Gynaecological Examination

GYNAECOLOGICAL EXAMINATION 

The gynecologic examination refers specifically to examination of a woman's reproductive system. 

Gynaecological examination includes :- 

A. Breast examination 

B. Abdominal examination

C. Pelvic examination

BREAST EXAMINATION :- 

A breast self-exam is a check-up a woman does at home to look for changes or problems in the breast tissue. Many women feel that doing this is important to their health.

This should be a routine especially in women above the age  of 30 to detect any breast pathology, the important being carcinoma. 

The best time to do a monthly self-breast exam is about 3 to 5 days after your period starts. Do it at the same time every month.

Step 1 :-

 1.stand in front of mirror

2.check both breast for anything unusual.

3.look for discharge from the nipple , Pickering,dimpling,or scaling of the skin.

Step 2 :-

Step 2 and 3 are done to check for any changes in the contour of your breasts .as you do them ,you should be able to feel your muscle tighten.

1.watch closely in the mirror as you clasp your hands behind your head and press your hands forward.

2.Note any changes in the contour of your breasts.

Step 3:-

1. Next,press your hands firmly on your hips and bow slightly toward the mirror as you pull your shoulders and elbows forward.

2. Note any changes in the contour of your breasts.

Step4:-

Your fingers will glide easily over soapy skin so you can concentrate on feeling for changes inside the breast.

1. Raise your left arm.

2. Use three or four fingers of your right hand to feel your left breast firmly , carefully,and thoroughly.

3.Beginning at the outer edge ,press the flat part of your fingers in small circles,moving the circles slowly around the breast.

4. Gradually work toward the nipple.

5.Be sure to cover the whole breast.

6.Pay special attention to the area between the breast and the underarms , including the underarm itself.

7. Feel for any unusual lumps or masses under the skin.

8.if you have any spontaneous discharge during the month whether or not it is during your breast self examination .

9. Repeat the examination on your right breast.

Step 5:-

1. Step 5 should be repeated lying down.

2. Lie flat on your back with left arm over your head and a pillow or folded towel under your left shoulder .

3. Use the same circular motion described earlier.

4.Repeat on your right breast.

Abnormal assessment finding during inspection of the breast :-

Retraction Signs 

1.Sign include skin dimpling ,creasing or changes in the contour of the breast or nipple.

2. They may be secondary to contraction of fibrotic tissue that can occur with underlying malignancy.

3. They may be secondary to scar tissue formation after breast surgery.

Nipple Inversion 

1. Considered normal if long standing

2. Associated with fibrosis and malignancy if recent development

Increased venous prominence

1. Unilateral localized increase in venous pattern associated with malignant tumors

2.Normal with bilateral and symmetrical breast enlargement associated with pregnancy and lactation

Acute mastitis

1. Associated with lactation but may occur at any age 

2. Nipple cracks or abrasions noted 

3. Breast skin reddened and warm to touch 

Peaud Orange  

1.Associated with inflammatory breast cancer 

2. Skin pores enlarge 

3.may be noted on the areola 

4. Skin becomes thick ,hard and immobile.

SPECIAL CONSIDERATION :-

1. Instruct patient not use creams, lotions and powders and not to shave underarm 48 hrs before the examination. 

2.Explain the breast self examination performed after menses (5th - 7th day) for pre menopausal women and first day of the month for postmenopausal women. 

3. Educate even men to perform a monthly BSE and obtain a clinical examination every 1 to 3 years because 1% of all breast cancer is found in men. 

4. During BSE pay special attention to upper quadrant area and the tail of spence where about 50% of breast cancer is develop. 

ABDOMINAL EXAMINATION :- 

Prerequisites :- 

• Bladder should be empty. The only exception to the procedure is the presence of history suggestive of stress incontinence. If history is suggestive of chronic retention of urine, catheterization should be done taking aseptic precautions, using sterile simple rubber catheter. 
• The patient is to lie flat on the table with the thigh slightly flexed and abducted to make the abdominal muscle relax. 
• The physician usually prefers to stand on the right side 
• Presence of a female for the support of the patient and the physician. 

Actual steps :- 

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Inspection:- 

The skin condition of the abdomen - presence of old scar, triae, prominent veins or eversion of the umblicus is to be noted. 

1. In pelvic peritonitis, the lower abdomen is only distended with diminished inspiratory movements. 
2. In ascites, one can find fullness only in the flanks with the center remaining flat

Palpation :-

1. The palpation should be done with the flat of the hand gently rather than the tips of the fingers. 
2. If rigidity of the abdominal muscles is encountered, it may be due to high tension or due to muscle guard. 
3. If a mass is felt in the lower abdomen, it's location, size above the symphasis pubis, consistency, feel, surface, mobility from side to side and from above to down, and margins are to be noted. 
4. In general, lower border cannot be reached in pelvic tumor, but in ovarian tumor with a long pedicle one can go below the lower pole. 
5. If the tumor is cystic and huge, one can exhibit a fluid thrill felt with a flat hand placed on one side of the tumor when the cyst is tapped on the other side of the tumor with the other hand. 

Percussion :-

A Pelvic tumor is usually dull on percussion with resonance on the flanks. 

1. If there are intestinal adhesions or the tumor is retroperitoneal, it will be resonant. 
2. In the presence of ascites, the flanks will be dull on percussion and shifting dullness, 
3. If elicited , confirms the diagnosis of free fluid in the peritoneal cavity. 

