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assessment of the female genitalia including diseases
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Physical Assessment ofPhysical Assessment of
Male & Female Genitalia,Male & Female Genitalia,
Anus & RectumAnus & Rectum
Maria Maria Carmela Carmela LacsaLacsa Domocmat, RN, MSNDomocmat, RN, MSNInstructor, School of NursingInstructor, School of NursingNorthern Luzon Adventist College Northern Luzon Adventist College
Female GenitaliaFemale GenitaliaFemale GenitaliaFemale GenitaliaFemale GenitaliaFemale GenitaliaFemale GenitaliaFemale Genitalia
Anatomy Anatomy Anatomy Anatomy
Physical AssessmentPhysical Assessment
AbnormalitiesAbnormalities
Anatomy Anatomy
Female External
Reproductive Organs
Maria Carmela L. Domocmat, RN, MSN
Female Internal
Accessory Organs
• uterine tubes• uterus• uterus• vagina
Maria Carmela L. Domocmat, RN, MSN
Uterus
22-38Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Assessment
Good News!!!
� Deaths due to uterine and cervical cancers have declined by more than 50% since 1960s
Maria Carmela L. Domocmat, RN, MSN
Why?Why?Why?Why?
� Because of early detection
�Physical Assessment�Papanicolau test (Pap Smear)�Papanicolau test (Pap Smear)�Increase patient knowledge
Maria Carmela L. Domocmat, RN, MSN
History takingHistory takingHistory takingHistory taking
Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination
Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination
1. Inspection and Palpation of the External Genitalia
2. Speculum assessment of Internal Genitalia
3. Collection of Specimens for 3. Collection of Specimens for Laboratory Analysis.
4. Inspection of the Vaginal walls5. Bimanual Examination6. Rectovaginal Assessment
Preparation for the examPreparation for the examPreparation for the examPreparation for the exam
Preparation for the examPreparation for the examPreparation for the examPreparation for the exam
• Instruct the patient while she is dressed
• Instruct her to empty her bladder prior to the exam (depending on prior to the exam (depending on the history and complaints of client)
• Close the door and curtain
• Ask for an assistant
Maria Carmela L. Domocmat, RN, MSN
External GenitaliaExternal GenitaliaExternal GenitaliaExternal Genitalia
•Mons Pubis and Pubic Hair•VulvaClitoris•Clitoris
•Urethral Meatus•Vaginal Introitus•Perineum and Anus
External GenitaliaExternal GenitaliaExternal GenitaliaExternal Genitalia
•Mons Pubis and Pubic Hair•VulvaClitoris•Clitoris
•Urethral Meatus•Vaginal Introitus•Perineum and Anus
Mons Pubis Mons Pubis Mons Pubis Mons Pubis & Pubic Hair& Pubic Hair& Pubic Hair& Pubic Hair
Inspection
InspectionInspectionInspectionInspection
• Observe the pattern of pubic hair distribution
• Note the presence of nits or lice
Normal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsSkin over Mons Pubis:
• Clear with normal hair distribution
Maria Carmela L. Domocmat, RN, MSN
Normal FindingsNormal FindingsNormal FindingsNormal Findings (cont’d)(cont’d)
� Pubic Hair
� Distribution – inverse triangle• There may be some growth on
abdomen and upper inner thighabdomen and upper inner thigh
• Note: Diamond-shaped pattern from the umbilicus may be due to cultural or familial differences
� No nits or lice
Maria Carmela L. Domocmat, RN, MSN
Geriatric Variation:Geriatric Variation:Geriatric Variation:Geriatric Variation:Geriatric Variation:Geriatric Variation:Geriatric Variation:Geriatric Variation:
� Gray and sparse
Maria Carmela L. Domocmat, RN, MSN
Abnormal FindingAbnormal FindingAbnormal FindingAbnormal Finding
Pediculosis Pubis
Crab lice, Pthirus pubis
Maria Carmela L. Domocmat, RN, MSN
VulvaVulvaVulvaVulvaVulvaVulvaVulvaVulva
Inspection
PalpationPalpation
InspectionInspectionInspectionInspectionInspectionInspectionInspectionInspection
• Observe the skin coloration and condition of the mons the mons pubis and vulva
• Inform the patient that you will touch the inside of her thigh before you touch the genitals
Maria Carmela L. Domocmat, RN, MSN
Inspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the Vulva
•• With gloved With gloved hands, separate hands, separate the labia majora the labia majora using the thumb using the thumb using the thumb using the thumb and the index and the index finger of the finger of the dominant hand.dominant hand.
