GENERAL APPROACH TO FEMALE GENITALIA

ASSESSMENT
 PRIOR TO ASSESSMENT

1. Ensure that the patient will not be menstruating at the time of the examination for
the optimal cytological specimen collection.
2. Instruct the patient not to use vaginal sprays, to douche, or to have coitus 24 to
48 hours before the scheduled physical assessment.
3. Encourage the patient to express any anxieties and concern about the physical
assessment
4. Show the speculum and other equipment to the patient and allow her to touch
and explore any items .
5. Inform the patient that the assessment should not be painful but may be
uncomfortable at times, and tell her to inform you if she experiencing any pain.
 6. Instruct the patient to empty her bladder and then to undress from the waist
to the ankles.
7. Ensure that the room is warm enough to prevent chilling, and provide
additional draping material as necessary.
8. Place drape or sheep skin over the stirrups to increase comfort.
9. Warm your hands with warm water prior to gloving.
10.Ensure that the privacy will be maintained during the assessment. Provide
screen and a closed door.
 DURING THE ASSESSMENT:
1. Inform that patient of what you are going to do before you do it. Tell her
she may feel pressure when the speculum is opened and a pinching sensation
when the Pap smear is done.
2. Adopt a non- judgmental and supportive attitude.
3. Maintain eye contact with the patient as much as possible to reinforce a
caring relationship.
4. Use a mirror to show the patient what you are doing and to educate her
about her body
5. Offer the patient the opportunity to ask questions about her body and
sexuality:
6. Encourage the patient to use relaxation techniques such as deep
breathing or guided imagery to prevent muscle tension during the assessment.
 AFTER THE ASSESSMENT:

1. Assess whether the patient needs assistance in dressing.

2. Offer tissues with which to wipe excess lubrication.
3. After the patient is dressed, discuss the experience with her,
invite questions and comments, listen carefully, and provide her with
information regarding the assessment and any laboratory information
that is available.
4. Tell the patient she may experience a small amount of spotting
following the pap smear.
FEMALE GENITALIA
 POSITIONED

Ask the client to lie down on the examination table

Assist her into a lithotomy position, and then have her slide her
hips as close to the end of the table as possible.
Place her feet in the stirrups
 INSPECTION OF THE EXTERNAL GENITALIA
 Vulva- The external female
genitalia, includes
 EXAMINATION IN EXTERNAL GENITALIA
 1. With the patient seated, place a drape
over the patient's torso and thighs until
positioning in completed.
 2. Instruct the patient to first sit on the
examination table between the stirrups,
facing away from the head of the table.
 3. Assist the patient in assuming a dorsal
recumbent or lithotomy position on the
examination table. Assist the patient in
placing her heels in the stirrups, thus
abducting her legs and flexing her hips.
 4. Don clean gloves.

 5. Assist the patient as she moves her

buttocks down to the lower end of the
examination table so that the buttocks are
flush with the edge of the table. If the
patient desires, raise the head of the
examination table slightly to elevate her
head and shoulders.
 6. Readjust the drape to cover the
abdomen, thighs, and knees; adjust the
stirrups as necessary for patient
comfort. Push the drape down between
the patient's knees so you can see the
patient's face.
 7. Sit on a stool at the foot of the
examination table facing the patient's
external genitalia.
 8. Adjust your lighting source and
provide the patient with a mirror.
Instruct her on how to hold the mirror in
order to view the examination prior to
touching the patient's genitalia.
 9. Finally, remember to inform the
patient of each step of the assessment
process before it is performed, and be
gentle.
 PUBIC HAIR

 1. Observe the pattern of pubic hair

distribution.
 2. Notes the presence of nits or lice.

