GYNECOLOGICAL EXAM

SFC WARD

Joint Special Operations Medical Training Center

 Do a Complete Physical
HEENT
Assessment
CV
Lungs
Breasts
Abdomen
Pelvic/rectal
Neuro
Musculoskeletal
Joint Special Operations Medical Training Center
 Essentials for an Adequate
Examination--Relaxation
Patient should be given an opportunity to
empty her bladder prior to the exam--
Routine UA specimen may be obtained at
this time
Explain what is to take place during the
exam
Drape her appropriately, cover extending
at least over her knees
Arms should be at her side or folded
across her chest.
Joint Special Operations Medical Training Center
 Essentials for an Adequate
Examination
Examiner's hands should be warmed,
also warm the speculum before the exam
Have eye to eye contact with the patient
during the exam
Explain in advance each step in the
examination, avoiding any sudden or
unexpected movements

Joint Special Operations Medical Training Center

 Correct Examining Position of
the Patient
The Lithotomy Position/or Semi-Sitting
Lithotomy Position
Lying in supine position
Thighs flexed and abducted
Feet resting in stirrups
Buttocks extended slightly beyond edge of
exam table
Head supported with a pillow

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center
 Male examiners should always be
attended by female assistants
Hx should be taken prior to patient
disrobing.
Do not enter the room with an unclothed
patient unless you have a female chaperone.

Joint Special Operations Medical Training Center

 Breast Examination (note the
following):
Breast development
Size, symmetry, contour and appearance
of the skin (Variation in breast contour
may include the presence of masses,
dimpling, or flattening.)

Joint Special Operations Medical Training Center

 Supernumerary Nipple

Joint Special Operations Medical Training Center

 Breast Examination (note the
Nipples
following):
Direction of the nipples may provide a clue
to masses when there is asymmetry
Discharge may indicate disease or may
merely occur with the hormonal fluctuation
of the menstrual cycle
Ulcerated areas and other nipple lesions
require further exploration
Lymph node, have patient press hands
against hip contracting pectoral muscles,
palpate lateral group of axillary lymph
nodes
Joint Special Operations Medical Training Center
 Nipple Laceration

Pagets Disease

Inverted Nipple
Joint Special Operations Medical Training Center
 Sequence of Breast Exam
Patient sitting or standing--press hands
on hips to contract pectoral muscles
(This maneuver accentuates any existing
tissue retraction.)
Observe size and contour and
appearance of the skin
Observe direction of nipples

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center
 Sequence of Breast Exam
Palpate
axillary
region

Joint Special Operations Medical Training Center

 Sequence of Breast Exam
Have patient lying flat with arm
abducted and hand under head (This
helps flatten breast tissue evenly over the
chest wall.)
Palpate entire breast and lymph nodes,
(axillary and infraclavicular)
Palpation is performed in a rotary
motion using an organized approach
Joint Special Operations Medical Training Center
Joint Special Operations Medical Training Center
 Sequence of Breast Exam
Some examiners start in
the upper outer
quadrant where tumors
develop most frequently
Breasts of young clients
are firm and elastic
Older clients, the tissue
may feel stringy and
nodular.
Joint Special Operations Medical Training Center
 Sequence of Breast Exam
Palpating large pendulous breasts, use a
bimanual technique. The inferior portion
of the breast is supported in one hand
while the other hand palpates breast
tissue against the supporting hand
Special attention is given to palpate the
nipples, and areola
Entire surface is gently palpated
With thumb and index finger compress the
nipple; note any discharge.

Joint Special Operations Medical Training Center

 NOTE: If client complains of a
mass or tenderness of one breast,
examine the opposite breast first
to ensure an objective
comparison of normal and
abnormal tissue.

Joint Special Operations Medical Training Center

 Breast Exam Video

Joint Special Operations Medical Training Center

 PELVIC EXAM

Joint Special Operations Medical Training Center

 Sequence of a Pelvic
Examination
Inspect the client's external genitalia
Perineal area must be well illuminated
Both hands are gloved to prevent the spread
of infection
Perineum is sensitive and tender, warn the
client by touching the neighboring thigh first
before advancing to the perineum.

Joint Special Operations Medical Training Center

 NOTE: A client suffering pain or
deformity of the joints may be
unable to assume a Lithotomy
position. It may be necessary to
have the client abduct only one
leg or have another person assist
in separating the client's thighs.

