The patient must have an empty bladder. The patient must be appropriately gownedand draped. Use non-sterile gloves on both hands. Properly dispose of soiled equipment andsupplies.
Both male and female examiners shouldbe chaperoned by a female assistant. Always tell the patient what you are about todo before you do it. The breast exam is usually done just beforeroutine pelvic exams.
Supine position with head elevated 30 to 45degrees. Assist the patient to place her heels in thestirrups. Have the patient slide her hips down until shecontacts your hand at the edge of the table. Have the patient relax her knees outward justbeyond the angle of the stirrups.
Taking History:- Do you experience hot flushes or flashes? Ifso, how bothersome are they? Are you experiencing menstrual irregularities? Do you practice contraception?
Are you having any problems or changes youattribute to menopause? What are they? Couldanything else be causing these problems orchanges? How do you feel about approachingmenopause? Are you receiving hormone therapy formenopause? If you have completed menopause, have youhad any bleeding?
FINDINGS :- Hair Distribution Skin Of Perineum Labia Majora Closed OrGapping Clitoris - About 2 Cm InLength And 0.5 Cm InWidth Urethral Orifice Vaginal Orifice Anus -
NORMAL FINDINGS:-Cervix :- pink midline usually about 2 to 3 cm indiameter smooth firm, rounded or oval odorless, creamy or clearsecretions
VAGINA Pink throughout; Clear or cloudy, Odorless secretions; About 10 to 15 cmin length.
Ovaries may or may not be palpable; firm,slightly tender, oval, mobile; about 4 cm indiameter Uterus – mobile, rounded, palpable at level ofpelvis. Skenes glands and Bartholins gland - normalfindings: nontender, no discharge.
Labial folds flatten Skin paler, shiny Meatus usually more posterior Cervix decreases in size; may appear paler Scanty cervical discharge Vagina shortens with age Decreased vaginal secretions Uterus diminishes in size; may not be palpable Ovaries atrophy with age
Uncover the vulva by moving the center of thedrape away from you. Try to avoid creating a"screen" with the drape pulled tight betweenthe patients knees. Announce what you are going to do and thentouch the patient on the thigh with the back ofyour hand before proceeding. Inspect the outer genitalia for redness,swelling, lesions, masses, or infestations.
Gently palpate the labia majora and minora. Inspect the labia, the folds between them, andthe clitoris. Note any redness, swelling, lesions, ordischarge. Reassure the patient, if the exam is normal sofar.
Speculum Examination Bimanual Examination
Warm and lubricate the speculum. Announce what you are going to do and thentouch the patient. Expose the introitis. Insert the speculum at a 45 degree anglepointing slightly downward.
Once past the introitis, rotate the speculum toa horizontal position and continue insertionuntil the handle is almost flush with theperineum. Open the "bills" of the speculum 2 or 3 cmusing the thumb lever. Secure the speculum by turning the thumb nutor clicking the ratchet mechanism. Do not move the speculum while it is lockedopen.
Observe the cervix and vaginal walls forlesions or discharge. Obtain specimens for culture and cytology asindicated. Withdraw the speculum slightly to clear thecervix. Loosen the speculum and allow the"bills" to fall together. Continue to withdrawwhile rotating the speculum to 45 degrees.
Remove the draping. Reassure the patient, if the exam is normal sofar, say so.
Apply a small amount of lubricant. Uncover the vulva and lower abdomen Announce what you are going to do and thentouch the patient. Spread the labia and insert your lubricatedindex and middle fingers into the vagina. Avoid contact with the anterior structures.
Cervix :-i. Palpate the cervix with your index fingernoting size, shape, and consistency.ii. Gently move the cervix side to side betweenyour fingers and note mobility andtenderness.iii. Gently lift the cervix forward and notemobility and tenderness.
iv. Examine the anterior uterine fundus.iv. Continue to lift the cervix with the vaginalhand.v. Press downward with the abdominal handand palpate the uterus.vi. Note consistency and tenderness. Attempt toestimate uterine size.
• Pull back vaginal hand to clear cervix.• Reposition vaginal hand into the right fornix, palmup.• Sweep the right ovary downward with theabdominal hand 3 or 4 cm medial to the iliac crest.• Gently "trap" the ovary between the fingers of bothhands (if possible). Note its size and shape alongwith any other palpable adnexal structures.• Pull back and repeat on the left side.
Switch off the examination light provide privacy Ensure the woman has tissue available is access to washing facilities and sanitarypads, if needed. Recording findings clearly in patient’s notes Provide correct information about the findingsand results of the examination.
If swabs are taken for screening following informationshould be given.How the results will be communicated.When to expect results.What to do if she does not get the expected results.Possible outcomes.Any further management.
In estrogen deficiency (or followingmenopause) the vaginal mucosa may be palewith loss of rugae. Swelling of Bartholin’s glands could indicateinfection (discharge should be cultured). Pregnancy enlarges the cervix; cancer hardensit. In PID the client will experience severe painwhen the cervix is manipulated.
Blue-coloured cervix = pelvic congestion andtumour or pregnancy. Infection may give the cervix a bright red orspotted red appearance. A cervix projecting low into the vagina canindicate uterine prolapse. A cystocele or rectocele may be observed inclients with weak pelvic muscles. A laterally placed cervix can indicate tumour oradhesions.
Cervical ulcerations, masses, nodules orsurface irregularities must be assessedcarefully and considered malignant untilproven otherwise. Endocervical lining may protrude outwards(ectropion or eversion).
Polyps – bright red, fragile, softprotrusions into the cervical canalendocervical tissue. Small, smooth, round, raised yellowcysts (Nabothian cysts) appear with orafter chronic cervicitis or with cervicalgland duct obstructions.
Cervical carcinoma appears as hard, granular, friablelesions usually beginning the os and growing outwardirregularly. Venereal warts (condolamata acuminata) are dark pinkto pale, cauliflower like lesions on the mucosal surface.They may or may not be visible and resemble irregularsmall pumps on the cervix. Ulcerations indicate trauma or infection (Herpessimplex, type I or II).
Trichomonal infection usually producesstrawberry spots (punctate haemorrhages). Tumourous uterus feels hard if cancerous. A palpable ovary in a postmenopausal womanis abnormal.