Reproductive System Flashcards
Location of the breast
2nd-3rd rib to the 6th-7th rib; from the sternal margin to the midaxillary line
Male breast anatomy
consists of a small nipple and areola overlying a thin layer of breast tissue
Anatomy of the breast
Composed of glandular, firbrous tissue and subcu and retromammary fat.
Glandular tissue contains 15-20 lobes per breast that radiate to the nipple
Each lobe has 20-40 lobules
Acini Cells
Each lobule consists of milk-producing cells that empty into lactiferous ducts
Small and inonspicuous in nonpregnant/nonlactating women
Cooper ligament (suspensory ligament) and muscles supporting the breast
Extends through the breast, attaching to the underlying fascia, providing further support
Pectoralis major, minor, serratus anterior, latissimus dorsi, subscapularis, external oblique and rectus abdominis
Arteries of the breast tissue
Internal mammary artery, and lateral thoracic artery
Proportions of glandular tissue vary with
age, nutrition, pregnancy, lactation and genetics
Four quadrants of the breast
Upper inner Lower innner Lower outer Upper outer - largest amount of tissue Tail of Spence - tissue extending into axilla
Nipple is composed of smooth muscle innervated by
tactile, sensory and autonomic stimuli
causes erection of nipple and lactiferous ducts to empty
Montgomery Tubercles
Sebaceous glands found on the areolar surface
Hair follicles found here too
Supernumerary nipples or breast tissue
Sometimes present along the mammary ridges that extends from the axilla to the groin
Lymphatics network of breasts
Superficial lymphatics drain the skin
Deep drain the mammary lobules
Axillary lymph nodes
easier to palpate when enlarged
anterior axillary (pectoral) nodes are located along the lower border of pec major
Midaxillary (central) high in axila close to ribs
Posterior axillary (subscapular) - lateral scapula, deep axillary psosterior fold
Lateral axillary (brachial) felt along upper humerus
Thelarche
Breast development
First sign of puberty
Occurs earlier in blacks
Onset of menses
Stage 3 = 25%
Stage 4 = 75%
Stage 5 = 10%
Appearance of breast bud (stage 2) to menarche is 2 years
Changes in pregnanct women
Luteal and placental hormones cause lactiferous ducts to proliferate and the alveoli to increase in size in number
Breasts enlarge 2-3x
Softer and looser
Colostrum is produced and accumulates in alveoli towards end of pregnancy
Areolar changes and vascularization in pregnant
Deeply pigmented and diameter increases
Nipples are prominent, darker and more erectile
Montgomery tubercles develop as sebaceous glands hypertrophy
Veins engorge and are visible on surface of skin
Lactating women
Colostrum secretes from breasts after delivery
Contains more protein and minerals then mature milk, antibodies and resistance factors
Surging prolactin levels 2-4 days after pregnancy
Milk production replaces colostrum in response to prolactin, estrogen, and stimulation of sucking
Breasts become full and tense as alveoli and lactiferous ducts fill
Tissue edema, delay in ejection reflex, produce engorgement
Termination of lactation
involution occurs over a period of 3 months
Breast size decreases without loss of lobular and alveolar components
Breasts rarely return to prelactation size
Older Adults
Menopause causes atrophy of grandular tissue and is replaced by fat
Inframmamary ridge at lower edge of breast thickens
Relaxation of suspensory ligaments lowers breasts
Nipples become small and flat and lose erectile ability
Skin becomes dry and thin, loss of axillary hair
Nonmodifiable risk factors for breast cancer
Age, gender, genetic factors (BRCA1 and BRCA2)
Personal Hx of breast cancer
FH
Previous breast biopsies
Race - white
Previous breast radiation (Hodgkin lymph)
Menarche before 12 and menopause after 55
Breast Density - more dense or fatty
Diethylstilbestrol therapy
Modifiable risk factors for breast cancer