 Normal Findings-

 The distribution of the female pubic hair

should be shaped like an inverse
triangle. There may be some growth on
the abdomen and upper inner thighs. A
diamond shape pattern from the
umbilicus may be due to cultural or
familial differences. There are no nits or
lice.
 ABNORMAL FINDINGS
 HIRSUTISM-excessive hairiness,
especially in women, or the growth
of hair in unusual places, which is
an indicative of endocrine disorder.
 ALOPECIA- in the genital or hair
distribution is sparse or hair is
absent at the genitalia area.
 THE PRESENCE OF NITS OR LICE
 Pubic lice ( pediculosis pubis) is the
infestation of the hairy regions of the
body, usually the pubic area, but it
sometimes involves the hairy aspects
of the abdomen, chest, and axillae.
 Pediculosis Pubis is a parasitic
infection usually transmitted by sexual
contact.
 PHYSICAL EXAMINATION OF MONS AND VULVA

 1. Observe the skin coloration and condition of

the mons pubis and vulva
 2. Inform the patient that you will touch the
inside of her thigh before you touch her
genitalia.
 3. With gloves hands separate the labia majora
using the thumb and index finger of the
dominant hand.
 4. Observe both the labia majora and the labia
minora for coloration, lesions and trauma.
 NORMAL FINDINGS:
 The skin over the mons pubis
should be clear except for nevi
and normal hair distribution. The
labia majora and minora should
appear symmetrical with a
smooth to somewhat wrinkled,
unbroken, slightly nodules,
swelling, rash or lesions. An
occasional sebaceous cyst is
within normal limits. These cysts
are nontender, yellow nodules
that are less than 1 cm in
diameter.
 ABNORMAL FINDINGS:

 1. Ecchymosis ( An extravasations' of blood under the skin; marked by

purple discoloration gradually changing to brown, green, yellow.)over
the mons pubis or labia. This is maybe due to blunt trauma that may
have resulted from accident or intentional abuse.
 2. EDEMA OR SWELLING of the labia-this maybe due to hematoma
formation, Bartholin's cyst, or obstruction of the lymphatic system.
 3. BROKEN AREAS ON THE SKIN SURFACE: this may be due to
ulcerations or abrasions secondary to infection or trauma
 4. RASH OVER THE MONS PUBIS AND LABIA

 Rashes have multiple etiologies including contact dermatitis and

infestations
 ABNORMAL FINDINGS:
5. CHANCRE- A primary lesion, usually of syphilis
or chancroid: formed at the site of infection two or  - A chancre appears during
three weeks after infection; usually on the lips, the primary stages of syphilis at the
genitals, or fingers; consist of an ordinary round site where the treponema enters the
body. The chancre last for 4 weeks
oval red spot that may go unnoticed as it is usually
and then disappears
painless; may develop into a papule, ulcer or  - Treponema a genus of
erosion that is highly infectious. A reddish, round motile, slender spiral shaped bacteri,
ulcer with a depressed center, and raised, some of which are pathogenic to
indurated edges. humans. T. Pallidum the causative
organism of syphilis
 6. CONDYLOMA LATUM - a flat,
highly contagious, moist, venereal
wart with a grayish yellow
discharge; found on the vulva,
penis, anus and axillae in late
secondary syphilis. A flat or raised,
round wartlike papules that have
moist surfaces covered by gray
exudates. This lesion occur during
the secondary stage of syphilis.
 7. CONDYLOMA ACUMINATUM- a pointed dry
wart found under the prepuce in the male and
on the vulva and vestibule of the female, or on
the skin of the perineal area not necessary
venereal.White, dry, painless growths that have
narrow bases are suggestive of condyloma
acuminatum. These warts are caused by the
human papillomavirus.- Any of the group of
small viruses that cause papilloma in humans.
 8. HERPES SIMPLEX LESIONS- a small, shallow, red
vesicles that fuse together to form a large ulcers that
may be painful and itch
 HERPES-Name given to conditions that are
caused by any one of five closely related herpesviruses
and that are characterized by vesicular eruptions on the
skin and mucous membrane of the facial and genital
areas and by the ability to remain quiescent in the body
until triggered by some events such as exposure to
sunlight or stressful events. Infectious recurring herpes
of the genitalia; very contagious, transmitted by sexual
intercourse; occurs in epidemics.
ABNORMAL FINDINGS:

 9. A painless mass that may be accompanied by pruritus or a mass that develops

into a cauliflowerlike growth. This type of mass is highly suggestive of
malignancy.
 - PRURITUS- an unpleasant sensation that produces itching and the desire to
scratch
 10. Venous Prominence of the labia . Varicose veins may develop due to a
congenital predisposition, prolonged standing, pregnancy or aging
Nose, Mouth, and Throat CLITORIS EXAMINATION:

 1. Using the dominant thumb

and index finger, separate the
labia minora laterally to expose
the prepuce of the clitoris.
 2. Observe the clitoris for size
and condition.

