This document provides guidance on performing a gynecological examination. It discusses obtaining consent and ensuring patient privacy and comfort. It describes examining the external genitalia, performing a speculum exam to inspect the cervix and vaginal walls, and obtaining specimen samples. It also covers the bimanual exam to palpate the uterus, ovaries, and surrounding structures to identify any masses or tenderness. Proper draping, positioning, infection control and communication with the patient are emphasized throughout the exam.

1. Gyaenocological examination
Desabandu Dr. G.H.K.K. Gunawardana
M.B.B.S.,M.S.(Obs & Gyn),
F.R.C.O.G.,F.C.O.C.(S.L )
Consultant Obstetrician and Gynaecologist
Teaching Hospital,
Peradeniya.

2. Approach
• Introduction
• Consent
• Chaperone
• Well screened
• Well exposed the patient
• Bladder should be empty

3. General examination
• Appearance
• Colour of mucous membrane
• Oedema
• Breasts, Thyroid gland
• CVS- Pulse
BP
Heart murmer
• RS – Type of breath sounds
Added sounds

4. Abdomen in general
Inspection
Distention & comments on umbilicus
Respiratory movements
Scars
Striae
Distended veins
Hernias

6. Palpation
• See whether is it extra- abdominal or intra -
abdominal
• Superficial palpation
Tender areas
Superficial Lumps
• Deep palpation
1. Lump
2. Liver,Spleen, Kidneys

8. Percussion
• It is done in order to identify
1.Free fluid in the abdomen
2.To locate the margins of a lump
3. A band of resonance over a
retroperitoneal lump

9. Percussion
Looking for free fluid in the abdomen.
• Start from the center of the abdomen and per cuss towards
lateral side.(Resonant to dull area)
In lying down position most resonant area will be around the
umbilicus. If there is a lump beyond the umbilicus start
percussion from the epigastrium where the gastric bubble is
present).
• Check for shifting dullness
• Also per cuss over
Lumps
Bladder
Liver

10. Auscultation
• Bowel sounds
• Bruits

11. Examination of an abdomino-pelvic
lump

12. Examination of an abdomino-pelvic
lump
Abdominal examination
• Site and whether the lump is extra abdominal or intra abdominal
• Size
• Shape
• Surface
• Consistency
Solid
Cystic
Soft
Firm
• Margins-well defined
Ill defined
• Tenderness
• Mobility ( longitudinal or transverse )
• Percussion note
• Ability to get below the lump

13. Examination of an abdomino-pelvic
lump cont..
• It could be either extra abdominal or intra
abdominal in nature.
• If it is an extra abdominal it could arise from
any tissue layer in the abdominal wall.
• If it is an intra abdominal it could arise from
pelvic structures.

14. Intra abdominal - Disappears with
head elevation

15. Extra abdominal- Prominent with
head
elevation

16. • Lump -1.Intra abdominal
Disappears with head elevation
2.Extra abdominal
Prominent with head elevation

17. • Female reproductive organs are inside the pelvic cavity
So, Gyaenocological lumps are usually abdomino-pelvic
& Could be bladder, Uterus or Adnexal lump

18. Examination of an intra abdominal
lump
1. Site
• Abdomino -pelvic lump
• Supra pubic
• Below umbilical
• Midline
• Iliac fossae

20. Size

21. Shape
Pear shape
Irregular
Globular

22. Surface
Smooth Rough

23. Consistency
Soft –Feel like lips
Firm- Feel like tip of the nose
Hard-Feel like forehead

24. Margins
• Well defined
• Ill defined

25. Tenderness
• Inflammatory lumps – usually tender
• Neoplasm – usually non tender

26. Mobility
• Uterine lumps-Mobility restricted in
longitudinal direction
• Moves with cervix in bimanual examination

27. Mobility
Ovarian Lump
Benign tumours –Well mobile in both
directions
Malignant tumours – Mobility may be
restricted

28. Ability to reach below
Uterine lump –cannot
get below the lump
except in
pedunculated fibroids
Ovarian lump –can
get below the lump
if not attached to the
uterus

