Examination

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TECHNIQUES OF EXAMINATION
A good genital examination can be done with the patient either standing or supine. To check
for hernias or varicoceles, however, the patient should stand, and you should sit
comfortably on a chair or stool. A gown conveniently covers the patient's chest and
abdomen. Wear gloves throughout the examination. Expose the genitalia and inguinal areas.
For younger patients, review the sexual maturity ratings on pages 843-844.
THE PENIS
Inspection
Inspect the penis, including:
• The skin
• The prepuce (foreskin). If present, retract the prepuce or ask the patient to retract it. This
step is essential for the detection of many chancres and carcinomas. Smegma, a cheesy,
whitish material, may accumulate normally under the foreskin.
EXAMPLES OF ABNORMALITIES
Phimosis is a tight prepuce that cannot be retracted over the glans. Paraphimosis is a tight
prepuce that, once retracted, cannot be returned. Edema ensues.
• The glans. Look for any ulcers, scars, nodules, or signs of inflammation.
EXAMPLES OF ABNORMALITIES
Balanitis (inflammation of the glans); balanoposthitis (inflammation of the glans and
prepuce)
Check the skin around the base of the penis for excoriations or inflammation. Look for nits
or lice at the bases of the pubic hairs.
EXAMPLES OF ABNORMALITIES
Pubic or genital excoriations suggest the possibility of lice (crabs) or sometimes scabies.
EXAMPLES OF ABNORMALITIES
Hypospadias is a congenital, ventral displacement of the meatus on the penis (p. 515).
Compress the glans gently between your index finger above and your thumb below. This
maneuver should open the urethral meatus and allow you to inspect it for discharge.
Normally there is none.

EXAMPLES OF ABNORMALITIES
Profuse yellow discharge in gonococcal urethritis; scanty white or clear discharge in
nongonococcal urethritis. Definitive diagnosis requires Gram stain and culture.
If the patient has reported a discharge that you are unable to see, ask him to strip, or milk,
the shaft of the penis from its base to the glans. Alternatively, do it yourself. This maneuver
may expel some discharge from the urethral meatus for appropriate examination. Have a
glass slide and culture materials ready.
Palpation
Palpate any abnormality of the penis, noting any tenderness or induration. Palpate the shaft
of the penis between your thumb and first two fingers, noting any induration. Palpation of
the shaft may be omitted in a young, asymptomatic male patient.
If you retract the foreskin, replace it before proceeding on to examine the scrotum.

EXAMPLES OF ABNORMALITIES
Induration along the ventral surface of the penis suggests a urethral stricture or possibly a
carcinoma. Tenderness of such an indurated area suggests periurethral inflammation
secondary to a urethral stricture.
THE SCROTUM AND ITS CONTENTS
Inspection
Inspect the scrotum, including:
• The skin. Lift up the scrotum so that you can see its posterior surface.
EXAMPLES OF ABNORMALITIES
Rashes, epidermoid cysts, rarely skin cancer
• The scrotal contours. Note any swelling, lumps, or veins.
There may be dome-shaped white or yellow papules or nodules formed by occluded
follicles filled with keratin debris of desquamated follicular epithelium. Such epidermoid
cysts are common, frequently multiple, and benign.
EXAMPLES OF ABNORMALITIES
A poorly developed scrotum on one or both sides suggests cryptorchidism (an undescended
testicle). Common scrotal swellings include indirect inguinal hernias, hydroceles, and
scrotal edema.
Palpation
Palpate each testis and epididymis between your thumb and first two fingers. Locate the
epididymis on the superior posterior surface of each testicle. It feels nodular and cordlike
and should not be confused with an abnormal lump.
EXAMPLES OF ABNORMALITIES
Tender, painful scrotal swelling in acute epididymitis, acute orchitis, torsion of the
spermatic cord, or a strangulated inguinal hernia.
Note size, shape, consistency, and tenderness; feel for any nodules. Pressure on the testis
normally produces a deep visceral pain.
EXAMPLES OF ABNORMALITIES
Any painless nodule in the testis must raise the possibility of testicular cancer, a potentially
curable cancer with a peak incidence between the ages of 15 and 35 years.
Palpate each spermatic cord, including the vas deferens, between your thumb and fingers,
from the epididymis to the superficial inguinal ring.
EXAMPLES OF ABNORMALITIES
Multiple tortuous veins in this area, usually on the left, may be palpable and even visible.
They indicate a varicocele
Note any nodules or swellings.
EXAMPLES OF ABNORMALITIES
The vas deferens, if chronically infected, may feel thickened or beaded. A cystic structure
in the spermatic cord suggests a hydrocele of the cord.
Swelling in the scrotum other than the testicles can be evaluated by transillumination. After
darkening the room, shine the beam of a strong flashlight from behind the scrotum through
the mass. Look for transmission of the light as a red glow.
EXAMPLES OF ABNORMALITIES