 NORMAL FINDINGS: The clitoris is

approximately 2.0 cm in length
and 0.5 cm in diameter and with
out lesions
 ABNORMAL FINDINGS:

 1. PSEUDOHERMAPHRODITISM-
 Hypertrophy of the clitoris due to androgen excess
 2. A reddish, round ulcer with a depressed center and raised, indurated
edges ( Chancre)
 URETHRAL MEATUS

 1. Using the dominant thumb and index finger, separate the labia
minora laterally to expose the urethral meatus. Do not touch the
urethral meatus; this may cause pain and urethral spasm.
 2. Observe the shape, color and size of the urethral meatus.

 NORMAL FINDINGS;

 1. The urethral opening is slitlike in appearance and midline; it is free

of discharge, swelling, or redness and is about the size of pea
 ABNORMAL FINDINGS;

 1. Discharge of any color from the meatus - it indicates possible

urinary infection.
 2. Swelling or redness around the urethral meatus- swelling indicates
possible infection of the skene's gland.
 Urethral caruncle ( small, red growth that protrudes from the meatus
 THE VAGINAL INTROITUS

 1. Keep the labia minora

retracted laterally to inspect the
vaginal introitus
 2. Ask the patient to bear down.

 3. Observe patency and bulging.

 NORMAL FINDINGS:

 The introitus mucosa should be

pink and moist. Normal vaginal
discharge is clear to white and
free to foul odor; some white
clumps may be seen that are
mass numbers of epithelial cells.
The introitus should be patent
and with out bulging
 ABNORMAL FINDINGS:
 1.Pale color and dryness of the introitus- possible etiologies include
atrophy from topical steroids and the aging process.
 2. Foul smelling discharge that is any color other than clear to slightly
pale white. Malodorous white, yellow, green, or gray discharge that
may be purulent are some possible findings.
 3. An external tear or impotency of
the vaginal introitus- possible
causes include trauma and fissure
of the introitus. An external tear
may indicate trauma from sexual
activity or abuse, and a fissure
may indicate a congenital
malformation or child birth trauma.
 4. CYSTOCELE- Bulging of the
anterior vaginal wall- The upper
two thirds of anterior vaginal wall
along with the bladder push
forward into the introitus due to
weakened supporting tissues and
ligaments.
 -Prolapse or pouching of the
posterior wall of the urinary
bladder into the anterior vaginal
wall.
 5. CYSTOURETHROCELE-Bulging of the anterior vaginal wall, bladder
and urethra into the vaginal introitus. The etiology is usually a
weakening of the entire anterior vaginal wall. A fissure may define the
urethrocele and cystocele
 URETHROCELE- a prolapsed of the urethra through the meatus
urinarius or a pouch like protrusion of the urethral walls into the
vaginal canal.
 6. RECTOCELE- Bulging of the posterior vaginal wall with a portion of
the rectum . This is caused by a weakening of the entire posterior
vaginal wall.
 BARTHOLIN"S GLANDS, also known as the greater vestibular glands. It
is a small, pea-shaped glands located deep in the perineal structures.
It is located in the cleft between the labia minora and the hymenal ring
. The DUCTAL opening are not usually visible. The glands secrete a
clear, viscid, odorless, alkaline mucus that improves the viability and
motility of sperm along the female reproductive tract.
 PERINEUM AND ANUS

 1. Observe for color and shape of the anus.

 2. Observe texture and color of the perineum.

 NORMAL FINDINGS:

 The perineum should be smooth and slightly darkened. A well healed

episiotomy scar is normal after vaginal delivery. The anus should be
dark pink to brown and puckered. Skin tags are not uncommon around
the anal area.
ABNORMAL FINDINGS:

 1. A fissure or tear of the perineum. Possible causes include trauma,

abscess, or unhealed episiotomy.
 2. Venous prominences of the anal area indicate external hemorrhoids .
An external hemorrhoid is the varicose dilatation of a vein of the
inferior hemorrhoidal plexus and is covered with modified anal skin.
PALPATION OF THE EXTERNAL GENITALIA

 1. palpate each labium between the thumb and the index finger of
your dominant hand
 2. Observe for swelling, induration, pain, or discharge from a
bartholin's gland duct.

 NORMAL FINDINGS:
 The labium should feel soft and uniform in structure with no swelling,
pain, induration, or purulent discharge.
ABNORMAL FINDINGS:

 1. Swelling, redness, induration, or purulent discharge from the labial

folds with hot, tender areas. These findings indicate a probable
Bartholin's gland infection. Causative organism include gonococci and
Chlamydia trachomatis.
 2. A firm mass that is possibly painful in the labia majora. This might
indicate an inguinal hernia. If this is suspected, re- palpate the mass
with the patient in a standing position.
URETHRAL MEATUS AND SKENE'S GLANDS
 1. Insert your dominant index finger into the vagina.
 2. Apply pressure to the anterior aspect of the vaginal wall and milk
the urethra.
 3. Observe for discharge and patient discomfort.

 NORMAL FINDINGS:
 Milking the urethra should not cause pain or result in any urethral
discharge.
ABNORMAL FINDINGS:

 Pain on contact and discharge from the urethra are abnormal findings..
This findings indicate a skene's gland infection or urinary tract
infection.
 SPECULUM EXAMINATION OF THE INTERNAL
GENITALIA

Materials needed

 1. Examination table with stirrups

 2. Goose neck lamp.
 3. Stool, preferably mounted on wheels.
 4. Clean gloves
 5. Large hand mirror.
 6. Linens for draping
 7. VAGINAL SPECULA
 a. GRAVES " BIVALVE SPECULA,
sizes medium and large, useful
for most adult sexually active
women.
 b. PEDERSON BIVALVE
SPECULA,sizes small and
medium, useful for nonsexually
active women, children,
menopausal women
8. CYTOLOGICAL MATERIALS
 a. Ayre spatulas
 b. Cyto brushes

 c. Cotton- tipped applicators

 d. Microscope slides, cover slips

 e.THAYER- MARTIN culture plates labeled with the patient's name,

identification number, and date specimen was collected.
 f. CYTOLOGY fixative spray
 g. REAGENTS:
 -Normal saline solution
 -Potassium hydroxide ( KOH)
 - Acetic acid ( white vinegar)

 9. Warm water
 10. Water soluble lubricant
 CERVIX
 1. Select the appropriate- sized
speculum. This selection should
be based on the patient's
history, size of vaginal introitus
and vaginal muscle tone.

 2. Lubricate and warm the

speculum by rinsing it under
warm water. Do not use other
lubricants because they may
interfere with the accuracy of
cytological samples and cultures.
 3. Hold the speculum on your
dominant hand with the closed
blades between the index and
middle fingers. The index finger
should rest at the proximal end of
the superior blade. Wrap the other
fingers around the handle, with
the thumbscrew over the thumb.
 4. Insert your non dominant index
and middle fingers, ventral sides
down, just inside the vagina and
apply pressure to the posterior
vaginal wall. Encourage the patient to
bear down. This will help to relax the
perineal muscles.
 5. Encourage the patient to relax by
taking deep breaths. Be careful not to
pull on pubic hair or pinch the labia.
 6. you feel the muscles relax, insert the
speculum at an oblique angle on a plane
parallel to the examination table until the
speculum reaches the end of the fingers
that are in the vagina.
 7. Withdraw the fingers of your non
dominant hand.
 8. Gently rotate the speculum
blades to a horizontal angle and
advance. The speculum at a 45º
downward angle against
posterior vaginal wall until it
reaches the end of the vagina.
 9.Using your dominant thumb,
depress the lever to open the
blades and visualize the cervix.
 10. 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.
 11.Once the cervix is fully visualized, lock the speculum blades into
place. This procedure varies based on the type of speculum being
used.
 12.Adjust your light source so that it shines through the speculum.

