assessment of the female genitalia

Physical Assessment of
Male & Female Genitalia,
Anus & Rectum

Maria Carmela Lacsa Domocmat, RN, MSN
Instructor, School of Nursing
Northern Luzon Adventist College

Female Genitalia

Anatomy
Physical Assessment
Abnormalities

Female External
Reproductive Organs

Maria Carmela L. Domocmat, RN, MSN

Female Internal
Accessory Organs

• uterine tubes
• uterus
• vagina


Uterus

22-38

Good News!!!

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


Why?

Because of early detection

Physical Assessment
Papanicolau test (Pap Smear)
Increase patient knowledge


Physical Examination

1. Inspection and Palpation of the
External Genitalia
2. Speculum assessment of Internal
Genitalia
3. Collection of Specimens for
Laboratory Analysis.
4. Inspection of the Vaginal walls
5. Bimanual Examination
6. Rectovaginal Assessment

Preparation for the exam

• Instruct the patient while she is
dressed
• Instruct her to empty her bladder
prior to the exam (depending on
the history and complaints of
client)
• Close the door and curtain
• Ask for an assistant

External Genitalia

•Mons Pubis and Pubic Hair
•Vulva

•Clitoris

•Urethral Meatus
•Vaginal Introitus

•Perineum and Anus

Mons Pubis
& Pubic Hair

Inspection

Inspection
• Observe the pattern of pubic
hair distribution
• Note the presence of nits or
lice
Normal Findings
Skin over Mons Pubis:
• Clear with normal hair

distribution


Normal Findings (cont’d)

Pubic Hair
Distribution – inverse triangle
• There may be some growth on
abdomen 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:

Gray and sparse


Abnormal Finding

Pediculosis Pubis

Crab lice, Pthirus
pubis


Vulva

Inspection
Palpation

Inspection

• Observe the skin
coloration and
condition of
the mons
pubis and vulva
• Inform the patient that
you will touch the inside of
her thigh before you touch
the genitals

Inspecting the Vulva

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


Inspecting the Vulva (cont’d)

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


Normal Findings
Labia majora and
minora
Symmetrical
Smooth to
somewhat
wrinkled,
unbroken,
slightly pigmented
skin surface.


Normal Findings
Labia majora and
minora (cont’d)

No ecchymosis,
ecchymosis,
excoriation,
nodules, swelling,
rash, lesions.

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

Skene’s glands
and Bartholin’s
glands


Normal Findings

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


Normal Deviations

Geriatric: atrophied- appears
flatter and smaller
Multiparrous women: majora are
separated and minora more
prominent


Abnormal Findings Vulva
Bartholin’s Cyst
Skene’s Gland Cyst
Vulvar epidermal cyst
Edema, Swelling
Rash (contact dermatitis, infestation)
Chancre (Syphilis)
Wartlike papules (condyloma latum)
Ulcer (Herpes)
Venous prominence (varicose veins)
Carcinoma

Inflammation of Bartholin Glands


Skene Gland Cyst


Vulvar epidermal
Vulvar hypertrophy cysts develop from sebaceous
glands.

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

Benign vulvar lesions. Pemphigus vulgaris

mucosal involvement vulvar involvement


Benign vulvar lesions
Allergic Vulvitis Psoriasis


Benign vulvar lesions
Vulvar Melanosis Hemangioma


Condyloma Latum Condyloma
(Secondary Syphilis) Acuminatum
(Genital Or Venereal
Wart)


Herpes genitalis


Well- Advanced
differentiated carcinoma of vulva,
involving entire vagina,
carcinoma of urethra and rectum
vulva


Palpating the Labia

Palpate each labium between the
thumb and the index finger of your
dominant hand.
Observe for swelling, induration, pain,
or discharge from a Bartholin’s gland
duct.


Palpating the Labia
Labium:
• Feel soft
and uniform
in structure
•No swelling,
pain,
induration,
or purulent
discharge

Palpating around the
vaginal introitus
(Bartholin glands)
glands)


If discharge is
present ,
obtain a
specimen and
change the
gloves into
clean ones.