Childbirth - nulliparity/late age of first child birth Hormone therapy - HRT after menopause Alcohol Obesity/high-fat diet Lack of PA
Breast inspection
compare size, symmetry, contour, skin color, texture, venous pattern and lesions
Check skin under each breast
Convex, pendulous, or conical
One breast is smaller then other
Male breasts are even c chest wall, obese men have a convex shape
Skin texture on inspection of breasts
Smooth, contour should be uninterrrupted
Retractions or dimpling may indicate fibrotic tissue associated c carcinoma
A peau d’orange (orange skin)
indicates edema caused by blocked lymph drainage in advanced inflammatory breast cancer. Thick skin c enlarged pores
healthy skin may look similar if pores are large
Venous network inpection of breasts
May be visible
Pronounced in pregnant or obese women
Patterns should symmetric
Unilateral patterns produced by dilated superficial veins as a result of increased BF to a malignancy
inspection of nevi on breasts
Markings and nevi that are long-standing, unchanging or nontender are of little concern
Changes in appearance of lesions always signal need for closer investigation
Inspection of nipples and areolae
Areola should be round or oval and bilaterally symmetrical
Color ranges from pink to black
Light-skinned women areola turns brown with the first pregnancy and remains dark
Dark-skinned - areola is brown before pregnancy
Nontender, nonsuppurative Montogomery tubercles is a common finding
Surface should be otherwise smooth
Peau d’orange seen on areola first usually
Contour of nipples
Most are everted
If inverted, ask if always like that
Recent inversion may signify malignancy
Retraction is seen as flattening or pulling back of the nipple or areola, which indicates inward pulling by inflammatory or malignant tissue
Firbrotic tissue of carcinoma can also change nipple axis, causing it to point in a different direction from other nipple
Color of nipples
Should be homogenous and match c areolae
Smooth or wrinkled is OK, but free of crusting, cracking or discharge
Color varies from light pink to very dark brown or black
Inflammation of the sebaceous glands in areola can result in retention cysts that are tender and suppurative
Supernumerary nipples
More common in black women
Occur mostly on embryonic mammary ridge
They are pink or brown and mistaken for moles
Can indicate congenital renal or cardiac abnormalities
Varied positions to inspect breasts
Seated c arms over head or flexed behind the neck
Tenses suspensory ligaments, accentuates dimples may reveal variations in contour and symmetry
Seated c hands pressed against hips c shoulder rolled forward
Contracts pectoral muscles
reveal deviations for contour and symmetry
Seated and leaning forward from the waist
Tension of suspensory ligaments
Breasts should hang equally
Helpful c contour and symmetry of large breasts
Breasts should appear bilaterally symmetrical with an even contour and absence of dimpling, retraction or deviation
Chest wall sweep
Sit c arms at sides
Sweep downward from clavicle to nipple
feel for lumps
Bimanual Digital Palpation
Place palmar surface facing up under the patient’s right breast
Place finger of other hand over breast and walk over tissue feeling for lumps as you compress tissue between your fingers and your flat hand
Virchow Nodes
Supraclavicular and Infraclavicular
Turning pt head to side being palpated and raise the same shoulder
Bend pt head forward
Sentinal nodes are indicators for invasion of the lymphatics by cancer
Three depths of palpation
Light, medium and deep
Vertical strip - palpate down then up
Circular - start at the outermost edge of breast tissue and work inward
Wedge - palpate center and work out and repeat
Avoid lifting your fingers
Breast mass characteristics
Location, size, shape, consistency, tenderness, mobility, borders, retraction, dimpling
Nipple compression
Palpate nipple well (behind nipple)
Only should be done if pt reports discharge
Is discharge bilateral or unilateral
Single duct or multi duct?
