assessment of the female genitalia

Physical Assessment ofPhysical Assessment of

Male & Female Genitalia,Male & Female Genitalia,

Anus & RectumAnus & Rectum

Maria Maria Carmela Carmela LacsaLacsa Domocmat, RN, MSNDomocmat, RN, MSNInstructor, School of NursingInstructor, School of NursingNorthern Luzon Adventist College Northern Luzon Adventist College

Female GenitaliaFemale GenitaliaFemale GenitaliaFemale GenitaliaFemale GenitaliaFemale GenitaliaFemale GenitaliaFemale Genitalia

Anatomy Anatomy Anatomy Anatomy

Physical AssessmentPhysical Assessment

AbnormalitiesAbnormalities

Anatomy Anatomy

Female External

Reproductive Organs

Maria Carmela L. Domocmat, RN, MSN

Female Internal

Accessory Organs

• uterine tubes• uterus• uterus• vagina


Uterus

22-38Maria Carmela L. Domocmat, RN, MSN

Assessment

Good News!!!

� Deaths due to uterine and cervical cancers have declined by more than 50% since 1960s


Why?Why?Why?Why?

� Because of early detection

�Physical Assessment�Papanicolau test (Pap Smear)�Papanicolau test (Pap Smear)�Increase patient knowledge


History takingHistory takingHistory takingHistory taking

Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination

Physical ExaminationPhysical ExaminationPhysical ExaminationPhysical Examination

1. Inspection and Palpation of the External Genitalia

2. Speculum assessment of Internal Genitalia

3. Collection of Specimens for 3. Collection of Specimens for Laboratory Analysis.

4. Inspection of the Vaginal walls5. Bimanual Examination6. Rectovaginal Assessment

Preparation for the examPreparation for the examPreparation for the examPreparation for the exam

Preparation for the examPreparation for the examPreparation for the examPreparation for the exam

• Instruct the patient while she is dressed

• Instruct her to empty her bladder prior to the exam (depending on prior to the exam (depending on the history and complaints of client)

• Close the door and curtain

• Ask for an assistant


External GenitaliaExternal GenitaliaExternal GenitaliaExternal Genitalia

•Mons Pubis and Pubic Hair•VulvaClitoris•Clitoris

•Urethral Meatus•Vaginal Introitus•Perineum and Anus

Mons Pubis Mons Pubis Mons Pubis Mons Pubis & Pubic Hair& Pubic Hair& Pubic Hair& Pubic Hair

Inspection

InspectionInspectionInspectionInspection

• Observe the pattern of pubic hair distribution

• Note the presence of nits or lice

Normal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsSkin over Mons Pubis:

• Clear with normal hair distribution


Normal FindingsNormal FindingsNormal FindingsNormal Findings (cont’d)(cont’d)

� Pubic Hair

� Distribution – inverse triangle• There may be some growth on

abdomen and upper inner thighabdomen and upper inner thigh

• Note: Diamond-shaped pattern from the umbilicus may be due to cultural or familial differences

� No nits or lice


Geriatric Variation:Geriatric Variation:Geriatric Variation:Geriatric Variation:Geriatric Variation:Geriatric Variation:Geriatric Variation:Geriatric Variation:

� Gray and sparse


Abnormal FindingAbnormal FindingAbnormal FindingAbnormal Finding

Pediculosis Pubis

Crab lice, Pthirus pubis


VulvaVulvaVulvaVulvaVulvaVulvaVulvaVulva

Inspection

PalpationPalpation

InspectionInspectionInspectionInspectionInspectionInspectionInspectionInspection

• Observe the skin coloration and condition of the mons the mons pubis and vulva

• Inform the patient that you will touch the inside of her thigh before you touch the genitals


Inspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the Vulva

•• With gloved With gloved hands, separate hands, separate the labia majora the labia majora using the thumb using the thumb using the thumb using the thumb and the index and the index finger of the finger of the dominant hand.dominant hand.


Inspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the VulvaInspecting the Vulva (cont’d)(cont’d)

•• Observe both Observe both the labia majora the labia majora and the labia and the labia minora forminora forminora forminora fordiscoloration, discoloration, lesions, trauma.lesions, trauma.


�� Labia majora and Labia majora and minora minora

�� Symmetrical Symmetrical

�� Smooth to Smooth to somewhat somewhat

Normal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal FindingsNormal Findings

Smooth to Smooth to somewhat somewhat wrinkled, wrinkled, unbroken, unbroken, slightly pigmented slightly pigmented skin surface. skin surface.


�� Labia Labia majoramajora and and minoraminora (cont’d)(cont’d)

�� No No ecchymosisecchymosis, , excoriation, excoriation,


excoriation, excoriation, nodules, swelling, nodules, swelling, rash, lesions.rash, lesions.

••Occasional sebaceous cyst is within normal limitsOccasional sebaceous cyst is within normal limits••Sebaceous cysts are nontenderSebaceous cysts are nontender, yellow nodules , yellow nodules that are less than 1 cm.that are less than 1 cm.


Skene’sSkene’s glandsglandsand and Bartholin’sBartholin’s

glandsglands



�� Skene’s glands and Bartholin’s glands are Skene’s glands and Bartholin’s glands are not normally seen by naked eyenot normally seen by naked eye


Normal DeviationsNormal DeviationsNormal DeviationsNormal DeviationsNormal DeviationsNormal DeviationsNormal DeviationsNormal Deviations

� Geriatric: atrophied- appears flatter and smaller

� Multiparrous women: majora are separated and minora more separated and minora more prominent


Abnormal Findings VulvaAbnormal Findings VulvaAbnormal Findings VulvaAbnormal Findings Vulva

Bartholin’s CystSkene’s Gland CystVulvar epidermal cystEdema, Swelling Rash (contact dermatitis, infestation)Chancre (Syphilis)Chancre (Syphilis)Wartlike papules (condyloma latum)Ulcer (Herpes)Venous prominence (varicose veins)Carcinoma

Inflammation of Bartholin Glands


Skene Gland Cyst


� Vulvar hypertrophy� Vulvar epidermal cysts develop from sebaceous

glands.

�Multiple, bilateral vulvar epidermal inclusion cysts, previously referred to as sebaceous cysts, are shown.Maria Carmela L. Domocmat, RN, MSN

Benign vulvar lesions. Pemphigus vulgaris

vulvar involvementvulvar involvementvulvar involvementvulvar involvementmucosal involvementmucosal involvementmucosal involvementmucosal involvement


Benign vulvar lesions

� Allergic Vulvitis � Psoriasis


Benign vulvar lesions

� Vulvar Melanosis � Hemangioma


� Condyloma Latum(Secondary Syphilis)

� CondylomaAcuminatum(Genital Or Venereal Wart)


Herpes genitalis


� Well-differentiated carcinoma of vulva

� Advanced carcinoma of vulva, involving entire vagina, urethra and rectum


Palpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the LabiaPalpating the Labia

�� Palpate each labium between the Palpate each labium between the thumb and the index finger of your thumb and the index finger of your dominant hand.dominant hand.

�� Observe for swelling, induration, pain, Observe for swelling, induration, pain,


�� Observe for swelling, induration, pain, Observe for swelling, induration, pain, or discharge from a Bartholin’s gland or discharge from a Bartholin’s gland duct.duct.



Labium:

• Feel soft and uniform in structurein structure

•No swelling, pain, induration, or purulent discharge


Palpating around the Palpating around the Palpating around the Palpating around the Palpating around the Palpating around the Palpating around the Palpating around the vaginal introitus vaginal introitus vaginal introitus vaginal introitus vaginal introitus vaginal introitus vaginal introitus vaginal introitus

((((((((Bartholin glandsBartholin glands))))))))


If discharge is If discharge is present , present , obtain a obtain a

specimen and specimen and specimen and specimen and change the change the gloves into gloves into clean ones.clean ones.


