Lesson 3 - Female Pelvic And Breast Exams

Front 1

External genitalia: Vulva

Back 1

Mons pubis
Labia majora
Labia minora
Clitoris
Vaginal vestibule
Urethral orifice

Front 2

Internal genitalia

Back 2

Vagina
Uterus - Corpus, Cervix
Adnexa - Fallopian tubes, Ovaries

Front 3

Pelvic exam equipment

Back 3

Drape
Speculum
Gloves
Water-soluble lubricant
Specimen collection equipment - Liquid-based Pap, Wet prep, GC/CT swab
Light source

Front 4

Types of speculums

Back 4

Graves and Pederson

Front 5

Graves speculum

Back 5

Multiparous
Obese
Unable to visualize the cervix with the Pederson

Front 6

Pederson speculum

Back 6

Virginal
Nulliparous
Thin
Menopausal
Adolescent

Front 7

Verbiage

Back 7

Use professional but not technical terminology

Avoid phrases such as “looks good”, “wow”, “stick in speculum”, “I need a bigger speculum”

Appropriate terms: examine, inspect, place, insert, remove, normal, healthy

Front 8

Positioning

Back 8

Lithotomy

Help place patient’s feet in the foot holders

Have her slide her buttocks down to the end of the table
-Buttocks should be slightly hanging over the edge
-If the patient is not positioned correctly, the speculum exam will be difficult

Ensure the sheet covers her abdomen to her knees

Front 9

Draping

Back 9

Drape for minimal exposure

Cover knees and symphysis then depress the drape between her knees
-Allows for eye contact between you and the patient
-Keeps the thighs covered for entire exam

Arrange the exam light and equipment to be used

Front 10

Gloving

Back 10

Wash hands and put on gloves
-Once you have touched any of the patient’s genital skin, assume that your glove is “contaminated”
-Do not touch anything except the patient, the drape, and what your MA hands you after you put on gloves

Front 11

Beginning the exam

Back 11

It is your job to minimize the patient’s apprehension and discomfort
Explain what you are doing before you do it
Maintain eye contact and sit down
Ask the woman to separate or relax her legs to the side
Inform her that you are going to begin your exam
Start with a neutral touch

Front 12

External examination

Back 12

Inspection and palpation
Labia major
Labia minora
Clitoris
Urethral orifice
Vaginal introitus
Skene and Bartholin glands
Muscle tone
Perineum
Anus

Front 13

Internal examination: Cervix

Back 13

Color
Position
Size
Surface characteristics
Discharge
Size and shape of the os
Nulliparous will have a tight circular hole, a multiparous will have a line.

Front 14

Two cell types of the cervix

Back 14

Columnar and squamous

Front 15

Columnar cells

Back 15

Line cervical canal (endocervix)
One cell layer thick

Front 16

Squamous cells

Back 16

On portion of cervix (ectocervix)
8-16 layers thick

Front 17

Squamocolumnar junction

Back 17

Where columnar and squamous cells meet
Most likely area for dysplasia

Front 18

Process of metaplasia

Back 18

Over time, columnar cells transform
into squamous cells (a normal process)

Front 19

Cervical squamocolumnar transformation zone

Back 19

The area between where the SCJ used to be and where it currently is equals
the Transformation Zone.

This is where you want to take the Pap smear because this is where dysplasia is most likely to occur.

Front 20

Screening for infection

Back 20

GC/CT culture - Cervical culture, DNA probe
Wet Prep - Vaginal specimen, Saline wet-mount
Trichomonas vaginalis - Trichomonads (flagellated organisms)
Bacterial vaginosis - Clue cells
Candidiasis - Pseudohyphae or budding yeast cells

Front 21

Withdrawal of speculum

Back 21

Unlock the speculum and remove it slowly and carefully
Inspect the vaginal walls
Note color, surface characteristics, and secretions
The blades will tend to close themselves
Avoid pinching the cervix and vaginal walls
Maintain downward pressure of the speculum
AVOID THE ANTERIOR STRUCTURES
Urethra and clitoris

Front 22

Bimanual examination

Back 22

Cervix, uterus, adnexa and ovaries
Be careful where you place your thumb during the bimanual exam. Don’t rest it on the clitoris.

Front 23

Feeling the cervix

Back 23

Located the cervix with the palmar surface of your fingers, run your fingers around its circumference to feel the fornices. Feel the size, length, and shape which should correspond with your observations from the speculum exam.
Grasp the cervix gently and move it from side to side to evaluate for cervical motion tenderness. The cervix should move 1-2 cm in each direction with minimal or no discomfort.

Front 24

Feeling the uterus

Back 24

Palpate the uterus. Place the palmar surface of your non-dominate hand on the patient’s abdomen (do not place it on top of the sheet…use direct contact with the patient’s skin). Place the intravaginal fingers in the posterior fornix (let the cervix rest on the fingers) and push inward and upward in attempts to capture the uterus between your two hands. Determine whether the uterus is anteverted, anteflexed, midposition, retroverterted or retroflexed. Determine size, shape, contour, and tenderness to palpation.

Front 25

Feeling the ovaries and adnexa: technique

Back 25

Palpate the adnexal areas and ovaries. Place the fingers of the abdominal hand on the right mid abdomen. With the intravaginal hand facing upward, place both fingers in the right lateral fornix. Press the intravaginal fingers deeply inward and upward toward the abdominal hand while sweeping the flat surface of the fingers of the abdominal hand deeply inward and obliquely downward toward the symphysis pubis. Repeat the maneuver the left side.

Front 26

Feeling the ovaries

Back 26

The ovaries, if palpable, should feel firm, smooth, ovoid, and approximately 3 by 2 by 1 cm in size. The healthy ovary is slightly to moderately tender on palpation.

Front 27

Feeling the adnexa

Back 27

The adnexa are often difficult to palpate because of their location and position and the presence of excess adipose tissue in some women. If you are unable to feel anything you can assume that no abnormality is present, provided no clinical symptoms exist.

Front 28

Rectovaginal examination

Back 28

Who needs this exam? Age > 50 years, Pelvic pain, Pelvic mass
Reaches almost 2.5 cm higher into the pelvis
Examines the back side of the uterus
Checks tone and alignment of pelvic organs
Guaiac
Rectal growths and/or masses

Front 29

What to look for in rectovaginal exam

Back 29

Anal sphincter
Rectal walls and rectovaginal septum
Uterus
Adnexa
Stool
Completion
Remove gloves with a downward motion

Front 30

Breast anatomy

Back 30

Breasts lie on the pectoralis major muscle

Composed of glandular ducts, lobules, connective tissue and fat

Cooper’s ligaments are attached to fascia of skin and pec major muscle

Lactiferous sinuses lie beneath the nipple

Front 31

Breast inspection

Back 31

Asymmetry
Dimpling
Retraction
Mass altering contour of breast
Skin color, edema
Nipple inversion, scaling, crusting

Front 32

Breast palpation

Back 32

Sitting and supine positions

Supraclavicular and infraclavicular regions, axilla, and breast

Systematic fashion

Pads of middle 3 fingers of both hands

Should take 3-5 minutes to complete

Front 33

Lymph nodes to feel during breast exam

Back 33

Central, pectoral, subscapular, lateral