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Chapter 27 Female Genitalia and Rectum
Terms in this set (74)
older adult considerations vaginal infections
The older client is more susceptible to vaginal infection because of atrophy of the vaginal mucosa associated with aging
older adult considerations estrogen
As women age, their estrogen production decreases, causing atrophy of the vaginal mucosa. These women may need to use lubrication to increase comfort during intercourse. Women experiencing surgical menopause, symptoms of which occur more abruptly, may also benefit from lubrication.
older adult considerations urinary incontinence
Urinary incontinence may develop in older women from muscle weakness or loss of urethral elasticity.
Inspect the mons pubis ABNORMAL
Absence of pubic hair in the adult client is abnormal. Lice or nits (eggs) at the base of the pubic hairs indicate infestation with pediculosis pubis. This condition, commonly referred to as "crabs," is most often transmitted by sexual contact.
Observe and palpate inguinal lymph nodes.
Enlarged inguinal nodes may indicate a vaginal infection or may be the result of irritation from shaving pubic hairs.
Inspect the labia majora and perineum NORMAL
The labia majora are equal in size and free of lesions, swelling, and excoriation. A healed tear or episiotomy scar may be visible on the perineum if the client has given birth. The perineum should be smooth. Keep in mind the woman's childbearing status during inspection. For example, the labia of a woman who has not delivered offspring vaginally will meet in the middle. The labia of a woman who has delivered vaginally will not meet in the middle and may appear shriveled.
Inspect the labia majora and perineum ABNORMAL
Lesions may be from an infectious disease, such as herpes or syphilis. Excoriation and swelling may be from scratching or self-treatment of the lesions. Evaluate all lesions and refer the client to a primary care provider for treatment.
Inspect the labia minora, clitoris, urethral meatus, and vaginal opening NORMAL
The labia minora appear symmetric, dark pink, and moist. The clitoris is a small mound of erectile tissue, sensitive to touch. The normal size of the clitoris varies. The urethral meatus is small and slit-like. The vaginal opening is positioned below the urethral meatus. Its size depends on sexual activity or vaginal delivery. A hymen may cover the vaginal opening partially or completely.
Inspect the labia minora, clitoris, urethral meatus, and vaginal opening ABNORMAL
Asymmetric labia may indicate abscess. Lesions, swelling, bulging in the vaginal opening, and discharge are abnormal findings. Excoriation may result from the client scratching or self-treating a perineal irritation.
Palpate Bartholin's glands ABNORMAL
Swelling, pain, and discharge may result from infection and abscess. If you detect a discharge, obtain a specimen to send to the laboratory for culture.
Palpate the urethra ABNORMAL
Drainage from the urethra indicates possible urethritis. Any discharge should be cultured. Urethritis may occur with infection with Neisseria gonorrhoeae or Chlamydia trachomatis.
Inspect the size of the vaginal opening and the angle of the vagina NORMAL
The normal vaginal opening varies in size according to the client's age, sexual history, and whether she has given birth vaginally. The vagina is typically tilted posteriorly at a 45-degree angle and should feel moist.
Inspect the size of the vaginal opening and the angle of the vagina ABNORMAL
A condition in which the vagina becomes thinner and dryer is vaginal atrophy. This occurs when the body lacks estrogen. Some causes may include: menopause, breast feeding, surgical removal of the ovaries, and cancer treatments. The risk increases if you smoke or with the absence of vaginal birth. Any loss of hymenal tissue between the 3 o'clock position and the 9 o'clock position indicates trauma (penetration by digits, penis or foreign objects) in children. This finding is not as relevant in adults.
Inspect the vaginal musculature NORMAL 1
The client should be able to squeeze around the examiner's finger. Typically, the nulliparous woman can squeeze tighter than the multiparous woman.
Inspect the vaginal musculature ABNORMAL 1
Absent or decreased ability to squeeze the examiner's finger indicates decreased muscle tone. Decreased tone may decrease sexual satisfaction.
Inspect the vaginal musculature NORMAL 2
No bulging and no urinary discharge.
Inspect the vaginal musculature ABNORMAL 2
Bulging of the anterior wall may indicate a cystocele. Bulging of the posterior wall may indicate a rectocele. If the cervix or uterus protrudes down, the client may have uterine prolapse. If urine leaks out, the client may have stress incontinence.
