Female Pelvic Exam

Question 1

What are common chief complaints that warrant a pelvic exam?

Answer 1

Abdominal or pelvic pain
Abnormal vaginal bleeding
Absence/cessation of menses
Painful menses
Decreased libido
Difficulty getting pregnant
Painful intercourse
Pelvic/abdominal mass
Symptoms of menopause
Vaginal discharge
Vulvovaginal itchiness

Question 2

What questions are included in the gynecologic history?

Answer 2

1. Ask about the age of menarche (when the first menses started); in the United States the range is between the ages of 9 and 16
2. Ask about menstruation patterns
3. If applicable, at what age did menopause occur?

Question 3

What questions are included in the menstruation patterns?

Answer 3

How often does the patient have menses? (Every 24 to 32 days is normal.)
How long are the menses? (3 to 7 days is normal.)
How heavy are the menses? (The number of pads or tampons used is an indicator.)

Question 4

What is the definitions of menopause?

Answer 4

Menopause is defined as no menses for 12 months. The average age of menopause is 45 to 52 years.

Question 5

Define amenorrhea

Answer 5

Amenorrhea is defined as the absence of menses

Question 6

Define primary amenorrhea

Answer 6

Primary amenorrhea refers to the failure of menses to be initiated (causes: chromosomal abnormalities, malnutrition, hypothalamic-pituitary-ovarian dysfunction)

Question 7

Define secondary amenorrhea

Answer 7

Secondary amenorrhea refers to a cessation of periods after they have previously existed (physiologic causes: pregnancy, breast feeding, menopause; pathologic causes: pituitary tumor, hypothyroidism, anorexia nervosa)

Question 8

Define dysmenorrhea

Answer 8

painful periods with cramping or aching in the lower pelvis and lower back

Question 9

Define PMS

Answer 9

Complex of symptoms occurring 4 to 10 days before the onset of menses
Psychological symptoms include tension, irritability, depression, and mood swings
Physical symptoms include weight gain, bloating, edema, headaches, and breast tenderness

Question 10

Define polymenorrhea

Answer 10

Polymenorrhea means having too frequent of periods

Question 11

Define Menorrhagia

Answer 11

Menorrhagia refers to an increased amount of bleeding or duration of flow

Question 12

Define Metrorrhagia

Answer 12

Metrorrhagia is bleeding that occurs between periods

Question 13

What questions need to be asked about pregnancy?

Answer 13

How many pregnancies in total? How many births were term? Preterm? Miscarriages? Induced abortion?
Were there any complications in prenatal care, labor, or delivery?
What kind of birth control is currently used or desired?

Question 14

What questions need to be asked about vulvovaginal sxs?

Answer 14

burning, itching, and the quantity and quality of discharge (including texture, amount, color, and smell)

Question 15

What questions need to be asked about the pt’s sex life?

Answer 15

Ask about sexual preference and sexual response; be professional and “matter of fact” in questioning and never assume all patients are heterosexual
Ask open-ended questions such as, “How is sex for you?” “Is your partner satisfied with your sex life?”

Question 16

What questions need to be asked about sexual dysfunction?

Answer 16

Lack of interest
Lack of physiologic response to desire (decreased lubrication)
Lack of orgasm
Dyspareunia, or discomfort during intercourse
Vaginismus, or spasms of the muscles surrounding the vagina making penetration painful and difficult

Question 17

What educational material does the pt need?

Answer 17

Cervical cancer screening: Pap smear and HPV screening
Options for family planning
Sexually transmitted diseases and HIV
Changes in menopause

Question 18

How should the pt be positioned for the pelvic exam?

Answer 18

Lie on the back, with head and shoulders elevated (such as on a pillow), with arms to the side or folded across the chest to reduce tightening the abdominal muscles

Question 19

How should the examiner set up the pelvic exam?

Answer 19

1. Obtain permission
2. Explain each step of the examination in advance; select a chaperone
3. Drape the patient from the abdomen to the knees
4. Avoid sudden movement
5. Choose a speculum of appropriate size
6. Warm the speculum with tap water
7. Monitor the comfort of the examination by watching the patient’s face
8. Use gentle insertion of the speculum

Question 20

What is the Proper Sequence of the Female Genital Examination?

Answer 20

1. Examine external genitalia
2. Perform speculum examination
3. Perform bimanual examination
4. Perform rectovaginal examination
5. Perform rectal examination

Question 21

What is involved in the Inspection of the female patient’s external genitalia?

