female GU Flashcards
lymph nodes: where do the vulva and lower vaginal drain?
what about internal genitalia? which are palpable?
- Vulva and lower vagina drain to inguinal nodes
- Internal genitalia, including the upper vagina, flow into the pelvic and abdominal nodes WHICH ARE NOT PALPABLE
what is the ectocervix?
Ectocervix- vaginal end of cervix (ecto = outer, on the outside)
external canal of os?
External canal of os— endocervical canal (endo = prefix indicating within, inner)
external canal of os: At puberty the ectropion (columnar cells encircling the os) is replaced by ________ _______
At puberty the ectropion (columnar cells encircling the os) is replaced by squamous epithelium
Squamocolumnar Junction:
_____ ________ lines canal
_______ ________lines the vagina
Squamocolumnar Junction
Columnar epithelium lines canal
Squamous epithelium lines the vagina
what area is tested for a pap smear?
squamocolumnar junction
during puberty these is an increase hormone production leading to what changes in the female sex organs?
increased size of uterus and its endometrial lining, vagina and its vaginal epithelium
how big is the ovary?
Ovary- usually 3.5 x 2x 1.5 cm from adulthood through menopause
what two pelvic slings support the pelvic organs? what does each support?
- Pelvic diaphragm: Deep support
2. Urogenital diaphragm: Support the distal urethra. vagina and uterus And the anal sphincter for support of gut
“the goal of cytology screening is to find the cells BEFORE they are _________”
dysplastic
Cervical cancer screening: Pap smear and HPV infection
Risk factors are ____ and ______.
_____ and _______ found in virtually all of cervical cancers
Cervical cancer screening: Pap smear and HPV infection
Risk factors are viral and behavioral (failure to undergo screening and multiple sex partners)
HPV 16 and 18 found in virtually all of cervical cancers
HPV vaccine- Gardasil targets which HPV strains?
when do girls get it? when do boys get it?
HPV vaccine- Gardasil targets HPV 16, 18 , 6 and 11
Girls ~11-12 but before sexually active ideally
Boys ~ 9-26 – for prevention of genital warts
____ - _____% are squamous cell carcinoma and ____ % adenocarcinoma
80-90 % are squamous cell carcinoma and 20 % adenocarcinoma
Pap smear:
First screen - age ____
Up to 30 yo – screen every ___ years with _____
30 - 65 yo – every ___yrs with _______ if __ consecutive annual cervical cytology results are neg or every 5 yrs if combined cytology and high-risk HPV testing results are neg
(likely weeds)
First screen - age 21
Up to 30 yo – screen every 3 years with cytology
30 - 65 yo – every 3 yrs with cytology if 3 consecutive annual cervical cytology results are neg or every 5 yrs if combined cytology and high-risk HPV testing results are neg
is there screening for ovarian cancer?
none that are effective - can do gene studies for BRCA but most ovarian are not linked to genetics
dysmenorrhea (abnormal periods): primary vs secondary cause
- usually from prostaglandins
2. includes endometriosis, adenomyosis, pelvic inflammatory disease, and endometrial polyps
amenorrhea (absence of periods): primary vs secondary cause
Primary amenorrhea: (NOT abnormal) Secondary amenorrhea: Pregnancy Low body weight Chronic illness Hypothalamic-pituitary-ovarian dysfunction
dysmenorrhea vs amenorrhea
dys: abnormal periods
a: no periods
what is polymenorrhea?
less then 21 days between cycles
oligomenorrhea vs menorrhaghia vs metrorrhagia
Oligomenorrhea- infrequent bleeding
Menorrhagia- excessive flow
Metrorrhagia- intermenstrual bleeding
Dx of PMS is based on what? (weeds)
Signs and symptoms 5 days prior to menses for at least three consecutive cycles
Cessation of symptoms within 4 days after onset of menses
Interference with daily activities
Gravida/Para Notation “Gs and Ps”
G= ? P= ?
TPAL?