29. Percussion node
Dull over lump
Resonant over bowel

31. Gyaenocological masses
Uterine Ovarian
Fibroids
Adenomyosis
Pregnancy
Malignancy
Tubal
Inflammatory
Ectopic pregnancy
Neoplasm - Benign
- Malignant
Inflammatory masses

32. CHARACTERISTICS OF UTERINE MASSES
1.Site -Midline
2.Size -Assessed in weeks of pregnancy
3.Consistency –Pregnancy –soft
Fibroids - firm
Adenomyosis-firm
4.Shape -Usually pear shaped
5.Margins – Well defined
6.Surface –Could be irregular with multiple fibroids
7.Mobility –More in the transverse plane
8.Non tender
9.Precussion node –Dull
10.Unable to get below the mass

33. Fibroids

34. CHARACTERISTICS -OVARIAN
MASSES
1.Site- Usually below the umbilicus, commonly
towards
one side
2.Shape –Can range ,usually round
3.Size –Variable, Should measure with a tape
4.Consistancy – Benign tumours – Usually cystic
Malignant tumours –Solid,
cystic/solid
Inflammatory –Firm
5.Margins – Benign tumours –Well defined
Malignant tumours -Illdefined
Inflammatory -Illdefined

35. CHARACTERISTICS OF OVARIAN MASSES
ctd…
6. Surface –Smooth in benign tumuors
Could be irregular in malignancy
7. Tenderness – Neoplasms -non tender
Inflammatory –tender
8. Mobility
Benign tumours –Mobile in both directions
Malignant tumours – Mobility may be
restricted
9. Percussion node –Dull
10.Can get below if not attached to the uterus

36. Ovarian carcinoma

37. Ovarian Cyst

38. Lump in the tubes
Ectopic pregnancy

39. Pelvic examination
What do you need?
1.Examination table or bed
2.Gloves
3.Flexible light source
4.Vaginal speculum in appropriate size for the
client(Cuscose bivalve or Sims )
Metal speculum that has been previously
sterilized or a clear plastic disposable one

40. Lubricating jelly
5.Lubricating jelly
Never contaminate the tube of lubricant by
touching it with your gloved hand after touching
the client. Allow the lubricant to drop onto your
gloved fingers without touching them. If you
should accidentally contaminate the lubricant
tube, Discard it.

41. 6. A paper or cloth drape
Privacy is always important
7. Paper towels-for clean-up after the
examination
8. Soap and hot water for hand washing

42. Preparation prior to examination
• Must have an empty bladder
• Assemble all items
Make sure all items are assembled and within
easy reaching distance
Materials for bacteriological cultures and
Papanicolaou smears (Pap smears) should be
available

43. POSITION
• Patient lying supine on the examination table with the head
elevated 30 to 45 degrees, her thighs flexed and abducted (knees
up), her feet resting in support, and her buttocks extending slightly
beyond the edge of the examining table. Assist the patient in
placing her heels in the stirrups. Adjust the angle and length to "fit"
the client. Have the patient slide her hips down until she contacts
your hand at the edge of the table. Have the patient relax her
knees outward just beyond the angle of the stirrups. A pillow
should support her head. If the exam table is a flat table, the
patient may need to in the lithotomic position (lying flat on back)
with a pillow under her head.