Answer 21

Mons pubis
Labia majora and minora
Clitoris
Urethral meatus
Introitus
Perineum
Note any inflammation, discharge, swelling, or nodules; palpate any lesions

Question 22

How is the Bartholin’s gland inspected?

Answer 22

Check the Bartholin’s glands by inserting the index finger into the vagina and placing the thumb at the posterior labia; palpate between finger and thumb

Question 23

How is the Internal Exam by Speculum performed?

Answer 23

1. Place the index finger of your non-dominant hand on the posterior portion of the introitus and push down gently
2. With the speculum in your dominant hand, turn it to the entry angle (approximately 45 degrees) and gently insert into the introitus; continue inserting the length of the speculum
3. Rotate the speculum horizontally and gently open it, catching the cervix in between the blades; it is common to have to close the speculum and reposition the blades to locate the cervix

Question 24

How is the cervix inspected?

Answer 24

1. Once the cervix is visualized, inspect the cervix and the os; note the color, position, and characteristics of the cervix
2. Look for discharge or bleeding from the os
   Note any ulcerations, masses, or nodules on the cervix
3. Obtain one specimen from the endocervix and one from the ectocervix, or a combination specimen using the cervical brush “broom”
   A. If indicated, obtain cultures for chlamydia, gonorrhea, or herpes; wet prep (saline slide of the vaginal and cervical secretions) for vaginitis

Question 25

How is the vagina inspected?

Answer 25

1. While withdrawing the speculum, assess the walls of the vagina
2. When removing the speculum, make sure the blades are closed; removing an open speculum can cause lacerations to the vaginal walls and to the urethral meatus
3. If indicated, place two fingers inside the labia and ask the patient to bear down in order to see if the vaginal walls bulge or if any part of the rectum protrudes from the anus

Question 26

How is the bimanual exam performed?

Answer 26

1. Stand at the end of the table between the patient’s legs
2. Lubricate the index and middle finger of the dominant hand and carefully place them inside the introitus
3. Make sure the 4th and 5th digits are flexed against your palm and that your thumb is abducted (away from the patient’s body)
4. Palpate the vaginal walls, feeling for any irregularities (note that the vaginal walls have rugae and will feel “bumpy”)
5. Palpate the cervix, noting its position (anterior, posterior, deviated to the left or right), shape, consistency (firm or soft), mobility, and tenderness
6. Palpate the uterus in the midline; take your non-dominant hand and place it over the suprapubic area just superior to the pubic bone
7. While you elevate the cervix with your dominant hand, press your non-dominant hand over the bladder, catching the uterus between your hands; feel its size, shape, consistency, mobility, and tenderness (easier in thin patients)
8. If you cannot feel the uterus, slide the fingers in the pelvis into the posterior fornix; if you can feel the uterus butting against the fingers, the uterus is tipped posterior (retroflexed)
9. Palpate the left ovary by placing your dominant hand in the left lateral fornix and your non-dominant hand just left of the midline superior to the pubic bone
10. Palpate the right ovary by placing the dominant hand in the right lateral fornix and the non-dominant hand just right to the midline
11. Identify the size, shape, consistency, mobility, and tenderness of each adnexal area
12. Before removing your hand, ask the patient to bear down on your fingers to assess the strength of the pelvic muscles

Question 27

What are the purposes of the rectovaginal exam?

Answer 27

1. Palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa
2. Screen for colorectal cancer
3. Assess pelvic pathology

Question 28

How is the rectovaginal exam performed?

Answer 28

1. Glove the dominant hand and lubricate the index finger
2. Place the index finger of the dominant hand inside the vagina as before but this time and place the middle finger within the anus; ask the patient to bear down so that the anal sphincter will relax

Question 29

How is the rectal exam performed?

Answer 29

1. Gently place the index finger in the anus; palpate for hemorrhoids and masses
2. If needed, check for occult blood with a hemoccult test
3. Wipe off the external genitalia and anus with gauze or tissue; give the patient some to clean herself after the exam
4. Always ask the patient to get dressed before discussing any findings; unclothed patients have difficulty concentrating

Question 30

How is a hernia screened for in a female pt?

Answer 30

1. Examination techniques are similar to that used for men; a woman should stand up to be examined
2. Palpate the labia majora just upward and lateral to the pubic tubercles

Question 31

How is urethritis screened for in a female pt?

Answer 31

If you suspect urethritis or inflammation of paraurethral glands, insert your index finger into the vagina and milk the urethra gently from inside outward; culture any discharge that has been “milked out”