Ppt14

Chapter 14
Female Genitalia
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy of the Female Genitalia
Female External Genitalia

Anatomy of the Female Genitalia (cont.)
Lateral View of Female Reproductive System

Anatomy of the Female Genitalia (cont.)
Cervix

Gynecologic History
• Ask about the age of menarche (when the first menses
started); in the United States the range is between
the ages of 9 and 16
• Ask about menstruation patterns
– How often does the patient have menses? (Every
24 to 32 days is normal.)
– How long are the menses? (3 to 7 days is normal.)
– How heavy are the menses? (The number of pads
or tampons used is an indicator.)
• If applicable, at what age did menopause occur?
Menopause is defined as no menses for 12 months.
The average age of menopause is 45 to 52 years.

Gynecologic History (cont.)
• Amenorrhea
– Amenorrhea is defined as the absence of menses
– Primary amenorrhea refers to the failure of menses
to be initiated (causes: chromosomal abnormalities,
malnutrition, hypothalamic-pituitary-ovarian
dysfunction)
– Secondary amenorrhea refers to a cessation of
periods after they have previously existed
(physiologic causes: pregnancy, breast feeding,
menopause; pathologic causes: pituitary tumor,
hypothyroidism, anorexia nervosa)

• Dysmenorrhea: painful periods with cramping or aching in
the lower pelvis and lower back
• PMS (premenstrual syndrome)
– Complex of symptoms occurring 4 to 10 days before
the onset of menses
– Psychological symptoms include tension, irritability,
depression, and mood swings
– Physical symptoms include weight gain, bloating, edema,
headaches, and breast tenderness
• Polymenorrhea means having too frequent of periods
• Menorrhagia refers to an increased amount of bleeding or
duration of flow
• Metrorrhagia is bleeding that occurs between periods

Question
A 26-year-old female presents to clinic complaining
of heavy periods lasting 10 to 12 days. Which of the
following is the most appropriate term to describe
this patient’s symptoms?
a. Dysmenorrhea
b. Polymenorrhea
c. Menorrhagia
d. Metrorrhagia

Answer
c. Menorrhagia
• Dysmenorrhea: painful periods with cramping or
aching in the lower pelvis and lower back
• Polymenorrhea: having too frequent of periods
• Menorrhagia: an increased amount of bleeding or
duration of flow
• Metrorrhagia: bleeding that occurs between
periods

• Ask about pregnancies
– How many pregnancies in total? How many births
were term? Preterm? Miscarriages? Induced abortion?
– Were there any complications in prenatal care,
labor, or delivery?
– What kind of birth control is currently used or
desired?
• Ask about vulvovaginal symptoms including burning,
itching, and the quantity and quality of discharge
(including texture, amount, color, and smell)

• Ask about sexual preference and sexual response; be
professional and “matter of fact” in questioning and never
assume all patients are heterosexual
• Ask open-ended questions such as, “How is sex for you?”
“Is your partner satisfied with your sex life?”
• Ask about symptoms of sexual dysfunction
– Lack of interest
– Lack of physiologic response to desire (decreased
lubrication)
– Lack of orgasm
– Dyspareunia, or discomfort during intercourse
– Vaginismus, or spasms of the muscles surrounding the
vagina making penetration painful and difficult

Health Promotion and Counseling
• Cervical cancer screening: Pap smear and HPV
screening
• Options for family planning
• Sexually transmitted diseases and HIV
• Changes in menopause

Physical Examination of the Female
Genitalia: Tips for the Successful Exam
The Patient
• Avoid intercourse or douching
for 1 to 2 days before exam
• Empty the bladder before exam
• Lie on the back, with head and
shoulders elevated (such as on
a pillow), with arms to the side
or folded across the chest to
reduce tightening the abdominal
muscles
The Examiner
• Obtain permission
• Explain each step of the examination
in advance; select a chaperone
• Drape the patient from the abdomen
to the knees
• Avoid sudden movement
• Choose a speculum of appropriate
size
• Warm the speculum with tap water
• Monitor the comfort of the
examination by watching the
patient’s face
• Use gentle insertion of the speculum

Proper Sequence of the
Female Genital Examination
• Examine external genitalia
• Perform speculum examination
• Perform bimanual examination
• Perform rectovaginal examination
• Perform rectal examination

Physical Examination of the
Female Genitalia
• Inspect the patient’s external genitalia
– Mons pubis
– Labia majora and minora
– Clitoris
– Urethral meatus
– Introitus
– Perineum
• Note any inflammation, discharge, swelling, or nodules;
palpate any lesions
• Check the Bartholin’s glands by inserting the index finger
into the vagina and placing the thumb at the posterior
labia; palpate between finger and thumb

