2Learning outcomesThe intended learning outcomes for teaching the pelvic examination is for the student to demonstrate ability to: 1. Interact with the patient in a way that elicits confidence and cooperation and assures the patient’s comfort. 2. Perform the complete examination in a sensitive manner. 3. Use appropriate medical terminology and communication skills when performing the exam and to communicate the results and educate the patient.
33 parts of the pelvic exam 1. The visual exam is a way to look for any signs of infection on the outside of the woman’s genitals 2. The speculum exam is a way to see inside the woman’s vagina and to test the health of her cervix. You use a tool called a speculum to do the speculum exam. 3. The bimanual exam (2-hand exam) is a way to check the health of a woman’s womb and ovaries or to check the size of the womb in pregnancy. To do a bimanual exam, you feel the womb with the fingers of one hand inside a woman’s vagina and the other hand on her belly at the same time
4Indications for pelvic exam include Vulvar or vaginal complaintsAbdominal pain in a womanExposure to sexually transmitted infectionPregnancy (known or proven)Health maintenance (to perform pap smear)
5AnatomyKeep in mind the basic anatomy of the vulva.
6Before the exam Help the woman relax Remind the woman to take deep breaths and to let her body relaxFearSome women are afraid to have pelvic exams, suchas women who have never had pelvic exams, and women who have had exams that were painful.ShameWhen you do a pelvic exam, you are examining a woman’s genitals and vagina. Many women are embarrassed or ashamed about these parts of their bodies.
7Preparation Wash hands Introduce yourself to the patient using full nameMake sure that you have privacy.Ensure that the room is sufficiently worm• Prepare all the tools you will need for the examExam best performed when patient has empty bladder
8Speculum (appropriate size plastic or metal) PreparationMake sure the nurse has all of the necessary materials for the exam:Speculum (appropriate size plastic or metal)GYN cotton-tippedover head lampGloves
9Slide and fixative or liquid media PreparationMake sure the nurse has all of the necessary materials for the exam:LubricantPap material (cytobrush, spatula, cervical broom.)Slide and fixative or liquid media
10Positioning Privacy Buttocks just off table Good Lighting Drape Standby
11Before the examAsk the woman to urinate before the exam. This will make the exam more comfortable for her.( a full bladder will obstruct the view of the cervix )Ask her to lie on her back with her knees up and her buttocks at the end of the exam table or bedIf she is not down far enough, inserting the speculum can be more difficult and uncomfortable for her.
12Before the examAppropriate draping should be used to help make the patient more comfortable.Good lighting is important and is often accomplished with a goose-neck lamp.• Wash your hands with clean water and soap. Your fingernails should be short and clean.• Put clean plastic gloves on your hands
13Inspection Inspect the client's external genitalia Perineal area must be well illuminatedBoth hands are gloved to prevent the spread of infectionMons pubis--note quantity and distribution of hair growthLabia--usually plump and well-formed in adult female
14InspectionPerineum--slightly darker than the skin of the rest of the body. Mucous membranes appear dark pink and moist
15Inspection Separate the labia and inspect the labia minora: ClitorisUrethral orificeHymenVaginal orifice
16Inspection Note the following: Discharge Inflammation Edema Ulceration LesionsProlapseStress incontinence
17Sequence of a Pelvic Examination Note abnormalities such as:Bulges and swelling of vulva and vaginaEnlarged clitorisSyphilitic chancresSebaceous cystPrimary Syphilis
18Skene's glands examination Near the urethraSuspect inflammation; check for urethral discharge
19Skene's glands examination Insert index finger with palm facing you into the vagina up to the 2d joint.Apply pressure upwards and milk the Skene's gland by moving your fingers outwardDo this on both sides and note any discharge.Obtain specimen for culture.Change glove if discharge is found.
20Bartholin's glands examination If there is history or appearance of labial swelling check Bartholin's glandsInsert index finger up to first knuckleWith your index finger and thumb, palpate the posterolateral area of the labia majora noting any:SwellingTendernessMassesHeat or discharge
21Bartholin's glands examination Bartholin's glands (CONT)A painful abscess is pus filled and usually staphylococcal or gonococcal in origin and should be incised and drained.
22Assess the support of the vaginal outlet With the labia separated by middle and index fingerAsk patient to strain downNote any bulging of the vaginal walls (cystocele and rectocele).
23InspectionInspect the anus at this time, note presence of lesions and hemorrhoids
24Speculum Examination of Internal Genitalia Select a speculum of appropriate size, lubricate and warm with warm water)Small--not sexually active femaleMedium--sexually activeLarge--women who have had childrenMedium to large speculum may be used if female has had children.