Concern = unilateral and from a single duct
Expected findings during a breast examination - FEMALE
Breast tissue will feel dense, firm and elastic
Soft nondiscrete bumps diffusely dispersed throughout breast tissue
Fine, granular feel in older women
Inframammary ridge felt along lower edge of breast, which can be mistaken for a breast mass
Common response to hormonal changes during menstrual cycle
Cyclical pattern of breast enlargement, increased nodularity and tenderness
Most likely premenstrually and during menses
Least noticeable after menses
Expected findings during a breast examination - MALE
Thin layer of fatty tissue overlying muscle
Obese men have thicker fatty layer - giving appearance of enlargement
A firm disk of glandular tissue can be felt
Breasts of infants
enlarged from passively transferred maternal estrogen
“Witch’s milk” squeezed out of breast bud
Enlargement rarely larger then 1 to 1.5 cm in diameter
Disappears in 2 weeks and rarely lasts beyond 3 month
Breasts - Children and Adolescents
Asymmetry
Breast tissue is homogeneous, dense, firm, and elastic
Subareolar masses transient and common unilaterally or bilaterally in males
Firm, tender, are concerning to patients
Gynecomastia caused by illicit drugs. Biopsy may be required, usually temporary and benign
Examination in patients with mastectomy
Pay attention to scar, reoccurence of malignancy is typical at scar site
Inspect for swelling, lumps, thickening, redness, color change, rash or irritation
Note muscle loss or lymphedema
Palpate surgical scar for swelling, lumps, thickening, or tenderness
Palpate lymph nodes axillary and clavicular
Perform normal breast exam even in those c a lumpectomy , augmentation, or reconstruction
Breast changes in pregnant
Enlargement during first trimester
Sensation of fullnss c tingling, tenderness and bilateral increase in size
Assess if pt is using adequate support
Nipples during pregnancy
Enlarge and more erectile Flattened or inverted Crust from dry colostrum can be evident Expect to see areolae that are broad and dark Montgomery tubercles are common
Palpation of pregnant breasts
Reveals generalized coarse nodularity and lobular feel d/t hypertrophy of the mammary alveoli
Dilated subcu veins may create network of blue tracings across breasts
Telangiecstasias (spider angiomas)
Second trimester May develop on upper chest, arms, neck and face D/t elevated estrogen Bluish and do not blanch Striae may be evident
Inspection of breasts during lactation
Assess if there is an adequately fitting bra
Palpate for degree of softness
Full breasts that are firm, dense and slightly enlarged may become engorged
Engorged breasts are hard, warm and are enlarged, shiny and painful
Occur 24-48 hours
May also be a sign of mastitis
Clogged Milk Ducts
Common in lactating women
Inadequate emptying or a tight bra
Creates tender spot that is lumpy and hot
Frequent breast feeding, application of hear
Can lead to mastitis
Nipples during lactation
Irritation signs (tender, red)
Look for blisters or petechiae
Cracked nipples may be sore or bleeding
Lighter-color nipples more prone to damage
Nipple damage d/t breast feeding
After lactation, retain color and become less firm then pre-pregnant
Breast in postmenopause
Flat, elongated and more loose
Smaller and flatter nipples
Finer granular feel on palpation replaces lobular feel of glandular tissue
Inframmatory ridge thickens and can be felt more easily
Vaginal Anatomy
Vulva, mons pubis, labia majora, labia minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice and urethral opening
Symphysis pubis is covered by a pad of adipose tissue called mons pubis or mons veneris
Hymen
Connective tissue membrane that may be circular, crescentic or fimbriated
After hymen tears and becomes divided, the edges either disappear or form hymental tags
Bartholin glands
secrete mucus into the introitus for lubrication
Vaginal Angle
45 degree posterior incline with the vertical plane of the body
Anterior wall of vagina is separated from the bladder and urethra by connective tissue called the vesicovaginal septum
Posterior wall separated from rectum and retrovaginal septum
Uterine Cervix
Dvidied into anterior, posterior and lateral fornicies
Internal pelvic organs can be palpated through these walls
Vagina
Menstrual flow from uterus, serves as terminal portion of the birth canal, and is receptive organ for penis
Uterus
Sits between bladder and rectum in pelvic cavity
Covered by the peritoneum and lined by endometrium, which is shed during menstruation
Pouch of Douglas
Formed by perotineum as it covers the lower posterior wall of the uterus and upper portion of the vagina separating it from rectum
Flattened and inclined at 45 degree angle
Can be anteverted, anteflexed, retroverted or retroflexed
Nulliparous uterine size
5.5-8cm long
3.5-4cm wide
2-2.5cm thick
Parous women may have 2-3cm larger
Nulliparous weight is 40-50g
Multiparous is 20 to 30g heavier
Adnexa
comprises fallopian tubes and ovaries
Each tube is 8-14cm and supported by mesosalpinx
Rhythmic contractions of the tubal musculature transport the ovum to the uterus
