female genitourinary system

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Female Genitourinary SystemFemale Genitourinary System

Chapter 26Chapter 26


Chapter 26: Female Genitourinary SystemChapter 26: Female Genitourinary System

Female Genitourinary SystemFemale Genitourinary System

External female genital structures include:External female genital structures include:

VestibuleVestibule Urethral meatusUrethral meatus Skene’s glandsSkene’s glands Vaginal orificeVaginal orifice HymenHymen Bartholin’s glandsBartholin’s glands

Vulva, or pudendumVulva, or pudendum Mons pubisMons pubis Labia majoraLabia majora Labia minoraLabia minora Frenulum or Frenulum or

fourchettefourchette ClitorisClitoris

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External Female GenitaliaExternal Female Genitalia

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Female Genitourinary SystemFemale Genitourinary System (cont.)(cont.)

Internal female genital structures include: Internal female genital structures include:

Rectouterine pouch, Rectouterine pouch, or cul-de-sac of or cul-de-sac of DouglasDouglas

UterusUterus Fallopian tubes Fallopian tubes

VaginaVagina CervixCervix Squamocolumnar Squamocolumnar

junctionjunction Anterior fornix Anterior fornix Posterior fornixPosterior fornix

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Internal Female GenitaliaInternal Female Genitalia

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Structure and FunctionStructure and Function

External genitaliaExternal genitalia Called vulva, or pudendumCalled vulva, or pudendum Mons pubis is a round, firm pad of adipose tissue Mons pubis is a round, firm pad of adipose tissue

covering the symphysis pubiscovering the symphysis pubis• After puberty, it is covered with hair in pattern of an After puberty, it is covered with hair in pattern of an

inverted triangleinverted triangle

Labia majora are two rounded folds of adipose Labia majora are two rounded folds of adipose tissue extending from mons pubis down and tissue extending from mons pubis down and around to perineumaround to perineum• After puberty, hair covers outer surfaces of the labia, After puberty, hair covers outer surfaces of the labia,

whereas inner folds are smooth and moist and contain whereas inner folds are smooth and moist and contain sebaceous folliclessebaceous follicles

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Structure and FunctionStructure and Function (cont.)(cont.)

External genitalia (cont.)External genitalia (cont.) Labia minora: inside labia majora as two smaller, Labia minora: inside labia majora as two smaller,

darker folds of skindarker folds of skin• Joined anteriorly at clitoris, forming a hood, or prepuceJoined anteriorly at clitoris, forming a hood, or prepuce

• Labia minora are joined posteriorly by a transverse fold, Labia minora are joined posteriorly by a transverse fold, the frenulum or fourchettethe frenulum or fourchette

Clitoris: small, pea-shaped erectile body Clitoris: small, pea-shaped erectile body homologous with male penis and highly sensitive homologous with male penis and highly sensitive to tactile stimulationto tactile stimulation

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External genitalia (cont.)External genitalia (cont.) Vestibule: a boat-shaped space, or cleft encircled Vestibule: a boat-shaped space, or cleft encircled

by the labial structuresby the labial structures• Within it are numerous openingsWithin it are numerous openings

Urethral meatus appears as dimple just posterior to clitorisUrethral meatus appears as dimple just posterior to clitoris Surrounding the urethral meatus are tiny, multiple Surrounding the urethral meatus are tiny, multiple

paraurethral (Skene’s) glands; their ducts are not visible, paraurethral (Skene’s) glands; their ducts are not visible, but open posterior to urethrabut open posterior to urethra

Vaginal orifice: posterior to urethral meatusVaginal orifice: posterior to urethral meatus• Appears either as a thin median slit or as a large opening Appears either as a thin median slit or as a large opening

with irregular edges, depending on presentation of the with irregular edges, depending on presentation of the membranous hymenmembranous hymen

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External genitalia (cont.)External genitalia (cont.) Hymen: thin, circular or crescent-shaped fold that Hymen: thin, circular or crescent-shaped fold that

may cover part of the vaginal orifice or may be may cover part of the vaginal orifice or may be absent completelyabsent completely

Vestibular or Bartholin’s glands: on either side and Vestibular or Bartholin’s glands: on either side and posterior to vaginal orifice, secrete clear posterior to vaginal orifice, secrete clear lubricating mucus during intercourselubricating mucus during intercourse• Their ducts are not visible, but open in groove between Their ducts are not visible, but open in groove between

labia minora and hymenlabia minora and hymen

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Internal genitaliaInternal genitalia Vagina: flattened, tubular canal extending from the Vagina: flattened, tubular canal extending from the

orifice up and backward into the pelvisorifice up and backward into the pelvis• 9 cm long, it sits between rectum posteriorly and bladder 9 cm long, it sits between rectum posteriorly and bladder

and urethra anteriorlyand urethra anteriorly

• Its walls are in thick transverse folds, or rugae, enabling Its walls are in thick transverse folds, or rugae, enabling the vagina to dilate widely during childbirththe vagina to dilate widely during childbirth

Uterine cervix: at end of the canal, projects into Uterine cervix: at end of the canal, projects into the vaginathe vagina• In nulliparous female, the cervix appears as a smooth In nulliparous female, the cervix appears as a smooth

doughnut-shaped area with a small circular hole, or os doughnut-shaped area with a small circular hole, or os

• After childbirth, os is slightly enlarged and irregularAfter childbirth, os is slightly enlarged and irregular

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Internal genitalia (cont.)Internal genitalia (cont.) Cervical epithelium is of two distinct typesCervical epithelium is of two distinct types

• Vagina and cervix covered with smooth, pink, stratified Vagina and cervix covered with smooth, pink, stratified squamous epitheliumsquamous epithelium

• Inside os, the endocervical canal lined with columnar Inside os, the endocervical canal lined with columnar epithelium that looks red and roughepithelium that looks red and rough

• Squamocolumnar junction: the point where these two tissues Squamocolumnar junction: the point where these two tissues meet and is not visiblemeet and is not visible

Anterior fornix in front and the posterior fornix in back Anterior fornix in front and the posterior fornix in back form a continuous recess around cervixform a continuous recess around cervix

Behind the posterior fornix is another deep recess Behind the posterior fornix is another deep recess called the rectouterine pouch, or cul-de-sac of Douglascalled the rectouterine pouch, or cul-de-sac of Douglas

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Internal genitalia (cont.)Internal genitalia (cont.) Uterus: pear-shaped, thick-walled, muscular Uterus: pear-shaped, thick-walled, muscular

organ, flattened anteroposteriorly, not fixed and organ, flattened anteroposteriorly, not fixed and freely movable, and usually tilts forward and freely movable, and usually tilts forward and superior to the bladdersuperior to the bladder

Fallopian tubes: two pliable, trumpet-shaped Fallopian tubes: two pliable, trumpet-shaped tubes, 10 cm in length, extending from the uterine tubes, 10 cm in length, extending from the uterine fundus laterally to the brim of the pelvisfundus laterally to the brim of the pelvis• There they curve posteriorly; their fimbriated ends There they curve posteriorly; their fimbriated ends

located near the ovarieslocated near the ovaries

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Internal genitalia (cont.)Internal genitalia (cont.) Ovaries are located one on each side of the uterus Ovaries are located one on each side of the uterus

at the level of the anterior superior iliac spineat the level of the anterior superior iliac spine• Oval shaped, 3 cm long by 2 cm wide by 1 cm thick and Oval shaped, 3 cm long by 2 cm wide by 1 cm thick and

serve to develop ova, eggs, and female hormonesserve to develop ova, eggs, and female hormones

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Structure and Function:Structure and Function:Developmental CompetenceDevelopmental Competence

Infants and adolescentsInfants and adolescents At birth, external genitalia are engorged because At birth, external genitalia are engorged because

of presence of maternal estrogenof presence of maternal estrogen• Structures recede in a few weeks, small until pubertyStructures recede in a few weeks, small until puberty

• Ovaries located in abdomen during childhoodOvaries located in abdomen during childhood

• Uterus small with a straight axis and no anteflexionUterus small with a straight axis and no anteflexion

At puberty, estrogens stimulate growth of cells in At puberty, estrogens stimulate growth of cells in the reproductive tract and development of the reproductive tract and development of secondary sex characteristicssecondary sex characteristics

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(cont.)(cont.) Infants and adolescents (cont.)Infants and adolescents (cont.)

First signs of puberty are breast and pubic hair First signs of puberty are breast and pubic hair development, beginning between ages 8½ and 13 development, beginning between ages 8½ and 13 • Signs usually concurrent, but not abnormal if not togetherSigns usually concurrent, but not abnormal if not together

• Take about 3 years to completeTake about 3 years to complete

Menarche occurs during latter half of this sequence, Menarche occurs during latter half of this sequence, just after peak of growth velocityjust after peak of growth velocity• Irregularity of cycle is common during adolescence Irregularity of cycle is common during adolescence

because of girl’s occasional failure to ovulatebecause of girl’s occasional failure to ovulate

• With menarche, the uterine body flexes on cervixWith menarche, the uterine body flexes on cervix

Ovaries are now in pelvic cavityOvaries are now in pelvic cavity

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(cont.)(cont.) Infants and adolescents (cont.)Infants and adolescents (cont.)

