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PD FINAL: Female Pelvic Exam
Terms in this set (80)
What is a pelvic exam?
A pelvic exam is a visual inspection of the external genitalia, internal inspection of the vagina and cervix and a bimanual inspection of the uterus and ovaries.
When should it be done?
Any female undergoing routine health maintenance, and any female w/ a gynecologic complaint (including children and adolescents).
This should be tailored to the specific situation.
Will it hurt?
The exam should not hurt, however it will be uncomfortable.
When should it be done?
Pap smear screening is rec at age 21.
-Birth control should be discussed at the onset of sexual activity.
-ACOG recs that W be seen between ages 13-15 to begin sexual education about the changes in her body.
How to make the pt comfortable.
-Est rapport w/ pt. Addressing fears during the hx will help in guiding the exam.
-Additionally, pts should be asked about a hx of rape or sexual violence that may make the exam more difficult.
-Always have a chaperone present at all times during the pelvic exam. Close the door and pull the drape if available.
-Additionally, draping all parts of the body that are not being examined will assist in comfort.
-Warm hands and speculum before beginning.
-Explain what you are going to do prior to doing it.
What does a pap smear detect?
-The Pap smear detects cervical cytology and may ID dysplasia which are pre-cancerous changes of the cervix.
Female Pelvic Anatomy
External Genitalia Notes
Symphysis pubis is covered by a pad of adipose tissue called mons pubis.
-in the postpubertal W is covered w/ coarse terminal hair.
Extending downward and backward are the labia majora, two folds of adipose tissue covered by skin.
-Outer surfaces are also covered w/ hair in the postpubertal female.
External Genitalia Notes cont.
Lying inside and usually hidden by the labia majora are the labia minora, two hairless, flat, reddish folds.
-meet at the anterior of the vulva, where each labium divides: the lower pair fusing to form the frenulum of the clitoris and the upper pair forming the prepuce.
The clitoris is a small bud of erectile tissue, the homolog of the penis.
Posteriorly, the labia minora meet as two ridges that fuse to form the fourchette.
Internal Genitalia Notes
The vagina is a musculomembranous tube that is transversely rugated.
-It inclines posteriorly at an angle of approximately 45 degrees w/ the vertical plane of the body.
The anterior wall of the vaginal is separated from the bladder and urethra by connective tissue called the vesicovaginal septum.
The posterior vaginal wall is separated from the rectum by the rectovaginal septum.
The upper end of the vagina is a blind vault into which the uterine cervix projects.
Internal Genitalia Notes cont.
The pocket formed around the cervix is divided into the anterior, posterior, and lateral fornices.
The uterus sits in the pelvic cavity btwn the bladder and the rectum.
-It is a muscular organ that is relatively mobile.
-The uterus may be anteverted, anteflexed, retroverted, or retroflexed.
Functions of the Vagina
The vagina has three functions:
1) carries menstrual flow from the uterus
2) serves as the terminal portion of the birth canal,
3) is the receptive organ for the penis during sex
Pelvic Exam Equipment
Specimen collection equipment
-available in a variety of sizes.
-Blades are curved w/ a space btwn the closed blades.
-Bottom blade is about ¼ inch longer than the top blade to conform to the longer posterior vaginal wall and to aid in visualization.
-Blades are as long as those of the Graves speculum but are both narrower and flatter.
Specula are available in either disposable plastic or reusable metal.
Choice of Speculum: Graves *TEST Q
Unable to visualize the cervix w/ the Pederson
Choice of Speculum: Pederson *TEST Q
*It is better to err on the side of small instead of too large.
A word on nerves...
The pt is often just as nervous as you are, and you can either increase her anxiety or help calm her by your presence.
"Act like you know what you are doing."
Use professional but not technical terminology
Avoid phrases such as "looks good", "wow", "stick in speculum", "I need a bigger speculum"
Appropriate terms: examine, inspect, place, insert, remove, normal, healthy
Help place pt's feet in the foot holders
Have her slide her buttocks down to the end of the table
-Buttocks should be slightly hanging over the edge
-If the pt is not positioned correctly, the speculum exam will be difficult
Ensure the sheet covers her abdomen to her knees
Draping and Gloving
Drape for minimal exposure
Cover knees and symphysis then depress the drape btwn her knees
-Allows for eye contact btwn you and the pt
-Keeps the thighs covered for entire exam
Arrange the exam light and equipment to be used
Wash hands and put on gloves
-Once you have touched any of the pt's genital skin, assume that your glove is "contaminated"
-Do not touch anything except the pt, the drape, and what your MA hands you after you put on gloves
Beginning the Exam
It is your job to minimize the pt's apprehension and discomfort
Explain what you are doing before you do it
Maintain eye contact and sit down
Ask the woman to separate or relax her legs to the side
Inform her that you are going to begin your exam
Start with a neutral touch
Inspection and palpation
Skene (not noticed unless infected) and Bartholin glands (4 and 8 o'clock)
*Ofen refer to introidus as points on the clock when referring to things.
