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Gynaecology Flashcards

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1
Q

What do female genitalia look like before puberty ?

A

Vaginal mucosa is not yet folded.
The transformation zone won’t be visible because it will be inside the endocervical canal.
The uterus and ovaries will be small.
The ectocervix does not yet protrude.

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2
Q

How does the female genitalia look like during the reproductive period ?

A

Vaginal mucosa is shiny and pinkish
Ectocervix shows the transformation zone.
Different aspect of cervical mucus cause various aspect of vaginal discharge.

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3
Q

How does the cervical mucus look like during ovulation ?

A

Clear and viscous.

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4
Q

What are the signs of pregnancy in the genitalia ?

A

Chadwick’s sign.
Hegar’s sign
Piscazech’s sign.
Throbbing arteries in the fornices

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5
Q

What is Chadwick’s sign ?

A

Bluish discolouration of vaginal and cervical lining due to increased vascularity.

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6
Q

What is Hegar’s sign ?

A

Palpable softening of cervical neck which feels like the uterus and cervix are moving separately.

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7
Q

What is Piscazech’s sign ?

A

Palpable asymmetrical growth of uterus due to one side implantation of the fetus.

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8
Q

What do the female genitalia look like after delivery ?

A

Uterus and ectocervix are still larger and softer.
Uterus will remain slightly larger than before and the external cervical ostium change form.

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9
Q

What does the female genitalia look like after menopause ?

A

Less pubic hair
Atrophic mucosa : appear smoother (fold/rugae disappear), dryer, lighter in colour, easily damaged
Smaller labia minora and ovaries
Transformation zone less visible : go back inside the endocervical canal
Uterus may change position : anteversion or straight
Fornices disappear

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10
Q

What should you ask the patient beforehand ?

A

Has she already done this kind of examination ?
How was the experience ? Any worries or expectations ?
Inform them what to expect.
Does she want a chaperone ?
Can she empty her bladder ?

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11
Q

What is the right position for gynaecology ?

A

Lying in the lithotomy position with buttock at the end of examination table
- if stirrups then adjust to her height
- if not then place a cushion under buttock

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12
Q

What equipment should you prepare for gynaecology ?

A

Non sterile gloves
Vaginal speculum of appropriate size
Kidney bassin
Cotton swab
Lubricant
Sanitary towel.

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13
Q

What are the different size of speculum ?

A

From smallest to biggest :
- 1 : used for virgin or post-menopause women
- 2 : used for sexually active women
- 3 : used for women that had vaginal delivery
- 4 : used for bigger women

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14
Q

What are the steps of a gynaecological exam ?

A

Inspection :
- general visual inspection
- inspection of external genitalia
Speculum exam : inspection of internal genitalia
Bimanual examination

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15
Q

What do you do in the general inspection of gynaecology ?

A

Inspect lower abdomen and groin by spreading the overlying skin.

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16
Q

How do you do inspection of external genitalia in gynaecology ?

A

Sit on a stool, always inform the patient.
You can observe further by separating the labia with thumb and index between the labia majora and minora, moving them sideways. (You can also use both hands)

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17
Q

What can you see in the basic external genitalia inspection (gynaecology) ?

A

Pubic hair : patterns varying by ethnicity, generally triangular over the vulva.

Labia majora : pigmented skin with pubic hair outside and epithelium inside.

Labia minora : protrude between the labia majora. Looks larger than expected, covered in pigmented mucosa.

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18
Q

What can you see in the extended external genitalia inspection (gynaecology) ?

A

Clitoris : hidden under prepuce formed by pinkish pigmented mucosa.

Urethral meatus : triangular bulging of pink epithelium. Sometimes possible to see the duct of the para-urethral glands.

Vaginal introitus : lined by pink mucosa. Hymen can be seen if intact as thin mucosa fold behind.

Duct opening of the bartholin’s gland at the base of the labia minora.

Posterior comisura : lower edge of the vagina, mark the transition to the perineum.

