GU female practical

Part 1: Inspection

Start with history questions “Have you noticed any recent changes in urination, defecation, sexual function, or your menstrual cycle?” Explain we start exam with 3 layers of gloves on dominant hand and 1 on non-dominant hand. Patient should be gowned and draped and lying supine. Inspect pubic hair pattern then underneath for lice, nits, rashes, or lesions. Palpate inguinal lymph nodes for size, tenderness and mobility, Inspect orifices and genital area for lesions, inflammation, fissures, fistulas.

Inspect urethral meatus by inserting index finger slightly into vagina and moving it up to separate labia, urethra should be a slit-like opening ~0.5 inch below clitoris. Ask patient to bear down and look for any redness or swelling at meatus (if present indicative of STD/UTI infection) & leakage of urine to assess urinary incontinence.

‘Milk’ skene’s glands just lateral to meatus by gently squeezing them between index finger and thumb. Palpate labia majora and minora downward then palpate Bartholin glands at posterior-lateral aspect of vaginal entroitus. Palpate perineum last and discard 1st glove on dominant hand.

Part 2: Speculum exam (4 main parts- 2 visualizations & 2 samples)

Warm speculum by running it under warm water (no lubricant used). Inform patient you’ll be inserting speculum and make sure blades are fully closed. Place 2 fingers of non-dominant hand at base of vaginal entroitus to protect perineum from sharp speculum blades. Insert speculum at 45º angle posteriorly toward sacrum (only insert halfway so you don’t hit cervix). Slide bottom of speculum up and tighten into place, then open blades up and insert speculum slightly deeper, just enough to position 1 blade above cervix and the other below, and tighten into place.

Visualize cervix for color, position, surface lesions, discharge, size, and shape of os and vaginal walls for lesions, secretions, etc. Cervix can range from very light pink (anemic) to dark purple (dark skin, asian). Visualize vaginal walls for any lesions or asymmetry. Correctly identify normal vs pathological cervix presented.

Take 2 cervical samples for “Pap smear”- 1st is 360º cell sample taken with cervical broom (put into solution) or wooden spatula (put on slide), 2nd is a vaginal secretion taken with swab (put on slide). Remove speculum by pulling until blades have cleared cervix, loosening both screws holding it open until blades close together, and withdraw from vagina without turning it. Take an additional swab of vaginal secretion from bill of speculum and add it to other sample. Remove glove from non-dominant hand.

Part 3: Bimanual exam (4 parts- 2 internal palpations, 2 abdominal palpations)

Let patient know and insert 2 lubricated fingers (of gloved dominant hand) into vagina at 45º angle back toward sacrum and ungloved hand on abdomen. Palpate vaginal walls for smoothness, tenderness, and lesions. Palpate cervix for size, shape, length, position, mobility, and tenderness. Move cervix back and forth between 2 fingers- if patient grimaces or reports pain suspect pelvic inflammatory disease or endometriosis. Put 1 finger inside os and 1 below cervix and push cervix in & up to help make uterus palpable through abdomen. Using non-dominant (ungloved) hand palpate uterus and ovaries on abdomen (just superior to symphysis pubis) noting size and shape and noting any pain upon palpation. Fallopian tubes not normally palpable unless condition like salpingitis or epic pregnancy is present. Remove 2nd glove off dominant hand.

Part 4: Recto-vaginal exam (4 parts- sphincter, septum, posterior, walls)

Inspect rectum for any pathologies, lubricate index & middle fingers and let patient know you’ll be inserting 1 finger into vagina and 1 into rectum. Have patient bear down while you insert lubricated index finger into vagina and middle finger into rectum.

4 main parts= 1st have patient squeeze around finger to assess anal sphincter tone. 2nd Squeeze finger together to assess recto-vaginal septum. 3rd palpate more deeply up through rectum with middle finger to feel posterior aspect of cervix and uterus. 4th remove index finger from vagina and palpate rectal walls 360º, have patient bear down and remove finger then smear it on GUIAC test kit.