Swellings containing serous fluid, as in hydroceles, light up with a red glow, or
transilluminate. Those containing blood or tissue, such as a normal testis, a tumor, or most
hernias, do not.
Inspection
Sitting comfortably in front of the patient, with the patient standing and an assistant present,
inspect the inguinal regions and genitalia for bulging areas and asymmetry. As you observe,
ask the patient to strain and bear down (the Valsalva maneuver) to increase intra-abdominal
pressure, making it easier to detect any hernias.
EXAMPLES OF ABNORMALITIES
A bulge that appears on straining suggests a hernia.
Palpation
Palpate for an inguinal hernia, using the techniques below. Continue to face the patient; the
patient should still be standing.
• To examine for right inguinal hernias, place the tip of your right index finger close to the
inferior margin of the scrotal sac, then move your finger upward along the inguinal canal,
invaginating the scrotum.
• Follow the spermatic cord upward to the inguinal ligament. Find the triangular slitlike
opening of the external inguinal ring just above and lateral to the pubic tubercle. Palpate the
external inguinal ring and its floor. Ask the patient to bear down. Search for any bulges or
masses against the side or pulp of the index finger above the inguinal ligament near the
pubic tubercle.
• The external ring may be large enough for you to gently palpate obliquely along the
inguinal canal toward the internal inguinal ring. Ask the patient to bear down. Check for a
bulge that slides down the inguinal canal and taps against the fingertip.
• To examine for left inguinal hernias, use the same techniques with the left index finger.
EXAMPLES OF ABNORMALITIES
A bulge near the external inguinal ring suggests a direct inguinal hernia. A bulge near the
internal inguinal ring suggests an indirect inguinal hernia. Experts note that distinguishing
the type of hernia is difficult, but detecting either type of mass warrants surgical
evaluation.7
Palpate for a femoral hernia by placing your fingers on the anterior thigh in the region of
the femoral canal. Ask the patient to strain down again or cough. Note any swelling or
tenderness.
Evaluating a Possible Scrotal Hernia.
If you find a large scrotal mass and suspect that it may be a hernia, ask the patient to lie
down. The mass may return to the abdomen by itself. If so, it is a hernia. If not:
• Can you get your fingers above the mass in the scrotum?
EXAMPLES OF ABNORMALITIES
If you can, suspect a hydrocele.
• Listen to the mass with a stethoscope for bowel sounds.
EXAMPLES OF ABNORMALITIES
Bowel sounds may be heard over a hernia, but not over a hydrocele.

If the findings suggest a hernia, gently try to reduce it (return it to the abdominal cavity) by
sustained pressure with your fingers. Do not attempt this maneuver if the mass is tender or
the patient reports nausea and vomiting.
History may be helpful here. The patient can usually tell you what happens to his swelling
on lying down and may be able to demonstrate how he reduces it himself. Remember to ask
him.
EXAMPLES OF ABNORMALITIES
A hernia is incarcerated when its contents cannot be returned to the abdominal cavity. A
hernia is strangulated when the blood supply to the entrapped contents is compromised.
Suspect strangulation in the presence of tenderness, nausea, and vomiting and consider
surgical intervention.
SPECIAL TECHNIQUES
The Testicular Self-Examination
The incidence of testicular cancer is low, about 4 per 100,000 men, but it is the most
common cancer of young men between ages 15 and 35. Although the testicular selfexamination (TSE) has not been formally endorsed as a screen for testicular carcinoma,
teach your patient the TSE to enhance health awareness and self-care. When detected early,
testicular carcinoma has an excellent prognosis. Risk factors include cryptorchidism, which
confers a high risk for testicular carcinoma in the undescended testicle; a history of
carcinoma in the contralateral testicle; mumps orchitis; an inguinal hernia; and a hydrocele
in childhood.
PATIENT INSTRUCTIONS FOR THE TESTICULAR SELF-EXAMINATION
This examination is best performed after a warm bath or shower. The heat relaxes the
scrotum and makes it easier to find anything unusual.


Standing in front of a mirror, check for any swelling on the skin of the scrotum.



Examine each testicle with both hands. Cup the index and middle fingers under the
testicle and place the thumbs on top.



Roll the testicle gently between the thumbs and fingers. One testicle may be larger
than the other … that's normal, but be concerned about any lump or area of pain.



Find the epididymis. This is a soft, tubelike structure at the back of the testicle that
collects and carries sperm, not an abnormal lump.



If you find any lump, don't wait. See your doctor. The lump may just be an
infection, but if it is cancer, it will spread unless stopped by treatment.

