The Female GU Exam Flashcards
Female Anatomy
External Genitalia
Mons Pubis: hair
Prepuce: front of beginning folds
Labium Majoris: outer folds
Labium Minoris: inner folds
Clitoris: anterior to the urethra
uerteral meatus: uretheral exit; located anterior to the vaginal opening
Vagina: middle
introitus: Vaginal opening
Skene’s Glands: anterior of vaginal opening
Bartholins Glands: posterior vaginal opening (lubrication glands) at 4 and 8 oclock positioning; internal and external
Perineum: between vaginal and anal opening
Anus: most posterior
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Vaginal Opening: depending on the parous of the female can vary in size
- virginal: small introitus
- nulliparous: no children via vaginal birth but has had sex
- parous: wider
Female Anatomy
Internal Genitalia
cerival appearance of a nulliparous or parous women
location of internal organs in comparison to others
Labia Minora: inner folds
give way to the vagina
Vagina: causeway between interoitus and the cervix
Cervix: the entrance to the Uterus
- external ox: seen on exam
- internal os: the top of the cervix before entering into the uterus
Uterus: muscualr organ
Fallopian tubes: connect uterus to the ovary
Ovary: on each side; conected to the uterus
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Nulliparous: cervix will appear with a donut, small hole that is round
Parous: cervix will appear with a horizontal slit, a bit wider than the nulliparous women’s
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the unriary bladder and the urethral opening are most anterior
the vagianl opening and the uterus sit posteroir
Uterus: sits superior/posterior to the bladder
posteriorly: the sigmois colo, rectum and the anus
Changes to the Uterus and Vagina during Menopause
Menopause
- vaginal lining = thin and dry
- decreasd blood flow to teh vaginal tissues
- decreased vaginal elasticity; shortens and narrows
- less secretions during sexual activity
these changes can be felt and observed on exam
Ovaries: produced less estorgen (or none at all)
History Taking for a GU exam: female
Gynecologic History is KEY
- conditions: infections, PID
- cancers: endometrial, cervical, ovarian, breast
- hx. of STIs : last test and results and proper treatment
Menstrual Hx.
- (remember in younger pt. can take up to 1 year for the menstrual cycle to get regular)
- DLMP MUST!!!
- frequency, length, heavy, character of blood, regulalrity of cycle, sx. or dysmenorrhea or PMS sx.
what is PMS
what is menopause
PMS: premenstrual syndrome
by definition: a collective emotional, behavioral, physical symptom collection for
- 5+ days BEFORE menses
- for 3 concecuative cycles
- symptoms stopping 4 days after start of menses
- interferring with daily activity
Menopause
- cessaion of the menstrual cycle for 12 consecutive months
- commmonly 48-55: median is 51
- symptoms: hot flases, mood changes, sleep issues
- (ask pt. about medication use and herbal/supplements used: soy and black cohosh)
Abnormal Bleeding: things to ask about during GYN Hx.
define the following
- amenorrhea
- polymenhorrhea
- oligomenhorrhea
- hypermennorrhea
- hypomennorrhea
- menorrhagia
- metrorrhagia
- menometrorrhagia
Abnormal Bleeding
- post-menopausal bleeding: is a RED FLAG!!!
- bleeding between menses
- menstrual abnromalities
- post coital (sex) bleeding
Terms
- amenorrhea: absence of menses
- polymenorrhea: shortened interval between menses
- oligomenorrhea: lengthened intervals between menses
- hypermonrrhea: excessive flow but time frame of menses is regular
- hypomenorrhea: decreases flow but timeframe of menses is regualr
- metrorrhagia: irregular intervals between periods, excessive flow and duration
- menometrorrhagia: irregular or excessive bleeding during and between peroids
History GYN taking (con.)
Contraception
Screenings
Obstetric
Contraceptions
- methods: appropriate use
- past methods
Screenings
- date and results of last peliv exam/pap
- past hx. or abnormal reuslts or further testings
Obstetric
- G (grava) : # of pregnancies
- P: Pregnanices that…
- T: term
- P: preterm
- A: abortion
- L: living
- asking about types of delivery and complications
History Taking GYN in currently pregnant pt.
Naegele’s Rule
- ask FIRST date of last menstral period
Naegele’s Rule
- (FDLMP + 7) - (3 months) + 1 year
- estiated day of confinement
Early Preg signs
- missed period
- breast symptosm
- fatigue
- urinary frequency
- N/V
- ask about vaginal bleeding and abd. pain
History Taking in GYN
surgical
sexual
Family
Surgical Hx.
- past OB/GYN proceudres
Sexual
- age, # of partners, lifetime partners, type of partner
- type of sex
- STDs: self and partner and testing
- IPV
- cleansing products
- smoking and drug hx.