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19
Q

What do you do if you suspect prolapse ?

A

Ask the patient to bear down at the end of the inspection. It makes it more visible.

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20
Q

Interpretation of findings of external genital examination ?

A

Abnormal hair patterns => hormonal disturbance

Redness, swelling of skin/mucosa => infection often accompanied by scratch.

Abnormal discharge => further examination

Scars of rupture or episiotomy can remain visible

Haemorrhoid seen on anal inspection

Labia swelling

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21
Q

What do you do in case of labia swelling ?

A

Indication to palpate :
- take labia major between thumb and index of opposite hand
Can be caused by obstruction of Bartholin’s glands => cause cyst / abscess

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22
Q

What are the different type of female circumcision ?

A

Removal of clitoris hood, clitoris gland, labia major / minora or closure of the vulva.

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23
Q

What is the aim of the speculum examination ?

A

Use to spread the vaginal wall, so you can perform a Pap smear, swab for STD or therapeutic intervention of the vaginal and ectocervix.

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24
Q

What do you use with the speculum ?

A

Lubricant or Luke warm water.
Lubricant may interfere with bacterial swab or the pap smear.
Water cannot interfere but isn’t a good lubricant for post menopausal women.

25
Q

How do you insert the speculum ?

A

Separate the labia with thumb and index.
Close the speculum, position it at 45° to the introitus to avoid pressure against anterior vaginal wal and urethra.
Follow a downward slope.

26
Q

How do you position the speculum ?

A

After 1/3 insertion, turn to horizontal position. Insert full length or until resistance is felt (coming from the posterior fornix).
Then open the blade carefully : see the ectocervix. Adjust speculum until the cervical optimum is visible.

OR

Open the blade when approaching the posterior fornix. It can prevent the speculum from sliding back out of the vagina due to pressure. If it is difficult to get the cervix in view, apply suprapubic pressure.
More difficult for multiparous women because the vaginal wall bulge together.

27
Q

What do you do if you need both hands during the speculum examination ?

A

Ask the patient to hold it with one hand. NEVER let the speculum free in the vagina.

28
Q

What do you inspect in speculum examination ?

A

Vaginal wall.
Vaginal content and fornices.
Cervix
Distal ectocervix.

29
Q

What do you assess in the vaginal wall ?

A

Mucosa : shiny and pinkish with transverse fold (rugae)
Clear white vaginal discharge or mucus could be in the cervical optimum.
- wipe away if view obstructed or take it for sample.

30
Q

What do you inspect in the cervix ?

A

Shape
Size
Position
Surface
Color
Optimum sternum
Transformation zone

31
Q

What do you inspect in the distal ectocervix ?

A

Smooth, lighter pink than vaginal wall.

32
Q

What shape can the cervical optimum have ?

A

Round : before pregnancy
Transverse or H shaped : after birth

33
Q

What does the transformation zone look like ?

A

Visible as a deep red ring or epithelium (during fertile life).

34
Q

How do you withdraw the speculum ?

A

Fix the position of speculum while unlocking it. Open it slightly further to clear the cervix. Follow the vaginal axis, hold speculum upward turning back to 45°.

Speculum blade close automatically due to movement and vaginal pressure : close gently but not totally so the mucosa doesn’t get stuck.

35
Q

What do you do if the ectocervix stick to the speculum blade ?

A

Open the speculum further and turn it gently before withdrawing. If the problem persist : hold back the ectocervix with a plier and gauze.

36
Q

What is a normal vaginal discharge ? What are the significances of others ?

A

Normal : clear + white
Others cause :
- infection of vagina / cervix
- cervical dysplasia
- cervical cancer

37
Q

What are the signs of an infection ?

A

Redness and irritation of the ectocervix / vaginal wall.

Need further laboratory examination.

38
Q

What are the signs of Candida vaginitis ?

A

Redness, swelling, white patches of discharge, white thick discharge, itching.

