Female Genitalia

Front 1

Anatomy and Physiology:
External Genitalia: Vulva: Mons pubis

Back 1

The symphysis pubis is covered by a pad of adipose tissue called the mons pubis or mons veneris, which in the postpubertal female is covered with coarse terminal hair

Front 2

Anatomy and Physiology:
External Genitalia: Vulva: Labia Majora/Minora

Back 2

 Extends downward and backwards from the mons pubis.
 Two folds of adipose tissue covered by skin
 Labia majora
 Vary in appearance depending on the amount of adipose tissue present,
 The outer surface of the labia majora is also covered in hair in the postpuberal female
 Labia minora
 Lying inside and usually hidden by the labia majora are the labia minora, two hairless, flat, reddish folds.
 The labia minora meet at the anterior of the vulva, where each labium divides with two lamellae, the lower pair fusing to form the frenulum of the clitoris.

Front 3

Anatomy and Physiology:
External Genitalia: Vulva: Clitoris

Back 3

 The labia minora meet at the anterior of the vulva, where each labium divides with two lamellae, the lower pair fusing to form the frenulum of the clitoris.
 Tucked behind the frenulum and the prepuce is the clitoris, a small bud or erectile tissue, the homolog of the penis and the primary center of sexual excitement,

Front 4

Anatomy and Physiology:
External Genitalia: Vulva: Vestibular glands

Back 4

Skene, Bartholin ducts

 Produces lubrication
 Prone to infection
 Skene ducts
 Skene ducts drain a group of urethral glands and open onto the vestibule on each side of the urethra
 Bartholin ducts
 Located posteriorly on each side of the vaginal orifice, open onto the sides of the vestibule in the groove between the labia minora and the hymen
 During sexual excitement, bartholin glands secrete mucus into the introitus for lubrication

Front 5

Anatomy and Physiology:
External Genitalia: Vulva: Vaginal Vestibule

Back 5

 The labia minora enclose the area designated as the vestibule, which contains six openings
 The urethra
 The vagina
 Two ducts of bartholin glands
 Two ducts of skene glands

Front 6

Anatomy and Physiology:
External Genitalia: Vulva: Vaginal oriface

Back 6

 Interiotus
 During sexual excitement, bartholin glands secrete mucus into the introitus for lubrication
 Aka vaginal orifaces
 The vaginal opening occupies the posterior portion of the vestibule and varies in size and shape
 Surrounding the vaginal opening is the hymen, a connective tissue membrane that may be circular, cresentric, or fimbriated,
 After the hymen tears and becomes permanently divided, the edges either disappear or form hymenal tags,

Front 7

Anatomy and Physiology:
External Genitalia: Vulva: Uretheral Opening

Back 7

 The lower two thirds of the urethra lie immediately above the anterior vaginal wall and terminate below the clitoris.
 Skene ducts drain a group of urethral glands and open onto the vestibule on each side of the urethra.
 The ductal openings may be visible.

Front 8

Anatomy and Physiology: Internal Genitalia: VAGINA

Back 8

 Musculomembranous tube that is transversely rugated during the reproductive phase of life.
 Inclines posteriorly at an angle of approx. 45 degrees with the vertical plane of the body,
 The anterior wall of the vagina is separated with the bladder and the urethra by connective tissue called the vesicovaginal septum.
 The posterior vaginal wall is separated from the rectum by the rectovaginal septum
 Usually, the anterior and posterior walls of the vagina lie in close proximity, with only a small space between them.
 The upper end of the vagina is a blind vault into which the uterine cervix projects.
 The pocket formed around the cervix is divided into the anterior, posterior, and lateral fornices.
 These are of clinical importance because the internal pelvic organs can be palpated through their thin walls.
 Vagina carries menstrual flow from the uterus, serves as the terminal portion of the birth canal, and is the receptive organ for the penis during sexual intercourse.

Front 9

Anatomy and Physiology: Internal Genitalia: UTERUS

Back 9

 Size of patient’s fist
 Thick and fibrous
 Sits in the pelvic cavity between the bladder and rectum.
 It in an inverted pear-shaped, muscular organ that is relatively mobile.
 Uterus is covered by the peritoneum and lined by the endometrium, which is shed during menstruation.
 The rectouterine cul-de-sac (pouch of douglas) is a deep recess formed by the peritoneum as it covers the lower posterior wall of the uterus and upper portion of the vagina, separating it from the rectum.
 Uterus is flattened anteroposteriorly and usually inclines forward at a 45 degree angle, although the size may be anteverted, anteflexed, retroverted, or retroflexed.

 Uterus is divided anatomically into two parts
 Corpus
 Consists of the fundus, which is the convex upper portion between the points of insertion of the fallopian tubes; the main portion of the body; the isthmus, which is the constricted lower portion adjacent to the cervix
 Cervix
 The cervix extends from the isthmus into the vagina.
 Distal part
 The uterus opens into the vagina via the external cervical os.

Front 10

Anatomy and Physiology: Internal Genitalia: UTERUS: CORPUS

Back 10

 Consists of the fundus, which is the convex upper portion between the points of insertion of the fallopian tubes; the main portion of the body; the isthmus, which is the constricted lower portion adjacent to the cervix

Front 11

Anatomy and Physiology: Internal Genitalia: UTERUS: CERVIX

Back 11

 The cervix extends from the isthmus into the vagina.
 Distal part
 The uterus opens into the vagina via the external cervical os.

Front 12

Anatomy and Physiology: Internal Genitalia: ADNEXA

Back 12

 Adnexa of the uterus comprise
 Fallopian tubes
 Ranges from 8-14 cm long and is supported by a fold of a broad ligament called the MESOSALPINX
 The isthmus of each fallopian tube ends in the uterine cavity
 The fimbriated end opens into the pelvic cavity, with a projection that extends to the ovary and captures the ovum
 Ovaries
 Pair of oval organs resting in a slight depression on the lateral pelvic wall at the level of the antereosuperior iliac spine.
 Approx. 3 cm long, 2 cm wide, and 1 cm thick in the adult woman during the reproductive years,
 Ovaries secrete estrogen and progesterone, hormones that have several functions, including controlling the menstrual cycle and supporting pregnancy.
 Uncommon to be able to palpate ovary.

Front 13

Anatomy and Physiology: Internal Genitalia: ADNEXA: FALLOPIAN TUBE

Back 13

 Ranges from 8-14 cm long and is supported by a fold of a broad ligament called the MESOSALPINX
 The isthmus of each fallopian tube ends in the uterine cavity
 The fimbriated end opens into the pelvic cavity, with a projection that extends to the ovary and captures the ovum

Front 14

Anatomy and Physiology: Internal Genitalia: ADNEXA: OVARIES

Back 14

 Pair of oval organs resting in a slight depression on the lateral pelvic wall at the level of the antereosuperior iliac spine.
 Approx. 3 cm long, 2 cm wide, and 1 cm thick in the adult woman during the reproductive years,
 Ovaries secrete estrogen and progesterone, hormones that have several functions, including controlling the menstrual cycle and supporting pregnancy.
 Uncommon to be able to palpate ovary.

Front 15

Anatomy and Physiology: Menstrual Cycle: MENSTRUAL PHASE

Back 15

 Days 1-4
 ovary
 Estrogen levels begin to rise, preparing follicle and egg for next cycle.
 uterus
 Progesterone stimulates endometrial prostaglandins that cause vasoconstriction
 Upper layers of endometrium shed
 CNS hormones
 Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels decrease
 Symptoms
 Menstrual bleeding may vary, depending on hormones and prostaglandins

Front 16

Anatomy and Physiology: Menstrual Cycle: POST MENSTRUAL PHASE

Back 16

 Days 5-12
 Proliferation
 Ovary
 Ovary and maturing follicle produce estrogen; follicular phase—egg develops within follicle
 Uterus
 Proliferative phase-uterine lining thickens
 Breast
 Parenchymal and proliferation (increased cellular activity) of breast ducts occurs
 CNS hormones
 FSH stimulates ovarian follicular growth

Front 17

Anatomy and Physiology: Menstrual Cycle: SECREATORY PHASE

Back 17

 Days 15-20
 Ovary
 Egg (ovum) is moved by cilia into the uterus
 Uterus
 After the egg is released, the follicle becomes a corpus luteum; secretion of progesterone increases and predominates
 CNS hormones
 LH and FSH decrease