Family
- cancers: gyn specific and colorectal
- miscarrige/abortions
- cogenital ab. or mutliple births (twins9
ROS in GYn pt.
Pelvic Pain Conditions to consider
ROS
Pelvic Pain
- OPQRST it and find out acute v chronic
Acute
- PID!!! : acute pain
- etopic pregnancy rule out
- mittelschmetrz
- cysts, torsions
- endometriosis
- dysmenorrhea
- GI and other GU causes
Chronic (lasting > 6 months)
- age, previosu surgery
- children and medical conditions
- fibroids, endometriosis, adnomyosis, other psych. conditions
Abnormal Bleeding
Sexual Dysfunction
Vulvovaginal symtptoms (discahrge, lumps/sores, ithcing)
Urinary symtpoms (buring, dysuria, frequent, urgent, etc.)
Physical Exam: Pelvic Exam
- incudes what
- general principles
- positioning of pt
those 21 and older should get an exam routinely (Q3years) under that; only if specific compliant warrenting
External exam
Internal exam: speculum, cervical sample (if needed), bimanual exam
Rectovaginal exam (if needed)
Principles
- CHAPARONE!!! 2 people in there
- consent, explain why and steps, showing equiptment
- gown/draps and gather supplies
- gloves, light and all materials
- Speculum choice: pederson (smaller blade) to graves & size variation
Positioning of Pt.
-drape pt: mid-abd to knees depress drape between knees to keep eye contact and asses pt. comfort/discomfot via facial expressions
- postioning: lithotomy: feet in stirrups & butt on edge of table (till you feel my hand)
- empty bladder prior to
Phsycial Exam: External Inspection & Palpation
External Inspection
- mons pubis: inspect distribution of hair & sexual matruity scale1-5 (if priamry amenorrhea or adolescent)
- Labia: swelling, redness, rash, lesions or trauma
- clitoris: adhesions, atrophy, inflammation
- uretheral meatus: discharge, polyps, fistuals
- introtius: swelling, discomofort, lesions
- perinuem: inflammation, fistulas, growths
- anus
External Palaption
- labia majora: tell pt youre going to spread labia & palpate with other hand: inflamamtion, discharge, uclers, etc.
- urethral meatus and clitoris and introtius
- bartholins glands: only if they report swelling
- perineum: tenderness
Physical Exam
Palaption of Bartholians glands
Bartholians Glands: at 4 and 8 oclock: Palpapte
- palpapte bilaterally
- insert index finger into vagina near the posterior aspect of the introtius: thumb on outside
- palpate for: swelling, tenderness, masses or fluxuation
Physical Exam
Speculum exam
- choosing tool
- inserting and postioning speculum
Speculum: choosing tool
- smaller spectum for non sexually acitve pt. or those with small features or those post-menopausal as they ahve atrophy
- medium size usually what fits most
Insertion and Inspection internally
- warn pt: warm with water speculum
- separate labia mainor to visualize the vaginal opening before inserting
- insert slowly at an oblique angle: downward to the path of least resistance
- continue inserting at the oblique downard angle as far as the canal: then straighten blades to horizontal postion
- open speculum: via prssing thumb piece
- reposition as necessary, light and instrument until cervix in view
- lock speculum in place: do not let go
Physical Exam: Speculum
- inspecting cervix
- nabothian cysts
- specimens
Inspect cervix
- lesions
- discharge
- polyps
- note size and shape of Os
- Postion of Cervix
- anterior pointin g= retroverted uterus
- posterior pointing = anterverted uterus
- horixonal positiong = midposition uterus
Nabothian Cysts
- mucinous retention cysts : small white and rounded or yellow raised areas on the cervix
- normal findng
Take note of
-friability
red pathces, white patches
granualr areas
Specimens
- pap, HPV test, culutre , DNa
PE: Speculum Exam
Cerival Sampleing
Cervical Sampling for Pap
- use cerivcal broom: singel speciemn collection of both the ecto and endocerivcal cells
- insert brush into the os and rotate 3-5 times to left and right
- brush into tube and swish
PE: Speculum Exam
Vaginal Wall Inspection
cystocele or rectocele
VAginal WAll
- release thumb screw to unlock
- hold the blades open , close as you exit introtius
- remove slowly while inspecting vaginal walls for
Inspection
- redness, color
- discharge
- ulcers
- masses: rectocele or cystocele
- lesions
- rugae = indicate premenopause
- smooth = indicated postmenopause
Cysto/rectocelce inspection : ask pt. to bear down
- observe
- upper anterior 2/3 wall buldge: cystocele
- posterior vaginal wall buldge: rectocele
close speculum slowly: idex finger over top of upper blade and keep thumb on handle
remove slowly
PE: Bimaunal Exam
vaginal walls
palapate cerivcal mobility
Bimanual Exam
- inform pt.