 13. If any discharge obstructs the visualization of the cervix, clean it

away with a cotton- tipped applicator.
 14. Inspect the cervix and the os for color; position, size, surface
characteristics such as polyps or lesions, discharge and shape
 COLOR

 Normal finding: The normal

cervix is a glistening pink; it may
be pale after menopause or blue
( CHADWICK's SIGN) during
pregnancy.
 ABNORMAL FINDING:

 1.Cyanosis not associated with pregnancy. Possible causes include

venous congestion of the area or systemic hypoxia as in congestive
heart failure.
 2.Redness or a friable appearance. Possible causes include infection
and inflammation,such as Chlamydia or gonorrhea.
 THE POSITION OF THE CERVIX

 The cervix is located midline in

the vagina with an anterior or
posterior position relative to the
vaginal vault and projecting
approximately 2.5 cm into the
vagina.
 ABNORMAL POSITION OF THE CERVIX
 1. Lateral position. Possible causes include tumor or adhesion that
would displace the cervix.
 2.Projection of the cervix into the vaginal vault greater than normal
limit. Uturine prolapsed is caused by weakened vaginal wall muscles
and pelvic ligaments and may push the cervix into the vaginal vault.
 NORMAL SIZE OF THE CERVIX
 2.5 CM

 ABNORMAL FINDINGS
 Cervical size greater than 4cm is indicative of hypertrophy.
Inflammation or tumor could result in the morbid enlargement of the
cervix.
 CHARACTERISTICS OF THE CERVIX
 The cervix is covered by the
glistening pink squamos
epithelium, which is similar to
the vaginal epithelium, and the
deep pink to red columnar
epithelium, which is continuation
of the endocervical lining
 ABNORMAL FINDINGS:
 1. A reddish circle around the os. This is known as ECTROPION or
EVERSION: It occurs when the squamocolumnar junctions appears on
the ectocervix. It results from laceration during childbirth or possibly
from congenital variations.
 2. Small round yellow lesions on
the cervical surface indicates
NABOTHIAN CYSTS. These
benign cysts result from the
obstruction of cervical glands.
 3. A bright red soft protrusion
through the cervical os indicates
a cervical polyps. The polyps
originates from the endocervical
canal; they are usually benign
but tend to bleed if abraded.
 4. Hemorrhages dispersed over the
surface and known as strawberry
spots. These may be seen in
conjunction with trichomonal infections
 5. Irregularities of the cervical surface
that may look cauliflowerlike.
Carcinoma of the cervix may manifest
as cauliflower overgrowth
 6. Columnar epithelium covering most of the
cervix and extending to the vaginal
wall( Vaginal adenosis), and collar- type ridge
between the cervix and the vagina. This
denotes fetal exposure to DES
(DIETTHYLSTILBOESTROL)
 SHAPE OF THE CERVICAL OS
 NORMAL FINDINGS:
 In the nulliparous woman, the os
is small and either round or oval.
In the parrous woman. The Os is
a horizontal slit.
 ABNORMAL FINDINGS:

 1. A unilateral transverse,
bilateral transverse, stellate, or
irregular cervical os. Possible
causes include cervical tears that
have occurred during rapid
second-stage childbirth delivery,
forceps delivery and trauma.
 COLLECTING SPECIMENS FOR CYTOLOGICAL SMEARS AND
CULTURES
 PAP SMEAR