Female

THE HEALTH HISTORY
Common Concerns


Menarche, menstruation, menopause, postmenopausal bleeding



Pregnancy



Vulvovaginal symptoms



Sexual preference and sexual response

Menarche, Menstruation, Menopause.
Learn to recognize patterns of menstrual flow, using the terms below.
THE MENSTRUAL HISTORY—HELPFUL DEFINITIONS


Menarche—age at onset of menses



Menopause—absence of menses for 12 consecutive months, usually occurring
between 48 and 55 years



Postmenopausal bleeding—bleeding occurring 6 months or more after cessation of
menses



Amenorrhea—absence of menses



Dysmenorrhea—pain with menses, often with bearing down, aching, or cramping
sensation in the lower abdomen or pelvis



Premenstrual syndrome (PMS)—a cluster of emotional, behavioral, and physical
symptoms occurring 5 days before menses for three consecutive cycles



Abnormal uterine bleeding—bleeding between menses; includes infrequent,
excessive, prolonged, or postmenopausal bleeding

Questions about menarche, menstruation, and menopause often give you an opportunity to
explore the patient's concerns and attitude toward her body. When talking with an
adolescent girl, for example, opening questions might include: “How did you first learn
about monthly periods? How did you feel when they started? Many girls worry when their
periods aren't regular or come late. Has anything like that bothered you?” You can explain
that girls in the United States usually begin to menstruate between the ages of 9 and 16

years, and often it takes 1 year or more before periods settle into a reasonable, regular
pattern. Age at menarche is variable, depending on genetic endowment, socioeconomic
status, and nutrition. The interval between periods ranges roughly from 24 to 32 days; flow
lasts from 3 to 7 days.
For the menstrual history, ask the patient how old she was when her menstrual periods
began, or age at menarche. When did her last period start, and, if possible, the one before
that? How often does she have periods, as measured by the interval between the first days
of successive periods? How regular or irregular are they? How long do they last? How
heavy is the flow? What color is it? Flow can be assessed roughly by the number of pads or
tampons used daily. Because women vary in their practices for sanitary measures, however,
ask the patient whether she usually soaks a pad or tampon, spots it lightly, etc. Further, does
she use more than one at a time? Does she have any bleeding between periods? Any
bleeding after intercourse?
EXAMPLES OF ABNORMALITIES
The dates of previous periods can signal possible pregnancy or menstrual irregularities.
EXAMPLES OF ABNORMALITIES
Unlike the normal dark red menstrual discharge, excessive flow tends to be bright red and
may include “clots” (not true fibrin clots).
Ask a middle-aged or older woman if she has stopped menstruating. When? Did any
symptoms accompany her changes to menopause? Has she had any bleeding since?
Up to 50% of women report dysmenorrhea, or pain with menses. Ask if the patient has any
discomfort or pain before or during her periods. If so, what is it like, how long does it last,
and does it interfere with usual activities? Are there other associated symptoms?
Dysmenorrhea may be primary, without an organic cause, or secondary, with an organic
cause.
EXAMPLES OF ABNORMALITIES
Primary dysmenorrhea results from increased prostaglandin production during the luteal
phase of the menstrual cycle, when estrogen and progesterone levels decline.
EXAMPLES OF ABNORMALITIES
Causes of secondary dysmenorrhea include endometriosis, adenomyosis (endometriosis in
the muscular layers of the uterus), pelvic inflammatory disease, and endometrial polyps.
Premenstrual syndrome (PMS) includes emotional and behavioral symptoms such as
depression, angry outbursts, irritability, anxiety, confusion, crying spells, sleep disturbance,
poor concentration, and social withdrawal.1 Ask about signs such as bloating and weight
gain, swelling of the hands and feet, and generalized aches and pains. Criteria for diagnosis
are symptoms and signs in the 5 days prior to menses for at least three consecutive cycles;
cessation of symptoms and signs within 4 days after onset of menses; and interference with
daily activities.
Amenorrhea refers to the absence of periods. Failure of periods to initiate is called primary
amenorrhea, whereas the cessation of periods after they have been established is termed
secondary amenorrhea. Pregnancy, lactation, and menopause are physiologic forms of the
secondary type.
EXAMPLES OF ABNORMALITIES

Other causes of secondary amenorrhea include low body weight from any cause, including
malnutrition and anorexia nervosa, stress, chronic illness, and hypothalamic-pituitaryovarian dysfunction.
Ask about any abnormal bleeding. The term abnormal uterine bleeding encompasses
several patterns:
EXAMPLES OF ABNORMALITIES
Causes vary by age group and include pregnancy, cervical or vaginal infection, or cancer,
cervical or endometrial polyps or hyperplasia, fibroids, bleeding disorders, and hormonal
contraception or replacement therapy. Postcoital bleeding suggests cervical polyps or
cancer, or in an older woman, atrophic vaginitis.