Tanner’s tableTanner’s table• Five stages of pubic hair development, sex maturity Five stages of pubic hair development, sex maturity

rating, SMR, helpful in teaching girls expected sequence rating, SMR, helpful in teaching girls expected sequence of sexual developmentof sexual development

• Data may not necessarily generalize to all racial groupsData may not necessarily generalize to all racial groups Mature Asian women normally have fine sparse pubic hairMature Asian women normally have fine sparse pubic hair African-American and Mexican-American girls had pubic African-American and Mexican-American girls had pubic

hair and had achieved menarche at younger ages than hair and had achieved menarche at younger ages than white girlswhite girls

Mean age at onset of pubic hair and menarche was 9.5 Mean age at onset of pubic hair and menarche was 9.5 and 12.1 years for black girls; 10.3 and 12.2 for Mexican-and 12.1 years for black girls; 10.3 and 12.2 for Mexican-American girls; and 10.5 and 12.7 for white girlsAmerican girls; and 10.5 and 12.7 for white girls

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(cont.)(cont.) Pregnant womanPregnant woman

Shortly after first missed menstrual period, Shortly after first missed menstrual period, genitalia show signs of the growing fetusgenitalia show signs of the growing fetus• Cervix softens (Goodell’s sign) at 4 to 6 weeks of Cervix softens (Goodell’s sign) at 4 to 6 weeks of

gestation, and vaginal mucosa and cervix look cyanotic gestation, and vaginal mucosa and cervix look cyanotic (Chadwick’s sign) at 8 to 12 weeks of gestation(Chadwick’s sign) at 8 to 12 weeks of gestation

• Changes occur because of increased vascularity and Changes occur because of increased vascularity and edema of cervix and hypertrophy and hyperplasia of edema of cervix and hypertrophy and hyperplasia of cervical glandscervical glands

• Isthmus of uterus softens (Hegar’s sign) at 6 to 8 weeks Isthmus of uterus softens (Hegar’s sign) at 6 to 8 weeks of gestationof gestation

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(cont.)(cont.) Pregnant woman (cont.)Pregnant woman (cont.)

Greatest change is in uterusGreatest change is in uterus• Increases in capacity by 500 to 1000 times its nonpregnant Increases in capacity by 500 to 1000 times its nonpregnant

state, first because of hormone stimulation, then because state, first because of hormone stimulation, then because of increasing size of its contents of increasing size of its contents

Nonpregnant uterus has flattened pear shapeNonpregnant uterus has flattened pear shape• Early growth encroaches on space occupied by bladder, Early growth encroaches on space occupied by bladder,

producing symptom of urinary frequencyproducing symptom of urinary frequency

• By 10 to 12 weeks’ gestation, uterus becomes globular in By 10 to 12 weeks’ gestation, uterus becomes globular in shape and is too large to stay in pelvisshape and is too large to stay in pelvis

• At 20 to 24 weeks’ gestation, uterus has oval shape; it At 20 to 24 weeks’ gestation, uterus has oval shape; it rises almost to the liver displacing intestines superiorly and rises almost to the liver displacing intestines superiorly and laterallylaterally

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Clot of thick, tenacious mucus forms in spaces of Clot of thick, tenacious mucus forms in spaces of cervical canal, the mucus plug, which protects cervical canal, the mucus plug, which protects fetus from infectionfetus from infection• Mucus plug dislodges when labor begins at end of term, Mucus plug dislodges when labor begins at end of term,

producing a sign of labor called “bloody show”producing a sign of labor called “bloody show”

• Cervical and vaginal secretions increaseCervical and vaginal secretions increase

• Increased acidity occurs by action of Lactobacillus Increased acidity occurs by action of Lactobacillus acidophilus, which changes glycogen into lactic acidacidophilus, which changes glycogen into lactic acid

• Acidic pH keeps pathogenic bacteria from multiplying in Acidic pH keeps pathogenic bacteria from multiplying in vagina, but increases in glycogen increase risk of vagina, but increases in glycogen increase risk of candidiasis (yeast infection) during pregnancycandidiasis (yeast infection) during pregnancy

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(cont.)(cont.) Aging womanAging woman

Female’s hormonal milieu decreases rapidly in Female’s hormonal milieu decreases rapidly in contrast with slow decline in aging malecontrast with slow decline in aging male• Menopause: cessation of mensesMenopause: cessation of menses

Usually this occurs around 48 to 51, although a wide Usually this occurs around 48 to 51, although a wide variation of ages from 35 to 60 years existsvariation of ages from 35 to 60 years exists

Stage of menopause includes preceding 1 to 2 years of Stage of menopause includes preceding 1 to 2 years of decline in ovarian function, shown by irregular menses that decline in ovarian function, shown by irregular menses that gradually become farther apart and produce lighter flowgradually become farther apart and produce lighter flow

Ovaries stop producing progesterone and estrogenOvaries stop producing progesterone and estrogen Because cells in the reproductive tract are estrogen Because cells in the reproductive tract are estrogen

dependent, decreased estrogen levels during menopause dependent, decreased estrogen levels during menopause bring dramatic physical changesbring dramatic physical changes

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(cont.)(cont.) Aging woman (cont.)Aging woman (cont.)

Uterus shrinks in size because of decreased Uterus shrinks in size because of decreased myometriummyometrium

Ovaries atrophy to 1 to 2 cm and are not palpable Ovaries atrophy to 1 to 2 cm and are not palpable after menopauseafter menopause• Ovulation still may occur sporadically after menopauseOvulation still may occur sporadically after menopause

Uterus droops as sacral ligaments relax and pelvic Uterus droops as sacral ligaments relax and pelvic musculature weakensmusculature weakens• Sometimes it may protrude, or prolapse, into vaginaSometimes it may protrude, or prolapse, into vagina

• Cervix shrinks, looks paler, thick, glistening epitheliumCervix shrinks, looks paler, thick, glistening epithelium

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Vagina becomes shorter, narrower, and less Vagina becomes shorter, narrower, and less elastic because of increased connective tissueelastic because of increased connective tissue• Without sexual activity, vagina atrophies to one-half its Without sexual activity, vagina atrophies to one-half its

former length and widthformer length and width

• Vaginal epithelium atrophies, becoming thinner, drier, Vaginal epithelium atrophies, becoming thinner, drier, and itchyand itchy

This results in a fragile mucosal surface that is at risk for This results in a fragile mucosal surface that is at risk for bleeding and vaginitisbleeding and vaginitis

Decreased vaginal secretions leave vagina dry and at risk Decreased vaginal secretions leave vagina dry and at risk for irritation and pain with intercourse, dyspareuniafor irritation and pain with intercourse, dyspareunia

Vaginal pH becomes more alkaline, and a decreased Vaginal pH becomes more alkaline, and a decreased glycogen content occurs from the decreased estrogenglycogen content occurs from the decreased estrogen

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Externally, mons pubis looks smaller because fat Externally, mons pubis looks smaller because fat pad atrophiespad atrophies

Labia and clitoris gradually decrease in sizeLabia and clitoris gradually decrease in size Pubic hair becomes thin and sparsePubic hair becomes thin and sparse

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Changes in female sexual response cycleChanges in female sexual response cycle• Declining estrogen levels produce some physiologic Declining estrogen levels produce some physiologic

changes in the female sexual response cyclechanges in the female sexual response cycle Reduced amount of vaginal secretion and lubrication Reduced amount of vaginal secretion and lubrication

during excitementduring excitement Shorter duration of orgasm; and rapid resolutionShorter duration of orgasm; and rapid resolution

• However, these changes do not affect sexual pleasure However, these changes do not affect sexual pleasure and functionand function

Sexual desire and need for full sexual expression continueSexual desire and need for full sexual expression continue

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Structure and Function:Structure and Function:Cultural CompetenceCultural Competence

Female circumcision, known as infibulation or Female circumcision, known as infibulation or female genital mutilationfemale genital mutilation• Invasive surgical procedure usually performed on girls Invasive surgical procedure usually performed on girls

before pubertybefore puberty

• Practiced within Aboriginal, Christian, and Muslim Practiced within Aboriginal, Christian, and Muslim families who have emigrated to U.S. from western and families who have emigrated to U.S. from western and southern Asia, Middle East, and large areas of Africa southern Asia, Middle East, and large areas of Africa

• It is a social custom, not a religious practiceIt is a social custom, not a religious practice

• Procedure involves removal, partial or total, of the clitoris Procedure involves removal, partial or total, of the clitoris and believed to inhibit sexual pleasureand believed to inhibit sexual pleasure

• About 130 to 140 million women alive today who have About 130 to 140 million women alive today who have had this procedurehad this procedure

• Procedure outlawed in U.S.Procedure outlawed in U.S.

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Subjective DataSubjective Data

Menstrual historyMenstrual history Obstetric historyObstetric history MenopauseMenopause Self-care behaviorsSelf-care behaviors Urinary symptomsUrinary symptoms Vaginal dischargeVaginal discharge HistoryHistory

Sexual activitySexual activity Contraceptive useContraceptive use Sexually transmitted Sexually transmitted

infection (STI) infection (STI) contactcontact

STI risk reductionSTI risk reduction

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Subjective DataSubjective Data (cont.)(cont.) Menstrual historyMenstrual history

Tell me about your menstrual periodsTell me about your menstrual periods• Age at first period? Date of your last menstrual period?Age at first period? Date of your last menstrual period?

