Female Genitourinary Examination

Indications for a female genitourinary exam

- pelvic complaint

- newborn examination

- sexually active patients (pelvic complaints)

- annual gynecological examination (pap smears)

- SANE (Sexual Assault Nurse Exam)

What is often performed at the same time as a genitourinary exam?

examination of the anus and rectum

What are the components of the external female genitalia?

vulva & perineum

What makes up the vulva?

- mons pubis

- labia majora

- labia minora

- vestibule

- urethral meatus

- prepuce

- hymen

- introitus

Where are Skene's glands located?

posterior and adjacent to the urethral meatus

Where are Bartholin glands located?

posteriorly on both sides of the vaginal introitus (typically not visible or palpable)

What makes up the internal female genitalia?

vagina, uterus, adnexa

What are the transverse folds of the vaginal walls called?

rugae

What are the parts of the uterus?

- fundus

- cervix

What does the cervix form as it protrudes into the vagina?

anterior/posterior/lateral fornices

What makes up the adnexa?

- fallopian tubes

- ovaries

- supporting tissue

What is the view seen with the speculum?

ectocervix

What is the external os?

opening

What will the external os look like in a multiparous patient?

slit like

What will the external os look like in a nulliparous patient?

round

What type of epithelium makes up the cervix?

columnar epithelium centrally and squamous epithelium surrounding

What is the transformation zone?

squamocolumnar junction; area at greatest risk for dysplasia

Is a fallopian tube generally palpable?

No; it is generally non-palpable

What size and shape is the average ovary?

3.5 x 2 x 1.5 cm; almond-shaped

Is an ovary generally palpable?

Palpable in about 1/2 of women during reproductive years

What is the pelvic floor?

sling of muscles, ligaments, and fascia creates the pelvic floor to support pelvic organs

At what age does menstruation generally begin?

between 9-16 yo in the US (median 12-13)

What is the typical interval for a cycle and flow?

Intervals range from 24-32 days; flow lasts from 3-7 days

What should you ask a patient about in the HPI?

age of menarche and last menstrual period

What age does menopause typically occur between?

48-55 yo

What might menopause be associated with prior to onset?

hot flashes, flushing, and sweating

What is a concerning finding in the HPI of a postmenopausal woman?

postmenopausal bleeding

What information should you obtain about abnormal bleeding?

- characteristics (how heavy is the flow? how many pads/tampons are being used?)

- change in flow?

- associated symptoms? pain/discharge?

- medications

What information should you obtain about vaginal discharge?

- characteristics of discharge

- occurrence

- douching/clothing habits

- presence of discharge or symptoms in sexual partner

- STD prophylaxis

- associated symptoms

- efforts to treat

- medications: oral contraceptives, antibiotics

What is infertility?

Inability to conceive after one year or longer of unprotected intercourse

What factors may influence infertility?

- length of time attempting pregnancy, sexual activity pattern, knowledge of fertile period in menstrual cycle, length of cycle

- partner factors (40-50% may be due to male factors)

- abnormalities of the vagina, cervix, uterus, fallopian tubes, ovaries

- contributing factors: stress, nutrition, chemical substances

- diagnostic evaluation to date

What are common urinary symptoms?

- dysuria

- burning on urination

- frequency

- urgency

What information should you obtain for someone with urinary symptoms?

- characteristics of the urine

- associated symptoms: flank pain, fever

- medications: urinary tract analgesics, antispasmodics

What PMHx should you obtain about obstetric history?

- gravidity

- term pregnancies

- preterm pregnancies

- abortions: spontaneous or induced

- living children

- complications of pregnancy, delivery, abortion, or with fetus or neonate

- blood type

What PMHx should you obtain about gynecologic history?

- prior pap smears, human papillomavirus (HPV) testing and results

- past and recent gynecologic procedures or surgery

- sexually transmitted infections (STIs)

- pelvic inflammatory disease

- vaginal infections

- diabetes

- cancer of reproductive organs

What family history is relevant to the female GU exam?

- diabetes

- cancer of reproductive organs (25% of ovarian cancers)

- mother received diethylstilbestrol (DES) while pregnant

- congenital anomalies

What is the effect of diethylstilbestrol (DES) use while pregnant?

Increases risk for clear cell adenocarcinoma (vaginal and cervical cancer)

What is important to obtain about contraceptive history?

current method & previous methods

What is important to obtain about sexual history?

- current sexual activity

- barrier protection

- prior STIs

- partner testing for STIs

- satisfaction with relationship

- sexual dysfunction

- sexual assault or abuse

What other information should be obtained about sexual history?

- date of last pelvic examination

- use of illicit drugs

Describe the 2025 cervical cancer statistics.

- 13,360 new cases of invasive cervical cancer will be diagnosed

- 4,320 people will die from cervical cancer

Which HPV types are associated with cervical cancer?