Polymenorrhea, or fewer than 21-day intervals between menses



Oligomenorrhea, or infrequent bleeding



Menorrhagia, or excessive flow



Metorrhagia, or intermenstrual bleeding



Postcoital bleeding

Menopause usually occurs between 48 and 55 years, following a period of fluctuation in
pituitary secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) and
ovarian function.2 If your patient is perimenopausal, with onset of variable cycle length, ask
about such vasomotor symptoms as hot flashes, flushing, and sweating. Sleep disturbances
are also common. After menopause, there may be vaginal dryness and dyspareunia, or
painful intercourse, hair loss, and mild hirsutism as the androgen-toestrogen ratio increases.
Urinary symptoms may also occur in the absence of infection because of atrophy of the
urethra and urinary trigone.
EXAMPLES OF ABNORMALITIES
Woman may ask about many alternative compounds and botanicals for relief of
menopause-related symptoms. Most have not been well-studied or proved to be beneficial.
Estrogen replacement relieves symptoms but increases risk of thrombosis. Some evidence
shows that some antidepressants and alpha-blockers can be helpful.3
Often you will ask, “How do (did) you feel about not having your periods anymore? Has it
affected your life in any way?” Ask about any bleeding after menopause.
EXAMPLES OF ABNORMALITIES
Postmenopausal bleeding in endometrial cancer, hormone replacement therapy, uterine and
cervical polyps
Pregnancy.
Questions relating to pregnancy include “Have you ever been pregnant? How many times?
… How many living children do you have? … Have you ever had a miscarriage or an
abortion? How many times?” Ask about any difficulties during pregnancy and the timing

and circumstances of any abortion, whether spontaneous or induced. How did the woman
experience these losses? Obstetricians commonly record the pregnancy history using the
“gravida-para” system.
THE GRAVIDA-PARA NOTATION


G = gravida, or total number of pregnancies



P = para, or outcomes of pregnancies. After P, you will often see the notations F
(full-term), P (premature), A (abortion), and L (living child).

Inquire about methods of contraception used by the patient and her partner. Is the patient
satisfied with the method chosen? Are there any questions about the options available?
If amenorrhea suggests a current pregnancy, inquire about the history of intercourse and
common early symptoms: tenderness, tingling, or increased size of the breasts; urinary
frequency; nausea and vomiting; easy fatigability; and feelings that the baby is moving,
usually noted at about 20 weeks. Be considerate of the patient's feelings about discussing
these topics and explore them when the patient has special concerns. (See also Chapter 19,
The Pregnant Woman.)
EXAMPLES OF ABNORMALITIES
Amenorrhea followed by heavy bleeding suggests a threatened abortion or dysfunctional
uterine bleeding related to lack of ovulation.
Vulvovaginal Symptoms.
The most common vulvovaginal symptoms are vaginal discharge and local itching. Follow
your usual approach. If the patient reports a discharge, inquire about its amount, color,
consistency, and odor. Ask about any local sores or lumps in the vulvar area. Are they
painful or not? Because patients vary in their understanding of anatomical terms, be
prepared to try alternative phrasing such as “Any itching (or other symptoms) near your
vagina? … between your legs? … where you urinate?”
Sexual Preference and Sexual Response.
Review the Tips for Taking a Sexual History. Using neutral and nonjudgmental questions,
ask about your patient's sexual preference and relationship status. Patients with same-sex or
transgender preferences may be anxious or fearful during clinical encounters. A reassuring
manner will help them express concerns about their sexual health and activity.
Start with general questions such as “How is sex for you?” Or “Are you having any
problems with sex?” You can also ask, “Are you satisfied with your sex life as it is now?
Has there been any significant change in the last few years? Are you satisfied with you
ability to perform sexually? How satisfied do you think your partner is? Do you feel that
your partner is satisfied with the frequency of sexual activity?”
If the patient has concerns about sexual activity, ask her to tell you about it. Direct
questions help you assess each phase of the sexual response: desire, arousal, and orgasm.
“Do you have an interest in (appetite for) sex?” inquires about the desire phase. For the
orgasmic phase, “Are you able to reach climax (reach an orgasm or ‘come’)?” “Is it

important for you to reach climax?” For arousal, “Do you get sexually aroused? Do you
lubricate easily (get wet or slippery)? Do you stay too dry?”
EXAMPLES OF ABNORMALITIES
Sexual dysfunction is classified by the phase of sexual response. A woman may lack desire,
she may fail to become aroused and attain adequate vaginal lubrication, or, despite adequate
arousal, she may be unable to reach orgasm. Causes include lack of estrogen, medical
illness, and psychiatric conditions.
Ask also about dyspareunia. If present, try to localize the symptom. Is it near the outside,
occurring at the start of intercourse, or does she feel it farther in, when her partner is
pushing deeper? Vaginismus refers to an involuntary spasm of the muscles surrounding the
vaginal orifice that makes penetration during intercourse painful or impossible.
EXAMPLES OF ABNORMALITIES
Superficial pain suggests local inflammation, atrophic vaginitis, or inadequate lubrication;
deeper pain may be from pelvic disorders or pressure on a normal ovary. The cause of
vaginismus may be physical or psychological.
In addition to ascertaining the nature of a sexual problem, ask about its onset, severity
(persistent or sporadic), setting, and factors, if any, that make it better or worse. What does
the patient think is the cause of the problem, what has she tried to do about it, and what
does she hope for? The setting of sexual dysfunction is an important but complicated topic,
involving the patient's general health; medications and drugs, including use of alcohol; her
partner's and her own knowledge of sexual practices and techniques; her attitudes, values,
and fears; the relationship and communication between partners; and the setting in which
sexual activity takes place.
EXAMPLES OF ABNORMALITIES
More commonly, however, a sexual problem is related to situational or psychosocial
factors.
Sexually Transmitted Diseases (STDs).
Local symptoms or findings on physical examination may raise the possibility of sexually
transmitted diseases. After establishing the usual attributes of any symptoms, identify
sexual preference (male, female, or both). Inquire about sexual contacts and establish the
number of sexual partners in the prior month. Ask if the patient has concerns about HIV
infection, desires HIV testing, or has current or past partners at risk. Also ask about oral and
anal sex and, if indicated, about symptoms involving the mouth, throat, anus, and rectum.
Review the past history of

