Female GU exam Flashcards
Preliminaries – Pelvic Exam
“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 BEFORE the examination
Position the patient: dorsal lithotomy position with feet in footrests and HOB raised ~~30 deg.
Be GENTLE and maintain EYE CONTACT
Be PREPARED – have all necessary equipment available + extra Pap supplies
Patient’s first exam??
Sit down with patient in your office FIRST.
Use a pelvic model to show a few basics.
Keep a Pederson speculum in your desk drawer and demonstrate what it does.
Ask pt if she wants mother/friend present.
ALWAYS coach pt about perineal muscle and relaxation of that exact area.
Touch neutral area first.
CONFIDENTIALITY?
- Privacy applies to female patient, without regard to her AGE!!
Anything remotely in the area of “sex”, “reproduction”, “pregnancy”, “STD’s”, “birth control”
You MUST respect wishes of patient
To “disclose”, get CONSENT and put it prominently in record
This means parents, spouse, friends, relatives – everybody!!!!!!
“But she is on my insurance!” is NOT a sufficient reason to disclose daughter’s information to her mother !!!!!!!!!
** Younger patient? - Always ask for consent (especially to mother) to disclose
Warn patient you’re noting it in record and remind her she may W/D consent any time
hair growth
should match developmental age
In general, female hair distribution is shaped like a triangle – but slight “diamond” is not necessarily “pathological” – ethnic component
…….ARCHE ??
Menarche = age at first period (11-12 avg) Thelarche = age at earliest breast development (“bud”) Pubarche = age at first pubic hair growth
Thelarche is 1-2 years before menarche
Menarche heavily dependent on % body fat – threshold ~~~ 20%
External Genitalia-Inspection
Labia majora-rashes,excoriation,ulcers, trauma
Labia minora-ulcerations, inflammation – length highly variable
Clitoris-size, usually 2 cm or less in length
Urethral orifice-inflammation, discharge
Vaginal introitus-hymen or remnants
Bartholin and Skene’s glands-swelling or tenderness, discharge from Skene’s
Clitoral Hypertrophy
Gloves????
Infant/child = “Intersex” issue
Adult = suggests testosterone issue
pictures
take a look at slides 15-19 and 22-24 for STD pics etc.
Vulvar squamous carcinoma
Pruritis – ddx Red or white lesion = biopsy There is an “in-situ” preliminary stage Treatment: - 5-FU - CO2 laser - LEEP - Vulvectomy – simple/radical
Lichen Planus
Advanced Dermatology
Tx isn’t easy
Know a Derm physician who is comfortable w/ gyn
Candida Infection = “yeast”
Disch = white/cheesy
Pruritis
Erythema
Wet mount w/ KOH or
VIP = hyphae
Assoc w/: OCP, Preg
antibx, DM, HIV
Trichomonas Infection
STD
Pruritis, odor, OTC yeast Tx fails
Greenish watery disch occ. w/ froth
WM w/ saline = active trich
Bartholin Glands found where?
5 and 7 o’clock
Labial swelling or pain: inspect and palpate the Bartholin glands
Bartholin Glands Abscess
Gonococcus and chlamydia infections are common causes
Abscess is usually preceded by a cyst
tx: Soaks, analgesics Antibiotics – choose wisely Surgical - I&D (incision and drainage) - I&D w/ “Word” catheter - Marsupialization - Full excision
Bartholin’s Gland in older patient??
Easy to check.
Do “short-interval” followup. Any growth should prompt referral for total excision.
Any mass or cyst should be pointed out to patient and early referral offered.
Cancers are rare, but I have personally seen one (age = 66).
Urethra/Skene’s - exam
“Stripping” or “milking” of urethra results cloudy discharge
Culture, antibx
Urological consult
Cystocele
Surgery not required
Pessary may help
“SUI” = stress urinary incontinence - often present
Rectocele
Surgery not required
“Degree” may not be apparent unless ValSalva is done
Ask about “digital defecation”
Uterine Prolapse degrees
First degree:The cervix droops into the vagina.
Second degree:The cervix comes down to the opening of the vagina.
Third degree:The cervix is outside the vagina.
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
Again, denial
Older, multiparous
Pessary = minimal help
Surgery works, but is very complicated – “urogynecologist”
Speculum
“Pediatric”, Pederson, medium Graves, large Graves, the dreaded “plastic”
Warm and lubricate (water or gel)
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!!!