Function of the ovaries
Secrete estrogen, progesterone which control menstrual cycle and support pregnancy
True pelvis
Lower curved bony canal, including the inlet, cavity, and outlet; fetus must pass through these during birth
Adolescence
Endometrial lining thickens and prepares for the onset of menarche
Average age of menarche is 12-13 years
Irregular menstrual cycles are not unusual during childhood as a result of anovulatory cycles (without ovulation)
Uterine enlargement
Occurs during first trimester due to estrogen and progesterone levels
Third months causes enlargement d/t to fetal enlargement
12 weeks is reaches into abdominal cavity
Relaxin and progesterone
Softens pelvic cartilage, allowing mobility and “waddle” gait
Resolution 3-5 months postpartum
Lordosis likely
Increased uterine BF and lymph
Pelvic congestion and edema
Chadwick sign - bluish color of cervix as a result of the uterus, cervix and isthmus softening
Goodell sign - softening of cervix
Mucus in cervical canal prevents infection of infant
Vaginal canal can also exhibit bluish color
“Bloody show”
Dislodgement of the mucus layer in cervical canal
Exaggerated uterine anteflexion during first 3 months
candida infection
Acidic pH d/t increased in lactic acid production by vaginal epithelium prevents bacteria from multiplying but can cause candida infections
Older Adults - Endocrine changes
Ovarian function diminishes during woman’s 40s
Menstrual periods may cease but ovarian function may continue
Median age of menopause is 51
Menopause
Defined as 1 year with no menses (amenorrhea)
Estrogen levels decrease causing the labia and clitoris to become smaller
Decrease in adrenal androgens and testosterone levels
Vaginal changes in older
Vagina constricts, narrows, shortens and loses rugae and mucosa becomes thin, pale and dry
Dyspareunia - pain during intercourse
Cervix becomes smaller and paler
Uterus decreases in size and endometrium thins
Ovarian and pelvic changes in older
Ovaries decrease to 1-2 cm in size and becomes convoluted. Ovulation ceases 1-2 years before menopause
Ligaments and connective tissue lose elasticity
Vaginal wall loses integrity
Systemic effects of menopause
Increase in body fat and intraabdominal deposition of body fat - more of a male pattern distribution
Total and LDL lipoprotein cholesterol increase
Thermoregulation is altered - hot flashes common
Draping and Gloving
Cover knees and symphysis and depress the drape between her knees to see the woman’s face
Instruct pt you are going to begin, start with a neutral touch on her lower thigh, and move hand along thigh without breaking contact to the external genitalia
Inspection and Palpation
Hair distribution
Notice mons pubis, labia majora
Skin should be smooth and clean hair should be free of infestations
Labia Majora
Gaping or closed; dry or moist
Symmetric, shriveled or full
Soft and homogeneous tissue
Look for excoriation, rahses or lesions associated c infection or inflammation
Ask if female has been scratching
Observe for discoloration, varicosities, stretching or signs of trauma or scarring
Bartholin gland infection - labial swelling or redness or tenderness that is unilateral
Labia Minora
Separate labia majora
Symmetric or asymmetric
Inner surface should be moist and dark pink
Soft, homogeneous tissue without tenderness
Excoriation, inflammation, irritation, or caking of discharge which suggest vaginal infection or poor hygiene
Discoloration or tenderness may be traumatic bruising
Ulcers or vesicles = STI
Palpate for irregularities and nodules
Clitoris
2 cm or less in length and 0.5 cm in diameter
Enlargement may by masculinizing condition
Observe for atrophy, inflammation or adhesions
Urethral Orifice
Appears as an irregular opening or slit
Close or slightly within vaginal introitus, usually midline
Inspect for discharge, polyps, caruncles and fistulas
Cauncle is a bright red polypoid growth that protrudes from the urethral meatus; most cause no symptoms
Irritation, inflammation or dilation suggest repeated UTIs or insertions of foreign objects
Ask questions after the pelvic exam
Vaginal Introitus
Can be thin vertical slit or a large orifice with irregular edges from hymenal remnants
Tissue should be moist
Look for swelling, discoloration, discharge, lesions, fistulas and fissures
Skene and Bartholin Glands
Look for discharge and note any tenderness
Note character if there is discharge
Discharge from Skene usually means infection
Palpate Bartholin glands at posterolateral portion of the labia majora noting tenderness, swelling, masses, hear or fluctuation
Note discharge
Swelling that is painful in infection of Bartholin gland
Perineum
Smooth, episiotomy scarring may be evident in women who have borne children
Thick and smooth in nulliparous
Thinner and rigid in multiparrous
Should not be tender
Look for inflammation, fistulas, lesions or growths
Anus
Darkly pigmented and coarse skin
Should be free of scarring, lesions and inflammation, fissures, lumps, skin tags or excoriations
Insertion of Speculum
Insert speculum the length of the vaginal canal and sweep upward to visualize the cervix.