TECHNIQUES OF EXAMINATION
Important Areas of Examination
External Examination

Internal Examination



Mons pubis



Vagina, vaginal walls



Labia majora and minora



Cervix



Urethral meatus, clitoris



Uterus, ovaries



Vaginal introitus



Pelvic muscles



Perineum



Rectovaginal wall

Approach to the Pelvic Examination.
Many students feel anxious or uncomfortable when they begin doing pelvic examinations.
At the same time, female patients have their own concerns. Some women have had painful,
embarrassing, or even demeaning experiences during previous examinations, whereas
others may be facing a pelvic examination for the first time. Some are fearful about what
the clinician may find and how findings may affect their lives. Asking the patient's
permission to perform the examination shows courtesy and respect. If a Pap smear is to be
collected using the glass-slide technique, time the examination so that it does not occur
during menses, because blood can interfere with interpretation.
EXAMPLES OF ABNORMALITIES
In liquid-based cytology, blood cells can be filtered out.36
A woman having her first pelvic examination may not know what to expect. Using threedimensional models, showing her the equipment and letting her handle the speculum, and
explaining each step in advance can help her learn about her body and be more
comfortable. Careful and gentle technique is especially important in minimizing any pain or
discomfort during the first pelvic examination.
The woman's response to the pelvic examination may reveal clues about her feelings about
the examination and her sexuality. If she pulls away, adducts her thighs, or reacts negatively
to the examination, you can gently comment “I notice you are having some trouble
relaxing. Is it just being here, or are you troubled by the examination? … Is anything
worrying you?” Behaviors that seem to present an obstacle may lead you to a better
understanding of your patient's concerns. Adverse reactions may signal prior abuse and
should be explored.
Indications for a pelvic examination during adolescence include menstrual abnormalities
such as amenorrhea, excessive bleeding, or dysmenorrhea; unexplained abdominal pain;
vaginal discharge; the prescription of contraceptives; bacteriologic and cytologic studies in
a sexually active girl; and the patient's own desire for assessment.
TIPS FOR THE SUCCESSFUL PELVIC EXAMINATION
The Patient

The Examiner



Avoids intercourse, douching, or use of
vaginal suppositories for 24 to 48 hours
before examination



Empties bladder before examination



Lies supine, with head and shoulders
elevated, arms at sides or folded across
chest to enhance eye contact and reduce
tightening of abdominal muscles



Obtains permission; selects
chaperone



Explains each step of the
examination in advance



Drapes patient from midabdomen
to knees; depresses drape
between knees to provide eye
contact with patient



Avoids unexpected or sudden
movements



Chooses a speculum that is the
correct size



Warms speculum with tap water



Monitors comfort of the
examination by watching the
patient's face



Uses excellent but gentle
technique, especially when
inserting the speculum (see
below)

Helping the patient to relax is essential for an adequate examination. Adopting the tips
above will help ensure the patient's comfort. Be sure always to wear gloves, both during the
examination and when handling equipment and specimens. Plan ahead, so that any needed
equipment and culture media are readily at hand.
Note that male examiners should be accompanied by female chaperones. Female examiners
should also be assisted if the patient is physically or emotionally disturbed, and to facilitate
the examination.
Rape Victims.
Regardless of age, rape merits special evaluation, usually requiring gynecologic
consultation and documentation. Often there is a special rape kit, provided in many
emergency departments, that must be used to ensure a chain of custody for evidence.
Specimens must be labeled carefully with name, date, and time. Additional information
may be needed for further legal investigation.