Maria Carmela L. Domocmat, RN, MSN
Inspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the Vulva (cont’d)(cont’d)
•• Observe both Observe both the labia majora the labia majora and the labia and the labia minora forminora forminora forminora fordiscoloration, discoloration, lesions, trauma.lesions, trauma.
Maria Carmela L. Domocmat, RN, MSN
�� Labia majora and Labia majora and minora minora
�� Symmetrical Symmetrical
�� Smooth to Smooth to somewhat somewhat
Normal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal Findings
Smooth to Smooth to somewhat somewhat wrinkled, wrinkled, unbroken, unbroken, slightly pigmented slightly pigmented skin surface. skin surface.
Maria Carmela L. Domocmat, RN, MSN
�� Labia Labia majoramajora and and minoraminora (cont’d)(cont’d)
�� No No ecchymosisecchymosis, , excoriation, excoriation,
Normal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal Findings
excoriation, excoriation, nodules, swelling, nodules, swelling, rash, lesions.rash, lesions.
••Occasional sebaceous cyst is within normal limitsOccasional sebaceous cyst is within normal limits••Sebaceous cysts are nontenderSebaceous cysts are nontender, yellow nodules , yellow nodules that are less than 1 cm.that are less than 1 cm.
Maria Carmela L. Domocmat, RN, MSN
Skene’sSkene’s glandsglandsand and Bartholin’sBartholin’s
glandsglands
Maria Carmela L. Domocmat, RN, MSN
Normal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal Findings
�� Skene’s glands and Bartholin’s glands are Skene’s glands and Bartholin’s glands are not normally seen by naked eyenot normally seen by naked eye
Maria Carmela L. Domocmat, RN, MSN
Normal DeviationsNormal DeviationsNormal DeviationsNormal DeviationsNormal DeviationsNormal DeviationsNormal DeviationsNormal Deviations
� Geriatric: atrophied- appears flatter and smaller
� Multiparrous women: majora are separated and minora more separated and minora more prominent
Maria Carmela L. Domocmat, RN, MSN
Abnormal Findings VulvaAbnormal Findings VulvaAbnormal Findings VulvaAbnormal Findings Vulva
Bartholin’s CystSkene’s Gland CystVulvar epidermal cystEdema, Swelling Rash (contact dermatitis, infestation)Chancre (Syphilis)Chancre (Syphilis)Wartlike papules (condyloma latum)Ulcer (Herpes)Venous prominence (varicose veins)Carcinoma
Inflammation of Bartholin Glands
Maria Carmela L. Domocmat, RN, MSN
Skene Gland Cyst
Maria Carmela L. Domocmat, RN, MSN
� Vulvar hypertrophy� Vulvar epidermal cysts develop from sebaceous
glands.
�Multiple, bilateral vulvar epidermal inclusion cysts, previously referred to as sebaceous cysts, are shown.Maria Carmela L. Domocmat, RN, MSN
Benign vulvar lesions. Pemphigus vulgaris
vulvar involvementvulvar involvementvulvar involvementvulvar involvementmucosal involvementmucosal involvementmucosal involvementmucosal involvement
Maria Carmela L. Domocmat, RN, MSN
Benign vulvar lesions
� Allergic Vulvitis � Psoriasis
Maria Carmela L. Domocmat, RN, MSN
Benign vulvar lesions
� Vulvar Melanosis � Hemangioma
Maria Carmela L. Domocmat, RN, MSN
� Condyloma Latum(Secondary Syphilis)
� CondylomaAcuminatum(Genital Or Venereal Wart)
Maria Carmela L. Domocmat, RN, MSN
Herpes genitalis
Maria Carmela L. Domocmat, RN, MSN
� Well-differentiated carcinoma of vulva
� Advanced carcinoma of vulva, involving entire vagina, urethra and rectum
Maria Carmela L. Domocmat, RN, MSN
Palpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the Labia
�� Palpate each labium between the Palpate each labium between the thumb and the index finger of your thumb and the index finger of your dominant hand.dominant hand.
�� Observe for swelling, induration, pain, Observe for swelling, induration, pain,
Palpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the Labia
�� Observe for swelling, induration, pain, Observe for swelling, induration, pain, or discharge from a Bartholin’s gland or discharge from a Bartholin’s gland duct.duct.