Gravida/Para Notation “Gs and Ps”
G= gravida, or total number of pregnancies
P= para, or outcomes of pregnancies or the number that were carried to a viable gestational age (twins still only count as 1 “P”)
T=full term birth >37 weeks
P=premature < 37 weeks
A=abortion includes therapeutic and elective
L=living child total number of living children
when asking about STDs what do you want to be “wary” of ?
Partner in room, parents in room, “cheating” partners
techniques of exam: Always interview the patient with.... Encourage patients to wear \_\_\_\_\_ Encourage patients to bring \_\_\_\_\_\_\_\_ Watch the patient’s \_\_\_\_ Warn the patient .... Touch \_\_\_\_ \_\_\_\_\_ \_\_\_\_ first Once you have touched her ... \_\_\_\_the speculum! \_\_\_\_the stirrups Don’t talk about “\_\_\_\_\_”
Always interview the patient with her clothes on! Encourage patients to wear socks Encourage patients to bring a companion Watch the patient’s face Warn the patient before you touch her Touch the upper thigh first Once you have touched her, don’t lose contact Warm the speculum! Pad the stirrups Don’t talk about “blades”
what two types of speculum do you use?
Pederson, Graves
positioning the pt :
Put your hand at the end of the table over the sheet and have the patient move down until what?
Drape the sheet around the legs and arrange so that you can see the patient and only the ______ is visible.
until she feels your hand.
only the perineum is visible.
what are you inspecting when you inspect the external genitalia?
assess tanner stage then... mons pubis labia majora perineum labia minora clitoris urethral meatus vaginal opening (introitus) Anything patient is concerned about
external exam:Palpate any _____
If any swelling or historical indications, check _______ _____
lesions, bartholin’s glands
external exam: If any historical indications, milk ______ _____
culture: ______
milk: Skene’s (paraurethral) glands
culture: any discharge
are bartholin’s or skenes glands usually palpable?
normally nonpalpable; swelling and tenderness indicate abnormality (e.g., abscess).
how would you test for relaxation of supporting structures? (what are you palpating and how are you doing this?
Palpate perineal tone.
–> Tell patient to hold breath and strain (Valsalva Maneuver).
3 parts of internal exam
Assess support of vaginal walls
Speculum examination
Bimanual Examination
how do you assess the support of vaginal walls? what would warrant further investigation?
Separate labia with two fingers ask patient to strain. – bulging of the vaginal walls
when yo u are testing the relaxation of supporting structures, what would inidicate abnormality? what would you maybe inquire about after?
Involuntary loss of urine, or descent of vaginal wall or cervix to the introitus indicates abnormality. Inquire about loss of urine with cough or sneeze.
3 characteristics you assess the vagina and cervix for?
Color
Discharge
Lesions
Nulliparous vs Multiparous Os?
Nulliparous (circular os)
Multiparous (slit like os)
what characteristics of the cervix do you need to note? (5)
Determine color, size, shape, consistency, and mobility
what doesa normal cervix look like? (size, color, type of epithelium)
Normal: 2-3 cm
Pink, smooth epithelium
Squamocolumnar junction
abnormal cervix will show what 4 possible things?
ulcer
growth
Eversion of cervix
Endocervical epithelium may grow out into vaginal portion of cervix
Nabothian (retention) cysts on the cervix, are these worrisome?
Nabothian (retention) cysts are of little clinical importance
inspect the vaginal wall while ….
removing the speculum
what should you take note of about the mucosa of the vaginal wall? (5)
- Color of mucosa- pink, rugated, pliable
- Inflammation
- Discharge-Thin, clear fluid (from cervical secretions)
- Ulcers
- Masses
what is bulging of the anterior vaginal wall? what avout posterior?
Bulging of anterior wall (cystocele); posterior wall (rectocele)
what must you note about any abnormal fluid in/near the vaginal wall? (4)
fluid characteristics (odor, color, consistency, quantity)
Be sure the speculum is ____ before removal!
closed
how do you warm the speculum?
with warm water
how do you insert the speculum: Apply \_\_\_\_\_\_\_ pressure at ...... Slide speculum .... Do NOT put pressure on the \_\_\_\_\_\_\_!!! Angle the speculum \_\_\_\_\_\_ Push along the \_\_\_\_\_ \_\_\_\_\_\_\_of the vagina Once inserted into the vagina....
