Regional Examination:

EMALE GENITALIA
Learning Objectives:
ANATOMY AND PHYSIOLOGY
 Anatomy and Physiology

EXTERNAL FEMALE GENITALIA

• Vulva, including the mons pubis, a hair-covered fat pad
overlying the symphysis pubis.
• Labia majora - rounded folds of adipose tissue
• Labia minora, thinner pinkishred folds that extend anteriorly
to form the prepuce.
• Clitoris
• Vestibule is the boat-shaped fossa between the labia minora
ANATOMY AND PHYSIOLOGY
 Anatomy and Physiology
EXTERNAL FEMALE GENITALIA

Vaginal opening (introitus)– lies in the posterior portion which in

virgins may be hidden by the hymen.

Perineum, as commonly used clinically, refers to the tissue between

the introitus and the anus.

The urethral meatus opens into the vestibule between the clitoris and
the vagina. Just posterior to it on either side lie the openings of
the paraurethral (Skene's) glands
Anatomy and Physiology
 Anatomy and Physiology
INTERNAL
• The vagina is a musculomembranous tube extending upward and
posteriorly between the urethra and the rectum.
• Its upper third takes a horizontal plane and terminates in the cup-
shaped fornix.
• The vaginal mucosa lies in transverse folds, or rugae.
ANATOMY AND PHYSIOLOGY
 Anatomy and Physiology
• UTERUS, a flattened fibromuscular structure shaped like an
inverted pear.
• The uterus has two parts: the body, or corpus, and the cervix, both
joined at the isthmus.
• The convex upper surface of the body is termed the uterine
fundus. The distal cervix protrudes into the vagina, dividing the
upper vagina into three recesses, the anterior,
posterior, and lateral fornices.
 Anatomy and Physiology
• The ectocervix -vaginal surface of the cervix is seen easily with the
help of a speculum.
• At its center is a round, oval, or slitlike depression, the external
os of the cervix, which marks the opening into the endocervical
canal.
• The ectocervix is covered by the plushy, red columnar
epithelium surrounding the os, which resembles the lining of the
endocervical canal, and a shiny pink squamous
epithelium continuous with the vaginal lining.
Anatomy and Physiology
 Anatomy and Physiology
• A fallopian tube with a fanlike tip extends from each side of the
uterus toward the ovary.
• The two ovaries are almond-shaped structures that vary
considerably in size but average approximately 3.5 × 2 × 1.5 cm
from adulthood through menopause.
• The ovaries are palpable on pelvic examination in roughly half of
women during the reproductive years. Normally, fallopian tubes
cannot be felt. The term adnexa, a plural Latin word meaning
appendages, refers to the ovaries, tubes, and supporting tissues.
 Anatomy and Physiology
The ovaries have two primary functions:
1. The production of ova and the secretion of hormones, including
estrogen, progesterone, and testosterone. Increased hormonal
secretions during puberty stimulate the growth of the uterus and its
endometrial lining, enlargement of the vagina, and thickening of the
vaginal epithelium.
2. Stimulate the development of secondary sex characteristics,
including the breasts and pubic hair.
 Anatomy and Physiology

• The parietal peritoneum extends downward behind the

uterus into a cul de sac called the rectouterine pouch (pouch
of Douglas). You can just reach this area on rectovaginal
examination.
• The pelvic organs are supported by a sling of tissues
composed of muscle, ligaments, and fascia, through which
the urethra, vagina, and rectum all pass.
 Anatomy and Physiology

• Assessment of sexual maturity in girls, as classified by

Tanner, depends not on internal examination, but on the
growth of pubic hair and the development of breasts.
 Anatomy and Physiology

• In most women, pubic hair spreads downward in a triangular

pattern, pointing toward the vagina.
• In 10% of women, it may form an inverted triangle, pointing
toward the umbilicus. This growth is usually not completed
until the middle 20s or later.
 Anatomy and Physiology

• Just before menarche, there is a physiologic increase in

vaginal secretions—a normal change that sometimes
worries a girl or her mother.
• As menses become established, increased secretions
(leukorrhea) coincide with ovulation. They also accompany
sexual arousal. These normal kinds of discharges must be
differentiated from those of infectious processes.
 Anatomy and Physiology

Lymphatics

• Lymph from the vulva and lower vagina drains into the
inguinal nodes. Lymph from the internal genitalia, including
the upper vagina, flows into the pelvic and abdominal lymph
nodes, which are not palpable.
 THE HEALTH HISTORY