“45 degree angle”
This is “traditional” and I respectfully DISAGREE
Vagina is oriented HORIZONTALLY = use “ZERO DEGREES”
Speculum Placement – a better way
- 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 - I
Epithelium
Rugae, atrophy, lesions
Discharge?
Be ready to do Wet Mount (WM)
Masses
Gartner’s duct remnants – cysts - leave it alone**
Inclusion cyst from episiotomy – just inside introitus between 5 & 7 o’clock - leave it alone**
** Often good to show pt, explain etiology, reassure
CAN’T FIND THE CERVIX??
OK to stop and do single-finger exam to locate
May be very far anterior – behind symphysis
Vagina may be “deep” – select longer/larger speculum
Sidewalls may cover – from 3 and 9 o’clock – select wider speculum
Has pt had hysterectomy?
Cervix
Os - ext Shape Polyps Pus Lesion Cysts
Transformation Zone
Define: “Portio” “Fornix”
Nabothian Cysts
Inclusion cyst of the endocervical glands
May resemble cervical pathology
Normal variant – do not needle or biopsy
Cervical polyp
Common cause of PCB (post coital bleeding)
Rarely is a CA
Twist off w/ polyp forceps
Nice to show pt w/ your mirror
Pap Smear
The Papanicolaou test (also called Pap smear or Pap test) is a medical SCREENING technique primarily designed to detect DYSPLASIA (“premalignancy”) of the cervix at the transformation zone = TZ.
This is THE model for an ideal “screening test”
Now done with liquid media (alcohol), computer assisted reading
NOT intended to screen for ovarian CA. MAY hint at endometrial CA. NOT an STD test.
If Pap shows an invasive cervical CA, something went wrong! (Compliance, access, failed reporting - $$$$)
Cells should be obtained from the TZ and endocervix
Transformation Zone = TZ
Squamocolumnar junction (SCJ) “moves” dependent on age, parity, and hormonal status
TZ = area between original and current squamocolumnar junction
The transformation zone is an area of metaplasia and it is the location of 90++% of cervical cancers
Metaplasia is an ESTROGEN effect
ECTOPY = a normal finding
Ectopy = columnar epithelium is “out” on “portio” of cervix.
Reddish or reddish/orange
Symmetrical and circumferential – see prior slide
OK to show pt w/ your mirror
Requires no intervention – just reassurance
May be source of PCB – various Tx
Cervicitis
Infectious cervicitis may be caused by Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus (HSV), or human papillomavirus (HPV).
Cervical DYSPLASIA = CIN/SIL
CIN = cervical intraepithelial neoplasia
SIL = squamous intraepithelial lesion
CIN I, II, III = mild, moderate, severe
LGSIL = low grade SIL, HGSIL – high grade SIL
CIS = carcinoma in-situ – not a “cancer” – but close!
Slow disease until it’s CIS
HPV origin – HR types = 16 + 18
Cervical Dysplasia
Not often 360 deg
Often in one quadrant only
Inspection is good enough to warrant colposcopy/biopsy even if Pap is normal!!!!! - $$$$$
Inspection of the Vagina - II
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
Uterus:
Size, shape, consistency, mobility
Position
Fibroids (nodules)
Ovaries:
Size, shape, mobility, tenderness
Remember to palpate bilaterally - may not be palpable
Strength of Pelvic Floor
Version and Flexion
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”
Adnexae
Palpate the “blank space” on either side of uterus. Best done just after period ends.
You likely won’t feel anything < 3 cm
Ovaries often not “palpable”
Know some sizes
Golf ball = 3 cm
Tennis ball = 5 cm
Softball = 9-10 cm
Adnexal mass?
less than 5 cm = recheck after one cycle
> 5 cm or bilateral or persistent:
Trans-vaginal ultrasound = “TVUS”
Gyn consultation
FYI – 5 cms = tennis ball
Rectal Exam ?????
For sure after age 50 + hemoccult
Earlier if high-risk
At any point if truly will give better insight
This is unpopular with patients and “doctor-shopping” occurs over just this issue!
Rectovaginal Exam - selective
Rectovaginal exam is
useful in assessing:
-Posterior wall of vagina
-Rectovaginal pouch
(Pouch of Douglas AKA the “cul-de-sac”)
-Retroverted/
Retroflexed uterusHernias – either gender!
