Pelvic Exam

Question 1

Anatomy of female rectal and genitourinary system

Answer 1

SEE DIAGRAM

Question 2

Understand physiology of female menstrual cycle

Answer 2

See Diagram

Question 3

Setting and equipment appropriate to the performance of the pelvic exam

Answer 3

Setting: Ensure privacy, comfortable room temperature and female chaperone. Explain in general terms what you are going to do. Marked anxiety before an exam may be a sign that something is not quite right. Find source of anxiety before exam.

Equipment:
· Exam Table Equipped with Footrests
· Flexible Light Source
· Vaginal Specula in Various Sizes
- chosen based on body habitus, age, parity
- Pederson (thinner bill)
- Grave (rounded bill)
- plastic disposable, metal reusable
· Warm Running Water
· Lubricating Jelly
· Materials needed to do Pap or other tests

Question 4

Inspection

Answer 4

Purpose: Inspect hair distribution, and surface characteristics. Skin should be smooth and clean. Look for excoriation, rashes, lesions, discoloration or other signs of infection or inflammation.
Method:

Question 5

Speculum examination

Answer 5

Purpose: The speculum is used to visualize the cervix and vaginal canal. The speculum should be lubricated. Select the appropriate size and gently insert finger of other hand just inside the vagina and apply pressure downward. When the patient is fully relaxed, insert gently and slightly downward. When properly in place the cervix should be fully exposed between the blades.
Method:

Question 6

Palpation

Answer 6

Purpose: Insert gloved index and middle fingers into the vagina. Palpate the vaginal wall for cysts, nodules, masses or growths. Vagina should be smooth, homogeneous, and non-tender. *Make sure thumb is not touching the clitoris. Locate the cervix and feel for size, length and shape- should correspond with visual findings during speculum exam. Cervix should be movable 1-2cm with no discomfort.
Method:

Question 7

Rectovaginal examination

Answer 7

Purpose: Place well lubricated index finger into the vagina and middle finger into the anus while having patient bear down. Palpate anterior rectal wall and rectovaginal septum for masses, polyps, nodules, sctrictures, irregularities and tenderness.
Method:

Question 8

Bimanual examination

Answer 8

Purpose: With palmar surface of one hand on the abdomen and other inside vagina palpate fundus of the uterus between fingers of two hands at the level of the pubis. Palpate the uterus for position, size, mobility, tenderness, shape and contour. It should be pear-shaped, non-tender, smooth, firm and 5-8cm long.
Method:

Question 9

Rectal examination

Answer 9

Purpose:
Method:

Question 10

Different types of vaginal specula and their clinical application

Answer 10

A vaginal speculum consists of 2 blades and a handle. The speculum is used to view the vaginal canal and cervix. All of these specula are available in either disposable plastic or stainless steel reusable.

There are 3 basic types of vaginal specula:
1. Graves Speculum- Blades are curved with a space between closed blades
Available in a variety of sizes with blades ranging from
Bottom blade is 1⁄4 inch longer than top to conform to the longer posterior vaginal wall and aid in visualization.

2. Pederson Speculumki
   Has blades as long as those of Graves but are both narrower and flatter
   Used for women with small vaginal openings
3. Pediatric or Virginal Speculum
   Smaller in all dimensions
   Short, narrow, flat blades

Question 11

Normal appearance of the cervical os in a nulliparous and a parous patient

Answer 11

The cervical os in a nullip has a small, rounded appearance. In a parous patient the os appears as a slit. The transformation zone will vary depending on the age, use of estrogen and pregnancy.

Question 12

Anteverted (anteflexed) uterus

Answer 12

Normal position of the uterus- fundus will be felt between two fingers at level of pubis.

Question 13

Gravida/gravidity/para/parity

Answer 13

gravida/gravidity- Total number of pregnancies, regardless of outcome.
para/parity- Number of births over gestational age of 24 weeks. Alive or stillborn, does not account for multiples

Question 14

Retroverted (retroflexed) uterus

Answer 14

Abnormal position of uterus- Uterus tilted toward coccyx. Palpate through rectocvaginal exam.

