Female Repro

Question 1

When looking at a patient’s skin, what may a maculo popular rash in the palm of the hands and soles of the feet be an indicator of?

Answer 1

Secondary Syphilis

Question 2

When looking at a patient’s skin, what could you find in a patient’s finger webs?

Answer 2

Burrows of scabies mite

Question 3

When looking at a patient’s skin, what could you find when examining a patient hairline, fingernails and extensor surfaces of limbs?

Answer 3

Psoriasis

Question 4

What signs might suggest heavy menstrual bleeding?

Answer 4

Pale nail beds or conjunctiva

Question 5

What may generalised bruising be a sign of?

Answer 5

A coagulation disorder or heavy menstrual bleeding

Question 6

What may general muscle wasting be a sign of?

Answer 6

Cachexia – Weight loss and deterioration of physical condition – Possibility of advanced cancer

Question 7

What is this sign?

Answer 7

Palmar erythema

Question 8

What is this sign?

Answer 8

Gynaecomastia

Question 9

What is this sign?

Answer 9

Axillary hair loss

Question 10

What is this sign?

Answer 10

Spider naevi (5+ significant)

Question 11

What are the signs of excessive oestrogen production?

Answer 11

Palmar erythema, Gynaecomastia, Axillary hair loss and Spider naevi

Question 12

What is this a sign of?

Answer 12

Cold sores indicate herpes simplex infection

Question 13

What is this a sign of?

Answer 13

Recurrent aphthous ulceration and oral candida may be present in HIV infection.

Question 14

What may generalised lymphadenopathy be suggestive of?

Answer 14

May be present in some infections.

Question 15

What may ascites be secondary to?

Answer 15

ovarian malignancy

Question 16

What may hepatosplenomegaly be secondary to?

Answer 16

Metastatic disease

Question 17

What may loin tenderness be secondary to?

Answer 17

Renal sepsis or stone

Question 18

What may lower abdominal pain and tenderness be secondary to?

Answer 18

Pelvic inflammatory disease and ectopic pregnancy.

Question 19

What may the distribution of pubic hair may reflect?

Answer 19

Endocrine conditions such as androgen excess of adrenal or ovarian origin, or hypogonadism.

Question 20

What may an examination of the genital skin reveal?

Answer 20

Genital warts, molluscum contagiosum, ulcers (most commonly herpetic but also consider syphilis).

Question 21

What should you look carefully for in the hair of the pubic region, lower abdomen and upper thighs?

Answer 21

Pubic lice

Question 22

What is this a sign of?

Answer 22

A fungal rash which often has a scaley surface and well-defined border.

Question 23

What is this a sign of?

Answer 23

Skin sensitivity rashes can be from the use of products, especially antiseptic soap.

Question 24

What areas of the female genital region should be examined ?

Answer 24

Labia majora, labia minora, clitoris, urethral meatus, introitus, perineum and perianal area should be inspected systematically. Again, one is looking for the conditions detailed above (warts, ulcers etc.) It is also important to check for any abnormalities of the skin. In order to examine the labia minora and introitus it is necessary to gently separate the labia majora and it may be necessary to wipe away any excess discharge with a cotton wool ball. In certain cultural settings signs of female genital mutilation may be present

Question 25

What are these signs of?
Fissuring
Scarring
Excoriation
Thickening
Erythema

Answer 25

These would suggest a vulval dystrophy or postmenopausal atrophic changes.

Question 26

How should a speculum be inserted?

Answer 26

The patient lying on her back, with knees flexed and hips abducted. The feet would be should be together at the ankles with knees flopped out to the sides. With the non-dominant hand make an upside down “V” shape and gently part the labia majora. The speculum (may be lubricated with gel or warm water ) can then be gently inserted by the dominant hand with the blades positioned vertically, avoiding pressure on the anterior structures which are more sensitive. Once the speculum has passed through the introitus the speculum is rotated whilst still being inserted. The handles can be positioned either anteriorly or posteriorly (usually anteriorly when using the dorsal position, posteriorly when the patient has legs elevated). Then the handles are squeezed together carefully which opens the blades. At this point the cervix may be visible. If not, the handles are released allowing the blades to close before the speculum is repositioned and any further attempt to visualise the cervix attempted. It is extremely important that the blades are always in the “closed” position before any further insertion is performed. Once the cervix has been visualised and any swabs taken the blades can be partially closed and the speculum slowly removed whilst inspecting the vaginal walls (if a clear plastic speculum is being used). The cervix should be inspected for the state of the os, presence of ectropion, Nabothian follicles, IUCD threads, unusual discharge, any bleeding, warts or suspicious lesions. The vagina should be inspected for discharge, atrophy, presence of blood, erythema or warts.

