Good draping method for a women pelvic exam
cover her knees and symphysis dress the drape between her knees
Labial swelling, redness, or tenderness, particularly unilateral may indicate
Bartholin gland infection
Excoriation, rashes, or lesions of the labial suggest
infectious or inflammatory process
palpate what parts of the external female genitalia?
labia minora, clitoris, urethral orifice, vaginal introitus, and perineum
discoloration or tenderness of the labia minora may be a result from
traumatic bruising
ulcers or vesicles on the labia minora may be a sign of
STIs
General size of the clitoris
2cm or less in lenght and 0.5cm in diameter
Enlarged clitoris may be a sign of
masculinizing condition
a bright red polypoid growth that protudes from the urethral meatus
caruncle
caruncle symptoms
none
signs of irritation, inflammation, or dilation of the urethral orifice suggests
repeated UTI or insertion of foreign objects
a thin verticle slit or a large orifice with irregular edges from hymenal remnants (myriform caruncles)
vaginal introitus
How do you examine the skene glands
exerting upward pressure with index finger (2nd joint deep), milk the Skene gland by moving the finger outward on both sides of the urethra and directly on the urethra
Discharge from skene glands or urethra indicates
infection, commonly gonococcal
Where is the female bartholin gland located
posterolateral portion of the labia majora
bartholin gland swelling that is painful, hot to touch, fluctuant is indicative of
infection of the gland
Infection of the Bartholin gland is usually ___ or ___ in origin and ______.
gonococcal or staphylococcal in origin and filled with pus
a nontender mass on the Bartholin gland is indicative of
Bartholin cyst
Bartholin cysts are a result of what
chronic inflammation of the gland
What is uterine prolapse marked by
protrusion of the cervix or uterus on straining
episiotomy scarring may be evident in who
women who have borne children
how should the perineum tissue feel in a nulliparous women
thick and smooth, and nontender
how should the perineum tissue feel in a multiparous women
thin and rigid, and nontender
how to hold a speculum
index finger over the top of the proximal end of the anterior bland and the other fingers around the handle.
how do you apply pressure when opening the speculum
apply gentle downward pressure
expected color of the cervix
pink, with the color evenly distributed
bluish cervix indicates
vascularity, which may be a sign of pregnancy
symmetric circumscribed redness around the os is a(n) ____ finding that indicates
expected finding that indicates exposed columnar epithelium fromt he cervical canal
a pale cervix is associated with
anemia
the anterior-posterior position of the cervix correlates with the position of the
uterus
a cervix that is pointing anteriorly indicates
retroverted uterus
a cervix that is pointing posteriorly indicates
anteverted uterus
a cervix in the horizontal position indicates
uterus in midposition
cervix deviating to left or right may indicate (3)
pelvic mass, uterine adhesion, or pregnancy
Normal protusion of the cervix into the vagina
1-3cm
projection of the cervix greater than 3cm into the vagina may indicate
a pelvic or uterine mass
the cervix of a women of childbearing age is usually how big in diameter
2-3cm
the junction of squamous and columnar epithelium cells is known as
transformation zone
Where is the transformation zone barely visible
inside the external os
____ occurs when eversion of the endocervix exposes columnar epithelium
cervical ectropion
Everted epithelium appears ___ and ___
has a red, shiny appearance around the os and may bleed easily
Ectropion is common in who
adolescents, pregnant women, or those taking estrogen-containing contraceptives
is ectropion an abnormality?