Abnormal FindingsAbnormal FindingsAbnormal FindingsAbnormal Findings

� Painless mass indicates malignancy

Painless mass indicates malignancy

� Painful mass indicates hernia

Hernia or not?

� If hernia is suspected, re-palpate the mass with the patient in a standing position

� (+) hernia: If increase in � (+) hernia: If increase in bulging when standing and ask patient to cough


ClitorisClitorisClitorisClitoris

Inspection


� Using the dominant hand and index finger, separate the separate the labia minora laterally to expose the prepuce of the clitoris


Normal FindingsNormal FindingsNormal FindingsNormal Findings

••Approximately 2 cm in length and 0.5 Approximately 2 cm in length and 0.5 cm in diametercm in diameter

••Without lesionsWithout lesionsMaria Carmela L. Domocmat, RN, MSN


Hypertrophy Hypertrophy

(clitoromegaly, pseudohermaphroditism)

Chancre

ClitoromegalyClitoromegalyClitoromegalyClitoromegaly� A 22-year-old

gravida O

� 20 mm

� 19-year-old gravida O

� 30 mm

clitoroplasty Maria Carmela L. Domocmat, RN, MSN

Urethral MeatusUrethral MeatusUrethral MeatusUrethral Meatus

Inspect

PalpatePalpate


� Using the dominant hand and index finger, separate the labia minora to expose the urethral meatus.

� Do not touch the urethral meatus.Do not touch the urethral meatus.

� may cause pain and urethral spasm

� Observe

� shape, color, and size of urethra



� Slitlike in appearance

� Midline

� Free from discharge, swelling, or redness

� About the size of a peaMaria Carmela L. Domocmat, RN, MSN


Discharge or swelling Urethral caruncleUrethral caruncleUrethral carcinomaProlapse of urethral mucosa

Urethral caruncle


PalpationPalpationPalpationPalpation

Milking the urethra andMilking the urethra andparaurethral glandsparaurethral glandsMilking the urethra andMilking the urethra andparaurethral glandsparaurethral glands


� Insert your dominant index finger into the vagina

� Apply pressure to the anterior aspect of the anterior aspect of the vaginal wall and milk the urethra

� Observe for discharge and client discomfort


Milking the urethra andMilking the urethra andparaurethral glandsparaurethral glands



� Should not cause pain

� Or result in any urethral discharge


� If urethral discharge is present, obtain a specimen and change to a clean pair of gloves


Let’s Watch: Palpating

the Skene Glands and

Bartholin GlandsBartholin Glands

Vaginal IntroitusVaginal IntroitusVaginal IntroitusVaginal Introitus

Inspect PalpatePalpate

� Keep labia minora retracted laterally to inspect the vaginal introitus.

� Ask the patient to bear down.


Ask the patient to bear down.

� Observe for patency and bleeding.


� Introitus Mucosa

� Pink and moist

� Patent


� Patent

� Without Bulging


NulliparousNulliparouswith intact with intact

hymenhymen

Multiparous with Multiparous with remaining hymenremaining hymen


� Normal Vaginal Discharge – white and free of foul odor (some white clumps may be seen—mass clamps of epithelia cells)



� Insert your dominant finger in the vagina, ask the client to squeeze the vaginal muscles around your finger.

� Evaluate muscle strength and tone


� Vaginal muscle tone

� In nulliparous woman: tight and strong

� In a parrous woman: it is diminishedMaria Carmela L. Domocmat, RN, MSN

Abnormal Findings

Pale color and dryness (atrophy, aging)

Tear, fissureTear, fissure

Bulging

Discharge

Pelvic Organ Prolapse

Cystocele

Cystourethrocele

RectoceleRectocele

Uterine Prolapse

Cystocele


Rectocele


Degrees of Uterine Prolapse


Second degree uterine prolapse


Symptomatic posthysterectomyvault prolapse in vault prolapse in 60-year-old patient.


