Learning outcomes The 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.
3 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
Indications for pelvic exam include Vulvar or vaginal complaints Abdominal pain in a woman Exposure to sexually transmitted infection Pregnancy (known or proven) Health maintenance (to perform pap smear)
Before the exam Help the woman relax Remind the woman to take deep breaths and to let her body relax Fear Some women are afraid to have pelvic exams, such as women who have never had pelvic exams, and women who have had exams that were painful. Shame When 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.
Preparation Wash hands Introduce yourself to the patient using full name Make sure that you have privacy. Ensure that the room is sufficiently worm Prepare all the tools you will need for the exam Exam best performed when patient has empty bladder
Preparation Make sure the nurse has all of the necessary materials for the exam: Gloves Speculum (appropriate size plastic or metal) GYN cotton-tipped over head lamp
Preparation Make sure the nurse has all of the necessary materials for the exam: Lubricant Pap material (cytobrush, spatula, cervical broom.) Slide and fixative or liquid media
Positioning Privacy Buttocks just off table Good Lighting Drape Standby
Before the exam Ask 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 bed If she is not down far enough, inserting the speculum can be more difficult and uncomfortable for her.
Before the exam Appropriate 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
Inspection Inspect the client's external genitalia Perineal area must be well illuminated Both hands are gloved to prevent the spread of infection Mons pubis--note quantity and distribution of hair growth Labia--usually plump and well-formed in adult female
Inspection Perineum--slightly darker than the skin of the rest of the body. Mucous membranes appear dark pink and moist
Inspection Separate the labia and inspect the labia minora: –Labia minora –Clitoris –Urethral orifice –Hymen –Vaginal orifice
Sequence of a Pelvic Examination Note abnormalities such as: –Bulges and swelling of vulva and vagina –Enlarged clitoris –Syphilitic chancres –Sebaceous cyst Primary Syphilis
Skene's glands examination Skene's glands –Near the urethra –Suspect inflammation; check for urethral discharge
Skene's glands examination Skene's glands 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 outward Do this on both sides and note any discharge. Obtain specimen for culture. Change glove if discharge is found.
Bartholin's glands examination If there is history or appearance of labial swelling check Bartholin's glands –Insert index finger up to first knuckle –With your index finger and thumb, palpate the posterolateral area of the labia majora noting any: Swelling Tenderness Masses Heat or dischar ge
Bartholin'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.
Assess the support of the vaginal outlet With the labia separated by middle and index finger Ask patient to strain down Note any bulging of the vaginal walls (cystocele and rectocele).
Inspection Inspect the anus at this time, note presence of lesions and hemorrhoids
Speculum Examination of Internal Genitalia Select a speculum of appropriate size, lubricate and warm with warm water) –Small--not sexually active female –Medium--sexually active –Large--women who have had children Medium to large speculum may be used if female has had children.
Appropriate Speculum Choice Pederson speculum Width 13-25 mm Length 75-120 mm Grave’s speculum Width 20-38 mm Length 75-115 mm
Metal speculae (side view): A) small Pedersen, B) medium Graves, C) large Graves Plastic speculae (side view): A) small Pedersen, B) medium Pedersen, C) large Pedersen
Angle of insertion Angle of insertion at entry and B) Angle at full insertion
Speculum Examination of Internal Genitalia Hold speculum in right hand Place two fingers just inside or at the introitus and gently press down, this will help guide the speculum into the vagina opening The speculum has to be closed Insert closed speculum obliquely into vagina at a 45 degree angle rotating 50 degrees counterclockwise Angle at full insertion
Spread labia Keep labia apart Blades remain closed until fully inserted Warm water Not too hot Lubricates speculum
Speculum Examination of Internal Genitalia Avoid trauma to the urethra Care is taken to avoid pulling pubic hair or pinching the labia Maintaining downward pressure, open blades slowly after full insertion and position the speculum so that the cervix can be visualized When the cervix is in full view, the blades are locked in the open position Open speculum cupping cervix
Examination/Collection Specimen of the Cervix Inspect the cervix –Os: Nulliparous—small round, oval Parous/multiparous-- linear, irregular, stellate
Inspect the cervix Color should be uniformly pink Ectropion Erosion Dysplasia
Inspect the cervix Pale--anemia Bluish--Chadwick's sign, presumptive sign of pregnancy. Physiological discharge--odorless, colorless Culture any discharge Polyps Erythema around cervix
Ayers Spatula Concave end to fit the cervix Convex end for vaginal wall and vaginal pool scrapings
Sample Cervix Use concave end Rotate 360 degrees Don’t use too much force (bleeding, pain) Don’t use too little force (inadequate sample)
Cytobrush Insert ~ 2 cm (until brush is fully inside canal) Rotate only 180 degrees (otherwise will cause bleeding)
Make Pap Smear As thin as possible Properly labeled
Spray with Fixative Within 10-15 seconds Allow to fully dry before packaging Cytologic Fixative (hairspray works acceptably also)
Inspection of the Vagina Withdraw the speculum slowly while observing the vaginal wall Close blades as the speculum emerges from the introitus Inspect vaginal mucosa as the speculum is withdrawn
3. Perform a Bimanual Examination From a standing position, introduce the index finger and middle finger of your gloved hand into the vagina Exert pressure posteriorly Your thumb should be adducted with the ring finger and little finger into your palm to avoid touching the clitoris.
Perform a Bimanual Examination Palpate the vaginal walls as you insert your fingers for tenderness, cysts, nodules, masses or growths Identify the cervix, noting the following: Position--anterior or posterior Shape--pear-shaped Consistency-firm or soft Size uterine enlargement suggests pregnancy, benign or malignant tumors. The uterus should be 5.5-8.0 cm long
Identify 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 pregnancy Tenderness-suggests PID process or ruptured tubal pregnancy Masses.
Perform a Bimanual Examination Palpate the fornix around the cervix The os should admit your fingertip 0.5 cm Place your free hand on the patient's abdomen midway between the umbilicus and symphysis pubis and press downward toward the pelvic hand
Bimanual Examination Identify Right Ovary and Masses in the Adnexa Place your abdominal hand on the right lower quadrant Place your pelvic hand in the right lateral fornix Maneuver your abdominal hand downward Use your pelvic hand for palpation.
Bimanual Examination Identify Right Ovary and Masses in the Adnexa Felt with the vaginal hand. The ovary has the size and consistency of a shelled oyster Note the size, shape, consistency, mobility and tenderness of any palpable organs or masses Repeat the procedure on the left side The normal ovary is somewhat tender when palpated Withdraw Fingers from Vagina and Change Gloves
Reference Bates’ 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.