Choosing Equipment.
You should have within reach a good light, a vaginal speculum of appropriate size, watersoluble lubricant, and equipment for taking Papanicolaou smears, bacteriologic cultures and
DNA probes, or other diagnostic tests, such as potassium hydroxide or normal saline.
Review the supplies and procedures of your own facility before taking cultures and other
samples.
Specula are made of metal or plastic and come in two basic shapes, named for Pedersen and
Graves. Both are available in small, medium, and large sizes. The medium Pedersen
speculum is usually most comfortable for sexually active women. The narrow-bladed
Pedersen speculum is best for the patient with a relatively small introitus, such as a virgin
or an elderly woman. The Graves specula are best suited for parous women with vaginal
prolapse.
Before using a speculum, become thoroughly familiar with how to open and close its
blades, lock the blades in an open position, and release them again. Although the
instructions in this chapter refer to a metal speculum, you can easily adapt them to a plastic
one by handling the speculum before using it. Plastic specula typically make a loud click or
may pinch when locked or released. Forewarning the patient helps to avoid unnecessary
surprise.
Positioning the Patient.
Drape the patient appropriately and then assist her into the lithotomy position. Help her to
place first one heel and then the other into the stirrups. She may be more comfortable with
shoes on than with bare feet. Then ask her to slide all the way down the examining table
until her buttocks extend slightly beyond the edge. Her thighs should be flexed, abducted,
and externally rotated at the hips. A pillow should support her head.
EXTERNAL EXAMINATION
Assess the Sexual Maturity of an Adolescent Patient.
You can assess pubic hair during either the abdominal or the pelvic examination.
EXAMPLES OF ABNORMALITIES
Delayed puberty is often familial or related to chronic illness. It may also arise from
abnormalities in the hypothalamus, anterior pituitary gland, or ovaries.
Examine the External Genitalia.
Seat yourself comfortably and warn the patient that you will be touching her genital area.
Inspect the mons pubis, labia, and perineum. Separate the labia and inspect:
EXAMPLES OF ABNORMALITIES
Excoriations or itchy, small, red maculopapules suggest pediculosis pubis (lice or “crabs”).
Look for nits or lice at the bases of the pubic hairs.
• The labia minora
• The clitoris
EXAMPLES OF ABNORMALITIES
Enlarged clitoris in masculinizing conditions
• The urethral meatus
EXAMPLES OF ABNORMALITIES
Urethral caruncle, prolapse of the urethral mucosa.
• The vaginal opening, or introitus

Note any inflammation, ulceration, discharge, swelling, or nodules. If there are any lesions,
palpate them.
EXAMPLES OF ABNORMALITIES
Herpes simplex, Behcet's disease, syphilitic chancre, epidermoid cyst. If there is a history
or an appearance of labial swelling, check Bartholin's glands. Insert your index finger into
the vagina near the posterior end of the introitus. Place your thumb outside the posterior
part of the labium majus. On each side in turn, palpate between your finger and thumb for
swelling or tenderness. Note any discharge exuding from the duct opening of the gland. If
any is present, culture it.
EXAMPLES OF ABNORMALITIES
A Bartholin's gland may become acutely or chronically infected and then produce a
swelling.
INTERNAL EXAMINATION
Assess the Support of the Vaginal Walls.
With the labia separated by your middle and index fingers, ask the patient to bear down.
Note any bulging of the vaginal walls.
EXAMPLES OF ABNORMALITIES
Bulging from a cystocele or rectocele.
Insert the Speculum.
Select a speculum of appropriate size and shape, and moisten it with warm, but not hot,
water. (Lubricants or gels may interfere with cytologic studies and bacterial or viral
cultures.) You can enlarge the vaginal introitus by lubricating one finger with water and
applying downward pressure at its lower margin. Check the location of the cervix to help
angle the speculum more accurately. Enlarging the introitus greatly eases insertion of the
speculum and the patient's comfort. With your other hand (usually the left), introduce the
closed speculum past your fingers at a somewhat downward slope. Be careful not to pull on
the pubic hair or pinch the labia with the speculum. Separating the labia majora with your
other hand can help to avoid this.
THE SMALL INTROITUS
Many virginal vaginal orifices admit a single examining finger. Modify your technique so
as to use your index finger only. A small Pedersen speculum may make inspection possible.
When the vaginal orifice is even smaller, an adequate bimanual examination can be
performed by placing one finger in the rectum rather than in the vagina, but warn the
patient first!
Similar techniques may be indicated in elderly women if the introitus has become atrophied
and tight.
EXAMPLES OF ABNORMALITIES
An imperforate hymen occasionally delays menarche. Be sure to check for this possibility
when menarche seems unduly late in relation to the development of a girl's breasts and
pubic hair.
Two methods help you to avoid placing pressure on the sensitive urethra. (1) When
inserting the speculum, hold it at an angle (shown below on the left), and then (2) slide the
speculum inward along the posterior wall of the vagina, applying downward pressure to
keep the vaginal introitus relaxed.