Question 27

How should the bimanual examination be done?

Answer 27

If required, this is normally performed after the speculum examination. Again, a clear explanation of the procedure and the patient’s consent is necessary. It is done either by standing on the patient’s righthand side, or if a couch with stirrups is available standing at the foot of the couch. The index and second fingers of the dominant hand are gently inserted into the vagina with the 3rd and 4th fingers flexed against the palm and the thumb hyperextended to keep it out of the way. The other hand is placed on the patient’s lower abdomen. The internal examination can be used to assess the state of the pelvic muscles. The cervix should be located with the middle finger and moved forwards and back to check for excitation (pain on movement). With the middle finger in the anterior fornix it may be possible to palpate an anteverted uterus between the examiner’s hands. An assessment of size and any tenderness is made.Then examine the adnexa (the ovaries and Fallopian tubes). These are examined by having the abdominal hand gently palpate in each iliac fossa in turn with the fingers of the other hand in the corresponding lateral fornix of the vagina. Normal sized ovaries may be palpable in a slim relaxed patient but often this is not possible. Check for any swelling, masses or tenderness. While the use of two fingers for vaginal examination is appropriate for the simulation, often in clinical practice use of the index finger only is appropriate, especially for any patient where pelvic pain or tenderness are part of the clinical problem.

Question 28

What would you see in women with chronic pelvic pain or dyspareunia?

Answer 28

The muscles may be tense and painful during bimanual examination

Question 29

How would you test for women with urinary incontinence

Answer 29

May find muscle weakness when asking the patient to ‘squeeze’ during bimanual examination

Question 30

What would a soft uterus suggest?

Answer 30

Pregnancy

Question 31

What would a firm uterus suggest?

Answer 31

Uterine fibroids

Question 32

What would a ‘craggy’ uterus suggest?

Answer 32

Malignant tumour

Question 33

The uterus is normally mobile on palpation, what may restricted mobility indicate ?

Answer 33

Chronic pelvic inflammatory disease, endometriosis or malignancy.

Question 34

Other examinations and tests that may be needed?

Answer 34

• Digital rectal examination
• Urine pregnancy test may be ordered if there is any doubt about possible pregnancy, intrauterine or ectopic.
• Urinalysis will be appropriate for suspected urinary tract infection.

Question 35

What may Vaginal discharge be caused by?

Answer 35

Bacterial vaginosis (disordered vaginal flora deficient in lactobacilli), candidiasis or infection with Trichomonas vaginalis (a sexually transmitted protozoal infection).

Question 36

What may cervical inflammation be due to?

Answer 36

Chlamydial infection or gonorrhoea

Question 37

What may purulent cervical discharge be due to?

Answer 37

Pelvic inflammatory disease/ salpingitis

Question 38

What does genital ulcer disease require?

Answer 38

Investigation for syphilis or other STIs

Question 39

How can we visualise pelvic organs?

Answer 39

Ultrasonography (transabdominal, transvaginal or transrectal) is very useful for visualisation of the pelvic organs.

Question 40

What are the different stages of the examination?

Answer 40

1. INTRODUCTION
2. GENERAL INSPECTION
3. CLOSE INSPECTION
4. SPECULUM EXAMINATION
5. BIMANUAL EXAMINATION
6. OTHER AREAS
7. CONCLUSION

Question 41

What should be covered in the Introduction

Answer 41

Collect equipment;

A. Ensure adequate hygiene of hands, wear appropriate PPE
- Currently wearing face mask, gloves, apron
B. Introduce self
C. Confirm patient’s name and date of birth
D. Ask if patient is in any discomfort
- Allow patient to empty their bladder before the examination – more comfortable and easier to palpate uterus.
E. Explain the procedure and seek permission to perform a gynaecological examination
- Explain the procedure and that you will stop at any point if the patient requests.
F. Offer a chaperone
- Offer a female chaperone. Required for male doctors. Document clearly if patient declines.
G. Allow privacy for patient to undress. Provide a cover until examination starts
H. Position patient – initially lying on the bed as for an abdominal examination
- Give unambiguous instructions to patient to remove their trousers/and underwear (and any sanitary protection), and to lie on the bed with modesty sheet (bedroll/sheet) to cover over. Ask patient to let you know when they are ready.

