Female GU/Breast (Dr Keeler) Flashcards
“Talk before – and as - you touch”
- Explain what to expect at each step
- Touch a neutral area before the sensitive ones
Have patient empty bladder ____ the examination
BEFORE
Pelvic Exam Patient Position:
dorsal lithotomy position with feet in footrests and HOB raised ~~30-40 deg
During the exam….
- Be gentle, maintain eye contact and be prepared
Use the term ____instead of “stirrups”.
“footrests”
A Pt’s First pelvic exam
- sit down w/pt in your office first
- use a model to show basics
- use a Pederson Speculum to demonstrate
- ask if she wants a mother/friend present
- coach pt about perineal mm and relaxation of that area
- touch neutral areas first
Confidentiality applies to?
any female pt regardless of her age
Confidentiality includes?
Anything remotely in the area of “sex”, “reproduction”, “pregnancy”, “STD’s”, “birth control”
To “disclose” information ….
get CONSENT and put it prominently in record
______ is NOT a sufficient reason to disclose daughter’s information to her mother !!!!!!!!!
“But she is on my insurance!”
A pt may _____consent at anytime
withdraw
When do you need a chaperon?
- Every time, no mater your gender
In general, female hair distribution is shaped like ____ – but a slight “diamond” is _____
a triangle…..not necessarily “pathological” – ethnic component
Thelarche
age at earliest breast development (“bud”)
Adrenarche
age at first pubic hair growth (awakening of the adrenal gland)
Menarche
= age at first period (11-12 avg)
Thelarche is ____menarche.
1-2 years before menarche
Menarche heavily dependent on ….
% body fat – threshold ~~~ 20%
Inspection: Labia majora
majora-rashes,excoriation,ulcers, trauma
Inspection: Labia minora
ulcerations, inflammation – length highly variable
Inspection:Clitoris
size, usually 2 cm or less in length
Inspection: Urethral orifice
inflammation, discharge
Inspection: Vaginal introitus
hymen or remnants
Inspection: Bartholin and Skene’s glands
swelling or tenderness, discharge from Skene’s
Clitoral Hypertrophy: Child? Adult?
Infant/child = “Intersex” issue
Adult = suggests testosterone issue
How to help prevent Vulvar Carcinoma in older pts?
brief, vulvar only exam
DDX for Vulvar squamous carcinoma?
Pruritis
Vulvar squamous carcinoma
- red or white lesions (need bx)
- there is an “in-situ” preliminary stage
Vulvar squamous carcinoma Treatment?
- 5-fluoro-uracil (FU) topically
- CO2 laser
- LEEP
- Vulvectomy
Lichen Planus treatment?
ts isnt easy - Refer to a dermatologist comfortable with gyn
Lichen sclerosis appearance - gross and bx
- Pruritic white change, widespread, tissue-paper thin
- Biopsy shows thin epithelium w/ underlying inflammatory infiltrate
Lichen sclerosis tx?
topical testosterone or steroids
Lichen sclerosis is _____ a “pre-malignant” condition
NOT
Candida Infection characteristics
- white cheesy discharge
- pruritis
- erythema
Candida Infection test
Wet mount (WM) w/KOH or VIP = looking for hyphae
Candida Infection Associations
OCP, Preg, antibx, DM, HIV
Trichomonas Infection Characteristics
- Pruritis, odor, OTC yeast Tx fails
- Greenish watery disch occurs w/ froth
Trichomonas Infection test
- WM w/ saline = active trich
- note KOH/VIP will kill it
Bacterial Vaginosis is an ______ and is ______.
an environmental issue and is very common
Bacterial Vaginosis Characteristics
- Yellow creamy frothy disch., “fishy” odor, Minimal pruritis
Bacterial Vaginosis causes
Obesity, hot tubs, uncercumcised partners, dietary
Bacterial Vaginosis test
WM esp w/VIP, saline OK = “clue cells”
Bacterial Vaginosis tx and prevention
- Tx: metronidazole x 7 d
- Prev: dietary (daily yogurt, probiotic)
Wet mount procedure
- On slide (2 or 3) – drop or 2 of KOH, saline, (optional) VIP. Put on slide before the sample.
