Pelvic exam across the life span Anne Moore, DNP, APN, FAANP Objectives • 1. 1.Evaluate current guidelines for pelvic examination and screening for women across the lifespan (pediatrics to geriatrics) 2.Rationalize the use of components of the pelvic examination based on age-related and cultural variables. 3.Evaluate techniques of the pelvic exam to accommodate age-related and cultural variables. Basic principles • Tools for history include: calendar, pelvic diagrams, gestation calculator • Greet her while she is dressed & obtain her history History: Essential Issues • Do not make assumptions about sexuality • Too old to be sexual • Heterosexual • Satisfied with sex life • Not at risk for pregnancy/STI’s History: Essential Issues • Ask about continence (urine & stool)-dribbling, urgency, wetness • Wears pads? Activities she avoids? Preparing for the Pelvic Exam • What are her previous experiences? • Tell her you will stop the exam if she asks • Discuss cues for pain Discussion “A pelvic exam should not be painful, pressure is normal, but pain is not. Let me know what you’re feeling and we can stop at any time if it’s too uncomfortable. “ Pelvic Exam with Older Women • May take longer • Positioning more challenging • Smaller specula necessary • Topical analgesic use • Pain control, pain vs. pressure Preparing the Older Woman • Provide estrogen creams, suppositories, rings directly to the vagina to facilitate ease of speculum insertion. • • Consider oral (NSAID) & topical analgesics. Lidocaine to KY? Tools of Your Trade • Good light • Older women can’t adjust to temperature change as well. Consider fan in room • Warm specula in a variety of sizes-pediatric size • Long handled mirror • Non-latex gloves-in your size Tools for the Pelvic • Cotton swabs • Pap smears • Scopettes or ring forcep + cotton balls • pH paper • Gc + CT tests or urine tests • Warmed lubricant • Various sized specula YES You Can Use Lubricant Before Paps and Infection Testing • Griffith-Uni Texas Southwestern 2005 • Randomized study 9,500 women ages 20-44 yrs.3,460 Paps & 5,535 DNA assays • Dime sized water soluble bacteriostatic gel lubricant • Does not effect Pap testing nor Gc or CT tests Tools for the Pelvic • Biopsy materials: lidocaine 1% w/o epinephrine • Small syringe with TB needle or 25g • Cleansing liquid-iodine • Biopsy container with formalin-lid off & labeled • Cervical biopsy forceps or other tool Beginning the Pelvic Exam • Positioning on table • Drape up or down? Watch reactions, assess discomfort • Tell her what you are going to do, explain sounds • Use positive terms, tell her what you see Positions for Exam • Decreased abduction of hips-side lying, assistant supports anterior leg & knee-chest on floor with specula upside down • Obese-knee chest, or place abdominal hand under panniculus • Ultrasound Inguinal Lymph Nodes • Assess inguinal nodes-enlarged nodes-herpes, perineal infections, inflamed hemorrhoids • Infections of feet & legs, DM, stasis ulcers= inguinal nodes • nodes may indicate systemic disease, infection, lymphoma The Vulva • Evaluate the hair distribution- sparse, gray, hypoestrogenic • Inspect skin of the vulva carefully-VIN • Look for signs of scratching from pruritus • Cancer is a great imitator The Clitoris • Inspect & retract prepuce • Dry skin, smaller clitoris =E • Clitoris 1 cm wide abnormal • Pale pink, mobile, agglutination suggests lichen planus • 10% vulvar cancers occur on clitoris Urethra and Skene's Ducts • Erythema- urethritis, prolapse • Milk anterior vaginal area for discharge (D/C) • Milk lat. vaginal introitus for D/C from Skene's ducts • Palpate Bartholin gland for swelling or tenderness Urethral Prolapse Sx: dyspareunia at introitus, dysuria; post-menopausal bleeding Palpating the Vagina of an Older Woman • Often small, narrow, atrophic • Assess vaginal tone: anterior –cystocele & posterior- rectocele • Have her grip your fingers- assess pelvic musculature Palpating the Vagina and Cervix • Palpate vaginal walls for cysts (Gartner duct cystsnormal variation, common along lateral vaginal walls) • Abnormal texture (HPV, cancer) & vaginal septum Find the Cervix (Cx) Before Speculum Exam! • Assess consistency- hard suggests cancer, nodular cx suggests