Gynecological Examination - A Brief Discussion

General Principles
The majority of women have varying degrees of anxiety about vaginal examination.
Examination is usually more informative in a relaxed patient and a number of simple measures can be used to make the patient feel at ease.

Women should be given an appropriate area to change in privacy. A sheet should be provided to allow the woman to cover herself. A chaperone should be present for any intimate examination. This should apply for both male and female practitioners. The chaperone provides two purposes, firstly as a source of support and distraction for the patient but also to provide evidence that no improper behavior has taken place.
Formal consent should be given for any intimate examination by a student including under anesthesia.

An explanation of the purpose of the examination should be given to the woman and permission sought to perform the examination. Simple terms should be used to explain the likely sensations experienced. The examination should be thorough but gentle. The patient should feel confident that you will stop the examination if she wishes.

Abdominal Examination:
This must never be omitted, whatever be the patient’s complaint.

• Many gynecological tumors form large swellings, which could be palpated on abdominal examination. 
• Also an abdominal examination may reveal an undisclosed pregnancy
• Always examine the upper abdomen. 
• Be certain that the bladder is empty.
• Ask the patient to tell you if you are hurting her.

All the classical techniques of inspection, palpation, percussion and auscultation are advised, but the most important is gentle palpation with the flat of the hand to detect solid or semi-solid tumors.
The examiner must bear in mind the various intra-abdominal structures which may give rise to swellings.

• Inspection may show the characteristic shape of a large ovarian cyst. The outline is rounded and uniform, the skin is stretched and a fluid thrill may be elicited.
• If ascites is present (and this means that the cyst is probably malignant), the outline tends to be cylindrical, with some flattening at the top. The umbilicus is everted, and the percussion note is dull in the flanks but tympanitic above because of the upward floating of the intestines.

Unfortunately, obesity is an increasing problem, and abdominal examination can be particularly
challenging in very obese patients.

Examination Of the Vulva

• The dorsal position is most convenient for patient and doctor although examination in a lateral position is useful to assess vaginal prolapse. 
• During palpation, visual inspection of the labia, clitoris, anus and surrounding skin should be performed. Raised or ulcerated areas should raise the question of vulval malignancy.
• There are specific skin conditions that affect the vulva, including lichen sclerosus, which often presents with itchy white patches and labial fusion. 
• Common benign lesions include sebaceous cysts. 
• Excoriation suggests an underlying irritation.

Palpation:

1. A single finger presses on the perineum, avoiding the sensitive vestibule, and accustoming the patient to the examiner’s touch.

2. Urethral meatus and vestibule are exposed. Pressure from the finger will squeeze any pus from the peri-urethral glands.

3. Bartholin’s gland is palpated (on both sides). It is difficult to feel the normal gland.

4. If there is room, a second finger is inserted and the perineal floor is palpated by stretching.

Bimanual Examination

This technique needs practice. The external hand is the more important and supplies more information. It is customary to use two fingers in the vagina, but an adequate outpatient examination may be made with only one finger.

Very little information is gained if the patient finds the examination painful. 

In a virgin or a child, vaginal examination should not be performed, unless there are exceptional circumstances, and examination under anesthesia should be considered.

Pelvic models are available, with interchangeable uterine and adnexal components to simulate normal and pathological conditions, for practice examination.

1. The vagina and cervix are palpated and any hardness or irregularity noted.

2. The whole uterus is identified, and size, shape, position, mobility and tenderness are noted.

3. The lateral pelvis is palpated and any swelling noted. Normal adnexa are difficult to feel, unless the ovary contains a corpus luteum.

4. Sometimes rectovaginal examination is helpful, particularly if the rectovaginal septum is to be examined, for example, in assessment of extent of malignant disease.

Speculum Examination

The bi-valve speculum is the most useful (Cusco’s ). It is made of either steel or Perspex (disposable) and is designed to open after insertion so that the cervix and vagina can be visualized. 

Versions with a screw or ratchet are available to hold the device open so that cytological smear or bacteriological swab can be taken as required.

1. The speculum is applied to the vulva at an angle of 45 degrees from the vertical. This allows the easiest insertion.

2. When fully inserted, it is gently opened out and held in position with the cervix between the blades. A good light is needed for inspection. Care is required when removing the speculum to ensure

that the blades have not caught the cervix or vagina and that the blades have not been held open by the ratchet or screw.

SIMS’ SPECULUM (the duckbill speculum) is designed to hold back the posterior vaginal wall so that air enters the vagina because of negative intra-abdominal pressure, and the anterior wall and cervix are exposed.