Female Genitalia / Pap Flashcards
Female anatomy image
Types of specula
A. Pediatric Pederson speculum. This may be selected for child, adolescent, or virginal adult examination.
B. Graves speculum. This may be selected for examination of parous women with relaxed and collapsing vaginal walls. (long as Pederson, but wider)
C. Pederson speculum. This may be selected for sexually active women with adequate vaginal wall tone. (regular size)
- There are larger ones. Why use them – obesity. Vaginal walls collapse.*
- Also some better for virginal adults – like Pederson but skinnier*
Speculum procedure
- Labia separated gently
- Insert below urethral meatus
- 45o angle
- Downward pressure
- Rotate blades, open
- Visualize cx
- Inspect (tighten blade)
Wet prep before cervical specimen
Ectropion
endocervical cells protrude out through os into vaginal portion. Normal in pregnancy, on OCPs, in teens.
Os after vaginal birth
Smiling/slit
Where to collect cervical specimen
specimen at os. Squamocolumnar junction & transformation zone
Nabothian cyst
Benign. Glandular secretion – mucous secreting columnar cells covered by squamous epithelium
Bimanual exam procedure
- Insert gloved index & middle finger
- Lubricant vaginal hand
- Palm up, watch thumb (clit)
- Palpate vagina for masses
- Cervical motion tenderness
- Cervix – size, shape, consistency, mobility, position, dilatation
- Palpate uterus with fingers
- Abdominal hand pressing down
- Position
- Size, consistency, mobility, contour
- Fibroids? Pregnant?
- Ovaries – often not palpable
- Pelvic tone (squeeze fingers – w/pelvic muscles)
- Rectocele, cystocele (bear down)
palpating uterine position
- Sweep index finger up along anterior length
- Anteverted – isthmus sweeps upward.
- Retroverted, may feel flatter, may feel it going backward (harder to feel for when retroverted).
- Obese – you may not feel – document this.
HPV common types
- Types 6,11: 90% genital warts
- Types 16,18: 70% cx CA
Risk Factors Cervical CA
- Onset intercourse ≤18
- Multiple sexual partners
- Partner with multiple partners
- Smoking (2-3 x ↑ risk cx CA)
- Immunosuppression (HIV, meds)
- OCPs
- Less barrier use, ↑ risk STIs, HPV
pap <21
not recommended
Pap recommendatations 21-65
q 3 years cytology
HPV cotest recommendations
- <30 not recommended
- 30-65 q 5 years preferred
HPV testing alone
not recommended
Pap >65yo
not indicated unless hx CIN2/3/AIS
pap post-hysterectomy
Cx removed – stop screening unless cervical CA
Cx present – continue per guidelines
Normal vaginal secretions, characteristics, pH
- Leukhorrea
- Changes – hormonal
- Normal secretions
- PH 3.8-4.5
- No itching or irritation
- Heterogeneous suspension
- Clear or white
- Consistency depends on cycle
Equipment for wet prep
- Microscope
- Slides, cover slips
- Cotton-tipped applicator
- 10% KOH solution
- Saline
- PH paper 3.0-5.5 range
Normal wet prep organisms
- Lactobacilli – predominate normal d/c
- Epithelial cells
- WBCs
- WBC: Epithelial ≤ 1:1
- RBCs
Wet prep: abnormal pathogens
Candida & trich: not seen 40% time
BV: often seen asymptomatic women
BV: discharge
- Thin, homogenous milky white, gray or yellowish
- Adherent, often increased
- Odor (d/t amines)
BV pH
>4.5
BV dx
- pH >4.5
- whiff test
- Wet prep
- No ↑ WBCs
- No candida
- Clue cells
BV bacteria
gardnerella vaginalis, bacteriodes, microplasma, reduced lactobacilli
Vaginitis: Trichomonas Vaginalis
What to expect on exam
- D/C yellow-green frothy, adherent
- Dysuria may be present
- Pruritis may be present
- Dyspareunia may be present
- Strawberry spots cx
Vaginitis: Trichomonas Vaginalis
What to expect on wet prep
- pH > 4.5 often > 5.5
- +/- “Whiff”
- ↑ WBCs
- Motile trichomonads
Can present similarly to BV, discharge different
Candidal Vulvovaginitis
what to expect on exam
- Intense burning, itching
- May have dysuria (esp if scratching, adds to dysuria)