Maria Carmela L. Domocmat, RN, MSN
Palpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the Labia
Labium:
• Feel soft and uniform in structurein structure
•No swelling, pain, induration, or purulent discharge
Maria Carmela L. Domocmat, RN, MSN
Palpating around the Palpating around the Palpating around the Palpating around the Palpating around the Palpating around the Palpating around the Palpating around the vaginal introitus vaginal introitus vaginal introitus vaginal introitus vaginal introitus vaginal introitus vaginal introitus vaginal introitus
((((((((Bartholin glandsBartholin glands))))))))
Maria Carmela L. Domocmat, RN, MSN
If discharge is If discharge is present , present , obtain a obtain a
specimen and specimen and specimen and specimen and change the change the gloves into gloves into clean ones.clean ones.
Maria Carmela L. Domocmat, RN, MSN
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
� Painless mass indicates malignancy
Painless mass indicates malignancy
� Painful mass indicates hernia
Hernia or not?
� If hernia is suspected, re-palpate the mass with the patient in a standing position
� (+) hernia: If increase in � (+) hernia: If increase in bulging when standing and ask patient to cough
Maria Carmela L. Domocmat, RN, MSN
ClitorisClitorisClitorisClitoris
Inspection
InspectionInspectionInspectionInspection
� Using the dominant hand and index finger, separate the separate the labia minora laterally to expose the prepuce of the clitoris
Maria Carmela L. Domocmat, RN, MSN
Normal FindingsNormal FindingsNormal FindingsNormal Findings
••Approximately 2 cm in length and 0.5 Approximately 2 cm in length and 0.5 cm in diametercm in diameter
••Without lesionsWithout lesionsMaria Carmela L. Domocmat, RN, MSN
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
Hypertrophy Hypertrophy
(clitoromegaly, pseudohermaphroditism)
Chancre
ClitoromegalyClitoromegalyClitoromegalyClitoromegaly� A 22-year-old
gravida O
� 20 mm
� 19-year-old gravida O
� 30 mm
clitoroplasty Maria Carmela L. Domocmat, RN, MSN
Urethral MeatusUrethral MeatusUrethral MeatusUrethral Meatus
Inspect
PalpatePalpate
InspectionInspectionInspectionInspection
� Using the dominant hand and index finger, separate the labia minora to expose the urethral meatus.
� Do not touch the urethral meatus.Do not touch the urethral meatus.
� may cause pain and urethral spasm
� Observe
� shape, color, and size of urethra
Maria Carmela L. Domocmat, RN, MSN
Normal FindingsNormal FindingsNormal FindingsNormal Findings
� Slitlike in appearance
� Midline
� Free from discharge, swelling, or redness
� About the size of a peaMaria Carmela L. Domocmat, RN, MSN
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
Discharge or swelling Urethral caruncleUrethral caruncleUrethral carcinomaProlapse of urethral mucosa
Urethral caruncle
Maria Carmela L. Domocmat, RN, MSN
PalpationPalpationPalpationPalpation
Milking the urethra andMilking the urethra andparaurethral glandsparaurethral glandsMilking the urethra andMilking the urethra andparaurethral glandsparaurethral glands
PalpationPalpationPalpationPalpation
� Insert your dominant index finger into the vagina
� Apply pressure to the anterior aspect of the anterior aspect of the vaginal wall and milk the urethra
� Observe for discharge and client discomfort
Maria Carmela L. Domocmat, RN, MSN
Milking the urethra andMilking the urethra andparaurethral glandsparaurethral glands
Maria Carmela L. Domocmat, RN, MSN
Normal FindingsNormal FindingsNormal FindingsNormal Findings
� Should not cause pain
� Or result in any urethral discharge
Maria Carmela L. Domocmat, RN, MSN
� If urethral discharge is present, obtain a specimen and change to a clean pair of gloves
Maria Carmela L. Domocmat, RN, MSN
Let’s Watch: Palpating
the Skene Glands and
Bartholin GlandsBartholin Glands
Vaginal IntroitusVaginal IntroitusVaginal IntroitusVaginal Introitus
Inspect PalpatePalpate
� Keep labia minora retracted laterally to inspect the vaginal introitus.
� Ask the patient to bear down.
InspectionInspectionInspectionInspection
Ask the patient to bear down.