Front 18

Anatomy and Physiology: Menstrual Cycle: PREMENSTRUAL PHASE: LUTEAL PHASE

Back 18

 Days 21-28
 Ovary
 If implantation does not occur, the corpus luteum degenerates; progesterone production decreases, and estrogen production drops and then begins to rise as a new follicle develops
 Uterus
 menstruation occurs around day 28, which begins day one of the menstrual cycle
 breast
 alveolar breast cells differentiate into secretory cells
 CNS hormones
 increased levels of gonadotropin-releasing hormone cause increased secretion of FSH
 symptoms
 vascular engorgement and water retention may occur

Front 19

Bony pelvis during pregnancy

Back 19

the bony pelvis is important in accommodating a growing fetus during pregnancy and in the birth process

Front 20

 Anatomy and Physiology: Bony Pelvis: FOUR BONES

Back 20

 Two innominate (ilium, ischium, pubis)
 Sacrum
 Coccyx

Front 21

 Four pelvic joints

Back 21

 Symphysis pubis
 Sacrococcygeal
 Two sacroiliac

Front 22

Pelvic joints during pregnancy

Back 22

 Pelvic joints that don’t move much
 during pregnancy, increased levels of circulating hormones estrogen and relaxin contribute to the strengthening elasticity of public ligaments and softening of the cartilage
 as a result, the public joint separate slightly, allowing some motility

Front 23

Anatomy and Physiology: Infants/Children: Vagina

Back 23

 the vagina of the female infant in a small narrow tube with fewer epithelial layers than that of the adult

Front 24

Anatomy and Physiology: Infants/Children: Cervix

Back 24

 the cervix constitutes about two thirds of the entire length of the uterus

Front 25

Anatomy and Physiology: Infants/Children: Ovaries

Back 25

 the ovaries are tiny and functionally immature

Front 26

Anatomy and Physiology: Infants/Children: labia majora

Back 26

hairless

Front 27

Anatomy and Physiology: Infants/Children: Hymen

Back 27

 Hymen intact
 Flap of tissue
 a thin diaphragm just inside the introitus, usually with a crescent shaped opening

Front 28

Anatomy and Physiology: Infants/Children: Genitalia growth

Back 28

 during childhood, the genitalia, except for the clitoris, grow incrementally at varying rates.
 Anatomic and functional development accelerates with the onset of puberty and the accompanying hormonal changes

Front 29

Anatomy and Physiology: Adolescents

Back 29

 Puberty - functional maturation of reproductive organs
 Increase in external genitalia
 during puberty, the external genitalia increase in size and begin to assume adult proportions
 Clitoris becomes erectile
 Pubic hair develops
 Vagina lengthens/secretions become acidic
 Uterus/ovaries/tubes increase in size
 Uterine musculature/vascular supply increase
 Endometrial lining thickens
 the endometrial lining thickens in preparation for the onset of menstruation (menarche), which on average occurs between 11 and 14 years of age United States
 just before menarche, vaginal secretions increase

Front 30

functional maturation of the reproductive organs is reached during __________

Back 30

functional maturation of the reproductive organs is reached during PUBERTY

Front 31

Anatomy and Physiology: Pregnant Women: INCREASE IN WHAT HORMONES

Back 31

estrogen and progesterone

Front 32

Anatomy and Physiology: Pregnant Women: UTERUS

Back 32

 Enlarged elastic uterus
 the high levels of estrogen and progesterone that are necessary to support pregnancy are responsible for uterine enlargement during the first trimester
 after the third month, uterine enlargement is primarily the result of mechanical pressure of the growing fetus
 as the uterus enlarges, the muscular walls strengthens and become more elastic
 as the uterus becomes larger and more ovoid, it rises out of the pelvis; by 12 weeks of gestation and reaches into the abdominal cavity.

Front 33

Anatomy and Physiology: Pregnant Women: PELVIC CARTILAGE AND LIGAMENTS

Back 33

 hormonal activity (relaxin and progesterone) is responsible for the softening of the pelvic cartilage and strengthening of the pelvic ligaments

 as a consequence, the public joint separate slightly, allowing more mobility; this results in the characteristic "waddle" gait

Front 34

Anatomy and Physiology: Pregnant Women: PELVIC CONGESTION

Back 34

 during pregnancy, and increasing uterine blood flow in live causes pelvic congestion and edema.
 As a result the uterus, cervix, and Isthmus soften, and the cervix takes on a bluish color

Front 35

Anatomy and Physiology: Pregnant Women: VAGINAL WALLS

Back 35

 both the mucosa of the vaginal walls and the connective tissue thickened, and smooth muscle cells hypertrophy
 these changes result in an increased length of the vaginal walls, so that at times it can be seen protruding from the valvular opening

Front 36

Anatomy and Physiology: Pregnant Women: VAGINAL SECRETIONS

Back 36

 the vaginal secretions increase and have an acidic pH due to the increase in lactic after production by the vaginal epithelium

Front 37

Anatomy and Physiology: Older Adults

Back 37

 Menopause
 one year without menses
 during this time, estrogen levels decrease, causing the labia and clitoris to become smaller
 the labia majora also becomes flatter as body fat is lost
 External/internal genitalia decrease in size
 Tissue loses elasticity/tone
 the ligaments and connective tissue of the pelvis sometimes lose their elasticity and tone, thus weakening the support of slaying of the public contents
 the vaginal walls may lose some of their structural integrity
 Pubic hair turns gray
 Decrease in libido
 both adrenal androgens in ovarian testosterone levels markedly decreased after menopause, which may account in part for decreased libido and in muscle mass and strength
 Vagina narrows/loses lubrication
 the vaginal introitus gradually constricts
 the vagina narrows, shortens, and loses its rogation; and the mucosa becomes thin, pale, and dry, which may result in dyspareunia
 tissue for intercourse for menopausal women
 recommend lubricant

Front 38

Metrorrhagia

Back 38

 Vaginal bleeding at anytime other then during the period

Front 39

 Menorrhagia

Back 39

 Excessive bleeding with period

Front 40

 Menarche

Back 40

 age of first period

Front 41

 Amenorrhea

Back 41

 no menses

Front 42

 Dysmenorrhea

Back 42

 pain with the period

Front 43

 Dysperunia

Back 43

 pain with intercourse

Front 44

 Post Coital

Back 44

 after intercourse

Front 45

 Threaten Miscarriage

Back 45

 when you have vaginal bleeding within the first 20 weeks of pregnancy. It suggests that a miscarriage may happen. Miscarriages that occur during the first 3 months of pregnancy are usually due to a problem in the way the baby develops.

Front 46

 Miscarriage

Back 46

 diagnosed by ultrasound
 A miscarriage is the spontaneous loss of a fetus before the 20th week of pregnancy. (Pregnancy losses after the 20th week are called preterm deliveries.)

Front 47

 Fetal Demise

Back 47

 the death of a baby in the uterus, during pregnancy and before birth.

Front 48

 Related History: Present Problem: ABNORMAL BLEEDING

Back 48

 Character
 shortened interval between periods (less than 19 to 21 days), lengthened interval between. (More than 37 days), amenorrhea, prolonged menses (more than seven days), bleeding between periods; postmenopausal bleeding
 Change in flow
 nature of change, number of pads or tampons used in 24 hours (tampons/pads soaked?), Presence of clots
 Temporal sequence
 onset, duration, precipitating factors, course since onset
 Associated symptoms
 pain, cramping, abdominal distention, pelvic fullness, change in bowel habits, weight loss or gain
 Medications
 oral contraceptives; hormones; tamoxifen

Front 49

Related History: Present Problem: PAIN

Back 49

 Temporal sequence
 date and time of onset, sudden versus gradual onset, course since onset, duration, reoccurrence
 Character
 specific location, type, and intensity of pain
 Associated symptoms
 vaginal discharge or bleeding, gastrointestinal symptoms, abdominal distention or tenderness, pelvic fullness
 Association with menstrual cycle
 timing, location, duration, changes
 Aggravating/relieving factor
 Previous medical treatment
 Efforts to treat
 Medications
 analgesics

Front 50

Related History: Present Problem: VAGINAL DISCHARGE

Back 50

 Character
 amount, color, odor, consistency, changes in characteristics
 Occurrence
 acute or chronic
 Douching
 Clothing habits
 use of cotton or ventilated underwear in pantyhose, tight pants or jeans
 Symptoms in sexual partner
 Use of condoms
 Associated symptoms
 itching; tender, inflamed, or bleeding external tissue; dyspareunia; dysuria or burning on urination; abdominal pain or cramping; pelvic fullness
 Efforts to treat
 antifungal vaginal cream
 Medications
 oral contraceptives, antibiotics

