Hanuman ibio

Goal:  After learning the prescribed information, learning the prescribed breast and pelvic exams and practicing them frequently, the student should be able to identify and describe pathology associated with GYN system in any given patient.

            For this section, I would recommend reviewing Bates, pp333-339

See Breast Exam Focus Sheet, page G-8.

Deb/  See syllabus, and this should be covered in more detail in lecture 

Note: C50.6 is the code for axillary tail or tail of breast.

            An Axillary tail of breast tissue extends towards the anterior Axillary fold. Alternatively, findings can be localized as the “time” on the face of a clock.

The 4 quadrants are defined by horizontal and vertical lines crossing at the nipple.

      Upper outer quadrant (includes the axillary tail of breast tissue)

      Upper inner quadrant

      Lower inner quadrant

Lower outer quadrant

Deb/Bates, pg. 298

             Upper outer quadrant (towards armpit), upper inner quadrant, Lower outer quadrant (towards armpit), lower inner quadrant/ tail of breast tissue is up towards armpit, extending upfrom upper outer quad. Toward armpit

To describe clinical findings, the breast is often divided into four quadrants based on horizontal and vertical lines crossing at the nipple. An axillary tail of breast tissue extends toward the anterior axillary fold.

            According to the lecturer from a previous in class, the upper outer quadrant and the tail of the breast are where most lumps are found.

      Upper outer quadrant

Deb/Bates, pg. ??  couldn’t find in Bates or Swartz 

The “tail” of the breast extends into the axilla and  tends to be thicker than the other breast areas. This upper outer quadrant contains the greater bulk of mammary tissue and is frequently the site of neoplasia.

Stage one:        Preadolescent. Elevation of nipple only

Stage two:        Breast bud stage. Elevation of breast and nipple as a small mound; enlargement. of areolar diameter.

Stage three:      Further enlargement of elevation of breast and areola, with no separation of their contours.

Stage four:        Projection of areola and nipple to form a secondary mound above the level of breast.

Stage five:         Mature stage; projection of nipple only. Areola has receded to general contour of the breast (although in some normal individuals the areola continues to form a secondary mound).

Anonymous  See Bates p. 336 for drawings

      The five stages of breast development as defined by Tanner’s sex maturity ratings (SMR) are (in summary):

      Stage 1:  Preadolescent; elevation of nipple only.

      Stage 2:  Breast bud stage; elevation of breast and nipple as small mound.

      Stage 3:  Further elevation of breast and areola, with no separation of their contours.

      Stage 4:  Projection of areola and nipple to form a secondary mound above the breast.

      Stage 5.  Mature stage; projection of nipple only (not areola) above breast.

Deb Swartz,pg. 408-409

             At birth, elevation of only nipple at this stage, after 5-7days, secretory activity of infant breast stops/ before puberty, theres elevation of breast and nipple  “breast bud” stage. At onset of puberty, areola enlarges further and darkens in color, a distinct mass of glandular tissue begins to develop beneath areola.  By onset of menstruation, breasts are well developed, and there is forward projection of areola and nipple at the apex of the breast.  One to two years later, when the breast has reached maturity, only the nipple projects forward. 

Fassil   please read Swartz  pg. 409-410

            Development of a woman’s breasts begins during puberty.  The preadolescent breast consists of a small elevated nipple, with no elevation of underlying breast tissue.  Between the ages of 8 and 13 (average age around 11), secondary sex characteristics become apparent.  Breast buds appear, and further enlargement of breast and areolae follows.  The five stages of breast development as defined by the Tanner’s sex maturity ratings (SMR) follow:

Stage 1:  Preadolescent.  Elevation of nipple only.

Stage 2:  Breast bud stage.  Elevation of breast and nipple as a small mound; enlargement of areolar diameter.

Stage 3:  Further enlargement of elevation of breast and areola, with no separation of their contours.

Stage 4:  Projection of areola and nipple to form a secondary mound above the level of breast.

Stage 5:  Mature stage; projection of nipple only.  Areola has receded to general contour of the breast (although in some normal individuals the areola continues to form a secondary mound).

            The sequence from SMR 2 to SMR 5 takes about 3 years on the average, with a range of 1.5 to 6 years.  There are differences in development among ethnic groups.  In about 1 out of 12 girls, breasts develop at different rates, and considerable asymmetry may result.  This is usually temporary and, unless it is very marked, reassurance is indicated.

            Please view diagram on page 337 and  408 of Bates.

Basically, these two developmental changes –in breasts and pubic hair- are useful in assessing growth and maturation, although they do not necessarily proceed synchronously. The sequence from SMR 2 to SMR 5 takes about three years on the average, with a range of 1.5 to 6 years.  Axillary hair usually appears about two years after pubic hair.

Deb/Swartz,pg. 409

            By onset menstruation, breasts are well developed, and there is forward projection of areola and nipple at the apex of the breast/  Couldn’t find any material on pubic hair development, but from memory of what I learned as a nurse, pubic hair begins to show about the time of menarche. 