� Observe for patency and bleeding.
Maria Carmela L. Domocmat, RN, MSN
� Introitus Mucosa
� Pink and moist
� Patent
Normal FindingsNormal FindingsNormal FindingsNormal Findings
� Patent
� Without Bulging
Maria Carmela L. Domocmat, RN, MSN
NulliparousNulliparouswith intact with intact
hymenhymen
Multiparous with Multiparous with remaining hymenremaining hymen
Maria Carmela L. Domocmat, RN, MSN
� Normal Vaginal Discharge – white and free of foul odor (some white clumps may be seen—mass clamps of epithelia cells)
Maria Carmela L. Domocmat, RN, MSN
PalpationPalpationPalpationPalpation
� Insert your dominant finger in the vagina, ask the client to squeeze the vaginal muscles around your finger.
� Evaluate muscle strength and tone
Normal FindingsNormal FindingsNormal FindingsNormal Findings
� Vaginal muscle tone
� In nulliparous woman: tight and strong
� In a parrous woman: it is diminishedMaria Carmela L. Domocmat, RN, MSN
Abnormal Findings
Pale color and dryness (atrophy, aging)
Tear, fissureTear, fissure
Bulging
Discharge
Pelvic Organ Prolapse
Cystocele
Cystourethrocele
RectoceleRectocele
Uterine Prolapse
Cystocele
Maria Carmela L. Domocmat, RN, MSN
Rectocele
Maria Carmela L. Domocmat, RN, MSN
Degrees of Uterine Prolapse
Maria Carmela L. Domocmat, RN, MSN
Second degree uterine prolapse
Maria Carmela L. Domocmat, RN, MSN
Symptomatic posthysterectomyvault prolapse in vault prolapse in 60-year-old patient.
Maria Carmela L. Domocmat, RN, MSN
PerineumPerineumPerineumPerineum
Inspect
PalpatePalpate
Inspection
• Observe texture and color of the perineum
• Observe for color and shape of the anus
Normal Findings
� Perineum
� Smooth
� Slightly darkened
� Well-healed episiotomy scar is normal after vaginal delivery
Normal Findings
Maria Carmela L. Domocmat, RN, MSN
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
Fissure or tear (trauma, abscess, or unhealed episiotomy)or unhealed episiotomy)
Keloid
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Giant perineal keloidGiant perineal keloidGiant perineal keloidGiant perineal keloid
Maria Carmela L. Domocmat, RN, MSN
Palpating the PerineumPalpating the PerineumPalpating the PerineumPalpating the Perineum
� Place the dominant index finger posterior to the perineum
Palpating the PerineumPalpating the PerineumPalpating the PerineumPalpating the Perineum
to the perineum and the thumb anterior to the perineum
Maria Carmela L. Domocmat, RN, MSN
� Assess perineum between the dominant thumb
Palpating the PerineumPalpating the PerineumPalpating the PerineumPalpating the Perineum(cont’d)(cont’d)(cont’d)(cont’d)
dominant thumb and index finger for muscular tone and texture
Maria Carmela L. Domocmat, RN, MSN
Normal FindingsNormal FindingsNormal FindingsNormal Findings
� Smooth & Firm
� Homogenous in nulliparous
� Thinner in parous womanwoman
� Well-healed episiotomy scar is also within normal limits for parous woman
Maria Carmela L. Domocmat, RN, MSN
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
Thin (atrophy)
Fissure or tear (trauma, abscess, Fissure or tear (trauma, abscess, or unhealed episiotomy)
Speculum Examination of the Speculum Examination of the
Internal GenitaliaInternal Genitalia
InspectionInspection
Cervical ExaminationCervical Examination
� Select the appropriate-sized speculum
� Based on client’s
� Based on client’s history, size vaginal introitus, and vaginal muscle tone
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
� Lubricate and warm the speculum by rinsing it with warm water
� Do not use lubricant, may � Do not use lubricant, may be bacteriostatic and can alter Pap test results
Maria Carmela L. Domocmat, RN, MSN
Holding the Speculum
•Hold the speculum by your dominant hand with the hand with the closed blades between the index and middle fingers
Maria Carmela L. Domocmat, RN, MSN
� Insert your nondominant index and middle fingers, ventral sides down, just inside the vagina and apply pressure to the and apply pressure to the posterior vaginal wall
Maria Carmela L. Domocmat, RN, MSN
� Encourage client to bear down
� This will help to relax the perineal musclesmuscles
� Encourage client to relax by taking deep breaths
� Be careful not to pull on pubic hair or pinch the labia
Maria Carmela L. Domocmat, RN, MSN
Preparing for the Preparing for the insertion insertion of of the the speculumspeculum
Apply Apply downward downward pressure in pressure in posterior posterior vaginal vaginal opening opening with two with two with two with two fingersfingers
Maria Carmela L. Domocmat, RN, MSN
Oblique insertion of the Oblique insertion of the speculumspeculum
When you feel the When you feel the muscles relax, muscles relax, insert the speculum insert the speculum at an oblique angle at an oblique angle on a plane parallel on a plane parallel to the examination to the examination on a plane parallel on a plane parallel to the examination to the examination table until the table until the speculum reaches speculum reaches the end of the the end of the fingers that are in fingers that are in the vagina.the vagina.
