Health Assessment of Female and Male Genitalia

Specimen collection equipment

Items needed for collecting specimens, including drapes, speculum, gloves, water-soluble lubricant, sterile cotton swabs, glass slides, wooden or plastic spatula, cervical brush devices, cytologic fixative, and culture plates or media.

Lithotomy position

Positioning of the patient for examination with legs apart and supported.

Mons pubis inspection

Expected findings include smooth and clean skin; unexpected findings may include improper hygiene.

Pubic hair inspection

Expected findings include regularly distributed female pubic hair; unexpected findings may include nits or lice.

Labia majora inspection

Expected findings include gaping or closed, dry or moist, shriveled or full, soft and homogeneous tissue, usually symmetric; unexpected findings may include swelling, redness, tenderness, discoloration, varicosities, obvious stretching, or signs of trauma or scarring.

Labia minora inspection

Expected findings include moist, dark pink inner surface, soft and homogeneous tissue; unexpected findings may include tenderness, inflammation, irritation, excoriation, caking of discharge, discoloration, ulcers, vesicles, irregularities, or nodules.

Clitoris inspection

Expected length is 2 cm or less and diameter is 0.5 cm; unexpected findings may include enlargement, atrophy, inflammation, or adhesions.

Urethral meatus inspection

Expected findings include a slit or irregular opening close to or in vaginal introitus, usually midline; unexpected findings may include discharge, polyps, caruncles, fistulas, lesions, irritation, inflammation, or dilation.

Vaginal introitus inspection

Expected findings include a thin vertical slit or large orifice with irregular edges, moist tissue; unexpected findings may include swelling, discoloration, discharge, lesions, fistulas, or fissures.

Milk Skene glands

Expected findings include no discharge or tenderness; unexpected findings may include discharge or tenderness.

Bartholin glands palpation

Expected findings include no swelling; unexpected findings may include swelling, tenderness, masses, heat, fluctuation, or discharge.

Vaginal muscle tone test

Expected findings include fairly tight squeezing by some nulliparous women, less so by some multiparous women; unexpected findings may include protrusion of cervix or uterus.

Cervix location

Expected findings include midline cervix that may point horizontally, anteriorly, or posteriorly; unexpected findings may include deviation to right or left.

Bulging and urinary incontinence inspection

Expected findings include no bulging; unexpected findings may include bulging of anterior or posterior wall, or urinary incontinence.

Perineum palpation

Expected findings include smooth perineum surface, generally thick and smooth in a nulliparous woman, thinner and rigid in a multiparous woman.

Perineum surface

Smooth—generally thick and smooth in a nulliparous woman, thinner and rigid in a multiparous woman. Possible episiotomy scarring in women who have borne children.

Tenderness

Inflammation, fistulas, lesions, or growths.

Skin characteristics

Skin darkly pigmented and possibly coarse.

Scarring

Lesions, inflammation, fissures, lumps, skin tags, or excoriation.

Speculum examination

If you touched the perineum or anal skin while examining the external genitalia, change gloves before beginning internal examination.

Lubrication

Lubricate speculum and gloved fingers with water or water-soluble gel lubricant. Water is preferred if obtaining a Pap smear.

Speculum insertion

Insert speculum along path of least resistance, often slightly downward, avoiding trauma to urethra and vaginal walls.

Cervix color

Evenly distributed pink. Symmetric, circumscribed erythema around os can be expected.

Cervix position

In midline, horizontal or pointing anteriorly or posteriorly. Protruding into vagina 1 to 3 cm.

Cervix size

3 cm in diameter.

Cervix shape

Uniform.

Cervix surface characteristics

Surface smooth. Possible symmetric, reddened circle around os (squamocolumnar epithelium). Possible small, white, or yellow, raised round areas on cervix (nabothian cysts).

Discharge characteristics

Odorless, creamy or clear, thick, thin, or stringy (often heavier at midcycle or immediately before menstruation).

Size and shape of os

Nulliparous woman: Small, round, oval. Multiparous woman: Usually a horizontal slit or irregular and stellate.