Indirect hernia is the most common inguinal hernia in women.
Femoral hernia is more common in women than in men.
Umbilical = common after pregnancy.
Hernias
Hard to diagnose in women
Unusual to find a “defect”
“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
Document your exam!
Everything normal? Here is your note:
Pelvic exam: External structures normal & without lesions. BUS no masses, NT. Vagina clear, normal rugae. Cervix parous, no lesions, slight circumferential ectopy. Bimanual shows no CMT, uterus midline, mobile, and AV/AF. Adnexae clear + NT. Rectal (if done) = normal sphincter tone, no masses, no blood, hemoccult (-).
Functional Anatomy of breast
The breast is composed of 15 to 20 lobes which are each composed of several lobules.
Fibrous bands of connective tissue travel through the breast (suspensory ligaments of Cooper), insert perpendicularly into the dermis, and provide structural support.
Each lobe of the breast terminates in a major (lactiferous) duct (2 to 4 mm in diameter), which opens through a constricted orifice (0.4 to 0.7 mm in diameter) into the ampulla of the nipple.
Deep to the nipple-areola complex, each major duct has a dilated portion (lactiferous sinus), which is lined with stratified squamous epithelium.
Major ducts are lined with two layers of cuboidal cells, while minor ducts are lined with a single layer of columnar or cuboidal cells.
more on the anatomy of the breast
The mature female breast extends from the level of the second or third rib to the inframammary fold at the sixth or seventh rib.
It 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.
The axillary “tail of Spence” extends laterally across the anterior axillary fold. The upper outer quadrant of the breast contains a greater volume of tissue than do the other quadrants.
breast Arterial Supply – generous!
The breast receives its principal blood supply from (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.
The second, third, and fourth anterior intercostal perforators and branches of the internal mammary artery arborize in the breast as the medial mammary arteries.
The lateral thoracic artery gives off branches to the serratus anterior, pectoralis major and minor, and subscapularis muscles. It also gives rise to lateral mammary branches.
breast exam Preliminaries
Adopt a reassuring attitude
Respect the patient’s modesty – avoid “total uncovering” – gown opens in BACK
Determine LNMP
The optimal time to examine the breast =
5-7 days following the onset of the LNMP
fair for the exam
lymph drainage. Look it up on the slides!
Symptoms of Breast Disease
Erythema
- Mastitis, inflammatory carcinoma
Masses
- Cysts, fibroadenoma, hematoma, carcinoma
Nipple Discharge – one or many ducts?
- Bloody, esp single duct - Papilloma, cancer
- Non-bloody – green/clear – may be physiologic (normal) or sign of esp prolactin disorder
Nipple Ulceration
- Paget’s disease
- Mechanical causes
Breast Inspection
This is easily incorporated into the “palpation portion” of the exam
“Total exposure” is unacceptable to most patients and should be avoided
Move the gown around! To expose only what you need.
Observe the breast for:
- Development
- Size and symmetry
- Contour
- Retractions or dimpling of skin
- Skin color and texture (Peau d’orange)
- Venous engorgement
Observe the nipple for: Retraction unilateral or bilateral Discharge Darkening Rash, crusting or ulcerations Supernumerary nipples
Breast Inspection – if you have a question
Tell patient that sometimes using additional positions will help with a more complete exam. Then, inspect the breast in four additional positions:
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 Inspection - Pregnancy
Nipple/areola = darkened - early Tubercles of Montgomery - early Venous engorgement – variable onset Tenderness – variable - early Size – pt will be aware - early Later – bilateral discharge Later - striae
Mastitis
May be peurperal or non-peurperal
Don’t need to stop nursing!
Antibx directed against Staph and Strep
Inflammatory Breast Cancer
Gown ? Denial – long delay This isn’t “mastitis” Immediate consult and imaging Is this a “different disease”? – yes Poor prognosis
Methods of palpation
Vertical or horizontal criss-cross Concentric SPIRAL !!!!!! Use two hands – one does exam, the other shifts and retracts Supine, hands over head Sitting, partially lying on side Discover YOUR OWN WAY
The Nipple??
Not necessary to “pinch” the nipples to try to elicit discharge.