Inspect the cervix NORMAL
The surface of the cervix is normally smooth, pink, and even. Normally, it is midline in position and projects 1-3 cm into the vagina. In pregnant clients, the cervix appears blue (Chadwick's sign).
Inspect the cervix ABNORMAL
In a nonpregnant woman, a bluish cervix may indicate cyanosis; in a nonmenopausal woman, a pale cervix may indicate anemia. Redness may be from inflammation.
observe the surface and the appearance of the os. Look for discharge and lesions NORMAL
The cervical os normally appears as a small, round opening in nulliparous women and appears slit-like in parous women.
observe the surface and the appearance of the os. Look for discharge and lesions ABNORMAL
Asymmetric, reddened areas, strawberry spots, and white patches are also abnormal. Cervical lesions may result from polyps, cancer, or infection. Cervical enlargement or projection into the vagina more than 3 cm may be from prolapse or tumor, and further evaluation is needed.
older adult considerations cervix
in older women, the cervix appears pale after menopause
obtain specimens for the Pap smear and, if indicated, speci-mens for culture and sensitivity testing to identify possible STIs NORMAL
Cervical secretions are normally clear or white and without unpleasant odor. Secretions may vary according to timing within the menstrual cycle.
obtain specimens for the Pap smear and, if indicated, speci-mens for culture and sensitivity testing to identify possible STIs ABRNORMAL
Colored, malodorous, or irritating discharge is abnormal; a specimen should be obtained for culture.
Inspect the vagina NORMAL
The vagina should appear pink, moist, smooth, and free of lesions and irritation. It should also be free of any colored or malodorous discharge.
Inspect the vagina ABNORMAL
Reddened areas, lesions, and colored, malodorous discharge are abnormal and may indicate vaginal infections, STIs, or cancer. Altered pH may indicate infection.
Palpate the vaginal wall bi manually NORMAL
The vaginal wall should feel smooth, and the client should not report any tenderness
Palpate the vaginal wall bi manually ABNORMAL
Tenderness or lesions may indicate infection.
Palpate the cervix (contour, consistency, mobility, tenderness) NORMAL
The cervix should feel firm and soft (like the tip of your nose). It is rounded, and can be moved somewhat from side to side without eliciting tenderness.
Palpate the cervix (contour, consistency, mobility, tenderness) ABNORMAL
A hard, immobile cervix may indicate cancer. Pain with movement of the cervix may indicate infection (Chandelier's sign).
Palpate the uterus NORMAL
The fundus, the large, upper end of the uterus, is normally round, firm, and smooth. In most women, it is at the level of the pubis; the cervix is aimed posteriorly (anteverted position). However, several other positions are considered normal; The normal uterus moves freely and is not tender.
Palpate the uterus ABNORMAL
An enlarged uterus above the level of the pubis is abnormal; an irregular shape suggests abnormalities such as myomas (fibroid tumors) or endometriosis; A fixed or tender uterus may indicate fibroids, infection, or masses.
Palpate the ovaries NORMAL
Ovaries are approximately 3 × 2 × 1 cm (or the size of a walnut) and almond-shaped.
Palpate the ovaries ABNORMAL
Enlarged size, masses, immobility, and extreme tenderness are abnormal and should be evaluated.
Rectovaginal Exam NORMAL
The rectovaginal septum is normally smooth, thin, movable, and firm. The posterior uterine wall is normally smooth, firm, round, movable, and nontender.
Rectovaginal Exam ABNORMAL
Masses, thickened structures, immobility, and tenderness are abnormal.
inspect the perianal area NORMAL
The anal opening should appear hairless, moist, and tightly closed. The skin around the anal opening is more coarse and more darkly pigmented. The surrounding perianal area should be free of redness, lumps, ulcers, lesions, and rashes.
inspect the perianal area ABNORMAL
Lesions may indicate STIs, cancer, or hemorrhoids. A thrombosed external hemorrhoid appears swollen. It is itchy, painful, and bleeds when the client passes stool. A previously thrombosed hemorrhoid appears as a skin tag that protrudes from the anus.A painful mass that is hardened and reddened suggests a perianal abscess. A swollen skin tag on the anal margin may indicate a fissure in the anal canal. Redness and excoriation may be from scratching an area infected by fungi or pinworms. A small opening in the skin that surrounds the anal opening may be an anorectal fistula.Thickening of the epithelium suggests repeated trauma from anal intercourse.