Front 51

Related History: Present Problem: PREMENSTRUAL SYMPTOMS

Back 51

 Symptoms
 headaches, weight gain, edema, breast tenderness, irritability or mood changes
 Frequency
 Every period?
 Interference with ADLs
 Relief measures
 Aggravating factors
 Medications
 analgesics, diuretics

Front 52

Related History: Present Problem: MENOPAUSAL SYMPTOMS

Back 52

 Age at menopause
 Symptoms
 menstrual changes, mood changes, tension, left lashes
 Postmenopausal bleeding
 Sign of endometrial cancer
 Feelings about menopause
 self-image, affected intimate relationships
 Mother’s experience
 Medications
 hormone therapy serum estrogen receptor modulators; soy, other natural estrogen products; black cohosh

Front 53

Related History: Present Problem: INFERTILITY

Back 53

 Time attempting pregnancy
 infertility is defined as one year of trying to get pregnant but not be able to
 Sexual activity pattern
 Knowledge of menstrual cycle
 Physical abnormalities
 vagina, cervix, uterus, fallopian tubes, ovaries
 fallopian tube scarring-cause of infertility. Also increases the chance of ectopic pregnancy
 Contributing factors
 stress, nutrition, chemical substances
 Partner factors
 Diagnostic evaluation to date

Front 54

Related History: Present Problem: URINARY SYMPTOMS

Back 54

 Character
 acute or chronic; frequency of occurrence; last episode; onset; for since onset; feel like bladder is empty or not after voiding; pain at start, throughout, or at cessation of urination
 Urine description
 color, presence of blood or particles, clear or cloudy
 Associated symptoms
 vaginal discharge or bleeding, abdominal pain or cramping, abdominal distention, pelvic fullness, flank pain
 Medications
 urinary tract analgesics, anti-spasmodic

Front 55

Related History: Past Medical History: MENSTRUAL HISTORY

Back 55

 Menarche
 LMP
 date of last normal menstrual period: first day of last cycle
 Days in cycle
 Character of flow
 amount (number of pads or tampons used 24 hours on heaviest days), duration, presence and size of clots
 Dysmenorrhea
 characteristics, duration, frequency (occurs with each cycle?), Relief measures
 Intermenstrual bleeding/pain
 severity and duration, timing; Association with ovulation
 Premenstrual symptoms
 headaches, weight gain, edema, breast tenderness, irritability or mood changes, frequency (occur with every period?), Interference with activities of daily living, relief measures

Front 56

Related History: Past Medical History: SEXUAL HISTORY

Back 56

 Current sexual activity
 Contraception
 Barrier protection
 Prior STDs
 Satisfaction with relationship

Front 57

Related History: Past Medical History: OBSTETRIC HISTORY

Back 57

 G
 gravida: the total number pregnancies
 P
 Para-number of viable pregnancies (last 24 weeks)
 #
 number of term pregnancies
 #
 Preterm pregnancies
 #
 number of abortions, spontaneous or induced
 #
 Living children

Front 58

Related History: Past Medical History: MENOPAUSAL HISTORY

Back 58

 Age of menopause
 Associated symptoms
 menstrual changes, mood changes, tension, hot flashes
 Postmenopausal bleeding
 Birth control
 Feelings about menopause
 self-image, effect on intimate relationships
 Mother’s experience
 Medications
 hormone therapy; does induration, related side effects; breast tenderness, bloating, vaginal bleeding; estrogen receptor modulators, related side effects; hot flashes, breast tenderness

Front 59

What is a sign of endometrial cancer

Back 59

postmenopausal bleeding

Front 60

Related History: Past Medical History: GYNECOLOGICAL HISTORY

Back 60

 Prior Pap smears
 Past/recent GYN procedures/surgery
 STDs
 PID
 Fallopian tube or ovarian inflammation- can cause abscess
 Shuffling gait
 Vaginal infections
 Diabetes
 Changes flora of the vagina
 Cancer of reproductive organs

Front 61

Related History: FAMILY HISTORY

Back 61

 Diabetes
 Cancer of reproductive organs
 Mother have DES while pregnant
 Multiple pregnancies
 Congenital anomalies

Front 62

Related History: PERSONAL/SOCIAL HISTORY

Back 62

 Cleansing routines
 use of sprays, powders, perfume, antiseptic soap, deodorants, or ointments
 Contraceptive history
 current method: length of time used, effectiveness, consistency of use, side effects, satisfaction with methods
 previous methods: duration of use for each, side effects, and reason for discontinuing each
 Douching history
 frequency: length of time since last douche; number of years douching
 method
 solution used
 reason for douching
 Sexual history
 current sexual activity: number of current and previous partners; number of their partners; gender of partner (S), sexual preference
 method (S) of contraception; current and past; satisfaction with
 use of barrier protection for sexually transmitted infections
 prior sexually transmitted infections
 satisfaction with relationships, sexual pleasure achieved, frequency
 problems: pain and penetration (entry are deep); decreased lubrication, lack of orgasm
 Date last pelvic exam/Pap smear
 Use of alcohol, drugs

Front 63

Related History: Infants/Children: BLEEDING

Back 63

 Character
 onset, duration, precipitating factor if known, course since onset
 Associated symptoms
 pain, change in crying of infant, child feel for parent or other adults
 Parental suspicion about foreign objects
 Suspicion about sexual abuse

Front 64

Related History: Infants/Children: PAIN

Back 64

 Character
 type of pain, onset, course since onset, duration
 Location
 Associated symptoms
 vaginal discharge or bleeding, urinary symptoms, gastrointestinal symptoms, child fearful parents or other adults
 Contributory problems
 use of bubble bath, irritating soaps, or detergents; parental suspicion about insertion of foreign objects by child or about possible sexual abuse

Front 65

Related History: Infants/Children: VAGINAL DISCHARGE

Back 65

 Relationship to diapers
 use of powder or lotions, how frequently diapers or changed
 Associated symptoms
 pain, bleeding
 Contributory problems
 parental suspicion about insertion of foreign objects by child or about possible sexual abuse

Front 66

 Related History: Adolescents

Back 66

 Same questions as any adult female
 Talk with teen in private

Front 67

Related History: Pregnant Women

Back 67

 EDC
 Estimated date of confinement
 Obstetrical history
 GPTAL, prenatal complications, infertility treatment
 Birth history
 length of gestation at birth, birth weight, fetal outcome, length of labor, fetal presentation, type of delivery, use of forceps, lacerations and/or episiotomy, complications (natal or postnatal)
 Menstrual history
 Surgical history
 prior uterine surgery and type of scar
 Family history
 diabetes, multiple births, preeclampsia, and genetic disorder
 Involuntary fluid leakage
 (may result in rupture of membranes)
 determine onset, duration, color, odor, amount, and it still leaking
 Bleeding
 character: onset, duration, precipitating factor if known (e.g., intercourse, trauma), course since onset, amount
 associated symptoms
 GI symptoms
 nausea, vomiting, heartburn

Front 68

Related History: Older Adults: MENOPAUSAL HISTORY

Back 68

 Menopausal history
 Age of menopause
 Associated symptoms
 Postmenopausal bleeding
 Birth control
 Feelings about menopause
 Mother’s experience
 Medications

Front 69

Related History: Older Adults: SYMPTOMS ASSOCIATED WITH AGE

Back 69

 Itching
 Dyspareunia
 Urinary problems

Front 70

Related History: Older Adults: SEXUAL CHANGES

Back 70

 Desire
 Behavior

Front 71

Exam & Findings: External Exam Inspection: Labia majora

Back 71

 Symmetry
 Redness/swelling
 we appeal swelling, redness, or tenderness, particularly if unilateral, may be indicative of a batholin gland infection
 Excoriation/rashes/ lesions
 Discoloration
 Varicosities
 Stretching
 Trauma

Front 72

Exam & Findings: External Exam Inspection: Labia Minora

Back 72

 Symmetry
 may be symmetric or asymmetric
 Moisture
 moist
 Color
 dark pink
 Inflammation
 indicates vaginal infection or poor hygiene
 Excoriation
 indicates vaginal infection or poor hygiene
 Discharge
 indicates vaginal infection or poor hygiene
 Ulcers
 sign of sexually transmitted infections

