Obgyn- Female Gu And Breast Exam

Front 1

What does a normal pelvic exam include?

Back 1

- inspection/palpation of external genitalia
- speculum exam
- bimanual palpation
- rectovaginal exam

Front 2

In what position should the patient be for a GU exam?

Back 2

Dorsal Lithotomy Position
- supine
- buttocks at front edge of table
- hips flexed at 45 and abducted at 45
- knees flexed at 45
- feet in stirrups
- head of table at 30 angle

Front 3

Vulva

Back 3

All structures external to vagina including and within labia majora

Front 4

Mons Pubis

Back 4

Area of skin overlying pubic symphysis
- hair normally shaped as ipsilateral triangle with base parallel to pubis bone and apex at labia majora

Front 5

Describe the tissue and contents of the labia majora

Back 5

= skin-covered pads of adipose tissue
- covered with hair
- multiple sebaceous and apocrine glands
- Bartholin Glands - post 1/3

Front 6

Describe the tissue and contents of the labia minora

Back 6

= thin ridges of tissue parallel to labia majora
- no hair
- clitoris and vestibule within

Front 7

What is the vestibule?
What does it contain?

Back 7

= superficial area bounded by post 2/3 labia minora
- contains uretrhal meatus, paraurethral glands of skene, introitus

Front 8

Introitus
- What is?
- Covering?

Back 8

opening of vagina
- may be covered with hymen (thin membrane) in young girls or nonsexually active women

Front 9

What are the relative locations of urethral meatus, clitoris and introitus?

Back 9

urethral meaturs post to clitoris and ant to introitus

Front 10

Bartholin Glands - location?

Back 10

located in post 1/3 of labia majora --> empty via ducts into post vestibule (labia minora)

Front 11

Fourchette

Back 11

posterior area of skin between vulva and anus - where labia minora and majora rejoin

Front 12

Perianal area
- location?
- innervation?

Back 12

- surrounds anus
- innervated mainly by Pudendal Nerve - branches of sacral roots 2, 3, 4, 5

Front 13

Hirsutism
- what is?
- % of women?
- causes?
- other sx

Back 13

= increase in quantity/distribution of hair
- often seen at mons pubis: diamond-shaped distribution -10% women
=> sign of virilization (androgen-mediated process)

Other sx of virlization:
- increased hair on chest and back
- abnormal loss of hair in temporal and occipital areas
- primary or secondary amenorrhea
- deepened voice
- clitoromegaly

Causes:
- Polycystic Ovarian Syndrome (PCOS)**most common**
INCREASED ANDROGENS:
- Athletes taking androgens
- Cushing Syndrome
DECREASED ESTROGEN:
- post-menopausal women

Front 14

What is the normal age of menarche?
What is it called when it's delayed? What should you then look for?

Back 14

12 years

Primary Amenorrhea - delayed puberty (after 14, 15 y.o.)
--> Look for other signs of delayed puberty
....**Look for the company it keeps!
- e.g., use Tanner Staging of Pubic Hair and Breast Development

Front 15

When does axillary hair develop?

Back 15

Usually 2 years after growth of pubic hair

Front 16

Tanner Staging of Pubic Hair
- what factors does it take into account?
- what are the stages?

Back 16

(looks at hair texture (downey v. coarse) and distribution)

Stage 1: None (preadolescence)
Stage 2: Long, straight downey hair along labia
Stage 3: Darker, coarse, curly hair; Spread sparsely over mons
Stage 4: Coarse curly hair over entire mons
Stage 5: Corase curly hair over entire mons and on extreme proximal aspect of medial thigh

Front 17

Tanner Staging of Breast Development

Back 17

Stage 1: None (preadolescence)
Stage 2: Elevation of Breast and Areola (Breast Bud)
Stage 3: Areola and breast enlargement (early adolesc)
Stage 4: Areola elevated above breast (mid adolesc)
Stage 5: Breast enlarged, areola in contour of breast itself (late adolesc, adult)

Front 18

What is the normal age of pubic hair growth?