PerineumPerineumPerineumPerineum

Inspect

PalpatePalpate

Inspection

• Observe texture and color of the perineum

• Observe for color and shape of the anus

Normal Findings

� Perineum

� Smooth

� Slightly darkened

� Well-healed episiotomy scar is normal after vaginal delivery

Normal Findings



Fissure or tear (trauma, abscess, or unhealed episiotomy)or unhealed episiotomy)

Keloid

Giant perineal keloidGiant perineal keloidGiant perineal keloidGiant perineal keloid


Palpating the PerineumPalpating the PerineumPalpating the PerineumPalpating the Perineum

� Place the dominant index finger posterior to the perineum

Palpating the PerineumPalpating the PerineumPalpating the PerineumPalpating the Perineum

to the perineum and the thumb anterior to the perineum


� Assess perineum between the dominant thumb

Palpating the PerineumPalpating the PerineumPalpating the PerineumPalpating the Perineum(cont’d)(cont’d)(cont’d)(cont’d)

dominant thumb and index finger for muscular tone and texture



� Smooth & Firm

� Homogenous in nulliparous

� Thinner in parous womanwoman

� Well-healed episiotomy scar is also within normal limits for parous woman



Thin (atrophy)

Fissure or tear (trauma, abscess, Fissure or tear (trauma, abscess, or unhealed episiotomy)

Speculum Examination of the Speculum Examination of the

Internal GenitaliaInternal Genitalia

InspectionInspection

Cervical ExaminationCervical Examination

� Select the appropriate-sized speculum

� Based on client’s

� Based on client’s history, size vaginal introitus, and vaginal muscle tone


� Lubricate and warm the speculum by rinsing it with warm water

� Do not use lubricant, may � Do not use lubricant, may be bacteriostatic and can alter Pap test results


Holding the Speculum

•Hold the speculum by your dominant hand with the hand with the closed blades between the index and middle fingers


� Insert your nondominant index and middle fingers, ventral sides down, just inside the vagina and apply pressure to the and apply pressure to the posterior vaginal wall


� Encourage client to bear down

� This will help to relax the perineal musclesmuscles

� Encourage client to relax by taking deep breaths

� Be careful not to pull on pubic hair or pinch the labia


Preparing for the Preparing for the insertion insertion of of the the speculumspeculum

Apply Apply downward downward pressure in pressure in posterior posterior vaginal vaginal opening opening with two with two with two with two fingersfingers


Oblique insertion of the Oblique insertion of the speculumspeculum

When you feel the When you feel the muscles relax, muscles relax, insert the speculum insert the speculum at an oblique angle at an oblique angle on a plane parallel on a plane parallel to the examination to the examination on a plane parallel on a plane parallel to the examination to the examination table until the table until the speculum reaches speculum reaches the end of the the end of the fingers that are in fingers that are in the vagina.the vagina.


Withdraw your nondominant Withdraw your nondominant hand from the vaginahand from the vagina


Directing speculum downward

at 45 angle. Gently rotate Gently rotate the speculum the speculum blades to a blades to a horizontal angle horizontal angle and advance and advance the speculum at the speculum at a 45a 45--degreedegree--

0000

a 45a 45--degreedegree--angle against angle against the posterior the posterior vaginal wall vaginal wall until it reaches until it reaches the end of the the end of the vagina.vagina.


Final Adjustment of the Speculum


Opening of the

speculum blades••With your With your dominant thumb, dominant thumb, depress the lever depress the lever to open the blades to open the blades and visualize the and visualize the cervix.cervix.


� If the cervix is not visualized, close the blades and withdraw the speculum 2 to 3 cm and reinsert it at a slightly different angle to ensure that the speculum is inserted far enough into the vagina.the vagina.

� Once the cervix is fully visualized, lock the speculum blades into place.

� Adjust your light source so that it shines through the speculum.


Speculum in place, locked, and

stabilized. Note cervix in full view.