Front 73

Exam & Findings: External Exam Inspection: Clitoris

Back 73

 Size
 generally 2 cm or less in length and 0.5 cm in diameter
 enlargement may be a sign of a masculinizing condition
 Atrophy
 Adhesions/inflammation

Front 74

Exam & Findings: External Exam Inspection: Urethral Oriface

Back 74

 Discharge
 Polyps/caruncles/ fistulas
 a carnucle is a bright red polypoid growth that protrudes from the urethral meatus; most urethral carnucle cause no symptoms
 Irritation/inflammation
 suggest repeated urinary tract infections or insertion of foreign objects
 ask questions about any finding that a later time-not during the pelvic examination when the woman feels most vulnerable

Front 75

Exam & Findings: External Exam Inspection: vaginal introitus

Back 75

 Moisture
 moist
 Swelling
 Discoloration
 Discharge
 Lesions/fistulas/fissures

Front 76

Exam & Findings: External Exam Inspection:  Perineum

Back 76

 Scarring
 Inflammation
 Fistulas/lesions/ growths

Front 77

Exam & Findings: External Exam Inspection: ANUS

Back 77

 Color
 darkly pigmented, and the skin may appear course
 Scarring/skin tags
 Excoriation
 Fissures, lesions

Front 78

Exam & Findings: External Exam PALPATION: SKENE/BARTHOLIN GLANDS

Back 78

 Discharge
 if discharge occurs, note is color, consistency, and odor entertainment culture
 discharge from the SKENE gland usually indicates an infection-most commonly, but not necessarily, gonococcal
 discharge from the bartholin gland is usually gonococcal are staphylococcal in origin is pus filled
 Tenderness
 Swelling
 Masses
 Temperature

Front 79

Exam & Findings: Internal Exam PALPATION: PERINEUM

Back 79

 Consistency
 should be smooth
 Thickness
 episiotomy scarring may be evident women who have borne children
 the tissue will fill thickened smooth and in nulliparous woman
 it will be thinner and rigid and multi-parous women
 Pliability

Front 80

Exam & Findings: Internal Exam: CERVIX: COLOR

Back 80

 the cervix should be pink, with the color evenly distributed
 a bluish color indicates increase vascularity, which may be a sign of pregnancy
 symmetric, circumscribed redness around the os is an expected finding that indicates expose columnar epithelium from the cervical canal
 a pale cervix associated with anemia

Front 81

Exam & Findings: Internal Exam: CERVIX: POSITION

Back 81

 the anterior-posterior position of the cervix correlate the position of uterus
 a cervix that is pointing anteriorly indicates a retroverted uterus; one pointing posteriorly indicates anteverted uterus
 a cervix in the horizontal position indicates a uterus in the position
 the cervix should be located in the midline. Deviation to the right or left may indicate a pelvic mass, uterine adhesions, or pregnancy
 the cervix may protrude 1 to 3 cm into the vagina. Projection greater than 3 cm may indicate a pelvic or uterine mass

Front 82

Exam & Findings: Internal Exam: CERVIX: SIZE

Back 82

 the cervix of a woman of childbearing age is usually 2 to 3 cm in diameter

Front 83

Exam & Findings: Internal Exam: CERVIX: SURFACE CHARACTERISTICS

Back 83

 the surface of the cervix should be smooth
 some squamo-columnar epithelium of the cervical canal may be visible as a symmetric red circle around the os
 columnar epithelium from the cervical canal appears as shiny red tissue around the os that may bleed easily

Front 84

Exam & Findings: Internal Exam: CERVIX: DISCHARGE

Back 84

 note any discharge
 determine whether the discharge comes with the cervix itself, or whether it's vaginal origin and has only been deposited on the cervix
 usual discharges odorless; may be creamy or clear; may be thick, thin, or stringy; and is often heavier admit cycle or immediately before menstruation
 the discharge of bacterial or fungal infection will more likely have in order and will vary in color from white to yellow, green, or gray

Front 85

Exam & Findings: Cervical os

Back 85

 Size
 Nulliparous woman- size is small and round or oval
 Multiparous woman-usually a horizontal slit or maybe a regular and stellate
 Shape

Front 86

Exam and Findings: Tests

Back 86

 Pap smear
 Gonococcal culture
 DNA probe
 Wet mount- CLUE CELLS come out when there is a yeast infection, WBC, Trichomonas.

Front 87

Exam & Findings: Bimanual Exam: CERVIX PALPATION

Back 87

 Position
 should be midline and may be pointing anteriorly or posteriorly
 Movement
 grasp the cervix gently between your fingers and move it from side to side
 observe the patient for any expression of pain or discomfort with movement (cervical motion tenderness)
 ultrasound should be ordered for high suspicion of public problem
 chandeliers sign-positive cervical motion tenderness-pelvic inflammatory disease
 the cervix should move 1 to 2 cm in each direction with minimal or no discomfort
 Nodules
 Tenderness
 grasp the cervix gently between your fingers and move it from side to side
 observe the patient for any expression of pain or discomfort with movement (cervical motion tenderness)
 ultrasound should be ordered for high suspicion of public problem
 chandeliers sign-positive cervical motion tenderness-pelvic inflammatory disease
 Open or Closed
 If os is open during pregnancy- miscarriage
 External and internal sphincter. External sphincter may be open after first pregnancy but internal sphincter should be shut.

Front 88

Exam & Findings: Bimanual Exam: UTERUS PALPATION: FUNDUS

Back 88

 The fundus of the uterus is the top portion, opposite from the cervix.

Front 89

Exam & Findings: Bimanual Exam: UTERUS PALPATION: POSITION

Back 89

 anteverted or anteflexed
 place the Palmer surface of your other hand on the abdominal midline, midway between the umbilicus in the symphysis pubis
 place the intravaginal fingers in the anterior fornix
 slowly slide the abdominal hand toward the pubis, pressing downward and forward with a flat surface of your fingers
 at the same time, push inward and upward with your fingertips of the intravaginal hand while you push downward on the cervix the backs of your fingers
 if the uterus is anteverted or anteflexed (the position of most uteri), you will feel the fundus between your fingers of your two hands at the level of the pubis
 retroverted or retroflexed
 if you do not feel the uterus to the previous maneuver, placed the intravaginal fingers together in the posterior for next, with the abdominal hand immediately above the symphysis pubis
 press firmly downward with the abdominal hand while you press against the cervix inward with the other hand
 a retroverted or retroflexed uterus should be felt with this maneuver
 should be located in the midline regardless of his position
 deviation to the right or left is indicative of possible adhesions, public masses, or pregnancy

Front 90

Exam & Findings: Bimanual Exam: UTERUS PALPATION: MOBILITY

Back 90

 gently move the uterus between the intravaginal hand and abdominal and to assess for mobility and tenderness
 the uterus should be mobile in the antero posterior plane
 a fixed uterus indicates adhesions

Front 91

Exam & Findings: Bimanual Exam: UTERUS PALPATION: TENDERNESS

Back 91

 tenderness on movement suggests a pelvic inflammatory process are ruptured tubal pregnancy

Front 92

Exam & Findings: Bimanual Exam: ADNEXA

Back 92

 Ovaries palpation
 palpate the adnexal areas and ovaries
 place the fingers of your abdominal hand on the right lower quadrant
 with the intravaginal hand facing upward, placed both fingers and the right lateral fornix
 press the intravaginal fingers deeply inward and upward toward the abdominal hand, while sweeping the flat surface of your fingers of the abdominal hand deeply inward and obliquely downward toward the symphysis pubis
 palpate the entire area by firmly pressing the abdominal he handed intravaginal fingers together
 repeat this maneuver on the left side
 the ovaries, if palpable, should be firm, smooth, ovoid, and approximately 3 x 2 x 1 cm in length
 Tenderness
 the healthy ovary a slightly to moderately tender on palpation
 marked tenderness, enlargement, and nodularity are unexpected
 Swelling
 Hard to palpate
 usually no other structures are palpable except for round ligaments
 fallopian tubes are usually not palpable, so a problem may exist that they are felt
 you are also palpating parade adnexal masses, and if they are found they should be characterized by shape, size, location, consistency, and tenderness
 the adnexa are often difficult to palpate because of their location and position in the presence of excess adipose tissue and some women
 if you're unable to feel anything in the adnexal area with thorough palpation, you can assume that no abnormality is present, provided no clinical symptoms exist