Note :- it is mandatory to elicit presence of free fluid in the peritoneal cavity in every cases of pelvic tumor. 

Auscultation :- 

Auscultation reveals only the intestinal sounds. 

1. Hypoactive bowel sounds are found in paralytic ileus. 
2. Hyperactive bowel sounds may be due to intestinal obstruction. 
3. The uterine souffle may be heard over a pregnant uterus or vascular fibroid, which is synchronous with the patient's pulse. 
4. If the tumor is of pregnant uterine origin, fetal heart sound can be heard beyond 24 weeks. 

PELVIC EXAMINATION :- 

Pelvic examination includes :- 

• Inspection of external genitalia
• Vaginal examination 

1. Inspection of the cervix and vaginal walls 
2. Palpation of the vagina and vaginal cervix by digital examination
3. Bimanual examination 

• Rectal examination
• Rectovaginal examination 

Prerequisite :- 

1. The patient's bladder must be empty - the exception being a case of stress incontinence
2. A female attendent should be present by the side. 
3. To examine a minor or unmarried , a consent from the parent or guardian is required
4. Lower bowel should preferably be empty
5. A light source should be available
6. Sterile gloves, sterile lubricant, speculum, sponge holding forceps and swabs are required. 

Position of the patient :- 

 1 . Dorsal position

 2.  Lateral or sims position 

INSPECTION OF VULVA :-

1. To note any anatomical abnormality starting from the pubic hair, clitoris, labia and perineum

2. To note any palpable pathology over the areas. 

3. To note the character of the visible vaginal discharge, if any 

4. To separate the labia using fingers of the left hand to note external urethral meatus , visible opening of the bartholin ducts (normally not visible unless inflammed) and character of the hymen.

 

VAGINAL EXAMINATION:- 

Inspection of the vagina and cervix  

1.Speculum examination :- should preferably be done prior to bimanual examination. 

The advanteges :- 

• Cervical scrape cytology and endocervical sampling can be taken as ' screening' in the same sitting
• Cervical or vaginal discharge can be taken for bacteriological examination 
• The cervical lesion may bleed during bimanual examination, which makes the lesion difficult to visualize.  

     2. Digital examination :- 

Digital examination is done using a gloved index finger lubricated with sterile lubricant. 

Palpation of any labial swelling is made with finger placed internally and thumb placed externally. 

The urethra is now pressed from above down for any discharge escaping out through the meatus. 

Palpation of the vaginal walls is to be done from below upwards to detect any abnormality either in the wall or in the adjacent structures. 

Integrity and tone of the perineal body are to be elicited by flexing in internal finger posteriorly and palpating the perineal body between the internal finger and thumb placed externally. 

The finger is now turned laterally above the level of levator any muscles. The muscles can be palpated between the vaginal finger and the thumb placed externally over the labium majus.

3. Bimanual examination 

The information obtained by bimanual examination includes :- 

a. Palpation of the uterus 

b. Palpation of the uterine  appendages 

c. Pouch of Douglas. 

• Palpation of the uterus :- The two internal fingers, which are placed in the anterior fornix exert a pushing force at the uterocervical junction in an upward direction towards the lumbar vertebrae and not towards the symphysis pubis. The pressure exerted by the left hand should be not only downwards but from behind forwards The uterine outline between the two hands can thus be palpated clearly as anteverted. If the uterus is retroverted, it will not be so felt but can be felt if the internal fingers push up the uterus through the posterior fornix. After the uterine outline is defined, one should note its position, size, shape, consistency and mobility. Normally, the uterus is anteverted, pearshaped, firm and freely mobile in all directions.

• Palpation of the uterine  appendages  :- For palpation of the adnexa, the vaginal fingers are placed in the lateral fornix and are pushed backwards and upwards. The counter pressure is applied by the abdominal hand placed to one side of the uterus in a backward direction. The normal uterine cannot be palpated. A normal ovary may not be felt. If it is palpable, it is mobile and sensitive to manual pressure.

• Pouch of Douglas. :-The pouch of Douglas can be examined effectively through the posterior fornix. Normally, the fecal mass in the rectosigmoid or else the body of a retroverted uterus is only felt. Some pathology detected in the pouch of Douglas should be supplemented by rectal examination.

RECTAL OR RECTOABDOMINAL EXAMINATION :- 

Rectal examination can be done in isolation or as an adjunct to vaginal examination. 

Indications of Rectal Examination 

1.Children or in adult virgins

2.Painful vaginal examination

3.Carcinoma cervix 

4. To corroborate the findings felt in the pouch of Douglas by bimanual vaginal examination. 

Atresia of the vagina. 

5. The lower bowel should preferably be empty. 

The rectoabdominal procedure is almost the same as that of vaginal examination except that only the gloved index finger smeared with Vaseline is to be introduced into the rectum. 

RECTOVAGINAL EXAMINATION :- 

The procedure consists of introducing the index finger in the vagina and the middle  finger in the rectum. 

1. This examination may help to determine whether the kesion is in the bowel or between the rectum and vagina. 
2. Any thickening of beadiness of urerosacral ligaments or presence of endometriotic nodules are noted. 
3. This is  of special help to differentiate a growtharising from the ovary or rectum.