Cervix:
Speculum Exam of
To evaluate the cervix and vaginal wall.
Method Of Exam
Author: A. Chandrasekhar
|
Consultant: P. Tomich
|
- Speculum technique
- To prepare for an adequate examination, the
patient should be given an opportunity to empty her bladder and should be
draped appropriately.
- The examiner should use warm gloved hands and a warm speculum.
- Each step of the examination should be explained in advance to the patient.
- Always do pelvic exam chaperoned.
- Ask the patient to assume the lithotomy
position.
- Select an appropriately sized
speculum, warmed with
water.
- Do not lubricate your gloved fingers, as this
may intefere with papsmear.
- Place two fingers just inside or at the introitus and gently press down on the perineal body.
- With your other hand, introduce the
closed speculum past
your fingers at a 45o angle downward.
- The blades should be held up obliquely and the
pressure exerted towards the posterior vaginal wall, avoiding the more
sensitive anterior wall and urethra.
- After the speculum has entered the vagina,
remove your fingers from the introitus.
- Rotate the blades of
the speculum into a horizontal position.
- Open the blades
after full insertion and
maneuver the speculum gently so that the cervix comes into full view.
- Inspection
- Cervix
- Note the color of the cervix
- Describe the mucous membrane
- Position of Cervix
- Cervical os
- Appearnce and location
- Mucous membrane
- note the nature of discharge.
Normal:
- Cervical os is small
and round in nulliparous and slit like after
child birth.
- The cervix is covered by smooth pink
epithelium
Pap
Smear
To detect cervical cancerMethod Of Exam
Author: A. Chandrasekhar
|
Consultant: P. Tomich
|
With the
blades open, secure the speculum by tightening the thumb screw. Take three
specimens:
- Endocervical swab: Insert a cotton applicator stick (wire brush
may also be used for endocervical specimens)
into the os of the cervix. Roll the stick gently
between the thumb and index finger. Remove and smear a labelled
glass slide.
- Cervical scrape: Place the longer end of a cervical spatula into
the os of the cervix and press gently, turn and
scrape. Smear a second labelled glass slide. Any
bleeding of the cervix during this procedure should be noted.
- Posterior fornix: Roll
a cotton applicator stick on the floor of the vagina posterior to the
cervix. Smear a third labelled glass slide.
Note: A
fixative must be immediately applied to each slide.
Vagina:
Speculum Exam of
To evaluate the vagina.
Method Of Exam
Author: A. Chandrasekhar
|
Consultant: P. Tomich
|
- Technique
- Inspection of vagina is done during withdrawl of speculum after inspection of cervix and
after taking pap smear.
- Release the thumb screw first.
- Slowly remove the speculum,
controlling the degree the blades are opened.
- Close the blades as the speculum emerges from
the introitus.
- During withdrawal, inspect the vaginal mucosa
- Inspect Vaginal mucosa for
- Color
- Inflammation
- Ulcers
- Discharge
- Masses.
Pelvis:
Bimanual Exam
To evaluate cervix, uterus and adnexa
Method Of Exam
Author: A. Chandrasekhar
|
Consultant: P. Tomich
|
- Palpate vagina and Cervix
- Technique
- Introduce the middle and index fingers of
your gloved and lubricated hand into the vagina.
- The thumb should be abducted and the ring and
little fingers flexed into the palm.
- Feel: Identify the cervix, noting its position, shape,
consistency, regularity, mobility and tenderness.
- Palpate uterus via bimanual exam
- Technique
- Place your other hand midway between the
umbilicus and the symphysis pubis and press
downward toward the pelvic hand.
- Using the palmar
surface of your fingers, palpate for the uterine fundus
while gently pushing the cervix anteriorly
with the pelvic hand.
- Feel the uterus and note
- Size
- Position
- Consistency
- Mobility
- Tenderness
- Palpate adnexa via bimanual exam.
- Technique
- Gently slide the vaginal fingers into the
lateral vaginal fornix while pushing
inferiorly with the abdominal hand.
- An attempt should be made to entrap the adnexa between the abdominal and vaginal hand.
- Feel:
Normal:
- Normal uterus
- is the size of a small orange. When enlarged
often described in size corresponding to weeks of Pregnancy
- Upside down Pear shaped
- firm
- smooth surface
- anteverted (80%) and anteflexed.
- freely movable.
- not tender
- Adnexa.
- Ovary 2x2 cms
- Almond shaped
- slightly tender to palpation
- very mobile
Rectovaginal
Exam
To evaluate rectovaginal septum.
Method Of Exam
Author: A. Chandrasekhar
|
Consultant: P. Tomich
|
- Technique
- Remove the gloves used for vaginal exam. Wear
new pair of gloves and lubricate the gloved fingers.
- Slowly reintroduce the index finger into the
vagina and the middle finger into the rectum.
- Ask the patient to bear down as the rectal
finger is introduced.
- Sweep from side to side and use abdominal hand
to bring utereus and adnexa
towards vaginorectal hand
- Feel:
- Examine the rectovaginal septum for thickening, nodularity
or tenderness.
- While gently pressing your fingers as
superiorly as possible, examine the rectouterine
pouch.
- During this procedure, palpate laterally,
identifying the right and left uterosacral ligaments and noting any masses or abnormal tenderness.
- Re-examine both the right and left adnexa with the rectovaginal
technique.
Note: Occasionally,
ovarian tumors or cysts may be palpated using this technique, but missed during
the bi-manual exam.