• How often are your periods?How often are your periods?

• How many days does your period last?How many days does your period last?

• Is your usual amount of flow light, medium, or heavy? How Is your usual amount of flow light, medium, or heavy? How many pads or tampons do you use each day or hour?many pads or tampons do you use each day or hour?

• Do you have any clotting?Do you have any clotting?

• Do you have any pain or cramps before or during your Do you have any pain or cramps before or during your period? How do you treat them? Do they interfere with daily period? How do you treat them? Do they interfere with daily activities? Are there any other associated symptoms, such as activities? Are there any other associated symptoms, such as bloating, breast tenderness, or moodiness? bloating, breast tenderness, or moodiness?

• Do you have any spotting between periods?Do you have any spotting between periods?

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Subjective DataSubjective Data (cont.)(cont.)

Obstetric historyObstetric history Have you ever been pregnant?Have you ever been pregnant? How many times?How many times? How many infants have you given birth to?How many infants have you given birth to? Have you had any miscarriages or abortions?Have you had any miscarriages or abortions? For each pregnancy, describe the duration, any For each pregnancy, describe the duration, any

complications, labor and delivery, and infant’s complications, labor and delivery, and infant’s gender, birth weight, and conditiongender, birth weight, and condition

Do you think you may be pregnant now? What Do you think you may be pregnant now? What symptoms have you noticed?symptoms have you noticed?

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MenopauseMenopause Have your periods slowed down or stopped?Have your periods slowed down or stopped? Do you have any associated symptoms of Do you have any associated symptoms of

menopause, such as hot flashes, night sweats, menopause, such as hot flashes, night sweats, numbness and tingling, headache, palpitations, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, drenching sweats, mood swings, vaginal dryness, or itching? Any treatment?or itching? Any treatment?

If you are using hormone replacement, how If you are using hormone replacement, how much? How is it working? Do you have any side much? How is it working? Do you have any side effects?effects?

How do you feel about going through menopause?How do you feel about going through menopause?

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Self-care behaviorsSelf-care behaviors How often do you have a gynecologic checkup?How often do you have a gynecologic checkup? When was your last Pap smear? What were the When was your last Pap smear? What were the

results?results? Has your mother ever mentioned taking hormones Has your mother ever mentioned taking hormones

while pregnant with you?while pregnant with you?

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Urinary symptomsUrinary symptoms Any problems with urinating? Frequently and small Any problems with urinating? Frequently and small

amounts? Cannot wait to urinate?amounts? Cannot wait to urinate? Any burning or pain on urinating?Any burning or pain on urinating? Do you awaken during night to urinate?Do you awaken during night to urinate? Is there blood in your urine?Is there blood in your urine? Is your urine dark, cloudy, or foul smelling?Is your urine dark, cloudy, or foul smelling? Do you have any difficulty controlling urine or Do you have any difficulty controlling urine or

wetting yourself?wetting yourself? Do you urinate when sneezing, laughing, coughing, Do you urinate when sneezing, laughing, coughing,

or bearing down?or bearing down?

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Vaginal dischargeVaginal discharge Any unusual vaginal discharge? Increased Any unusual vaginal discharge? Increased

amount? Is it white, yellow-green, gray, curdlike, amount? Is it white, yellow-green, gray, curdlike, or foul smelling?or foul smelling?

When did this begin?When did this begin? Is the discharge associated with vaginal itching, Is the discharge associated with vaginal itching,

rash, or pain with intercourse?rash, or pain with intercourse? Are you taking any medications?Are you taking any medications? Do you have a family history of diabetes?Do you have a family history of diabetes?

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Vaginal discharge (cont.)Vaginal discharge (cont.) What part of your menstrual cycle are you in now?What part of your menstrual cycle are you in now? Do you use a vaginal douche? How often?Do you use a vaginal douche? How often? Do you use feminine hygiene spray?Do you use feminine hygiene spray? Do you wear nonventilating underpants or Do you wear nonventilating underpants or

pantyhose?pantyhose? Have you treated the discharge with anything? Have you treated the discharge with anything?

What was the result?What was the result?

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HistoryHistory Any other problems in genital area? Do you have Any other problems in genital area? Do you have

any sores or lesions, now or in past? How were any sores or lesions, now or in past? How were these treated?these treated?

Do you have any abdominal pain?Do you have any abdominal pain? Have you had any surgery on uterus, ovaries, or Have you had any surgery on uterus, ovaries, or

vagina?vagina?

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Sexual activitySexual activity Often women have a question about their sexual Often women have a question about their sexual

relationship and how it affects their health. Do relationship and how it affects their health. Do you?you?

Are you in a relationship involving sex now?Are you in a relationship involving sex now? Are aspects of sex satisfactory to you and your Are aspects of sex satisfactory to you and your

partner?partner? Satisfied with the way you and partner Satisfied with the way you and partner

communicate about sex?communicate about sex?

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Sexual activity (cont.)Sexual activity (cont.) Are you satisfied with your ability to respond Are you satisfied with your ability to respond

sexually?sexually? Do you have more than one sexual partner?Do you have more than one sexual partner? What is your sexual preference: do you prefer a What is your sexual preference: do you prefer a

relationship with a man, with a woman, or with relationship with a man, with a woman, or with both?both?

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Contraceptive useContraceptive use Currently planning a pregnancy or avoiding Currently planning a pregnancy or avoiding

pregnancy?pregnancy? Do you and your partner use a contraceptive? Do you and your partner use a contraceptive?

Which method? Is this satisfactory? Do you have Which method? Is this satisfactory? Do you have any questions about this or other methods?any questions about this or other methods?

Which methods have you used in the past?Which methods have you used in the past? Have you and partner discussed having children?Have you and partner discussed having children? Have you ever had any problems becoming Have you ever had any problems becoming

pregnant?pregnant?

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Sexually transmitted infection (STI) contactSexually transmitted infection (STI) contact Any sexual contact with partner having an STI, Any sexual contact with partner having an STI,

such as gonorrhea, herpes, HIV, AIDS, chlamydial such as gonorrhea, herpes, HIV, AIDS, chlamydial infection, venereal warts, or syphilis? When? How infection, venereal warts, or syphilis? When? How was this treated? Were there any complications?was this treated? Were there any complications?

STI risk reductionSTI risk reduction Do you use any precautions to reduce risk of Do you use any precautions to reduce risk of

STIs? Do you use condoms at each episode of STIs? Do you use condoms at each episode of sexual intercourse?sexual intercourse?

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Additional history for infants and childrenAdditional history for infants and children Does your child have any problem urinating? Pain Does your child have any problem urinating? Pain

with urinating, crying, holding genitals? Urinary with urinating, crying, holding genitals? Urinary tract infection?tract infection?

If child is older than 2 to 2½, has toilet training If child is older than 2 to 2½, has toilet training started? How is it progressing?started? How is it progressing?

Does the child wet bed at night? Is this a problem Does the child wet bed at night? Is this a problem for child or you (parents)? What have you for child or you (parents)? What have you (parents) done?(parents) done?

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Additional history for infants and children Additional history for infants and children (cont.)(cont.) Problem with genital area: itching, rash, vaginal Problem with genital area: itching, rash, vaginal

discharge?discharge? To child: Has anyone ever touched you between To child: Has anyone ever touched you between

your legs and you did not want them to? your legs and you did not want them to? Sometimes that happens to children; they should Sometimes that happens to children; they should

remember they have not been bad; they should try remember they have not been bad; they should try to tell a big person about itto tell a big person about it• Can you tell me three different big people you trust who Can you tell me three different big people you trust who

you could talk to?you could talk to?

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Additional history for preadolescents and Additional history for preadolescents and adolescentsadolescents Use following questions to assess sexual growth, Use following questions to assess sexual growth,

development, and sexual behavior development, and sexual behavior Ask questions that seem appropriate for girl’s age, Ask questions that seem appropriate for girl’s age,

but norms vary widelybut norms vary widely When in doubt ask too many questions rather than When in doubt ask too many questions rather than

omit somethingomit something Children obtain information, often misinformation, Children obtain information, often misinformation,

from media and peers at surprisingly early agesfrom media and peers at surprisingly early ages

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Additional history for preadolescents and Additional history for preadolescents and adolescents (cont.)adolescents (cont.) Ask direct, matter-of-fact questions; avoid Ask direct, matter-of-fact questions; avoid

sounding judgmentalsounding judgmental Start with a permission statement, “Often girls Start with a permission statement, “Often girls

your age experience . . .” This conveys that it is your age experience . . .” This conveys that it is normal to think or feel a certain waynormal to think or feel a certain way

Try open-ended, “When did you . . .” rather than Try open-ended, “When did you . . .” rather than “Do you . . .” This is less threatening because it “Do you . . .” This is less threatening because it implies that the topic is normal and unexceptionalimplies that the topic is normal and unexceptional

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Subjective DataSubjective Data

Additional history for preadolescents and Additional history for preadolescents and adolescents (cont.)adolescents (cont.) Around age 9 or 10, girls start to develop breasts Around age 9 or 10, girls start to develop breasts

and pubic hairand pubic hair• Have you ever seen charts and pictures of normal Have you ever seen charts and pictures of normal

growth patterns for girls? Let us go over these now.growth patterns for girls? Let us go over these now.

Have your periods started? How did you feel? Have your periods started? How did you feel? Were you prepared or surprised?Were you prepared or surprised?