Question 42

What should be covered in the general inspection?

Answer 42

2. GENERAL INSPECTION
   A. Demeanour, weight change, skin conditions e.g. psoriasis
   B. Hands – signs of anaemia, scabies
   C. Face – hirsuitism, mouth ulcers, cold sores, oral thrush NOT looking in mouth during Covid-19

Question 43

What should be covered in the close inspection?

Answer 43

3. CLOSE INSPECTION
   A. Position patient
   - Instruct patient to bend knees, keeping ankles together (or hip distance apart) and allow knees to relax outwards.
   B. Inspect perineum
   - Inspect perineum for hair distribution, cliteromegaly (hyperandrogenism), skin (e.g. lichen sclerosis, ulcers, thrush), discharge (colour, odour, blood), swellings (e.g. Bartholin cyst)
   C. Ask patient to cough to look for urinary incontinence/prolapse
   - Look for leakage of urine or a bulge within the vagina on coughing.

Question 44

What should be covered in the speculum examination?

Answer 44

4. SPECULUM EXAMINATION
   A. Explain to patient and reconfirm consent
   B. Gently part labia
   C. Insert (lubricated) speculum
   - Lubricate speculum (ideally water or minimal gel for smear). Gently part the labia with your left hand. With your right hand, gently insert the speculum with blades vertical and rotate 90 degrees so the handle points anteriorly/upwards and blades are horizontal.
   D. Open blades
   - Open the blades and identify the cervix and os. If not visible, try re inserting at a more downward angle as the cervix may be behind the posterior blade. You may need to try a different length of speculum depending on the patient.
   E. Inspect cervix and vaginal walls
   - Inspect the cervix. The os may be slit-like after childbirth. The squamocolumnar junction (i.e. transition zone) may be visible as an ectropion. Small cysts may be visible – Nabothian follicles. Note any other abnormalities of the cervix – e.g. lumps/bumps (polyps/malignancy) or other mucosal changes (ulceration or bleeding). Note any discharge (odour/colour/blood) or abnormalities of the vaginal wall.
   F. (take swabs or smear at this stage if required)
   G. Remove speculum
   - Remove the speculum allowing the blades to close as it is withdrawn – take care not to trap the cervix in the blades as they close.

Question 45

What should be covered in the bimanual examination?

Answer 45

5. BIMANUAL EXAMINATION
   A. Explain to the patient and reconfirm consent
   B. Apply gel to right index and middle finger
   C. Gently insert index and middle finger into vagina and palpate cervix
   - Feel for the firm cervix. Cervical excitation (acute pain when touching the cervix) suggests an acute pelvic condition such as infection, cyst accident or tubal rupture.
   D. Push fingers into posterior fornix and bimanually palpate uterus with left hand on abdomen
   - The uterus is usually anteverted and can be palpated between the right-hand fingers placed in the posterior fornix, lifting the uterus upwards against the left hand palpating the abdomen from above the umbilicus downwards. A retroverted uterus will be difficult to palpate bimanually. The uterus should feel regular and mobile and plum sized. Fibroids can cause uterine irregularity and enlargement.
   E. Assess for adnexal masses on each side
   - Place your vaginal fingers into the lateral fornix and with your left hand above and lateral to the umbilicus, bring it down to assess any adnexal mass between your hands. Repeat on both sides.

Question 46

What should be covered in the Other Areas?

Answer 46

6. OTHER AREAS
   A. Abdominal examination including inguinal lymph nodes
   B. Consider need for urinary pregnancy test
   C. Consider urinalysis
   D. Cervical and inguinal lymph nodes
   E. BP/BMI
   F. Consider DRE

Question 47

What should be covered in the Conclusion?

Answer 47

7. CONCLUSION
   A. Thank patient and dispose of gloves and speculum and remove PPE + wash hands
   B. Ensure privacy to allow patient to dress
   C. Summarise and present findings in patients notes and orally