- change gloves & stand
- insert index and middle finger & press downward to relax muscles: wait for relax
- insert fingers to full length
Assess Vaginal Walls
- nodules, tenderness, masses and growth
Palpate Cervix
- shape, size, firm like tip of nose using palmar side of fingers
- mobility: grab cervix between both fingers and move side to side normal response: minimal discomfort: extreme pain = CMT cerivcal motion tenderness
PE: BiManual Exam
Uterus Palpation
types of uterus postions
Ovary Palpaption
Palpat Uterus
- place top hand between umbillicus and pubic symphsis: press downward
- use intravaginal fingers to elevate cervix and uterus : press up
- want to grasp uterus between the two hands
Postions
- normal: uterus sits superior and slighting posterior to the bladder
Retroverted: cervix faces forward
- uterus posterior: felt from the retcum , bt normal angle
Retroflexed: uterus is angled backwards, can be palpated from rectum
Ovary Palapation (adenxae : fallopain and ovary)
- not always palpable
- place hand over RLQ/LLQ
- intravaginal fingers: face upwards into right/left lateral fornix : push up and in
- external hand: sweep downwards toward symphysis to push adenxal structures toward the internal hand
- normal ovaries: slightly tender but not often felt
PE:
Bimanual: Pelvic Floor Muscles
Rectovaginal Exam
indications
exam
Pelvic Floor Muscles
- sqeeuze vaginal opeing around fingers for as long as they can
- full strength = compression and snug finges for > 3 seconds
- with fingers against the wall of vagina: ask pt. to couhg or beardown: feel for incontinence or prlapse of vaginal wal l
Rectovaginal Exam
indications
- palpate retroverted uterus, cul-de0 sac, uterosacral ligamens
- colorectal cancer screening
Exam
- cahnge gloves: relubercate finger
- insert finger in rectum
- ask pt. to bear down to relax sphincter
- apply pressure on the walls with downward pressure from hand outside the abd.
- feel for massses, polyps, nodules or tenderness
Epidermal Cysts
Epidermal Cysts : on vulva
- benign finding, yellow/pink painless papules with a central puncta
- can be found on the labia
Genital Warts
Herpes Simplex
Genital Warts : on vulva
- soft, pink/flesh colored
- painless
- no discahrge
Herpes SImples: vuvla
- painful
- shallow ulcers on a red base
- no induration & usually multiple
Primary Syphilis
Condolymoa Lata (secondary syphilis)
Primary Syphilis
- painless priamary ulcer
- shallow ucler with clear base and induration
- no discharge
Seondary: Condolyoma Lata
- falt, round or oval papules
- grey/white exudate
- wart-like appearance
- nontender with no discharge
Bartholian Gland Abcess
Bartholian Gland ABcess
- if the gland gets infected and does not get better: over time can created abcess
- red, tender and fluctuant
- can open with copious discharge
Vulvara Carcinoma
Carcinoma
- if any symptoms: will be itchy
- Red-white indurated (thickened) lesion on the lulva
Vaginal Discharge and organisms that cause it
BV
- organism: gardenlla vag. , M. hominis, bacteroides
- grey/white discharge
- fishy smell
- wiff test and clue celss on wet mount
candidias
- candida: yeast
- thick, white curdy
- ithcy!!
- KOH: spors and hyphae
Trich
- trichomoiaisis
- green/yellow, watery discharge
- itchy, dysuria
- see the trichomnads (flagella)
Cystocele and Rectocele
Cystocele
- see on anterior 2/3 of vaginal wall
- due to bladder prolapse int the vaginal cana
Rectocelce
- posterior wall of vagina
- rectal prolapse intot eh vagain
Cervicitis
Strawberry cervix
Cervical Polyps
Cervicitis
- red and friable (easily bleeds) on exam
- discharger from the os
Strawberry Cervix
- associtated with trich infections
- small petechiae on the cervix surface
Cerival Polyps
- simialr to the ectocervix, or can be more red and friable
- just a polpy through the os of the cervix
Cervical Cancer
Cervical CAncer
- assocaited with bleed: especially post-coital
- can see a fungated mass: indicated advanced cerival cancer
Fibroids
Uterine prolapse
Fibroids
- within the uterus
- can be asymptomatic (usually)
- can have: pain, abnormal bleeding, infertility
- masses: can be palpable on funduse (globular like)
- uterus can feel enlarged
Uterine Prolapse
- due to weak peliv floor muscles and strucutre surouddnign it
- uterus falss down vaginal canal or outwards in severe cases
Adenxal masses
Adenxal
- ovarian cancer
- ovarian cysts
- if feeling enlarged ovaries in premeno or post meno. keep CA on differential