Cervix- Color
Should be pink
Blue indicates increased vascularity that indicates pregnancy
Symmetric circumscribed redness around the os is expected finding
Pale color indicates anemia
Consider reddened areas as unexpected, especially if patchy or irregular borders
Position of Cervix
Should be anterior-posterior
Retroverted = pointing anterior
Anteverted = posterior
Midposition = horizontal
Deviation of the right or to the left may indicate pelvic mass, uterine adhesions or pregnancy
Projection greater than 3 cm may indicate pelvic or uterine mass
Childbearing women will have diameter of 2-3cm
Surface Characteristics of Cervix
Squamocolumnar epithelium may be symmetric reddened circle around os
Cervical ectropion = eversion of endocervix collapses columnar epithelium
Everted epithelium has a red, shiny appearance around the os that may bleed easily
Ectropion
Common in adolescents, pregnant women, or those taking estrogen-containing contraceptives
Not abnormality
Nabothian cysts
Small, white or yellow, raised, round areas on the cervix
Mucinous retention cysts of endocervical glands are considered expected
Infected cyst may become swollen and distort the shape of the cervix
vary in size and occur singly or multiples
Cervicitis, infection or carcinoma , cervical polyps
Friable tissue, red patcy, granular areas and white patches
Bright red, soft and fragile are cervical polyps
Usual discharge of cervix
Cervix or vaginal in origin
Usual discharge is odorless, may be creamy or clear, may be thick, thin or stringy
Heavier at midcycle or immediately before menstruation
Bacterial or fungal infection will have an odor and vary in color from white to yellow, green or grey
Size and shape of cervix
Os of nulliparous is small and round or oval
Mulliparous is horizontal slit c irregular or stellate
Lateral, bilateral transverse or stellate scarring from childbirth
Bimanual Examination
Insertion of fingerss into the vaginal canal
Palpate for smoothness, homogeneous, and nontender
Feel for cysts, nodules, masses and growths
Bimanual Examination of Cervix
Feel for size length and shape
Cervix is firm when nonpregnant and softer while pregnant
Feel for nodules, hardness, and roughness
Note position (pointing anterior or posterior)
Should move 1-2cm
Painful cervical movement suggests pelvic inflammatory disease or a ruptured tubal pregnancy
Examination of the Uterus
Deviations of the left or right could indicate possible adhesions, pelvic masses or pregnancy
Size, Shape and Contour of Uterus
Pear-shape
5.5-8cm long
Larger in multiparous women
If larger then normal during childbearing age is indicative of pregnancy, fibroid or tumor
Countour = rounded, firm and smooth walls
Fixed uterus = adhesions
Tenderness = inflammation
Palpation of ovaries
firm, smooth, ovoid and 3x2x1cm in size
Healthy ovary is moderately tender on palpation
Marked tenderness, enlargement or nodules is irregular
Palpate for adnexal masses
Adnexa are generally difficult to palpate
Observe sphincter tone
Tight sphincter may be due to anxiety, scarring, or indicate spasticity caused by fissures, lesions or inflammation
Lax sphincter is neurologic deficit
Absent = improper repair after childbirth or trauma
Palpation of rectal wall
palpate for masses, polyps, nodules, strictures, irregularities, and tenderness
Should be smooth and uninterrupted
Palpate rectovaginal septum for thickness, tone and nodules
May feel uterus if retroflexed
Palpation of the uterus
location, position, size, shape, contour, consistency and tenderness
Used for retroverted uterus
Evaluate stool
and secretions
note color, presence of blood, prepare specimen for occult blood testing
Completion of Exam
Assist woman into a sitting position
Provide sanitary pad if menstruating
Either leave the room for her to dress then discuss findings or immediately discuss findings and ask her feelings on the exam
Changes in Infants
Use frog position
Labia majora is widely separated and clitoris up to 36 weeks
Majora and minora may be swollen, minora more prominent
Hymen protruding, thick and vascular and may look like a mass
enarged clitoris in newborns = congenital adrenal hyperplasia
Imperforate hymen is rare but can cause difficulty
Breech deliveries can cause bruised genitalia
Unusual orifices in vulva should be explored prior to gender assignment
whitish discharge common during newborn period - result of passive hormonal transfer from mother
Adhesions common between minora during first months
Sometimes cover vulva, may require separation
Mucoid discharge common from irritation from diaper and powder
Indications for Examination - Children
Depend on age and parental concerns