Abnormal Findings

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
bulging when standing
and ask patient to cough


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

Normal Findings

•Approximately 2 cm in length and 0.5
cm in diameter
•Without lesions

Abnormal Findings

Hypertrophy
(clitoromegaly,
pseudohermaphroditism)
Chancre

Clitoromegaly
A 22-year-old 19-year-old
gravida O gravida O
20 mm 30 mm

clitoroplasty Maria Carmela L. Domocmat, RN, MSN

Urethral Meatus

Inspect
Palpate

Inspection
Using the dominant hand and index
finger, separate the labia minora to
expose the urethral meatus.
Do not touch the urethral meatus.
may cause pain and urethral spasm
Observe
shape, color, and size of urethra


Normal Findings

Slitlike in appearance
Midline
Free from discharge, swelling, or
redness
About the size of a pea

Abnormal Findings

Discharge or swelling
Urethral caruncle
Urethral carcinoma
Prolapse of urethral mucosa

Urethral caruncle


Palpation

Milking the urethra and
paraurethral glands

Palpation
Insert your dominant
index finger into the
vagina
Apply pressure to the
anterior aspect of the
vaginal wall and milk
the urethra
Observe for discharge
and client discomfort


Milking the urethra and
paraurethral glands


Normal Findings
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 Glands

Vaginal Introitus

Inspect
Palpate

Inspection
Keep labia minora retracted
laterally to inspect the vaginal
introitus.
Ask the patient to bear down.
Observe for patency and bleeding.


Normal Findings

Introitus Mucosa
Pink and moist
Patent
Without Bulging


Nulliparous Multiparous with
with intact remaining hymen
hymen


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


Palpation
Insert your dominant finger in the
vagina, ask the client to squeeze the
vaginal muscles around your finger.
Evaluate muscle strength and tone

Normal Findings
Vaginal muscle tone
In nulliparous woman: tight and
strong
In a parrous woman: it is diminished

Abnormal Findings
Pale color and dryness (atrophy, aging)
Tear, fissure
Bulging
Discharge

Pelvic Organ Prolapse
Cystocele
Cystourethrocele
Rectocele
Uterine Prolapse

Cystocele


Rectocele


Degrees of Uterine Prolapse


Second degree uterine prolapse


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


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

Abnormal Findings

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

Giant perineal keloid


Palpating the Perineum

Place the
dominant index
finger posterior
to the perineum
and the thumb
anterior to the
perineum


Palpating the Perineum
(cont’d)

Assess perineum
between the
dominant thumb
and index finger
for muscular tone
and texture


Normal Findings
Smooth & Firm
Homogenous in
nulliparous
Thinner in parous
woman
Well-healed
episiotomy scar is
also within normal
limits for parous woman


Abnormal Findings

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

Speculum Examination of the
Internal Genitalia

Inspection

Select the
appropriate-
sized
speculum
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
be bacteriostatic and can
alter Pap test results


Holding the
Speculum
•Hold the
speculum by
your dominant
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
posterior vaginal
wall


Encourage client to
bear down
This will help to
relax the perineal
muscles
Encourage client to
relax by taking deep
breaths
Be careful not to
pull on pubic hair
or pinch the labia

Preparing for the Apply
insertion of the downward
pressure in
speculum posterior
vaginal
opening
with two
fingers


Oblique insertion of the
speculum
When 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.

Withdraw your nondominant
hand from the vagina

Directing speculum downward
0
at 45 angle. Gently rotate
the speculum
blades to a
horizontal angle
and advance
the speculum at
a 45-degree-
45-degree-
angle against
the posterior
vaginal wall
until it reaches
the end of the
vagina.


Final Adjustment of the Speculum


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


Normal Findings
Color
Glistening pink
Pale after menopause
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 squamous
epithelium, which is
similar to vaginal
epithelium
Discharge:
Note characteristics of any
discharge Maria Carmela L. Domocmat, RN, MSN

Shape of cervical os
In nulliparous
woman: os is small
and either round
or oval.
In a parrous
woman: os is a
horizontal slit


Let’s Watch:
Inspecting the Cervix

Abnormal Findings
Lacerations
Cyanosis
Redness or friable appearance
Reddish circle around os (ectropion
or eversion)
Small, round, yellow lesion
(nabothian cyst)

Abnormal Findings

Condyloma Acuminata
Candidiasis
Cervicitis
Endocervical Gonorrhea
Strawberry spots (trichomonal
infection)
Cauliflower overgrowth (carcinoma)

Cervical Nabothian Cyst
Ectropion


Condyloma
acuminata Candidiasis
(venereal warts)

caused by "Human Papilloma Virus"
(HPV).