- Plain swabs (2) of discharge – obtain from vagina. “Roll” onto microscope slide. Apply cover slip.
VIP = ?
crystal violet + alcohol + saline.
What will kill Trichomona on a WM? what to use instead?
- KOH and VIP will kill
- Use saline instead
Pt will often believe their vaginal infection is ____ and will ___?
is yeast and will try to treat with OTC methods
If OTC treatment is used ______.
WAIT 4-5 days before appointment – Tx will obscure the micro on your WM
Position of Bartholin Glands?
5 and 7 o’clock
What to do with Labial swelling or pain?
inspect and palpate the Bartholin glands
Bartholin Glands Abscess is usually preceded by what?
a cyst
Common causes of Bartholin Glands Abscess?
Gonococcus and chlamydia
Bartholin’s Gland Abscess- Tx
- Soaks, analgesics
- Antibiotics – choose wisely = need 2nd gen cephalosporin
- Surgical: I&D, I&D w/ “Word” catheter, Marsupialization create a pouch, Full excision
Urethra/Skene’s - exam
- “Stripping” or “milking” of urethra results in cloudy discharge
- Culture, antibx
- Urological consult
Skene’s Gland Abscess
- Danger to urethra
- Don’t I&D yourself
- Urological referral !
Cyctocele
wall between the bladder and vagina is weak
Rectocele
wall between rectum and vagina is weak
What is often present with a Cyctocele?
“SUI” = stress urinary incontinence - often present
Cyctocele tx?
Surgery not required; Pessary may help
What to ask about with a Rectocele?
Ask about “digital defecation”
Rectocele tx?
Surgery not required;
How to check for severity of a rectocele?
“Degree” of rectocele may not be apparent unless ValSalva is done
Uterine Prolapse First degree:
The cervix droops into the vagina.
Uterine Prolapse Second degree:
The cervix comes down to the opening of the vagina.
Uterine Prolapse Third degree:
The cervix is outside the vagina
Uterine Prolapse Fourth degree:
The entire uterus is outside the vagina. This condition is also called procidentia. This is caused by weakness in all of the supporting structures.
Pelvic Prolapse - advanced Pt characteristics
- older, multiparous, denial
Advanced Pelvic Prolapse Risks
Ulcers and cancer
Advanced Pelvic Prolapse Tx?
- Pessary - minimal help
- Surgery works, but is very complicated – “urogynecologist”
Insertion of the Speculum
- Separate the labia minora with 2 fingers of one hand and insert the speculum with the other.
- Pressure should be on the perineum and then the posterior wall of the vagina (not the anterior wall which is very sensitive)
- AVOID catching pubic hair & labia
- Follow the posterior wall as it angles down towards the sacrum.
- Do not open the speculum until fully inserted.
- Adjust set-screws for maximal visualization. –> Release them before removal!!!
Speculum angle of insertion: “traditional” and Keeler
- Traditional = 45 deg angle
- Keeler = horizontally ( 0 deg)
Speculum Placement – a better way (zero degrees)
- Select appropriate type.
- Warm and lubricate with warm water or gel.
- Hold HORIZONTALLY and point downward or posterior.
- Put gentle downward pressure on the posterior introitus. COACH!!
- Gently advance, maintaining posterior pressure.
- Slowly open the speculum to visualize the cervix.
Inspection of vagina Epithelium and dischage
- looking for rugae, atrophy, and lesions
- be ready to do a WM if discharge is present
inspection of vagina: Gartner’s duct remnants
- = cysts
- found to the side of the cervix
- LEAVE ALONE
inspection of vagina: Inclusion cyst from episiotomy
just inside introitus between 5 & 7 o’clock - leave it alone**
CAN’T FIND THE CERVIX??
- OK to stop and do single-finger exam to locate
- May be very far anterior – behind [pubic] symphysis
- Vagina may be “deep” – select longer/larger speculum – tell pt to remind you in future
- Sidewalls may “bulge” inwards and cover – from 3 and 9 o’clock – select wider speculum
What to look for on cervical inspection?