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Additional history for preadolescents and Additional history for preadolescents and adolescents (cont.)adolescents (cont.) Who in your family do you talk to about your body Who in your family do you talk to about your body

changes and about sex information?changes and about sex information? Do you think you get enough information? Do you think you get enough information? What about sex education classes at school? Is What about sex education classes at school? Is

there a teacher, a nurse, a minister, to whom you there a teacher, a nurse, a minister, to whom you can talk?can talk?

Often girls your age have questions about sexual Often girls your age have questions about sexual activity; Do you have questions? Are you dating?activity; Do you have questions? Are you dating?

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Additional history for preadolescents and Additional history for preadolescents and adolescents (cont.)adolescents (cont.) Do you and your boyfriend have intercourse? Are Do you and your boyfriend have intercourse? Are

you using condoms? What kind of protection did you using condoms? What kind of protection did you use the last time you had sex?you use the last time you had sex?

Has anyone ever talked to you about sexually Has anyone ever talked to you about sexually transmitted infections, such as chlamydia, herpes, transmitted infections, such as chlamydia, herpes, gonorrhea, or AIDS?gonorrhea, or AIDS?

Have you and your parents discussed the human Have you and your parents discussed the human papillomavirus vaccine? It is recommended before papillomavirus vaccine? It is recommended before girls become sexually active.girls become sexually active.

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Additional history for preadolescents and Additional history for preadolescents and adolescents (cont.)adolescents (cont.) Sometimes a person touches a girl in a way that Sometimes a person touches a girl in a way that

she does not want them toshe does not want them to Has that ever happened to you? If that happens, Has that ever happened to you? If that happens,

the girl should remember it is not her faultthe girl should remember it is not her fault She should tell another adult about itShe should tell another adult about it

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Additional history for aging womanAdditional history for aging woman After menopause, have you noted any vaginal After menopause, have you noted any vaginal

bleeding?bleeding? Any vaginal itching, discharge, or pain with Any vaginal itching, discharge, or pain with

intercourse?intercourse? Any pressure in genital area, loss of urine with Any pressure in genital area, loss of urine with

cough or sneeze, back pain, or constipation?cough or sneeze, back pain, or constipation? Are you in a relationship involving sex now? Are Are you in a relationship involving sex now? Are

aspects of sex satisfactory to you and your aspects of sex satisfactory to you and your partner? Is there adequate privacy for a sexual partner? Is there adequate privacy for a sexual relationship?relationship?

Slide 26-47



Objective DataObjective Data

PreparationPreparation Assemble equipment before helping woman into Assemble equipment before helping woman into

positionposition Arrange within easy reachArrange within easy reach Familiarize yourself with vaginal speculum before Familiarize yourself with vaginal speculum before

examinationexamination• Practice opening and closing blades, locking them into Practice opening and closing blades, locking them into

position, and releasing themposition, and releasing them

• Try both metal and plastic typesTry both metal and plastic types

Note that plastic speculum locks and unlocks with Note that plastic speculum locks and unlocks with a resounding click that can be alarminga resounding click that can be alarming

Slide 26-48



Objective DataObjective Data (cont.)(cont.)

●● Equipment neededEquipment needed• GlovesGloves

• Goose-necked lampGoose-necked lamp

• Vaginal speculum of appropriate Vaginal speculum of appropriate sizesize

• Graves’ speculum, useful for most Graves’ speculum, useful for most adult women, available in varying adult women, available in varying lengths and widthslengths and widths

• Pederson speculum, narrow blades, Pederson speculum, narrow blades, useful for young or postmenopausal useful for young or postmenopausal women with narrowed introituswomen with narrowed introitus

• Large cotton-tipped applicators, Large cotton-tipped applicators, rectal swabsrectal swabs

• LubricantLubricant

• Materials for cytologic study:Materials for cytologic study:

• Glass slide with frosted endGlass slide with frosted end

• Sterile Cytobrush or cotton-tipped Sterile Cytobrush or cotton-tipped applicatorapplicator

• Ayre’s spatulaAyre’s spatula

• Spray fixativeSpray fixative

• Specimen container for gonorrhea Specimen container for gonorrhea culture (GC)/Chlamydiaculture (GC)/Chlamydia

• Small bottle of normal saline Small bottle of normal saline solution, potassium hydroxide solution, potassium hydroxide (KOH), and acetic acid (white (KOH), and acetic acid (white vinegar)vinegar)

Slide 26-49




PositionPosition Initially, the woman should be sitting upInitially, the woman should be sitting up

• An equal-status position is important to establish trust An equal-status position is important to establish trust and rapport before vaginal examinationand rapport before vaginal examination

For examination, woman should be placed in For examination, woman should be placed in lithotomy position, with examiner sitting on stoollithotomy position, with examiner sitting on stool• Help woman into lithotomy position, with body supine, Help woman into lithotomy position, with body supine,

feet in stirrups, knees apart, and buttocks at edge of feet in stirrups, knees apart, and buttocks at edge of examining tableexamining table

• Ask woman to lift hips as you guide them to edge of tableAsk woman to lift hips as you guide them to edge of table

• Some women prefer to leave their shoes or socks onSome women prefer to leave their shoes or socks on

Slide 26-50



Lithotomy Position and DrapingLithotomy Position and Draping

Slide 26-51



Objective DataObjective Data (cont.)(cont.) Position (cont.)Position (cont.)

For examination, woman should be placed in lithotomy For examination, woman should be placed in lithotomy position, with examiner sitting on stool (cont.)position, with examiner sitting on stool (cont.)• Place arms at her sides or across chest, not over head, Place arms at her sides or across chest, not over head,

because this position only tightens abdominal musclesbecause this position only tightens abdominal muscles

• Traditional mode is to drape woman fully, covering stomach Traditional mode is to drape woman fully, covering stomach and legs, exposing only vulva to viewand legs, exposing only vulva to view

• Be sure to push down drape between woman’s legs and Be sure to push down drape between woman’s legs and elevate her head so that you can see her faceelevate her head so that you can see her face

Lithotomy position leaves many women feeling helpless and Lithotomy position leaves many women feeling helpless and vulnerablevulnerable

Indeed, many women tolerate pelvic examination because they Indeed, many women tolerate pelvic examination because they consider it basic for health care, yet find it uncomfortableconsider it basic for health care, yet find it uncomfortable

Slide 26-52




Position (cont.)Position (cont.) You can help woman relax, decrease her anxiety, You can help woman relax, decrease her anxiety,

and retain a sense of control by using these and retain a sense of control by using these measuresmeasures• Have her empty bladder before examinationHave her empty bladder before examination

• Position examination table so that her perineum is not Position examination table so that her perineum is not exposed to an inadvertent open doorexposed to an inadvertent open door

• Ask if she would like a friend, family member, or chaperone Ask if she would like a friend, family member, or chaperone present; position this person by woman’s head to maintain present; position this person by woman’s head to maintain privacyprivacy

• Elevate her head and shoulders to semisitting position to Elevate her head and shoulders to semisitting position to maintain eye contactmaintain eye contact

• Place stirrups so that legs are not abducted too farPlace stirrups so that legs are not abducted too far

Slide 26-53




Position (cont.)Position (cont.) You can help woman relax, decrease her anxiety, You can help woman relax, decrease her anxiety,

and retain a sense of control by using these and retain a sense of control by using these measures (cont.)measures (cont.)• Explain each step in examination before you do itExplain each step in examination before you do it

• Assure woman she can stop examination at any point Assure woman she can stop examination at any point should she feel any discomfortshould she feel any discomfort

• Use a gentle, firm touch, and gradual movementsUse a gentle, firm touch, and gradual movements

• Communicate throughout examination; maintain a dialog Communicate throughout examination; maintain a dialog to share informationto share information

• Use techniques of educational or mirror pelvic Use techniques of educational or mirror pelvic examinationexamination

Slide 26-54




Position (cont.)Position (cont.) Educational or mirror pelvic examinationEducational or mirror pelvic examination

• Routine examination with some modifications in attitude, Routine examination with some modifications in attitude, position, and communicationposition, and communication

• First, woman considered active participant, one who is First, woman considered active participant, one who is interested in learning and in sharing decisions about her interested in learning and in sharing decisions about her own health careown health care

• Woman props herself up on one elbow, or head of table Woman props herself up on one elbow, or head of table is raised; her other hand holds a mirror between her is raised; her other hand holds a mirror between her legs, above examiner’s handslegs, above examiner’s hands

Woman can see all that examiner is doing and has a full Woman can see all that examiner is doing and has a full view of her genitaliaview of her genitalia

Slide 26-55




Position (cont.)Position (cont.) Mirror works well for teaching normal anatomy and Mirror works well for teaching normal anatomy and

its relationship to sexual behaviorits relationship to sexual behavior• Even women who are in a sexual relationship or who Even women who are in a sexual relationship or who

have had children may be surprisingly uninformed about have had children may be surprisingly uninformed about their own anatomytheir own anatomy

• You will find woman’s enthusiasm on seeing her own You will find woman’s enthusiasm on seeing her own cervix is rewarding toocervix is rewarding too

• Mirror pelvic examination also works well when Mirror pelvic examination also works well when abnormalities arise because woman can see rationale for abnormalities arise because woman can see rationale for treatment and can monitor progress at next appointmenttreatment and can monitor progress at next appointment