Patient will tell you if she has noticed discharge. She can elicit it for you….
Samples for micro (fat globules) and hemoccult.
Breast Self-Exam = “BSE”
Actually not of much “screening” value for patient to do a “formal” and “detailed” exam.
Better terminology is BREAST AWARENESS. 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.
Spouse/partner is often the “discoverer”.
Breast mass - ddx
Cancer Cyst Fibroadenoma “Clustering” of FCBD Infection Hematoma/trauma
Breast mass? - Careful
ALWAYS believe the patient! If she finds a mass, she has a mass, EVEN if YOU can’t find it! Imaging and followup!!
A breast mass isn’t “resolved” until it is either (a) GONE or (b) a tissue diagnosis
Have patient feel it, too. Be sure you both agree.
Even if you are “sure” (“by exam”) of a dx, don’t “believe” your own exam – do workup (lawyers love this one, too
Breast mass - imaging
Mammogram – screening vs. diagnostic
Digital mammography
Sonogram !!!!!!!!!! – the $$ is here
MRI – only if very high risk profile or proven cancer – this checks the other breast esp.
Ductogram – for bloody d/c - papilloma
(+) mass & (-) mammogram = you’re not done!!!!!!!! (lawyers love this one)
Breast Cancer Risk Factors
Previous personal history of Breast Cancer
Family history of Breast Cancer in first degree relative
Age - Risk increases with age: 5% of cases present before age 40 (2% before age 35). Majority over 50.
Nulliparous, or didn’t breast-feed
First child after age 30
Early Menarche
Estrogens and progesterone component of HRT
Radiotherapy to chest
Smoking
Alcohol use/abuse
Obesity (the more fatty tissue, the more “estrogenic” is the “environment”)
Role of BRCA-I and BRCA-2 testing
Most breast CA patients do NOT have a family history. A “negative” family history is NOT a “safe harbor”.
Clinical Presentation of Breast Cancer
90% present with positive mammogram
20% as a lump which may or may not be painful
3% with nipple discharge
5% with skin contour changes.
Breast pain/mastalgia alone is a very uncommon presentation of breast cancer
Other signs 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 cancer
The tumor is no more than 2 cm in diameter
The cancer hasn’t spread to the lymph nodes
There is no distant metastasis
The five-year survival rate for women treated for stage I breast cancer is 98 percent.
Stage II
The tumor is 2 to 5 cm in diameter. The cancer may or may not have spread to the axillary lymph nodes
The tumor is more than 5 cm in diameter, but the cancer hasn’t spread to the axillary lymph nodes (A)
The tumor is less than 2 cm in diameter, but the cancer has spread to less than four of the (axillary) lymph nodes (B)
There is no distant metastasis
The five-year survival rate for women treated for stage II breast cancer is 76 percent to 88 percent.
Stage III
In stage III breast cancer, known as locally advanced cancer, the cancer has spread to the lymph nodes near the breast
The tumor may be larger than 5 cm, with spread to the axillary lymph nodes.
The tumor is smaller than 5 cm, but the cancer has spread to the axillary lymph nodes above the collarbone
Stage III
Inflammatory breast cancer
Inflammatory breast cancer, in which the cancer has spread to the breast skin, causing swelling and redness, is classified as stage III breast cancer
The five-year survival rate for women treated for stage III breast cancer is 49 percent to 56 percent
Stage IV
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.
Document your exam
Describe what you see and feel. Normal – see II For positive findings: Location (R, L, clock, distance to nipple) Size in cm (use your fingers to estim) Mobility (fixated, mobile) Tenderness Texture (cystic, rubbery, hard)
Normal history and exam? Here is your note:
Breast exam shows normal color and contour. No skin retraction. Nipples everted and symmetrical, no discharge. Palpation shows no masses or tenderness. Axillae negative bilaterally
Mass found? – part of your note reads:
2 cm rounded, well-delineated mobile oval rubbery mass at 2 o’clock on R, about 3 cm away from nipple (fibroadenoma)
Part of your note reads: 1.5 cm tender easily-outlined cystic mobile mass at 3 o’clock on L, about 4 cm away from nipple (cyst)
Mass found? Part of your note reads: 2 cm non-tender hard fixated mass at 4 o’clock on R. Mass has a “point” effect and it is difficult to outline the borders (highly suspicious for cancer)