After the speculum has entered the vagina, remove your fingers from the introitus. You may
wish to switch the speculum to the right hand to enhance maneuverability of the speculum
and subsequent collection of specimens. Rotate the speculum into a horizontal position,
maintaining the pressure posteriorly, and insert it to its full length. Be careful not to open
the blades of the speculum prematurely.
Inspect the Cervix.
Open the speculum carefully. Rotate and adjust the speculum until it cups the cervix and
brings it into full view. Position the light until you can visualize the cervix well. When the
uterus is retroverted, the cervix points more anteriorly than illustrated. If you have
difficulty finding the cervix, withdraw the speculum slightly and reposition it on a different
slope. If discharge obscures your view, wipe it away gently with a large cotton swab.
EXAMPLES OF ABNORMALITIES
A yellowish discharge on the endocervical swab suggests mucopurulent cervicitis,
commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex.
Raised, friable, or lobed wartlike lesions in condylomata or cervical cancer.
Obtain Specimens for Cervical Cytology (Papanicolaou Smears).
Obtain one specimen from the endocervix and another from the ectocervix, or a
combination specimen using the cervical brush (“broom”). For best results the patient
should not be menstruating. She should avoid intercourse and use of douches, tampons,
contraceptive foams or creams, or vaginal suppositories for 48 hours before the
examination. In addition to obtaining the Pap smear, for sexually active women age 25 or
younger, and for other asymptomatic women at increased risk for infection, plan to culture
the cervix routinely for Chlamydia trachomatis.21
EXAMPLES OF ABNORMALITIES
Chlamydial infection is linked to urethritis, cervicitis, pelvic inflammatory disease, ectopic
pregnancy, infertility, and chronic pelvic pain. Risk factors include age younger than 25,
multiple partners, and prior history of STDs.
OBTAINING THE PAP SMEAR: OPTIONS FOR SPECIMEN COLLECTION
Cervical Scrape and Endocervical Brush
Cervical Scrape. Place the longer end of the scraper in the cervical os. Press, turn, and
scrape in a full circle, making sure to include the transformation zone and the
squamocolumnar junction. Smear the specimen on a glass slide. Set the slide in a safe spot
that is easy to reach. Note that doing the cervical scrape first reduces obscuring cells with
blood, which sometimes appears after use of the endocervical brush.
Endocervical Brush. Take the endocervical brush and place it in the cervical os. Roll it
between your thumb and index finger, clockwise and counterclockwise. Remove the brush
and pick up the slide you have set aside. Smear the slide with the brush, using a gentle
painting motion to avoid destroying any cells. Place the slide into an ether-alcohol solution
at once, or spray it promptly with a special fixative.
Note that for pregnant women, a cotton-tip applicator, moistened with saline, is advised in
place of the endocervical brush.
Cervical Broom
Many clinicians use a plastic brush tipped with a broomlike fringe for collection of a single
specimen containing both squamous and columnar epithelial cells. Rotate the tip of the

brush in the cervical os, in a full clockwise direction, then stroke each side of the brush on
the glass slide. Promptly place the slide in solution or spray with a fixative as described
above. Alternatively, place the sample directly into preservative so that the laboratory can
prepare the slide (liquid-based cytology).
Inspect the Vagina.
Withdraw the speculum slowly while observing the vagina. As the speculum clears the
cervix, release the thumb screw and maintain the open position of the speculum with your
thumb. Close the speculum as it emerges from the introitus, avoiding both excessive
stretching and pinching of the mucosa. During withdrawal, inspect the vaginal mucosa,
noting its color and any inflammation, discharge, ulcers, or masses.
EXAMPLES OF ABNORMALITIES
Vaginitis with discharge from Candida, Trichomonas vaginalis, bacterial vaginosis.
Diagnosis depends on laboratory tests because sensitivity and specificity of discharge
characteristics are low. Vaginal cancer is rare; DES exposure in utero and HPV infection are
risk factors.
Perform a Bimanual Examination.
Lubricate the index and middle fingers of one of your gloved hands, and from a standing
position, insert them into the vagina, again exerting pressure primarily posteriorly. Your
thumb should be abducted, your ring and little fingers flexed into your palm. Pressing
inward on the perineum with your flexed fingers causes little if any discomfort and allows
you to position your palpating fingers correctly. Note any nodularity or tenderness in the
vaginal wall, including the region of the urethra and the bladder anteriorly.
EXAMPLES OF ABNORMALITIES
Stool in the rectum may simulate a rectovaginal mass, but unlike a malignant mass, can
usually be dented by digital pressure. Rectovaginal examination confirms the distinction.
Palpate the cervix, noting its position, shape, consistency, regularity, mobility, and
tenderness. Normally the cervix can be moved somewhat without pain. Feel the fornices
around the cervix.
EXAMPLES OF ABNORMALITIES
Pain on movement of the cervix, together with adnexal tenderness, suggest pelvic
inflammatory disease.
Palpate the uterus. Place your other hand on the abdomen about midway between the
umbilicus and the symphysis pubis. While you elevate the cervix and uterus with your
pelvic hand, press your abdominal hand in and down, trying to grasp the uterus between
your two hands. Note its size, shape, consistency, and mobility, and identify any tenderness
or masses.
EXAMPLES OF ABNORMALITIES
Uterine enlargement suggests pregnancy, uterine myomas (fibroids), or malignancy.
Now slide the fingers of your pelvic hand into the anterior fornix and palpate the body of
the uterus between your hands. In this position your pelvic fingers can feel the anterior
surface of the uterus, and your abdominal hand can feel part of the posterior surface.
EXAMPLES OF ABNORMALITIES
Nodules on the uterine surfaces suggest myomas.If you cannot feel the uterus with either of
these maneuvers, it may be tipped posteriorly (retrodisplaced). Slide your pelvic fingers