External Exam notes
Look at the hair distribution.
Labia majora: may be gaping or closed and may appear dry or moist.
-Usually symmetric and may be shriveled or full.
-Note any swelling, redness, or tenderness.
-Look for excoriation, rashes, or lesions.
Separate the labia majora w/ the fingers of one hand and inspect the labia minora, clitoris, urethral orifice, vaginal introitus, and perineum.
(Cheatham uses non-dominant hand).
-The tissue should feel soft, homogeneous, and w/o tenderness.
-Look for inflam, irritation, excoriation, or caking of discharge in the tissue folds.
-Eval for ulcers or vesicles suggestive of an STI.
External Exam notes cont.
Inspect the clitoris for size (usually 2cm or less).
The vaginal introitus can be a thin vertical slit or a large orifice.
-Look for swelling, discoloration, discharge, lesions, fistulas, or fissures.
Visually look at the Skene and Bartholin glands.
-Do not milk the glands like mentioned in the chapter.
-Can eval for muscle tone by having pt perform a Kegel while your index finger is in her vagina.
The perineal surface should be smooth.
-An episiotomy scar may be present in W who have borne children.
The anus is more darkly pigmented and the skin may appear coarse.
-It should be free of scarring, lesions, inflam, fissures, lumps, skin tags, or excoriation.
-If you touch the anus or perianal skin be sure to change your gloves so that you do not introduce bacteria into the vagina during the internal examination.
The labia minora enclose the area designated as the vestibule, which contains six openings:
-two ducts of Bartholin glands
-two ducts of Skene glands.
Surrounding the vaginal opening is the hymen, a connective tissue membrane that may be circular, crescentic, or fimbriated.
-After the hymen tears and becomes permanently divided, the edges either disappear or cicatrize, leaving hymenal tags.
It is essential that you become familiar with how the speculum operates before you begin the exam.
-Be familiar w/ both the metal and plastic specula b/c their MOAs are different.
You can use a small amt of water-based lubricant on the outside of the speculum.
Hold the speculum w/ the index finger over the top of the proximal end of the anterior blade and the other fingers around the handle.
Use non-dominant hand to separate the labia majora.
-Place the speculum at the introitus and WAIT.
-Let the vaginal muscles relax then insert the speculum POSTERIORLY, avoiding the anterior structures (i.e. the clitoris and the urethra).
Internal Exam cont.
Some clinicians insert the speculum blades at an oblique angle
-others prefer to keep the blades horizontal.
-You decide which method works well for you.
Insert the speculum fully before attempting to open and locate the cervix.
-If tissue is rugated, dark pink, and falls into your view...you most like haven't inserted the speculum far enough.
-If tissue is light pink, non-rugated and smooth then you are likely in the anterior or posterior cul-de-sac (which is where you want to be).
-Now adjust your speculum to find the cervix.
Once the cervix is visualized, manipulate the speculum so that the cervix is well exposed btwn the anterior and posterior blades.
-Lock the speculum blades into place to stabilize the speculum.
Internal Exam: Cervix
-Size and shape of the os
The cervix should be pink.
The position correlates w/ the position of the uterus.
-The cervix may protrude 1-3 cm into the vagina.
The surface of the cervix should be smooth.
-Some squamocolumnar epithelium of the cervical canal may be visible as a symmetric reddened circle around the os.
Cervix notes cont.
Note any discharge.
-Usual discharge is odorless
-May be creamy or clear
-May be thick, thin, or stringy
-Often heavier at midcycle or immediately before menstruation.
The os of the nulliparous W is small and round or oval.
The os of a multiparous W (if she has been in labor or had a vaginal delivery) is usually a horizontal slit or may be irregular and stellate
The Cervix: 2 cell types
-Line cervical canal (endocervix)
-One cell layer thick
-On portio of cervix (ectocervix)
-8-16 layers thick
-Where columnar and squamous cells meet
-Most likely area for dysplasia
*where pap smear done
The Process of Metaplasia
Over time, columnar cells transform
into squamous cells (a normal process, from intercourse, tampons, etc.)
younger pt = more columnar
SCJ moves inward as you age
post-menopausal = may not even see columnar.