COMMON CONCERNS:

• Menarche, menstruation, menopause, postmenopausal

bleeding

• Pregnancy

• Vulvovaginal symptoms

• Sexual preference and sexual response

 THE HEALTH HISTORY

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
 THE HEALTH HISTORY

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.
 THE HEALTH HISTORY

Sexual Preference and Sexual Response

• Using neutral and nonjudgmental questions, ask about your
patient's sexual preference and relationship status.
• Ask also about dyspareunia.
• Vaginismus refers to an involuntary spasm of the muscles
surrounding the vaginal orifice that makes penetration during
intercourse painful or impossible.
 THE HEALTH HISTORY

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.
 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
 TECHNIQUES OF EXAMINATION

PELVIC EXAMINATION
Indications for a pelvic examination during adolescence:
• 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
• patient's own desire for assessment.
 TECHNIQUES OF EXAMINATION

TIPS FOR PATIENT TO ENSURE SUCCESSFUL PELVIC

EXAMINATION
• 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
 TECHNIQUES OF EXAMINATION
TIPS FOR EXAMINER TO ENSURE SUCCESSFUL PELVIC
EXAMINATION
• 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
 TECHNIQUES OF EXAMINATION
RAPE VICTIMS
• 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.
 TECHNIQUES OF EXAMINATION
CHOOSING EQUIPMENTS:
• Good light
• Vaginal speculum of appropriate size
• Water-soluble lubricant
• Equipment for taking Papanicolaou smears
• Bacteriologic cultures and DNA probes
• Other diagnostic tests, such as potassium hydroxide or normal
saline.
 TECHNIQUES OF EXAMINATION
SPECULA
• 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 thepatient 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.
TECHNIQUES OF EXAMINATION
 TECHNIQUES OF EXAMINATION
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.
 TECHNIQUES OF EXAMINATION
EXTERNAL EXAMINATION

• Assess the Sexual Maturity of an Adolescent Patient.

• You can assess pubic hair during either the abdominal or the
pelvic examination.
• Note its character and distribution, and rate it according to
Tanner's stages
 TECHNIQUES OF EXAMINATION
EXTERNAL EXAMINATION

• Seat yourself comfortably and warn the patient

• that you will be touching her genital area.
• Inspect the mons pubis, labia, and perineum.
TECHNIQUES OF EXAMINATION

A urethral caruncle is a small, red, benign tumor visible

at the posterior part of the urethral meatus. It occurs
chiefly in postmenopausal women and usually causes
no symptoms.
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Cystocele
A cystocele is a bulge of the upper two thirds of
the anterior vaginal wall, together with the
bladder above it. It results from weakened
supporting tissues.
TECHNIQUES OF EXAMINATION
TECHNIQUES OF EXAMINATION

Mucopurulent Cervicitis

Carcinoma of the Cervix

 TECHNIQUES OF EXAMINATION

SHAPES OF THE CERVICAL OS

NORMAL
TECHNIQUES OF EXAMINATION

TYPES OF LACERATIONS FROM DELIVERY

 TECHNIQUES OF EXAMINATION
• 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”).
TECHNIQUES OF EXAMINATION

Mucopurulent Cervicitis
TRICHOMONAL VAGINITIS

CANDIDAL VAGINITIS
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POSITIONS OF THE UTERUS
RETROVERSION OF THE UTERUS
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RETROVERSION OF THE UTERUS

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ABNORMALITIES OF THE UTERUS
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ABNORMALITIES OF THE UTERUS
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 RECORDING YOUR FINDINGS

Recording the Pelvic Examination—Female Genitalia

• “No inguinal adenopathy. External genitalia without erythema, lesions, or
masses. Vaginal mucosa pink. Cervix parous, pink, and without discharge.
Uterus anterior, midline, smooth, and not enlarged. No adnexal
tenderness. Pap smear obtained. Rectovaginal wall intact. Rectal vault
without masses. Stool brown and hemoccult negative.
OR
• “Bilateral shotty inguinal adenopathy. External genitalia without erythema
or lesions. Vaginal mucosa and cervix coated with thin white
homogeneous discharge with mild fishy odor. After swabbing cervix, no
discharge visible in cervical os. Uterus midline; no adnexal masses. Rectal
vault without masses. Stool brown and hemoccult negative.”