� Color

� Glistening pink

� Pale after menopause

� Blue (Chadwick’s sign) during pregnancy


Blue (Chadwick’s sign) during pregnancy

� Position

� Located midline in the vagina with an anterior or posterior position relative to the vaginal vault


� Size:

� 2.5 cm to 3 cm in young woman. Smaller in elderly

� Surface characteristics:

� Covered by glistening pink squamouspink squamousepithelium, which is similar to vaginal epithelium

� Discharge:

� Note characteristics of any discharge Maria Carmela L. Domocmat, RN, MSN

� Shape of cervical os

� In nulliparouswoman: os is small and either round or oval.

In a parrous�In a parrouswoman: os is a horizontal slit


Let’s Watch:

Inspecting the Cervix


Lacerations Cyanosis Redness or friable appearanceRedness or friable appearanceReddish circle around os (ectropion or eversion)Small, round, yellow lesion (nabothian cyst)


Condyloma AcuminataCandidiasisCervicitisCandidiasisCervicitisEndocervical GonorrheaStrawberry spots (trichomonal infection)Cauliflower overgrowth (carcinoma)

� Cervical Ectropion

� Nabothian Cyst


� Condyloma acuminata(venereal warts)

� Candidiasis

caused by "Human Papilloma Virus" (HPV).


Chlamydial cervicitis


Endocervical gonorrhea


� “Strawberry” cervix (Trichomonasis)

� Cervical Cancer


Collecting Specimens for Collecting Specimens for Cytological Smears and Cytological Smears and CulturesCultures••Pap SmearPap Smear

••Gonococcal Culture SpecimenGonococcal Culture Specimen••Gonococcal Culture SpecimenGonococcal Culture Specimen

••Saline Mount or “Wet Prep”Saline Mount or “Wet Prep”

••KOH PrepKOH Prep

••Five Percent Acetic Acid WashFive Percent Acetic Acid Wash

••Anal CultureAnal Culture

Pap SmearPap SmearPap SmearPap Smear

Endocervical Endocervical SmearSmear

Cervical SmearCervical Smear

Vaginal Pool Vaginal Pool SmearSmear

Pap Smear Equipments


� A collection of three specimens that are obtained from three sites

� Cervix

� Vaginal pool

� Posterior � Posterior fornix of the vagina


� Using your nondominant hand, insert the cytobrush through the speculum into the cervical os approximately 1

Endocervical SmearEndocervical Smear

the cervical os approximately 1 cm

� May cause cramping sensation, so forewarn the patient.


� Rotate the cytobrush between your index finger and thumb 360

Endocervical Endocervical SmearSmear (cont’d)(cont’d)

finger and thumb 360 degrees clockwise, then counterclockwise.

� Keep cytobrush in contact with the cervical tissue� If you have to use a cotton-tipped applicator instead of cytobrush, leave the applicator in the os for 30 seconds to ensure saturation.Maria Carmela L. Domocmat, RN, MSN

� Remove the cytobrush and, using a rolling motion, spread the cells on the section of the slide marked E, if a sectional slide is being used.Do not press down hard or

EndocervicalEndocervical SmearSmear(cont’d)(cont’d)

� Do not press down hard or wipe the cytobrush back and forth. Doing so will destroy the cells.

� Discard the brush.


� Insert the bifurcated end of Ayre spatula through the speculum

Cervical SmearCervical Smear

end of Ayre spatula through the speculum base.

� Place the longer projection of the bifurcation into the cervical os.


� The shorter projection should be snug against the ectocervix

Rotate the spatula 360

Cervical SmearCervical Smear(cont’d)(cont’d)

� Rotate the spatula 360 degrees one time only

� Remove the spatula and gently spread the specimen on the section of the slide labeled C, if a sectional slide is being used.


Vaginal Pool Smear

� Reverse the Ayre spatula and insert the rounded end into rounded end into the posterior fornix and gently scrape the area


� Cotton-tipped applicator may be the preferred vehicle for obtaining specimen if vaginal secretions are viscous or dry.

