OnExam
- Obstetric and Gynecological Pelvic Examination & Pap Smear
Before the Examination
General approach
- Explain steps in advance
- Be aware of wording (avoid trigger words such as "relax," “spread your legs”)
- If this is 1st pap, show equipment, explain steps before beginning the procedure
- Monitor comfort
- Be gentle
Introduction
- Wash hands
- Introduce yourself
- Your role
- Obtain consent
- How the patient would like to be addressed
- Confidentiality
- Offer to have a female chaperone
- Last 24-48 hours, has the patient had
- Intercourse
- Vaginal Suppositories
- Douching
- Is the bladder empty?
Prepare equipment
- Gloves - 2 pairs
- Speculum
- Choose appropriate size (small, medium, large)
- Small Pedersen - for patients who have never been sexually active, elderly
- Medium Pedersen - for sexually active women
- Graves - for women who have had vaginal deliveries
- Warm metal speculum with water
- Light (overhead or attached to speculum)
- Cervical broom and solution
- Swabs for cultures
- Water-soluble lubricant, wipes
- Drape for midabdomen
Position patient
- Dorsal lithotomy position
- Lay down with pillow under head (head and shoulders elevated to 30°), arms at sides or folded across chest, heels in stirrups, slide all the way down until buttocks are at the edge, let knees fall out to the sides
- Drap for midabdomen to knees and depress drape for eye contact
- Ask if patient is comfortable
External Examination
- Inspection
- Adolescent patients: assess sexual maturity using Tanner Stages
- Stage 1: no pubic hair
- Stage 2: long slightly pigmented hair along labia majora
- Stage 3: darker coarser curly hair over pubic symphysis
- Stage 4: more curly hair, no hair on thighs
- Stage 5: hair is present on the thighs
- Inspect external genitalia for masses, excoriations, erythema, maculopapules, vesicles, nits/lice
- Mons pubis
- Labia majora
- Perineum
- Perianal area
- Separate labia and inspect the following for any inflammation, ulcerations, discharge, swelling, nodules
- Labia minora
- Clitoris (enlarged in masculinizing conditions
- Urethral meatus (urethral caruncle, prolapse
- Introitus
- Assess for vaginal prolapse
- Separate labia between index and middle fingers
- Ask the patient to bear down
- Look for bulging
- Palpation
- Any lesions
- If labial swelling, palpate Bartholin's glands for tenderness and discharge
Internal Examination
- Apply small amount of water-soluble lubricant to the speculum
- Water-soluble lubricant does not interfere with Pap cytology or culture
- Enlarge introitus with finger
- Push down at the lower margin of introitus
- Introduce speculum
- Right hand: separate labia
- Left hand: gently insert speculum at slight angle from midline (e.g.2 o'clock)
- Avoid pressure on sensitive urethra
- Apply downward pressure and slide speculumalong posterior wall of vagina
- Remove fingers from labia
- Rotate speculum into a horizontal plane
- Keep applying downward pressure and sliding speculum along posterior wall of vagina
- Instert speculum to full length
- Open speculum
- Find cervix. Rotate and adjust speculum until entire cervix is visualized
- If cannot find cervix: withdraw speculum slightly, reposition to a different slope. A retroverted may point more anteriorly.
- Tighten screw to maintain open position
- Wipe discharge that obscures the view of cervix with a cotton swab
- Inspect cervix
- Note colour, position, surface characteristics, ulcerations, nodules, masses, bleeding, discharge (colour, consistency, amount, odour)
- Pap smear: use cervical broom to sample both endocervix and ectocervix.