Chlamydial cervicitis


Endocervical gonorrhea


“Strawberry”
cervix Cervical Cancer
(Trichomonasis)


Collecting Specimens for
Cytological Smears and
CulturesSmear
•Pap
•Gonococcal Culture Specimen
•Saline Mount or “Wet Prep”
•KOH Prep
•Five Percent Acetic Acid Wash
•Anal Culture

Pap Smear

Endocervical
Smear
Cervical Smear
Vaginal Pool
Smear

Pap Smear Equipments


A collection of three specimens
that are obtained from three sites
Cervix
Vaginal pool
Posterior
fornix of
the vagina


Endocervical Smear
Using your nondominant
hand, insert the cytobrush
through the speculum into
the cervical os approximately 1
cm
May cause cramping sensation,
so forewarn the patient.


Endocervical
Smear (cont’d)
Rotate the cytobrush
between your index
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.

Endocervical Smear
(cont’d)
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. Doing so will
destroy the cells.
Discard the brush.


Cervical Smear

Insert the bifurcated
end of Ayre spatula
through the speculum
base.
Place the longer projection of
the
bifurcation into the cervical os.


Cervical Smear
(cont’d)

The shorter projection
should be snug against
the ectocervix
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
the posterior
fornix and gently
scrape the area


Vaginal Pool Smear
Cotton-tipped applicator
may be the preferred vehicle
for obtaining specimen if
vaginal secretions are
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.

Vaginal Pool Smear
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
applicator .
Spray the entire slide or the slides
with cytological fixative.
Submit the specimens to the
laboratory.

Normal findings

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


Inspection of the
Vaginal Wall

Inspection
Disengage the locking device of the
speculum
Slowly withdraw the speculum but do
not 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 texture

Normal findings

Vaginal walls
Pink
Moist
Deeply ruggated
Without lesions or
redness


Geriatric Variation

Thinner
Drier
Less vascular


Abnormal Findings

Vaginitis
Adenosis
Carcinoma

Atrophic vaginitis

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


Vaginal inclusion Bacterial
cysts contain epithelial Vaginosis
tissue


Vaginal adenosis Vaginal
Carcinoma


Bimanual Examination

•Vagina •Fornices •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
legs of the client as
she remains in the lithotomy
position, and place your non-
dominant hand on
her abdomen and below the
umbilicus. Maria Carmela L. Domocmat, RN, MSN


5. Insert your lubricated
index and middle
fingers
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.
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
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
meatus and clitoris
throughout the
palpation in order to
prevent pain or
spasm.

Vagina

Complete steps 1-8 of
the bimanual exam.
Rotate the wrist so that
the fingers are able to
palpate all surface
aspects of the vagina.


Vagina

Normal Findings

Vaginal wall non tender
Smooth or ruggated surface
No lesions, masses, or cysts


Cervix

1. Position the dominant
hand so that the
palmar surface faces
upward.
2. Place the non-dominant hand on the
abdomen approximately 1/3 of the
way down between the umbilicus and
the symphysis pubis.

Cervix
3. Use the palmar surfaces
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.

Cervix
Normal Findings
Mobile
Without pain
Smooth and
firm
Symmetrically
rounded
Midline Softening between 5th or 6th
week of pregnancy- Goodell’s sign


Abnormal Findings

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

Fornices

• With the fingertips
and palmar
surfaces of the
fingers, palpate
around the
fornices.
• Note nodules or
irregularities.

Fornices

Normal Findings
Walls should be
smooth
No nodules


Uterus
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, performs
the palpation.

Uterus

2. Press the hand
that is on the
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,
and try to grasp the
uterus between your
hands.


Bimanual palpation of Uterus


Uterus

Normal Findings
Size varies based on
parity
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)
Non palpable uterus is
normal in older women
Due to secondary uterine
atrophy

Anteverted uterus


Anteverted uterus Anteflexed Uterus


Retroverted Retroflexed
Uterus Uterus


Abnormal Findings
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 anterior iliac spine.
2. Press deeply inward and upward
toward the abdominal hand.


Adnexa
3. Push inward and
downward with the
abdominal hand and
try to catch the ovary
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
Ovaries
Almond-shaped
Firm
Smooth
Mobile
Without
tenderness

Geriatric Variation

Rarely palpable


Let’s Watch:
Bimanual Palpation
of Uterus

Abnormal Findings

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

Five Percent Acetic Acid Wash

1. After completing all other vaginal
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)


Abnormal Findings

Rapid acetowhitening or blanching
with jagged borders (HPV)

Apparently normal cervix


After application of acetic acid


Rectovaginal Examination


assessment of the female genitalia

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Ähnlich wie assessment of the female genitalia

Ähnlich wie assessment of the female genitalia (20)

Mehr von Carmela Domocmat

Mehr von Carmela Domocmat (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

assessment of the female genitalia