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Pelvic exam across the life span Anne Moore, DNP, APN, FAANP.

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Presentation on theme: "Pelvic exam across the life span Anne Moore, DNP, APN, FAANP."— Presentation transcript:

1 Pelvic exam across the life span Anne Moore, DNP, APN, FAANP

2 Objective s 1. 1.Evaluate current guidelines for pelvic examination and screening for women across the lifespan (pediatrics to geriatrics) 2.Rationalize the use of components of the pelvic examination based on age-related and cultural variables. 3.Evaluate techniques of the pelvic exam to accommodate age-related and cultural variables.

3 Basic principles Tools for history include: calendar, pelvic diagrams, gestation calculator Greether while she is dressed & obtain her history

4 History: Essential Issues Do not make assumptions about sexuality Too old to be sexual Heterosexual Satisfied with sex life Not at risk for pregnancy/STI’s

5 History: Essential Issues Ask about continence (urine & stool)-dribbling, urgency, wetness Wears pads? Activities she avoids?

6 Preparing for the Pelvic Exam What are her previous experiences? Tell her you will stop the exam if she asks Discuss cues for pain

7 Discussi on “ A pelvic exam should not be painful, pressure is normal, but pain is not. Let me know what you’re feeling and we can stop at any time if it’s too uncomfortable. “

8 Pelvic Exam with Older Women May take longer Positioning more challenging Smaller specula necessary Topical analgesic use Pain control, pain vs. pressure

9 Preparing the Older Woman Provide estrogen creams, suppositories, rings directly to the vagina to facilitate ease of speculum insertion. Consider oral (NSAID) & topical analgesics.Lidocaine to K- Y?

10 Tools of Your Trade Good light Older women can’t adjust to temperature change as well.Consider fan in room Warm specula in a variety of sizes-pediatric size Long handled mirror Non-latex gloves-in your size

11 Tools for the Pelvic Cotton swabs Pap smears Scopettes or ring forcep + cotton balls pH paper Gc + CT tests or urine tests Warmed lubricant Various sized specula

12 YES You Can Use Lubricant Before Paps and Infection Testing Griffith-Uni Texas Southwestern 2005 Randomized study 9,500 women ages yrs.3,460 Paps & 5,535 DNA assays Dime sized water soluble bacteriostatic gel lubricant Does not effect Pap testing nor Gc or CT tests

13 Tools for the Pelvic Biopsy materials: lidocaine1% w/o epinephrine Small syringe with TB needle or 25g Cleansing liquid-iodine Biopsy container with formalin-lid off & labeled Cervical biopsy forceps or other tool

14 Beginning the Pelvic Exam Positioning on table Drape up or down? Watch reactions, assess discomfort Tell her what you are going to do, explain sounds Use positive terms, tell her what you see

15 Positions for Exam Decreased abduction of hips-side lying, assistant supports anterior leg & knee-chest on floor with specula upside down Obese-knee chest, or place abdominal hand under panniculus Ultrasound

16 Inguinal Lymph Nodes Assess inguinal nodes-enlarged nodes-herpes, perineal infections, inflamed hemorrhoids Infections of feet & legs, DM, stasis ulcers=  inguinal nodes  nodes may indicate systemic disease, infection, lymphoma

17 The Vulva Evaluate the hair distribution- sparse, gray, hypoestrogenic Inspect skin of the vulva carefully-  VIN Look for signs of scratching from pruritus Cancer is a great imitator

18 The Clitoris Inspect & retract prepuce Dry skin, smaller clitoris =  E Clitoris  1 cm wide abnormal Pale pink, mobile, agglutination suggests lichen planus 10% vulvar cancers occur on clitoris

19 Urethra and Skene's Ducts Erythema- urethritis, prolapse Milk anterior vaginal area for discharge (D/C) Milk lat. vaginal introitus for D/C from Skene's ducts Palpate Bartholin gland for swelling or tenderness

20 Urethral Prolapse Sx: dyspareunia at introitus, dysuria;post-menopausal bleeding

21 Palpating the Vagina of an Older Woman Often small, narrow, atrophic Assess vaginal tone: anterior –cystocele & posterior- rectocele Have her grip your fingers- assess pelvic musculature

22 Palpating the Vagina and Cervix Palpate vaginal walls for cysts (Gartner duct cysts- normal variation, common along lateral vaginal walls) Abnormal texture (HPV, cancer) & vaginal septum

23 Find the Cervix (Cx) Before Speculum Exam! Assess consistency- hard suggests cancer, nodular cx suggests Nabothian cysts or cancer Note position-up, down, lateral? How far from introitus? Don’t bump into it!

