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Pelvic examination

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1 Pelvic examination

2 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 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

4 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)

5 Anatomy Keep in mind the basic anatomy of the vulva.

6 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.

7 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

8 Speculum (appropriate size plastic or metal)
Preparation Make sure the nurse has all of the necessary materials for the exam: Speculum (appropriate size plastic or metal) GYN cotton-tipped over head lamp Gloves

9 Slide and fixative or liquid media
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

10 Positioning Privacy Buttocks just off table Good Lighting Drape

11 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.

12 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

13 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

14 Inspection Perineum--slightly darker than the skin of the rest of the body. Mucous membranes appear dark pink and moist

15 Inspection Separate the labia and inspect the labia minora:
Clitoris Urethral orifice Hymen Vaginal orifice

16 Inspection Note the following: Discharge Inflammation Edema Ulceration
Lesions Prolapse Stress incontinence

17 Sequence of a Pelvic Examination
Note abnormalities such as: Bulges and swelling of vulva and vagina Enlarged clitoris Syphilitic chancres Sebaceous cyst Primary Syphilis

18 Skene's glands examination
Near the urethra Suspect inflammation; check for urethral discharge

19 Skene'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 outward Do this on both sides and note any discharge. Obtain specimen for culture. Change glove if discharge is found.

20 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 discharge

21 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.

22 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).

23 Inspection Inspect the anus at this time, note presence of lesions and hemorrhoids

24 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.

25 Appropriate Speculum Choice
Grave’s speculum Width mm Length mm Pederson speculum Width mm Length mm

26 Plastic 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

27 Angle of insertion Angle of insertion at entry and B) Angle at full insertion

28 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

29 Warm water Not too hot Lubricates speculum Spread labia
Keep labia apart Blades remain closed until fully inserted

30 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

31 Examination/Collection Specimen of the Cervix
Inspect the cervix Os: Nulliparous—small round, oval Parous/multiparous--linear, irregular, stellate

32 Inspect the cervix Erosion Ectropion Color should be uniformly pink
Dysplasia Color should be uniformly pink

33 Bluish--Chadwick's sign, presumptive sign of pregnancy.
Inspect the cervix Pale--anemia Bluish--Chadwick's sign, presumptive sign of pregnancy. Physiological discharge--odorless, colorless Culture any discharge Erythema around cervix Polyps

34 Ayers Spatula Concave end to fit the cervix
Convex end for vaginal wall and vaginal pool scrapings The 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.

35 Sample 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 promptly 3. it is caused by the Pap smear.

36 Cytobrush 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.

37 Make 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.

38 Spray with Fixative Within 10-15 seconds
Allow to fully dry before packaging Cytologic 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.

39 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

40 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.

41 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 cm long

42 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.

43 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

44 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.

45 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


47 SUMMARY PELVIC EXAM Inspect Externally Palpate Skene’s Glands
Palpate Bartholin’s Glands Assess Outlet Speculum Exam Bimanual Exam Vagina, Cervix, Uterus, Adnexa

48 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.

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