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In operational settings,
patients may develop symptoms that require a pelvic examination. This
video demonstrates the procedure for this exam.
The free, short version was
produced by the US Navy as training for medical personnel in isolated
settings. It may be freely
downloaded. The longer
version was produced by the Brookside Associates for civilian
training. It is longer (5-minutes) and is available for download.
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Evaluate the pelvis systematically.
Position the patient at the
very edge of the exam table, with her feet in stirrups, knees bent and
relaxed out to the side. If she is not down far enough, the exam will
be more difficult for you and more uncomfortable for her.
Pad the stirrups to avoid the
stirrups digging into her feet. Kitchen pot-holders work well for
this, but almost any soft material can be used.
Use a bright light to
visually inspect the vulva, vagina and cervix. Most examiners find it
easiest to look just over the light to get the best view. Separate the
labia with your gloved fingers to look for any surface lesions,
redness, or swellings. Look within the pubic hair for the tiny
movement of pubic lice or nits. Look on the labia for the
cauliflower-like bumps that are known as venereal warts. Using
magnification (magnifying lenses or colposcope) is very useful when
the patient has vulvar complaints and the diagnosis is not obvious.
Look between the folds of
skin for ulcerative lesions that can indicate an active herpes
infection. Gently retract the clitoral hood back, exposing the
clitoris while looking for peri-clitoral lesions.
Look for the hymen or
remnants of the hymen and identify any redness just exterior to the
hymen that can indicate vulvar vestibulitis.
The periurethral glands
(Skene's glands) have tiny ducts that open onto the surface. Look for
them next to the urethra. While looking at the urethra, note any
discharge coming from the urethral opening that might suggest
gonorrhea or chlamydia.
Palpate the upper labia
majora for masses related to hernias extending through the Canal of
Nuck. Palpate the middle and lower portion of the labia majora for
masses suggesting a Bartholin Duct Cyst.
After warming a vaginal
speculum with warm water, separate the labia with one hand while
gently inserting the speculum with the other hand. It is frequently
more comfortable for the patient if you insert the speculum rotated
about 45 degrees (so the blades are not horizontal but are oblique).
Once past the introitus, rotate the speculum back to it's normal
position.
The labia, particularly the
labia minora, are very sensitive to stretching or pinching, so try not
to catch the labia minora in the speculum while inserting it.
Some gynecologists ask their
patients to "bear down" while they are inserting the speculum and feel
that this assists with insertion. Others find this instruction to be
be confusing and don't use it.
Obtain specimens for a
Pap smear and any cultures that may be indicated.
Then feel the pelvis by
application of a "bimanual
exam." For a normal examination:
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External genitalia are of
normal appearance. There is no enlargement of the Bartholin or Skene
glands.
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Urethra and bladder are
non-tender.
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Vagina is clean, without
lesions or discharge
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Cervix is smooth, without
lesions. Motion of the cervix causes no pain.
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Uterus is normal size,
shape, and contour. It is non-tender.
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The adnexa (tubes and
ovaries) are neither tender nor enlarged.
During the bimanual exam, you
may use one finger or two fingers inside the vagina. Two fingers
allows for deeper penetration and more control of the pelvic
structures, but one finger is more comfortable for the patient. You
should individualize your exam for the specific patient.
Turning your hand palm up,
compress the urethra against the underside of the pubic bone.
Normally, this doesn't hurt. If it causes discomfort for the patient,
it is likely that at least some degree of urethritis is present.
Then insert your fingers
deeper into the pelvis. Keeping your palm up, curl your vaginal
finger(s) up, compressing the bladder against the back of the pubic
bone. Normally, this pressure creates the sensation that the patient
needs to urinate, but is not painful. If it is painful, this is good
clinical evidence of cystitis (urinary tract infection), or (less
likely) endometriosis.
In some patients,
particularly those with difficult to feel pelvic masses, a combined
rectovaginal exam is useful. Change gloves, lubricate the rectum, and
then gently insert your index finger into the vagina and your middle
finger into the rectum. The rectovaginal exam is helpful in feeling
the uterosacral ligaments, a common site of endometriosis involvement.
On completion of the rectal
exam, stool can be checked for the presence of occult blood.
If the hymen is intact, it
may still be possible to perform a comfortable and complete exam, but
if the exam is causing too much pain, stop the exam and consider these
alternatives:
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Rectal exam with your index
finger can often provide all the information you need at that time.
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Exam under anesthesia will
provide full access without causing pain to the patient.
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Ultrasound scan,
abdominally and trans-perineal, can sometimes provide you with the
information you need.
From OBGYN-101 |
