Superior view Front view

• General examination • Gynecological examination

• Vital signs

• Abdominal examination

• Pelvic examination

• Position

• Technique

Vital signs

• Height, weight and blood pressure examination • Skin color, edema, examination of chest, auscultation of lung and heart

Abdominal examination

• Inspection • Palpation • Percussion

Position

• Dorsal Position • Lateral Position • Lithotomy Position

Technique

• Inspection of external genitalia • Visualization of and with speculum • Bimanual examination of the and the adnexa

• A routine procedure to assess the well-being of the female patients' - a part of a health checkup - for gynecological disease screening • During the exam, a health care provider or a gynecologist checks the reproductive organs (Q1:?) Answer: Including the , vagina, cervix, uterus, , and fallopian tubes by inspection and by palpation Q2: Adnexa of uterus () refers to ?

Who and When • Routine checkup every year for a healthy woman with sexual activities • Heavy that itches, burns or smells • Heavy or bleeding between periods • (Painful intercourse) • (menstrual cramps) or abdominal pain • Any symptoms or signs associated with abortion or pregnancy • Side-effects of birth control (contraception) • No menarche by age 16 • Others If the patient is a virgin, DOS and DON’TS

• If the patient is a virgin, the virginal examination should be avoided, and perform rectal examination instead • If the examiner is male, a female companion should be present.

• Explaining to the patient every procedure that she will go through • Empty her bladder before the exam, exclude urinary incontinence • Lithotomy Position • Your hands and the speculum should be warm • Perform slowly and gently • Observe her facial expression for signs of discomfort, and ask her if she feels any discomfort

Lithotomy position Always bear in mind: Empathy and Privacy

•Lie on their back with the legs widely open, feet on stirrups •Adequate gowning and draping with a sheet the patient should be as relaxed as possible

Pelvic examination

n Inspection and palpation of the external genitalia n Speculum examination n Bimanual examination & Rectovaginal examination

Step by step!

Step I Inspection & Palpation of External Genitalia

Inspection & Palpation of External Genitalia Note quantity and distribution of hair growth • and pubis hair - Hair pattern (feminine or masculine) Skin - Redness, excoriation, discoloration, ulceration, warts, scars

Inspection & Palpation of External Genitalia

• – Size and shape ( < 2.5cm in length) – Enlarged clitoris in masculinizing conditions, Like Congenital Adrenal Hyperplasia • – Development , symmetry, tenderness. • Urethral meatus –Purulent discharge, cyst. • Bartholin’s glands –Usually impalpable, abscess or cyst • Introitus – (intact, imperforate, open) • Perineal body –Scars, fissures, and fistulas • Sign of prolapse – , , , obvious when undertaking valsalva maneuver. • Anus is inspected for hemorrhoids, sphincter injury, warts, etc.

Palpation

Check Skene's glands (periurethral glands)

• Note any discharge from or about the urethral orifice. • Insert your index finger into the vagina and press the gently from the inside outward. • If present (e.g. from gonorrhea) , a Gram stain and culture should be taken.

Palpation Check vestibular glands (Bartholin's glands) - Swelling - Tenderness - Discharge Gram stain and culture • At about 4 and 8 o'clock of the introitus between the labia minus and the hymen • Insert your index finger into the vagina near the posterior end of the introitus. • Place your thumb outside the posterior part of the . • On each side in turn palpate between your finger and thumb for swelling or tenderness.

Inspection

Sign of prolapse

bulge bulge

Cystocele Rectocele

Inspection Prolapse of uterus

Summary for step I

Inspection & Palpation of External Genitalia • Mons pubis & hair – mons for lesions & swelling. Hair for pattern, lice. Vulva for redness, excoriation, masses, , and pigmentation, lesions for tenderness. • Labia – shape, development , symmetry, tenderness. • Clitoris – size and shape • Urethral meatus – pus, inflammation, cyst. • Bartholin’s glands – abscess or cyst • Perineal body –scars, fissures, and fistulas, perineal skin reddening. • Sign of prolapse – cystocele, rectocele, prolapse of uterus

Step II Speculum examination

Speculum examination

Choose the appropriate speculum

Graves Pederson

Graves- are best for sexually active woman Pederson- are narrow-bladed, best for an elderly woman.

Speculum examination

• Place two fingers at the introitus and separate the labia to facilitate the entrance. • With your other hand introduce the closed speculum over your fingers at a 45-degree angle downward

Speculum examination

• The blades should be held obliquely and the pressure exerted toward the posterior vaginal wall in order to avoid the more sensitive vestibule and urethra. • Be careful not to pull on the pubic hair or to pinch the labia with two blades.

Speculum examination

• After the speculum has entered the vagina, remove your fingers from the introitus. • Rotate the blades of the speculum into a horizontal position as it goes deeper, maintaining the pressure posteriorly.