Apply downward pressure at the lower margin of the introitus
Slide speculum at an angle in a slightly downward slope
Do NOT put pressure on the urethra!!!
Angle the speculum vertically
Push along the back wall of the vagina
Once inserted into the vagina, open speculum and find the cervix
how to remove the speculum:
First,…..
Disengage the speculum from the ______, then slide the speculum out slowly while ….
Let the _______ close the speculum and you rotate …. This ensures you do NOT …..
First, unscrew the thumb screw- KEEPING pressure on the handle to keep speculum open
Disengage the speculum from the cervix, then slide the speculum out slowly while you inspect the vaginal walls.
Let the pressure from the vagina close the speculum and you rotate the same way you did to put it in. This ensures you do NOT pinch the labia.
which speculum for sexually active women? virgins/elderly? parous women with vaginal prolapse?
The medium Pederson is usually comfortable for sexually active women. The Narrow Pederson for virgins or elderly women Graves speculum are suited for parous women with vaginal prolapse
bimanual exam.. what fingers do you use? what are you palpating? (4)
LUBRICATE! (water vs. jelly). Use index and middle finger Palpation: Cervix Uterus (and it's fornices (arches)) Ovaries Vaginal wall
when you palpate the vaginal wall on bimanual exam, what are you noting?
(Note nodularity or tenderness of vaginal wall)
what are you looking for when you palpate and move the cervix?
Chandelier’s sign (PID)
when you palpate the cervix, what are you noting? (6)
Position Shape Consistency Regularity Mobility Tenderness
how do you palpate the uterus? (long explanation)
place exterior hand midway between umbilicus and symphysis pubis. Elevate the cervix and uterus with your pelvic hand and capture uterus between the two hands. Then move your pelvic hand to the anterior fornix to evaluate the anterior uterus; abdominal hand can now evaluate the posterior uterus
what are you noting when you palpate the uterus? (5)
Size Shape Consistency Mobility Tenderness and or masses
how do you palpate the ovary ?
abdominal hand in right lower quadrant. Pelvic hand in right lateral fornix. Try to capture the ovary between the two hands.
how do you palpate the vaginal wall? (what are you checking for?)
Check for strength of pelvic muscles
Spread fingers to touch the vaginal walls. Ask patient to squeeze her muscles around them and hold for as long as she can. Normal is compresses fingers snugly, pulls them upward and inward and held for at least 3 seconds.
what can you feel with the rectovaginal exam?
the posterior cervix and uterus and evaluating a retroverted uterus.
instead of “blades” of the speculum, call them what?
bills - like a birds
what would you do if you suspect gonorrhea or chlamydia? what is the process for this?
culture
Must use Dacron Q-tip and turn in os and leave in os at least 20 seconds.
for wet mount, use saline for what? KOH or what?
saline: trichomonas
KOH: BV and yeast
what do you used to determine vaginal pH? what is normal?
Determine pH with Nitrazine or pH paper (normal is 4.5 and below)
what is the “whiff” test for?
for amine odor characteristic of bacterial vaginosis
cervical scrape pap smear
Longer end of scraper in cervical os, press and turn in full circle including transformation zone in sample. Smear on glass slide; may cause some bleeding
endocervical brush pap smear
Place brush in os and roll between thumb and index finger clockwise and counterclockwise; Smear slide with brush gently
for pap smear, spray slide with ______
Spray slide with fixative
what do you use in place of endocervical brush in pregnant women?
Cotton-tipped applicator with saline in place of endocervical brush in pregnant women
cervical broom pap smear: what specimen do you do this for? how do you do it?
– Single specimen with both squamous and columnar epithelial cells. Rotate tip of brush in os in full clockwise direction then stroke each side of brush on glass slide. Promptly place slide in solution or spray with fixative or place sample directly into preservative (liquid-based cytology)