• She is more willing to comply with treatment when she She is more willing to comply with treatment when she shares in decisionsshares in decisions

Slide 26-56




External genitaliaExternal genitalia InspectionInspection

• Skin color is even; labia minora are darker pinkSkin color is even; labia minora are darker pink

• Hair distribution in usual female pattern of inverted Hair distribution in usual female pattern of inverted triangle, although it normally may trail up abdomentriangle, although it normally may trail up abdomen

• Labia majora normally are symmetric, plump, and well Labia majora normally are symmetric, plump, and well formed; in nulliparous woman, labia meet in midline; after formed; in nulliparous woman, labia meet in midline; after a vaginal delivery, labia are gaping and slightly shriveleda vaginal delivery, labia are gaping and slightly shriveled

• No lesions should be present, except for occasional No lesions should be present, except for occasional sebaceous cystssebaceous cysts

Slide 26-57




External genitalia (cont.)External genitalia (cont.) InspectionInspection

• With your gloved hand, separate labia majora to inspect:With your gloved hand, separate labia majora to inspect: ClitorisClitoris Labia minora are dark pink and moist, usually symmetricLabia minora are dark pink and moist, usually symmetric Urethral opening appears stellate or slitlike and is midlineUrethral opening appears stellate or slitlike and is midline Vaginal opening, or introitus, may appear as narrow Vaginal opening, or introitus, may appear as narrow

vertical slit or as larger openingvertical slit or as larger opening Perineum is smooth; a well-healed episiotomy scar, midline Perineum is smooth; a well-healed episiotomy scar, midline

or mediolateral, may be present after vaginal birthor mediolateral, may be present after vaginal birth Anus has coarse skin of increased pigmentationAnus has coarse skin of increased pigmentation

Slide 26-58




External genitalia (cont.)External genitalia (cont.) PalpationPalpation

• Assess urethra and Skene’s glandsAssess urethra and Skene’s glands Dip gloved finger in bowl of warm water to lubricateDip gloved finger in bowl of warm water to lubricate Insert index finger into vagina, and gently milk urethra by Insert index finger into vagina, and gently milk urethra by

applying pressure up and outapplying pressure up and out Procedure should produce no painProcedure should produce no pain If any discharge appears, culture itIf any discharge appears, culture it

• Assess Bartholin’s glandsAssess Bartholin’s glands Palpate posterior parts of labia majora with index finger in Palpate posterior parts of labia majora with index finger in

vagina and your thumb outside; normally, labia feel soft vagina and your thumb outside; normally, labia feel soft and homogeneousand homogeneous

Slide 26-59



Palpation: Bartholin’s Glands Palpation: Bartholin’s Glands

Slide 26-60




External genitalia (cont.)External genitalia (cont.) PalpationPalpation

• Assess support of pelvic musculature by using these Assess support of pelvic musculature by using these maneuvers:maneuvers:

Palpate perineumPalpate perineum Normally, it feels thick, smooth, and muscular in Normally, it feels thick, smooth, and muscular in

nulliparous woman; thin and rigid in multiparous womannulliparous woman; thin and rigid in multiparous woman

• Ask woman to squeeze vaginal opening around your Ask woman to squeeze vaginal opening around your fingers; it should feel tight in nulliparous woman and fingers; it should feel tight in nulliparous woman and have less tone in multiparous womanhave less tone in multiparous woman

• Using index and middle fingers, separate vaginal orifice Using index and middle fingers, separate vaginal orifice and ask woman to strain down; normally, no bulging of and ask woman to strain down; normally, no bulging of vaginal walls or urinary incontinence occursvaginal walls or urinary incontinence occurs

Slide 26-61




Internal genitalia: speculum examinationInternal genitalia: speculum examination Select proper-sized speculum; warm and lubricate Select proper-sized speculum; warm and lubricate

speculum under warm running waterspeculum under warm running water Evidence shows applying a small amount, dime Evidence shows applying a small amount, dime

size water soluble gel lubricant on the outer size water soluble gel lubricant on the outer inferior blade increases patient comfort and yields inferior blade increases patient comfort and yields no more unsatisfactory slides than does water onlyno more unsatisfactory slides than does water only

However, effect of gel lubricant on interference However, effect of gel lubricant on interference with bacterial or viral cultures has not been testedwith bacterial or viral cultures has not been tested

Slide 26-62




Internal genitalia: speculum examination (cont.)Internal genitalia: speculum examination (cont.) Good technique is to dedicate one hand to patient Good technique is to dedicate one hand to patient

and other to picking up equipmentand other to picking up equipment• For example, hold speculum in your left hand with index and For example, hold speculum in your left hand with index and

middle fingers surrounding blades and thumb under middle fingers surrounding blades and thumb under thumbscrewthumbscrew

This prevents blades from opening painfully during insertion; This prevents blades from opening painfully during insertion; with your right index and middle fingers push introitus down with your right index and middle fingers push introitus down and open to relax pubococcygeal muscle and open to relax pubococcygeal muscle

Tilt width of blades obliquely and insert speculum past your Tilt width of blades obliquely and insert speculum past your right fingers, applying any pressure downward; this avoids right fingers, applying any pressure downward; this avoids pressure on sensitive urethra above itpressure on sensitive urethra above it

Ease insertion by asking woman to bear downEase insertion by asking woman to bear down

Slide 26-63




Internal genitalia: inspect cervix and its osInternal genitalia: inspect cervix and its os Color: normally cervical mucosa is pink and evenColor: normally cervical mucosa is pink and even

• During second month of pregnancy it looks blue During second month of pregnancy it looks blue

(Chadwick’s sign); after menopause it is pale(Chadwick’s sign); after menopause it is pale

Position: midline, either anterior or posterior; Position: midline, either anterior or posterior; projects 1 to 3 cm into vaginaprojects 1 to 3 cm into vagina

Size: diameter is 2.5 cm (1 inch)Size: diameter is 2.5 cm (1 inch) Os: small and round in nulliparous woman; in Os: small and round in nulliparous woman; in

parous woman, it is horizontal irregular slit and parous woman, it is horizontal irregular slit and also may show healed lacerations on sidesalso may show healed lacerations on sides

Slide 26-64




Internal genitalia: inspect cervix (cont.)Internal genitalia: inspect cervix (cont.) Surface: normally smooth, but cervical eversion, or Surface: normally smooth, but cervical eversion, or

ectropion, may occur after vaginal deliveriesectropion, may occur after vaginal deliveries• Endocervical canal everted; looks like red, beefy halo Endocervical canal everted; looks like red, beefy halo

inside pink cervix surrounding osinside pink cervix surrounding os

• Difficult to distinguish this normal variation from an Difficult to distinguish this normal variation from an abnormal condition and biopsy may be neededabnormal condition and biopsy may be needed

• Nabothian cysts are benign growths commonly appear Nabothian cysts are benign growths commonly appear on cervix after childbirth; they are small, smooth, yellow on cervix after childbirth; they are small, smooth, yellow nodules that may be single or multiple; they are retention nodules that may be single or multiple; they are retention cysts caused by obstruction of cervical glandscysts caused by obstruction of cervical glands

Slide 26-65



Variations of the cervixVariations of the cervix

Slide 26-66




Internal genitalia: inspect cervix (cont.)Internal genitalia: inspect cervix (cont.) If secretions are copious, swab area with a thick-If secretions are copious, swab area with a thick-

tipped rectal swabtipped rectal swab This method sponges away secretions, and you This method sponges away secretions, and you

have better view of structureshave better view of structures

Slide 26-67




Obtain cervical smears and culturesObtain cervical smears and cultures PapanicolaouPapanicolaou

• Pap smear screens for cervical cancer, but not for Pap smear screens for cervical cancer, but not for endometrial or ovarian cancerendometrial or ovarian cancer

• Do not obtain during woman’s menses or if a heavy Do not obtain during woman’s menses or if a heavy infectious discharge presentinfectious discharge present

• Instruct woman not to douche, have intercourse, or put Instruct woman not to douche, have intercourse, or put anything into vagina 24 hours before collecting specimenanything into vagina 24 hours before collecting specimen

• Obtain Pap smear before other specimens so you will Obtain Pap smear before other specimens so you will not disrupt or remove cellsnot disrupt or remove cells

Slide 26-68




Obtain cervical smears and cultures (cont.)Obtain cervical smears and cultures (cont.) Pap smear: usually consists of three specimens:Pap smear: usually consists of three specimens:

• Vaginal pool: gently rub blunt end of an Ayre spatula over Vaginal pool: gently rub blunt end of an Ayre spatula over vaginal wall under and lateral to cervix; wipe specimen on vaginal wall under and lateral to cervix; wipe specimen on glass slideglass slide

• Cervical scrape: insert bifid end of Ayre spatula into Cervical scrape: insert bifid end of Ayre spatula into vagina with the more pointed bump into cervical os; rotate vagina with the more pointed bump into cervical os; rotate 360 to 720 degrees, using firm pressure; this specimen 360 to 720 degrees, using firm pressure; this specimen important for adolescent whose endocervical cells have important for adolescent whose endocervical cells have not yet migrated into endocervical canalnot yet migrated into endocervical canal

• Endocervical: insert a Cytobrush into os; Cytobrush gives Endocervical: insert a Cytobrush into os; Cytobrush gives a higher yield of endocervical cells at squamocolumnar a higher yield of endocervical cells at squamocolumnar junction, and is safe for use during pregnancyjunction, and is safe for use during pregnancy

Slide 26-69




Obtain cervical smears and culturesObtain cervical smears and cultures (cont.)(cont.) Pap smear (cont.)Pap smear (cont.)