Inspect the sacrococcygeal area NORMAL
Area is normally smooth, and free of redness and hair
Inspect the sacrococcygeal area ABNORMAL
A reddened, swollen, or dimpled area cov-ered by a small tuft of hair located midline on the lower sacrum suggests a pilonidal cyst.
This is a normal finding in many women and usually occurs after vaginal birth or when the woman takes oral contraceptives. The columnar epithelium from within the endocervical canal is everted and appears as a deep red, rough ring around the cervical os, surrounded by the normal pink color of the cervix.
NABOTHIAN (RETENTION) CYSTS
Nabothian (retention) cysts (normal findings after childbirth) are small (less than 1 cm), yellow, translucent nodules on the cervical surface. Normal odorless and nonirritating secretions may be present on pink, healthy tissue. (Irritating secretions would appear on reddened tissue.) The viscosity of these secretions ranges from thin to thick; their appearance ranges from clear to cloudy, depending on the phase of the menstrual cycle. Nabothian cysts may occur when the everted columnar epithelium spontaneously transforms into squamous epithelium, a process called squamous metaplasia. Occasionally the tissue blocks endocervical glands and cysts develop.
BILATERAL TRANSVERSE LACERATION
a type of healed laceration that may be seen in a woman who has given birth vaginally.
UNILATERAL TRANSVERSE LACERATION
Vaginal birth may cause trauma to the cervix and produce tears or lacerations. Therefore, healed lacerations may be seen as a normal variation. This drawing illustrates a unilateral transverse laceration.
a type of healed laceration that may be seen in a woman who has given birth vaginally.
This is the most typical position of the uterus. The cervix is pointed posteriorly, and the body of the uterus is at the level of the pubis over the bladder.
This is a normal variation. The cervix is pointed slightly more anteriorly (compared with the anteverted position), and the body of the uterus is positioned more posteriorly than the anteverted position, midway between the bladder and the rectum. It may be difficult to palpate the body through the abdominal and rectal walls with the uterus in this position.
a normal variation that consists of the uterine body flexed anteriorly in relation to the cervix. The position of the cervix remains normal.
a normal variation that consists of the cervix and body of the uterus tilting backward. The uterine wall may not be palpable through the abdominal wall or the rectal wall in moderate retroversion. However, if the uterus is prominently retroverted, the wall may be felt through the posterior fornix or the rectal wall.
a normal variation that consists of the uterine body being flexed posteriorly in relation to the cervix. The position of the cervix remains normal. The body of the uterus may be felt through the posterior fornix or the rectal wall.
Syphilitic chancres often ﬁrst appear on the perianal area as silvery white papules that become superﬁcial red ulcers. Syphilitic chancres are painless. They are sexually transmit-ted and usually develop at the site of initial contact with the infecting organism.
GENITAL HERPES SIMPLEX
The initial outbreak of herpes may have many small, painful ulcers with erythematous base. Recurrent herpes lesions are usually not as extensive.
Genital warts, caused by the human papilloma virus (HPV), are moist, ﬂeshy lesions on the labia and within the vestibule. They are painless and believed to be sexually transmitted.
A cystocele is a bulging in the anterior vaginal wall caused by thickening of the pelvic musculature. As a result, the bladder, covered by vaginal mucosa, prolapses into the vagina.
A rectocele is a bulging in the posterior vaginal wall caused by weakening of the pelvic musculature. Part of the rectum covered by the vaginal mucosa protrudes into the vagina.
Uterine prolapse occurs when the uterus protrudes into the vagina. It is graded according to how far it protrudes into the vagina. In ﬁrst-degree prolapse, the cervix is seen at the vaginal opening; in second-degree prolapse the uterus bulges outside of vaginal openings; in third-degree pro-lapse, the uterus bulges completely out of the vagina.
CYANOSIS OF THE CERVIX
The cervix normally appears bluish in the client who is in her ﬁrst trimester of pregnancy. However, if the client is not pregnant, a bluish color to the cervix indicates venous congestion or a diminished oxygen supply to the tissues.
CANCER OF THE CERVIX
A hardened ulcer is usually the ﬁrst indication of cervical cancer, but it may not be visible on the ectocervix. In later stages, the lesion may develop into a large cauliﬂower-like growth. A Pap smear is essential for diagnosis.
A polyp typically develops in the endocervical canal and may protrude visibly at the cervical os. It is soft, red, and rather fragile. Cervical polyps are benign.