Front 93

Exam & Findings: Rectovaginal Exam: ANAL SPHINCTER

Back 93

 place your index finger in the vagina, and press your middle finger against the anus and asked the patient to bear down
 as she does, slipped the tip of your fingers into the rectum and just past the sphincter
 palpate the area of the anorectal junction and just above it
 ask the woman to tighten and relax or anal sphincter
 observe sphincter tone
 Tone
 an extremely tight sphincter may be the result of anxiety about the examination; may be caused by scarring; or may indicate spasticity caused by fissures, lesions, or inflammation
 a lax sphincter suggest neurologic deficit, whereas in absent sphincter may result from improper repair of third-degree perineal laceration after childbirth or trauma

Front 94

Exam & Findings: Rectovaginal Exam: RECTAL WALLS

Back 94

 slide both your vaginal and rectal fingers in as far as they will go, then asked the woman to bear down
 this will bring in additional centimeter within the reach of your fingers
 rotate the rectal finger to explore the anterior rectal wall for masses, polyps, nodules, strictures, irregularities, and tenderness
 Masses/polyps/nodules/ strictures
 Irregularities
 Tenderness
 the walls should feel smooth and uninterrupted

Front 95

Exam & Findings: Rectovaginal Exam: STOOL

Back 95

 as you withdraw your fingers, rotate the recto finger to evaluate the posterior rectal wall just as you did earlier for the anterior wall.
 Gently remove your examination finger and observe for secretions and stool
 note:
 Color
 Blood

Front 96

Exam & Findings: Rectovaginal Exam: RECTOVAGINAL SEPTUM

Back 96

 palpate the rectovaginal septum along the anterior wall for thickness, tone, and nodules
 Tone
 Thickness
 Nodules

Front 97

Exam & Findings: Rectovaginal Exam: UTERUS

Back 97

 press firmly in deeply downward with the abdominal hand just above the symphysis pubis while you position the vaginal finger in the posterior vaginal fornix, and press strongly upward against the posterior side of the cervix
 palpate is much is the posterior side of the uterus possible, confirming your findings from the vaginal examination regarding:
 Location/position
 Size/shape/contour
 Consistency
 Tenderness
 it's this maneuver is particularly useful in evaluating a retroverted uterus

Front 98

 Exam & Findings: Infants

Back 98

 Inspect/palpate external genitalia only
 the newborn genitalia reflects the influence of maternal hormones
 Expected swelling
 Milky discharge
 a mucoid, widest vaginal discharge is commonly seen during the newborn. And sometimes as late as four weeks after birth
 the discharges occasionally mixed with blood
 this is a result of passive hormonal transfer from the mother and is an expected finding
 parental reassurance is often necessary
 Enlarged clitoris
 the clitoris may appear relatively large; this usually has no significance
 true hypertrophy is not common; however, in newborns, an enlarged uterus must alert the clinician to the possibility of congenital adrenal hyperplasia
 Ambiguous appearance
 any ambiguous appearance or unusual orifice in the vulvar vault or perineum must be expeditiously explored before gender assignment occurs
 Adhesions between labia minora
 thin but difficult to separate adhesions between them labia menorah are often seen during the first few months or even few years of life
 sometimes a completely cover the vulvar vestibule
 there may be just the smallest of openings through which urine can escape
 these may require separation, using the gentlest of teasing or the application of estrogen creams

Front 99

Exam & Findings: Children: EXTERNAL GENITALIA

Back 99

 for the well child, the examination includes only inspection and palpation of the external genitalia
 the internal vaginal examination is performed at a young child only when there is a specific problem such as bleeding, discharge, trauma, or suspected sexual abuse
 Inspect/palpate external genitalia
 Redness/irritation
 vaginal discharge often irritates the perineal tissues, causing redness and perhaps excoriation
 other sources of peritoneal irritation include bubble baths, soaps, detergents, and urinary tract infections
 Swelling
 swelling of vulvar tissues, particularly if accompanied by bruising or foul smelling discharge, should alert you to the possibility of sexual abuse
 and must always be suspected if a younger child has a sexually-transmitted infection or if there is injury to the external genitalia
 injuries to the softer tissues of the external genitalia are not caused by bicycle seats
 a straddle injury for bicycles feet is generally evident over the symphysis pubis with the structures are more fixed
 injuries resulting from sexual abuse are generally more posterior and may involve the perineum grossly
 such findings cannot be ignored, careful questioning of the parent or guardian is mandatory, as well as a report to the appropriate social service agencies for further investigation
 in most cases of sexual abuse, the physical examination is normal. Abnormal examination does not rule out sexual abuse if there is a suspicion
 Discharge/bleeding
 a foul odor is more likely indicative of a foreign body (particularly in preschool children), especially if the secondary infections present
 vaginal discharge may also result from Trichomonal, gonococcal, or monolial infection
 vaginal bleeding in children is often the result of unintentional injury, experimentation with a foreign body (e.g., doit), or sexual abuse
 rarely there may be an ovarian tumor carcinoma of the cervix's

Front 100

Exam & Findings: Children: INTERNAL GENITALIA

Back 100

 Bleeding
 Discharge
 Trauma/abuse

Front 101

Exam & Findings: Children: Sexual abuse signs

Back 101

 General neglect/abuse
 Trauma/scarring of genitals/anus
 Unusual coloring of genitals/anus
 STD presence
 Anorectal problems
 Genitourinary problems
 Behavioral manifestations/problems

Front 102

Exam & Findings: Adolescents

Back 102

 all adolescent female should have a pelvic examination within three years of initiating sexual intercourse, including a Pap smear with cervical cytology evaluation and sexually-transmitted infection evaluation
 young women who are not sexually active should have their first examination by age 21 years
 Allay anxiety for what may be first exam
 Use Small Speculum
 a pediatric speculum with plates that are 1 to 1.5 cm wide can be used in should cause minimal discomfort
 if the adolescent is sexually active, a small adult speculum may be used
 Inspect/palpate
 Tanner Stages
 as the girl ghost of puberty, you will see the match racial changes of sexual development
 just before menarche there is a physiologic increase in vaginal secretions
 the hymen may or may not be stretched across the vaginal opening
 by menarche opening should be at least 1 cm wide
 as the adolescent matures, the findings are the same as those for the adult

Front 103

 Exam & Findings: Pregnant Women

Back 103

 gynecologic examination further pregnant woman follows the same procedure as that for nonpregnant adult woman
 assessment of pregnant women include gestational age examination, uterine size and contour, public size estimates, and cervical dilation and length
 examination also includes fetal assessment: growth, position, and well-being
 during labor, fetal station and had position are also assessed
 Inspect/palpate for expected changes
 Softening cervix
 Increased vascularity
 Bluish color
 Full/soft/flexible fundus
 Lateral uterine bulge
 Increasing size - bony pelvis/uterus
 Cervical dilation
 Fetal position
 Leopold maneuver

Front 104

 Exam & Findings: Older Adults

Back 104

 Inspect/palpate for age-related changes
 Smaller labia
 labia appears flatter and smaller, corresponding with the degree of loss of subcutaneous fat elsewhere in the body
 Dry skin/membranes
 the skin is dryer and shinier than that of the younger adult
 Gray/sparse pubic hair
 pubic hair is gray and may be sparse
 Less mobile cervix
 Hard to palpate uterus
 the uterus diminishes in size and may not be palpable
 Nonpalpable ovaries
 ovaries are rarely palpable due to atrophy
 ovaries that are palpable should be considered suspicious for tumor and additional workup, such as ultra sound, to exclude cancer is required
 Diminished rectal tone

Front 105

 Exam & Findings: Women with Disabilities

Back 105

 Alternative positions for pelvic exam
 the woman is the best charge for of which position will work for her and how to use assistants most effectively
 these decisions should be made by the patient and clinician together
 examples
 knee chest position
 diamond shaped position
 obstetric stirrups position
 M-shaped position
 V-shaped position
 Transfer methods to exam table
 Special concerns
 Spasticity
 Hyperreflexia
 Hypersensitivity
 Bowel/bladder functional alterations