• Send specimens to laboratory with following necessary Send specimens to laboratory with following necessary data:data:

Date of specimenDate of specimen Woman’s date of birthWoman’s date of birth Date of last menstrual periodDate of last menstrual period Any hormone medicationAny hormone medication If pregnant, with estimated date of deliveryIf pregnant, with estimated date of delivery Known infectionsKnown infections Prior surgery or radiationPrior surgery or radiation Prior abnormal cytologyPrior abnormal cytology Abnormal findings on physical examinationAbnormal findings on physical examination

Slide 26-70




Obtain cervical smears and cultures (cont.)Obtain cervical smears and cultures (cont.) To screen for STIs, and if you note any abnormal To screen for STIs, and if you note any abnormal

vaginal discharge, obtain gonorrhea vaginal discharge, obtain gonorrhea (GC)/chlamydia culture(GC)/chlamydia culture• Insert a sterile cotton applicator into os, rotate it 360 Insert a sterile cotton applicator into os, rotate it 360

degrees, and leave it in place 10 to 20 seconds for degrees, and leave it in place 10 to 20 seconds for complete saturationcomplete saturation

• Insert into labeled specimen containerInsert into labeled specimen container

Slide 26-71




Occasionally you will need following samples:Occasionally you will need following samples: Saline mount, or wet preparation: spread sample of Saline mount, or wet preparation: spread sample of

discharge onto a glass slide and add one drop of discharge onto a glass slide and add one drop of normal saline solution and a coverslipnormal saline solution and a coverslip

KOH preparation: add one drop of potassium KOH preparation: add one drop of potassium hydroxide and a coverslip to a sample of discharge hydroxide and a coverslip to a sample of discharge on slide on slide

Anal culture: insert sterile cotton swab into anal Anal culture: insert sterile cotton swab into anal canal about 1 cm; rotate and move it side to sidecanal about 1 cm; rotate and move it side to side• Leave in place 10 to 20 secondsLeave in place 10 to 20 seconds

• If the swab collects feces, discard it and begin again If the swab collects feces, discard it and begin again

• Insert into specimen containerInsert into specimen container

Slide 26-72




Occasionally you will need following samples Occasionally you will need following samples (cont.)(cont.) Acetic acid wash: acetic acid (white vinegar) Acetic acid wash: acetic acid (white vinegar)

screens for asymptomatic human papilloma virus screens for asymptomatic human papilloma virus (HPV), which causes genital warts(HPV), which causes genital warts• After all other specimens are gathered, soak a thick-After all other specimens are gathered, soak a thick-

tipped cotton rectal swab with acetic acid and “paint” the tipped cotton rectal swab with acetic acid and “paint” the cervixcervix

• Acetic acid dissolves mucus and temporarily causes Acetic acid dissolves mucus and temporarily causes intracellular dehydration and coagulation of proteinintracellular dehydration and coagulation of protein

• Normal response, indicating no HPV infection, is no Normal response, indicating no HPV infection, is no change in cervical epitheliumchange in cervical epithelium

Slide 26-73




Inspect vaginal wallInspect vaginal wall Loosen thumbscrew but continue to hold Loosen thumbscrew but continue to hold

speculum blades openspeculum blades open• Slowly withdraw speculum, rotating it as you go, to fully Slowly withdraw speculum, rotating it as you go, to fully

inspect vaginal wallinspect vaginal wall

• Normally wall looks pink, deeply rugated, moist and Normally wall looks pink, deeply rugated, moist and smooth, and free of inflammation or lesionssmooth, and free of inflammation or lesions

• Normal discharge is thin and clear, or opaque and Normal discharge is thin and clear, or opaque and stringy, but always odorlessstringy, but always odorless

• When blade ends near vaginal opening, let them close, When blade ends near vaginal opening, let them close, but be careful not to pinch mucosa or catch any hairsbut be careful not to pinch mucosa or catch any hairs

Slide 26-74



Objective Data:Objective Data:Bimanual ExaminationBimanual Examination

Vaginal wallVaginal wall Rise to a stand, and have woman remain in Rise to a stand, and have woman remain in

lithotomy position; drop lubricant onto first two lithotomy position; drop lubricant onto first two fingers of your gloved intravaginal handfingers of your gloved intravaginal hand• Assume “obstetric” position with first two fingers Assume “obstetric” position with first two fingers

extended, last two flexed onto palm, and thumb abductedextended, last two flexed onto palm, and thumb abducted

• Insert fingers into vagina, with any pressure directed Insert fingers into vagina, with any pressure directed posteriorly; wait until vaginal walls relax, then insert your posteriorly; wait until vaginal walls relax, then insert your fingers fullyfingers fully

• Use both hands to palpate internal genitalia Use both hands to palpate internal genitalia

• Assess location, size, and mobility, and screen for any Assess location, size, and mobility, and screen for any tenderness or masstenderness or mass

Slide 26-75



Objective Data:Objective Data:Bimanual ExaminationBimanual Examination (cont.)(cont.)

Vaginal wall (cont.)Vaginal wall (cont.) One hand is on abdomen while other hand inserts One hand is on abdomen while other hand inserts

two fingers into vaginatwo fingers into vagina• Palpate vaginal wall; normally, it feels smooth and has Palpate vaginal wall; normally, it feels smooth and has

no area of induration or tendernessno area of induration or tenderness

Slide 26-76




CervixCervix Locate cervix in midline, often near anterior Locate cervix in midline, often near anterior

vaginal wallvaginal wall Palpate using palmar surface of fingers; note Palpate using palmar surface of fingers; note

these characteristics of normal cervix:these characteristics of normal cervix:• Consistency: feels smooth and firm; softens and feels Consistency: feels smooth and firm; softens and feels

velvety at 5 to 6 weeks of pregnancy (Goodell’s sign)velvety at 5 to 6 weeks of pregnancy (Goodell’s sign)

• Contour: evenly roundedContour: evenly rounded

• Mobility: with a finger on either side, move cervix gently Mobility: with a finger on either side, move cervix gently from side to side; normally, this produces no painfrom side to side; normally, this produces no pain

• Palpate all around fornices; the wall should feel smoothPalpate all around fornices; the wall should feel smooth

Slide 26-77




Cervix (cont.)Cervix (cont.) Next, use abdominal hand to push pelvic organs Next, use abdominal hand to push pelvic organs

closer for your intravaginal fingers to palpatecloser for your intravaginal fingers to palpate• Place your hand midway between umbilicus and Place your hand midway between umbilicus and

symphysis; push down slowlysymphysis; push down slowly Brace elbow of your pelvic arm against your hip, and keep Brace elbow of your pelvic arm against your hip, and keep

it horizontal; woman must be relaxedit horizontal; woman must be relaxed

Slide 26-78




UterusUterus Assess with intravaginal fingers in anterior fornixAssess with intravaginal fingers in anterior fornix

• Determine position, or version, of uterusDetermine position, or version, of uterus

• In many women, uterus is anteverted; you palpate it at In many women, uterus is anteverted; you palpate it at level of pubis with cervix pointing posteriorlylevel of pubis with cervix pointing posteriorly

• Two other positions occur normally: midposition and Two other positions occur normally: midposition and retrovertedretroverted

• Palpate uterine wall with your fingers in fornicesPalpate uterine wall with your fingers in fornices Bounce uterus gently between your abdominal and Bounce uterus gently between your abdominal and

intravaginal handsintravaginal hands Normally, it feels firm and smooth, with contour of fundus Normally, it feels firm and smooth, with contour of fundus

rounded; it softens during pregnancy; it should be freely rounded; it softens during pregnancy; it should be freely movable and nontendermovable and nontender

Slide 26-79




AdnexaAdnexa Move both hands to right to explore adnexaMove both hands to right to explore adnexa

• Place abdominal hand on lower quadrant inside anterior Place abdominal hand on lower quadrant inside anterior iliac spine and place intravaginal fingers in lateral fornixiliac spine and place intravaginal fingers in lateral fornix

• Push abdominal hand in and try to capture ovaryPush abdominal hand in and try to capture ovary Often you cannot feel ovary; normally feels smooth, firm, Often you cannot feel ovary; normally feels smooth, firm,

almond shaped, and movable, sliding through fingersalmond shaped, and movable, sliding through fingers Fallopian tube is not palpable normally; no other mass or Fallopian tube is not palpable normally; no other mass or

pulsation should be feltpulsation should be felt Move to left to palpate other side Move to left to palpate other side Then, withdraw your hand and check secretions on fingers Then, withdraw your hand and check secretions on fingers

before discarding the glovebefore discarding the glove Normal secretions are clear or cloudy and odorlessNormal secretions are clear or cloudy and odorless

Slide 26-80




Adnexa (cont.)Adnexa (cont.) Note of cautionNote of caution

• Normal adnexal structures often are not palpableNormal adnexal structures often are not palpable

• Be careful not to mistake an abnormality for a normal Be careful not to mistake an abnormality for a normal structurestructure

• To be safe, consider abnormal, any mass that you To be safe, consider abnormal, any mass that you cannot positively identify, and refer woman for further cannot positively identify, and refer woman for further studystudy

Slide 26-81



Objective Data:Objective Data:Rectovaginal ExaminationRectovaginal Examination

Use this technique to assess rectovaginal Use this technique to assess rectovaginal septum, posterior uterine wall, cul-de-sac, septum, posterior uterine wall, cul-de-sac, and rectumand rectum Change gloves to avoid spreading any possible Change gloves to avoid spreading any possible

infection; lubricate first two fingersinfection; lubricate first two fingers Instruct woman this may feel uncomfortable and Instruct woman this may feel uncomfortable and

will mimic feeling of moving her bowelswill mimic feeling of moving her bowels Ask her to bear down as you insert your index Ask her to bear down as you insert your index

finger into vagina and your middle finger gently finger into vagina and your middle finger gently into rectuminto rectum

Slide 26-82



Objective Data:Objective Data:Rectovaginal ExaminationRectovaginal Examination (cont.)(cont.)