- Nabothian Cyst
- Discharge/pus
- Mass
- Tumor
- Erosion – dangerous word –> cancer until proven otherwise
- Lesion
- Color
- Describe the external os – nullip, parous, lacerated, etc.
Nabothian Cysts
- Inclusion cyst of the endocervical glands
- May resemble cervical pathology
- Normal variant – do not needle or biopsy
Common cause of post coital bleeding?
Cervical polyp
Cervical polyp is rarely _____.
CA
Pap Smear
The Papanicolaou test (also called Pap smear) is a medical SCREENING technique primarily designed to detect DYSPLASIA (“premalignancy”) of the cervix at the transformation zone = TZ
PAP Smear: NOT intended to screen for ____. MAY hint at ____. NOT an ______ – but some labs will add this if you request it separately.
NOT intended to screen for ovarian CA. MAY hint at endometrial CA. NOT an STD test – but some labs will add this if you request it separately.
If Pap shows an_____, something went wrong!
invasive cervical CA
Cells should be obtained from the _____.
TZ and endocervix
Transformation Zone
TZ = area between original and current squamocolumnar junction
Squamocolumnar junction (SCJ) “moves” dependent _____.
on age, parity, and hormonal status
Metaplasia is an ____ effect
ESTROGEN
The transformation zone is an area of metaplasia and it is ____.
the location of 90++% of cervical cancers
ECTOPY = ?
- a normal finding
- columnar epithelium is “out” on “portio” of cervix.
- Reddish or red/orange
- symmetrical and circumferential
- may be source of PCB
Ectopy tx?
- requires no intervention - just reassurance
Infectious cervicitis may be caused by:
Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus (HSV), or human papillomavirus (HPV).
CIN =
- cervical intraepithelial neoplasia
- CIN I, II, III = mild, moderate, severe
SIL =
- squamous intraepithelial lesion
LGSIL and HGSIL = ?
low grade SIL and high grade SIL
CIS =
carcinoma in-situ – not a “cancer” – but close!
Cervical DYSPLASIA =
- CIN/SIL
- Slow disease until it’s CIS
- HPV origin – HR types = 16 + 18
- Not often 360 deg
- Often in one quadrant only
- Inspection is good enough to warrant colposcopy/biopsy even if Pap is normal!!!!!
Inspection of the vagina is usually done ____.
as you withdraw speculum, but do it also w/ insertion of speculum
Lesions of the vagina
- Epidermal cysts
- Venereal warts
- Genital herpes
- Chancre (Syphilis)
- Carcinoma
Palpation: Bimanual Exam - Cervix
Tenderness, size, position, mobility
Palpation: Bimanual Exam - uterus
- Size, shape, consistency, mobility
- Position
- Fibroids (nodules)
Palpation: Bimanual Exam - Ovaries
- Size, shape, mobility, tenderness
- Remember to palpate bilaterally - may not be palpable
Palpation: Bimanual Exam - what to inspect?
- cervix
- Uterus
- Ovaries
- Strength of pelvic floor
Version
is the relationship between the fundus of the uterus and the vagina
Flexion
is the relationship between the fundus of the uterus and the cervix – think of this as a “hinge”
size of a golf ball, tennis, soft,
Golf ball = 3 cm
Tennis ball = 5 cm
Softball = 9-10 cm
Adnexae Palpate
- Palpate the “blank space” on either side of uterus. Best done just after period ends.
- You likely won’t feel anything
What do to if you have an adnexal mass
- recheck after one cycle
- Be more suspicious if pt is on BCP - they shouldn’t be ovulating and have functional cysts
What do to if you have an adnexal mass >5 ?
> 5 cm or bilateral or persistent:
- Trans-vaginal ultrasound = “TVUS”
- CA-125 marker
- Gyn consultation
When to do rectal exam?
- Definitely after age +50
- earlier if high risk
- at any point if truly will give better insight
Rectovaginal exam is useful in assessing:
- Posterior wall of vagina
- Rectovaginal pouch (Pouch of Douglas AKA the “cul-de-sac”)
- Retroverted/Retroflexed uterus
the most common inguinal hernia in women?