Vaginal wall inspection

Vaginal wall color same pink as cervix or lighter; moist, smooth or rugated; and homogeneous.

Vaginal secretions

Thin, clear or cloudy, odorless secretions.

Unexpected cervix color

Bluish, pale, or reddened cervix (especially if patchy or with irregular borders).

Unexpected cervix position

Deviation to right or left. Protrusion into vagina greater than 1 to 3 cm.

Unexpected cervix size

Larger than 3 cm.

Unexpected cervix shape

Distorted.

Unexpected cervix surface characteristics

Friable tissue, red patchy areas, granular areas, or white patches.

Unexpected discharge characteristics

Odorous and white to yellow, green, or gray.

Unexpected size and shape of os

Slit resulting from trauma from induced abortion, difficult removal of intrauterine device (IUD), or sexual abuse.

Unexpected vaginal wall characteristics

Reddened patches, lesions, pallor, cracks, bleeding, nodules, swelling. Secretions that are profuse; thick, curdy, or frothy; gray, green, or yellow; or malodorous.

Vaginal Smears and Cultures

Vaginal specimens are obtained while the speculum is in place in the vagina but after the cervix and its surrounding tissue have been inspected.

Papanicolaou (Pap) smear

A test for cervical cancer that involves collecting cells from the cervix.

Standard precautions

Guidelines to prevent the transmission of infections during the collection of human secretions.

Palpate vaginal wall

To feel the vaginal wall while inserting fingers into the vagina.

Expected findings of vaginal wall palpation

Smooth and homogeneous.

Unexpected findings of vaginal wall palpation

Tenderness, lesions, cysts, nodules, masses, or growths.

Palpate cervix

Locate cervix with palmar surface of fingers, feel end, and run fingers around circumference to feel fornices.

Expected size, shape, length of cervix

Consistent with speculum examination.

Expected consistency of cervix

Firm in nonpregnant woman; softer in pregnant woman.

Unexpected consistency of cervix

Nodules, hardness, or roughness.

Expected position of cervix

In midline horizontal or pointing anteriorly or posteriorly, protruding into vagina 1 to 3 cm.

Unexpected position of cervix

Deviation to right or left, protrusion into vagina greater than 1 to 3 cm.

Mobility of cervix

Grasp cervix gently between fingers and move from side to side.

Expected mobility of cervix

1 to 2 cm movement in each direction, minimal discomfort.

Unexpected mobility of cervix

Pain on movement ('cervical motion tenderness').

Palpate uterus

Place palmar surface of outside hand on abdominal midline, halfway between umbilicus and symphysis pubis, and place intravaginal fingers in anterior fornix.

Expected location and position of uterus

In midline, horizontal, or pointing anteriorly or posteriorly, protruding into vagina 1 to 3 cm.

Unexpected location and position of uterus

Deviation to right or left, protrusion into vagina greater than 1 to 3 cm.

Size, shape, contour of uterus

Expected: Pear-shaped and 5.5 to 8 cm long (larger in all dimensions in multiparous women), contour rounded and, in nonpregnant women, walls firm and smooth.

Unexpected size, shape, contour of uterus

Larger than expected or interrupted contour or smoothness.

Mobility of uterus

Expected: Mobile in anteroposterior plane.

Unexpected mobility of uterus

Fixed uterus or tenderness on movement.

Palpate ovaries

Place fingers of outside hand on lower right quadrant. With intravaginal hand facing up, place both fingers in right lateral fornix.

Palpate ovaries

If palpable, ovaries should feel firm, smooth, slightly to moderately tender.

Palpate ovaries - Unexpected findings

Marked tenderness or nodularity. Palpable fallopian tubes.

Ovaries size

About 3 × 2 × 1 cm.

Ovaries size - Unexpected findings

Enlargement.

Ovaries shape

Ovoid.

Palpate adnexal areas

Adnexa difficult to palpate.

Palpate adnexal areas - Unexpected findings

Masses and tenderness. If adnexal masses are found, characterize by size, shape, location, consistency, tenderness.