Maria Carmela L. Domocmat, RN, MSN
Withdraw your nondominant Withdraw your nondominant hand from the vaginahand from the vagina
Maria Carmela L. Domocmat, RN, MSN
Directing speculum downward
at 45 angle. Gently rotate Gently rotate the speculum the speculum blades to a blades to a horizontal angle horizontal angle and advance and advance the speculum at the speculum at a 45a 45--degreedegree--
0000
a 45a 45--degreedegree--angle against angle against the posterior the posterior vaginal wall vaginal wall until it reaches until it reaches the end of the the end of the vagina.vagina.
Maria Carmela L. Domocmat, RN, MSN
Final Adjustment of the Speculum
Maria Carmela L. Domocmat, RN, MSN
Opening of the
speculum blades••With your With your dominant thumb, dominant thumb, depress the lever depress the lever to open the blades to open the blades and visualize the and visualize the cervix.cervix.
Maria Carmela L. Domocmat, RN, MSN
� If the cervix is not visualized, close the blades and withdraw the speculum 2 to 3 cm and reinsert it at a slightly different angle to ensure that the speculum is inserted far enough into the vagina.the vagina.
� Once the cervix is fully visualized, lock the speculum blades into place.
� Adjust your light source so that it shines through the speculum.
Maria Carmela L. Domocmat, RN, MSN
Speculum in place, locked, and
stabilized. Note cervix in full view.
Maria Carmela L. Domocmat, RN, MSN
� Color
� Glistening pink
� Pale after menopause
� Blue (Chadwick’s sign) during pregnancy
Normal FindingsNormal FindingsNormal FindingsNormal Findings
Blue (Chadwick’s sign) during pregnancy
� Position
� Located midline in the vagina with an anterior or posterior position relative to the vaginal vault
Maria Carmela L. Domocmat, RN, MSN
� Size:
� 2.5 cm to 3 cm in young woman. Smaller in elderly
� Surface characteristics:
� Covered by glistening pink squamouspink squamousepithelium, which is similar to vaginal epithelium
� Discharge:
� Note characteristics of any discharge Maria Carmela L. Domocmat, RN, MSN
� Shape of cervical os
� In nulliparouswoman: os is small and either round or oval.
In a parrous�In a parrouswoman: os is a horizontal slit
Maria Carmela L. Domocmat, RN, MSN
Let’s Watch:
Inspecting the Cervix
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
Lacerations Cyanosis Redness or friable appearanceRedness or friable appearanceReddish circle around os (ectropion or eversion)Small, round, yellow lesion (nabothian cyst)
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
Condyloma AcuminataCandidiasisCervicitisCandidiasisCervicitisEndocervical GonorrheaStrawberry spots (trichomonal infection)Cauliflower overgrowth (carcinoma)
Maria Carmela L. Domocmat, RN, MSN
� Cervical Ectropion
� Nabothian Cyst
Maria Carmela L. Domocmat, RN, MSN
� Condyloma acuminata(venereal warts)
� Candidiasis
caused by "Human Papilloma Virus" (HPV).