Joint Special Operations Medical Training Center

 Sequence of a Pelvic
Examination
Mons pubis--note quantity
and distribution of hair
growth
Labia--usually plump and
well-formed in adult
female
Perineum--slightly darker
than the skin of the rest of
the body. Mucous
membranes appear dark
Joint Special Operations Medical Training Center
 Sequence of a Pelvic
Examination
Separate the labia and inspect the labia
minora:
Labia minora
Clitoris
Urethral orifice
Hymen
Vaginal orifice

Joint Special Operations Medical Training Center

 Sequence of a Pelvic
Examination
Note the following:
Discharge
Inflammation
Edema
Ulceration
Lesions

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center
 Sequence of a Pelvic
Examination
Note abnormalities
such as:
Bulges and swelling of
vulva and vagina
Enlarged clitoris
Syphilitic chancres
Sebaceous cyst

Primary Syphilis

Joint Special Operations Medical Training Center

 Sequence of a Pelvic
Examination
Skene's glands
Near the urethra
Suspect inflammation; check for urethral
discharge (Dc = Infxn Most likely GC)
Insert index finger with palm facing you into the
vagina up to the 2d joint. Apply pressure
upwards and milk the Skene's gland by moving
your fingers outward
Do this on both sides and note COCA on any
discharge. Obtain specimen for culture.
Change glove if discharge is found.

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center
 Sequence of a Pelvic
Examination
If there is history or appearance of labial
swelling check Bartholin's glands
Insert index finger up to first knuckle
With your index finger and thumb, palpate
the posterolateral area of the labia majora
noting any:
Swelling
Tenderness
Masses
Heat or discharge

Joint Special Operations Medical Training Center

 Sequence of a Pelvic
Examination
Bartholin's glands (CONT)
A painful abscess is pus filled and usually
staphylococcal or gonococcal in origin and
should be incised and drained to perform
C+S.

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center
 Sequence of a Pelvic
Examination
Assess the support of the vaginal outlet:
With the labia separated by middle and
index finger
Ask patient to strain down
Note any bulging of the vaginal walls
(cystocele and rectocele).

Joint Special Operations Medical Training Center

 Sequence of a Pelvic
Examination
Inspect the anus at this time, note
presence of lesions and hemorrhoids

Joint Special Operations Medical Training Center

 Speculum Examination of
Internal Genitalia
Select a speculum of appropriate size,
lubricate and warm with warm water
(Commercially prepared lubricants
interfere with pap smear studies)
Small--not sexually active female
Medium--sexually active
Large--women who have had children
Medium to large speculum may be used
if female has had children.
Joint Special Operations Medical Training Center
Joint Special Operations Medical Training Center
 Speculum Examination of
Internal Genitalia
Hold speculum in right hand
Place two fingers just inside or at the
introitus and gently press down, this will
help guide the speculum into the vagina
opening
The speculum has to be closed
Insert closed speculum obliquely into
vagina at a 45 degree angle rotating 50
degrees counterclockwise
Joint Special Operations Medical Training Center
Joint Special Operations Medical Training Center
 Speculum Examination of
Internal Genitalia
Avoid trauma to the urethra
Care is taken to avoid pulling pubic hair
or pinching the labia
Maintaining downward pressure, open
blades slowly after full insertion and
position the speculum so that the cervix
can be visualized
When the cervix is in full view, the blades
are locked in the open position
Joint Special Operations Medical Training Center
Joint Special Operations Medical Training Center
 Examination/Collection
Specimen of the Cervix
Inspect the cervix
Color should be uniformly pink
Erythema around os:
Ectropion--expressed columnar epithelium
Erosion--term has been used to describe both the
exposed columnar epithelium and the erythema
seen with cervicitis
Pale--anemia
Bluish--Chadwick's sign, presumptive sign of
pregnancy.

Joint Special Operations Medical Training Center

 Examination/Collection
Specimen of the Cervix
Inspect the cervix
Lesions/cysts:
Nabothian cyst--endocervical retention cysts
usually secondary to cervical
infection/inflammation
Friable, granular, red or white patchy areas--be
suspicious of dysplasia, needs to be evaluated
with colposcopy
Ulcerative lesions--may be herpetic; do viral
culture of lesions and refer for colposcopy
Polyps--soft, friable mass protruding through os;
may bleed if traumatized; refer for eval/removal
Joint Special Operations Medical Training Center
 Examination/Collection
Specimen of the Cervix
Inspect the cervix
Discharge:
Endocervical vs. from vaginal vault
Physiological discharge--odorless, colorless
Culture any discharge.