44. • WITHOUT EXAMINATION TABLE
Patient can be examined on her bed
Lay on her back with knees bent and legs apart
and can bring her buttocks to the edge of the bed
and in place of stirrups
Pillows or other padding can be placed under the
buttocks to raise the buttocks

45.  Patient must be appropriately gowned and draped
 Arms should be at her sides
 Use gloves on both hands. Double-glove your dominant hand
if you intend to perform a rectal or rectovaginal exam.
 Make sure a waste receptacle is close-by for throw-away
items.
 Always tell the patient what you are about to do before you
do it. This helps to keep her relaxed
 Have warm hands and a warm speculum

46. Pelvic examination
Inspect the
Vulva
Hair distribution
Ulcers
Discharge
Perineum
Mons pubis
Labia

47. Cross Section, Side View

48. Separate the labia and inspect the outer genitalia
A. Inspect
1. Labia majora and minora. Gently palpate. Inspect folds
around them
2. The clitoris. Enlarged clitoris in masculinizing conditions.
3. The urethral orifice
4. The vaginal opening or introitus
5. Vestibule
6. Note any redness, swelling, or discharge and Lesions of
the vulva
B. Ask to cough - look for stress incontience and prolapse

49. Checking for Discharge
• from the inside outward. Note any
discharge from or about the urethral
orifice. If present, a culture should be
taken.

50. Checking Bartholin's Glands

51. • Inflammation may be acute or chronic
• Acutely, it is a tense, hot, very tender
abscess. Look for pus coming out of the
duct
• Chronically, a non-tender cyst occupies
the posterior labium. It may large or
small.

52. • Assess the support of the vaginal outlet
• With the labia separated by her middle
and index finger; ask the patient to
strain down
• Note any bulging of the vaginal walls

53. Cystocele
• The anterior wall of the vagina, together with
the bladder above it, bulges into the vagina
and sometimes out the introitus
• Look for the bulging vaginal wall as the Patient
strains down

54. Rectocele
• A rectocele is formed by the anterior and
downward bulging of the posterior
vaginal wall together with the rectum
behind it. To identify it, spread the
client's labia and ask her to strain down.

55. SPECELUM EXAMINATION
• Use Cusco's bivalve
• Check whether working properly
• Close the blades of the speculum
• Lubricate
• Insert transversely fully
• Once well inside open blades fully

56. Inserting the Speculum

57. Opening the Speculum

58. Viewing The Cervix

59. A. Inspect cervix
• Normal cervix – pink smooth covered with clear
mucus os – pinpoint in nulliparous women,
transverse in multparous women
• The cervix will appear as purplish in color if a
woman is pregnant
• Look for abnormalities
– Color of the cervix
– Position of the cervix
– Errosions
– Ectropian
– Polyps
– Masses
– Ulcers
– Bleeding
– Discharge
– IUCD threads
– Inspect the vaginal walls for lesions and redness.

60. Normal cervix

61. • The nullparous cervical os is small and
either round or oval. The cervix is
covered by smooth pink epithelium

62. • After childbirth, the cervical os
presents a slit-like appearance

63. • The trauma of difficult deliveries may
tear the cervix, producing permanent
transverse or stellate lacerations.

64. Squamous metaplasia Inflamed
cervix

65. OBTAINING SPECIMEN SAMPLES
• The Endocervical Swab: Moisten the end of a
cotton applicator stick with saline and insert it
into the os of the cervix. Roll it between the
thumb and index finger, clockwise and counter
clockwise. Remove it.
• Smear a glass slide with the cotton swab, gently
in a painting motion. (Rubbing hard on the slide
will destroy the cells.) Place the slide into the
ether-alcohol fixative at once.

66. OBTAINING SPECIMEN

67. Obtaining Cervical Spatula
Sample
• Cervical Scrape: Place the longer end of
the scraper on the os of the cervix.
Press, turn and scrape. Smear on a
second slide as before.

68. Vaginal Pool
• Vaginal Pool: Roll a cotton applicator
stick on the floor of the vagina below
the cervix.
• If the client has an infection or a
discharge from the cervix or the vagina,
this would be a good time to take a
sample with a cotton swab for analysis.