Maria Carmela L. Domocmat, RN, MSN
Chlamydial cervicitis
Maria Carmela L. Domocmat, RN, MSN
Endocervical gonorrhea
Maria Carmela L. Domocmat, RN, MSN
� “Strawberry” cervix (Trichomonasis)
� Cervical Cancer
Maria Carmela L. Domocmat, RN, MSN
Collecting Specimens for Collecting Specimens for Cytological Smears and Cytological Smears and CulturesCultures••Pap SmearPap Smear
••Gonococcal Culture SpecimenGonococcal Culture Specimen••Gonococcal Culture SpecimenGonococcal Culture Specimen
••Saline Mount or “Wet Prep”Saline Mount or “Wet Prep”
••KOH PrepKOH Prep
••Five Percent Acetic Acid WashFive Percent Acetic Acid Wash
••Anal CultureAnal Culture
Pap SmearPap SmearPap SmearPap Smear
Endocervical Endocervical SmearSmear
Cervical SmearCervical Smear
Vaginal Pool Vaginal Pool SmearSmear
Pap Smear Equipments
Maria Carmela L. Domocmat, RN, MSN
� A collection of three specimens that are obtained from three sites
� Cervix
� Vaginal pool
� Posterior � Posterior fornix of the vagina
Maria Carmela L. Domocmat, RN, MSN
� Using your nondominant hand, insert the cytobrush through the speculum into the cervical os approximately 1
Endocervical SmearEndocervical Smear
the cervical os approximately 1 cm
� May cause cramping sensation, so forewarn the patient.
Maria Carmela L. Domocmat, RN, MSN
� Rotate the cytobrush between your index finger and thumb 360
Endocervical Endocervical SmearSmear (cont’d)(cont’d)
finger and thumb 360 degrees clockwise, then counterclockwise.
� Keep cytobrush in contact with the cervical tissue� If you have to use a cotton-tipped applicator instead of cytobrush, leave the applicator in the os for 30 seconds to ensure saturation.Maria Carmela L. Domocmat, RN, MSN
� Remove the cytobrush and, using a rolling motion, spread the cells on the section of the slide marked E, if a sectional slide is being used.Do not press down hard or
EndocervicalEndocervical SmearSmear(cont’d)(cont’d)
� Do not press down hard or wipe the cytobrush back and forth. Doing so will destroy the cells.
� Discard the brush.
Maria Carmela L. Domocmat, RN, MSN
� Insert the bifurcated end of Ayre spatula through the speculum
Cervical SmearCervical Smear
end of Ayre spatula through the speculum base.
� Place the longer projection of the bifurcation into the cervical os.
Maria Carmela L. Domocmat, RN, MSN
� The shorter projection should be snug against the ectocervix
Rotate the spatula 360
Cervical SmearCervical Smear(cont’d)(cont’d)
� Rotate the spatula 360 degrees one time only
� Remove the spatula and gently spread the specimen on the section of the slide labeled C, if a sectional slide is being used.
Maria Carmela L. Domocmat, RN, MSN
Vaginal Pool Smear
� Reverse the Ayre spatula and insert the rounded end into rounded end into the posterior fornix and gently scrape the area
Maria Carmela L. Domocmat, RN, MSN
� Cotton-tipped applicator may be the preferred vehicle for obtaining specimen if vaginal secretions are viscous or dry.
Vaginal Pool Smear
viscous or dry.
� By moistening the cotton-tipped applicator with normal saline solution, viscous secretions can be removed with less trauma to the surrounding membranes.
Maria Carmela L. Domocmat, RN, MSN
� Remove the spatula and gently spread the specimen on the section of the slide marked V, if a sectional slide is being used.
Dispose of the spatula cotton-tipped
Vaginal Pool Smear
� Dispose of the spatula cotton-tipped applicator .
� Spray the entire slide or the slides with cytological fixative.
� Submit the specimens to the laboratory.
Maria Carmela L. Domocmat, RN, MSN
� Normal classifications for all cervicovaginal cytology should read “within normal limits” (WNL) using Bethesda system.
Normal findings
Bethesda system.
� Denotes lack of pathogenesis
Maria Carmela L. Domocmat, RN, MSN
Inspection of the Inspection of the Inspection of the Inspection of the
Vaginal WallVaginal WallVaginal WallVaginal Wall
Inspection
� Disengage the locking device of the speculum
� Slowly withdraw the speculum but do not close the bladesnot close the blades
� Rotate the speculum into oblique position as you retract it
� to allow full inspection of the vaginal walls
� Observe vaginal wall color and textureMaria Carmela L. Domocmat, RN, MSN
Normal findings
� Vaginal walls
� Pink
�Moist�Moist
�Deeply ruggated
�Without lesions or redness
Maria Carmela L. Domocmat, RN, MSN
Geriatric VariationGeriatric VariationGeriatric VariationGeriatric Variation
� Thinner
� Drier
� Less vascular� Less vascular
Maria Carmela L. Domocmat, RN, MSN
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
Vaginitis
AdenosisAdenosis
Carcinoma
Atrophic vaginitis
� External genitalia of a 67-year-old woman who is naturally menopausal for two years and is not on estrogen replacement on estrogen replacement therapy. Note loss of labial and vulvar fullness, pallor of urethral and vaginal epithelium, and decreased vaginal moisture.