16 and 18

What are the cervical cancer risk factors?

- failure to undergo screening (1/2 of women diagnosed with cervical CA)

- multiple sex partners

- smoking, immunosuppression, long-term use of contraception, coinfection with Chlamydia, parity, prior cervical cancer, family history

What age should you begin pap smear screening?

age 21

Describe the recommendations for Pap smear screening.

21-29 = cervical cytology every three years

30-65 = 3 year cervical cytology, 5-year high-risk HPV testing alone, 5 year co-testing (cytology and hrHPV testing)

In terms of pap smear screening, what does the USPSTF recommend against?

- screening in people under 21

- screening in hysterectomy with removal of the cervix with no CIN or cervical CA history

- screening in people over 65

What patient population should receive the HPV vaccine?

all patients aged 11 or 12, before their first sexual encounter, preferably (can begin the series as early as 9 years of age)

Do patients who have been vaccinated still require screening?

yes

What is the recommendation for GC/Chlamydia screening?

Annually for all sexually active women < 25 and older women with risk factors

What STIs should pregnant women be screened for?

chlamydia, syphilis, hepatitis B, and HIV for all pregnant women & gonorrhea for higher risk, repeat testing as needed throughout the pregnancy

What is the recommendation for HIV testing?

once for all adults/adolescents (13-64 yo)

What are tips for a successful exam of the female genitalia?

- Obtain permission

- Explain each step of the examination in advance - allow them to be involved

- Drape the patient from the abdomen to the knees, depress the drape between knees to provide eye contact with patient

- Avoid sudden movement

- Choose a speculum of appropriate size

- Warm the speculum with tap water or lubricant

- Monitor the comfort of the examination by watching the patient's face

- Use gentle insertion of the speculum

- Allow patient to empty their bladder prior to exam

- Use a chaperone

- Use intentional touch

- Avoid language like "looks great", "perfect"- try "healthy and normal"

How should you position the patient for the exam?

- assist the patient into the lithotomy position on the examination table

- help stabilize the feet in the stirrups and slide the buttocks down to the edge of the examination table

Describe the correct draping and gloving technique.

- drape in such a way that minimizes exposure

- cover knees and symphysis, dressing the drape between knees (allows you to see the person's face for comfort and them yours)

- equipment nearby and set up

- ensure proper lighting

- wash your hands and put gloves on both hands

What should you examine the labia majora for?

- symmetry

- redness, swelling, or tenderness

- excoriation, rashes, or lesions

- trauma or scarring

What should you examine the labia minora for?

- symmetry

- moisture

- color

- soft, homogeneous, and without tenderness

What should you examine the clitoris for?

- size

- atrophy

- adhesions or inflammation

- female genital mutiliation/cutting

What should you examine the urethral orifice for?

- discharge

- polyps, carbuncles, or fistulae

- irritation or inflammation

What should you examine the vaginal introitus for?

- moisture

- swelling

- discoloration/discharge

- lesions, fistulae, or fissures

- trauma

What should you examine the Skene glands for?

- periurethral location

- assess for discharge

What should you examine the Bartholin glands for?

- posterolateral portion of the labia majora

- discharge

- masses

- tenderness or swelling

Techniques for the speculum exam

- Ensure the perineum is relaxed to allow for insertion of the speculum using the index finger at the introitus, pushing down gently.

- Use dominant hand to insert the speculum. The speculum should be inserted at an angle and gently in the introitus aiming towards the posterior aspect with the speculum closed.

- Rotate the speculum horizontally and gently open it as the speculum is fully inserted. Observe the view of the cervix

between the blades.

- If unable to see the cervix, close the speculum and reposition the blades to locate the cervix.

What should you do once the cervix is visualized?

inspect the cervix and the os; note the color, position, and characteristics of the cervix

What is normal color of the cervix?

pink and even

What is normal position of the cervix?

midline (ant/post), projects 1-3 cm into the vagina

What is normal size of the cervix?

2.5 cm in diameter

What does a normal os look like?

small round (nulliparous) or slit-like (multiparous)

What do normal secretions look like?

clear/thin, stringy, odorless, nonirritating

What else should you look for and note during exam of the cervix?

- look for discahrge or bleeding from the os, open vs closed

- note any ulcerations, massess, or nodules on the cervix

What might chandelier sign/cervical motion tenderness be indicative of?

PID

When should you avoid a pap smear?

- avoid during menstruation

- avoid during intercourse, tampons, creams, foams, douches, suppositories within 48 hours prior

What samples should you obtain during the examination?

obtain one specimen from the endocervix, and one from the ectocervix, or a combination specimen using the cervical brush "broom"

What additional samples can you obtain/tests can you perform?

- gonococcal culture or DNA probe (gonorrhea and chlamydia)

- wet mount (trichomonas, bacterial vaginosis, or candidiasis)

What should you do as the speculum is being withdrawn?