•        Stage 1  -  Preadolescent : elevation of nipple only

•        Stage 2 -   Breast bud stage: elevation of breast and nipple as a small mound; enlargement of areolar diameter

•        Stage  3 -  Further enlargement of elevation of breast and areola, with no separation of their contours

•        Stage  4 -  Projection of areola and nipple to form a secondary mound above the level of breast

•        Stage  5 -  Mature stage; projection of nipple only. Areola has receded to general contour of the breast

temporary asymmetry in girls p337 -  In about 1 out of 12 girls, breasts develop at different rates, and considerable asymmetry may result.  This is usually temporary and, unless it is very marked, reassurance is indicated.

premenstrual breast enlargement, tenderness, and texture changes p64, 337 - A normal adult breast may be soft but it often feels granular, nodular or lumpy.  It is often bilateral and may be evident throughout the breast or only in parts of it.  The nodularity may increase premenstrually -  a time when breasts often enlarge and become tender or even painful.  Symptoms are typically mild but can become severe.

changes in pregnancy p431-2, 439-40 - During pregnancy the breasts enlarge due to hyperplasia of glandular tissue and increased vascularity.  They can also become nodular by the 3rd month of gestation as the mammary tissue hypertrophies.  The nipples enlarge, darken and become more erectile.  From mid- to late pregnancy a normal thick, yellowish discharge called colostrum may be expressed from the nipple.  The areolae darken, and Montgomery glands appear prominent around the nipples.  The venous pattern over the breasts becomes increasingly visible as the pregnancy progresses.

changes with aging p338 - With aging, breast size diminishes as glandular tissue atrophies and is replaced by fat.  The breasts often become flaccid and more pendulous (they sag).  The ducts surrounding the nipple may become more easily palpable as firm, stringy strands.  Axillary hair diminishes.

adolescent male gynecomastia p338 - Approximately 2 out of 3 adolescent boys develop gynecomastia which is breast enlargement on one or both sides.  This is usually slight, but obvious enlargement may be embarrassing.  This usually resolves spontaneously within a year or two.

Lymphatics from most of the breast drain toward the axilla.  Pectoral nodes drain the anterior chest wall and much of the breast.  Subscapular nodes drain posterior chest wall and a portion of the arm.  Lateral nodes drain most of the arm.  All pectoral, subscapular and lateral nodes drain into the central nodes.  Lymph drains from the central axillary nodes to the infraclavicular and supraclavicular nodes.  However, not all lymph of the breast drains into the axilla as malignant cells may spread directly into the infraclavicular nodes or into deep channels within the chest.
Anonymous

1)      The pectoral (anterior) nodes are located along the lower border of the pectorals major inside the anterior axillary fold. These nodes drain the anterior chest wall and much of the breast.

2)      The subscapular (posterior) nodes lie along the lateral border of the scapula and are felt deep in the posterior axillary fold.  They drain the posterior chest wall and a portion of the arm.

3)      The lateral nodes lie along the upper humorous and drain most of the arm.

Lymph drains from the central axillary nodes to the infraclavicular and supraclavicular nodes.

retraction

 

retraction p352 - Dimpling or retraction of the breasts suggests an underlying cancer.  As BC (breast cancer) advances, it causes scar tissue.  When a cancer or its associated scar tissue (fibrous strands) are attached to both the skin and the fascia overlying the pectoral muscles, pectoral contraction can draw the skin inward causing dimpling or retraction.  Other causes are fat necrosis and mammary duct ectasia.

dimpling p352 - See retraction.  Look for skin dimpling with pt’s arm at rest, during special positioning, and on moving or compressing the breast.

redness p340 - is usually from local infection or inflammatory carcinoma.

edema peau d’orange p352 - is produced by lymphatic blockade.  It appears as thickened skin with enlarged pores.  Often seen in the lower portion of the breast or areola.

recent nipple inversion, flattening, deviation or retraction p341, 352 - Recent or fixed flattening or depression of the nipple suggests nipple retraction, which suggests an underlying cancer.  It may also be broadened and feel thickened.

Paget’s disease p352 - an uncommon form of BC that usually starts as a scaly, eczema-like lesion.  The skin may also weep, crust or erode.  A breast mass may also be present.  Paget’s should be suspected in any persisting dermatitis of the nipple and areola.

nipple discharge p346-7 - Milky discharge unrelated to a prior pregnancy and lactation is called nonpuerperal galactorrhea.  Leading causes are hormonal and pharmacalogic.  A nonmilky unilateral discharge suggests local breast disease.  The causative lesion is usually benign, but may be malignant, esp. in elderly women.  Bloody nipple discharge also suggests BC.

loss of nipple elasticity  p344 - Thickening of the nipple and loss of elasticity suggest an underlying cancer.
Anonymous

Retraction:  fixed flattening or depression of the nipple may be broadened and thickened.  Suggests underlying cancer.

Dimpling:  dimpling occurs when cancer or its associated fibrous strands are attached to both the skin and the fascia overlying the pectoral muscles, pectoral contraction can draw the skin inward, causing dimpling.

Redness:  redness can be from local infection or inflammatory carcinoma.

Edema:  edema of the skin is produced by lymphatic blockade, it appears as thickened skin with enlarged pores, the so-called peau d’ orange sign.

Recent nipple inversion, flattening deviation, or retraction: when nipple retraction, flattening, deviation or inversion occur and is radially asymmetrical from its normal counterpart it is typically caused by underlying cancer.

Paget’s disease: an uncommon form of breast cancer that usually starts as a scaly, eczema like lesion.  The skin may also weep, crust, or erode.  A breast mass may be present.  Suspect Paget’s disease in any persisting dermatitis of the nipple and areola.

Nipple discharge: a nonmilky unilateral discharge suggests local breast disease.  The causative lesion is usually benign, but may be malignant, especially in elderly women.

Loss of nipple elasticity: if thickening of the nipple occurs with loss of elasticity it suggests an underlying cancer.

