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:

  1. 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.
  2. 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.
  3. 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.