Intimate Examinations Flashcards
Breast, testicular, vaginal and Rectal
What should you say in the introduction for all intimate examinations?
• Tell them there is a Chaperone who a medical professional who knows this exam for the comfort of both you and me;
Ask: do you have a preference of their gender?
What should you do before a per vaginal examination?
- ALWAYS do an ABDOMINAL INSPECTION & PALPATION before PV
- then gather equip - gloves, lubricant, speculum and paper towels
- position patient w/heels to bottom then let knees fall to the side
- wash hands and put on gloves
What should you look for on inspection of the vulva?
Ulcers abnormal vaginal discharge/bleeds scars from previous surgery vaginal atrophy masses e.g. bartholins cysts varicosities ASK to cough -?evidence of vaginal prolapse
What should you do for speculum examination of the vagina?
warn patient you are going to examine the vagina and are they still happy for you to do so
warn patient going to insert the speculum
eparate labia, insert sideways speculum then rotate and open blades until optimal cervix view is achieves and tighten locking nut
a. Cervical inspection
i. External os
ii. Cervical erosions (ectropion)
iii. Masses
iv. Ulcers
v. Abnormal discharge
2. Remove speculum via loosening locking nut on speculum and partially close the blades – rotate back to lateral orientation and gently remove the speculum, inspecting vagina walls as do so
What should you do for bimanual examination of the vagina?
i. Vaginal exam - Palpate walls of vagina for irregularities or masses
1. Lube index and middle fingers on dom hand
2. Non dom hand separate labia
3. Gently insert gloved index and middle finger of dominant hand into vagina – lateral facing palm firs then rotate 90 degrees so palm is upwards
ii. Assess cervix
1. Position
2. Consistency (hard/soft)
3. Is os open or closed
4. ?cervical excitation (in PID palpation of cervix = severe pain)
iii. Assess fornicies
1. Check for Masses: Gently palpate fornicies on either side of cervix for
iv. Palpate uterus
1. Size (norm ~orange sized)
2. Shape (?fibroid mass distortion)
3. Position (anteverted vs retro)
4. ?palpation tenderness
v. Assess adnexa (ovaries and uterine tubes etc)
1. LIF and left lateral fornix / RIF and right lateral fornix
a. Bimanual palpation for any palpable masses
i. ?size and shape
vi. On withdrawal of fingers inspect glove for blood or abnormal discharge
What should you inspect for on rectal examination?
i. Inspection • Skin excoriation • Skin tags • Rashes • Haemorrhoids • Anal fissures • External bleeding • Perianal fistulae and abcesses
What should you palpate for on rectal examination?
ii. Palpation
• Prostate – in males anterior
a. Size (norm=walnut; enlargement ~BPH or malig if irregular), symmetry and texture (tip of the nose like; prostatitis =boggy)
• Rotate 360 for rectum assessment
a. ?masses or irregularity
b. ?stool in rectum – soft vs impacted
iii. Assess anal tone – ask patient to squeeze your finger
iv. Withdraw finger
• Inspecting for blood – (fresh red vs melaena)
• Inspect for stool / mucous
What should be done in an introduction for examination of the testicles?
wash hands, introduce, confirm patient details, explain exam, “I need to carry out an examination of your genitals, this will involve me examining your penis, testicles and the surrounding area“
“I have a chaperone present…are you ok with that?“
gain consent, ?understood you? happy for you to examine them?
Position patient lying on an examination couch - ask them to stand at the end, expose patient from waist down and DON GLOVES
What should you look for on a general inspection of the testicles?
Inspect the patient’s genital region and the surrounding areas (i.e. penis / groin / lower abdomen):
Skin changes – rash / bruising / swelling / erythema / hair loss
Scars – especially in the inguinal region (hernia or orchidopexy)
Obvious masses
How what should you look for on inspection of the scrotum and perineum?
Ask the patient to hold their penis out of the way to allow easier inspection of the scrotum.
Inspect the scrotum from the front, sides and the posterior aspect by lifting the scrotum.
Inspect the perineum
- Skin changes – rash / ulcers / erythema (e.g. cellulitis / fungal infection)
- Scars – may provide clues as to previous operations (e.g. vasectomy or testicular fixation)
- Masses – note any obvious lumps, these will require examination later
- Swelling – unilateral or bilateral? / associated with erythema?
- Bruising
- Necrotic looking tissue – Fournier’s gangrene is a diagnosis not to be missed and is often first noted on the perineum
[3S’s MB]
What should you do in palpation of the penis?
- Retract the foreskin to check for phimosis (narrowing of the foreskin) or adhesions and describe any abnormalities on the glans (ulcers/discharge/scarring)
If you are unable to retract the foreskin, ask the patient to do this himself
Be aware that a patient may be circumcised and comment on this to the examiner
2. Open the urethral meatus to check patency.
- Replace the foreskin once examined to prevent paraphimosis (this is where the retracted foreskin obstructs venous return from the glans, thus resulting in painful swelling of the glans
What should you do for palpation of the testicles?
- Use both thumbs and index fingers to gently palpate the whole testicle:
Your remaining fingers should be placed behind the testicle to immobilise it
Palpation involves a gentle rubbing motion between thumb and index finger to methodically examine the whole body of the testicle
- If you are unable to locate a testicle, palpate along the path of the inguinal ligament for an undescended testicle (if the patient also has a scar in their inguinal region this would suggest a previous orchidectomy or orchidopexy).
What should you assess if a testicular mass is found?
Size / shape
Regularity – regular vs irregular
Consistency – hard (solid) / soft (cystic) / “Bag of worms” (varicocele)
Discomfort – try to identify the specific area causing pain
Are you able to get above the mass?- No = inguinal scrotal hernia
Is the mass fixed to the testicle or separate?
Separate + hard (solid) = epididymitis / orchitis
Separate + cystic (soft / fluctuant) = epididymal cyst / spermatocele
Is there a cough impulse? – presence of a cough impulse suggests hernia / varicocele
Does the mass transilluminate?
To transilluminate place a pen torch behind the scrotal swelling in a darkened room and it will produce a red glow
Transillumination suggests the mass is fluid filled – e.g. hydrocele (some hydroceles are so large that you cannot properly palpate the testicles)
How should you palpate the epididymis?
Palpate the epididymis (located at the posterior aspect of the testicle).
Pain in the epididymis may suggest epididymitis.
Phren’s test
If testicular pain is relieved by elevating the testes this is strongly suggestive of epididymitis.
Cremaster reflex
Stroke or pinch the patient’s medial thigh which leads to stimulation of the cremaster reflex and elevates the testicle
Loss of cremaster reflex may suggest testicular torsion
How should you palpate the spermatic cord?
Spermatic cord
Start palpation at the superior aspect of the testicle using your thumb and index finger.
The spermatic cord should be palpable connecting to the testicle at this region.
Palpate along the cord assessing for masses and tenderness.