Joint Special Operations Medical Training Center

 Examination/Collection
Specimen of the Cervix
Inspect the cervix
Os:
Nulliparous--small,
round, oval
Parous/multiparou
s--linear, irregular,
stellate

Joint Special Operations Medical Training Center

 Examination/Collection
Specimen of the Cervix
Obtain specimens
Chlamydia culture--most prevalent STD
GC culture--gram stain not reliable, done for
screening, must do Thayer-Martin for
confirmation
PAP smear for cytology--sites of collection:
Endocervical brush--all patients
Endocervical scrape with spatula--all patients
Posterior fornix--all
Vaginal cuff and area of former posterior fornix
for post-hysterectomy patient.

Joint Special Operations Medical Training Center

 Examination/Collection
Specimen of the Cervix
Obtain specimens
Wet mount of normal saline:
WBCs--evidence of infection/inflammatory
process
Flagellated trichomonads--trichomonas
Granulated epithelial cells,"clue cells"--
Gardnerella

Joint Special Operations Medical Training Center

 Examination/Collection
Specimen of the Cervix
Obtain specimens
KOH prep--budding yeast--candidiasis +
"whiff" (fishy odor)--Gardnerella
Viral cultures of suspected lesions
Others:
STS (RPR/VDRL)--if suspected STDs
Beta HCG--if pregnancy suspected.

Joint Special Operations Medical Training Center

 Examination/Collection
Specimen of the Cervix
Obtain specimens
Collect during routine PAP smear/pelvic
exam:
Wet mount if suspicious discharge
KOH prep if suspicious discharge
Thayer-Martin of Transgrow cultures
Chlamydia cultures

Joint Special Operations Medical Training Center

 Inspection of the Vagina
Withdraw the speculum slowly while
observing the vaginal wall
Close blades as the speculum emerges
from the introitus
Inspect vaginal mucosa as the speculum
is withdrawn

Joint Special Operations Medical Training Center

 Perform a Bimanual Examination

Joint Special Operations Medical Training Center

 Perform a Bimanual Examination
From a standing position, introduce the
index finger and middle finger of your
gloved hand into the vagina
Exert pressure posteriorly
Your thumb should be adducted with the
ring finger and little finger into your
palm to avoid touching the clitoris.

Joint Special Operations Medical Training Center

 Perform a Bimanual Examination
Palpate the vaginal walls as you insert
your fingers for tenderness, cysts,
nodules, masses or growths
Identify the cervix, noting the following:
Position--anterior or posterior
Shape--pear-shaped
Consistency--firm or soft
Regularity
Mobility--move from side to side 1-2 cm in
each direction
Tenderness
Joint Special Operations Medical Training Center
 Perform a Bimanual Examination
Palpate the fornix around the cervix
The os should admit your fingertip 0.5
cm
Place your free hand on the patient's
abdomen midway between the umbilicus
and symphysis pubis and press
downward toward the pelvic hand

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center
 Perform a Bimanual Examination
Many vaginal orifices will readily admit a
single examining finger. The technique
can be modified so that the index finger
alone is used. Special small speculum or
nasal speculum may make inspection
possible also. When the orifice is even
smaller, a fairly good bimanual
examination can be performed with one
finger in the rectum.
Joint Special Operations Medical Training Center
 Perform a Bimanual Examination
Your pelvic hand should be kept in a
straight line with your forearm and
inward pressure exerted on the perineum
by your flexed fingers. Support and
stabilize your arm by resting your elbow
either on your hip or on your knee which
is elevated by placing your foot on a stool

Joint Special Operations Medical Training Center

 (Bimanual Examination) Identify
the Uterus Noting the Following:
Size--uterine enlargement suggests
pregnancy, benign or malignant tumors.
The uterus should be 5.5-8.0 cm long
Shape--pear-shaped
Consistency--firm or soft.

Joint Special Operations Medical Training Center

 (Bimanual Examination) Identify
the Uterus Noting the Following:
Mobility--should be mobile in the antero-
postero plane and deviation to the left or
right is indicative of adhesions, pelvic
masses of pregnancy
Tenderness--suggests PID process or
ruptured tubal pregnancy
Masses.

Joint Special Operations Medical Training Center

 (Bimanual Examination) Identify
Right Ovary and Masses in the
Adnexa
Place your abdominal hand on the right
lower quadrant
Place your pelvic hand in the right lateral
fornix
Maneuver your abdominal hand
downward
Use your pelvic hand for palpation.