Back 18

8-13 y.o.
(androgen mediated)

Front 19

What is the normal age of pubic hair growth?

Back 19

8-13 y.o.
(androgen mediated)

Front 20

What are some possible reasons for primary amenorrhea?

Back 20

- Loss of function anterior pituitary
- Hypothyroidism
- Adrenal insufficiency
- Malnutrition- anorexia nervosa/bulimia

Front 21

What are some vulvar abnormalities you might find on a pelvic exam?

Back 21

Seborrheic Dermatitis
Tinea Cruris
Candidal Vulvovaginitis
Contact Dermatitis

Front 22

Seborrheic Dermatitis
- what is?
- location?

Back 22

1 or more red patches/plaques with greasy scales in mons pubis or labia majora
- symmetric distribution
- often concurrent patches in other hair-bearing areas (scalp, eyebrows)

Front 23

Tinea Cruris
- what is?
- cause?
- location?
- associated with?

Back 23

Erythematous, macerated, pruritic patches in inguinal folds on labia majora
- due to infection with candida
- also on axilla and feet
- often associated with diabetes and/or elevated levels of glucocorticoids

Front 24

Candidal Vulvovaginitis

Back 24

= moderate vulvar and vaginal pruritis
- vulva is red, pruriric, macerated areas
- thick, white, curdled-milk-like discharge

Front 25

Contact Dermatitis
- what is?
- cause?

Back 25

= maculopapular erythematous rash on entire vulva
- extremely pruritic
- severe: excoriations and oozing/crusting vesicles

- cause: exposure to topical agent - e.g., laundry soap, new underpants, sanitary pad, etc.

*HX VERY IMPORTANT FOR DX

Front 26

What are the types of Vulvar Dystrophis?
- main population?
- when occur?
- cause?

Back 26

Lichen Sclerosis
Squamous Cell Hyperplasia
Mixed Dystrophy

- most common in post-menopuasal women

- may occur any time in life

- idopathic
- evidence of autoimmune??

Front 27

Lichen Sclerosis
- patient presentation
- exam

Back 27

Presentation:
- bloody vaginal discharge
- vulvar pain and pruritis
- dyspareunia
- often post-coital bleeding

Exam:
- multiple, very fragile macules on vulva -- increase in number and size and coalesce over time = "Keyhole Pattern"
- loss of skin appendages, pigment, hair: shiny, atrophic appearance
- breaks in skin and mucosa
- severe: fibrosis, obliteration of vulvar tissue

Front 28

Dyspareunia

Back 28

Painful intercourse

Front 29

Squamous Hyperplasia
- presentation
- palpation
- name, when gynecological

Back 29

Presentation:
- Usually multiple whitish papules and plaques = thickened areas of keratin

Palpation: lesions are firm and pumpy

When limited to vulva, called "hyperplastic dystrophy"

Front 30

Mixed Dystrophy

Back 30

Mixture of lichen sclerosis and squamous hyperplasia

Front 31

Inclusion Vulvar Cysts
- what are?
- location?

Back 31

- 1 or more
- nontender
- lateral aspects of labia majora
- yellow hue
- if erupts: thick, caseous, malodorous material

Front 32

Follicular Cysts
- what are?
- location?

Back 32

mildly pruritic, smooth papules or nodules at base of hair shaft due to obstruction/infection of gland that supports the hair
- limited to mons and labia majora

Front 33

Bartholin Cysts/Abscess
- what are?
- location?
- when should you consider it a possible abnormality?

Back 33

- tender nodule in post labia majora protruding into introitus on that side
- due to acute obstruction of bartholin gland duct
- pain specific to post vagina into fourchette

- Abscess: VERY tender; overlying erythema and warmth; purulent discharge;

**If in a post-menopausal woman, consider Bartholin Duct Adenocarcinoma

**If bilateral abscesses, usually neisseria gonorrhea

Front 34

Condyloma Acuminatum
- what are?
- location?
- cause?

