Abnormal Female Pelvic Exam Steven Swift MD Professor Department of Obstetrics and Gynecology Medical University South Carolina Components of a female pelvic exam Visual inspection of external genitalia. Speculum exam to visualize the cervix and vagina. Bimanual exam with 2 fingers placed in the vagina and the other hand on the abdomen. Why Perform a Female Pelvic Exam? Cervical cancer prevention through pap smears. Visualize the external genitalia,cervix and vagina for abnormalities. Identify structural abnormalities of the internal pelvic organs. Identify the source of pelvic pain. Confirm normalcy. Inspection of External Genitalia Visual identify the labia minora, labia majorum, urethral meatus and perineum. – Identify any mucosal abnormalities, or anatomic defects. – Identify infectious dz and congenital anomalies. Female external genital exam Herpes Simplex appears as small painful vesicles on the labia and vestibule. Female external genital exam Condyloma appear as painless verucous lesions on the vulva Female external genital exam A Bartholin’s gland abscess. – typically exquisitely painful – Can occur as a sequela of pelvic inflamatory dz. Hematocolpos secondary to an imperforate hymen Speculum exam Visualize the cervix and perform a Pap smear. – Pap smears detect premalignant changes in the cervical cytology that are invisible to the naked eye. – Pap smears should be performed annually in all women over the age of 21 yrs or 3 years after the onset of coitus. Female Speculum Exam Normal appearance of the cervix Pap smear involves sampling the ecto- and endocervix. Speculum exam Allows visual inspection of the cervix and vagina for evidence of anatomic pathology or infection. – Polyps or ulcers – Leukorrhea – Vaginal discharge Endocervical polyps Female Speculum Exam Luekorrhea – gross pus coming from the cervical os – Uterus is generally exquisitely tender – Associated with pelvic inflammatory disease Female Speculum Exam Trichomonas vaginosis – A sexually transmitted dz of the vagina. – Few symptoms except vaginal discharge. Bimanual exam Performed by placing 2 fingers placed in the vagina and the other hand on the lower abdomen. – The uterus, ovaries a fallopian tubes are palpated between the 2 hands. Structural abnormalities and pain can be defined and apperciated. – Often difficult to localize the abnormality Bimanual Exam Leiomyomata (or fibroids) are a common anatomic abnormality. Fibroids can usually be easily palpated. Can be assymptomatic or present with abnormal bleeding patterns. Bimanual Exam Hydrosalpinx can be palpated as a lateral cystic mass. Can be tender if infection is active. Bimanual exam Paratubal cyst can be palpated as a large cystic lateral mass. Generally non- tender Bimanual Exam Ovarian cystadenoma can be felt as a large non-tender lateral mass. Can be malignant as a cystadenocarcinoma. Can not reliably differentiate benign from malignant on bimanual exam. Large ovarian tumors Cystoadenomas can be very large distorting the abdomen. These tend to be benign. Bimanual Exam Solid ovarian tumors. – palpated as solid lateral structures. Easily confused with fibroids. Can not reliably differentiate benign from malignant on bimanual exam. Bimanual Exam The final component is the recto- vaginal exam. Done with 1 finger in the rectum and the second in the vagina. Structures in the cul-de-sac and distal rectum can be palpated. Controversial as to when it should be initiated. Bimanual exam The bladder and urethra can also be palpated for tenderness and anatomic anomalies. Some large and small bowel processes can be appreciated on bimanual exam but are best diagnosed with other modalities. Summary The female pelvic exam is important in evaluating for pain, infection and anatomic abnormalities of the female GU system. It is also used to screen for premalignant disease of the cervix. It can not reliably distinguish between benign and malignant conditions of the uterus and ovary.
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