Pelvic examination
http://article.wn.com/view/2012/08/14/The_
pelvic_examination_put_to_the_test/
Learning outcomes
The intended learning outcomes for teaching the
pelvic examination is for the student to
demonstrate ability to:
1. Interact with the patient in a way that elicits
confidence and cooperation and assures the
patient’s comfort.
2. Perform the complete examination in a sensitive
manner.
3. Use appropriate medical terminology and
communication skills when performing the exam
and to communicate the results and educate the
patient.
3 parts of the pelvic exam
1. The visual exam is a way to look for any signs of
infection on the outside of the woman’s genitals
2. The speculum exam is a way to see inside the
woman’s vagina and to test the health of her cervix. You
use a tool called a speculum to do the speculum exam.
3. The bimanual exam (2-hand exam) is a way to check
the health of a woman’s womb and ovaries or to check
the size of the womb in pregnancy. To do a bimanual
exam, you feel the womb with the fingers of one hand
inside a woman’s vagina and the other hand on her
belly at the same time
Indications for pelvic exam include
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Vulvar or vaginal complaints
Abdominal pain in a woman
Exposure to sexually transmitted infection
Pregnancy (known or proven)
Health maintenance (to perform pap smear)
Anatomy
Before the exam
• Help the woman relax
Remind the woman to take deep breaths and
to let her body relax
• Fear
• Some women are afraid to have pelvic exams, such
as women who have never had pelvic exams, and women
who have had exams that were painful.
• Shame
When you do a pelvic exam, you are examining a woman’s
genitals and vagina. Many women are embarrassed or
ashamed about these parts of their bodies.
Preparation
• Wash hands
• Introduce yourself to the patient using full
name
• Make sure that you have privacy.
• Ensure that the room is sufficiently worm
• Prepare all the tools you will need for the
exam
• Exam best performed when patient has
empty bladder
Preparation
• Make sure the nurse has all of the necessary materials
for the exam:
Speculum
(appropriate size
plastic or metal)
Gloves
GYN cotton-tipped
over head
lamp
Preparation
• Make sure the nurse has all of the necessary materials
for the exam:
Lubricant
Pap material (cytobrush,
spatula, cervical broom.)
Slide and fixative or
liquid media
Positioning
• Privacy
• Buttocks just off
table
• Good Lighting
• Drape
• Standby
Before the exam
• Ask the woman to urinate before
the exam. This will make the exam
more comfortable for her.( a full
bladder will obstruct the view of
the cervix )
• Ask her to lie on her back with her
knees up and her buttocks at the
end of the exam table or bed
• If she is not down far enough,
inserting the speculum can be
more difficult and uncomfortable
for her.
Before the exam
• Appropriate draping should be
used to help make the patient
more comfortable.
• Good lighting is important and is
often accomplished with a
goose-neck lamp.
• Wash your hands with clean
water and soap. Your fingernails
should be short and clean.
• Put clean plastic gloves on your
hands
Inspection
• Inspect the client's external
genitalia
Perineal area must be well
illuminated
Both hands are gloved to
prevent the spread of
infection
Mons pubis--note quantity
and distribution of hair
growth
Labia--usually plump and
well-formed in adult female
Inspection
• Perineum--slightly
darker than the skin of
the rest of the body.
Mucous membranes
appear dark pink and
moist
Inspection
• Separate the labia and inspect the labia
minora:
– Labia minora
– Clitoris
– Urethral orifice
– Hymen
– Vaginal orifice
Inspection
• Note the following:
– Discharge
– Inflammation
– Edema
– Ulceration
– Lesions
– Prolapse
– Stress incontinence
Sequence of a Pelvic Examination
• Note abnormalities
such as:
– Bulges and swelling
of vulva and vagina
– Enlarged clitoris
– Syphilitic chancres
– Sebaceous cyst
Primary Syphilis
Skene's glands examination
• Skene's glands
– Near the urethra
– Suspect inflammation;
check for urethral
discharge
Skene's glands examination
Skene's glands
• 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
any discharge.