Nabothian cysts or cancer • Note position-up, down, lateral? How far from introitus? Don’t bump into it! The Cervix Insertion of Speculum in Elderly Woman • Viscous lidocaine, before exam • 2-3 weeks of E cream before exam • Use smallest speculum • Spread labia to see introitus, insert gently & obliquely Cervix & Vagina of the Older Woman • Cervix is small, os closed, no cx neck- may be flat against wall • Decreased vaginal rugae, pale, thin, bleeds easily from E • Vaginal pH is high >5.0 from lactobacilli from E • Polyps common Pap Smear in Older Women • WHY? • Stenotic Os is common-to find os use OsFinder, cytobrush, lacrimal probes (ENT) • Hypoestrogenic smears may look abnormal-prep with E for 3 wks before Pap • SCJ is high within the canal-use cytobrush is necessary Order of Specimen Collections • 1. pH-from side walls • 2. Vaginal specimens- wet prep-take from side walls • 3. Pap Smear • 4. Gc, Ct tests or urine tests • Avoid contaminating with blood if possible Hysterectomy • Surgical & path report? Bilateral oophorectomy? • Taking exogenous hormones(estrogen & testosterone)? • If hysterectomy for cancer-continue PAP smears from cervical/vaginal cuff & close inspection of vulva-vagina USIN G YOUR MANO & FINGER M E A S U R EM EN TS T O S 'Z E U T E R IN E L E N G T H & W ID T H & S iZ E O VA R lE S l C m d istance o f b o t h f in aers VAGrNAL FIN GERS D E T ERMIN fNG S IZ E O F O VA R IES D ETER MIN IN G WIDTH O F UT E R U S DETERMINING LENG,TH OF UTERUS AB DOMINAL HAND C·m distance middle digit to notch ...._....cm distance from index dig it to notch ' - . . - Cm distance fro m 1 t j o int to notch not DETERMINI;NG L ENGTH OF C;E RVIX Cm d·s t,anc,e to 151 j1o int Cm distance to 1 st joi nt Palpation of Uterus • Assess cervix & uterus for nodularity (myomas, tumors) • Fibroids feel rock-hard & irregular • Fibroids-associated with enlarged, irregular, tender uteri and abnormal bleeding Palpation of Uterus • Assess position • Assess flexion & mobility • Assess for cervical motion tenderness (CMT) • Assess length & width •• I cervical motion tenderness Palpating Uterine Position • Anterior • Anteflexed >45 anterior curvature • Mid Position • Posterior • Retroflexed >45 posterior curvature Palpating Uterus-Position • If Rt fingers in vagina: Rt foot on step • Locate cervix (Cx); if cannot feel it, use abd. hand to pull uterus down until you can feel Cx internally • Slide internal fingers along posterior & anterior neck of Cx • Can you feel the neck going upward? Anterior position? Palpating Uterus-Position • If you feel the cervical neck going downward could be posterior or retroflexed position? • If anterior position-lift uterus up with internal fingers & palpate with your abd hand • Width? Regularity? Mobility? Palpating Uterine Contour • If the uterus is posterior, it could also be retroflexed • You must do a recto-vaginal exam to determine the position & feel the fundus more accurately Performing a Rectal-Vaginal Exam • With index finger in the vagina & middle finger in the rectum, find the cervix-your land-mark by touching her cervix with both fingers Palpating Uterine Contour … • With posterior or retroflexed uteri, the ovaries fall back or are posterior & are easier to palpate rectally Determining Uterine Size • Width: when palpating cervix, feel the widening neck & estimate width with your measured fingers; this estimates the width of the lower uterine segment • Lift up uterus, estimate length with abd hand measurements Pelvic Examination Techniques in challenging Clinical Situations Physical Exam of the Obese Woman • Will table support? Is table wide enough? Have assistant stand to side of table to stabilize & reassure her • The vulva may be hidden by the panniculus & a longer speculum is often necessary Providing Pelvic Examinations with Obese Women • The vulva may be larger-insure the labia are examined carefully, completely • Obese women may have difficulty reaching their vulva; discuss use of flexible shower heads to reach her perineum & rectal area or squatting positions in bath for cleansing Special Issues Providing Pelvic Examinations with Obese Women • The extra adipose tissue of the vulva makes visualization of the cervix difficult and may require a