24 TheCervixTheCervix

25 Insertion of Speculum in Elderly Woman Viscous lidocaine, beforeexam 2-3 weeks of E cream before exam Use smallest speculum Spread labia to see introitus, insert gently & obliquely

26 Cervix & Vagina of the Older Woman Cervix is small, os closed, no cx neck- may be flat against wall Decreased vaginal rugae, pale, thin, bleeds easily from  E Vaginal pH is high >5.0 from  lactobacilli from  E Polyps common

27 Pap Smear in Older Women WHY? Stenotic Os is common-to find os use OsFinder, cytobrush, lacrimal probes (ENT) Hypoestrogenic smears may look abnormal-prep with E for 3 wks before Pap SCJ is high within the canal-use cytobrush is necessary

28 Order of Specimen Collections 1. pH-from side walls 2. Vaginal specimens- wet prep-take from side walls 3.Pap Smear 4. Gc, Ct tests or urine tests Avoid contaminating with blood if possible

29 Hysterectomy Surgical & path report? Bilateral oophorectomy? Taking exogenous hormones(estrogen & testosterone)? If hysterectomy for cancer-continue PAP smears from cervical/vaginal cuff & close inspection of vulva-vagina

30 USING YOUR MANO & FINGER MEASUREMENTS TO S'ZE UTERINE LENGTH & WIDTH & SiZE OVARllES VAGrNAL FINGERS DETERMINING WIDTH OF UTERUS l Cm distance of both finaers DETERMINfNG SIZE OF OVARIES

31 DETERMINING LENG,TH OF UTERUS ABDOMINAL HAND C·m distance middle digit to notch....._....cm distance from index digit to notch '-..- Cm distance from 1 t joint to notch notnot

32 DETERMINI; NG LENGTH OF C;ERVIX Cm d·st,anc,e to 1 51 j1oint Cm distance to 1st joi nt

33 Palpation of Uterus Assess cervix & uterus for nodularity (myomas, tumors) Fibroids feel rock-hard & irregular Fibroids-associated with enlarged, irregular, tender uteri and abnormal bleeding

34 Palpation of Uterus Assess position Assess flexion & mobility Assess for cervical motion tenderness (CMT) Assess length & width

35 I cervical motion tenderness

36 Palpating Uterine Position Anterior Anteflexed >45  anterior curvature Mid Position Posterior Retroflexed >45  posterior curvature

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38 Palpating Uterus- Position If Rt fingers in vagina: Rt foot on step Locate cervix (Cx); if cannot feel it, use abd. hand to pull uterus down until you can feel Cx internally Slide internal fingers along posterior & anterior neck of Cx Can you feel the neck going upward? Anterior position?

39 Palpating Uterus-Position If you feel the cervical neck going downward could beposterior or retroflexed position? If anterior position-lift uterus up with internal fingers & palpate with your abd hand Width? Regularity? Mobility?

40 Palpating Uterine Contour If the uterus is posterior, it could also be retroflexed You must do a recto-vaginal exam to determine the position & feel the fundus more accurately

41 Performing a Rectal-Vaginal Exam With index finger in the vagina & middle finger in the rectum, find the cervix-your land-mark by touching her cervix with both fingers

42 Palpating Uterine Contour … With posterior or retroflexed uteri, the ovaries fall back or are posterior & are easier to palpate rectally

43 Determining Uterine Size Width:when palpating cervix, feel the widening neck & estimate width with your measured fingers; this estimates the width of the lower uterine segment Lift up uterus, estimate length with abd hand measurements

44 Pelvic Examination Techniques in challenging Clinical Situations

45 Physical Exam of the Obese Woman Will table support?Is table wide enough? Have assistant stand to side of table to stabilize & reassure her The vulva may be hidden by the panniculus & a longer speculum is often necessary

46 Providing Pelvic Examinations with Obese Women The vulva may be larger-insure the labia are examined carefully, completely Obese women may have difficulty reaching their vulva; discuss use of flexible shower heads to reach her perineum & rectal area or squatting positions in bath for cleansing

