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Pelvic Examination

Pelvic Examination. & Rectal Examination. Pelvic Examination. Also known as Vaginal Examination, Per Vaginal Examination, Pap Smear, and PV. Indications: As a screening test for pre-malignant or malignant lesions of the cervix.

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Pelvic Examination

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  1. Pelvic Examination & Rectal Examination

  2. Pelvic Examination • Also known as Vaginal Examination, Per Vaginal Examination, Pap Smear, and PV. • Indications: • As a screening test for pre-malignant or malignant lesions of the cervix. • To assist in the diagnosis of intra-abdominal pathology in the female patient with abdominal pain. • To obtain specimens to diagnose vaginal and uterine infections. • Part of a female complete physical examination.

  3. Human Papillomavirus -HPV • Attacks the surface epithelial cells of the skin and the mucosa. • Lesions of HPV infection may involve the vulva, vaginal introitus, anus, cervix and the perineum. • High Risk Types: 16, 18, 31, and 35 • Intermediate Risk Types: 33, 35, 39, 51, 52, 56, 58, 59, and 68 • 75% of cervical cancers are caused by the High Risk Types.

  4. Contraindications and Cautions • Warm water should be used on the speculum instead of lubricant if cultures or other specimens are to be obtained. • Gloves should be changed before a rectal exam. This prevents the spread of infection from the vagina to the rectum. • Female chaperone require, especially if the examiner is a male.

  5. Equipment • Light source • Vaginal Speculum (appropriate size per patient) • Papanicolaou smear/ThinPrep Method • Lubricating jelly (water based) • Sterile cotton swabs, cytobrush, wooden or plastic spatula • Specimen slide with cover slips • KOH • NS solns • Gonorrhea and chlaymdia transport media • Drape or sheet

  6. Risk Factors & Historical Characteristics Correlated with Abnormal Paps • Tobacco smoking • Early age of 1st intercourse( <age 16) • Multiple sex partners (> 3)or vice versa • Hx of sexual abuse • STD Hx , Condyloma, and HIV • Illicit drug abuse (IV and Oral) • Hx of Abnl Paps • Diethylstilbestrol (DES): Rare Now

  7. ThinPrep Method • Latest papsmear technology • Relies on “liquid-based samples.” • More sensitive and specific • Another advantage is that the residual cytologic material left over after the Pap is completed can be used for HPV-DNA typing when Pap smears are equivocal (atypical). This is termed “Reflex DNA typing.”

  8. Patient Preparation • For a woman’s 1st Pelvic exam, time should be spent explaining what will occur. Models and illustrations may be used as adjuncts to the discussion. • Have the patient empty her bladder. • Assist the patient into the lithotomy position with her buttocks at the edge of the table and place a pillow under her head. Do not place the patient into this position until the actual commencement of the pelvic examination.

  9. Procedural Steps • First obtain Hx (especially sexual aspects of age at 1st intercourse, number of sexual partners, and Hx of sexual abuse or rape). • The pelvic exam should be carried out in a comfortable fashion for both the patient and physician. • To avoid startling the patient, advise her she will feel you touching her.

  10. General Inspections • Inspect the external genitalia and perineum for swelling, ulcers, condylaomata, inflammation, bleeding, color changes and discharges. • Pay close attention to the clitoris, the vestibule, labias, Bartholin’s gland ( at 4 or 8 o’clock) • Inspect the vaginal orifice for d/c, or protrusions of the walls by asking the pt to bear down (cystocele, rectocele, urethral prolapse).

  11. Speculum Examination • Use appropriate size speculum moistened with warm water Not withlubricant because it will interfere with cytology testing. • Insert one or two fingers into the introitus and press downward on the posterior or lower edge. • Insert the speculum at a 45 degree angle to the floor of the vagina and gently rotated pressing posteriorly.

  12. Speculum Exam Cont’d • Then remove your fingers. The cervix should pop into view with some manipulation as the speculum is opened and then tightened. • Inspect the cervix and the vagina for color, lacerations, nabothian cysts and other lesions, and evidence of atrophy. • Inspect the cervical os for size, shape, color, and d/c. Obtain the Pap smear by using an endocervical sampling device, first insert into the canal and rotate 90 to 180 degrees with a cytobrush.

  13. Speculum Exam Cont’d • With other devices (eg. Cervex-brush) rotate 360 degrees one or a few times. • Obtain adequate sampling from ectocervix with a plastic or wooden spatula by rotating 360 degrees or more. • Inspect the vagina for secretions and obtain specimen for cultures and other smears. • Gradually withdraw the speculum while rotating it to allow the visualization of the walls and the entire canal.

  14. Bimanual Examination • While standing, place 2nd and 3rd lubricated glove fingers of the dominant hand inside the introitus . • Palpate the cervix note the size, shape, consistency, motility, and test for tenderness (the chandelier’s sign) or cervical motion tenderness, which is suggestive of PID or ruptured ectopic pregnancy. • With your fingers in the vagina posterior to the cervix and your hand on the abdomen place just above the symphysis, force the corpus of the uterus between the two examining hands. Note size, shape, consistency, position, and motility.

