gynecology and obstetrics
General Gynecologic Evaluation
Physical Examination
The examiner should explain the examination, which includes a Breast examination and an abdominal examination, to the patient. Pelvic examinations should be done when indicated based on a women's medical history or symptoms. The patient and her gynecologic care practitioner should discuss and decide together whether a pelvic examination is needed. For thepelvic examination,the patient lies supine on an examination table with her legs in stirrups and is usually draped. A chaperone is usually required, particularly when the examiner is male, and may also provide assistance. The pelvic examination includes the following: External examination Speculum examination Bimanual examination Rectal examination (sometimes) A pelvic examination is indicated for Symptomatic patients (eg, those with pelvic pain) Asymptomatic patients with specific indications (eg, need for cervical cancer screening) No evidence supports or refutes pelvic examinations for asymptomatic, low-risk patients. Thus, for such patients, the decision about how often these examinations should be done should be made after the health care practitioner and patient discuss the issues. 3 cm may indicate infibulation, a severe form of Female Genital Mutilation . Next, the introitus is palpated between the thumb and index finger for cysts or abscesses in Bartholin glands. While spreading the labia and asking the patient to bear down, the examiner checks the vaginal opening for signs of pelvic organ prolapse: an anterior bulge (suggesting Anterior and Posterior Vaginal Wall Prolapse ), a posterior bulge (suggesting rectocele), and displacement of the cervix toward the introitus (suggesting Before the speculum examination, the patient is asked to relax her legs and hips and breathe deeply. The speculum is sometimes kept warm with a heating pad and may be moistened or lubricated before insertion, particularly when the vagina is dry. If a Screening tests for cervical cancer or cervical culture is planned, the speculum is rinsed with warm water; lubricants have traditionally been avoided, but current-generation water-based lubricants can be used to increase patient comfort. A gloved finger is inserted into the vagina to determine the position of the cervix. Then, the speculum is inserted with the blades nearly in the vertical plane (at about 1 and 7 o’clock) while widening the vagina by pressing 2 fingers on the posterior vaginal wall (perineal body). The speculum is fully inserted toward the cervix, then rotated so that the handle is down, and gently opened; it is pulled back as needed to visualize the cervix. When the cervix is seen, the blades are positioned so that the posterior blade is deeper than the cervix (in the posterior fornix) and the anterior blade is allowed to rise gently and rest anterior to the cervix (in the anterior fornix). The examiner should take care to open the anterior blade slowly and gently and not to pinch the labia or perineum as the speculum is opened. Normally, the cervix is pink and shiny, and there is no discharge. A specimen for the Pap test is taken from the endocervix and external cervix with a brush and plastic spatula or with a cervical sampler that can simultaneously collect cells from the cervical canal and the transition zone; the specimen is rinsed in a liquid, producing a cell suspension to be analyzed for cancerous cells and human papillomavirus. Specimens for detection of sexually transmitted infections (STIs) are taken from the endocervix. The speculum is withdrawn, taking care not to pinch the labia with the speculum blades. Before the bimanual examination, the patient is asked to relax her legs and hips and breathe deeply. The index and middle fingers of the dominant hand are inserted into the vagina to just below the cervix. The other hand is placed just above the pubic symphysis and gently presses down to determine the size, position, and consistency of the uterus and, if possible, the ovaries. Normally, the uterus is about 6 cm by 4 cm and tilts anteriorly (anteversion), but it may tilt posteriorly (retroversion) to various degrees. The uterus may also be bent at an angle anteriorly (anteflexion) or posteriorly (retroflexion). The uterus is normally movable and smooth; irregularity suggests uterine fibroids (leiomyomas). Normally, the ovaries are about 2 cm by 3 cm in young women and are not palpable in postmenopausal women. With ovarian palpation, mild nausea and tenderness are normal. Significant pain when the cervix is gently moved from side to side (cervical motion tenderness) suggests pelvic inflammation. After bimanual palpation, the examiner palpates the rectovaginal septum by inserting the index finger in the vagina and the middle finger in the rectum. The examination should be adjusted according to children’s psychosexual development and is usually limited to inspection of the external genitals. Young children can be examined on their mother’s lap. Older children can be examined in the knee-chest position or on their side with one knee drawn up to their chest. Vaginal discharge can be collected, examined, and cultured. Sometimes a small catheter attached to a syringe of saline is used to obtain washings from the vagina. If cervical examination is required, a fiberoptic vaginoscope, cystoscope, or flexible hysteroscope with saline lavage should be used. In children, pelvic masses may be palpable in the abdomen. For adolescents who are not sexually active, the examination is similar to that of children. Some experts recommend that patients < 21 years have pelvic examinations only when medically indicated (eg, if a patient has a persistent, symptomatic vaginal discharge). All sexually active girls and those who are no longer active but have a history of a sexually transmitted infection may be offered a pelvic examination. However, clinicians can often check for STIs using a urine sample or a vaginal swab and thus avoid doing a speculum examination. Sexually active girls should also be screened annually for Screening for Chlamydia and Puberty is assessed. During the visit, information about Overview of Contraception should be offered as appropriate, and recommendations for the 