Internal genitalia - Rectovaginal examination

This examination may be uncomfortable for the patient.

Assess sphincter tone

Even sphincter tightening.

Assess sphincter tone - Unexpected findings

Extremely tight, lax, or absent sphincter.

Palpate anterior rectal wall

Smooth and uninterrupted.

Palpate anterior rectal wall - Unexpected findings

Masses, polyps, nodules, strictures, irregularities, tenderness.

Palpate posterior aspect of uterus

Consistent with bimanual examination regarding location, position, size, shape, contour.

Palpate posterior aspect of uterus - Unexpected findings

Tenderness.

Palpate posterior rectal wall

Smooth and uninterrupted.

Palpate posterior rectal wall - Unexpected findings

Masses, polyps, nodules, strictures, irregularities, tenderness.

Note characteristics of feces

Light to dark brown.

Note characteristics of feces - Unexpected findings

Blood.

Premenstrual syndrome (PMS)

Symptoms occur 5 to 7 days before menses (luteal phase) and subside with onset of menses.

Endometriosis

Diagnosis confirmed by laparoscopy.

Condylomata acuminata (genital warts)

Flesh-colored, whitish pink to reddish brown, discrete, soft growths on labia, vestibule or perianal area.

Genital herpes

Small, red vesicles in genital area.

Vaginal infections

Subjective Data: Vaginal discharge, possibly accompanied by urinary symptoms. Sometimes asymptomatic.

Cervical carcinoma

Subjective Data: Often asymptomatic; sometimes vaginal bleeding. Objective Data: Hard granular surface at or near cervical os. Lesion can evolve to form extensive, irregular, easily bleeding cauliflower growth. Precancerous and early cancer changes detected by Pap smear, not by physical examination.

Uterine bleeding

Associated with various conditions including cervical carcinoma and pelvic inflammatory disease.

Pelvic inflammatory disease (PID)

Subjective Data: Painful intercourse, painful urination, irregular menstrual bleeding, pain in the right upper abdomen. Objective Data: Acute PID: Very tender bilateral adnexal areas. Chronic PID: Bilateral tender, irregular, fairly fixed adnexal areas.

Ovarian cancer

Subjective Data: Persistent and unexplained vague gastrointestinal symptoms such as generalized abdominal discomfort and/or pain, gas, indigestion, pressure, swelling, bloating, cramps or feeling of fullness even after a light meal. Objective Data: May have no physical findings; on bimanual examination an enlarged ovary in premenopausal woman or a palpable ovary in postmenopausal women.

Midcycle spotting

Common Causes: Midcycle estradiol fluctuation associated with ovulation.

Delayed menstruation

Common Causes: Anovulation or threatened abortion with excessive bleeding.

Frequent bleeding

Common Causes: Chronic pelvic inflammatory disease, endometriosis, dysfunctional uterine bleeding (DUB), anovulation.

Profuse menstrual bleeding

Common Causes: Endometrial polyps, DUB, adenomyosis, submucous leiomyomas, intrauterine device.

Intermenstrual or irregular bleeding

Common Causes: Endometrial polyps, DUB, uterine or cervical cancer, oral contraceptives.

Postmenopausal bleeding

Common Causes: Endometrial hyperplasia, estrogen therapy, endometrial cancer.

Pediatric Variations

Examination techniques and expected findings in infants and children regarding genitalia.

Inspect external genitalia

Examine infant using the frog-leg position. EXPECTED: Genitalia of newborn reflect influence of maternal hormones. Labia majora and minora may be swollen, with labia minora often more prominent.

Inspect clitoris

EXPECTED: The clitoris of a term infant is usually covered by labia minora and may appear relatively large.

Inspect urethral meatus and vaginal opening

Inspect for discharge in infants and children. EXPECTED: Mucoid whitish discharge is frequently seen during newborn period and sometimes as late as 4 weeks after birth. Discharge may be mixed with blood.

Unexpected discharge in children

UNEXPECTED: Mucoid discharge from irritation by diapers or powder; any discharge in children.