GYNECOLOGICAL EXAM INATION

1. GYNECOLOGICAL EXAMINATION Doç Dr Aslı Somunkıran İŞ

2. Anamnesis • Name and identity • Gynecologic Anamnesis anamnez • Obstetric Anamnesis • Sexual fonx • Medical history • Family history • Complaints

3. Identity • Age • Marital status • Duration of marriage • Number of marriages • Educational status-job

4. Gynecologic Anamnesis • Age at Menarche (The first menstrual period); 13±2 • Menstrual cycle anamnesis • Cyclus length; 28±7 days • Duration of mns flow; 2-7 days • Amount of bld; 2-3 pads/day • LMP • Dysmenorrhea • PMS

5. Polymenorrhea; cycles with intervals of 21 days or fewer (anovulatory cycles) Oligomenorrhea; menstrual periods occurring at intervals of greater than 35 days, with only four to nine periods in a year (anovulatory cycles-PCOS)

6. Menorrhagia /hypermenorrhea; abnormally heavy and/or prolonged menstrual period at regular intervals • End polyps • Leiomyoma • End hyperplasia • Hypomenorrhea‎; • Asherman Syndrome • Genital tb

7. Cryptomenorrhea • Imperforate hymen • Cervical stenosis

8. Obstetric history • Gravida • Parity • Abortions; • Induced abortions • Miscarriages

9. Sexual history • Dyspareunia • Postcoital bleeding • Contraception (metod; duration..)

10. Medical history • Previous ops • Diseases • Medications • Hirsutism • galactorrhea • Dysuria • SUI, urgency

11. Complaints Present complaints; • Duration • Location • Relation to other organic functions (mens flow, coitus, bowel movements....)

13. Do a Complete Physical Assessment • HEENT • CV.. BLOOD PRESSURE • Lungs • Breasts • Abdomen • Pelvic/rectal • Neuro • Musculoskeletal

14. Essentials for an Adequate Examination--Relaxation • Patient should be given an opportunity to empty her bladder prior to the exam-- Routine UA specimen may be obtained at this time • Explain what is to take place during the exam • Drape her appropriately, cover extending at least over her knees • Arms should be at her side or folded across her chest.

15. Essentials for an Adequate Examination • Examiner's hands should be warmed, also warm the speculum before the exam • Have eye to eye contact with the patient during the exam • Explain in advance each step in the examination, avoiding any sudden or unexpected movements

16. Essentials for an Adequate Examination • Male examiners should always be attended by female assistants • Hx should be taken prior to patient disrobing. • Do not enter the room with an unclothed patient unless you have a female chaperone.

17. Correct Examining Position of the Patient • The Lithotomy Position/or Semi-Sitting Lithotomy Position • Lying in supine position • Thighs flexed and abducted • Feet resting in stirrups • Buttocks extended slightly beyond edge of exam table • Head supported with a pillow

18. Correct Examining Position of the Patient

20. Sequence of a Pelvic Examination • Inspect the patient's external genitalia • Perineal area must be well illuminated • Both hands are gloved to prevent the spread of infection • Perineum is sensitive and tender, warn the patient by touching the neighboring thigh first before advancing to the perineum.

21. Note • A patient suffering pain or deformity of the joints may be unable to assume a Lithotomy position. • It may be necessary to have the patient abduct only one leg or have another person assist in separating the patient's thighs.

23. Sequence of a Pelvic Examination • Mons pubis--note quantity and distribution of hair growth • Labia--usually plump and well-formed in adult female • Perineum--slightly darker than the skin of the rest of the body. Mucous membranes appear dark pink and moist

25. Sequence of a Pelvic Examination • Separate the labia majora and inspect the labia minora; • Labia minora • Clitoris • Urethral orifice • Hymen • Vaginal orifice

27. Sequence of a Pelvic Examination • Note the following: • Discharge • Inflammation • Edema • Ulceration • Lesions

28. Sequence of a Pelvic Examination • Note abnormalities such as: • Bulges and swelling of vulva and vagina • Enlarged clitoris • Syphilitic chancres • Sebaceous cyst • Condylomas Primary Syphilis

29. Sequence of a Pelvic Examination • Skene's glands • Near the urethra • Suspect inflammation; check for urethral discharge (Dc = Infxn Most likely GC) • 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 obtain specimen for culture in case of discharge. • Change glove if discharge is found.

31. Sequence of a Pelvic 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: • Swelling • Tenderness • Masses • Heat or discharge

32. Sequence of a Pelvic Examination • Bartholin's glands (CONT) • A painful abscess is pus filled and usually staphylococcal or gonococcal in origin and should be incised and drained to perform C+S.

34. Sequence of a Pelvic Examination • 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).

36. Sequence of a Pelvic Examination • Inspect the anus at this time, note presence of lesions and hemorrhoids

37. Speculum Examination of Internal Genitalia • Select a speculum of appropriate size, lubricate and warm with warm water (Commercially prepared lubricants interfere with pap smear studies) • 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.

41. 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

42. 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

45. Examination/Collection Specimen of the Cervix • Inspect the cervix • Color should be uniformly pink • Erythema around os: • Ectropion--expressed columnar epithelium • Erosion--term has been used to describe both the exposed columnar epithelium and the erythema seen with cervicitis • Pale--anemia • Bluish--Chadwick's sign, presumptive sign of pregnancy.

46. Cervical inspection Lesions/cysts: • Nabothian cyst--endocervical retention cysts usually secondary to cervical infection/inflammation • Friable, granular, red or white patchy areas--be suspicious of dysplasia, needs to be evaluated with colposcopy • Ulcerative lesions--may be herpetic; do viral culture of lesions and refer for colposcopy • Polyps--soft, friable mass protruding through os; may bleed if traumatized; refer for evaluation/removal

47. Cervical inspection Discharge: • Endocervical vs. from vaginal vault • Physiological discharge--odorless, colorless • Culture any discharge.

48. Cervical inspection Cervical Os: • Nulliparous--small, round, oval • Parous/multiparous--linear, irregular, stellate

49. Cervical inspection

50. Examination/Collection Specimen of the Cervix • Obtain specimens • Chlamydia culture--most prevalent STD • GC culture--gram stain not reliable, done for screening, must do Thayer-Martin for confirmation