25Appropriate Speculum Choice Grave’s speculumWidth mmLength mmPederson speculumWidth mmLength mm
26Plastic speculae (side view): A) small Pedersen, B) medium Pedersen, C) large Pedersen Metal speculae (side view): A) small Pedersen, B) medium Graves, C) large Graves
27Angle of insertionAngle of insertion at entry and B) Angle at full insertion
28Speculum Examination of Internal Genitalia Hold speculum in right handPlace two fingers just inside or at the introitus and gently press down, this will help guide the speculum into the vagina openingThe speculum has to be closedInsert closed speculum obliquely into vagina at a 45 degree angle rotating 50 degrees counterclockwiseAngle at full insertion
29Warm water Not too hot Lubricates speculum Spread labia Keep labia apartBlades remain closed until fully inserted
30Speculum Examination of Internal Genitalia Avoid trauma to the urethraCare is taken to avoid pulling pubic hair or pinching the labiaMaintaining downward pressure, open blades slowly after full insertion and position the speculum so that the cervix can be visualizedWhen the cervix is in full view, the blades are locked in the open positionOpen speculum cupping cervix
31Examination/Collection Specimen of the Cervix Inspect the cervixOs:Nulliparous—small round, ovalParous/multiparous--linear, irregular, stellate
32Inspect the cervix Erosion Ectropion Color should be uniformly pink DysplasiaColor should be uniformly pink
33Bluish--Chadwick's sign, presumptive sign of pregnancy. Inspect the cervixPale--anemiaBluish--Chadwick's sign, presumptive sign of pregnancy.Physiological discharge--odorless, colorless Culture any dischargeErythema around cervixPolyps
34Ayers Spatula Concave end to fit the cervix Convex end for vaginal wall and vaginal pool scrapingsThe Ayers spatula is specially designed for obtaining Pap smears. The concave end (curving inward) fits against the cervix, while the convex end (curving outward) is used for scraping vaginal lesions or sampling the "vaginal pool," the collection of vaginal secretions just below the cervix.The spatula is made of either wood or plastic. Both give very satisfactory results.
35Sample Cervix Use concave end Rotate 360 degrees Don’t use too much force (bleeding, pain)Don’t use too little force (inadequate sample)The concave end of the spatula is placed against the cervix and rotated in circular fashion so that the entire area around the cervical opening (os) is sampled. Usually this can be done without causing any discomfort, although some women are sensitive to the sensation and may experience minor cramping. Sometimes, obtaining this sample causes some bleeding. In this case, reassure the patient that:1. although she may have some minor bleeding or spotting for a few hours, it is not dangerous,2. it will stop spontaneously and promptly3. it is caused by the Pap smear.
36Cytobrush Insert ~ 2 cm (until brush is fully inside canal) Rotate only 180 degrees (otherwise will cause bleeding)Push the cytobrush into the canal, no deeper than the length of the brush (1.5 cm cm). Rotate the brush 180 degrees (half a circle) and pull the cytobrush straight out. Don't keep spinning the brush round and round or you will cause bleeding. Even the 180 degree rotation may cause a little bleeding but usually it doesn't.
37Make Pap Smear As thin as possible Properly labeled Label the slide with pencil on the frosted end.Two slides may be made, one for the spatula and one for the brush (“two-slide” technique). Alternatively, a single slide may be used (the “one-slide” technique) in which the brush is spread on one half the slide and the spatula is used on the other half. Both techniques give good results.
38Spray with Fixative Within 10-15 seconds Allow to fully dry before packagingCytologic Fixative (hairspray works acceptably also)Allow the slides to dry completely before placing them in the Pap smear container. Once dry and packaged, it is best to send them out promptly for interpretation. When operational circumstances disallow prompt sending of the slides, they can be held for weeks to months without significant loss of readability.Make sure the slides are properly labeled and that important clinical information is included with the requisition. Telling the cytologist that the patient has had a hysterectomy will save considerable amounts of time in evaluating the smear.For women who have had a hysterectomy, Pap smears are obtained by using the convex end of the Ayers spatula, scraping it horizontally across the top of the vagina. Then the cytobrush is used to reach into the the right and left top corners of the vagina.
39Inspection of the Vagina Withdraw the speculum slowly while observing the vaginal wallClose blades as the speculum emerges from the introitusInspect vaginal mucosa as the speculum is withdrawn
403. Perform a Bimanual Examination From a standing position, introduce the index finger and middle finger of your gloved hand into the vaginaExert pressure posteriorlyYour thumb should be adducted with the ring finger and little finger into your palm to avoid touching the clitoris.
41Perform a Bimanual Examination Palpate the vaginal walls as you insert your fingers for tenderness, cysts, nodules, masses or growthsIdentify the cervix, noting the following:Position--anterior or posteriorShape--pear-shapedConsistency-firm or softSizeuterine enlargement suggests pregnancy, benign or malignant tumors.The uterus should be cm long
42Identify the Uterus Noting the Following Mobility-should be mobile in the antero-postero plane- deviation to the left or right is indicative of adhesions, pelvic masses of pregnancyTenderness-suggests PID process or ruptured tubal pregnancyMasses.
43Perform a Bimanual Examination Palpate the fornix around the cervixThe os should admit your fingertip 0.5 cmPlace your free hand on the patient's abdomen midway between the umbilicus and symphysis pubis and press downward toward the pelvic hand
44Bimanual Examination Identify Right Ovary and Masses in the Adnexa Place your abdominal hand on the right lower quadrantPlace your pelvic hand in the right lateral fornixManeuver your abdominal hand downwardUse your pelvic hand for palpation.
45Bimanual Examination Identify Right Ovary and Masses in the Adnexa Felt with the vaginal hand. The ovary has the size and consistency of a shelled oysterNote the size, shape, consistency, mobility and tenderness of any palpable organs or massesRepeat the procedure on the left sideThe normal ovary is somewhat tender when palpatedWithdraw Fingers from Vagina and Change Gloves
48ReferenceBates’ guide to physical examination & history taking, Ninth edition, Lynn S. Bickley and Peter G. Szilagyi, Lippincott Williams & Wilkins, 2007.Textbook of physical diagnosis history and examination, Fourth edition, Mark H. Swartz, W.B. Saunders Company.Edelman A, Anderson J, Lai S, Braner DAV, Tegtmeyer K. Pelvic examination. NEJM 2007;356:e26.