Front 106

Common Abnormalities: PMS

Back 106

 Definition
 a collection of physical, psychological, and mood symptoms related to a woman's menstrual cycle
 Pathophysiology
 etiology unclear; likely causes include hormonal factors and responses to hormonal factors
 usually begins in the woman's late 20s and increases in incidence and severity as menopause approaches
 subjective data
 symptoms may include breast swelling and tenderness, acne, bloating and weight gain, headache or joint pain, food cravings, irritability, difficulty concentrating, mood swings, crying spells, and oppression
 symptoms occur 5 to 7 days before menses (luteal phase) and subside for the onset of menses
 objective data
 none
 diagnosis based on symptoms and temp oral relationship to menstrual cycle

Front 107

Common Abnormalities:Infertility

Back 107

 Definition
 the inability to conceive over a period of one year of unprotected sexual intercourse
 Pathophysiology
 many causes, including both male and female conditions
 contributing factors in the women include abnormalities of the vagina, cervix, uterus, fallopian tubes, and ovaries
 male infertility can be caused by insufficient non-motile, or immature sperm; ductal obstruction of sperm; and transport related factors
 factors influencing infertility in both women and men in could stress, nutrition,, go substances, chromosomal abnormalities, certain disease processes, sexual and lesion should problems, and hematologic and immunologic disorders
 subjective data
 unsuccessful attempts to become pregnant
 objective data
 varies the underlying cause
 often no findings of physical examination

Front 108

Common Abnormalities: Endometriosis

Back 108

 Definition
 the presence of growth of endometrial tissue outside the uterus
 Pathophysiology
 pathogenesis not definitive
 thoughts to be due to retrograde reflux of menstrual tissue from the fallopian tubes during menstruation
 subjective data
 pelvic pain, dysmenorrhea, and heavy or prolonged menstrual flow
 objective data
 no findings
 on bimanual examination, tender nodules may be palpable along the uterosacral ligaments
 diagnosis confirmed by laparoscopy

Front 109

Common Abnormalities: STD: vaginitis

Back 109

 Trichomonos

Front 110

Common Abnormalities: STD: cervicitis

Back 110

Chlamydia: DNA Probe, Gonnorhea: DNA Probe

Front 111

Common Abnormalities: STD: PID

Back 111

 Definition
 infection of the uterus, fallopian tubes, and other reproductive organs; a common and serious complication of some sexually transmitted infections
 pathophysiology
 often caused by Neisseria gonorrhoeae and chlamydia tachomatis
 may be acute or chronic
 subjective data
 symptoms may be mild or absent
 unusual vaginal discharge that may have a foul odor
 symptoms include painful intercourse, painful urination, a regular menstrual bleeding, and pain in the right upper abdomen
 objective data
 acute PID produces very tender, bilateral adnexal areas; the patient guards and usually tolerate bimanual examination
 symptoms of chronic PID or bilateral, tender, a regular, and fairly fixed adnexal areas
 Lower abdominal Tenderness
 Cervical Motion Tenderness
 Adnexal Tenderness

Front 112

Common Abnormalities: STD: Vulvovaginitis

Back 112

 Vulvovaginitis: Bacterial vaginosis: Caused by overgrowth of anaerobes and garderella (tx with flagyl), Yeast Infection: Candida albicans (cottage cheese-itching) tx with fluconazole/nystatin/clotrimazole
 Bubble baths

Front 113

Common Abnormalities: STD: Foreign Body

Back 113

x

Front 114

Common Abnormalities: STD: Genital Warts

Back 114

 Definition
 watery lesions due to sexually-transmitted infection with HPV. Spreads with contact (Wart touches other skin surface and spreads)
 Pathophysiology
 HPV invades the basal layer of the epidermis; virus penetrates through skin and causes mucosal micro-abrasions
 latent viral phase begins with no signs or symptoms and can last for a month to several years
 following latency, viral DNA, capsids, and particles are produced; host cells become infected in develop the characteristics skin lesions
 subjective data
 soft, painless, wartlike lesions
 history of sexual contact
 objective data
 flesh colored, whitish pink to reddish brown, discrete, soft growths on labia, vestibule or perianal area
 lesions may occur singly or in clusters and may enlarge to form cauliflower like masses

Front 115

Common Abnormalities: STD: Molluscum Contagium

Back 115

 Definition
 viral infection of the skin and mucous membranes; considered a sexually-transmitted infection in adults, in contrast to the common non-sexually-transmitted infections occurring in young children
 Molluscum Contagium: umbilicated small papular lesions, very contagious
 Pathophysiology
 caused by poxvirus, the virus enters the skin through small breaks of hair follicles
 spreads through direct person-to-person contact and through contact with contaminated object
 genital lesions are sexually-transmitted
 incubation period is from 2 to 7 weeks
 subjective data
 painless lesions and genital area
 sexually active
 objective data
 white or flesh colored, dome shaped papules that are round or oval
 surface has a characteristic central umbillication from which a thick creamy core can be expressed
 lesions may last from several months to several years
 diagnosis usually based on the clinical appearance of the lesions
 direct microscopic examination of stained material from the core will reveal typical molluscum bodies within the epithelial cell

Front 116

Common Abnormalities: STD: Dysperunia

Back 116

x

Front 117

Common Abnormalities: STD: Lesions: Herpes

Back 117

 Pathophysiology
 most commonly caused by the herpes simplex virus 2 virus (HSV-2)
 most transmission of HSP occurs when individual shed virus in the absence of symptoms
 subjective data
 painful lesions and genital area
 history of sexual contact
 may report burning or pain with urination
 objective data
 superficial vesicles in the genital area; internal or external; may be eroded
 initial infection is often extensive, whereas reoccurring infection is usually confined to a small localized patch on the vulva, perineum, vagina, or cervix

Front 118

Common Abnormalities: STD: Lesions: Syphillis

Back 118

 Syphilis: RPR, VDRL
 Definition
 skin lesion associated with primary syphilis
 Pathophysiology
 sexually-transmitted infection caused by the bacterium treponema pallidum
 transmitted through direct contact with the syphilis sore
 lesion of primary syphilis generally occurs two weeks after exposure
 Tinker last 3 to 6 weeks, heels without treatment
 subjective data
 often no lesion noted, as may be internal
 painless genital ulcer
 sexually active
 objective data
 solitary lesion; firm, round, small, painless ulcer
 lesion has indurated borders with a clear base
 scrapings from the ulcer, examined microscopically, show spirochetes.

Front 119

Common Abnormalities: STD: Hepatitis

Back 119

x

Front 120

Common Abnormalities: STD: HIV

Back 120

x

Front 121

Painful lesions

Back 121

herpes

Front 122

Painless lesions

Back 122

syphillis

Front 123

Common Abnormalities: Vulva/Vagina: Inflammation of Bartholin Gland

Back 123

 Pathophysiology
 commonly, but not always, caused by niesseria gonorrhea
 may be acute or chronic
 subjective data
 pain and swelling in the growing
 objective data
 hot, red, tender, fluctuant swelling of the bartholin gland that may drain pus
 chronic inflammation results in a non-tender cyst on the labium

Front 124

Common Abnormalities: Vulva/Vagina: Cystocele

Back 124

 Bladder wall is relaxed

Front 125

Common Abnormalities: Vulva/Vagina: Rectocele

Back 125

 Rectal wall is relaxed

Front 126

Common Abnormalities: Vulva/Vagina: Carcinoma

Back 126

 indurated

Front 127

Common Abnormalities: Cervix; Lacerations

Back 127

x

Front 128

Common Abnormalities: Cervix; Infected nabothian cysts

Back 128

cysts to cervix

goes away by itself

Front 129

Common Abnormalities: Cervix; cervical carcinoma

Back 129

 Definition
 classified according to the type of tissue from which the cancer arises squamous cell carcinoma and the adenocarcinoma; there are a few other rare types of cervical cancer
 Pathophysiology
 typically originates from the dysplastic or premalignant lesion present at the active squamocolumnar junction
 lesions gradually progress through recognizable stages before developing into invasive disease
 the transformation from mild dysplastic to invasive carcinoma generally occurs slowly over several years
 HPV is now recognizes the most important causative agent cervical carcinogenesis at the molecular level
 HPV vaccines available
 subjective data
 usually asymptomatic
 many report unexpected vaginal bleeding or spotting
 objective data
 often no findings on physical examination
 a hard granular surface at or near the cervical os
 lesion can evolve to form an extensive irregular cauliflower growth that bleeds easily
 early lesions are indistinguishable from ectropian
 precancerous in early cancer changes are detected by Pap smear, not by physical examination