  15. Bimanual Exam Cont. • Move the fingers in the vagina to one or the other fornix, and place the hand on the abdomen in a more lateral position to bring the adnexal areas under the examination. Palpate the ovaries, if possible, for any masses, consistency, and motility. • Unless, the fallopian tubes are diseased they are usually not palpable.

  16. Rectovaginal Exam • Insert your index finger into the vagina, and place the well lubricated middle finger into the rectum. • Palpate the posterior surface of the uterus and the broad ligament for nodularity, tenderness, or other masses. Exam the uterosacral and rectovaginal septum. Nodularity here may represent endometriosis.

  17. Wet Mount/ Vaginal Saline Prep • Helpful in Dx of Trichomonas or BV • Mix a drop of discharge with a drop of NS on a glass slide and cover with a cover slip. • Observe the slide while still warm to see the flagellated, motile trichomonads. BV is diagnosed by the presence of “clue cells,” which represent polymorphonuclear white cells (PMNs).

  18. KOH Prep • BV gives a fishy amine odor with the addition of KOH • For thick white, curdy discharge the patient may have Candida albicans (Yeast Infection). Prepare a slide with one drop of discharge and one drop of aqueous 10% KOH soln. • The KOH dissolves the epithelial cells and debris and facilitates viewing of the hyphae and mycelia of the fungus that cause the infection.

  19. GC and Chlamydia Cx • Use a sterile cotton swab to obtain specimen from the endocervical canal and plate it out on Thayer-Martin medium for GC. • Chlamydia testing varies but can include DNAprobe, EIA, or DFA testing.

  20. Pap Report (Bethesda 2001) • Atypical Squamous Cells (ASC) • ASC-US ( undetermined significance) • Three follow-up approaches are possible: • (1) Do DNA typing • (2) Immediately refer to colposcopy if risks factors are present. • (3) If repeated pap is abnormal then refer for colposcopy.

  21. Pap Report • ASC-H ( cannot rule out High-grade dysplasia) • All require colposcopy • Evidence of SIL of any degree ( LGSIL and HGSIL): All require Colposcoy with ECc. • Evidence of Malignant cells: Colposcopy with ECC • Evidence of glandular atypia/atypical glandular cells (AGS) : Colposcoy with ECC. • EndocervicalAdenocaricinoma In Situ: Oncologist referral

  22. Colposcopy • Nothing more than the observation of a cervix under magnification after it has been stained with acetic acid to identify the most abnormal areas for Bx.

  23. Colposcopic Exam • Serves to : • Identify normal landmarks • Identify abnormal areas in relation to these landmarks • Facilitate directed Bx of abnormal areas for histologic Dx • R/O Invasive cancer

  24. Self-Breast Exam (SBE) • Educate the patient: • That the best time to do a SBE is just after or up to a week after her menses. • To Inspect skin for any color changes, obvious lesions, changes in the nipple, and the areola.

  25. SBE • Lying Supine: • Lie down with pillow under right shoulder and right arm behind your head. • Use the “Strip” pattern or Circular or Wedge pattern techniques with the finger pads. • Check the entire breast area, and remember how your breast feels from month to month • Repeat exam with the left breast.

  26. SBE • Standing in Shower: • Follow same technique as supine • Upright position makes it easier to check the UOQ (toward the armpit). This is where about half of breast cancers are found. • Standing In front of the Mirror: • Especially for pendulum breasts, hands on hips and leaning forward with breast dangling. • Look for mirror reflections of dimpling or retractions of breast tissue and or nipples.

  27. Rectal Exam –DRE • As a screening test for CRC, anorectal Ds and for Prostate exam. • Positions: • Left lateral decubitus position • Lithotomy position • Standing with upper body leaning over table.

  28. External Anal Exam • Look for signs of perianal inflammation that may suggest Pruritus ani or other dermatologic conditions. • Gently separate the buttocks; looking for fissures, fistulas, sentinel skin tag, perianal abscess, and external hemorrhoids.

  29. Digital Anorectal Exam • Inform Pt. that anus will be touched with a lubricated gloved finger. • Gently pressure at the anal verge and ask the pt. to bear down to enter the anal canal. • Assess the prostate in males • Sweep the rectal vault and extend the examining finger as far as possible for any palpable lesion or mass.

  30. Continence & Anal Sphincter function • Flex index finger slightly posterior and ask pt. to “squeeze down” as if trying to stop a BM. • If NL anatomic sphincter function, you feel the tightening of the distal extent of the External Sphincter at the base of your finger.

  31. Removal of IUD Strings • No need for Sterile technique. • Insert Speculum and visualize the IUD strings. • Using forceps, grasp the strings and pull toward the introitus. • Can pre-medicate with Motrin 800mg for possible momentary discomfort.

  32. If Strings are not Visible • Use a cytobrush or similar instrument and insert it (the brush portion) the full depth into the cervical canal (2cm) • Rotate and extract the brush in a repeated, continuous motion .

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