Maria Carmela L. Domocmat, RN, MSN
� Vaginal inclusion cysts contain epithelial tissue
� Bacterial Vaginosis
Maria Carmela L. Domocmat, RN, MSN
� Vaginal adenosis � Vaginal Carcinoma
Maria Carmela L. Domocmat, RN, MSN
Bimanual ExaminationBimanual ExaminationBimanual ExaminationBimanual Examination
•Vagina
•Cervix
•Fornices
•Uterus
•Adnexa
•Cervix •Uterus
Steps of Bimanual Exam:
1. Observe the client’s face for signs of discomfort during the assessment process.
2. Inform the client of the steps of the bimanual assessment, and tell her that the lubricant gel may be cold.
Maria Carmela L. Domocmat, RN, MSN
Steps of Bimanual Exam: (cont’d)
3. Squeeze the lubricant onto the fingertips
of your dominant hand.
4. Stand between the 4. Stand between the legs of the client as she remains in the lithotomy position, and place your non-dominant hand on her abdomen and below the umbilicus.
Maria Carmela L. Domocmat, RN, MSN
Steps of Bimanual Exam: (cont’d)
5. Insert your lubricated index and middle fingers 1 cm into the vagina. 1 cm into the vagina. The fingers should be extended with the palmer side up. Exert gentle posterior pressure.
Maria Carmela L. Domocmat, RN, MSN
Steps of Bimanual Exam: (cont’d)
6. Inform the client that pressure from palpation may be uncomfortable. uncomfortable. Instruct the patient to relax the abdominal muscles by taking deep breaths.
Maria Carmela L. Domocmat, RN, MSN
Steps of Bimanual Exam (cont’d)
7. When you feel the client’s muscles relax, insert your your fingers slowly to their full length into the vagina. Simultaneously palpate the vaginal walls.
Maria Carmela L. Domocmat, RN, MSN
Steps of Bimanual Exam (cont’d)
8. Remember to keep your thumb widely abducted and away from the urethral from the urethral meatus and clitoris throughout the palpation in order to prevent pain or spasm.
Maria Carmela L. Domocmat, RN, MSN
� Complete steps 1-8 of the bimanual exam. Rotate the wrist so that the fingers are able to
VaginaVagina
the fingers are able to palpate all surface aspects of the vagina.
Maria Carmela L. Domocmat, RN, MSN
VaginaVagina
�� Normal FindingsNormal Findings
�� Vaginal wall non tenderVaginal wall non tender
Smooth or ruggated surfaceSmooth or ruggated surface�� Smooth or ruggated surfaceSmooth or ruggated surface
�� No lesions, masses, or cystsNo lesions, masses, or cysts
Maria Carmela L. Domocmat, RN, MSN
1. Position the dominant
hand so that the
palmar surface faces
upward.
Cervix
upward.
2. Place the non-dominant hand on the abdomen approximately 1/3 of the way down between the umbilicus and the symphysis pubis.
Maria Carmela L. Domocmat, RN, MSN
3. Use the palmar surfaces of the dominant hand’s fingerpads, which are in the vagina, to assess the
Cervix
the vagina, to assess the cervix for consistency, position shape, and tenderness.
4. Grasp the cervix between the fingertips and move the cervix from side to side to assess mobility.
Maria Carmela L. Domocmat, RN, MSN
Cervix
�� Normal FindingsNormal Findings
�� MobileMobile
�� Without painWithout pain
�� Smooth and Smooth and �� Smooth and Smooth and firmfirm
�� Symmetrically Symmetrically roundedrounded
�� MidlineMidline �Softening between 5th or 6th week of pregnancy- Goodell’s sign
Maria Carmela L. Domocmat, RN, MSN
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
Extreme pain on palpation (Chandelier’s sign –PID)(Chandelier’s sign –PID)Irregular surface (malignancy, nabothian cyst, polyps)
• With the fingertips and palmar surfaces of the fingers, palpate
Fornices
fingers, palpate around the fornices.