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49 Special Issues Providing Pelvic Examinations with Obese Women The extra adipose tissue of the vulva makes visualization of the cervix difficult and may require a longer specula to reach the cervix

50 Examinations with Obese Women Speculum Exam Use an instrument: ring forceps (closed) or tongue blade to gently push walls to the side to improve visibility Use larger speculum as comfort dictates

51 Special Issues Providing Pelvic Examinations with Obese Women The cervix may be difficult to visualize or palpate…have her pull her knees up …curled up in this position may give better speculum visualization of the cervix

52 Difficult Palpation of the Uterus Obese women Virginal women A digital rectal exam with the woman in lithotomy position (or any position that works) With anterior pelvic compression this technique can be very helpful

53 , ' 08/ UTHSCSA © 1998

54 Visualizing or Palpating the Cervix in Very Obese Women Place woman on covered floor in knee-chest position; kneeling behind her, insert two fingers into the vagina, the cervix will be easier to locate For Pap: place a Pap brush between 2 fingers, insert into vagina, feel for cervix and obtain pap

55 Special Issues Providing Pelvic Examinations with Obese Women The bimanual exam is more challenging & may be very difficult to palpate uterus or ovaries Place the abdominal hand UNDER the panniculus to decrease amount of adipose tissue between the examiner’s hand & the uterus A pelvic US may be indicated

56 Pelvic Tenderness Tender uterus: ectopic cervical motion tenderness (CMT), myoma, cancer, endometritis- salpingitis, adhesions Ballot to assess mobility Fixed uterus suggests adhesions

57 Consider Non-Gynecologic Causes of "pelvic pain” Spine-palpate sacrum & coccyx via rectum Radiculopathy-back exam: ROM, vertebral compression (osteoporosis), disc disease- straight leg lift, osteoarthritis

58 Pelvic Pain Bladder-interstitial cystitis Cystitis-less symptoms in older women Palpate bladder with vaginal fingers under bladder & abd fingers pressing down on bladder Bowel-cancer, impaction ALWAYS do rectal exam

59 Adenomyosis Endometrial tissue within the myometrium of the uterus Heavy, painful menses & large, boggy uterus- Halban’s sign 20% of uteri removed for abnormal bleeding show adenomyosis

60 Ovary Norms Normal ovaries can range from 2-4 cm depending on time in cycle During ovulation the ovary may be as large as 4 cm; bring pt back in 2 weeks to recheck if concerned or pelvic US

61 Older Ovaries By 2 years post menopause most ovaries not palpable If palpable consider ovarian cancer Consider ultrasound if unsure

62 Follicular Ovarian Cysts 95% Follicular cysts are < 5 cm Found duringfollicular-proliferative phase Most common; can rupture, hemorrhage (rare) Usually ~3 cm; can range to 8-10 cm

63 Corpus Luteum Cyst Occur during luteal or post-ovulatory phase Rarely exceed 4 cm, but can get up to 11 cm Can rupture & bleed & mimic ectopic All cysts can tort, very painful

64 The Recto-Vaginal Exam Apply lubricant or lidocaine Explain exam will cause pressure, but should NOT be painful; feeling an urge to defecate is normal With index finger in vagina, place lubricated middle finger at the anus

65 Recto-Vaginal Exam Ask her to bear down gently against your finger, insert only to 1 st joint, stop, ask her to relax muscles & don’t move finger Once muscles relax; ask her to bear down & gently insert finger; stop & don’t move until she relaxes

66 Recto-Vaginal Exam Then palpate slowly & tell her when you rotate finger-feel septum between rectum & vagina with both fingers (1 in rectum, 1 in vagina) Palpate rectal ampulla note polyps or masses Assess uterus & ovaries with bimanual as indicated

67 Rectal Exam Use single digit Palpate high for masses Ampulla tight, stenotic, stiff ? Look at finger for bleeding Stool for occult blood, colonoscopy

68 T he First Pelvic Exam What has she heard? Previous experiences with providers? What does she expect? ACOG recommends first appointment with GYN provider between ages 13 and 15

69 First Pelvic Does itneed to be done? Risk? contraception? Does it all have to be done the 1st visit? Cultural issues, translators, chaperones? Mom, boyfriends and 4 girlfriends want to be in room for exam…oh my!

70 Reasons for pelvic exam in a younger woman Pelvic pain Unusual bleeding/discharge Assault Request


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