- Insert tip of cervical brrom into os and rotate clockwise and counterclockwise 3-5 times
- Goal: collect cells from both endocervix and ectocervix
- Remove brush and plae it into solution for liquid cytology
- Swabs for culture (Chlamydia, gonorrhea, bacterial vaginosis, trichomonas, yeast)
- Pink - Chlamydia and gonorrhoea - gently insert swab into cervical os
- Blue - trichomonas, vaginosis - slide swab along vaginal wall in a zigzag pattern
- Withdraw speculum slowly
- Release thumb screw, maintain open position with thumb as speculum clears cervix
- Close epculum as it emerges from introitus
- Note: colour of vaginal mucose, inflammation, discharge, ulcers, masses
Bimanual Examination
- Lubricate index and middle fingers
- If fingers touch lubricant tube, discard lubricant (results in contamination)
- Stand at patient's side
- Applying posterior pressure towards perineum, insert two fingers into vagina
- Abduct thumb, flex 4th and 5th fingers into the palm
- This is the pelvic hand
- Place the other hand on patient's lower abdomen midway between umbilicus and symphysis pubis
- This is the abdominal hand
- Palpate pelvic organs
- Vaginal wall (urethra, anterior bladder)
- Palpate for nodules and tenderness
- Cervix and fornices
- Body of uterus
- Pelvic hand: Place fingers into anterior fornix, elevate cervix and uterus
- If uterus is retroverted, place fingers into posterior fornix
- Abdominal hand: press down on the andomen to capture the uterus between 2 hands
- Paplate for position, size, shape, masses, tenderness, mobility
- Ovaries
- Pelvic hand: place fingers into right lateral fornix for right ovary and left lateral fornix for left ovary
- Abdominal hand: press down in right lower quadrant of abdomen for right ovary and left lower quadrant of abdomen for left ovary
- Try to capture the ovary between to hands
- Palpate for position, size, shape, adnexal masses, tenderness, mobility
- Normally, ovaries are slightly tender
- Ovaries may not be palpable in females who are obese, poorly relaxed, or 3-5 years after menopause
- Strength of pelvic muscles
- 2 fingers to touch vaginal walls
- Ask the patient to squeeze pelvic muscles as hard and as long as she can
- Normally, fingers become compressed and move inwards and upwards. The patient can squeeze for ≥3 seconds.
- If not planning to do a rectovaginal examination
- Provide patient with towel to wipe herelf and panty-liner/pad
- Explain that some spotting may occur
Rectovaginal Examination
- Some providers perform this examination on all patients while others use specific indications (Eg. Pelvic pain/mass, rectal symptoms, colon cancer screening, Hx of pelvic cancer)
- Always perform AFTER bimanual examination. Put on new set of gloves.
- Lubricate index and middle fingers of pelvic hand
- If fingers touch lubricant tube, discard lubricant (results in contamination)
- Stand at patient's side
- Pelvic hand: index finger inserted into vagina and middle finger inserted into rectum. Ask patient to strain down as you are inserting the fingers.
- Note sphincter tone
- It is normal for the patient to feel like she is going to have a bowel movement.
- Place the other hand (abdominal hand) on patient's lower abdomen midway between umbilicus and symphysis pubis. Press downwards
- Pelvic hand: sweep fingers horizontally against each other in a scissoring fashion to assess septum (e.g., scarring). Then remove index finger from vagina and use middle finger to palpate all sides of rectum for tenderness, nodules, and masses
- Remove middle finger from rectum and look for frank blood
- Provide patient with towel to wipe herself and panty-liner/pad
- Explain that some spotting may occur
References
- Bernstein HB, Weinstein M. Normal pregnancy & prenatal care. In: Decherney AH, Goodwin TM, Nathan L, Laufer N, eds. CURRENT Diagnosis & Treatment Obstetrics & Gynecology. 10th ed. New York: McGraw-Hill; 2007:187-202.
- Bickley LS. Female genitalia. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 429-457.
- Bickley LS, Thompson, JE. The pregnant woman. In: Bickley LS, Szilagyi, PG. Bates’ Guide to Physical Examination and History Taking. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007: 817-838.
- Harmanli O, Jones KA. Using lubricant for speculum insertion. Obstet Gynecol. 2010;116(2):415-417.
- Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, Calver LE. Chapter 14. Pediatric Gynecology. In: Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, Calver LE, eds. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com.proxy.lib.nosm.ca/content.aspx?aID=56701893. Accessed November 17, 2013.
- Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG, eds. Well Woman Care. In: Williams Gynecology. New York: McGraw-Hill; 2008:2-24.
- Rowe T, Senikas V, Pothier M, Fairbanks J, Sams D. Canadian consensus guidelines on human papillomavirus. SOGC Clinical Practice Guidelines. No. 196. J Obstet Gynaecol Can. 2007;29(8 Suppl 3):S1-S56. http://www.sogc.org/guidelines/documents/gui196CPG0708revised.pdf. Accessed February 17, 2011.