Examination of Female Genitalia

BREAST EXAMINATION IN EXAMINATION OF THE FEMALE GENITALIA:

A routine breast examination must done especially above the age of 30 years, to detect any abnormality or pathology.

ABDOMINAL EXAMINATION IN EXAMINATION OF THE FEMALE GENITALIA:

The patient should first instruct to empty the urinary bladder before coming in for examination. Examination done with patient lying flat on the table with thighs slightly flexed and abducted.

INSPECTION:

The abdomen observe for the presence of umbilical eversion (e.g. large tumours, ascites, pregnancy), straie (e.g. pregnancy, obesity and parous women), surgical scars especially in the lower abdomen also prominent veins. Asking the patient to cough can elicit the presence of an incisional hernia. Besides this, Movements of abdomen are observed, especially lower abdomen, to look for pelvic peritonitis.

PALPATION:

The abdomen palpate for any swellings arising from the pelvis. The consistency, mobility and margins are to felt. In case of pelvic tumours, the lower border of the swelling cannot felt, whereas ovarian neoplasms can palpate below the lower pole. Testing for fluid thrill will elicit if the swelling is cystic or not. Intense tenderness on palpating below the umbilicus is suggestive of pelvic peritoneal irritation which can indicate PID, ectopic pregnancy, red degeneration of fibroid or twist ovarian cyst.

PERCUSSION in Examination of Female Genitalia :

Pelvic tumours are dull to percussion but the flanks are resonant. In cases of ascites, the flanks will dull to percussion and shifting dullness can elicit. (Ascites may associate with Pseudo-Meig’s syndrome, malignancy and tuberculous peritonitis).

AUSCULTATION in Examination of Female Genitalia:

Auscultation done to affirm the presence of bowel sounds. Absence of bowel sounds seen in cases of generalize peritonitis. Auscultation also reveals uterine soufflé in vascular fibroids and pregnant uterus and the presence of fetal heart sounds in pregnancy.

Examination of Female Genitalia

PELVIC EXAMINATION IN EXAMINATION OF THE FEMALE GENITALIA:

EXTERNAL GENITAL EXAMINATION:

The distribution of pubic hair note, as well as whether any anatomic abnormalities are present in the clitoris, labia and perineum. Presence of any vaginal discharge or blood is looked for and noted. The patient ask to cough/strain to elicit the presence of a genital prolapse or stress urinary incontinence. Labia separate using fingers and the external urethral meatus also character of hymen are noted. Usually, the openings of the Bartholin’s ducts cannot be visualized, but if they can seen, an inflammation of the ducts suspect.

VAGINAL EXAMINATION:

SPECULUM EXAMINATION

Speculum examination ideally done prior to a bimanual examination especially when a Pap smear needs to take or a specimen of any discharge needs to collect for bacteriological investigations. Also, if a lesion is present in the cervix, it may bleed on digital examination, making it difficult to visualize during a subsequent speculum examination.
The Cusco’s self-retaining speculum use for satisfactory inspection of the cervix and vaginal fornices and for collection of cervical and vaginal smears. The anterior vaginal wall, however, best visualize with a Sims’ speculum. It permits the evaluation of presence of cystocele or rectocele.

DIGITAL EXAMINATION

In brief, Digital examination always carried out using well-lubricated, gloved fingers.

Cervix in Examination of Female Genitalia

Two fingers of the right hand introduce in the vaginal introitus and moved up to the fornices. Whether the anterior or posterior lip of cervix felt first is noted. If the anterior lip felt first, it means that the cervix push downwards and hence the uterus anteverted. If the posterior lip felt first, the cervix upwards and the uterus retrovert. After making note of the position of cervix, its consistency note; in the pregnant state, the cervix feels soft, whereas in the non-pregnant state, it feels as firm as the tip of the nose. Movement of the cervix elicits pain in cases of ectopic pregnancy and acute salpingo-oophoritis .

Uterus

A bimanual examination done by placing the left hand over the hypogastrium. The fingers in the introitus are then used to push the fornices up so that the uterus (if anteverted) then palpated between both hands and its shape, size, tenderness and any pathology is noted. A retroverted uterus can examine using the fingers present internally only, through the posterior fornix.

Adnexa in Examination of Female Genitalia

Lateral fornices then felt and push up so that any swellings in the lateral part of the pelvis can palpate bimaually. A mass felt separate from the uterus (or a mass that does not move on movement of the cervix) indicative of an adnexal swelling, the most common of which are ovarian cyst, paraovarian cyst, ovarian tumour, chronic ectopic pregnancy or tubo-ovarian mass.
Fallopian tubes are non-palpable, unless they enlarge. Ovaries usually are non-palpable.

Pouch of Douglas

Generally, The pouch of Douglas palpate from the posterior fornix and swellings, if any, note. Additionally, Swelling felt in this area can indicated a retroverted uterus, loaded rectum, pelvic inflammatory masses, chocolate cyst of ovary, pelvic abscess or ovarian neoplasm.

RECTAL EXAMINATION in Examination of Female Genitalia

A rectal examination can do additionally to a vaginal examination or on its own. The lower bowel should ideally empty during a rectal examination and it  always carry out with well-lubricated glove fingers.
A rectal examination carried out as part of a gynaecological work-up in cases of i.e.:

• Virgins also children
• Carcinoma of cervix to determine the extent of its spread posteriorly
• Pelvic endometriosis
• Vaginal atresia
• Rectocele to distinguish it from an enterocele
• Swelling in the pouch of Douglas (already determined by vaginal examination), for better appreciation

Examination of Female Genitalia

External Examination:

This involves a visual inspection of the external genitalia (vulva) to check for any signs of irritation, infection, or abnormalities like sores, rashes, or growths. The clitoris, labia majora, labia minora, and vaginal opening are examined.

Female external genitalia

Internal Examination

Speculum Examination:

Speculum examination

A speculum, a duck-billed instrument, is gently inserted into the vagina to visualize the cervix and vaginal walls. This allows for the collection of cells for a Pap smear, which screens for cervical cancer.

Bimanual Examination:

Bimanual examination

The healthcare provider inserts two lubricated, gloved fingers into the vagina while gently pressing on the lower abdomen with the other hand. This helps assess the size, shape, and position of the uterus and ovaries, and detect any tenderness or masses.

Additional Tests:

Depending on the patient’s medical history and symptoms, additional tests may be performed during the pelvic exam. These could include:

• Rectovaginal Examination: The healthcare provider inserts one finger into the vagina and another into the rectum to assess the muscles and tissues between the vagina and rectum.
• STI Testing: Samples may be collected to test for sexually transmitted infections (STIs).
• Urine Test: A urine sample may be collected to check for infections or other conditions.

Patient Comfort and Privacy:

Maintaining patient comfort and privacy is paramount during the pelvic exam. The healthcare provider should explain each step of the procedure, address any concerns, and ensure the patient feels relaxed and comfortable throughout the process.