Inspection and palpation ONLY for well children
Internal is performed when there is bleeding, discharge, trauma or suspected SA
Bubble bath vaginitis does not require internal
Parent may need to hold child at 30 degrees and at frog position
Always necessary for a chaperone
Inspection and Palpation - Children
Anterior labial traction - view foreign bodies
Bartholin and Skene glands usually not palpable
Ask girl to cough and view hymen - if hymen bulge, if imperforated
Discharge - Children
Often irritates perineal tissues causing redness and excoriation
Bubble bath, soaps, detergents and UTIs cause irritation
Injuries - Children
Swelling of vulvar tissues, accompanied by bruising or foul-smelling discharge should indicate SA
Should be suspected if there is STI, or injury
SA injuries are more posterior
Use knee-chest position
Bleeding - Children
Unintentional, foreign body or SA
Further evaluation if precocious puberty
Rectal Examination - Children
Detect presence or absence of uterus or foreign body
Techniques for Adolescents
Most important examination
Use models or illustrations
Deep breathing, alternating tightening and relaxation
Chaperone is necessary
Increased secretions, stretched hymen before menarche
Gestational Age - Pregnancy
EDD - Estimated due date
Naegle rule - add 1 year to the first day of LNMP, subtract 3 months and add 7 day
Average duration of pregnancy is 280 days or 40 weeks
Uterus Size and Contour - Pregnancy
Estimate length of pregnancy, fetal growth and gestational age
Use measuring tape to measure from upper part of pubic symphysis to superior uterine fundus
1cm inrease per week in fundal height is expected
Twin pregnancy suspected if uterus is larger than expected during 2nd trimester based on EDD
More than 2cm variation may indicated need for US
Factors affecting fundal height
Obesity, amount of amniotic fluid, multiple gestations, fetal size and position of uterus
Pelvic Exam - Pregnancy
Softened isthmus, firm cervix Second month - cervix, vagina and vulva acquire bluish color Cervix softens Fundus flexes easily Slight fullness and softening of fundus Increased vaginal secretions
Cervical Effacement and Dilation
Effacement - thinning of cervix, reducing length
Shortening of cervix (less than 29mm) indicates preterm delivery
Usually occurs before dilation in premipara
Dilation - Opening of cervical canal to allow passage of fetus
10cm is complete dilation
Fetal Well-Being
Assess fetal heart rate and fetal movement
Heard by doppler first then fetoscope
Count FHR and compare it to mothers
Note quality and rhythm
Fetal movement
Appreciated by mothers 16-20 weeks of gestation
Cardiff count-to-10 method - mother counts 10 movements and noted length of time
Usually 10 movements in 1 hour to 10 in 12 hours
Fewer then 10 in 12 should alert HCP
Risk factors for uteroplacental insufficiency, should start counting at 28 weeks
Leopold Maneuvers
Four steps used to assess fetal position
Presence of twins
Two fetal heart tones
Abdominal palpation detects two distinct fetal parts
Diagnose c ultrasound
Station
Relationship of the presenting part to the ischial spines of the mother’s pelvis
Vaginal examination and palpation are performed during labor to estimate the descent of presenting part
Record findings for dilation, cervical length and station in that order
Contractions
Begin as early as the 3rd month of gestation
Braxton Hicks contractions
4-6 contractions before 37 weeks needs evaluation
Mild, moderate and strong - one that does not indent with fingertips
Seconds from beginning to when relaxation occurs
Fetal Head Position
Vaginal exam when dilation has begun
Other pregnancy changes
Uterus more anteflexed during first 3 months from softening of the isthmus
Fundus may press on bladder - increasing frequency
Examination in Older Adults
Older women likely to defer examination
May need more time and assistance to get into lithotomy position
Pts c orthopnea may need head raised and chest elevated
Inspection and Palpation of Older
Labia is flatter and smaller - loss of subcu fat
Dry skin and shinier; clitoris smaller
Relaxed perineal musculature will cause more posterior urinary meatus, almost into vaginal canal
Introitus constricted, gaping, walls roll to opening
Vagina is narrow, short, lack of rugae,, cervix less mobile
Uterus smaller, hard to palpate and ovaries shrink
Rectovaginal septum thin, smooth and pliable
Anal tone diminished
Look for incontinence and prolapse of uterus and vaginal walls
Look for signs of inflammation, tenderness, trauma, mass, nodules, enlargement,
Alternative positions for pelvic exam
Knee-Chest Diamon shape Obstetric Stirrups M-shaped V-shaped
