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

 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
 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

Paget’s Disease

Inverted Nipple
 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

 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
 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
pink and moist
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

 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
 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

 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
 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 Skene’s Glands
• Palpate Bartholin’s 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