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