 The purpose of the pap smear: is to evaluate cervico vaginal cells for
pathology that may indicate carcinoma. It is recommended that all
females over age of 18 or any female who is sexually active undergo this
screening examination on a yearly basis. If the patient has three or more
consecutive normal Pap smears. The Pap may be done every 2 or 3
years. It the patient had a hysterectomy for benign disease, repeat the
Pap smear from the vaginal cuff one year after surgery and then every 2
years. Though Pap smears can be spaced every 3 years, a woman should
have an annual pelvic examination at least until age 80-85
 ENDOCERVICAL SMEAR
EXAMINATION

 1. Using your dominant hand, insert the cytobrush through the speculum into
the cervical Os approximately 1cm. Many patients find that this procedure
causes a cramping sensation, so forewarn your patient, that she may feel
discomfort during this element of the assessment.
 2. Rotate the cytobrush between your index finger ant thumb 360º clockwise
then counter clockwise. Keep the cytobrush in contact with the cevical tissue.
Note: If you have to use a cotton- tipped applicator instead of a cytobrush,
Leave the applicator in the cervical os for 30 seconds to ensure saturation.
 EXAMINATION

 3. 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 wipe the cytobrush back and forth
because doing so will destroy the cells.
 4. Discard the brush
 Insert the bifurcated end of the 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 360º one time only

 Remove the spatula and gently spread the specimen on

the section or labeled the slide C, if the sectional slide is
being used
 1. Reverse the Ayre spatula and insert the rounded end into the
posterior vaginal fornix and gently scrape the area.
 2. Remove the spatula and gently spread the specimen on the section
of the slide marked V, if a sectional slide is being used.
 3. Dispose of the spatula or cotton- tipped applicator.

 4. Spray the entire slide or the slides with cytological fixative.

 5. Submit the specimen to the appropriate laboratory per your

institution’s guidelines for cytology specimens
GONOCOCCAL CULTURE SPECIMEN
 Insert a sterile cotton swab applicator 1 cm into the cervical os.
 Hold the applicator in place for 20 to 30 seconds.

 Remove the swab

 Roll the swab in a large Z pattern over the Thayer- martin culture plate.
Simultaneously rotate the swab as you roll it to ensure that all of the
specimen is used.
 Dispose of the swab

 Submit the specimen to the appropriate laboratory per your

institution’s guidelines for culture specimens.
NORMAL FINDINGS
 Cervicovaginal tissues are normally free of Neisseria Gonorrhea

 ABNORMAL FINDINGS
 Itis abnormal to find a large number of gram negative diplococci present in
cervicovaginal secretions. N. gonorrhoeae are gram- negative diplococci
organism that prefer to invade columnar and stratified epithelium
SALINE MOUNT OR “WET PREP”
 This test is performed for the rapid evaluation of white blood cells and
protozoa.
 Examination
 1. Spread a sample of the cervical or vaginal pool specimen onto a
microscope slide, add one drop of normal saline solution, and apply a cover
slip
 2. Examine under a microscope
 NORMAL FINDINGS
 The sample should have fewer than 10 white blood cells ( WBC) per field
 ABNORMAL FINDINGS
 A sample with more than 10 WBC’s per
field, protozoa, bacteria field epithelial
cells ( Clue cells ). Or other organism.
 A large number of WBC’s can be indicative
of an inflammatory response. CLAMMYDIA
TRACHOMATIS, or a bacterial infection.
Protozoan are indicative of trichomoniasis
 KOH PREP
 This test is performed for the rapid evaluation of Candida
 EXAMINATION
 Spread a sample of the cervical or vaginal pool specimen onto a microscope
slide, add one drop of potassium hydroxide ( KOH), and apply a cover slip
 Note any odor
 Examine under a microscope
 NORMAL FINDINGS
 Cervicovaginaltissues are normally free of candida albicans except in a small
percentage of women. There should be no odor.
 ABNORMAL FINDINGS