- Often worst immediately preceding menses
- Often have dyspareunia
- Discharge white, cottage cheese-like
Candidal Vulvovaginitis
What to expect on wet prep
- pH usually < 4.5
- No amine odor
- KOH (wet prep): Hyphae, spores
may see lots or very little on wet prep, not correspond to symptoms
Condylomata Acuminata
- Genital warts
- They are bumps, st cauliflower like
- Can be all over, to perianal
- NO test
- Treat w/acid, creams, laser, etc
Herpes Simplex Virus
- Mucocutaneous lesions
- Herpes has many stages – this stage is easiest to do swab, get positive culture result
- Earlier stages can show bumps/vesicles
- Severe dysuria, pain
- Can treat pain
primary dysmenorrhea, causes
d/t increased PG production during luteal phase of menstrual cycle, when estrogen adn progesterone levels decline
secondary dysmenorrhea, causes
e.g., endometriosis, adenomyosis (endometeriosis in the muscular layers of uterus), PID, endometrial polyps
Primary amenorrhea
period never starts
secondary amenorrhea
cessation of periods - e.g., d/t pregnancy, lactation, menopause
low body weight (d/t malnutrition, anorexia, stress, chronic illness, hypothalamic pituitary ovarian dysfunction)
postcoital bleeding
cervical polyps or cancer, or, in older women, atrophic vaginitis
causes of postmenopausal bleeding
endometrial cancer, hormone replacement therapy, uterine & cervical polyps
amenorrhea followed by heavy bleeding suggests
threatened abortion or dysfunctional uterine bleeding related to lack of ovulation
gravida para notation
, outcome, Full term, Premature, Abortion, LIving
GPFPAL
dyspareunia suggests
Superficial: local inflammation, atrophic vaginitis, inadequate lubrication
Deep pain: pelvic d/os or pressure on a normal ovary
Most common causes of acute pelvic pain
- PID
- Ruptured ovarian cyst
- appendicitis
always r/o ectopic 1st w/UPT, and consider mittelschmerz, tubo-ovarian abscess
mittelschmerz
pain from ovulation at midcycle
Endometriosis
causes chronic pelvic pain
from retrograde menstrual flow and extension of uterine lining outside uterus (50-60% of women w/pelvic pain)
Chronic pelvic pain, consider
endometriosis, adenosis, fibroids, red flag for hx sexual abuse
also consider pelvic floor spasm from myofscial pain w/trigger points on exam
reasons for delayed puberty
familial or r/t chronic illness
abnormal function of hypothalamus, anterior pituitary gland, ovaries
pediculosis pubis
lice/crabs
on exam: excoriations or itchy, small, red maculopapules. Nits or lice at bases of pubic hairs
why enlarged clitoris
in masculinizing conditions
menarche unduly late in relation to development of breasts, pubic hair, check for…
imperforate hymen
lateral displacement of cervix suggests
endometriosis involving uterosacral ligaments
yellowish discharge on endocervical swab suggests
mucopurulent cervicitis d/t chlamydia trachomatis, neisseria gonorrhoeae, or herpes simplex
Raised wartlike lesions occur in…
condylomata or cervical cancer
vaginitis w/discharge can result from…
candida, trichomonas vaginalis, bacterial vaginosis
rectovaginal mass could be…
stool or malignancy
Stool: can usually be dented by digital pressure. Do rectovaginal exam
cervical motion tenderness suggests
PID, ectopic pregnancy, appendicitis
ovaries 3-5 y after menopause
usually atrophic and nonpalpable. If palpable, investigate for ovarian cyst or cancer.
If pelvic pain bloating, increased abdominal size, urinary tract sx, more common in women w/ovarian cancer
most common hernia in women
indirect inguinal. Femoral is 2nd
lab eval trich
saline wet mount for trichomonads
lab eval candidal vaginitis
Potassium hydroxide (KOH) prep for branching hyphae of Candida
lab eval BV
- saline wet mount for clue cells (epithelial cells w/stippled borders);
- sniff for fishy odor after applying KOH (whiff test)
- vaginal secretions pH >4.5