Question 15

Multiparous / multigravida

Answer 15

More than 1 birth over gestational age of 24 weeks. Grand multip 4-6 births, great grand multip- >7 births

Question 16

Corpus/ fundus/ cervix/ adnexa

Answer 16

corpus- body of uterus- includes fundus and isthmus- examined during bimanual exam
fundus- convex upper portion of uterus- extends to insertions of fallopian tubes. Fundal height is used to estimate stage of pregnancy
cervix- extends from Isthmus of uterus into vagina. Assessed during speculum exam. epithelial collection (pap smear) at cervical os.
adnexa- fallopian tubes an ovaries

Question 17

Nulliparous/ nulliparity

Answer 17

AKA Nullip- has not carried a pregnancy to 24 weeks

Question 18

Tanner stages for breast and pubic hair development in the female adolescent

Answer 18

See Diagram

Question 19

Physical findings that may suggest a ‘reg flag’ for sexual abuse

Answer 19

Should be taken in consideration with history and behavior, never make assumptions:

    	* Signs of general physical Abuse or Neglect (Bruising, Malnourished)
    	* Evidence of trauma, scars in genital area
    	* Unusual changes in skin color in genitals
    	* Presence of STI, oral, anal, or genital
    	* Anorectal problems (anal itching, bleeding, pain, fecal incontinence, poor sphincter                 	        	 tone, bowel habit dysfunction)
    	* Genitourinary Problems(Rash or sore in genital areas, vaginal odor, discharge, pain,               	        	itching, bleeding, UTI)

Question 20

Patient education regarding the pelvic examination and the genital self-exam

Answer 20

Recommend for anyone at risk for an STI, Instruct patient to wash hands before and after, position mirror so that pubic area is visible, inspect under hair for bumps, sores, blisters, and warts, spread vaginal lips and look at clitoral hood, clitoris, inspect inside of vaginal lips, urinary and vaginal openings, any abnormalities should be cause to seek healthcare provider

Question 21

Cervical motion tenderness

Answer 21

during the bimanual exam, locate the cervix with the palmar surface of fingers. Grasp the cervix between your fingers and ,move it from side to side while watching the patient for any pain or discomfort. Pain suggests a pelvic inflammatory process.

Question 22

Vaginal discharge

Answer 22

– during the external exam, while inspecting and palpating the labia minora, look for caking of discharge in the tissue folds, which suggests vaginal infection or poor hygiene. Discharge from the skene glands, bartholin glands, or urethra usually indicates infection.

Question 23

Abnormal vaginal bleeding

Answer 23

abnormality in menstrual bleeding or inappropriate uterine bleeding are common gynecologic problems caused by a variety of issues (hormone changes throughout cycle, chronic PID, endometrial polyps, etc). In pregnancy, may have little consequences or may be life-threatening, and should be evaluated.

Question 24

Cystocele

Answer 24

– a bladder hernia that protrudes into vagina

Question 25

Rectocele

Answer 25

protrusion or herniation of the posterior vaginal wall with the anterior wall of the rectum through the vagina

Question 26

Urethrocele

Answer 26

pouchlike protrusion of the urethral wall

Question 27

Uterine prolapse

Answer 27

descent or herniation of the uterus into or beyond the vagina

Question 28

Cervical stenosis

Answer 28

narrowing of cervical opening

Question 29

Friable cervix

Answer 29

fragile, easily irritable, prone to bleeding cervix

Question 30

Cyanotic cervix

Answer 30

bluish in color, may indicate really pregnancy as new vascularity forming

Question 31

Ectropion

Answer 31

endocervical columnar epithelium protrudes out through external os of cervix

Question 32

Entropion

Answer 32

a

Question 33

Disabled women

Answer 33

●Promote comfort – alternative positions
● Dependent upon impairment (ex: hearing, visual, physical, etc.)
●An assistant to help the women while the provider does exam
●Same as women exam to the extent possible

Question 34

Older women

Answer 34

●Same as women of child-bearing age with few modifications for comfort
●Post menopausal changes: thinning of tissues, flattening of tissues, loss of rugae of tissues, vaginal walls atrophy
●Vagina is narrower and shorter
●Uterus shrinks in size
●Ovaries are no longer present
●Prolapse more common
●May require more time and assistance to assume position, and holding legs
●May need head elevated
●May need smaller speculum

Question 35

Children

Answer 35

●Inspection and palpation of EXTERNAL genitalia (well child)
● Internal exam only done when there is a specific problem or concern
●Speculum exam requires special equipment and experienced/knowledgeable pediatrician or gynecologist
●Legs held in frog position or lying back with head at 30°

Question 36

Pregnant women

Answer 36

●Same procedure as nonpregnant women
●Assess gestational age estimation
● Assess uterine size and contour
●Pelvic size estimate
●Cervical dilation and length
●Also include fetal assessment (growth, position, well being)
●Softening of cervix, uterine isthmus, coloration, palpable prominences

Question 37

Adolescents

Answer 37

●Positioned same as adults
● Explain thoroughly each step
● Interview without the parent (always chaperone)
●Chose appropriate sized speculum
● Maturational changes in girls undergoing puberty
●Possible stretched hymen
●Possible increased vaginal secretions
●Opening should be at least 1 cm wide by menarche
●More mature adolescents will have the same findings as adults