Indirect hernia
_____is more common in women than in men
Femoral hernia
_________ = common after pregnancy
Umbilical hernia
Ways to to find a hernia?
- “Hooking” of your index finger under inguinal zone during bimanual exam
- Ultrasound with experienced tech
- Diagnostic laparoscopy
A hernia can be present, but it isn’t necessarily______.
the cause of the pain
The breast is composed of _____ which are each composed of several lobules.
15 to 20 lobes
________ travel through the breast (suspensory ligaments of Cooper), insert __________, and provide structural support.
Fibrous bands of connective tissue…..perpendicularly into the dermis
Each lobe of the breast terminates in a _____( 2 to 4 mm in diameter), which opens through a constricted orifice (0.4 to 0.7 mm in diameter) into the________
major (lactiferous) duct …..ampulla of the nipple
Deep to the nipple-areola complex, each major duct has a_________, which is lined with _________.
dilated portion (lactiferous sinus)…….stratified squamous epithelium
Major ducts are lined with________, while minor ducts are lined with _______.
two layers of cuboidal cells…..a single layer of columnar or cuboidal cells
The mature female breast extends from the level of the ______to the inframammary fold at the________
second or third rib ….. sixth or seventh rib.
The mature female breast extends transversely from the ______.
lateral border of the sternum to the anterior axillary line
The deep or posterior surface of the breast rests on the fascia of the ______.
pectoralis major, serratus anterior, and external oblique abdominal muscles, and the upper extent of the rectus sheath.
______quadrant of the breast contains a greater volume of tissue than do the other quadrants.
The upper outer
The axillary “tail of Spence” extends laterally _____
across the anterior axillary fold.
The breast receives its principal blood supply from: (3)
(1) perforating branches of the internal mammary artery;
(2) lateral branches of the posterior intercostal arteries; and
(3) branches from the axillary artery, including the highest thoracic, lateral thoracic, and pectoral branches of the thoracoacromial artery.
______arborize in the breast as the medial mammary arteries
The second, third, and fourth anterior intercostal perforators and branches of the internal mammary artery
______gives off branches to the serratus anterior, pectoralis major and minor, and subscapularis muscles. It also gives rise to _______.
The lateral thoracic artery …… lateral mammary branches
The optimal time to examine the breast =?
5-7 days following the onset of the LNMP
Avoid _____ during a breast exam to respect the pt’s modesty.
total uncovering
Symptoms of Breast Disease
- Erythema
- Masses
- Nipple Discharge
- Nipple Ulceration
DDX for breast erythema?
Mastitis, inflammatory carcinoma
DDX for Breast masses?
Cysts, fibroadenoma, hematoma, carcinoma
DDX for Nipple discharge?
- Bloody, esp single duct - Papilloma, cancer
- Non-bloody – green/clear – may be physiologic (normal) or sign of esp prolactin disorder
DDX for Nipple Ulceration?
- Paget’s disease
- Mechanical causes
_____ is easily incorporated into the “palpation portion” of the exam.
Breast inspection
_____is unacceptable to most patients during a breast exam and should be avoided.
What to do instead?
- “Total exposure”
- Move the gown around! To expose only what you need.
Patient Position for breast Exam?
Supine position is usually sufficient – use sitting only if needed
During Breast inspection, Observe the breast for? (6)
- Development
- Size and symmetry
- Contour
- Retractions or dimpling of skin
- Skin color and texture (Peau d’orange)
- Venous engorgement
During breast inspection, Observe the nipple for? (5)
- Retraction unilateral or bilateral
- Discharge
- Darkening
- Rash, crusting or ulcerations
- Supernumerary nipples
Breast Inspection – if you have a question/suspicion?
Tell patient that sometimes using additional positions will help with a more complete exam. Then, inspect the breast in four additional (sitting) positions
four sitting positions for breast exam:
- Arm over head (gown covers other side)
- Hand against hip (gown covers other side)
- (Maybe) - Palms pressed together
- (Maybe) - Arms extended and bent forward at the waist
Breast Changes in early pregnancy?