69. B. VAGINAL INSPECTION
• Withdraw the speculum slowly while observing
the vagina
• Always use both hands. Use both gloves
• Note its color, inflammation, discharge, ulcers or
masses
• As the speculum clears the cervix, release the
thumb screw and maintain the speculum in its
open position with your thumb.
• Close the blade by releasing the screw with the
thumb of the speculum and allow the "bills" to
fall together as the speculum emerges from the
introitus

70. BIMANUAL EXMINATION
• Dorsal position
• Patient should be relaxed
• Lubricate fingers
• Insert 2 fingers of the right hand
• The left hand should be placed above the
symphysis pubis

71. BIMANUAL examination
• Apply a small amount of lubricant to the index
and middle fingers of the dominant hand.
• Uncover the vulva and lower abdomen by
moving the center of the drape away from the
examiner
• Perform a bimanual examination. From a
standing position, introduce the index and
middle finger of the gloved and lubricated
hand into the vagina
• Note any nodularity or tenderness in the
vaginal wall, including the region of the
urethra and bladder anteriorly.

72. BIMANUAL examination

73. CERVIX
• Identify the cervix
• Note its position, shape, size, consistency,
regularity, mobility and tenderness
• Palpate the fornix around the cervix

74. CERVIX
Consistency
Firm – normal
Soft (like palpating the lips) – pregnancy
Hard (like the end of the nose) – malignancy
If the woman is in the latter stages of her pregnancy, the
cervix may be very "squishy" feeling and pliable. Dilation
and/or effacement of the cervix may have already began
OS (Internal) - Opened/Closed
Surface - Smooth-normal
Velvet like –ectropian
Ulcer – malignancy

75. • Place the abdominal hand about midway
between the umbilicus and symphysis
pubis and press downward toward the
pelvic/vaginal hand
• The pelvic/vaginal hand should be kept in
a straight line with the forearm, and
inward pressure exerted on the perineum
by the flexed fingers.

76. UTERUS
• Continue to lift the cervix with the vaginal hand
• Identify the uterus between the hands
• Note its
1.size - in weeks of pregnancy
2. shape
3. consistency
4.Direction
5. mobility- if restricted
ADHESIONS – Inflammation
- Endometriosis
- Maligancy
6.tenderness
7.masses
Enlargement
Soft and smooth – pregnancy
Firm and smooth –adenomyosis,submucous
fibroid/earlyendomentrial carcinoma
Erregular and firm -fibriods

77. Palpating Uterine Fundus

78. Palpating Behind Uterus

79. • Place the abdominal hand on the right lower
quadrant, the pelvic hand in the right lateral
fornix
• Maneuver the abdominal hand downward 3 or 4
cm medial to the iliac crest, and using the
pelvic hand for palpation, identify the right
ovary and nay masses in the adnexa
• Gently "trap" the ovary between the fingers of
both hands (if possible
• If you can feel an ovary in a post-menopausal
woman, suspect an ovarian tumor

80. TENDERNESS-inflammation masses
• Adenexae –masses –Ovarian cysts
Ectopic pregnancy
Hydrosalphinx
Broad ligament cysts
Pedunculated fibroids
Tenderness with cervical motion is an
important sign of pelvic disease. You should
both observe the patient's face and ask her
if the examination is painful in any way

81. • Note the size, shape, consistency,
mobility and tenderness of any palpable
organs or masses
• The normal ovary is somewhat tender
• Repeat the procedure on the left side.

82. Vaginal-Rectal Exam
• Withdraw your fingers, removing your gloves and
throwing them away. Re-glove using fresh, clean
gloves. Place lubricant on internal exam glove.
• Then slowly reintroduce the index finger into the
vagina, the middle finger into the rectum
• Ask the patient to strain down, so that her anal
sphincter will relax.
• Repeat the maneuvers of the bimanual examination,
giving special attention to the region behind the cervix
which may be accessible only to the rectal finger.
• Try to push the uterus backward with your abdominal
hand so that your rectal finger can explore as much of
the posterior uterine surface as possible
• Check the rectum itself and other nearby structures for
any abnormalities.

83. Vaginal-Rectal Exam

84. AFTER EXAMINATION
• Wipe off the external genitalia and anus or
offer the patient some tissue with which to
do it herself
• Throw away any used disposable items