longer specula to reach the cervix Examinations with Obese Women Speculum Exam • Use an instrument: ring forceps (closed) or tongue blade to gently push walls to the side to improve visibility • Use larger speculum as comfort dictates Special Issues Providing Pelvic Examinations with Obese Women • The cervix may be difficult to visualize or palpate…have her pull her knees up …curled up in this position may give better speculum visualization of the cervix Difficult Palpation of the Uterus • Obese women • Virginal women • A digital rectal exam with the woman in lithotomy position (or any position that works) • With anterior pelvic compression this technique can be very helpful , ' 0 8/ UTHSCSA © 1998 Visualizing or Palpating the Cervix in Very Obese Women • Place woman on covered floor in knee-chest position; kneeling behind her, insert two fingers into the vagina, the cervix will be easier to locate • For Pap: place a Pap brush between 2 fingers, insert into vagina, feel for cervix and obtain pap Special Issues Providing Pelvic Examinations with Obese Women • The bimanual exam is more challenging & may be very difficult to palpate uterus or ovaries • Place the abdominal hand UNDER the panniculus to decrease amount of adipose tissue between the examiner’s hand & the uterus • A pelvic US may be indicated Pelvic Tenderness • Tender uterus: ectopic cervical motion tenderness (CMT), myoma, cancer, endometritis- salpingitis, adhesions • Ballot to assess mobility • Fixed uterus suggests adhesions Consider Non-Gynecologic Causes of "pelvic pain” • Spine-palpate sacrum & coccyx via rectum • Radiculopathy-back exam: ROM, vertebral compression (osteoporosis), disc diseasestraight leg lift, osteoarthritis Pelvic Pain • Bladder-interstitial cystitis • Cystitis-less symptoms in older women • Palpate bladder with vaginal fingers under bladder & abd fingers pressing down on bladder • Bowel-cancer, impaction • ALWAYS do rectal exam Adenomyosis • Endometrial tissue within the myometrium of the uterus • Heavy, painful menses & large, boggy uterusHalban’s sign • 20% of uteri removed for abnormal bleeding show adenomyosis Ovary Norms • Normal ovaries can range from 2-4 cm depending on time in cycle • During ovulation the ovary may be as large as 4 cm; bring pt back in 2 weeks to recheck if concerned or pelvic US Older Ovaries • By 2 years post menopause most ovaries not palpable • If palpable consider ovarian cancer • Consider ultrasound if unsure Follicular Ovarian Cysts • 95% Follicular cysts are < 5 cm • Found during follicular-proliferative phase • Most common; can rupture, hemorrhage (rare) • Usually ~3 cm; can range to 8-10 cm Corpus Luteum Cyst • Occur during luteal or post-ovulatory phase • Rarely exceed 4 cm, but can get up to 11 cm • Can rupture & bleed & mimic ectopic • All cysts can tort, very painful The Recto-Vaginal Exam • Apply lubricant or lidocaine • Explain exam will cause pressure, but should NOT be painful; feeling an urge to defecate is normal • With index finger in vagina, place lubricated middle finger at the anus Recto-Vaginal Exam • Ask her to bear down gently against your finger, insert only to 1st joint, stop, ask her to relax muscles & don’t move finger • Once muscles relax; ask her to bear down & gently insert finger; stop & don’t move until she relaxes Recto-Vaginal Exam • Then palpate slowly & tell her when you rotate finger-feel septum between rectum & vagina with both fingers (1 in rectum, 1 in vagina) • Palpate rectal ampulla note polyps or masses • Assess uterus & ovaries with bimanual as indicated Rectal Exam • Use single digit • Palpate high for masses • Ampulla tight, stenotic, stiff ? • Look at finger for bleeding • Stool for occult blood, colonoscopy The First Pelvic Exam • What has she heard? • Previous experiences with providers? • What does she expect? • ACOG recommends first appointment with GYN provider between ages 13 and 15 First Pelvic • Does it need to be done? • Risk? contraception? Does it all have to be done the 1st visit? • Cultural issues, translators, chaperones? • Mom, boyfriends and 4 girlfriends want to be in room for exam…oh my! Reasons for pelvic exam in a younger woman • Pelvic pain • Unusual bleeding/discharge • Assault • Request