Female Repro Flashcards

Question

What are these signs of? Fissuring Scarring Excoriation Thickening Erythema

Answer 1

These would suggest a vulval dystrophy or postmenopausal atrophic changes.

Answer 2

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.

Answer 3

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.

Answer 4

The muscles may be tense and painful during bimanual examination

Answer 5

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

Answer 6

Uterine fibroids

Answer 7

Malignant tumour

Answer 8

Chronic pelvic inflammatory disease, endometriosis or malignancy.

Answer 9

- 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.

Answer 10

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

Answer 11

Chlamydial infection or gonorrhoea

Answer 12

Pelvic inflammatory disease/ salpingitis

Answer 13

Investigation for syphilis or other STIs

Answer 14

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

Answer 15

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

Answer 16

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.

Answer 17

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

Answer 18

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.

Answer 19

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.

Answer 20

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.

Answer 21

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

Answer 22

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