8/3/2014 Describe at least two techniques for performing pelvic examination with a patient who has Jacki Witt, JD, MSN, WHNP-BC, SANE-A, FAANP experienced sexual assault/abuse Caroline Hewitt, DNS, RN, NP Practice at least two new pelvic examination techniques with a standardized patient Select appropriate screening and diagnostic testing for women with specific pelvic organ symptoms Jacki Witt Watson Pharmaceuticals – Honorarium – Advisory Board Agile Pharmaceuticals – Honorarium – Advisory WHO Afaxus Pharmaceuticals – Honorarium – Advisory Committee Bayer Pharmaceuticals – Honorarium – Advisory Board WHAT WHEN Caroline Hewitt WHERE Prior to February 5, 2014 disclosures: Watson Pharmaceuticals – Honorarium-Advisory Board HOW After February 5, 2014: Nothing to disclose WHY Identify the indications for a pelvic examination -Lithotomy common in US Describe at least two techniques for performing -Some patients pelvic examination with an obese patient find it disempowering, Describe at least two techniques for performing abusive & humiliating pelvic examination with a patient who has Haar, et al 1997 signs/symptoms of decreased estrogen stimulation -Patient’s have to vaginal tissues described metal Describe at least two techniques for performing stirrups as ‘cold’ pelvic examination with a & ‘hard’; say their use developmentally/cognitively disabled person is impersonal, sterile or degrading Olson 1981 1 8/3/2014 • 197 adult women having routine cervical cytology • Patients reported less discomfort and feelings of vulnerability if: PLASTIC : direct lamp connection, • Semi-reclining vs. supine transparency facilitates visualization, • No stirrup method used audible and sensible clicks distressing and • No significant differences in quality of cyto specimen considered not ‘green’ (but study not powered to definitively look at this outcome) • Routine in UK, Australia, N. Zealand Seehusen et al, BMJ, 2006. No real industry standard for size or type METAL: can be too hot or too cold, are Pedersen medium is generally 2.5 cm (1 in) considered ‘green’ and come in more sizes wide and 10 cms (4 in) long and varieties than plastic Pediatric speculae are shorter and confer an CONCUSIONS: advantage only if the cervix is < 8 cms (3 in) Choice primarily related to provider familiarity from the introitus and opinion Pedersen extra narrow is 1.5 cm (3/4 in) wide No studies comparing patient comfort and 11.5 cms (4 ¼ in) long and is useful for No analysis comparing landfill impact of plastic women with postmenopausal atrophy vs resources required to sterilize and reuse metal Bates, et al, 2011 Longest speculum is the Graves supersize • 4 RCTs XL with an 18 cm (7 inch) bill appropriate • RCT X 2 comparing water-soluble gel to for women with long vaginal vault where water alone with conventional cytology • cervix is barely reachable by examining No difference in rate of unsatisfactory cytology in any of the studies fingers • No difference in rate of unsatisfactory cytology or in Chlamydia detection rate in one study Griffith et al, Contraception, 2005; Amies et al, Obstet Gynecol, 2002 2 8/3/2014 If you can’t find it, perform bimanual 10, 241 Paps using ThinPrep over 1 year If deep in vault and barely reachable, need Spatula + cytobrush extra long speculum AND Significant uterine flexion will cause cervix to Broom + cytobrush be anterior Close partially retract slightly redirect anteriorly Extreme retroversion of uterus will cause ↓ cervix to be lodged behind symphysis pubis Exert more pressure on posterior fornix to manipulate it into view Statistical significance over broom alone in Pap Bates et al 2011 adequacy (endocervical component) Selvaggi et al 2000 281 HIV positive & 68 HIV negative women Abnormal anal cytology diagnosed in 26% of HIV+ & 8% of HIV- women Increased risk of anal disease as viral load increased & CD4 decreased History of anal intercourse & abnormal cervical cytology were statistically significantly associated with abnormal anal cytology Holly, et al 2001 Recommendations from manufacturers: Dacron cotton swab on plastic stick Broom Avoid using a cotton swab on a wooden stick, ▪ Rotate in one direction for 5 rotations (do not reverse because these often break and will splinter directions) Spatula and cytobrush ▪ Rotate spatula 360 degrees ▪ Rotate brush 180 degrees in one direction (more than 180 degrees may cause bleeding and does not improve adequacy) 3 8/3/2014 Swab is rotated and slowly withdrawn from the anal canal Make sure to sample the transition zone during removal, as this area, which separates the columnar epithelium of the rectum from the keratinizing anal squamous mucosa, is the site where most anal intraepithelial neoplasms arise Normal