• Note nodules or irregularities.
Maria Carmela L. Domocmat, RN, MSN
Fornices
� Normal Findings
� Walls should be smoothsmooth
� No nodules
Maria Carmela L. Domocmat, RN, MSN
Uterus
1. With the dominant hand, which is in the vagina, push the pelvic organs out of the pelvic organs out of the pelvic cavity and provide stabilization while the non-dominant hand, which is on the abdomen, performs the palpation.
Maria Carmela L. Domocmat, RN, MSN
Uterus
2. Press the hand that is on the abdomen inward and downward abdomen inward and downward toward the vagina, and try to grasp the uterus between your hands.
Maria Carmela L. Domocmat, RN, MSN
Uterus
2. Press the hand that is on the abdomen inward and downward toward the vagina, toward the vagina, and try to grasp the uterus between your hands.
Maria Carmela L. Domocmat, RN, MSN
Bimanual palpation of UterusBimanual palpation of Uterus
Maria Carmela L. Domocmat, RN, MSN
Uterus
� Normal Findings
� Size varies based on parity
Nongravid client: � Nongravid client: Pear-shaped
� Parous: more rounded
� Smooth
� Without masses
Maria Carmela L. Domocmat, RN, MSN
Uterus
� Normal Findings (cont’d)
� May be non-palpable if it is retroverted or retroflexed (rectovaginal assessment)assessment)
� Non palpable uterus is normal in older women
� Due to secondary uterine atrophy
Maria Carmela L. Domocmat, RN, MSN
Anteverted uterus
Maria Carmela L. Domocmat, RN, MSN
Anteflexed UterusAnteverted uterus
Maria Carmela L. Domocmat, RN, MSN
� Retroverted
Uterus
� Retroflexed
Uterus
Maria Carmela L. Domocmat, RN, MSN
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
� Enlargement and changes in shape
� Nodules or irregularities (leiomyomas)
� Non palpable uterus (hysterectomy)
Maria Carmela L. Domocmat, RN, MSN
Adnexa
1. Move the intravaginal hand to the right lateral fornix, and the hand on the abdomen to the right lower quadrant just inside the abdomen to the right lower quadrant just inside the anterior iliac spine.
2. Press deeply inward and upward toward the abdominal hand.
Maria Carmela L. Domocmat, RN, MSN
3. Push inward and downward with the abdominal hand and try to catch the ovary between your fingertips.
Adnexa
between your fingertips.
� Palpate for size, consistency, and mobility of the adnexa.
� Repeat the above maneuvers on the left side.
Maria Carmela L. Domocmat, RN, MSN
Palpation of Left Adnexa
Maria Carmela L. Domocmat, RN, MSN
Adnexa
�� Normal Findings Normal Findings Ovaries
� Almond-shaped
Firm� Firm
� Smooth
� Mobile
� Without tenderness
Maria Carmela L. Domocmat, RN, MSN
Geriatric VariationGeriatric VariationGeriatric VariationGeriatric VariationGeriatric VariationGeriatric VariationGeriatric VariationGeriatric Variation
� Rarely palpable
Maria Carmela L. Domocmat, RN, MSN
Let’s Watch:
Bimanual Palpation
of Uterus
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
Enlarged, irregular, nodular, painful, with decreased mobility painful, with decreased mobility (ectopic pregnancy, ovarian cyst, PID or malignancy)
Collecting Specimens
Five Percent Acetic Acid Wash
1. After completing all other vaginal specimens, swab the cervix with specimens, swab the cervix with cotton-tipped applicator that has been soaked in 5% acetic acid.
2.Leave for one minute.
Normal Finding
� There should be no change in the appearance of the cervix (HPV)
Maria Carmela L. Domocmat, RN, MSN
Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings
Rapid acetowhitening or blanching with jagged borders (HPV)with jagged borders (HPV)
Apparently normal cervix
Maria Carmela L. Domocmat, RN, MSN
After application of acetic acid
Maria Carmela L. Domocmat, RN, MSN
RectovaginalRectovaginalRectovaginalRectovaginalExaminationExaminationExaminationExamination
Rectovaginal ExaminationRectovaginal Examination
Maria Carmela L. Domocmat, RN, MSN