Front 130

Common Abnormalities: Uterus: Uterine prolapse

Back 130

 Definition
 dissent or herniation of the uterus into her beyond the vagina
 pathophysiology
 result of weakening of the supporting structures of the pelvic floor, often occurring concurrently with a cystocele or rectocele
 uterus becomes progressively retroverted and descends into the vaginal canal
 subjective data
 sensation the pelvic heaviness and/or uterus falling out
 tissue protruding from vagina
 may report urine leakage or urge incontinence, difficulty having a bowel movement, or low back pain
 objective data
 first-degree prolapse: the cervix remains within the vagina
 second-degree prolapse: the cervix is at the introitus
 third-degree prolapse: the cervix and vagina drop outside the introitus

Front 131

Common Abnormalities: Uterus: myomas

Back 131

 definition
 common, benign, uterine tumors
 mass or tumor inside muscle of uterus
 pathophysiology
 arise from the overgrowth of smooth muscle and connective tissue in the uterus
 may occur singly or in multiples and may vary greatly in size
 subjective data
 fibroid symptoms are related to the number of tumors, as well as their size and location; symptoms may include the following
 heavy menses
 abdominal cramping usually felt during menstruation
 urinary frequency, urgency, and/or incontinence from pressure on the bladder
 constipation, difficulty defecation, or rectal pain from pressure on the colon
 abdominal cramping from pressure on the small bowel
 generalized pelvic and/or lower abdominal discomfort
 objective data
 firm, a regular nodules in the contour of the uterus on bimanual examination
 uterus maybe enlarged

Front 132

Common Abnormalities: Uterus: endometrial cancer

Back 132

 Pathophysiology
 occurs most often in postmenopausal women
 nearly all endometrial cancers are cancers of the glandular cells found in the lining of the uterus; most known risk factors for endometrial cancer are linked to the balance between estrogen and progesterone in the body
 women taking tamoxifen are at increased risk
 subjective data
 postmenopausal vaginal bleeding-red flag for endometrial cancer
 objective data
 diagnosed by endometrial biopsy

Front 133

Common Abnormalities: Ovaries: Torsion

Back 133

UNILATERAL
OFTEN ASSOCIATED WITH OVARIAN CYST
ALMOST ALWAYS WITH N/V
 Definition
 Twisting of the ovary on the fallopian tube
 Causes ischemia/infarction of the ovary
 Usually younger ages average 26
 20% are pregnant
 50% of the time associated with an adenexal mass
 Can occur in postmenopause and after hysterectomy
 Presentation
 Non Specific Findings
 Sudden onset of lower abdominal pain on the involved side. Radiation to the back, pelvis and thigh.
 Nausea/Vomiting
 The patient may describe a prior history of similar episodes

Front 134

Common Abnormalities: Ovaries: Mittelschmertz

Back 134

 German for “Middle Pain”
 Associated with ovulation
 Typically pain lasts for hours (2-4 hours-goes away-if lasts longer then consider something different)

Front 135

Common Abnormalities: Ovaries: Ovarian Cysts

Back 135

 Definition
 fluid filled sac in the ovary
 Pathophysiology
 follicle undergoes varying rates of maturation in this can occur as a result of hypothalamus-pituitary dysfunction or because of native anatomic defects in the reproductive system
 can occur unilaterally are bilaterally
 most ovarian cysts occur during infancy and adolescence, which are hormonally active. The development
 most are functional in nature and resolve with minimal treatment
 Egg not released and continues to grow
 Ruptured a small vessel when released
 If arterial can produce significant bleeding.
 subjective data
 usually asymptomatic
 may report lower abdominal pain; sharp, intermittent, setting, and severe
 sudden onset of abdominal pain may suggest cyst rupture
 objective data
 pelvic mass may be palpated
 cervical motion tenderness may be elicited
 often an incidental finding during ultrasound performed for other reasons

Front 136

Ectopic Pregnancy

Back 136

 Definition
 ectopic pregnancy occurs outside the uterus
 pathophysiology
 most common site is in one of the fallopian tubes but can occur in other areas
 ectopic pregnancy usually caused by condition that boxer slows the movement of the fertilized egg through the fallopian tube to the uterus
 may be caused by physical blockage in the tube; most cases from scarring caused by past ectopic pregnancy, past infection in the fallopian tubes, pelvic inflammatory disease, or surgery of the fallopian tubes
 subjective data
 abnormal vaginal bleeding
 low back pain
 mild cramping on one side of the pelvis
 pain in the lower abdomen or public area
 if the area of the abnormal pregnancy ruptures and bleeds, symptoms may worsen
 feeling lightheaded or syncope
 pain that is felt in the shoulder area
 severe, sharp, and sudden pain in the lower abdomen
 objective data
 marked pelvic tenderness, with tenderness and rigidity of the lower abdomen
 cervical motion tenderness; a tender, unilateral adnexal mass may indicate the site of the pregnancy
 tachycardia hypotension reflect hemorrhage of the ruptured tubal pregnancy into the peritoneal cavity and impending cardiovascular collapse
 a ruptured tubal pregnancy is a surgical emergency
 Accounts for 10-15% of maternal mortality in 1st trimester.
 Presentation
 Lower abdominal pain to associated side.
 Usually 6-10 weeks after conception (fetus grows to the point where it outgrows the fallopian tube)
 Risk Factors
 History of PID
 Multiple Partners especially at a young age
 Infertility Treatment
 Pelvic Surgery
 Previous History of same
 Smoking


METHOTREXATE-CHEMOTHERAPY CAN BE GIVEN TO TREAT (KILLS RAPIDLY DEVELOPING CELLS)

Front 137

Positive pregnancy test_______ after implantation

Back 137

 Positive pregnancy test 5 days after implantation

Front 138

 If BHCG is greater then _____ should see a gestational sac on ultrasound

Back 138

 If BHCG is greater then 2000 should see a gestational sac on ultrasound

Front 139

 Fetal Heart Beat _____ should be seen by ultra sound.

Back 139

 Fetal Heart Beat 6-7 weeks should be seen by ultra sound.

Front 140

 Fetal Heart Tones heard by doppler at ________

Back 140

 Fetal Heart Tones heard by doppler at 8-10 weeks

Front 141

 Fetal Movement (quickening) at _______

Back 141

 Fetal Movement (quickening) at 16-20 weeks

Front 142

 Fetal Viability is _____ gestation

Back 142

 Fetal Viability is 24 weeks gestation

Front 143

 After _____ the fetus is mature enough to survive if necessary

Back 143

 After 34 weeks the fetus is mature enough to survive if necessary

Front 144

 IF clear vaginal secretions have a pH of greater then _____ consider it to be amniotic fluid.

Back 144

 IF clear vaginal secretions have a pH of greater then 6.5 consider it to be amniotic fluid.

Front 145

Pregnancy: first trimester: Hyperemesis Gravidarum

Back 145

 Vomiting
 Resolve after 1st trimester
 Ketouria
 Monitor
 Ketouria is due to catabolism, digesting fats for calories. You need sugar to stop that, that is why you need to give some sugar containing fluid.
 Dehydrated
 IV fluids
 0.9 NS
 D5 .9 NS
 Antiemetic

Front 146

Pregnancy: first trimester: Bleeding

Back 146

 Spotting to Heavy with Clots
 Trauma
 Consider abuse
 Rule out ectopic pregnancy
 Labs
 QHCG
 Type & Rh
 CBC
 Anxiety
 50% can go to normal delivery
 Education
 Not parents fault
 Don’t forget father
 Rest
 Pelvic Rest
 No intercourse

Front 147

Pregnancy: First Trimester: Miscarriage

Back 147

 Miscarriage
 No cardiac activity with ultra sound
 Labs
 CBC
 QHCG
 Type & Rh
 If mom is Rh negative need shot of rhogam to prevent sensitization. If mom becomes sensitized a Rh positive child will cause an immune response and kill the fetus through hemolysis of the fetuses blood. The moms body produces antigens to the Rh.
 Explain findings simply
 Your child is dead
 Caution using terms like passed away, eternal sleep, gone to heaven. People hear what they want to hear. You need to make it simple to understand. Always ask if they have questions and did understand what you said.
 Don’t Forget the parents just lost a child
 Offer condolences
 Not parents fault
 If available offer religious support
 If tissue passed ask about baptism

Front 148

If quantitative HCG is 2000 and there is no visible uterine pregnancy...suspect.?