Back 34

- one or more fleshy, warty, exuberant, exophytic lesions
- may be so numerous that they become confluent
- may be pedunculated
- asymmetric distribution
- vulva and perianal areas
- due to HPV 16, 18 (STI)

Front 35

Squamous Cell Carcinoma of the vulva

Back 35

- manifests with solitary ulcer - erythematous, often painless, discrete margins, clean base.... slowly increases in size

company it keeps: enlarged ipsilateral inguinal lymph nodes

Front 36

Malignant Melanoma

Back 36

pigmented lesion wiht dysplastic features
- rare
- accounts for <2% of all vulvar neoplastic lesions

Front 37

Chancre
- aka
- cause
- descrip

Back 37

= primary lues
- due to primary infection with syphilis (treponema pallidum)
- solitary
- painless relative to depth
- usually on mucous membrane
- no sx antecedent to ulcer
- well-demarcated, firm indurated borders, clean base

Front 38

HSV
- cause
- sx

Back 38

- usually due to HSV II
- cluster of painful vesicles
- pain and dysthesia prior to onset of vesicles
- primary episode more severe than recurrent ones

Front 39

Skenes Glands
- aka?
- location?
- function?

Back 39

= Paraurethral Glands
- lie on the sides of the urethral meatus
- secrete mucus into the urethra
* homologous to prostate

Front 40

How do you perform a Papaninocolou Smear?

Back 40

Want to get a sample of the cells within the Transformation/Transition Zone (most common site of cervical neoplasia) between the Ectocervical Cells (stratified squamous) and Endocervical Cells (simple columnar)

- Ecto: use a wooden spatula and rotate 360 degrees
- Endo: use a cytobrush

Front 41

When visualizing the cervix, what are you looking for?

Back 41

Inspect for discharge, inflammation, lesions

Front 42

What is the difference between the vaginal discharge of CANDIDA and TRICH?

Back 42

candida = thick, curdled-milk discharge
trich = white, frothy discharge

Front 43

Describe the vagina's anatomical position?

Back 43

Posterior to urinary bladder, anterior to rectum
Begins at the vestibule, ends at the cervix of the uterus

Front 44

Fornices within vagina
- names?
- locations/descriptions?

Back 44

Posterior Fornix
- deepest
- located immediately between rectum and distal uterus
- immediately ant to POUCH OF DOUGLAS (peritoneal space)

Anterior Fornix
- between anterior cervix and urinary bladder

Lateral Right and Lateral Left Fornices
- close to Fallopian Tubes

Front 45

Cervical Os
- what is?
- shape?

Back 45

center opening of the cervix
- round and narrow in women without vaginal deliveries
- slit-like in women who have had vaginal deliveries

Front 46

Cervix
- shape/size
- mucosa

Back 46

- Dome-shaped
- 2-3 cm diameter; 3-5 cm length
- mucosa:
ECTOCERVIX - majority of covering of cervix; stratified squamous
ENDOCERVIX - extension of endometrial lining; simple columnar
TRANSFORMATION ZONE - between

Front 47

Transformation Zone of the Cervix
- description
- location

Back 47

= Line of demarcation between ecto/endocervix
- Location changes throughout life:
--- menstruating woman: outside os, so red, columnar endocervical mucosa is visible (Ectropian Cervix)
--- premenopausal woman: migrated deeply into os, so not visible

Front 48

What is the most common site of cervical neoplasia?

Back 48

TRANSITION ZONE

Front 49

Ectropian Cervix

Back 49

when the transformation zone is outside the cervical os so that it is visible on exam

Front 50

What types of specula are used for a vaginal/cervical exam?
What other tools are required?

Back 50

Grave's Speculum - wide-billed
Pederson Speculum - narrow-billed

Also need spatula and cervical os cytobrush for pap smear

Front 51

Vaginal/Cervical Exam
- position of patient
- speculum insertion and removal?

Back 51

- Dorsal Lithotomy Position
- On a table with stirrups

- Speculum should be warmed with water
**Do not use lubricant - can interfere with pap smear!

