The gynecological exam traditionally includes an examination of the external and internal genitalia. Under some conditions, it may be necessary to perform a rectal examination as well. A gynecological exam is typically needed for females with gynecological complaints or for screening for cervical cytology at 21 years of age.
Relevant anatomy includes the external and internal anatomy. The external genitalia, or vulva, include the mons pubis, labia majora and minora, the clitoris vestibular bulbs, vulvar vestibule, Skene’s and Bartholin glands, urethral meatus, and the vaginal opening.
The mons pubis is a rounded area of fatty tissue overlying the pubic symphysis. The 2 cutaneous folds that work posteriorly from the mons pubis are the labia majora. The clitoris is a small projection of erectile tissue located at the anterior end of the labia majora. Typically, there is a flap of skin overlying the clitoris known as the clitoral hood. From the clitoris extending posteriorly are 2 inner cutaneous folds called the labia minora, which often vary widely in shape, color, and size. The perineum is the area located posterior to the labia majora extending to the anus. The almond-shaped area encompassed by the labia minora is termed the vestibule. The vestibular bulbs are 2 elongated masses of erectile tissue that are joined together by a narrow band anteriorly and partially extend laterally around the vaginal opening. The urinary meatus can be found just anterior to the vaginal opening in the vestibule and typically takes the shape of a sagittal cleft. The Skene’s glands are located to either side of the urinary meatus within the vestibule. The Bartholin glands are found at 4 o’clock and 8 o’clock positions in the vestibule.
The internal genitalia encompasses the vagina, cervix, fornix, as well as the uterus, fallopian tubes, and ovaries. The vagina is a muscular, elastic canal that extends from the vulva to the protrusion of the cervix. The part of the vagina which surrounds the cervix is the fornix and can be described as anterior, posterior or lateral to the cervix. The hymen is a membrane of tissue that covers or partially covers the vaginal opening, typically crescentic. There are many variations to the shape of the hymen, and it may disappear completely after intercourse, masturbation, pelvic examination, disease, injury or physical exercise. Without arousal, the vaginal canal is generally 3 inches long. The cervix is a once inch cylindrical structure that bulges into the vagina with a narrow cervical canal running its entire length which connects the vaginal canal to the uterus. The cervical opening on the vaginal side is called the external os and the opening on the uterine side is called the internal os. The uterus is a triangular shaped muscular organ typically about three inches long in a nongravid woman. The uterine cavity opens into two fallopian tubes bilaterally which overly the ovaries on either side of the uterus.
The gynecologic exam is used to assess the external and internal genitalia as well as the urethra and rectum as needed. Practitioners should be cautious in patients that are critically unstable, whether medically, emotionally or psychologically. Informed consent needs to be obtained before proceeding with the examination. The following are complaints that would warrant a gynecological exam:
Absolute contraindication includes a lack of consent for the procedure
Specula come in a variety of sizes and types. Metal specula are not disposable and need sterilization between each use. Plastic specula are disposable and individually used. The Graves speculum is the most commonly used speculum; it has 2 handles and a fixed base. The handles can either be opened like a duckbill or spread further apart with the mechanism on the handle. The Pederson speculum is similar to a Graves speculum but with narrower blades for pediatric patients or to accommodate a narrower vagina.
Many speculums are designed with a light source. If the speculum is not designed with a light source, ensure proper lighting with an adjustable lamp. Simple room lighting will not be adequate for the examination.
Many gynecological exams include the presence of a chaperone. Male providers almost always have a female chaperone present and female providers frequently feel comfortable without one. It is recommended that a patient be asked whether she would prefer to have a chaperone present and her request be obliged when preferred. When possible, it is good practice to have a chaperone present both for the patient's and provider's security, although there is little evidence suggesting that the presence of a chaperone reduces litigation.
The patient should be undressed from the waist down and covered with a sheet to maintain modesty. The patient should be uncovered for only as much time as is necessary for the exam. Until the patient is properly positioned, she should remain draped.
Instruct the patient to lie on her back on the bed in the dorsal lithotomy position. This is achieved by placing her feet in the foot supports and scooting herself down in the bed until her thighs are roughly perpendicular to the ground or further bent toward the abdomen. The patient’s buttocks should be at the edge of the bed or slightly farther to provide for better mobility of the speculum and better visualization. If a table with foot supports is unavailable, the pelvic exam can be done by placing the patient’s hips on top of a padded flipped washbasin or bedpan with the patient’s legs bent toward her chest or placed in frog-leg position with the bottoms of her feet together.