Joint Special Operations Medical Training Center

 (Bimanual Examination) Identify
Right Ovary and Masses in the
Adnexa
Felt with the vaginal hand. The ovary
has the size and consistency of a shelled
oyster
Note the size, shape, consistency, mobility
and tenderness of any palpable organs or
masses

Joint Special Operations Medical Training Center

 (Bimanual Examination) Identify
Right Ovary and Masses in the
Adnexa
Repeat the procedure on the left side
The normal ovary is somewhat tender
when palpated
Withdraw Fingers from Vagina and
Change Gloves

Joint Special Operations Medical Training Center

 Techniques of a Rectovaginal
Examination
The rectovaginal exam allows the
examiner to reach almost 1" higher into
the pelvis
The rectovaginal exam is usually
performed after the bimanual
examination.

Joint Special Operations Medical Training Center

 Techniques of a Rectovaginal
Examination
There is a risk of spreading infection between
the vagina and rectum. Gonorrhea may infect
the rectum, as well as the female genitalia. It is
recommended that gloves be changed between
bimanual and rectovaginal examination, in
order to avoid spreading gonococcal infection.
In order to avoid fecal soiling, gloves should
always be changed, if for some reason the
practitioner examines the vagina after the
rectum.

Joint Special Operations Medical Training Center

 Techniques of a Rectovaginal
Examination
Tell the patient that this may be
somewhat uncomfortable, and will make
her feel as if she has to move her bowels
Lubricate dominant gloved hand
Inspect the perianal area for lesions,
discoloration, inflammation and
hemorrhoids.

Joint Special Operations Medical Training Center

 Techniques of a Rectovaginal
Examination
Client is instructed to bear down as though she
as having a bowel movement, caution her; she
will feel as though she must pass a bowel
movement
As the anal sphincter relaxes, insert your
fingertip of the second finger gently into the
anal canal and the 1st finger into the vagina.
Sphincter tone is palpated

Joint Special Operations Medical Training Center

 Techniques of a Rectovaginal
Examination
Palpate the anorectal junction. Tell the
woman to bear down, palpate the
anterior rectal wall and check for
sphincter tone. A loose sphincter may be
present due to neurologic deficit or 3d
degree perineal laceration after
childbirth

Joint Special Operations Medical Training Center

 Techniques of a Rectovaginal
Examination
Insert fingers as far as they will go. Tell
the woman to bear down, and that should
bring another centimeter of palpation.
Check the rectal walls, rotating your
finger, checking for masses, polyps,
irregularities or tenderness.

Joint Special Operations Medical Training Center

 Techniques of a Rectovaginal
Examination
Palpate the rectovaginal septum for tone
and thickness
With your vaginal finger in the posterior
fornix, perform a bimanual exam and
palpate the bottom of the uterus and
adnexa completely.
Withdraw your fingers and evaluate the
posterior rectal wall.
Joint Special Operations Medical Training Center
 Techniques of a Rectovaginal
Examination
Prepare guaiac of rectal finger
Give the patient a towel or tissues to
cleanse herself

Joint Special Operations Medical Training Center

 Common Abnormalities
Vulva
Bartholin's cyst
Condyloma acuminatum

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center
 Common Abnormalities
Cervix
Polyps
Discharge
Discoloration

Joint Special Operations Medical Training Center

 Common Abnormalities
Uterus--enlarged
Pregnancy
Fibroids

Joint Special Operations Medical Training Center

 Common Abnormalities
Adnexa
Ectopic pregnancy
Ovarian tumor or cyst

Joint Special Operations Medical Training Center

 PELVIC EXAM VIDEO

Joint Special Operations Medical Training Center

 SUMMARY
BREAST EXAM
Inspect
Palpate Axilla
Palpate Breast
Palpate Nipple

Joint Special Operations Medical Training Center

 SUMMARY
PELVIC EXAM
Inspect Externally
Palpate Skenes Glands
Palpate Bartholins Glands
Assess Outlet
Speculum Exam
Bimanual Exam
Vagina, Cervix, Uterus, Adnexa
Joint Special Operations Medical Training Center
 SUMMARY
RECTOVAGINAL EXAM
Palpate sphincter tone
Palpate rectal wall
Palpate rectovaginal septum
Palpate Uterus
Palpate Adnexa
Guaiac

Joint Special Operations Medical Training Center

 ?
Joint Special Operations Medical Training Center
Joint Special Operations Medical Training Center