 The presence of yeast and pseudohyphae

forms ( Chain of budding yeast). The
presence of budding yeast is indicative of
an overgrowth of candida.A fishy odor
( “ The whiff test”) indicates bacterial
vaginosis
 FIVE PERCENT ACETIC ACID WASH
 EXAMINATION
 Aftercompleting all other vaginal specimens, swab the cervix with a cotton-
tipped applicator that has been soaked in 5% acetic acid.
 NORMAL FINDINGS
 The normal response is no change in the appearance of the cervix.
 ABNORMAL FINDINGS
A rapid acetowhitening or blanching with jagged borders. The cause may be
the human papillomavirus, which is the causative agent of genital warts
 ANAL CULTURE
 EXAMINATION
 1. Insert a sterile cotton swab applicator 1 cm into the anal canal.
 2. Hold the applicator in place for 20 to 30 seconds
 3. Remove the swab. If fecal materials is collected, discard the applicator and
start again.
 4. Roll and rotate the swab in a large Z pattern over a Thayer- Martin culture
plate.
 5. Dispose of the swab
 NORMAL FINDINGS
 Anal tissues are normally free of Neisseria Gonorrhoeae.
 ABNORMAL FINDINGS
 The presence of a large number of gram- negative diplocci. This is an
indicative of N. Gonorrhoea
 INSPECTION OF THE VAGINAL WALL
 EXAMINATION
 1. Disengage the locking device of the speculum.
 2. Slowly withdraw the speculum but do not close the blades
 3. Rotate the speculum into an oblique position as you retract it to allow full
inspection of the vaginal walls. Observe vaginal color and texture.
 NORMAL FINDINGS
 The vaginal walls should be pink, moist deeply rugated and without lesions or
redness
 ABNORMAL FINDINGS
 Spots that appear as white paint on the wall. A possible cause is
leukoplakia from Candida Albicans. Repeated occurrence even after
treatment may indicate HIV infection.
 Pallor of the vaginal walls. Possible causes include anemia and
menopause.
 Redness of the vaginal wall. Possible causes include inflammation,
hyperemia, and trauma from tampon insertion or removal.
 Vaginal lesions or masses. Possible causes include carcinoma, tumors
and DES exposure.
THANK YOU
FOR
LISTENING
1. The speculum used for visualization of cervix in children and

QUIZ
menopausal women.
2. Rationale of rinsing the speculum by warm water to lubricate it.
3. When is the time you are going to insert the speculum into the
vagina?
4. What is the normal color of the cervix?
5. What do you call the condition of women of not having borne
any children?
6. Normal size of the cervix.
7. It is a round yellow lesion on the cervical surface.
8. It is one of the manifestation in the carcinoma of the cervix.
9. It is a synthetic estrogen substance- used therapeutically as a
substitute for natural estogenic hormones.
10. The shape of the cervical Os of a parrous woman.
11. This test is used to detect cancer of the cervix.
12. Above 18 years old and sexually active women need to undergo
the test mention in no.11 in every?__________.
13. If the female patient required to undergo the procedures in no.11
every 2 to 3 years means?
14. The maximum age of woman to undergo this annual pelvic
examination.
15. This is the materials needed used to collect specimen in
Endocervical smear.
16. This test is performed for the rapid evaluation of WBC and
protozoa.
17. Reagent use to detect the presence of Candida Albicans.
18. Indication that there is an overgrowth Candida Albicans in the
Thayer Martin culture plate.
19. The causative agent of genital warts.
20. The appearance of the cervix positive in the five percent acetic acid
wash.
 BIMANUAL EXAMINATION
 EXAMINATION
 1. Observe the patient’s face for signs of discomfort during the assessment
process.
 2. Inform the patient of the steps of the bimanual assessment, and warn her
that the lubricant gel may be cold.
 3. Squeeze water- soluble lubricant onto the fingertips of your dominant hand.
 4. Stand between the legs of the patient as she remains in the lithotomy
position, and place your nondominant hand on her abdomen and below the
umbilicus.
 5.Insert your dominant index and middle fingers 1cm into the vagina. The
fingers should be extended with the palmar side up. Exert gentle posterior
pressure.
 6. Inform the patient that pressure from palpation may be uncomfortable.
Instruct the patient to relax the abdominal muscles by taking deep breaths.
 7. When you feel the patient’s muscles relax. Insert your fingers to their full
length into the vagina. Inser your fingers slowly so that you can
simultaneously palpate the vaginal walls.
 8. Remember to keep your thumb widely abducted and away from the
urethral meatus and clitoris throughout the palpation in order to prevent pain
or spasm.
 VAGINA
 EXAMINATION
 Complete steps 1-8 from bi- manual examination.
 Rotate the wrist so that the fingers are able to palpate all surface aspects of
the vagina.
 NORMAL FINDINGS
 The vaginal wall is non- tender and has a smooth or rugated surface with no
lesions, masses or cysts.
 ABNORMAL FINDINGS
 The presence of lesions, masses, scarring, or cysts. The findings maybe
indicative of benign lesions such as inclusions cysts, myomas, or fibromas.
The most common site for malignant lesions of the vagina is the upper one
third of the posterior vaginal wall
 CERVIX