No but because it is indistinguishable from early cervical carcinoma, further dx studies are needed (pap smear, biopsy)
small, white or yellow raised, round areas on the cervix
Nabothian cysts
are Nabothian cysts normal?
yes, an expected finding
mucinous retetion cyst of the endocervical glands
nabothian cysts
Occur during the process of metaplasia at the transformation zone when endocervical columnar cells continue to secrete but are covered by squamous epithelium
nabothian cysts
T or F, Nabotian cyst can occur in multiples or singularly
T
Friable tissue, red patchy polyps, granular areas, and white patche on the cervix could indicate
cervicitis, infection, or carcinoma
Where do cervical polyps usually arise from
endocervical canal
Bright red, soft, and fragile
cervical polyps
Ususal cervix discharge
odorless, creamy or clear, thick/thin/or stringy, heavier at midcycle or immediately before menstruation
odory discharge from cervix that varies from white to yellow, green or gray indicates
bacterial or fungal infection
Os is small and round or oval in __ women
nulliparous
the os is a horizontal slit or may be irregular and stellate in __ women
multiparous
lateral transverse, bilateral transverse, or stellate scarring of the cervix is caused by
trauma from childbirth
Trauma from induced abortion or difficult removal of an intrauterine device may change the shape of what
the os to a slit
cylindric-type brush collects
endocervical cells only
collect a sample of the ectocervix with a
spatula
First collect cells from _____ then use ____ to collect from ______
ectocervix then use a brush to collect from cervical os
rotate spatula ___ degrees
360 degrees
rotate brush ___ degrees
180 degrees
what device is used for collecting both ectocervical and endocervical cells at the same time
broom-type device
what Pap testing requires the broom type device
liquid based cytology
what sample is used to test for HPV
liquid sample
how to test for gonoccocal culture
insert sterile swab into cervical os, hold for 10-30 sec then spread specimen in a large Z pattern
what do you use when DNA testing for organisms
Dacron swab (with plastic or wire shaft)
single organsim tests are available for
chlamydia trachonmatis and N. gonorrhea
multiorganism tests are available for
Trichomonas vaginalis, Gardnerella vaginalis, and Candida species
in a woman with vaginal discharge, ___ and ___ examinatios can demonstrate the presences of Trichomonas vaginalis, bacterial vaginosis, or candidiasis
wet mount and potassium hydroxide (KOH) exams
KOH dissolves what and facilitates what
epithelial cells and debris and facilitates visualization of the presence of mycelia of a fungus
appearance of vaginal walls in premenopausal women
will have rugae
appearance of vaginal walls in postmenopausal women
will be smooth
hernial protrusion of the urinary bladder through the anterior wall of the vagina, sometimes even exiting the introitus
cystocele
a hernial protrusion of part of the rectum through the posterior vaginal wall
rectocele or proctocele
make sure the speculum is fully closed when the blades pass through the ___
hymenal ring
consistency of the cervix in a nonpregnant woman will be
firm
consistency of the cervix in a pregnant woman will be
soft
the cervix should move ____ in each direction
1-2cm with minimal or no pain
painful cervical movement suggests
pelvic inflammatory process such as pelvic inflammatory disease or ruptured tubal pregnancy
if you feel the fundus between the fingers of your 2 hands at the level of the pubis, the uterus is ___
anteverted or anteflexed (most common)
a ___ uterus will be felt by placing the intravaginal fingers together in teh posterior fornix, with the abdominal hand immediately above the symphysis pubis, press down firmly wiht the adominal hand when you press against the cervix inward with the other
retroverted
expected shape and size of the uterus
pear shaped, 5.5-8cm long
the uterus is ___ in all dimension in multiparous women
larger
uterus contour smoothness will be interrupted by
pregnancy or tumor
uterus should be mobile in what plane
anteroposterior plane
a fixed uterus indicates
adhesions
palpable ovaries should feel
firm, smooth, ovoid
approximate size of ovaries
3 x 2 x 1cm
lower abdominal pain associated wiht ovulation
Mittelschmerz
cervical screening should being at age
21
pap testing should be done how often for women 21-29
every 3 years
women 30-65 need what testing
pap plus an HPV every 5 years or pap test alone every 3 years
a woman with CIN grade 2 or 3 should be tested for at least ___ years after diagnosis
20 years
women vaccinated against HPV should follow up __
same as recommendatins for their age group
rectovaginal exam allows you to reach almost ___ higher into the pelvis
2.5cm or 1 inch
gonorrhea is caused by
a bacteria
Trichomoniasis is caused by a
protozoan
a prolapsed bladder
cystocele
cessation of menses for 1 year because of age.