Breast tenderness can stem from any of the following:

   - premenstrual fullness
   - hormonal changes and use (ie. oral contraceptives)
   - with pregnancy
   - nodules - cysts, masses, etc.
   - inflamed areas such as with dermatitis
   - inflammatory breast cancer
   - breast cords (suggests mammary duct ectasia or dilation of the ducts)

When nodules are present, describes:

   - location - by quadrant or clock, w/ cm from nipple
   - size in cm
   - shape (round, disclike, regular, irregular)
   - consistency (soft, firm, hard)
   - delimitation (well circumscribed or not)
   - mobility (in relation to skin, pectoral fascia, and chest wall)
   - tenderness

Enlarged axillary nodes are most commonly due to infection of the hand or arm or to recent immunizations or skin tests in the arm.  They may also be part of a generalized lymphadenopathy.  Nodes that are large (>1cm) and firm or hard, matted together, or fixed to the skin or to underlying tissues suggest malignant involvement.
Sarra Swartz 419

Freely mobile nodes 3-5 mm in diameter are common and are usually indicative of lymphadenitis secondary to minor trauma of the hand and arm.

 cysts (fibrocystic disease or physiologic nodularity) –

Sarra S&L 424

Fibroadenoma- composed of both epithelial and stromal components.  Although lesions form localized, circumscribed lumps, they are believed to be hyperplastic rather than neoplastic.  A benign, localized proliferation of breast ducts and stroma.  Seen most frequently in women aged 25-35 years as solitary discrete lesions, but histologically identical areas may also be a component of fibrocystic disease.  Fibroadenoma is therefore best regarded as a form of hormone-dependent nodular hyperplasia, rather than a true benign tumor.  Macroscopically, fibroadenomas are typically 1-4 cm in diameter, appearing as firm, rubbery, well- circumscribed, white lesions that are mobile in the breast. They have a glistening cut surface and a tough texture. There are two histological components the epithelial component, which forms gland –like structures lined by duct-type epithelium, and the stromal component, which is a loose, cellular fibrous tissue around the epithelial areas. A specialized type of fibroadenoma, termed a juvenile fibroadenoma, occurs in adolescents, forming huge masses that are frequently the same size or larger than the original breast. Histologically they resemble normal fibroadenomas.

The best thing to do for this is look at our branching exam sheet and each focus.  That clearly depicts the exam.  To summarize, it’s as follows:

•        Name & purpose, wash hands, check pt’s comfort, pt in lithotomy position, pt properly draped, prepare light source, glove up, seat yourself comfortably

•        Inspect:  pubic hair, labia minora and majora, urethra, clitoris, Skene’s glands

•        Palpate: Bartholin’s glands, milk urethra

•        Retract clitoral hood

•        Pt. bears down – check for cystocele and rectocele

•        Speculum exam – lubricate speculum, locate cervix w/finger, depress pubococcygeus muscle, insert speculum at 45* angle, rotate speculum and insert to full length, open speculum and identify cervix

•        Inspect cervix

•        Obtain pap smear and other cultures (GC-gonorrhea, CT-chlamydia, wet mounts)

•        Reinspect cervix

•        Loosen speculum, inspect vaginal walls as it closes and remove speculum

•        Bimanual exam- gloved index and middle fingers into posterior fornix, identify and palpate cervix, use dipping motion to palpate both ovaries and uterus, remove fingers

•        Rectovaginal exam – middle finger into rectum and index into vagina while pt bears down

•        Palpate rectovaginal septum

•        Withdraw fingers and test stool for guaiac blood

Greg R.  Swartz 508-522.  (This all likely be on our focus sheets).  This is in order of the text.

   Inspect external genitalia & hair – mons for lesions & swelling.  Hair for pattern, lice, nits.  Vulva for redness, excoriation, masses, leukoplakia, and pigmentation, lesions for tenderness.

   Inspect the labia – lesions, discharge, scarring, swelling, masses, warts, trauma.

   Inspect the clitoris – size and lesions (normal size is 3-4mm).

   Inspect the urethral meatus – pus, inflammation, masses.

   Inspect the area of bartholon’s glands – abscess.

   Inspect the perineum – masses, scars, fissures, and fistulas, perineal skin reddening.  Anus is inspected for hemorrhoids, irritation, and fissures.

   Test for pelvic relaxation – cyctocele, rectocele.

   Inspect the cervix – shape, color, discharge, erythema, erosion, ulceration, leukoplakia, scars, & masses.

   Pap smear – cervical cancer.

   Inspect the vaginal walls – masses, lacerations, leukoplakia, & ulcerations.

   Palpate cervix & uterine body – cervix (consistency, mobility, pain), uterus (position, size, shape, consistency, mobility, tenderness).

   Palpate the adnexa – masses, size, shape, consistency, mobility, & tenderness.  Also inspect the pouch of Douglas (uterosacral ligaments at the posterior fornix) for tenderness and nodules (possible endometriosis).

   Palpate the rectovaginal septum – rectovaginal septum for consistency, tenderness, nodules, masses.  Rectum (with middle finger) for tenderness, masses, or irregularities.

   Test stool for occult blood – blood in stool.

Pages 405 and 406 in Bates are good sources.  P405 shows external anatomy and P406 shows internal.  Three on the above list are not shown in these diagrams so I’ve listed their definitions.  An anatomy book would be a good way to cross-reference for all of these.

Fundus – The convex upper surface of the uterus

Adnexa – refers to the ovaries, tubes and supporting tissues.

Rectouterine pouch (cul de sac) – this area is where the parietal peritoneum extends downward behind the uterus.  You can just reach this area on rectal exam.

Vulva: The external genitalia (organs of reproduction) of the female are collectively called the vulva. The vulva contains the labia majora, labia minora, mons pubis, clitoris, vestibule, and ducts of glands that open into the vestibule.

Mons pubis:  Pubic eminence.

Prepuce:  Fold of the labia minora which covers the clitoris.

Clitoris:  Organ ofsensitive, erectile tissue located anterior to the vaginal orifice and in front of the urethral meatus.

Labia majora:  are the outer lips lying on either side of the vaginal opening.

Labia minora:  smaller, inner lips which lie within the labia majora and enclose the vestibule.