This condition differs from cervical eversion in that normal tissue around the external os is inﬂamed and eroded, appearing reddened and rough. Erosion usually occurs with mucopurulent cervical discharge.
This condition produces a mucopurulent yellowish dis-charge from the external os. It usually indicates infection with Chlamydia or gonorrhea. However, these STIs may also occur with no visible signs, although the discharge may change the cervical pH
MALFORMATIONS FROM EXPOSURE TO DIETHYLSTILBESTROL (DES)
DES, a drug used more than 50 years ago to prevent spontaneous abortion and premature labor, was learned to be teratogenic (capable of causing malformations in the fetus). Women who were exposed to this drug as fetuses may have cervical abnormalities that may progress to cancer. Some abnormalities associated with maternal DES use include columnar epithelium that covers most or all of the ectocervix; columnar epithelium that extends onto the vaginal wall; a circular column of tissue that separates the cervix from the vaginal wall; transverse ridge; and enlarged upper ectocervical lip.
TRICHOMONAS VAGINITIS (TRICHOMONIASIS)
This type of vaginal infection is caused by a protozoan organism and is usually sexually transmitted. The dis-charge is typically yellow-green, frothy, and foul smelling. The labia may appear swollen and red, and the vaginal walls may be red, rough, and covered with small red spots (or petechiae). This infection causes itching and urinary frequency in the client. Upon testing, the pH of vaginal secretion will be greater than 4.5 (usually 7.0 or more). If a sample of vaginal secretions is stirred into a potassium hydroxide solution (KOH prep), a foul odor (typically known as a "+" amine) may be noted.
Atrophic vaginitis occurs after menopause when estrogen production is low. The discharge produced may be blood-tinged and is usually minimal. The labia and vaginal mucosa appear atrophic. The vaginal mucosa is typically pale, dry, and contains areas of abrasion that bleed easily. Atrophic vaginitis causes itching, burning, dryness, and painful urination.
CANDIDAL VAGINITIS (MONILIASIS)
This infection is caused by the overgrowth of yeast in the vagina. It causes a thick, white, cheesy discharge. The labia may be inﬂamed and swollen. The vaginal mucosa may be reddened and typically contains patches of the discharge. This infection causes intense itching and discomfort.
The cause of bacterial vaginosis is unknown (possibly anaerobic bacteria), but it is thought to be sexually trans-mitted. The discharge is thin and gray-white, has a positive amine (ﬁshy smell), and coats the vaginal walls and ectocervix. The labia and vaginal walls usually appear normal and pH is greater than 4.5 (5.5-6.0).
NORMAL ENLARGEMENT: PREGNANCY
The only uterine enlargement that is normal results from pregnancy and fetal growth. In such cases, the isthmus feels soft (Hegar's sign) on palpation, and the fundus and isthmus are compressible at between 10 and 12 weeks of pregnancy.
UTERINE FIBROIDS (MYOMAS)
Uterine ﬁbroid tumors are common and benign. They are irregular, ﬁrm nodules that are continuous with the uterine surface. They may occur as one or many and may grow quite large. The uterus will be irregularly enlarged, ﬁrm, and mobile.
UTERINE CANCER (CANCER OF THE ENDOMETRIUM)
The uterus may be enlarged with a malignant mass. Irregular bleeding, bleeding between periods, or postmenopausal bleeding may be the ﬁrst sign of a problem.
In endometriosis, the uterus is ﬁxed and tender. Growths of endometrial tissue are usually present throughout the pelvic area and may be felt as ﬁrm, nodular masses. Pelvic pain and irregular bleeding are common.
PELVIC INFLAMMATORY DISEASE (PID)
PID is typically caused by infection of the fallopian tubes (salpingitis) or fallopian tubes and ovaries (salpingo-oopho-ritis) with an STI (i.e., gonorrhea, Chlamydia). It causes extremely tender and painful bilateral adnexal masses (positive Chandelier's sign)
Ovarian cysts are benign masses on the ovary. They are usually smooth, mobile, round, compressible, and nontender.
Masses that are cancerous are usually solid, irregular, non-tender, and ﬁxed.
Ectopic pregnancy occurs when a fertilized egg attaches to the fallopian tube and begins developing instead of con-tinuing its journey to the uterus for development. A solid, mobile, tender, and unilateral adnexal mass may be palpated if tenderness allows. The cervix and uterus will be softened, and movement of these structures will cause pain.
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