Genitalia: Internal Exam by Speculum
• Place the index finger of your non-dominant hand on the
posterior portion of the introitus and push down gently
• With the speculum in your dominant hand, turn it to the
entry angle (approximately 45 degrees) and gently insert
into the introitus; continue inserting the length of the
speculum
• Rotate the speculum horizontally and gently open it,
catching the cervix in between the blades; it is common
to have to close the speculum and reposition the blades
to locate the cervix

Genitalia: Cervix Inspection
• Once the cervix is visualized, inspect the cervix and
the os; note the color, position, and characteristics of
the cervix
• Look for discharge or bleeding from the os
• Note any ulcerations, masses, or nodules on the cervix
• Obtain one specimen from the endocervix and one
from the ectocervix, or a combination specimen using
the cervical brush “broom”
– If indicated, obtain cultures for chlamydia,
gonorrhea, or herpes; wet prep (saline slide of the
vaginal and cervical secretions) for vaginitis

Genitalia: Inspecting the Vagina
• While withdrawing the speculum, assess the walls of
the vagina
• When removing the speculum, make sure the blades
are closed; removing an open speculum can cause
lacerations to the vaginal walls and to the urethral
meatus
• If indicated, place two fingers inside the labia and
ask the patient to bear down in order to see if the
vaginal walls bulge or if any part of the rectum
protrudes from the anus

Genitalia: Bimanual Exam
• Stand at the end of the table between the patient’s legs
• Lubricate the index and middle finger of the dominant
hand and carefully place them inside the introitus
• Make sure the 4th and 5th digits are flexed against your
palm and that your thumb is abducted (away from the
patient’s body)
• Palpate the vaginal walls, feeling for any irregularities
(note that the vaginal walls have rugae and will feel
“bumpy”)
• Palpate the cervix, noting its position (anterior, posterior,
deviated to the left or right), shape, consistency (firm or
soft), mobility, and tenderness

Genitalia: Bimanual Exam (cont.)
• Palpate the uterus in the midline; take your non-dominant
hand and place it over the suprapubic area
just superior to the pubic bone
• While you elevate the cervix with your dominant hand,
press your non-dominant hand over the bladder,
catching the uterus between your hands; feel its size,
shape, consistency, mobility, and tenderness (easier in
thin patients)
• If you cannot feel the uterus, slide the fingers in the
pelvis into the posterior fornix; if you can feel the
uterus butting against the fingers, the uterus is tipped
posterior (retroflexed)

Genitalia: Bimanual Exam (cont.)
• Palpate the left ovary by placing your dominant hand in
the left lateral fornix and your non-dominant hand just
left of the midline superior to the pubic bone
• Palpate the right ovary by placing the dominant hand in
the right lateral fornix and the non-dominant hand just
right to the midline
• Identify the size, shape, consistency, mobility, and
tenderness of each adnexal area
• Before removing your hand, ask the patient to bear
down on your fingers to assess the strength of the pelvic
muscles

Question
• Is the following statement true or false?
The speculum exam should be performed after the
bimanual exam to ensure adequate sampling.

Answer
False
• The speculum exam should be performed before
the bimanual exam.

Genitalia: Rectovaginal Exam
• Rectovaginal exams has three primary purposes
– Palpate a retroverted uterus, the uterosacral
ligaments, cul-de-sac, and adnexa
– Screen for colorectal cancer
– Assess pelvic pathology
• Glove the dominant hand and lubricate the index finger
• Place the index finger of the dominant hand inside the
vagina as before but this time and place the middle finger
within the anus; ask the patient to bear down so that
the anal sphincter will relax

Genitalia: Rectal Exam
• Gently place the index finger in the anus; palpate
for hemorrhoids and masses
• If needed, check for occult blood with a hemoccult
test
• Wipe off the external genitalia and anus with gauze
or tissue; give the patient some to clean herself
after the exam
• Always ask the patient to get dressed before
discussing any findings; unclothed patients have
difficulty concentrating

Genitalia: Special Circumstances
• Hernias
– Although thought of as primarily a male problem, women
can also have hernias in the groin
– Examination techniques are similar to that used for men;
a woman should stand up to be examined
– Palpate the labia majora just upward and lateral to the
pubic tubercles
• Urethritis
– If you suspect urethritis or inflammation of paraurethral
glands, insert your index finger into the vagina and milk
the urethra gently from inside outward; culture any
discharge that has been “milked out”

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