the vagina. If a plastic speculum is used, the patient should be informed that this sound will occur. Check the bills to make sure that there are no rough edges.

Before using the speculum in a patient, practice opening and closing it. If the patient has never had a speculum examination, show the speculum to her. You should warm the speculum with warm water and then touch it to the dorsum of your hand to ensure that the temperature is suitable. Jelly lubricant should not be used because it may interfere with cervical cytologic determination and gonococcal cultures. Tell the patient that you are now going to perform the speculum part of the internal examination.

Technique

While the examiner's left index and middle fingers separate the labia and firmly depress the perineum, the closed speculum, held in the examiner's right hand, is introduced slowly into the introitus at an oblique angle of 45° from the vertical over the examiner's left fingers. This procedure is demonstrated in Figures 19-18 and 19-19 and is diagrammed in Figure 19-20. Do not introduce the speculum vertically, because injury to the urethra or meatus may occur.

Vagianal Exam
Figure 19-18 Technique for insertion of the vaginal speculum. Note the examiner's fingers pressing downward on the perineum.

Figure 19-19 Technique for insertion of the vaginal speculum. Note that the speculum rides over the examiner's fingers, avoiding contact with the external urethral meatus and clitoris.

Figure 19-19 Technique for insertion of the vaginal speculum. Note that the speculum rides over the examiner's fingers, avoiding contact with the external urethral meatus and clitoris.

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Responses

  • Amanuel
    Is labia minora smooth or rough?
    2 years ago
  • stefano
    How to treat white patches on vag?
    2 years ago
  • Sarama
    Why is the labia spread during examination?
    1 year ago

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