- Darkened nipple/areola
- Tubercles of Montgomery (round bumbs found on the nipple)
- Size
- Tenderness (Variable/early)
- Venous engorgement (variable)
Breast changes in late pregnancy?
- BL discharge
- striae
- venous engorgement (Variable)
- Tenderness (Variable/early)
Breast mastitis can be ___ or ____.
puerperal or non-puerperal
Breast Mastitis tx?
- Don’t stop nursing
- ABX directed against staph and strep
Inflammatory Breast Cancer requires? Prognosis?
- Immediate consult and imaging
- poor prognosis
Methods of palpation
- Use pads of your fingers – not the tips
- Vertical or horizontal criss-cross
- Concentric
- SPIRAL !!!!!!
- Use two hands – one does exam, the other shifts and retracts
- Supine, hands over head
It is not necessary to ____ the nipples to _____. What if pt tells you she has had discharge?
- Not necessary to “pinch” the nipples to try to elicit discharge.
- Have her elicit the discharge for you and take sample for micro
____ is often the discoverer of breast abnormalities
Spouse/partner
Breast awareness?
- better term for breast self exam
- Advise pt to just pay attention, esp in shower w/ soapy water and in front of mirror. Emphasize it’s OK to “report” any question.
Breast mass - ddx 6
- Cancer
- Cyst
- Fibroadenoma
- “Clustering” of FCBD
- Infection
- Hematoma/trauma
What if the pt feels a mass and you dont?
- Believe the pt
- do imaging and follow up
A breast mass isn’t resolved until:
(a) GONE - have the pt feel and make sure it is gone too
(b) a tissue diagnosis
Even if you are sure of a dx through your exam…..
- do a work up to confirm your dx
When to do a MRI?
only if very high risk profile or proven cancer – this checks the other breast esp. High incidence of false +.
Test for bloody discharge?
Ductogram
(+) mass and (-) mammogream?
- you are not done –> need to do an US
A neg FMH for breast cancer is…..
not a safe harbor for pts
Breast Cancer Risk Factors (11)
- prev or fam hx
- age >50
- nulliparous/didnt breast feed
- 1st child after 30yo
- early menarche
- Estrogens and progesterone component of HRT
- Radiotherapy to chest
- Smoking
- ETOH
- Obesity
- BRCA1/2
90% of breast CA present with a ___
positive mammogram
_____alone is a very uncommon presentation of breast cancer
Breast pain/mastalgia
20% of breast CA present with a ___
lump which may or may not be painful
3% of breast CA present with ___
with nipple discharge
5% of breast CA present with ___
with skin contour changes
0-1% of breast CA cases are ___
in MALE patients
Other signs or breast CA might include:
- Lump or swelling in the armpit
- Changes in breast size or shape
- Dimpling or puckering of the skin
- Redness, swelling and increased warmth in the affected breast
- Inverted nipple
- Crusting or scaling on the nipple
Stage I breast CA: def and prognosis
- The tumor is
Stage 2 breast CA: def and prognosis
- tumor is 2 - 5 cm in diameter. The cancer may or may not have spread to the axillary lymph nodes
- tumor is more than 5 cm in diameter, but the cancer hasn’t spread to the axillary lymph nodes
- The tumor is
Stage 3 breast CA: def
- known as locally advanced cancer, CA has spread to the lymph nodes near the breast
- The tumor may be > 5 cm, with spread to the axillary lymph nodes.
- The tumor is
Stage 3 Inflammatory breast CA: def and prognosis
- the cancer has spread to the breast skin, causing swelling and redness, is classified as stage III breast cancer
- 5 yrr survival rate = 49% - 56%
Stage 4 breast CA: def and prognosis
- Distant metastasis (lung, liver, brain, bony, adrenals)
- Treatment may help shrink or control the cancer for a while, but it usually won’t completely cure the cancer.
- At this stage, symptom relief becomes a priority.
What to record for positive breast exam findings?
- Location (R, L, clock, distance to nipple)
- Size in cm (use your fingers to estim)
- Mobility (fixated, mobile)
- Tenderness
- Texture (cystic, rubbery, hard)