The exam should start with an evaluation of the external vulva first. The clinician should look at the basic development of vulvar anatomy, symmetry, hair distribution, any swelling, bruising, erythema, rashes, lesions, discharge, growths and assessment of tenderness of any abnormalities. The labia should be palpated for tenderness or growths. This is done by placing the thumb on the perineal area with the index finger in the vaginal opening. The fingers are then moved along both labia feeling for nodules, abscesses, cysts, and tenderness.
Next is the internal speculum examination. First, the tips of the speculum should be lubricated with petroleum jelly or water. The speculum is held with the right hand with the index and middle fingers at the base of either blade holding them closed. The examiner should spread the labia slightly with the left hand to allow for easier insertion of the speculum. The speculum should then be inserted at an angle that guides insertion typically from 0 to 90 degrees and then immediately after insertion, rotating the speculum as necessary so that handle is pointing downward. Typically, women can accommodate a downward-angled handle right away but some narrower vaginas will require a slanted insertion. The inferior blade should be placed in the posterior fornix before opening. This can require a significantly posterior pathway to the speculum, especially in nulliparous women. Once the inferior blade is in the posterior fornix, the cervix should pop into view once the blades are opened like a duckbill. At this point, the cervix should be examined for color, lesions, discharge, blood and whether the external os looks open or closed. If the cervix is not visible right away, a bimanual exam may be necessary next to ascertain its location. A retroverted uterus may have anterior positioning of the cervix. Samples are taken at this time. To take out the speculum, the clinician should release the blades loosely while starting to slowly withdraw to avoid pinching the cervix and vaginal walls. At this time, the clinician should examine the vaginal wall for any irregularities.
The bimanual examination is next. Typically, if the examiner is right-handed, they will use their right hand internally and their opposite hand externally and vice versa. The examiner will use lubrication on their dominant hand on their two first fingers. The fingers are inserted into the vagina slowly. With either finger, locate the cervix. It may be necessary to push down and inferiorly with the non-dominant hand on the abdomen to push the cervix closer to the fingers. The external os and, as needed, the internal os are evaluated. The examiner will see if either the external or internal os are open with one finger. Cervical motion tenderness is elicited now as well. The non-dominant hand should help push the uterus between the hands to palpate its size and position. Next, both hands evaluate either adnexa by evaluating for masses and tenderness. This concludes the bimanual exam and the fingers are withdrawn.
Sometimes, clinicians will feel a rectovaginal examination is necessary to examine the rectovaginal septum and posterior cul-de-sac. The presence of hemorrhoids, polyps, and growths should be noted. The lubricated third digit is slowly inserted into the rectum to allow for relaxation of the sphincter to minimize discomfort. At the same time, the index finger is inserted into the vagina and both fingers are used to feel the rectovaginal septum and tenderness.
Complications can be encountered in a number of special circumstances. In women with atrophic vaginitis, the speculum exam may be very painful and liberal lubrication, and a narrow speculum is recommended for these patients.
There may be challenges when encountering a patient with a history of sexual trauma; a pelvic examination may trigger anxiety or post-traumatic stress disorder. Consent must be acquired. Especially during these examinations, thorough explanations of the procedure should be emphasized. Mental health counseling, anxiolytics, and various alternatives to the exam can be suggested such as only removing the underwear, having a chaperone present, self-insertion of the speculum, offering the option to have a female provider present or having a friend or family member in the room for comfort. It should be stressed that the examiner can stop the exam at any time when requested by the patient.
Clinical significance includes better management and decision-making for cases involving ectopic pregnancy, antepartum vaginal bleeding, sexually-transmitted infections, ovarian, uterine, cervical, and vaginal pathology.
The pelvic examination presents very useful information in certain clinical circumstances, but it is important that the examination is done from a patient-centered approach with proper preparation and procedure to avoid iatrogenic effects, such as pain, traumatization, and anxiety. Physicians, physician assistants, and nurse practitioners should be familiar with exam techniques. Nurses should be experienced in providing examination support and assuring patient modesty. (Level V)
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