Vaginal Pool Smear

viscous or dry.

� By moistening the cotton-tipped applicator with normal saline solution, viscous secretions can be removed with less trauma to the surrounding membranes.


� Remove the spatula and gently spread the specimen on the section of the slide marked V, if a sectional slide is being used.

Dispose of the spatula cotton-tipped

Vaginal Pool Smear

� Dispose of the spatula cotton-tipped applicator .

� Spray the entire slide or the slides with cytological fixative.

� Submit the specimens to the laboratory.


� Normal classifications for all cervicovaginal cytology should read “within normal limits” (WNL) using Bethesda system.

Normal findings

Bethesda system.

� Denotes lack of pathogenesis


Inspection of the Inspection of the Inspection of the Inspection of the

Vaginal WallVaginal WallVaginal WallVaginal Wall

Inspection

� Disengage the locking device of the speculum

� Slowly withdraw the speculum but do not close the bladesnot close the blades

� Rotate the speculum into oblique position as you retract it

� to allow full inspection of the vaginal walls

� Observe vaginal wall color and textureMaria Carmela L. Domocmat, RN, MSN

Normal findings

� Vaginal walls

� Pink

�Moist�Moist

�Deeply ruggated

�Without lesions or redness


Geriatric VariationGeriatric VariationGeriatric VariationGeriatric Variation

� Thinner

� Drier

� Less vascular� Less vascular



Vaginitis

AdenosisAdenosis

Carcinoma

Atrophic vaginitis

� External genitalia of a 67-year-old woman who is naturally menopausal for two years and is not on estrogen replacement on estrogen replacement therapy. Note loss of labial and vulvar fullness, pallor of urethral and vaginal epithelium, and decreased vaginal moisture.


� Vaginal inclusion cysts contain epithelial tissue

� Bacterial Vaginosis


� Vaginal adenosis � Vaginal Carcinoma


Bimanual ExaminationBimanual ExaminationBimanual ExaminationBimanual Examination

•Vagina

•Cervix

•Fornices

•Uterus

•Adnexa

•Cervix •Uterus

Steps of Bimanual Exam:

1. Observe the client’s face for signs of discomfort during the assessment process.

2. Inform the client of the steps of the bimanual assessment, and tell her that the lubricant gel may be cold.


Steps of Bimanual Exam: (cont’d)

3. Squeeze the lubricant onto the fingertips

of your dominant hand.

4. Stand between the 4. Stand between the legs of the client as she remains in the lithotomy position, and place your non-dominant hand on her abdomen and below the umbilicus.



5. Insert your lubricated index and middle fingers 1 cm into the vagina. 1 cm into the vagina. The fingers should be extended with the palmer side up. Exert gentle posterior pressure.



6. Inform the client that pressure from palpation may be uncomfortable. uncomfortable. Instruct the patient to relax the abdominal muscles by taking deep breaths.


Steps of Bimanual Exam (cont’d)

7. When you feel the client’s muscles relax, insert your your fingers slowly to their full length into the vagina. Simultaneously palpate the vaginal walls.


Steps of Bimanual Exam (cont’d)

8. Remember to keep your thumb widely abducted and away from the urethral from the urethral meatus and clitoris throughout the palpation in order to prevent pain or spasm.


� Complete steps 1-8 of the bimanual exam. Rotate the wrist so that the fingers are able to

VaginaVagina

the fingers are able to palpate all surface aspects of the vagina.


VaginaVagina

�� Normal FindingsNormal Findings

�� Vaginal wall non tenderVaginal wall non tender

Smooth or ruggated surfaceSmooth or ruggated surface�� Smooth or ruggated surfaceSmooth or ruggated surface

�� No lesions, masses, or cystsNo lesions, masses, or cysts


1. Position the dominant

hand so that the

palmar surface faces

upward.

Cervix

upward.

2. Place the non-dominant hand on the abdomen approximately 1/3 of the way down between the umbilicus and the symphysis pubis.