menopause
menarche
the first menstruation
Amenorrhea
no menstruation
when are Skene glands, Bartholin glands, and the urinary meatus examined
external genitalia examinaton
benign cysts that may appear on the cervix after childbirth.
nabothian cysts
to collect a gonococcal culture you would use a ___ and collect it from ___
use a sterile swab and collect it from the cervical os
to collect a gonococcal culture you would ____ then ___ with it
hold it in place for 10-30 seconds then spread in on a plate in a Z formation
What would you use to collect DNA for chlamydia and gonorrhea? and where would you collect the specimen?
Dacron swab, and the cervical os
to collect the specimen for DNA chlamydia and gonorrhea you would ___ with the swab and ___ after with it
rotate it for 30 seconds then, put it in a special tube containing specimen reagent
What would you use to collect trichomonas vaginalis? and where would you collect the specimen?
sterile cotton swab, vaginal discharge
collection time for trichomonas vaginalis? and then what do you do with the sample?
no specific time, place it on a glass and add a drop of normal saline
What would you use to collect bacterial vaginosis or candida vulvovaginitis? and where would you collect the specimen?
sterile cotton swab, vaginal discharge
collection time for bacterial vaginosis or candida vulvovaginitis? and then what do you do with your sample
no specific time, Place it on a glass slide and add a drop of aqueous 10% KOH
male escutcheon pattern
pubic hair narrowing midline to umbilicus
amount of hair on scrotum
scant amount
what vein should be apparent on the penis
dorsal vein
A white cheesy sebaceous matter that collects between the glans penis and foreskin
smegma
tight foreskin that cannot be retracted
phimosis
when does phimosis occur or what causes it
may occur first 6 yrs of life or as a result of recurrent balanitis or balanoposthitis
balantitis
inflammation of the glans penis
balanoposthitis
inflammation of the glans penis or prepuce
cause of balanoposthitis
bacteria or fungal infections
balanoposthitis is commonly seen in men with
uncircumcised penis or poorly controlled DM
if a man is circumcised, how should the glans appear
erythematous and dry, no smegma
where is the male urtethral meatus located
ventral surface just millimeters from tip on the glans
normal appearance of the male urethral meatus
glistening and pink
bright erythema or discharge on the male urethral meatus indicates
inflammatory disease
pinpoint or round urethral meatus opening on a male indicates
meatal stenosis
presence of discharge while palpating the penile shaft and striping the urethra may indicate
STI
priapism
prolonged penile eretion
cause of priapism (4)
- often idiopathic
- leukemia patients
- hemoglobinopathies such as sickle cell
- a result of mediation for impotence
Why is the scrotum asymmetric
bc left testicle has a longer spermatic cord and therefore often lower
thickness of scrotum varies with
age and temperature
lumps in scrotal skin are commonly caused by
sebaceous cysts (aka epidermoid cysts)
sebaceous cysts or epidermoid cysts may appear ___
small, enlarged, and discharge oily material
scrotum edema typically indicates fluid retention associated w/ what?
cardiac, renal, or hepatic disease
bowel sounds are present in what type of hernia
reducible hernia
if the hernia lies within the inguinal canal (or comes through the external canal and even pass inot the scrotum) it is described as
a indirect hernia
if viscus is felt medial to the external canal the hernia is described as
a direct inguinal hernia
testis totally insensitive to painful stimuli is often seen in what diseases?
syphilis and diabetic neuropathy
Where is the epididymis located
posterolateral surface of the testis
how should the epididymis feel with palpation
smooth, discrete, larger cephalad, and nontender
beaded or lumpy vas deferen may indicate
diabetes or old inflammatory changes (ex. TB)
length of non-erect penis at birth
2-3cm
microphallus
unusually small penis
microphallus may be associated with
conditions with abnormal testicular development (ex. Klinefelter syndrome)
clitoromegalgy
enlarged clitoris
a hooked, downward bowing of the penis suggests
chordee
male foreskin is fully retracted by age
3-4y/o
dribbling or reduced forece or caliber in male infants may indicate
stenosis of urethral meatus
scrotum appearance of a preterm infant vs full-term neonate
premature infant- appear underdeveloped, w/o rugae, w/o testes
full term infant- loos, pendulous scrotum, w/ rugae, and midline raphe
what end of the infant scrotum should be the widest?