ovaries can range from 2-4 In women, the dorsal lithotomy position may be used cm depending on time in cycle A moistened dacron swab is inserted 5 to 6 cm without direct visualization During ovulation the ovary may be Firm lateral pressure is applied to the swab as large as 4 cm; bring patient handle back in 2 weeks to recheck if concerned or perform pelvic US Liquid cytology preferred 84 women undergoing pelvic surgery Eliminates artifact with drying and reduces With patient consent, examined under amount of fecal material and bacteria that can anesthesia by attending, resident and obscure cellular detail medical student Pelvic exam accurate compared to surgery: 70.2% Attending 64% Residents Beam and Chhieng, 2010 57.3% Students 4 8/3/2014 Sensitivity to detect adnexal masses much If right handed, right index and middle lower than sensitivity to assess uterine fingers are in vagina-place right foot up on size/countour. step of exam table, your knee is flexed Obesity reduced detection of adnexal masses Conclusions: Keep right elbow into your body Bimanual exam appears to be a limited screening test for upper genital tract abnormalities (even under the best possible circumstances – anesthesia) Push forward with your body, not with arm Uterine assessment appears to be more accurate muscles. than adnexal assessment • – Ovaries can be difficult to palpate Move your fingers to side of cervix and lift • – Ovaries detected in bimanual exam fingers high on vaginal roof to form a flat performed by Ob/Gyn under anesthesia: landing pad for the ovary • 30% in women > 55 years old Pivot your entire body toward the ovary • 51% in women < 55 years old you are palpating • 9 % in women > 200 lbs Your body, fingers, arm should be in direct alignment with the patient’s ovary Poor evidence for distinguishing benign DROP wrist down, keep fingers flat and from malignant adnexal masses: raised Abdominal fingers sweep ovaries down Pooled sensitivity: 45% from iliac crest toward your internal fingers Pooled specificity: 90% Myers, et al 2006 Internal fingers: feel ovary slide between fingers, assess size (compare with fingers’ width), nodular?, smooth?, tender? 5 8/3/2014 First exam Trauma survivor Obese women may avoid exams due Vaginismus and vulvodynia to embarrassment or fear of clinician Postmenopausal atrophy reactions or admonitions about their Post-radiation stricture weight Women with disabilities Redundant vaginal walls Morbid obesity A sensitive approach is essential Female circumcision PSYCHOLOGICAL TECHNICAL Will the table support her? Is table Education Exam table wide enough? Have assistant stand Consent Positioning Support Speculum choice to side of table to stabilize and Chaperone? Lubrication reassure her Advocate? Topical anesthetic Empowerment Finding the os The vulva may be hidden by the panniculus and a longer speculum is often necessary There is a higher risk of What has she heard? diabetes; check for fungal Previous experiences with providers? infections and intertrigo What does she expect? She has CONTROL (mirror, asking permission for next step of exam) Check skin folds carefully; she An exam done WITH her&not to her may not be able to inspect Show her PICTURES herself as well as you can 6 8/3/2014 Speculum exam: vaginal walls may have The cervix may be difficult to visualize or more relaxation and decrease visibility palpate…have her pull her knees up Use Grave’s vs Pederson speculum; may ( “cannon ball”) need more length She pulls her knees back and exposes the vaginal opening Use condom or finger cut off latex …curled up in this position may give glove to hold vaginal walls back better speculum visualization of the cervix Have her hips over the edge of the exam table. This drops her pelvis and cervix forward and makes visualization easier Use an instrument: ring forceps (closed) or tongue blade to gently push vaginal walls to the side to improve visibility Use larger/longer speculum as comfort dictates 7 8/3/2014 • An option in women with postmenopausal Place woman on covered floor in knee- vaginal atrophy chest position; kneeling behind her, insert two fingers into her vagina, the • How much? cervix will be easier to locate • – ½ gram QHS x 2 weeks • Reduces reactive cellular changes For cytology: place brush between your 2 fingers, insert into the vagina, • Not studied for ability to reduce pelvix exam feel for cervix and obtain the Pap discomfort, but shown to improe symptoms and findings of atrophic vaginitis Bachman, et al, 2008 The bimanual exam is more challenging and it may be difficult to impossible to palpate Cervix small, os closed, short cervical the uterus or ovaries neck; neck may be flat against vaginal wall Place the abdominal hand UNDER