• Obtain specimen for culture.
• Change glove if discharge is
found.
Bartholin's glands 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:
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Swelling
Tenderness
Masses
Heat or discharge
Bartholin's glands examination
• Bartholin's glands (CONT)
– A painful abscess is
pus filled and usually
staphylococcal or
gonococcal in origin
and should be incised
and drained.
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).
Inspection
• Inspect the anus at
this time, note
presence of lesions
and hemorrhoids
Speculum Examination of Internal
Genitalia
• Select a speculum of
appropriate size, lubricate
and warm with warm
water)
– 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.
Appropriate Speculum
Choice
Grave’s speculum
Width 20-38 mm
Length 75-115 mm
Pederson speculum
• Width 13-25 mm
Length 75-120 mm
Metal speculae (side view): A) small
Pedersen, B) medium Graves, C) large
Graves
Plastic speculae (side view): A)
small Pedersen, B) medium
Pedersen, C) large Pedersen
Angle of insertion
Angle of insertion at entry and B) Angle at full insertion
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
Angle at full insertion
Warm water
Not too hot
Lubricates speculum
Spread labia
Keep labia apart
Blades remain closed until fully inserted
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
Open speculum cupping
cervix
Examination/Collection Specimen of the Cervix
• Inspect the cervix
– Os:
• Nulliparous—small
round, oval
• Parous/multiparous-linear, irregular, stellate
Inspect the cervix
Erosion
Ectropion
Color should be uniformly pink
Dysplasia
Inspect the cervix
Pale--anemia
Bluish--Chadwick's
sign, presumptive sign
of pregnancy.
Physiological
discharge--odorless,
colorless Culture any
discharge
Erythema around cervix
Polyps
Ayers Spatula
• Concave end to fit the
cervix
• Convex end for
vaginal wall and
vaginal pool scrapings
Sample Cervix
• Use concave end
• Rotate 360 degrees
• Don’t use too much
force (bleeding, pain)
• Don’t use too little
force (inadequate
sample)
Cytobrush
• Insert ~ 2 cm (until
brush is fully inside
canal)
• Rotate only 180
degrees (otherwise will
cause bleeding)
Make Pap Smear
• As thin as possible
• Properly labeled
Spray with Fixative
• Within 10-15
seconds
• Allow to fully dry
before packaging
• Cytologic Fixative
(hairspray works
acceptably also)
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
3. 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.
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
• Size
• uterine enlargement suggests
pregnancy, benign or malignant
tumors.
• The uterus should be 5.5-8.0 cm long
Identify the Uterus Noting the Following
Mobility
-should be mobile in the anteropostero plane
- deviation to the left or right is
indicative of adhesions, pelvic
masses of pregnancy
• Tenderness-suggests PID
process or ruptured tubal
pregnancy
• Masses.
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
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.
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
• Repeat the procedure on the left side
• The normal ovary is somewhat tender when palpated
• Withdraw Fingers from Vagina and Change Gloves
PELVIC EXAM VIDEO
• http://www.youtube.com/watch?v=SE-wbjUZAY&feature=related
• http://www.medicalvideos.us/play.php?vid
=279
• http://www.youtube.com/watch?v=kTwxNT
FP-YA
SUMMARY
PELVIC EXAM
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Inspect Externally
Palpate Skene’s Glands
Palpate Bartholin’s Glands
Assess Outlet
Speculum Exam
Bimanual Exam
– Vagina, Cervix, Uterus, Adnexa
Reference
• Bates’ guide to physical examination & history
taking, Ninth edition, Lynn S. Bickley and Peter
G. Szilagyi, Lippincott Williams & Wilkins, 2007.
• Textbook of physical diagnosis history and
examination, Fourth edition, Mark H. Swartz,
W.B. Saunders Company.
• Edelman A, Anderson J, Lai S, Braner DAV,
Tegtmeyer K. Pelvic examination. NEJM
2007;356:e26.