The area btwn where the SCJ used to be and where it currently is = the Transformation Zone.
This is where you want to take the Pap smear bc this is where dysplasia is most likely to occur.
Most severe dysplasia will be by SCJ.
Screening for Infection
Wet Prep (2 dots, one w/ saline and one w/ KOH)
-Trichomonads (flagellated organisms)
-Pseudohyphae or budding yeast cells
Wet prep: Clue cells
A Clue Cell is the microscopic thumbprint of bacterial vaginosis.
-Clue cells are collections of vaginal lining cells, which have been shed into the vaginal secretions and which are distinguished by a "ground glass" appearance produced by large numbers of anaerobic bacteria adhering to their surfaces.
Clue cells are epithelial cells of the vagina that get their distinctive stippled appearance by being covered w/ bacteria.
-They are a medical sign of bacterial vaginosis, particularly that caused by Gardnerella, a group of G- bacteria.
-This bacterial infection gives a foul, fishy smelling vaginal discharge, also the vaginal pH is increased.
It is not generally considered to be an STI.
-BV is caused by an imbalance of naturally occurring bacterial flora.
Withdrawal of Speculum
Unlock the speculum and remove it slowly and carefully
Inspect the vaginal walls
-Note color, surface characteristics, and secretions
The blades will tend to close themselves
Avoid pinching the cervix and vaginal walls
Maintain downward pressure of the speculum
AVOID THE ANTERIOR STRUCTURES
-Urethra and clitoris
Adnexa and Ovaries
Bimanual Exam Notes
Inform pt that you are going to examine her internally w/ your fingers.
-Use water-based lubricant in the gloved index and middle fingers of your dominant hand.
-Insert the tips of the 2 fingers into the vaginal opening and press downward, again waiting for the muscles to relax.
-Gradually and gently insert your fingers their full length into the vagina.
-Palpate the vaginal wall
Be careful where you place your thumb during the bimanual exam.
-Don't rest it on the clitoris.
Bimanual Exam Notes cont.
Located the cervix w/ the palmar surface of your fingers, run your fingers around its circumference to feel the fornices.
-Feel the size, length, and shape which should correspond w/ your observations from the speculum exam.
-Grasp the cervix gently and move it from side to side to eval for cervical motion tenderness.
-The cervix should move 1-2 cm in each direction w/ minimal or no discomfort.
Palpate the uterus.
-Place the palmar surface of your non-dominate hand on the pt's abd (do not place it on top of the sheet...use direct contact with the pt's skin).
-Place the intravaginal fingers in the posterior fornix (let the cervix rest on the fingers) and push inward and upward in attempts to capture the uterus btwn your 2 hands.
-Determine whether the uterus is anteverted, anteflexed, midposition, retroverterted or retroflexed.
-Determine size, shape, contour, and tenderness to palpation.
Bimanual Exam Notes cont....
Palpate the adnexal areas and ovaries.
-Place the fingers of the abdominal hand on the R mid abdomen.
-With the intravaginal hand facing upward, place both fingers in the R lateral fornix.
-Press the intravaginal fingers deeply inward and upward toward the abdominal hand while sweeping the flat surface of the fingers of the abdominal hand deeply inward and obliquely downward toward the symphysis pubis.
-Repeat the maneuver the L side.
The ovaries, if palpable, should feel firm, smooth, ovoid, and approximately 3 by 2 by 1 cm in size.
-The healthy ovary is slightly to moderately tender on palpation.
The adnexa are often difficult to palpate bc of their location and position and the presence of excess adipose tissue in some W.
-If you are unable to feel anything you can assume that no abnormality is present, provided no clinical sx exist.
Rectovaginal Examination - Why?
Who needs this exam?
-Age > 50 years
Reaches almost 2.5 cm higher into the pelvis
Examines the back side of the uterus
Checks tone and alignment of pelvic organs
Guaiac (not a colon CA screen)
Rectal growths and/or masses
Also helpful for PID and appendicitis
Rectal walls and rectovaginal septum (check for hernias here)
-Remove gloves with a downward motion
RV Exam Notes
Change gloves after bimanual exam and lubricate fingers w/ water-based lubricant.
Place your index finger in the vagina, then press your middle finger against the anus and ask the pt to bear down.