Vestibule: The vestibule lies between the labia minora and is bounded anteriorly by the clitoris and posteriorly by the perineum.

Introitus: An opening or entrance into a canal or cavity, as the vagina. Exterior orifice of vagina.

Hymen:  A mucus membrane that normally partially covers the entrance to the vagina

Perineum:  The region between the vaginal orifice and the anus. This is the area that an episotomy is often done during childbirth to avoid tearing.

Urethral meatus:  External opening of the urethra.

Skene’s glands (paraurethral glands):  Glands lying just inside of and on the posterior urethra in the female.

Bartholin’s glands: Two small, rounded exocrine glands on either side of the vaginal orifice that produce a mucous secretion that lubricates the vagina.

Vagina:  3 inch long tube extending from the uterus to the exterior of the body. Functions as an intromission of the penis, for the reception of semen, and for the discharge of the menstrual flow and the passageway through which the fetus is delivered.

Fornix:  Anterior and posterior spaces into which the upper vagina is divided. These recesses are formed by protrusion of the cervix uteri into the vagina.

Uterus:  A muscular, hollow, pear-shaped structure situated in the mid pelvis used for containing and nourishing the embryo and fetus from the time the fertilized egg is implanted to the time of birth of the fetus.

Fundus:  The body of the uterus from the internal os of the cervix upward above the fallopian tubes.

Cervix:  The narrow, lower portion (neck) of the uterus.

Os:  Mouth of the uterus.

Fallopian tube:  The tube or duct which extends laterally from the lateral angle of the fundal end of the uterus and terminates near the ovary.

Ovaries:  Two almond-shaped glands in the female that produce the reproductive cell, the ovum, and two known hormones 9estrogen & progesterone).

Adnexa:  Collectively, the fallopian tubes, ovaries, and supporting ligaments are called the adnexa (accessory structures) of the uterus.

Rectouterine pouch (cul de sac):  Midway between the uterus and the rectum is a region in the abdominal cavity. The region is often examined for the presence of cancerous growths.

Greg R.  See: Martini p. 1035-36; Bates’ p. 383-384; Swartz p. 496-499.

Pubic hair development occurs throught the following stages:

The pubic hair stage is written in notes as PH1, PH2, etc.

Stage 1- preadolescent; no pubic hair except for fine hair (vellus hair)

Stage 2- sparse growth of long slightly pigmented, downy hair, straight or slightly cured, chiefly along the labia.

Stage 3- darker, courser, curlier hair spreading sparsely over the pubic symphysis.

Stage 4- greater coverage than in stage 3 but not completely filled in.

Stage 5- hair as in adults spread on medial surface of the thighs but not over abdomen.

Anonymous  Bates, p 408

According to Tanner, there are 5 stages of sex maturity ratings in girls.  

Stage 1:  Preadolescent-no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen

Stage 2:  Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly along the labia.

Stage 3:  Darker, coarser, curlier hair, spreading sparsely over the pubic symphysis.

Stage 4:  Coarse and curly hair as in adults; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs.

Stage 5:  Hair adult in quantity and quality, spread on the medial surfaces of the thighs but not up over the abdomen.  

In 10% or more of women, pubic hair spreads further up the abdomen in a triangular pattern, pointing toward the umbilicus.  This spread can be classified as stage 6; because it is usually not completed until the mid 20s or later, however, it is not considered a pubertal change.

There are five stages for sexual maturity ratings of pubic hair in girls.

Stage 1 – Preadolescent; no pubic hair except for fine body hair (vellus hair) similar to that on the abdomen.

Stage 2 – Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly along the labia.

Stage 3 – Darker, coarser, curlier hair, spreading sparsely over the pubic symphysis.

Stage 4 – Coarse and curly hair as in adults; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs.

Stage 5 – Hair adult in quantity and quality, spread on the medial surfaces of the thighs but not up over the abdomen.

Height spurt 9.5-14.5 yo

Menarche 10-16.5 yo

Breast 8-13 yo stage 1; 13-18 yo stage 2

Pubic hair 8-14 yo

A girl’s first sign of puberty is usually the appearance of breast buds.  Sometimes, however, pubic hair appears first.  On average, these changes start at around 11 years of age, with a range from 8 to 13 years for breast buds, 9.5-14.5 years for height spurt, and 8 to 14 years for pubic hair.  The transformation from preadolescent to adult form takes about 3 years, with a range of 1.5 to 6 years.  Menarche tends to occur during breast stage 3 or 4, at ages ranging from 10 to 16.5 years according to Tanner’s studies in England, which are summarized graphically on p.409.  The age of menarche in the United States is a little earlier, roughly from 9 to 16 years. (Bates p 408-409)

Greg R.  Swartz p. 725 or Bates p. 713.  See the chart that illustrates the developmental sequence in girls.

Bates describes leukorrhea as increased vaginal secretions occuring normally coinciding with ovulation, and accompanying sexual arousal.  (pp 409).  Note:  the discharge coinciding w/ ovulation is often referred to as eggwhite or “tacky” cervical fluid (because it stretches) and is associated with a woman’s period of fertility each month.

Discharge from the vagina of white or yellowish viscid fluid.

Occur with ovulation and with sexual arousal.

Greg R.  Bates’ p. 385-389.  Vaginal secretions that coincide with ovulation.

menopause =  age 45-52  

pubic hair becomes sparse and gray

estrogen stimulation falls

labia and clitoris become smaller

vagina narrows and shortens

vaginal mucosa becomes thin, pale and dry

uterus and ovaries diminish in size

Anonymous

Ovarian function diminishes, periods cease, pubic hair becomes gray, estrogen stimulation falls, the labia and clitoris become smaller, vagina narrows and shortens, mucosa becomes thin, pale, dry, and the uterus and ovaries diminish in size.