into the posterior fornix and feel for the uterus butting against your fingertips. An obese or
poorly relaxed abdominal wall may also prevent you from feeling the uterus even when it is
located anteriorly.
See retroversion and retroflexion of the uterus.
Palpate each ovary. Place your abdominal hand on the right lower quadrant, your pelvic
hand in the right lateral fornix. Press your abdominal hand in and down, trying to push the
adnexal structures toward your pelvic hand. Try to identify the right ovary or any adjacent
adnexal masses. By moving your hands slightly, slide the adnexal structures between your
fingers, if possible, and note their size, shape, consistency, mobility, and tenderness. Repeat
the procedure on the left side.
EXAMPLES OF ABNORMALITIES
Three to five years after menopause, ovaries are atrophic and usually nonpalpable. In
postmenopausal women, investigate a palpable ovary for possible ovarian cyst or ovarian
cancer. Pelvic pain, bloating, increased abdominal size, and urinary tract symptoms are
more common in women with ovarian cancer.
Normal ovaries are somewhat tender. They are usually palpable in slender, relaxed women
but are difficult or impossible to feel in others who are obese or poorly relaxed.
EXAMPLES OF ABNORMALITIES
Adnexal masses can also arise from a tubo-ovarian abscess, salpingitis or inflammation of
the fallopian tubes from PID, or ectopic pregnancy. Distinguish such a mass from a uterine
myoma.
Assess the Strength of the Pelvic Muscles.
Withdraw your two fingers slightly, just clear of the cervix, and spread them to touch the
sides of the vaginal walls. Ask the patient to squeeze her muscles around them as hard and
long as she can. A squeeze that compresses your fingers snugly, moves them upward and
inward, and lasts 3 seconds or more is full strength.
EXAMPLES OF ABNORMALITIES
Impaired strength may be because of age, vaginal deliveries, or neurologic deficits.
Weakness may be associated with urinary stress incontinence.
Do a Rectovaginal Examination.
The rectovaginal examination has three primary purposes: to palpate a retroverted uterus,
the uterosacral ligaments, cul-de-sac, and adnexa; to screen for colorectal cancer in women
50 years or older; and to assess pelvic pathology.36,41
After withdrawing your fingers from the bimanual examination, change your gloves and
lubricate your fingers as needed (see note below on lubricants). Slowly reintroduce your
index finger into the vagina and your middle finger into the rectum. Ask the patient to strain
down as you do this to relax her anal sphincter. Mention that this may stimulate an urge to
move her bowels, but this will not occur. Apply pressure against the anterior and lateral
walls with the examining fingers, and downward pressure with the hand on the abdomen.
Check the rectal vault for masses. If a hemoccult test is planned, you should change gloves
to avoid contaminating fecal material with any blood provoked by the Pap smear. After the
examination, wipe off the external genitalia and rectum, or offer the patient some tissue so
she can do it herself.
USING LUBRICANTS

If you use a tube of lubricant during a pelvic or rectal examination, you may inadvertently
contaminate it by touching the tube with your gloved fingers after touching the patient. To
avoid this problem, let the lubricant drop onto your gloved fingers without allowing contact
between the tube and the gloves. If you or your assistant should inadvertently contaminate
the tube, discard it. Small disposable tubes for use with one patient circumvent this
problem.
HERNIAS
Hernias of the groin occur in women as well as in men, but they are much less common.
The examination techniques (see pp. 510-512) are basically the same as for men. A woman
too should stand up to be examined. To feel an indirect inguinal hernia, however, palpate in
the labia majora and upward to just lateral to the pubic tubercles.
EXAMPLES OF ABNORMALITIES
An indirect inguinal hernia is the most common hernia that occurs in the female groin. A
femoral hernia ranks next in frequency.
SPECIAL TECHNIQUES
If you suspect urethritis or inflammation of the paraurethral glands, insert your index finger
into the vagina and milk the urethra gently from inside outward. Note any discharge from
or about the urethral meatus. If present, culture it.
EXAMPLES OF ABNORMALITIES
Urethritis may arise from infection with Chlamydia trachomatis or Neisseria gonorrhoeae.

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