-As she does, slip the tip of the finger into the rectum just past the sphincter.
-Palpate the area of the anorectal junction.
-Observe sphincter tone.
Slide both your vaginal and rectal fingers in as far as they will go.
-Rotate the rectal finger to explore the anterior rectal wall for masses, polyps, modules, strictures, irregularities and tenderness.
-Palpate the rectovaginal septum along the anterior wall.
-Palpate the uterosacral ligament, esp if concerned for endometriosis.
-Eval for nodularity indicating endometriotic implants.
RV Exam Notes cont.
Press firmly and deeply downward w/ the abdominal hand just above the symphysis pubis while you position the vaginal finger in the posterior vaginal fornix and depress strongly upward against the posterior side of the cervix.
-Palpate the posterior side of the uterus.
Repeat the adnexal exam using the same maneuvers described in the bimanual exam.
Remove the finger from the rectum and guaiac the stool if indicated (age >50 or other complaints of rectal bleeding).
-Assist the woman into a sitting position and give her the opportunity to regain her equilibrium and composure.
-Share w/ her the findings and ask her if she has any questions.
-This conversation may be brief, but it should never be avoided.
-Some clinicians prefer to leave the room and give the W the opportunity to dress before discussing the findings.
In front of uterus = bladder
Behind uterus = rectum
ECP HERE ON
Not including steps on pelvic, some contradict Cheatham and we know it's her way or the highwayyyyyyyyyyy... ;)
Screening test, does not provide a dx.
Current standard of care requires further workup of any abnormality found on Pap.
-this usually consists of screening for HPV, colposcopy, and bx of cervical samples.
Decreases the incidence and mortality of cervical CA.
Different organizations rec different things.
-Start w/in 3y of sexual activity or age 21.
-At least q3y
-No cytologic testing after total hysterectomy for benign condition
-D/C after age 65
-Insufficient evidence to rec for routine HPV screen
-Same start recs as above
-Annually w/ conventional cytology or q2y w/ liquid-based cytology.
-After age 30, w/ 3 consecutive normal tests may be screened q2-3y. (didn't Cheatham say this changed?)
-D/C after age 70
-Routine HPV screen not yet FDA approved.
Risk for abnl Pap: Coitus-related
-young age at 1st intercourse
-multiple sex partners
-HPV (leading risk)
Risk for abnl Pap: Non-coitus related
-illicit drug use
-prior hx of abnl pap
-uncircumcised partner (in my opinion this would be sex related...just sayin)
No absolute CIs.
Make sure you have permission
False negative Paps do occur.
-Sampling error (poor technique, or peripherally located lesions missed; MCC)
-Lesions that do not shed cells well
-Interpretation error (most publiczed)
Others: failure for clinician to understand or respond appropriately to results; failure of pt to follow the clinician's recs.
The "elusive" hymen
Membrane that partially or wholly occludes the introidus.
The shape and opening can vary greatly, but only completely imperforate hymen is pathologic.
There is a pic on p.233 of the different types, which include:
I can't believe I just had to make this notecard.
Internal anatomy tid bits
Vagina meets uterus at angle of 45-90 degrees.
Cervix projects into the upper portion of the anterior vagina, making the anterior vaginal wall shorter than the posterior.
3 parts of uterus: fundus, body, cervix
Opening in cervix varies in shape (slit-type) w/ parity, and leads to the endocervical canal.
All pelvic organs are supported w/in the lower abd cavity by a system of muscles, ligs, and fascia.
Pt prep: 1st timer
-Schedule enough time to allow a complete explanation beforehand.
-Diagram or model is recommended
-Show the equipment you'll use
-Use your closed fist to simulate the cervix and vagina and show what you'll do (i swear it says this)
-Explain terms she is scared of (wtf?)
-Educate about the lithotomy position
-EMPOWER THE PT! - let her hold a mirror if she wants to observe her own anatomy during the exam (can't make this stuff up)
- Assure that the exam is indicated and will not be painful
The returning pt
-Ask if she has any concerns
-Reassure her you will be gentle
-Tell her if she has any discomfort you'll stop
-Explain every step
For every exam.
Don't get sued.
The vaginal speculum
Pederson - narrow; more comfortable
Graves - "duck-billed" shape; overweight or severely retroverted uterus
Disposable - usually a graves, plastic, loud click.
Pediatric - for children or virginal and geriatric W. Use this one when explaining exam.
Be sure you know how to open, insert, and lock into place before beginning.