Speculum examination

• Open the blades after full insertion and expose the whole. • Secure the speculum with the blades open by tightening the thumb screw

Speculum examination

Vaginal inspection

Inspect the vaginal walls – inflammation, masses, lacerations, leukoplakia & ulcerations.

Ask the patient whether she has vaginal or vulvar itching, burning, and soreness.

Discharge sent for lab test – inspect the change in color, consistency or odor of discharge.

Speculum examination:

Yellow, green, frothy Thin, gray, fishy smell White, curdy, "cottage cheese"

Trichomonads Clue cell Budding yeast with pseudohyphae

Speculum examination

Cervix inspection

- Shape, color, ulceration, nodules, masses, polyps, bleeding or abnomal discharge

Speculum examination • Transformation zone: Single-layered columnar epithelium replaced by stratified squamous epithelium.

Nabothian cyst

Speculum examination

Papanicolaou smear, PAP smear (cervical scrape) • A screening test for cervical cancer • Low sensitivity and high specificiy

Liquid-based cytology test Thinprep® cytology test (TCT) • Broom • Can be coupled with HPV test for the same specimen

PAP smear

Results are reported according to the Bethesda system.

Ø Negative for Intraepithelial Lesion or Malignancy （NILM） Ø Epithelial Cell Abnormality Ø Squamous cell

l Atypical squamous cells (ASC)

lLow-grade squamous intraepithelial lesions (LSIL)

lHigh-grade squamous intraepithelial lesions (HSIL)

lSquamous cell carcinoma Ø Glandular cell

lAtypical glandular cells (AGC)

lTypical glandular cells, favor neoplastic

lEndocervical adenocarcinoma in situ (AIS)

lAdenocarcinoma

Summary for step II

Examination

Inspect the vaginal walls – masses, lacerations, leukoplakia, & ulcerations.

Discharge lab test –

Inspect the cervix – shape, color, discharge, erythema, erosion, ulceration, leukoplakia, scars, & masses.

Cytology test– cervical cancer

Release the thumb screw and maintain the blades open to let go the cervix first, then withdraw the speculum slowly while observing the lower vaginal wall. Close the blades as the speculum emerges from the introitus, to avoid both excessive stretching and pinching of the mucosa.

Step III

Bimanual examination & Rectovaginal examination

Bimanual examination

• Vaginal wall Elasticity, tenderness • Cervix Position, shape, size, consistency, mobility and tenderness • Uterus Size, shape, position, mobility, tenderness, consistency

Bimanual examination

1. Introduce the index and middle finger of your gloved and lubricated hand into the , exerting pressure posteriorly. 2. With your thumb abducted, your ring and little fingers flexed into your palm. Note any nodularity or tenderness in the vaginal wall. 3. Place your abdominal hand about midway between the umbilicus and symphysis pubis and press downward toward the pelvic hand.

Bimanual examination

4. Your pelvic hand should be kept in a straight line with the vaginal axis and go deeper to elevate the cervix in anterior cephalic direction. 5. Identify the , noting its position, shape, size, consistency, mobility and tenderness. Palpate the fornix around the cervix. Note that during pregnancy, the cervix will be softer in consistency (like palpating your lips) as compared to non-pregnancy (like the end of your nose). If the patient has pelvic inflammatory disease or , moving the cervix will cause .

Bimanual examination

6.Identify the uterus between your hands and its size, shape, consistency, mobility, tenderness and any masses. 7.This procedure may cause some discomfort for the patient. Uterine enlargement suggests pregnancy, or benign or malignant tumors.

Anteversion, mid-plane, retroversion Anteversion and antereflexion

Adnexa •Size •Shape •Mobility •Tenderness •Masses

1. Place your abdominal hand on the right lower quadrant, your pelvic hand in the right lateral fornix. 2. Press your abdominal hand downward, and using your pelvic hand for palpation, identify the right and any masses in the adnexa. 3. Three to five years after menopause, the ovaries have usually atrophied and are no longer palpable. If you can feel an ovary in a post-menopausal woman, suspect an ovarian tumor. 4. The normal ovary is somewhat tender. Repeat the procedure on the left side.

Rectovaginal examination

Rectovaginal Septum • Consistency • Tenderness • Nodules • Masses

Rectum • Tenderness • Masses • Blood in stool

Summary for step III

Bimanual Palpation Palpate cervix & uterine – cervix (consistency, mobility, pain), uterus (position, size, shape, consistency, mobility, tenderness). Palpate the adnexa – masses, size, shape, consistency, mobility, & tenderness. Also inspect the pouch of Douglas (uterosacral at the posterior fornix) for tenderness and nodules (possible endometriosis).

Rectovaginal Palpation Palpate the rectovaginal septum – rectovaginal septum for consistency, tenderness, nodules, masses. Rectum (with middle finger) for tenderness, masses. Test stool for occult blood – blood in stool.