 EXAMINATION
 1. Position the dominant hand so
that the palmar surface faces
upward.
 2. Place the nondominant hand on
the abdomen approximately one
third of the way down between the
umbilicus and the symhysis pubis.
 3. Use the palmar surface of the
dominant hand’s fingerpads, which
are in 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.
 NORMAL FINDINGS

 The normal cervix is mobile

without pain, smooth and firm,
symmetrical rounded and
midline.
 ABNORMAL FINDINGS

 The presence of pain on palpation

or the assessment of mobility is a
positive CHANDELIER’s SIGN. This
is indicative of possible pelvic
inflammatory disease or ectopic
pregnancy.
 Softening of the cervix ( Goodell’s
sign) is a significant finding. This
sign is seen at the fifth to sixth
week of pregnancy.
 Irregular surface, immobility, or
nodular surface structure of the
cervix indicates abnormality.
Possible causes include
malignancy, nabothian cysts and
polyps.
 FORNICES
 EXAMINATION
 With the fingertips and palmar surfaces of the fingers, palpate around the
fornices
 NORMAL FINDINGS
 The walls should be smooth and without nodules
 ABNORMAL FINDINGS
 Thepresence of nodules or irregularities. Possible causes include malignancy,
polyps and herniations if the walls of the fornices are impatent
 UTERUS
 EXAMINATION
 1. With the dominant hand, which is
in the vagina, push the pelvic organs
out of the pelvic cavity and provide
stabilization while the non dominant hand,
which is on the abdomen, perform the
palpation
 2. Press the hand that is on the abdomen
inward and downward toward the vagina,
and try to grasp the uterus between your
hand
 3. Evaluate the uterus for size, shape,
consistency, mobility, tenderness, masses
and position.
 4. Place the fingers of the intravaginal
hand into the anterior fornix and palpate
the uterine surface
 NORMAL FINDINGS
The size of the uterus
varies based on parity; it
should be pear- shaped in the
nongravida patient and more
rounded in the parous
patient. The uterus should be
smooth, firm, mobile, non
tender, and without masses.
For uterine position. A uterus
may be non palpable if it is
retroverted or retroflexed.
The uterus in these position
can be assed only via
rectovaginal examination. A
non palpable uterus in the
older woman may be a
normal finding secondary to
uterine atrophy.
PALPABLE UTERUS
NON PALPABLE UTERUS
 ABNORMAL FINDINGS

 Significant exterior enlargement

and changes in the shape of the
uterus . Uterine enlargement
indicates possible intra uterine
pregnancy or tumor.
 Presence of nodules or
irregularities indicates
leiomyomas, (ALSO CALLED
FIBROIDS are common benign
uterine tumors that affect
approximately 25% of women
over age 35

These are tumors containing

muscle tissue.
EXAMINATION
 NORMAL FINDINGS

 The Ovaries are normally almond shaped firm, smooth and mobile
with out tenderness

ABNORMAL FINDINGS
 NORMAL FINDINGS
The rectal walls are normally smooth and free of
lesions. The rectal pouch is rugated and free of
masses. Anal sphincter tone is strong. The cervix
and uterus if palpable are smooth. The
rectovaginal septum is smooth and intact.