Back 148

ECTOPIC PREGNANCY

Front 149

Pregnancy: 2nd Trimester: PIH (Pregnancy Induced Hypertension)

Back 149

 7% of pregnancy
 7% of pregnancies are associated with hypertension
 Unknown cause, believed to be associated with vascular response to endogenous vasopressors in the pregnant women.
 Risks:
 Young age less then 20 years old, primagravidas, twins or molar pregnancies, and family history of PIH
 Proteinuria
 BP > 140/90
 Usually with a diastolic under 100
 Edema
 Look for end organ involvement
 Headaches
 Visual changes
 Abdominal Pain
 Increased liver function tests
 Sign of preeclampsia
 Increased Uric Acid Level
 Sign of preeclampsia

Front 150

Pregnancy: 2nd Trimester: Preeclampsia

Back 150

 One type of PIH-more severe
 Believe it is a relative increase in various substances including prostaglandins associated with vasconstriction and platelet aggregation. This may results in vascular injury which causes the symptoms of preeclampsia
 Must look for it
 Bedrest is the only demonstrated means to reduce BP
 Diastolic Blood Pressure 100 or above
 Proteinuria
 2+ or more consistently
 Edema
 Usually involving the face and hands
 End organ damage
 Visual changes, headaches
 Hyperreflexia

Front 151

Pregnancy: 2nd Trimester: Eclampsia

Back 151

 Seizures
 All the symptoms of preeclampsia are also present
 Magnesium Sulfate
 Dosage: 6g IV (20% solution) over 15 minutes, then 2g IV per hr.
 Consider getting a CT scan to rule out cerebral pathology
 Rule out other causes of seizure, trauma, hypoglycemia, overdose
 Initial Treatment
 Get labs
 Acucheck
 IV access
 Monitor Urine Output
 Close monitoring of patients vitals
 Emotional Support

Front 152

Pregnancy: 2nd Trimester: Abruptio Placenta

Back 152

 30% cause of vaginal bleeding
 May have only acute abdominal pain. Can be associated with blunt trauma or happen spontaneously
 Usually at triage patient over 24 weeks with abdominal pain go directly to the OB department for initial treatment for fetal monitoring and evaluation by OB.
 Painful vaginal bleeding
 Dark red bleeding
 May be minor or no bleeding
 Hard/Tender Uterus
 Risks
 HTN, High maternal age, smoking and cocaine use

Front 153

Pregnancy: 2nd Trimester: Placenta Previa

Back 153

 20% cause of vaginal bleeding
 Placenta inserts itself low in the uterus and communicates with the cervical os. The vessels begin to rupture as the uterus elongates or when cervical dilitation starts.
 Digital exam can exacerbate bleeding. If needed only a brief speculum exam to determine if the blood is coming from the os or some other area.
 Risks: c section history, previous hx of same
 Painless vaginal bleeding
 Bright red
 Caution doing pelvic exam
 No digital exams

Front 154

Common Abnormalities: Infants/Children: Ambigious Genitalia

Back 154

 Definition
 the newborn genitalia are not clearly either male or female
 Pathophysiology
 presence or absence of male hormones controls the development of the sex organs during fetal development; male genitalia develop because of male hormones from the fetal testicles; in the female fetus, without the effects of male hormones, the genitalia develop as female
 a deficiency of male hormones in a genetic male fetus results in ambiguous genitalia; in a female fetus, the presence of male hormones during development results in ambiguous genitalia
 most causes of ambiguous genitalia are due to genetic abnormalities
 subjective data
 family history of
 genital abnormalities
 known congenital adrenal hyperplasia
 unexplained deaths in early infancy
 infertility and close relatives
 abnormal development during puberty
 objective data
 ambiguous genitalia in a genetic female:
 an enlarged clitoris that has the appearance of a small penis
 the urethral opening anywhere along, above, or below the surface of the clitoris
 fused labia resembling scrotum
 a lump of tissue is felt within the fused labia, making it look like a scrotum with testicles
 ambiguous genitalia and the genetic male
 a small penis that resembles an enlarged clitoris
 urethral opening anywhere along, above, or below the penis; or as low as on the peritoneum, further making the infant appeared to be female
 small scrotum with any degree of separation, resembling labia
 undescended testicles commonly accompany ambiguous genitalia

Front 155

Common Abnormalities: Infants/Children: Hydrocolpos

Back 155

 Hydrocopos: inperferate hymen. Amenorrhea.
 Definition
 distention of the vagina caused by accumulation of fluid due to congenital vaginal obstruction
 Pathophysiology
 obstruction usually caused by imperforate hymen or, less commonly, a transverse vaginal septum
 subjective data
 none
 objective data
 small midline lower abdominal mass or small cystic mass between the labia
 condition may resolve spontaneously or may require surgical intervention
 abdominal sonography is helpful in making a correct diagnosis, showing a large midline translucent mass placing the bladder forward

Front 156

Common Abnormalities: Pregnant Women: Premature ROM

Back 156

 Definition
 the spontaneous premature rupture of membranes in a preterm pregnancy carries a high risk for perinatal morbidity and mortality, as well as maternal morbidity and mortality
 pathophysiology
 cause of premature rupture of membranes is not known; however, certain conditions such as infection and hydramnios has been implicated; some healthcare professionals also consider the rupture of membranes before the onset of labor in a term pregnancy to be premature rupture of labor does not begin in 12 hours
 subjective data
 during pregnancy prior to term, premature passage of fluid from the vagina
 physical findings
 premature rupture of membranes should be verified with a sterile speculum examination to collect fluid for testing with nitrazine paper and microscopic examination
 amniotic fluid has a pH of 7.15 and will turn nitrazine paper blue-green
 amniotic fluid place in the slide and air dried will have a “fern” pattern
 ultrasound evaluation of fluid will reveal decreased or absent amniotic fluid

Front 157

Common Abnormalities: Pregnant Women: Prolapse for umbillical cord

Back 157

X

Front 158

Common Abnormalities: Pregnant Women: Vulvar Varicosities

Back 158

X

Front 159

Common Abnormalities: Older Adults: Atrophic Vaginitis

Back 159

 Definition
 inflammation of the vagina due to thinning intriguing of the tissues as well as decreased lubrication
 pathophysiology
 caused by lack of estrogen during perimenopause and menopause
 subjective data
 vaginal soreness or itching
 discomfort or bleeding with sexual intercourse
 objective data
 vaginal mucosa is dry and pale, although it may become right-handed develop petechiae and superficial erosions
 accompanying vaginal discharge may be white, gray, yellow, green, or blood tinged
 can be thicker watery and, although it varies in amount, rarely profuse

Front 160

Common Abnormalities: Older Adults: Urinary Incontinence: Stress

Back 160

 Coughing, sneezing, laughing
 Stress: sphincter insufficency

Front 161

Common Abnormalities: Older Adults: Urinary Incontinence: Urge

Back 161

 Sudden urge to urinate
 Urge: Uninhibited bladder, unable to control urge to urine

Front 162

Common Abnormalities: Older Adults: Urinary Incontinence: Overflow

Back 162

 Overdistention of bladder
 Overflow: neuropathy or outflow obstruction

Front 163

Common Abnormalities: Older Adults: Urinary Incontinence

Back 163

 Can’t make it to the toilet
 Functional: Unable to make it to bathroom in time. New enviroment, diuretics or other meds

Front 164

Which of the following findings indicates a possible gonococcal infection?

Back 164

Discharge from urethra or Skene glands

Front 165

Which one of the following is a proper technique for use of a speculum during a vaginal examination?

Back 165

Press introitus downward; insert closed speculum obliquely

Front 166

What structures are located at the 5-o’clock and the 7-o’clock positions of the vaginal orifice and open onto the sides of the vestibule in the groove between the labia minora and the hymen

Back 166

Bartholin glands

Front 167

The adnexa of the uterus are composed of the

Back 167

fallopian tubes and ovaries

Front 168

The conventional definition of menopause is

Back 168

1 year with no menses

Front 169

The presence of cervical motion tenderness may indicate

Back 169

pelvic inflammatory disease

Front 170

Which risk factor is associated with cervical cancer?

Back 170

Multiple sex partners

Front 171

Pregnancy-related cervical changes include

Back 171

softening and bluish coloring

Front 172

The female patient should ideally be in which position for the pelvic examination?

Back 172

Lithotomy

Front 173

Prolonged menses is usually defined as bleeding for longer than _____ days

Back 173

7