39
Q

What are the signs of bacterial vaginosis ?

A

Grayish white discharge.
Elevated pH, positive whiff test (fishy odor)
Fishy odor after applying KOH, clues cell in the saline wet mount.

40
Q

What are the signs of trichomonas vaginitis ?

A

Yellowish green discharge. Malodorous.
Red and swollen cervix with petechiae.
Elevated pH, trichomonads can be seen moving.

41
Q

What are the signs of chlamydia and gonorrhea ?

A

Yellow purulent discharge with an asymptomatic course for chlamydia.

42
Q

What signify a red cervix that bleed easily ?

A

Ectocervix erosion, cervicitis, malignant cell.
Need a Pap smears.

43
Q

What do you pay attention in case of endometriosis history ?

A

Posterior fornix where endometriosis plaque may be visible.

44
Q

What are the signs of prolapse ?

A

Bulging of vaginal wall visible : cystoceles (anterior), rectoceles (posterior)

Uterine prolapse : ectocervix is very low close to the introitus.

45
Q

What is the goal of the Bimanual examination ?

A

Palpate the internal female genitalia. Evaluate the vaginal wall, cervix, uterus and adnexa.

46
Q

How do you insert a finger ?

A

Standing between the stirrups or next to the thigh.
Insert middle and index finger, lubricated. Thumb and index of other hand spread the labia.
Internal finger avoid to pressure urethra and follow the vaginal axis. Others finger form a fist to avoid touching clitoris.
Press inward on the perineum to allow the internal finger to get in the correct position.
External hand on the lower abdomen above the pubic bone.

47
Q

What do you assess palpating the ectocervix ?

A

Smooth surface, firm and elastic consistency, closed external ostium (except during delivery of miscarriage).
Fornices.
Position related to the vaginal axis.

Moving the cervix sideways or upward should not cause pain : adnexa and cervical motion tenderness.

48
Q

How do you palpate the uterus ?

A

Put finger in the posterior fornix, move uterus upward and centrally.
Move toward the external hand. Press abdomen down.
Palpate uterus between both hands.

49
Q

What do you assess in the palpation of the uterus ?

A

Smooth surface, firm and elastic consistency, pear shaped.

If :
- anterversion flexion position : palpable between both hands
- retroversion flexion position : difficult to palpate
- others : possible but difficult

50
Q

How do you palpate the adnexa ?

A

Let all tissue next to the uterus slide between internal and external finger.
- internal finger in lateral fornix
- abdominal hand, 3 cm medially of ASIS, press in and down moving toward symphysis
- push adnexa structure towards internal finger

Assess ovaries : palpable in 1/2 women during fertility stage. Beware even in the absence of pathology ovaries are sensible.

51
Q

What do you assess palpating the vaginal wall ?

A

While withdrawing the internal finger :
- folded surface
- soft but non painful consistency : assess bulging
- prolapse : ask the patient to bear down

52
Q

What is the significance of irregular cervical surface ?

A

Retention cyst = Nabothian cyst : firm and smooth
Cervical polyp : soft, come out of the external ostium
Premalignancy and malignancy : bleed easily

53
Q

Significance of adnexa tenderness ?

A

While moving cervix sideways.
Salpingitis : often accompanied by a palpable mass (ectopic pregnancy)
If painful right side could be appendicitis.

54
Q

Significance of cervical motion pain ?

A

Peritonitis.

55
Q

Significance of enlarged uterus ?

A

Uterine myomas
Pregnancy

56
Q

Significance of palpable ovary ?

A

Ovarian cyst, ovarian cancer.

57
Q

What is the goal of the ultrasound ?

A

Gather more objective information about the internal genital organ following the Bimanual exam.
Learn about :
- size and swelling of adnexa
- wall of uterus and size
- asses presence of fluid in abdominal cavity
- assess mobility of certain structures

58
Q

What are the type of ultrasound used ?

A

Abdominal : needs a full bladder

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