While pushing with abdominal hand, repeat While pushing with abdominal hand, repeat steps of bimanual examinationsteps of bimanual examination Keep intravaginal finger on cervix so intrarectal Keep intravaginal finger on cervix so intrarectal

finger does not mistake cervix for a massfinger does not mistake cervix for a mass• Rectovaginal septum should feel smooth, thin, firm, and Rectovaginal septum should feel smooth, thin, firm, and

pliablepliable

• Uterine wall and fundus feel firm and smoothUterine wall and fundus feel firm and smooth

• Rotate intrarectal finger to check rectal wall and anal Rotate intrarectal finger to check rectal wall and anal sphincter tonesphincter tone

• Check your gloved finger as you withdraw; test any Check your gloved finger as you withdraw; test any adherent stool for occult bloodadherent stool for occult blood

• Give woman tissues to wipe area; help her to sit upGive woman tissues to wipe area; help her to sit up

Slide 26-83



Objective Data:Objective Data:Developmental CompetenceDevelopmental Competence

Infants and childrenInfants and children PreparationPreparation

• Infant: place on examination tableInfant: place on examination table

• Toddler/preschooler: place on parent’s lapToddler/preschooler: place on parent’s lap Frog-leg position: hips flexed, soles of feet together and up Frog-leg position: hips flexed, soles of feet together and up

to bottomto bottom Preschool child may want to separate her own labiaPreschool child may want to separate her own labia No drapes: young girl wants to see what you are doingNo drapes: young girl wants to see what you are doing

• School-age child: place on examination table, frog-leg School-age child: place on examination table, frog-leg position, no drapesposition, no drapes

• During childhood routine screening limited to inspection During childhood routine screening limited to inspection of external genitalia to determine that (1) structures are of external genitalia to determine that (1) structures are intact, (2) vagina is present, and (3) hymen is patentintact, (2) vagina is present, and (3) hymen is patent

Slide 26-84




(cont.)(cont.) Infants and childrenInfants and children (cont.)(cont.)

NewbornNewborn• Genitalia somewhat engorgedGenitalia somewhat engorged

• Labia majora swollen, labia minora prominent and Labia majora swollen, labia minora prominent and protrude beyond labia majora; clitoris looks relatively protrude beyond labia majora; clitoris looks relatively large, and hymen appears thicklarge, and hymen appears thick

• Because of transient engorgement, vaginal opening Because of transient engorgement, vaginal opening more difficult to see now than it will be latermore difficult to see now than it will be later

• Place your thumbs on labia majora; push laterally while Place your thumbs on labia majora; push laterally while pushing perineum down, and try to note vaginal opening pushing perineum down, and try to note vaginal opening above hymenal ring; do not palpate clitoris as it is very above hymenal ring; do not palpate clitoris as it is very sensitivesensitive

Slide 26-85





Newborn (cont.)Newborn (cont.)• A sanguineous vaginal discharge or leukorrhea (mucoid A sanguineous vaginal discharge or leukorrhea (mucoid

discharge) normal during first few weeks due to maternal discharge) normal during first few weeks due to maternal estrogen effect; may also cause transient breast estrogen effect; may also cause transient breast engorgement and secretionengorgement and secretion

• During early weeks, genital engorgement resolves, and During early weeks, genital engorgement resolves, and labia minora atrophy and remain small until pubertylabia minora atrophy and remain small until puberty

• Between the ages of 2 months and 7 years, labia majora Between the ages of 2 months and 7 years, labia majora are flat, labia minora thin, clitoris relatively small, and are flat, labia minora thin, clitoris relatively small, and hymen is tissue-paper thinhymen is tissue-paper thin

• Normally, no irritation or foul-smelling discharge is Normally, no irritation or foul-smelling discharge is presentpresent

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School-age girlSchool-age girl• Around 7 to 10 years of age, the mons pubis thickens, Around 7 to 10 years of age, the mons pubis thickens,

labia majora thicken, and labia minora become slightly labia majora thicken, and labia minora become slightly roundedrounded

• Pubic hair appears beginning around age 11, although Pubic hair appears beginning around age 11, although sparse pubic hair may occur as early as age 8sparse pubic hair may occur as early as age 8

• Normally hymen is perforateNormally hymen is perforate

• Almost always in these age groups, an external Almost always in these age groups, an external examination will sufficeexamination will suffice

• If needed, an internal pelvic examination is best If needed, an internal pelvic examination is best performed by a pediatric gynecologist using specialized performed by a pediatric gynecologist using specialized instrumentsinstruments

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(cont.)(cont.) AdolescentAdolescent

Girl has special needs during genitalia Girl has special needs during genitalia examinationexamination• Examine her alone, without mother present Examine her alone, without mother present

• Assure her of privacy and confidentialityAssure her of privacy and confidentiality

• Allow plenty of time for health education and discussion Allow plenty of time for health education and discussion of pubertal progressof pubertal progress

Assess her growth velocity and menstrual history, Assess her growth velocity and menstrual history, and use SMR charts to teach breast and pubic and use SMR charts to teach breast and pubic hair developmenthair development• Assure her that increased vaginal fluid (physiologic Assure her that increased vaginal fluid (physiologic

leukorrhea) is normal because of estrogen effectleukorrhea) is normal because of estrogen effectSlide 26-88




(cont.)(cont.) Adolescent (cont.)Adolescent (cont.)

Perform pelvic examination Perform pelvic examination • When contraception is desiredWhen contraception is desired

• When girl’s sexual activity includes intercourseWhen girl’s sexual activity includes intercourse

• At age 18 in virginsAt age 18 in virgins

Start periodic Pap smears when intercourse Start periodic Pap smears when intercourse beginsbegins• Although techniques of examination are listed in adult Although techniques of examination are listed in adult

section, you will need to provide additional time and section, you will need to provide additional time and psychologic support for adolescent having her first pelvic psychologic support for adolescent having her first pelvic examinationexamination

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(cont.)(cont.) Adolescent (cont.)Adolescent (cont.)

First pelvic examination experience determines First pelvic examination experience determines how adolescent will approach future carehow adolescent will approach future care• Your accepting attitude and gentle, unhurried approach Your accepting attitude and gentle, unhurried approach

are important; you have unique teaching opportunity hereare important; you have unique teaching opportunity here

• Take time to teach, using girl’s own body as illustration Take time to teach, using girl’s own body as illustration

• Your frank discussion of anatomy and sexual behavior Your frank discussion of anatomy and sexual behavior communicates that these topics are acceptable to communicates that these topics are acceptable to discuss and not taboo with health care providersdiscuss and not taboo with health care providers

• This affirms girl’s self-conceptThis affirms girl’s self-concept

• During bimanual examination, note that adnexa are not During bimanual examination, note that adnexa are not palpable in adolescentpalpable in adolescent

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(cont.)(cont.) Pregnant womanPregnant woman

• Depending on week of gestation of pregnancy, Depending on week of gestation of pregnancy, inspection shows enlarging abdomen inspection shows enlarging abdomen

• Height of fundus ascends gradually as fetus Height of fundus ascends gradually as fetus growsgrows

16 weeks: fundus is palpable halfway between 16 weeks: fundus is palpable halfway between symphysis and umbilicussymphysis and umbilicus

20 weeks: fundus is at lower edge of umbilicus20 weeks: fundus is at lower edge of umbilicus 28 weeks: fundus is halfway between umbilicus and 28 weeks: fundus is halfway between umbilicus and

xiphoid xiphoid 34 to 36 weeks: fundus is almost to xiphoid 34 to 36 weeks: fundus is almost to xiphoid Near term, fundus drops as fetal head engages in pelvisNear term, fundus drops as fetal head engages in pelvis

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External genitalia show hyperemia of perineum External genitalia show hyperemia of perineum and vulva because of increased vascularityand vulva because of increased vascularity• Varicose veins may be visible in the labia or legs Varicose veins may be visible in the labia or legs

• Hemorrhoids may show around anusHemorrhoids may show around anus Both are caused by interruption in venous return from Both are caused by interruption in venous return from

pressure of fetuspressure of fetus

• Vaginal walls appear violet or blue (Chadwick’s sign) Vaginal walls appear violet or blue (Chadwick’s sign) because of hyperemiabecause of hyperemia