Anonymous. Bates p 409

Ovarian function usually starts to diminish during a woman’s 40s, and menstrual periods cease on the average between the ages of 45 and 52, sometimes earlier and sometimes later.  Pubic hair becomes sparse as well as gray.  As estrogen stimulation falls, the labia and the clitoris become smaller.  The vagina narrows and shortens and its mucosa becomes thin, pale, and dry.  The uterus and ovaries diminish in size

AT  Swartz p. 737.  Estrogen production decreases in postmenopausal women and is associated with a reduction in size of the labia and clitoris, and thinning and dryness of the vaginal mucosa.  The uterus and ovaries also decrease in size.

EChing, Bates 4^th, P50 &377

To help a woman relax enough to allow you to insert the speculum with the least amount of discomfort try the following:

Insert your index finger into her vagina and find her cervix. With your finger still in place, ask the woman to tighten her muscles as though she's trying not to urinate (this is a useful technique to help a woman identify her PC (pubococcygeal) muscle to learn Kegal exercises-it also helps the provider assess vaginal tone). Once you feel her muscles contract, ask her to relax that muscle, as well as her bottom. As she relaxes, apply FIRM posterior (downward towards floor) pressure.

After you initially insert your finger, you might say something like, 'In order for you to be able to relax this muscle, I'm going to help you find it. Go ahead and squeeze your muscle as though you're trying not to pee...ok, now let that muscle, as well as your whole bottom relax          

The result can be quite impressive.

a.      Ask the patient to empty her bladder before the examination

b.      Explain each step in advance, and tell the patient what she might feel.

c.       Avoid any sudden or unexpected movements.

d.     Position and drape her appropriately.

e.      The patients arms should be at either her sides or across her chest – not over her head, a position that may cause tightening of the abdominal muscles.

f.        Show the patient the speculum and how it works.

g.      The speculum and your hands should be warmed before the examination begins.

h.      If the patient is virginal, smaller speculums should be available. Assure the patient that he hymen will remain intact.

i.        Describe the process for obtaining a PAP smear, reassuring the patient that it generally takes longer to describe the procedure than it takes to perform it.

j.        Describe to bimanual examination and tell her how to relax.

                 i.   Instruct the patient to keep her bottom on the table and allow her knees to fall apart. If her knees are together, this tightens the introitus (the vaginal opening) and makes the speculum examination and bimanual examination more difficult.

              ii.   She should try to keep her face and neck relaxed, focusing on a relaxing poster placed on the ceiling above the examination table.

            iii.   Remind her not to hold her breath, but continue to slow, deep breathing in through the nose and out through the mouth.

            iv.   Having an experienced nursing assistant in the room can help in coaching he patient with relaxation.

k.      Elevate the head of the bed slightly to give the patient a greater sense of participation and control.

l.        Have a mirror available to let her see her cervix if she wishes.

m.   Before touching the patient’s genitalia, gently touch the patient’s inner thigh, then slowly slide your hand down to the vulva, so as not to startle her.

n.      Explain that you will first examine the external glands and urethra. Then gently insert a finger into the vagina and gauge the opening to select the proper sized speculum.

o.      Monitor the patient’s facial expression for signs of discomfort.

p.     Above all, be gentle.

AT  Swartz p.  508-509.  Perform the exam slowly and gently.  Communication is key, explaining to the patient everything that is being done.  Eye contact will also help reduce the patient’s anxiety.  If it is a male examiner, a female attendant should be present.

EChing, Bates 4^th, P378

1.      Sensitivity to her feelings.

2.      Ask the pt to empty her bladder before the examination.

3.      Drape her appropriately.  Some pts are more comfortable when drapes cover their thighs and knees.  Others prefer to watch both the practitioner and the examination itself and object to drapes that obscure their view.  A girl or woman may wish to use a mirror to see her own genitalia during the examination.  Ask the pt which method she prefers.

4.      The patient’s arms should be at her sides or folded across her chest – not over her head, since this last position tends to tighten the abdominal muscles.

5.      Explain in advance each step of the examination and tell the pt what she may feel.  Avoid any sudden or unexpected movements.  When beginning palpation or using a speculum, it may be helpful to make initial contact not on the genitalia themselves but on the upper inner thigh.

6.      Have warm hands and a warm speculum.

7.      Monitor your examination when possible by watching the pt’s face.  Depressing the center of the drape onto the pt’s abdomen allows you to maintain eye contact while you are seated.

8.      Be as gentle as possible.

Graves- are best for sexually active woman

Pederson- are narrow-bladed best for pts with small introitus, such as a virgin or an elderly woman. Can be more comfortable for other pts to.

Specula are made of either metal or plastic and come in two basic shapes.

            Graves specula are usually best for sexually active women. They are available in small, medium, and large sizes.

            Pederson specula are narrow-bladed and are used for a patient with a relatively small introitus, such as a virgin or an elderly woman, and is often more comfortable for other patients as well.

AT  Swartz p. 513.  Graves speculum – bills are wider and curved on the sides.  Used best for adult women.  Pedersons speculum – narrower flat bills.  Used for women with smaller introitus.

EChing, Bates 4^th, P 379  

Before starting an examination of the female genitalia, obtain a history of any urinary tract infection symptoms, such as pain, frequency, and urgency.  If the patient has symptoms, you can then determine the appropriate method of specimen collection.  The next step is to ask the patient to void.  After voiding (or collecting a specimen), place her in the dorsal lithotomy position (lying on the back with thighs flexed and abducted).  Place a pillow under her head and put the feet in stirrups. 

The buttocks should extend slightly over the edge of the table.  The examination of the genitals will be divided into three distinct parts. 

