OnExam

Before the Examination

General approach

  • Explain steps in advance
    • Be aware of wording (avoid trigger words such as "relax," “spread your legs”)
  • If this is 1st pap, show equipment, explain steps before beginning the procedure
  • Monitor comfort
  • Be gentle

Introduction

  • Wash hands
  • Introduce yourself
  • Your role
  • Obtain consent
  • How the patient would like to be addressed
  • Confidentiality
  • Offer to have a female chaperone
  • Last 24-48 hours, has the patient had
    • Intercourse
    • Vaginal Suppositories
    • Douching
  • Is the bladder empty?

Prepare equipment

  • Gloves - 2 pairs
  • Speculum
    • Choose appropriate size (small, medium, large)
      • Small Pedersen - for patients who have never been sexually active, elderly
      • Medium Pedersen - for sexually active women
      • Graves - for women who have had vaginal deliveries
    • Warm metal speculum with water
  • Light (overhead or attached to speculum)
  • Cervical broom and solution
  • Swabs for cultures
  • Water-soluble lubricant, wipes
  • Drape for midabdomen

Position patient

  • Dorsal lithotomy position
    • Lay down with pillow under head (head and shoulders elevated to 30°), arms at sides or folded across chest, heels in stirrups, slide all the way down until buttocks are at the edge, let knees fall out to the sides
  • Drap for midabdomen to knees and depress drape for eye contact
  • Ask if patient is comfortable

External Examination

  • Inspection
    • Adolescent patients: assess sexual maturity using Tanner Stages
      • Stage 1: no pubic hair
      • Stage 2: long slightly pigmented hair along labia majora
      • Stage 3: darker coarser curly hair over pubic symphysis
      • Stage 4: more curly hair, no hair on thighs
      • Stage 5: hair is present on the thighs
    • Inspect external genitalia for masses, excoriations, erythema, maculopapules, vesicles, nits/lice
      • Mons pubis
      • Labia majora
      • Perineum
      • Perianal area
    • Separate labia and inspect the following for any inflammation, ulcerations, discharge, swelling, nodules
      • Labia minora
      • Clitoris (enlarged in masculinizing conditions
      • Urethral meatus (urethral caruncle, prolapse
      • Introitus
    • Assess for vaginal prolapse
      • Separate labia between index and middle fingers
      • Ask the patient to bear down
      • Look for bulging
    • Palpation
      • Any lesions
      • If labial swelling, palpate Bartholin's glands for tenderness and discharge

Internal Examination

  • Apply small amount of water-soluble lubricant to the speculum
    • Water-soluble lubricant does not interfere with Pap cytology or culture
  • Enlarge introitus with finger
    • Push down at the lower margin of introitus
  • Introduce speculum
    • Right hand: separate labia
    • Left hand: gently insert speculum at slight angle from midline (e.g.2 o'clock)
      • Avoid pressure on sensitive urethra
      • Apply downward pressure and slide speculumalong posterior wall of vagina
  • Remove fingers from labia
  • Rotate speculum into a horizontal plane
    • Keep applying downward pressure and sliding speculum along posterior wall of vagina
  • Instert speculum to full length
  • Open speculum
  • Find cervix. Rotate and adjust speculum until entire cervix is visualized
    • If cannot find cervix: withdraw speculum slightly, reposition to a different slope. A retroverted may point more anteriorly.
  • Tighten screw to maintain open position
  • Wipe discharge that obscures the view of cervix with a cotton swab
  • Inspect cervix
    • Note colour, position, surface characteristics, ulcerations, nodules, masses, bleeding, discharge (colour, consistency, amount, odour)
  • Pap smear: use cervical broom to sample both endocervix and ectocervix.
    • Insert tip of cervical brrom into os and rotate clockwise and counterclockwise 3-5 times
      • Goal: collect cells from both endocervix and ectocervix
    • Remove brush and plae it into solution for liquid cytology
  • Swabs for culture (Chlamydia, gonorrhea, bacterial vaginosis, trichomonas, yeast)
    • Pink - Chlamydia and gonorrhoea - gently insert swab into cervical os
    • Blue - trichomonas, vaginosis - slide swab along vaginal wall in a zigzag pattern
  • Withdraw speculum slowly
    • Release thumb screw, maintain open position with thumb as speculum clears cervix
    • Close epculum as it emerges from introitus
    • Note: colour of vaginal mucose, inflammation, discharge, ulcers, masses

Bimanual Examination

  • Lubricate index and middle fingers
    • If fingers touch lubricant tube, discard lubricant (results in contamination)
  • Stand at patient's side
  • Applying posterior pressure towards perineum, insert two fingers into vagina
    • Abduct thumb, flex 4th and 5th fingers into the palm
    • This is the pelvic hand
  • Place the other hand on patient's lower abdomen midway between umbilicus and symphysis pubis
    • This is the abdominal hand
  • Palpate pelvic organs
    • Vaginal wall (urethra, anterior bladder)
      • Palpate for nodules and tenderness
    • Cervix and fornices
    • Body of uterus
      • Pelvic hand: Place fingers into anterior fornix, elevate cervix and uterus
        • If uterus is retroverted, place fingers into posterior fornix
      • Abdominal hand: press down on the andomen to capture the uterus between 2 hands
      • Paplate for position, size, shape, masses, tenderness, mobility
    • Ovaries
      • Pelvic hand: place fingers into right lateral fornix for right ovary and left lateral fornix for left ovary
      • Abdominal hand: press down in right lower quadrant of abdomen for right ovary and left lower quadrant of abdomen for left ovary
        • Try to capture the ovary between to hands
      • Palpate for position, size, shape, adnexal masses, tenderness, mobility
        • Normally, ovaries are slightly tender
      • Ovaries may not be palpable in females who are obese, poorly relaxed, or 3-5 years after menopause
  • Strength of pelvic muscles
    • 2 fingers to touch vaginal walls
    • Ask the patient to squeeze pelvic muscles as hard and as long as she can
    • Normally, fingers become compressed and move inwards and upwards. The patient can squeeze for ≥3 seconds.
  • If not planning to do a rectovaginal examination
    • Provide patient with towel to wipe herelf and panty-liner/pad
    • Explain that some spotting may occur

Rectovaginal Examination

References

  1. Bernstein HB, Weinstein M. Normal pregnancy & prenatal care. In: Decherney AH, Goodwin TM, Nathan L, Laufer N, eds. CURRENT Diagnosis & Treatment Obstetrics & Gynecology. 10th ed. New York: McGraw-Hill; 2007:187-202.
  2. Bickley LS. Female genitalia. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 429-457.
  3. Bickley LS, Thompson, JE. The pregnant woman. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 817-838.
  4. Harmanli O, Jones KA. Using lubricant for speculum insertion. Obstet Gynecol. 2010;116(2):415-417.
  5. Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, Calver LE. Chapter 14. Pediatric Gynecology. In: Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, Calver LE, eds. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com.proxy.lib.nosm.ca/content.aspx?aID=56701893. Accessed November 17, 2013.
  6. Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG, eds. Well Woman Care. In: Williams Gynecology. New York: McGraw-Hill; 2008:2-24.
  7. Rowe T, Senikas V, Pothier M, Fairbanks J, Sams D. Canadian consensus guidelines on human papillomavirus. SOGC Clinical Practice Guidelines. No. 196. J Obstet Gynaecol Can. 2007;29(8 Suppl 3):S1-S56. http://www.sogc.org/guidelines/documents/gui196CPG0708revised.pdf. Accessed February 17, 2011.