Pap smear slide or vial of preservative
Good light source
Water-soluble lubricating jelly
Choice of wooden spatula, cytobrush, or plastic broom to collect samples is dictated by sampling system available.
Spatula and cytobrush = fixation on slide
Plastic broom = liquid-based prep
1) Inspection of external genitalia
2) inspection of internal genitalia (including Pap)
A couple differences
At end of external inspection, have pt valsalva to check for cytocele, rectocele, or uterine prolapse.
(avoid unnecessary contact w/ clitoris during exam)
Before internal, ECP says use water for lubricant, not actual lubricant can be used bc may interfere w/ cytologic studies. Idk what C thinks about this.
Don't forget the 45/45 tilt rule for inserting speculum (sideways and down)
Lock speculum in place to take sample.
Pap sample: Spatula
Used for cells from cervix and vaginal wall.
-Use pointed, longer end and insert it into the external cervical os
-mild pressure used, turn 360 degrees, obtain cells from SCJ or transformation zone.
-use opposite, rounded end to get sample from vaginal wall.
-apply cells to slide by dragging spatula for both samples on slide.
Pap sample: cytobrush
Used for cells from endocervical canal.
-insert brush into cervical os until bristles no longer seen
-turn 2 full revolutions
-warn pt this may induce uterine cramping and mild bleeding
-immediately place cells on slide by rotating brush counterclockwise while moving brush from L to R.
Pap sample: Plastic broom
-Insert long central bristles into os until lateral bristles bend against ectocervix.
-Rotate 3-5x in both directions
-Transfer material onto slide w/ a stroke of both sides placing 2nd stroke exactly over 1st.
-OR place entire broom into vial solution and stir vigorously (can remove or leave in)
Transfer cells from Pap quickly no matter what medium.
-Quickly but evenly spread cellular material in a monolayer on the slide or in vial.
-Thin out large clumps as much as possible while avoiding excessive manipulation (damages cells)
-Immediately fix specimen either w/ immersing slide in 95% ethanol or coating w/ surface fixative.
Be sure to obtain adequate sample to avoid having pt have to repeat exam and to reduce false-negative rate.
In a W w/ a uterus, endocervical cells must be obtained.
Lab will say "no endocervical cells seen" if sample inadequate, and exam must be repeated.
Wet mount and Cx
If indicated, are obtained after Pap cells obtained.
Bimanual and RV exam
Just some extras to Cheathams...
A palpable ovary in a postmenopausal W needs further eval.
RV exam allows assessment of retroverted uterus and region behind cervix.
Pediatric genital exams
-obviously need a lot more attention and consideration
-"frog leg" position
Geriatric and post-hysterectomy exam frequency decreased to around 3-5y.
If ovaries still present, bimanual exam still important.
Postmenopausal = atrophic = use small speculum to not tear thin tissue.
-Inform pt of results, don't promise normal until lab back
-Educate her about next screening test
-Let her know when and how she will get lab results, and to call if doesn't hear anything
-Pt ed handouts on Pap results
Interpretation of the Pap Smear
Used to use classes 1-5, but lack of reproducibility and didn't even reflect pathophys, so not anymore.
Now use Bethesda system (2001) which incorporates important changes:
-Pap smear analysis considered medical consult
-Pathologist responsible for making dx
-Referring physician provides hx
-Must have a statement of adequacy
Recs regarding f/u made by pathologist.
Includes following info:
-Adequacy of sample
-Incidental findings (i.e. infection)
-Evidence of lesions (low-grade squamous intraepithelial lesion (SIL), high grade SIL, or CA)
Low Grade SIL
Cellular change assoc w/ HPV
Mild (slight) dysplasia/CIN1
High Grade SIL
Carcinoma in situ/CIN3
Atypical Squamous Cells (ASC)
Unspecified (ASC-US) - included unspecified and favor benign/inflammation
Cannot exclude HSIL (ASC-H)
Atypical Glandular Cells of Uncertain Significance (AGC-US)
AGC is broken down into favoring endocervical, endometrial, or not otherwise specified origin or endocervical adenocarcinoma in situ.
Unspecified (AGC-US) (ASC-US)
Atypical glandular cells, favor neoplastic (AGC-H)
Summary of changes for management of abnl Pap.
Algorithms delineate proper management of abnl results and include management for benign endometrial cells (BEC), ASC-US, and new LSIL management in special pops.
There is a website listed...knock yourself out. It's a .gov....so i won't be looking at it.
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