External Genitalia—Inspect the mons pubis, labia, perineum, thighs, and lower abdominal regions.  Using a gloved hand, separate the labia majora and inspect the labia minors, the clitoris, urethral orifice, and the introitus.  Make a note of any swellings, ulcerations, inflammations, and nodules.  Note any sign of discharge and any sores or lesions.  Insert your index finger into the vagina, and milk the urethra gently from the inside to the outside.  If there is any discharge, culture it on room temperature, Thayer-Martin media.  If the labia are swollen, or if the patient has a history of past infections of the Bartholin’s gland duct, insert your finger into the vagina at the posterior aspect of the introitus and your thumb on the outside posterior aspect of the labia majora.  Palpate for swelling or tenderness, and check for signs of discharge around the duct openings.  Repeat the procedure for the opposite side.  Note any bulgings of the anterior vaginal wall. 

 

Internal Genitalia—Use a vaginal speculum that has been warmed to body temperature.  Use a medium-sized Graves for women without a hymen and medium-sized Pederson for women with an intact hymen.  Instruct the patient to bear down.  Place your gloved index and middle fingers at or just inside the introitus as shown in figure I, and exert downward pressure on the perineum.  With your other hand, gently insert the speculum at a 45° downward angle (fig.II).  When inserting the speculum, make sure that the blades are closed and held at an oblique angle.  Remove your fingers from the introitus, and rotate the blades of the speculum horizontally while maintaining downward pressure with the speculum.  When the blades are fully inserted, open the blades and rotate the speculum until the cervix comes into view.  Lock the blades into the open position using the thumbscrew (fig. III).  Inspect the cervix, making note of the color, position, bleeding, discharge, ulcerations, and masses.  After obtaining the necessary cervical specimens, withdraw the speculum while slowly rotating it to observe the vaginal mucosa.  Release the thumbscrew, but keep the speculum blades in the open position with hand pressure.  During withdrawal of the speculum, note the color of the vaginal mucosa and any signs of masses, ulcera- tions, inflammations, and discharges.  Allow the blades to close only when the speculum is free of the introitus. 

 

Bimanual Examination—Insert your well- lubricated gloved index and middle fingers into the vagina, exerting pressure posteriorly.  Note any areas of tenderness or swelling in the vaginal walls.  Identify the cervix and note its position, con- sistency, mobility, and indications of cervical tenderness on motion.  Palpate the fornix as illustrated in figure I.  Using your other hand (referred to as the abdominal hand), palpate downward midway between the umbilicus and the symphysis pubis toward your pelvic hand.  Identify the uterus between your hands, noting any masses or tenderness, the size, shape, consistency, and mobility (fig. II).  Place your pelvic hand in the right lateral fornix and your abdominal hand in the right lower abdominal quadrant.  Exert downward pressure with your abdominal hand and palpate the ovary.  Note the size, shape, consistency, and presence of any masses or tenderness.  Repeat the procedures for the left side. 

Withdraw your fingers from the vagina.  Relubricate, if necessary, and then slowly intro- duce your middle finger into the patient’s rectum and your index finger into her vagina (fig. III).  The anal sphincter may be relaxed by asking the patient to bear down while you are introducing your fingers.  Repeat the steps of the bimanual examination.  Pay special attention to the region that lies behind the cervix and the posterior uterine surface itself, as these areas may only be accessible to the rectal finger.  Take note of any masses or areas of tenderness.  Look for signs of rashes, excoriation, and external hemorrhoids.

AT  Should be in discussed in class during Grace’s lecture.

1.      Sebaceous cysts: (epidemoid cysts) Small, firm round cystic nodules in the labia suggets epidemoid cysts. They are sometimes yellowish in color. Look for the dark punctum marking the blocked opening of the gland.

2.      Veneral Wart: (condyloma acuminatum) Warty lesions on the labia and within the vestibule suggest ondylomata acuminata. They are due to infection with human papillomavirus (HPV).

3.      Secondary syphilis: (Condyloma latum) Slightly raised, flat round or oval papules covered by a gray exudates suggest condylomata lata. These constitute one manifestation of secondary syphilis.

4.      Genital herpes:  Shallow, small, painful ulcers on red bases suggest a herpes infection. Initial infection may be extensive. Recurrent infections are usually confined to a small local patch.

5.      Carcinoma of the Vulva: An ulcerated or raised red vulvar lesion in an elderly woman may indicate vulvar carcinoma.

AT  Bates p. 401.

Sebaceous cysts (epidermoid) – Small, firm, round, cystic nodules in the labia, sometimes yellow.  Look for dark punctum indicating blocked opening of the gland.

Venereal wart – A wart on the labia and within the vestibule.  Due to infection w/ HPV.

Genital Herpes – Shallow, small, painful ulcers on red bases.  May be extensive.  Recurrent infections are in a smaller area.

Syphilitic Chancre – Firm, painless ulcer suggests primary syphilis can be internal and go undetected.

Secondary Syphilis – Slightly raised, flat, round or oval papules covered by grey exudates.  These are contagious.

Carcinoma of the Vulva – An ulcerated or raised lesion in an elderly patient.

VB.  Bates pg 401 

EChing, Bates 4^th, P 388  

Sebaceous cyst (epidemoid cysts)- small, firm, round cyctic nodules in the labia, sometimes yellowish in color.  Look for the dark punctum marking the blocked opening of the gland.

Venereal warts (condyloma acuminatum)- warty lesions on the labia and within the vestibule. Like warts elsewhere, they are reactions to a viral infection.

Secondary syphilis (condyloma latum) – slightly raised, flat, round or oval papules covered by a gray exudate.  These constitute one manifestation of secondary syphilis and are contagious.

Syphilitic chancre – a firm, painless ulcer suggests the chancre of primary syphilis.  Since most chancres in women develop internally, they often go undetected.

