Gynae Examination

Question 1

What are the overall components of this gynae exam?

Answer 1

1. Intro - NB chaperone
2. Inspection; general, closer; part labia; cough
3. Bimanual examination; bartholin cyst, vagina, cervix, uterus, adnexae, conclusion and check fingers
4. Speculum; lube, insert like cig to side, inspect cervix, smear test, vaginal swab
5. conclusion

Question 2

Gynae Exam Introduction:

Answer 2

Wash hands
Introduce
Confirm details
explain
chaperone
consent
toilet
adequately exposed below the pelvic region
Pain

Question 3

General Inspection Gynae Exam:

Answer 3

On general inspection the patient appears comfortable, no signs of distress, is adequately exposed below the pelvic region and is positioned well.

Question 4

Closer Inspection: Gynae Exam

Answer 4

I am now going to have a closer look at the vulval area. I can appreciate no obvious lesions on the vulvar region, no erythema, perineal scars, bruising, discharge, scratch marks, lumps or ulcers.

NB Cough Reflex
I will now part the labia and ask the patient to cough and observe any signs of urinary incontinence or prolapse.

Question 5

Speculum exam gynae exam:

Answer 5

Next I will move on to the speculum exam which involves me inserting this gently into the vagina to have a look at the vaginal walls and cervix. It should not be painful but may be uncomfortable. We can stop at any time.

So I will lube the speculum, warn the patient, insert it gently and advance forward and down to the cervix, rotate so handle facing up and screw when the cervix is located.

On inspection the cervix appears normal, round, closed external os, erosions, polyps, growths, ulcers, discharge, redness, bleeding or prolapse

Smear test:
now I will insert the cytobrush into the external os and rotate 360 5 times without touching the speculum. I will drop the cytobrush into cytofix and shake for 10 seconds. I will label, confirm the patient details and send it to the lab/cytology.

Vaginal swab:
swab from under the cervix for chlamydia/ gonhorrhea label and send to lab

remove and unscrew speculum, open it, rotate laterally, close and pull out

Question 6

Bimanual examination:

Answer 6

gloves, lube warn patient on insertion

Firstly there are no signs of bartholins cyst or abscess.

No signs of abnormal vaginal tone, tenderness, foreign bodies, prolapse
Cervix: round, firm, smooth, anteverted, mobile, non tender, no polyps, growths or nodules on the uterosacral ligaments

uterus: left hand 1/2 way between umbilicus and PS. right hand fingers are sliding under the cervix into posterior fornix and pushing up. uterus is normal size, regular, mobile, non tender.

adnexae: moving my fingers into the right fornix and my left hand into the left iliac fossa I am now feeling for any masses or tenderness.
repeat other side

conclusion: remove fingers and check on gloves.

Question 7

What are the risk factors for cervical cancer?

Answer 7

1 Risk factors
! Human papilloma virus infection – particularly types 16 & 18
(all girls aged 12–13 are now offered HPV vaccination in the UK)
! Smoking
! Immunosuppresion (HIV+, post-transplant)
! Young age of first coitus
! High number of sexual partners
! Partners of promiscuous males
! Young age of first pregnancy
! High parity
! Low socioeconomic class
! Long-term OCP use

Question 8

What are the symptoms of cervical cancer?

Answer 8

! Often asymptomatic – many cases detected by screening
! Abnormal PV bleeding (postcoital, postmenopausal, intermenstrual)
! Blood-stained vaginal discharge
! Pelvic pain may indicate advanced disease extending beyond the cervix

Question 9

What is the pathology of cervical cancer?

Answer 9

! 70–80% squamous cell carcinoma
! 10–15% adenocarcinoma
! Remainder melanoma, sarcoma, lymphoma

Question 10

Mgmt of cervical cancer?

Answer 10

Management – depending on stage of disease
! Surgery (many options including cryotherapy, LLETZ, hysterectomy)
! Radiotherapy often used
! Chemotherapy in advanced / recurrent disease or where radiotherapy ineffective