proximal end
bifid scrotum is usually associated w/
GU anomalies or ambigous genitalia
testicle diameter of a newborn
~1cm
a retractile testis has significant risk of becoming
an ascending or an acquired undescended testis
a testicel that is palpable in inguinal canal but cannot be pushed inot scrotum or not palpable at all is considered
an undescended testicle
well formed rugae in male children indicate
the testes have descended during infacny even if the testes are not apparent in scrotum
a scrotum that remains small, flat, and undeveloped indicates
cryptorchidism
cryptorchidism
undescended testes
most common type of hernia
indirect hernia
least common hernia
femoral hernia
direct hernias are more common in what gender
males
femoral hernias are more common in what gender
females
what hernia has the pathway of: through internal inguinal ring, can remain in canal, exit the external ring and pass into the scrotum; may be bilateral
indirect inguinal hernia
what hernia has the pathway of: through external inguinal ring; located in regionof hesselbach triangle; rarely enters scrotum
direct inguinal hernia
what hernia has the pathway of: through femoral ring, femoral canal, and fossa ovalis
femoral hernia
what hernia presents with: soft swelling in area of internal ring; hernia comes down canal and touches fingertip on exam
indirect inguinal hernia
what hernia presents with: bulge in area of hesselbach triangle; usually painless; easily reduced; hernia bulges anteriorly, pushes against side of finger on exam
direct inguinal hernia
what hernia presents with: right-sided presentation more common than left; pain may be severe; inguinal canal empty on exam
femoral hernia
What term is used to describe a loop of bowel that cannot be reduced
incarcerated hernia
rectal exam can be performed in these positions (4)
- knee-chest
- lithotomy
- left lateral w/ hips and knees flexed
- standing with hips flexed and upper body supported by exam table
__ infections are more common in adults with diabetes
fungal infections
__ infections are more common in children
pinworm infestation
skin around anus should appear
coarsr and more darkly pigmented
a lax sphincter may indicate
neurologic deficit or sexual abuse
internal hemorrhoids are felt when
they are thrombosed
nodules palpable just above the prostate in males and in the cul-de-sac in females
shelf lesions
you palpate the prostate on what wall of the rectum
anterior wall (may feel urge to urinate)
the size of a healthy prostate
4cm diameter w/ less than 1cm protrusion into the rectum
a rubbery or boggy consistency of the prostate may indicate
benign hypertrophy
stony hard nodularity prostate may indicate
carinoma, prostatic calculi or chronic fibrosis
the ___ or ___ uterus maybe be palpable through rectal exam
retroflexed or retroverted uterus
cervix may be palpable through what rectal wall?
anterior
very light tan or gray stool could indicate
obstructive jaundice
taryy black stool could indicate
upper intestinal tract bleeding
chemial guaiac procedure is used to
test for blood in stool
rectal prolapse results from
constipation, diarrhea, or something sever coughing or straining
hemorrhoids in children could indicate
portal hypertension
small flat flaps of skin around the rectum
condylomas
condylomas are commonly from ___
HPV infections
light touching anal opening in children should produce
anal contraction or wink
lack of anal contraction with touch may indicate
lower spinal cord lesion or chronic abuse
to determine patency in a child, insert catheter no more than __ into the rectum
1cm
suspect ___, if there is no passage of stool in 24 hrs in a newborn
rectal atresia, hirschsprung disease, or cystic fibrosis
the cervix and prostate should or should not be palpable in a rectal exam in children?
Should not
what tool is used to further evaluate for suspected fissures, fistulae, or polyps
small proctoscope
Bidigital palpation is used to detect
perianal abcesses