3. Use the palmar surfaces of the dominant hand’s fingerpads, which are in the vagina, to assess the

Cervix

the vagina, to assess the cervix for consistency, position shape, and tenderness.

4. Grasp the cervix between the fingertips and move the cervix from side to side to assess mobility.


Cervix

�� Normal FindingsNormal Findings

�� MobileMobile

�� Without painWithout pain

�� Smooth and Smooth and �� Smooth and Smooth and firmfirm

�� Symmetrically Symmetrically roundedrounded

�� MidlineMidline �Softening between 5th or 6th week of pregnancy- Goodell’s sign



Extreme pain on palpation (Chandelier’s sign –PID)(Chandelier’s sign –PID)Irregular surface (malignancy, nabothian cyst, polyps)

• With the fingertips and palmar surfaces of the fingers, palpate

Fornices

fingers, palpate around the fornices.

• Note nodules or irregularities.


Fornices

� Normal Findings

� Walls should be smoothsmooth

� No nodules


Uterus

1. With the dominant hand, which is in the vagina, push the pelvic organs out of the pelvic organs out of the pelvic cavity and provide stabilization while the non-dominant hand, which is on the abdomen, performs the palpation.


Uterus

2. Press the hand that is on the abdomen inward and downward abdomen inward and downward toward the vagina, and try to grasp the uterus between your hands.


Uterus

2. Press the hand that is on the abdomen inward and downward toward the vagina, toward the vagina, and try to grasp the uterus between your hands.


Bimanual palpation of UterusBimanual palpation of Uterus


Uterus

� Normal Findings

� Size varies based on parity

Nongravid client: � Nongravid client: Pear-shaped

� Parous: more rounded

� Smooth

� Without masses


Uterus

� Normal Findings (cont’d)

� May be non-palpable if it is retroverted or retroflexed (rectovaginal assessment)assessment)

� Non palpable uterus is normal in older women

� Due to secondary uterine atrophy


Anteverted uterus


Anteflexed UterusAnteverted uterus


� Retroverted

Uterus

� Retroflexed

Uterus



� Enlargement and changes in shape

� Nodules or irregularities (leiomyomas)

� Non palpable uterus (hysterectomy)


Adnexa

1. Move the intravaginal hand to the right lateral fornix, and the hand on the abdomen to the right lower quadrant just inside the abdomen to the right lower quadrant just inside the anterior iliac spine.

2. Press deeply inward and upward toward the abdominal hand.


3. Push inward and downward with the abdominal hand and try to catch the ovary between your fingertips.

Adnexa

between your fingertips.

� Palpate for size, consistency, and mobility of the adnexa.

� Repeat the above maneuvers on the left side.


Palpation of Left Adnexa


Adnexa

�� Normal Findings Normal Findings Ovaries

� Almond-shaped

Firm� Firm

� Smooth

� Mobile

� Without tenderness


Geriatric VariationGeriatric VariationGeriatric VariationGeriatric VariationGeriatric VariationGeriatric VariationGeriatric VariationGeriatric Variation

� Rarely palpable


Let’s Watch:

Bimanual Palpation

of Uterus


Enlarged, irregular, nodular, painful, with decreased mobility painful, with decreased mobility (ectopic pregnancy, ovarian cyst, PID or malignancy)

Collecting Specimens

Five Percent Acetic Acid Wash

1. After completing all other vaginal specimens, swab the cervix with specimens, swab the cervix with cotton-tipped applicator that has been soaked in 5% acetic acid.

2.Leave for one minute.

Normal Finding

� There should be no change in the appearance of the cervix (HPV)



Rapid acetowhitening or blanching with jagged borders (HPV)with jagged borders (HPV)

Apparently normal cervix


After application of acetic acid


RectovaginalRectovaginalRectovaginalRectovaginalExaminationExaminationExaminationExamination

Rectovaginal ExaminationRectovaginal Examination


assessment of the female genitalia

Health & Medicine