Genital herpes – shallow, small, painful ulcers on red bases suggest a herpes infection.  Initial infection may be extensive.  Recurrent infections are usually confined to a small local patch.

Carcinoma of the vulva – an ulcerated or raised red vulvar lesion in an elderly woman.

prolapsed urethral

Cystocele= bulge of the anterior vaginal wall together with the bladder above it, that results from weakened supporting tissues. Upper two thirds of vagina are involved.

Rectocele= bulge of the posterior wall of the vagina, together with the rectal wall behind it. Weakened supporting structures are the cause.

Inflammation of the Bartholins gland= Acutely appears as a tense, hot very tender abcess. Look for pus coming out of the duct or erythema around the duct opening. Chronically a small non tender cyst may be felt.

Prolapsed urethral mucosa=  Forms a swollen red ring around the urethral meatus. It usually occurs before menarche or after menopause. Identify the urethral meatus at the center of the swelling to make this diagnosis.

Urethral caruncle= Is a small red benign tumor visible at the posterior part of the urethral meatus. It occurs chiefly in postmenopausal women and usually causes no symptoms. Occasionally a carcinoma of the urethra is mistaken for a caruncle. To check for this palpate the urethra through the vagina for thickening nodularity or tenderness and check for inguinal lymphadenopathy.

cystocele: prolapse of the base of the bladder into the vaginal vault in women. It will be accentuated when the patient bears down. It is associated with stress incontinence and weakness of the abdominal wall. Noble 1412

rectocele: posterior vaginal wall protrusion compose of the rectum which can also be accentuated with the Valsalva maneuver. This prolapse arises from a defect in the pelvic floor allowing herniation of the rectum. Noble 1412

inflammation of Bartholin’s gland: Barthonitis is inflammation of this gland along the side of the vaginal opening. It will present enlarged, red, swollen, and tender. It can be acute and become clogged and abscess or chronic and form cysts.

prolapsed urethral mucosa: Probably associated with aging but could not find much on this other than urethritis, ect. Hopefully more from lecture.

urethral caruncle: a small red fleshy swelling at the urethral opening. Usually from trauma, or infection.

VB.  Bates pg 402 

Normal nulliparous cervix= is round or oval or slitlike. It is a O in shape with the opening in the center.

Parous cervix= may have trauma because of the delivery of the fetus you may see the following.

Lacerations of the cervix= after giving birth you may see lacerations called unilateral transverse, bilateral transverse, and stellate.

Nabothians cysts= during metaplasia all or part of the columnar epitheilium are transformed into squamous epithelium. This causes a block of secretions and may cause what are called retention cysts or Nabothian cysts. They appear as translucent nodules on the surface of the cervix and have no pathological significance.

Cervical polyp= Usually arise from the endocervical canal, becoming visible when it protrudes through the cervical Os. It is bright red soft and fragile. Polyps are benign but may bleed.

Carcinoma of the cervix= Begins in an area of metaplasia. In its early stages it cannot be distinguished from a normal cervix. In late stage it is cauliflower irregular appearance. Early frequent intercourse and multiple partners and infection with the HPV increase risk of cervical CA.

Normal nulliparous cervix:  The os is round or oval.

Normal parous cervix: per lecture. “a smiley face.” A slitlike or lacerated os.

Lacerations of the cervix:  trauma of one or more vaginal deliveries may tear the cervix, producing lacerations described as unilateral transverse, bilateral transverse, or stellate.

Ectropion:  eversion or turning outward.

Nabothian cysts:  appear as one or more translucent nodules on the cervical surface, and have no pathologic significance.  This occurs when all or part of the columnar epithelium is transformed into squamous epithelium again which may block the secretions of columnar epithelium and thus cause retention cysts (nabothian cysts). (Bates p. 425)

Cervical polyp:  usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os.  It is bright red, soft, and rather fragile.  Benign but may bleed.

Carcinoma of the cervix:  begins in an area of metaplasia.  In its earliest stages, it cannot be distinguished from a normal cervix.  In a late stage, an extensive, irregular, cauliflowerlike growth may develop.  Early frequent intercourse, multiple partners, and infection with human papillomavirus increase the risk for cervical cancer.  

Normal nulliparous cervix:  Observable with the use of a vaginal speculum in non-child bearing females.  The shape of the os is round or oval.  Lecture from Grace Landel

Normal parous cervix:  The os of the cervix appears slit like.  Females who have delivered children vaginally.  Lecture from Grace Landel  

Lacerations of the cervix:  The cervix can become torn during the trauma of one or more vaginal deliveries.  They can appear as unilateral transverse, bilateral transverse, and stellate.  Bates page 425

Ectropion:  When the endocervical region of the os in a cervix protrudes outward towards the ectocervical region.

Nabothian cysts:  A blockage of columnar epithelium secretions, which may appear as one or more translucent nodules on the cervical surface with no pathologic significance.  Bates page 425

Cervical polyp:  This usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os.  It is bright red, soft, and rather fragile.  Polyps are benign but may bleed. Bates p. 426

Carcinoma of the cervix:  This begins in a area of metaplasia.  In its earliest stages, it cannot be distinguished from a normal cervix.  In a late stage, an extensive, irregular, cauliflower like growth may develop.  Early frequent intercourse, multiple partners, and infection with HPV increase the risk for cervical cancer.  Bates p. 426

VB. Bates pg 403-404 

                                 

Myomas

Prolapse of the uterus

Retroversion of the uterus

Retroflexion of the uterus

Myomas are very common benign uterine tumors.  They may be single or multiple and vary greatly in size.  They feel like firm, irregular nodules in continuity with the uterine surface.  