Walls are deeply rugated and vaginal mucosa thickensWalls are deeply rugated and vaginal mucosa thickens Cervix looks blue, feels velvety, and feels softer than in Cervix looks blue, feels velvety, and feels softer than in

nonpregnant state, making it a bit more difficult to nonpregnant state, making it a bit more difficult to differentiate from vaginal wallsdifferentiate from vaginal walls

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During bimanual examination, the isthmus of During bimanual examination, the isthmus of uterus feels softer and is more easily compressed uterus feels softer and is more easily compressed between your two hands (Hegar’s sign)between your two hands (Hegar’s sign)

Fundus balloons between your two hands; feels Fundus balloons between your two hands; feels connected to, but distinct from cervix because connected to, but distinct from cervix because isthmus is so softisthmus is so soft

Search adnexal area carefully during early Search adnexal area carefully during early pregnancy; normally, adnexal structures are not pregnancy; normally, adnexal structures are not palpablepalpable

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(cont.)(cont.) Aging womanAging woman To avoid painful examination, take care to lubricate To avoid painful examination, take care to lubricate

instruments and examining hand adequatelyinstruments and examining hand adequately• Use Pedersen speculum, rather than Graves, because its Use Pedersen speculum, rather than Graves, because its

narrower, flatter blades are more comfortable in women narrower, flatter blades are more comfortable in women with vaginal stenosis or drynesswith vaginal stenosis or dryness

• Menopause and resulting decrease in estrogen production Menopause and resulting decrease in estrogen production cause numerous physical changescause numerous physical changes

Pubic hair gradually decreases, becoming thin and sparse in Pubic hair gradually decreases, becoming thin and sparse in later years later years

• Skin is thinner and fat deposits decrease, leaving mons Skin is thinner and fat deposits decrease, leaving mons pubis smaller and labia flatterpubis smaller and labia flatter

• Clitoris size also decreases after age 60 yearsClitoris size also decreases after age 60 years

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Internally, rugae of vaginal walls decrease, and Internally, rugae of vaginal walls decrease, and walls look pale pink because of thinned epithelium walls look pale pink because of thinned epithelium • Cervix shrinks and looks pale and glisteningCervix shrinks and looks pale and glistening

May retract, appearing to be flush with vaginal wallMay retract, appearing to be flush with vaginal wall Sometimes hard to distinguish cervix from surrounding Sometimes hard to distinguish cervix from surrounding

vaginal mucosavaginal mucosa Alternately, cervix may protrude into vagina, if uterus has Alternately, cervix may protrude into vagina, if uterus has

prolapsedprolapsed

• With bimanual examination, you may need to insert only With bimanual examination, you may need to insert only one gloved finger if vaginal stenosis existsone gloved finger if vaginal stenosis exists

• Uterus feels smaller and firmer, and ovaries are not Uterus feels smaller and firmer, and ovaries are not palpable normallypalpable normally

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Older women may have special needs and will Older women may have special needs and will appreciate following plans of careappreciate following plans of care• For those with arthritis, taking a mild analgesic or anti-For those with arthritis, taking a mild analgesic or anti-

inflammatory before appointment may ease joint pain in inflammatory before appointment may ease joint pain in positioningpositioning

• Schedule appointment times when joint pain or stiffness Schedule appointment times when joint pain or stiffness is at its leastis at its least

• Allow extra time for positioning and “unpositioning” after Allow extra time for positioning and “unpositioning” after examination; be careful to maintain dignity and privacyexamination; be careful to maintain dignity and privacy

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Promoting a Healthy Lifestyle: Promoting a Healthy Lifestyle: New HPV VaccineNew HPV Vaccine

New vaccine to prevent cervical cancerNew vaccine to prevent cervical cancer Breakthrough in cancer preventionBreakthrough in cancer prevention

• In June, 2006, the Advisory Committee on Immunization In June, 2006, the Advisory Committee on Immunization Practices (ACIP) voted to recommend first vaccine Practices (ACIP) voted to recommend first vaccine developed to prevent cervical cancer developed to prevent cervical cancer

FDA licensed vaccine for girls and women ages 9 to 26FDA licensed vaccine for girls and women ages 9 to 26 One of most important advances in women’s health in One of most important advances in women’s health in

recent years recent years Vaccine targets human papillomavirus, HPV, responsible Vaccine targets human papillomavirus, HPV, responsible

for most cases of cervical cancerfor most cases of cervical cancer

• It is recommended for girls and women before they It is recommended for girls and women before they become sexually active because it is not effective if become sexually active because it is not effective if individual is already infected with HPVindividual is already infected with HPV

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Promoting a Healthy Lifestyle: Promoting a Healthy Lifestyle: New HPV VaccineNew HPV Vaccine (cont.)(cont.)

New vaccine to prevent cervical cancer (cont.)New vaccine to prevent cervical cancer (cont.) Human papillomavirus, or HPV, is a very common Human papillomavirus, or HPV, is a very common

sexually-transmitted virussexually-transmitted virus• Most people who have had sex, both men and women, Most people who have had sex, both men and women,

have been infected at some point in their liveshave been infected at some point in their lives

• Most people never even know they have HPV because Most people never even know they have HPV because virus usually does not cause any symptoms and body is virus usually does not cause any symptoms and body is able to fight it offable to fight it off

• However, sometimes virus lingers in a woman’s cervix However, sometimes virus lingers in a woman’s cervix and can cause changes that may eventually lead to and can cause changes that may eventually lead to cervical cancercervical cancer

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Promoting a Healthy Lifestyle: Promoting a Healthy Lifestyle: New HPV VaccineNew HPV Vaccine (cont.)(cont.)

New vaccine to prevent cervical cancer (cont.)New vaccine to prevent cervical cancer (cont.) Remind women that obtaining vaccine does not Remind women that obtaining vaccine does not

mean they can forget about routine pelvic mean they can forget about routine pelvic examinations and Pap tests examinations and Pap tests • Vaccine will protect against major types of HPV that Vaccine will protect against major types of HPV that

cause cervical cancer, but not all typescause cervical cancer, but not all types

• Pap tests detect cell changes in cervix before they turn Pap tests detect cell changes in cervix before they turn into cancer, at an early, curable stageinto cancer, at an early, curable stage

• Only other way to prevent HPV is to abstain from all Only other way to prevent HPV is to abstain from all sexual activitysexual activity

Condoms may not protect against HPV because areas not Condoms may not protect against HPV because areas not covered by condom can be exposed to viruscovered by condom can be exposed to virus

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Sample ChartingSample Charting

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Sample ChartingSample Charting (cont.)(cont.)

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Sample ChartingSample Charting (cont.)(cont.)

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Abnormal Findings:Abnormal Findings:Abnormalities of External GenitaliaAbnormalities of External Genitalia

Pediculosis pubis, crab licePediculosis pubis, crab lice Syphilitic chancreSyphilitic chancre Herpes simplex virus, type 2 herpes genitalisHerpes simplex virus, type 2 herpes genitalis Red rash, contact dermatitisRed rash, contact dermatitis Human papillomavirus, HPV wartsHuman papillomavirus, HPV warts UrethritisUrethritis Abscess of Bartholin’s glandAbscess of Bartholin’s gland Urethral caruncleUrethral caruncle

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Abnormal Findings:Abnormal Findings:Abnormalities of Pelvic MusculatureAbnormalities of Pelvic Musculature

CystoceleCystocele RectoceleRectocele Uterine prolapseUterine prolapse

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Abnormal Findings:Abnormal Findings:Abnormalities of CervixAbnormalities of Cervix

Bluish cervix, cyanosisBluish cervix, cyanosis ErosionErosion Human papillomavirus, HPV, condylomataHuman papillomavirus, HPV, condylomata PolypPolyp Diethylstilbestrol (DES) syndrome ErosionDiethylstilbestrol (DES) syndrome Erosion CarcinomaCarcinoma

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Abnormal Findings:Abnormal Findings:Vulvovaginal InflammationsVulvovaginal Inflammations

Atrophic vaginitisAtrophic vaginitis Candidiasis (moniliasis)Candidiasis (moniliasis) TrichomoniasisTrichomoniasis Bacterial VaginosisBacterial Vaginosis ChlamydiaChlamydia GonorrheaGonorrhea

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Abnormal Findings:Abnormal Findings:Uterine EnlargementUterine Enlargement

PregnancyPregnancy Myomas, leiomyomas, uterine fibroidsMyomas, leiomyomas, uterine fibroids Carcinoma of the endometriumCarcinoma of the endometrium EndometriosisEndometriosis

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Abnormal Findings:Abnormal Findings:Adnexal EnlargementAdnexal Enlargement

Fallopian tube mass, acute salpingitis, pelvic Fallopian tube mass, acute salpingitis, pelvic inflammatory disease (PID)inflammatory disease (PID)

Fallopian tube mass, ectopic pregnancyFallopian tube mass, ectopic pregnancy Fluctuant ovarian mass, ovarian cystFluctuant ovarian mass, ovarian cyst Solid ovarian mass, ovarian cancerSolid ovarian mass, ovarian cancer

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Abnormal Findings:Abnormal Findings:Abnormalities in Pediatric GenitaliaAbnormalities in Pediatric Genitalia

Ambiguous genitaliaAmbiguous genitalia Vulvovaginitis in childVulvovaginitis in child

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female genitourinary system

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