- 2nd and 3rd fingers on nondominant hand spread labia minora to open introitus

- Fingers move post to gently press on fourchette; when inserting speculum, press downward to avoid urethra and clitoris

- Insert speculum with bill closed and parallel to labia with slight downward slopw --> insert completely --> turn 90 degrees --> gently open bill

- Once positioned with view of cervix, tighten side screw to maintain position of speculum

- When removing speculum, keep bill slightly open so as to inspect vaginal mucosa

Front 52

Tests to evaluate vaginal discharge?

Back 52

Wet Mount - sterile cotton-tipped swab to obtain sample to discharge, dip swab into test tube with 3 cc of normal saline, then place a drop on microscope slide
--- normally, would see vaginal epith cells

KOH Prep - add 2-3 drops KOH 10% soln to the slide and inspect under microscope -- the KOH breaks down cellular debris to make easier to observe fungal elements
---note any odor

Front 53

Bacterial Vaginosis
- cause
- discharge
- phys exam
- wet mount
- KOH prep

Back 53

Cause: overgrowth of Gardenerella bacteria in vagina, loss of lactobacilli --> lysis and destruction of vaginal epithelial cells

Discharge: malodorous whitish-gray, thin, homogenous liquid - coats surface of vagina and vulva

Phys Exam: vaginal walls are diffusely red

Wet Mount: "CLUE CELLS" = clumps of pigment, which are made up of the bacteria, on the vaginal cells

KOH Prep: fishy, amine odor

Front 54

Trichomonas Vaginitis
- cause
- discharge
- phys exam
- wet mount
- KOH prep

Back 54

Cause: STI trichomonas

Discharge: copious quantity of frothy, clear white discharge with particular odor

Phys Exam: "STRAWBERRY CERVIX" - petechiae on walls of vagina and in cervix

Wet Mount: shows motile protozoan organisms

KOH Prep: nonmotle protozoan organisms

Front 55

Candida Vaginitis
- cause
- discharge
- phys exam
- KOH prep

Back 55

Cause: candida infection to mucosa itself - related to antibiotic use, hormone use, diabetes, etc.

Discharge: thich, white, "curdled milk" appearing discharge adhering to walls of vulva and vagina

Phys Exam: erythema of vaginal wall and vulva

KOH prep: yeast present

**Dx usually made on inspection alone

Front 56

Gardner's Duct Cyst
- physical exam
- what is it?

Back 56

- discrete, nontender, thin-walled nodule in anterolateral wall of vagina
- yellow hue
- 2-3 cm diameter
*Rarely, if ever, causes problems for patient

= vestigial tissue in vaginal wall sue to failure of Wolffian Duct (mesonephric duct) to degenerate

Front 57

What is the most common reason for problems with pelvic relaxation?

What might that patient complain of?

What exam will you perform?

Back 57

**Multiple pregnancies with vaginal deliveries

- may complain of urinary incontinence, bulge/fullness/"rupture" in vagina or rectal areas, especially with cough

**Do VALSALVA MENEUVER - bulges increase

Front 58

Cystocele

Back 58

Soft, bulging mass in wall of anterior vagina due to abnormal descent of urinary bladder into vagina
- Increases with Vasalva
- Severe cases, protrudes beyond introitus

Front 59

Rectocele

Back 59

Soft, bulging mass in lower 2/3 of post vaginal wall due to abnormal descent of rectum into vagina
- Increases with Vasalva
- Severe cases, protrudes beyond introitus

Front 60

Enterocele

Back 60

Soft, bulging mass in upper 1/3 of post wall vagina due to abnormal descent of loops of bowel at pouch of douglas into vagina
- Increases with Vasalva
- Severe cases, protrudes beyond introitus

Front 61

Uterine Prolapse

Back 61

Cervix abnormally displaced inferiorly into vagina
- Severe cases: cervix and body of uterus may protrude beyond introitus
**Degree of prolapse defined by location of tip of cervix
-- first-degree: tip of cervix in proximal 1/3 of vagina
-- second-degree: tip of cervix in distal vagina, but not past introitus
-- third-degree: protrusion of cervix, and even body of uterus, past introitus

Front 62

Rectal Prolapse

Back 62

manifests with abnormal protrusion of anus and rectum - mucosa everted and exposed past anus

-- distinct from, but may be concurrent to a rectocele
- valsalva increases size

Front 63

Uterus
- 3 areas?
- 2 appendages?
- size?
- lining?