Assess the walls of the vaginal vault for lesions or bulging

What should you do before withdrawing the speculum?

Slightly open the speculum to avoid clamping the cervix

How should you maneuver the speculum while withdrawing?

blades of the speculum should slowly close upon withdrawal and be fully closed as they exit the introitus; if blades are open, it can cause lacerations to the vaginal wall or urethral meatus

How do you perform a bimanual exam?

- provider will stand at the end of the table

- use index and third finger, lubricated, to insert into the introitus

- make sure the 4th and 5th digits are flexed against your palm and that your thumb is away from the patient's genitalia

- palpate the vaginal walls, feeling for any irregularities (note that the vaginal walls have rugae and will feel "bumpy")

- evaluate cervix and fornices

What characteristics of the cervix should you note on a bimanual exam?

- size, length, and shape (should be evenly rounded)

- position (palpate all fornices)

- consistency (smooth and firm)

- movement (move with inserted fingers; should be painless)

How do you feel the fundus on a bimanual exam?

- with the dominant hand in the vaginal vault, use the non-dominant hand along the lower abdomen

- elevate the cervix with the dominant hand internally

- palpate along the midline of the lower pelvis to evaluate the fundus

- feel its size, shape, consistency, mobility, and tenderness (easier in thin patients)

What might a retroverted uterus feel like?

may internally feel the uterus against fingers along the posterior fornix

How do you feel the ovaries and adnexa on a bimanual exam?

- internal dominant hand will move towards the right and left fornix

- at the same time, the non-dominant hand will palpate in the left and right lower pelvic region

- identify the size, shape, consistency, mobility, and tenderness of each adnexal area on internal exam

How can you assess the strength of the pelvic floor?

ask the patient to bear down

What are the purposes of the rectovaginal exam?

- palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa

- screen for colorectal cancer

- assess pelvic pathology

How do you perform a rectovaginal exam?

- glove the dominant hand and lubricate the index finger

- place the index finger of the dominant hand inside the vagina, place the middle finger within the anus; ask the patient to bear down so that the anal sphincter will relax

What are techniques for ending the exam?

- provide patient with wipes to clean off excess lubricant with gauze or tissue

- allow patient to clean self and get dressed

- help them off the stirrups

- always ask the patient to get dressed before discussing any findings

True or False: Hernias are less common in female patients than in male patients.

True, but they can still experience hernias in the groin

How should you assess for a hernia?

- ask the patient to stand and evaluate for bulging in the inguinal region with valsalva

- palpate the labia majora just upward and lateral to the pubic tubercles

How can you assess for urethritis?

Milk skene's or paraurethral glands by inserting finger into the introitus and milking the urethra superiorly with the internal digit - may test discharge

What should a physical exam in a transgender patient be relevant to?

the anatomy that is present

Techniques of the exam in transgender patients.

- use gender affirming care

- only examine body parts that pertain to the specific visit

What are the STI guidelines?

risk assessment based on anatomy, sexual behaviors, and symptoms

- self-collection (gonorrhea, chlamydia, and trichomonas similar S&S to provider-collected)

- newly FDA-approved self-collection HPV testing

What might hormone therapy cause in transgender men?

facial/body hair, clitoromegaly, increased muscle mass, androgenic alopecia, acne

Considerations for a pelvic exam in transgender men.

- may be traumatic or anxiety-inducing

- transgender men are less likely to be up-to-date on cervical cancer screenings

- pap testing - clearly indicate cervical sampling to avoid confusion with male gender on patient chart; identify if they are amenorrheic or using testosterone for lab

- if uterus and fallopian tubes remain - consider PID in DDx

- testosterone can cause vaginal atrophy - use of lubricant and smaller speculum may be appropriate

- allow for self-collection for vaginal discharge and PAP testing (newly FDA approved)

Post-surgery considerations in transgender men.

- some men retain patent vaginas after metoidioplasty; continue with risk assessment and testing based on Hx

- often associated with hysterectomy and oophorectomy

What might hormone therapy cause in transgender women?

breast development that is often underdeveloped, feminine fat redistribution, reduced muscle mass, thinned or absent facial/body hair, testicles that have decreased in size or retracted

What might you see on vaginal exam post-vaginoplasty?

blind cuff without cervix or fornices

Considerations for a pelvic exam post-vaginoplasty in transgender women.

- anoscope may be more appropriate for exam

- cervical HPV testing not necessary (no cervix)

- testing when clinical symptoms indicate need (typically urinary screening/testing is often appropriate)

- retained prostate tissue (consider prostatitis in DDx when appropriate)

What does estrogen stimulate at puberty?

development of secondary sexual characteristics

When does breast and pubic hair development begin?

8-10 years old

What is Tanner staging?

sexual maturity rating (based on Caucasian females)