Prolapse of the uterus results from weakness of the supporting structures of the pelvic floor, and is often associated with a cystocele and rectocele.  In first degree prolapse, the cervix is still well within the vagina.  In second degree prolapse, it is at the introitus.  In third degree prolapse, the cervix and vagina are outside the introitus.

Retroversion of the uterus refers to a tilting backward of the entire uterus.  It is a common variant occurring in about 1 in 5 women.  Early clues on a pelvic examination are a cervix that faces forward and a uterine body that cannot be felt by the abdominal hand.  

Retroflexion of the uterus refers to a backward angulation of the body of the uterus in relation to the cervix.  The cervix maintains its usual position.  The body of the uterus is often palpable through the posterior fornix or through the rectum.

Please see Bates 428 and 429 for good pictures of the above conditions.

Myomas (fibroids):  common, benign tumors.  Single or multiple and vary in size.  They feel like firm, irregular nodules in continuity with the uterus surface.  

Prolapse of the uterus:  results from weakness of the supporting structures of the pelvic floor, and is often associated with a cystocele and rectocele.  There are first degree, second degree, and third degree types.

Retroversion of the uterus:  refers to a tilting backward of the entire uterus, including both body and cervix.  Common. 1 out of 5 women.  It is usually both mobile and asymptomatic.

Retroflexion of the uterus:  refers to a backward angulation of the body of the uterus in relation to the cervix.  

A.     Myomas (fibroids): Myomas are very common benign uterine tumors.  They may be single or multiple and vary greatly in size, occasionally reaching massive proportions.  They feel like firm, irregular nodules in continuity with the uterine surface.  Occasionally a myoma projecting laterally can be confused with an ovarian mass; a nodule projecting posteriorly can be mistaken for a retroflexed uterus.  Submucous myomas project toward the endometrial cavity and are not themselves palpable, although they may be suspected because of an enlarged uterus.

 

B.      Prolapse of the uterus: Prolapse of the uterus results form weakness of the supporting structures of the pelvic floor, and is often associated with a cystocele and rectocele.  In progressive stages, the uterus becomes retroverted and descends down the vaginal canal to the outside.  In first-degree prolapse, the cervix is still well within the vagina.  In second-degree prolapse, it is at the introitus.  In third degree prolaplse (procidentia), the cervix and vagina are outside the introitus.

  

C.    Retroversion of the uterus: Retroversion of the uterus refers to a tilting backward of the entire uterus, including both body and cervix.  It is a common variant occurring in about 1 out of 5 women. Early clues on pelvic examination are a cervix that faces forward and a uterine body that cannot be felt by the abdominal hand.  A retroverted uterus is usually both mobile and asymptomatic.  Occasionally, such a uterus is fixed and immobile, held in place by conditions such as endometriosis or pelvic inflammatory disease.

  

D.    Retroflexion of the uterus: Retroflexion of the uterus refers to a backward angulation of the body of the uterus in relation to the cervix.  The cervix maintains its usual position.  The body of the uterus is often palpable through the posterior fornix or through the rectum.

Ovarian cysts and tumors may be detected on one or both sides. Later, they may extend out of the pelvis.  Cysts tend to be smooth and compressible, tumors more solid and often nodular.  Uncomplicated cysts and tumors are not usually tender.  Small (<6cm in diameter), mobile, cystic masses in a young woman are usually benign and often disappear after the next menstrual period.

A ruptured tubal pregnancy spills blood into the peritoneal cavity, causing sever abdominal pain and tenderness.  Guarding and rebound tenderness are sometimes associated.  A unilateral adnexal mass may be palpable, but tenderness often prevents its detection.  Faintness, syncope, nausea, vomiting, tachycardia, and shock may be present, reflecting the hemorrhage.  There may be a prior history of amenorrhea or other symptoms of a pregnancy.

Pelvic inflammatory disease (PID) is most often a result of sexually transmitted infection of the fallopian tubes (salpingitis) or the tubes and ovaries (salpingo-oophoritis),  it is caused by Neisseria gonorrhoeae, Chlamydia trachomatis, and others.  Acute disease is associated with very tender, bilateral adnexal masses, although pain and muscle spasm usually make it impossible to delineate them.  Movement of the cervix produces pain.  In not treataed, a tuboovarian aabscess or infertility may ensue.

Ovarian cysts and tumors:  may be detected as adnexal masses on one or both sides.  Later, they may extend out of the pelvis.  Cysts tend to be smooth and compressible, tumors more solid and often nodular.  Uncomplicated cysts and tumors are not usually tender.  

Pelvic inflammatory disease (salpingitis or salpingo-oophoritis):  PID is most often a result of sexually transmitted infection of the fallopian tubes (salpingitis) or of the tubes and ovaries (salpingo-oophoritis).  Caused by Neisseria gonorrhoeae, Chlamydia trachomatis, and other organisms.  

Ruptured tubal pregnancy (ectopic pregnancy):  a ruptured tubal pregnancy spills blood into the peritoneal cavity, causing severe abdominal pain and tenderness.  Guarding and rebound tenderness are sometimes associated.  A unilateral adnexal mass may be palpable, but tenderness often prevents its detection.  Faintness, syncope, nausea, vomiting, tachycardia, and shock may be present, reflecting the hemorrhage.

Anonymous Source: Bates, pg. 430

C.    Ruptured tubal pregnancy (ectopic pregnancy): A ruptured tubal pregnancy spills blood into the peritoneal cavity, causing severe abdominal pain and tenderness.  Guarding and rebound and tenderness are sometimes associated.  A unilateral adnexal mass may be palpable, but tenderness often prevents its detection.  Faintness, syncope, nausea, vomiting, tachycardia, and shock may be present, reflecting the hemorrhage.  There may be a prior history of amenorrhea or other symptoms of a pregnancy.

VB.  Bates pg 408