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who gets pelvic exam
all women 21+, unless you have an OB or GYN problem-specific complaint
<21 years old, inspect lesions but do not perform internal
what does the pelvic exam look at
size, position of vagina, cervix, uterus, and ovaries
when do you get a pelvic exam
annually over 21 (regardless of sexual activity)
during pregnancy
suspect infection
women with pain in her pelvic or low back area
why do you do a pelvic exam
diagnosis pathology such as pregnancy, infection or cancer
Mons pubis
fat pad over pubic symphysis
Labia majora
rounded folds of adipose tissue
labia minora
thinnner, pinkish red folds that extend anteriorly to form prepuce
vestibule
boat-shaped fossa btw labia minora
introitus
vaginal opening
perineum
tissue btw introitus and anus
urethral meatus
open into vestibule btw clitoris and vagina
paraurethral (skenes) glans
posterior to the urethral meatus on either side
lubrication during sexual activity
Bartholins glands
located posteriorly on either side of vaginal opening
normal secretion for lubrication
vagina
musculomembranous tube extending upward and posteriorly btw urethra and rectum
uterus
flattened fibromuscular structure shaped like inverted pear
cervix
lower part of the uterus (extend into vagina)
Adnexa
refer to ovaries, fallopian tubes and supporting tissues
where is the clitoris found
between the prepuce
size of ovaries
3.5 cm
when are ovaries palpable
only in childbearing age
shrink after menopause due to increase in hormones→ if felt may indicate cancer
ectoervix
outer surface, squamous epithelium surround the os
transformation zone
squamocolumbar junction migrates toward os as patient ages
where is cervix located
top of vaginal canal
where is pap smear sampled from
transformation zone
describe cervix during puberty
broad band of deep red columnar epithelium around os is replaced by squamous epithelium
why do you look at cervical os when doing an exam
slit like indicate pregnancy
average age of menarche
12.5
normal cycle length
21-35 days
average 28 days
why is menarche before average age concerning
increased exposure to hormones = increased risk for endometrial or breast cancer
typical length of menses
3-7 days
why is long menses (7+ days) of concern?
risk of anemia (same with heavy flow)
dyspareunia
pain with intercourse
how to classify heavy, light, moderate flow?
number of tampons per hour
amenorrhea
absence of menses
no menarche by 15 yo (primary) or >3 missed menstrual periods (secondary)
PMS
emotion, behavioral and physical sx occurring 5 days before menses for 3 consecutive days
menopause
12 mo without menses
premenopausal
intermittent menses
premature ovarian failure
menopause < 40 yo
post menopausal bleeding
bleeding >6 mo or more after cessation of menses
polymenorrhea
cycle last <21 days
oligomenorrhea
infrequent bleeding
menorrhagia
abnormally heavy menstrual bleeding
metrorrhagia
uterine bleeding at irregular intervals
postcoital bleeding
bleeding after intercourse
Gravida
total # of pregnancies
Para
outcome of pregnancies
GP (FPAL)
full term
premature
abortions
living children
what is considered premature
under 37 weeks but over 20
20-36 weeks
what is considered a full term pregnancy
37 weeks
what is considered abortion
under 20 weeks
acute pelvic pain is considered? chronic
< 6 mo
at least 6 mo
DES exposure if likely if pt born before
1971
may be at risk for vaginal or cervical cancer due to exposure
myomectomy
removal of fibroids (benign)
common surgeries
hysterectomy
partial or complete
Ovarian cystectomy
C section
Myomectomy
A 34 yo female present today for her first pre-natal visit. She tells you that she has 1 living child that was preemie. She had 2 elective abortions when she was 17, 1 miscarriage, 1 full term child that passed away at 6 mo due to SID. What are her G and P
G6 P(F1 P1 A2 L1)
patients should have nothing in the vagina for …. hours prior to a pelvic exam
48 hours
no sexual activity, tampons, douching
T/F you should no void prior to exam
F- you should void
pressing on bladder can be uncomfortable
position of pelvic exam
dorsal lithotomy
bimanual exam palpation
used to check a woman's internal pelvic organs
inserts two fingers into the vagina and then places pressure with the other hand to the lower part of the belly
tanner stage 1 (typically prior to age 11)
elevation of nipple only
no pubic hair, only fine hair
tanner stage 2 (typically age 11-12)
breast bud stage. Elevation of breast and nipple as small bud
sparse pubic hair, mostly along labia
tanner stage 3 (typically age 12-13)
further elevation of breast and areola with no separation of their contour
pubic hair become darker, coarser, curlier
tanner stage 4 (typically 13-14)
projection of areola and nipple to form a secondary moud
almost adult like, but pubic hair does not cover medial thigh
tanner stage 5 (14-15)
mature breast, projection of nipple, but areola receded to general contour
adult quality and quantity of hair, extending to thigh
inspect external genitalia
mons pubis
vulva
vaginal introitus
clitoris / urethral meatus
perineum
T/F hymnal ring break with pregnancy, intercourse, tampons
F- stretches, it doesnt break
risk factors of vulvar carcinoma
HPV and DES exposure
anatomic variation of normal hymen
vulvar carcinoma
cancer of labia and genital skin
Bartholin cyst
usually 4 and 8 oclock
need drainage
Condyloma Accuminata (HPV)
genital region and anus
difficult to treat
M and F
Syphilitic chancre
1st sign of syphilis
NOT painful
indurated red base
same in M and F
Genital herpes
itchy, burning and tingling (may occur before lesion even appear)
2 types
I- cold sores
II- genital
only distinguish with culture
Pubic lice
Different speculums
Pederson or Graves
Metal or plastic
Small, medium and large
what you need for internal pelvic exam
speculum
culture supplies
pap smear: scrap, brush, broom
water based lubricant / gloves
good lighting
regular culture screening should be done on individuals who are…
under 25 and sexually active → over 25+ dont need culture unless abnormality
screen for chlamydia
pederson or graves
pederson: long and skinner
Graves: shorter and wider
what angle do you hold speculum at when youre inserting for a pelvic exam
45 degree downward slope
yellow-green d/c indicative of
STI
red d/c indicative of
menstruation, cervical infection, cervical polyps, endometrial or cervical cancer
pink d/c indicative of
cervical bleeding, vaginal irritation, implantation bleeding
grey d/c indicative of
BV