Back 63

Areas:
- Cervix - most inferior, protrudes into prox vagina
- Body - bulk of uterus
- Fundus - superior aspect between insertion sites of fallopian tubes

Appendages
- Fallopian Tubes - distal eds open with fibrae; adjacent to ovaries

7-9 cm long
3-5 cm diam

Lining: endometrium - simple columnar

Front 64

Adenexa

Back 64

= fallopian tubes + distal oviducts + fibrae + ovaries

Front 65

Normal size of ovaries

Back 65

= 3-4 cm long

Front 66

What 2 maneuvers are used for examination of uterus and adnexa?

Back 66

1. Bimanual Palpation
2. Rectovaginal Exam

Front 67

Bimanual Palpation for uterine/adnexa exam

Back 67

- Dorsal Lithotomy position
- **Performed after any speculum exam

- Water-soluble jelly to 2nd and 3rd finger on gloved, dominant hand
- Slightly flexed fingers; Thumb fully abducted and extended --> insert fingers into vagina to level of cervix
- Gently palpate cervix, os, fornices
- Place nondominant hand's palm on skin --> directly palpate suprapubic area; grasp body and fundus between hands
- Assess height of fundus - shouldn't be superior to pubic bones

- Move fingers inside laterally to palpate adnexa on each side

Front 68

Rectovaginal Exam
- when do you perform this?

Back 68

***Particularly important for patient in whom can't easily palpate uterus (retroflexed + retroverted)

- Apply water-soluble lubricant to 2nd and 3rd fingers on dominant hand --> insert 2nd finger into post vagina and 3rd into anus/rectum
- Palpate area between fingers

Front 69

Chandelier Sign

Back 69

Cervical motion tenderness noted on bimanual exam -- seen with PID

Front 70

Uterine Positions
- names?
- most common?
- most difficult to palpate?

Back 70

Anteverted/Retroverted - angle of cervix
Anteflexed/Retroflexed - angle of body of uterus in relation to cervix

Anteflexed and Anteverted = most common
Retroverted and Retroflexed = most difficult to palpate on bimanual exam --> do rectovaginal exam

Front 71

Uterine Fibroids
- presentation, sx
- types

Back 71

- very common
- often asymptomatic
- sx: dysmenorrhea, menorrhagia
- exam: one or more rubbery, nontender entities in uterus

1. subserosal - pedunculated, may cause pain and mischief
2. intramural - excessive menstrual bleeding and pelvic pain
3. submucosal - increased risk of miscarriage; most unlikely to be felt on exam; = benign tumors/leimyomata of uterus; extremely common

Front 72

Uterine Endometrial Cancer
- when advanced, how does it present?

Back 72

- irregular vaginal bleeding
- presence of uterine mass on bimanual exam

**any post-menopausal bleeding should lead to suspicion of endometrial carcinoma and be aggressively assessed

Front 73

Ovarian Cyst
- descrip
- size
- cause
- progression

Back 73

- Solitary, smooth, round, mobile mass - indistinguishable from ovary
- ave size: 5 cm
- spontaneously regress in 6-8 wks
= 75% of all ovarian masses
- derived from either follicle or corpus luteum

Front 74

PID
- manifestation
- causes

Back 74

- manifests with tenderness in one or both adnexa, sometimes SEVERE, exquisite pain on papation of cervix
- often concurrent vaginal discharge
- erythema and discharge from cervical ox

Cause: neiserria gonorrhea, chlamydia trachomatis, gram neg rods, aerobes (usually STI)

Front 75

Tuboovarian Abscess
- what is?
- cause?

Back 75

mass in one adnexa in patient who has antecedent or concurrent PID