GYNECOLOGY

OFFICE GYNECOLOGY The gynecologist often serve both as specialist and generalist,
Dr. SSM hence is given the opportunity to prevent and treat a wide
variety of diseases
Source: PPT + RECORDINGS
Hence, a complete history and PE is a must
OFFICE GYNECOLOGY- Talks about procedure that we can The intimate and highly personal nature of many
do in the clinics. gynecologic conditions requires particular
sensitivity to evoke an honest response

INITIAL ASSESSMENT - COMMUNICATION

In the clinics, the most important thing is communication;
establish communication skills with your patient. •
Good communication is essential to patient assessment and
treatment .
Key Skills:
- Empathy
- Attentive listening capabilities
- Rapport
- Expert knowledge
- Interviewing technique
Trust (should be established)
Gyne- we ask question that are too personal. Kelangan
may kabuddy ka, so dapat may kasama ka pag mag
examine ka, baka makasuhan ka ng sexual harassment.
Be sincere enough to listen to them, at the end of the day,
the very important thing is for you to gain their trust. The
initial contact with patient, they might not tell you
everything. As simple as “may sexual contact na po ba
kayo?” so most of them will lie. So you have to really gain
their trust.
MEDICAL HISTORY AND PE
CC/HPI
√ Allow patient to talk about her chief complaint
- Temporal relation to total duration of the illness
√ Associated symptoms
- Put in chronological order, character of each
symptom.
- Pertinent negative andpositive symptoms
√ Differential diagnosis
√ Review of systems
Consider:
- Probable cause of symptoms or illness
- Severity of patient’s illness
- Patient’s psychological reaction to her illness
Know how to deliver your questions.
As gynecologists, it’s a privilege that you don’t only treat
the actual presenting symptom of patient, both as a
specialist and generalist. Address also problems of your
patient not only the chief complaint.
PHYSICAL EXAMINATION

Thorough:
VARIABLES THAT AFFECT PATIENT STATUSES ▪Vital signs
▪Patient’s “significant others”
▪Breast examination
▪Psychologic, genetic, biologic, social and economic issues
▪Abdomen
- Intra-abdominal mass
▪Patient’s education, attitudes, understanding of human
- Organomegaly
reproduction and sexuality
- Distension of the bowels
▪Cultural factors, socioeconomic status, religion, ethnicity,
sexual preference ▪Pelvic examination

The physician must avoid being judgmental with respect to Important to conduct a complete history and physical
questions about sexual practices and preferences - even examination, vital signs, breast exam, abdomen.
though you know your patient is lying, you have to be
accepting. Later on, they will admit along the course of Remember the temporal sequence of events- first
your interview and interaction to them. symptom until you will be able to create a differential
diagnosis.
Most of them will not go to the clinic alone.
When you advice your patients, after leaving your clinic they
must know about their health status, they know why you
BREAST EXAMINATION
prescribed them medicines. Your level of explanation depends
on your patient’s educational attainment. Clinical breast examination (CBE)

Cultural factors- ex: Muslims (upon giving birth male √ Identify small portion of malignancies, which may not be
nurse/clerk/intern/resident not allowed.), Jehovah’s witnesses- identified on mammography
blood transfusion not allowed. √ Identify cancer in young women who are not typically
candidates for mammography

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 GYNECOLOGY
√ Inspection – woman sits on edge of table with hands √ Percussion to measure the liver
pushing against her hips to flex the pectoralis muscle
- Asymmetry √ Auscultation – bowel sounds
- Intestinal obstruction – “rushes” or “high-pitched” sound
- Erythema
- Retraction - Ileus – less frequent but same pitch as normal bowel
- Scaling sound
- Edema PELVIC EXAMINATION
√ Lymph node evaluation
- Cervical METHOD OF FEMALE PELVIC EXAMINATION:
- Supraclavicular
- Infraclavicular √ She is placed in dorsal lithotomy position:
- Axillary
√ The patient is instructed to empty the bladder – full
bladder can interfere with your findings
Sentinel node – located just behind the midportion of the
pectoralis major muscle
√ Patient’s feet should rest comfortably in the stirrups
Even if your patient comes to your clinic just because she with the edge of the buttocks at the lower end of the
wants to have pap smear, as gynecologists, you have to table
advocate breast examination. Done by a professional
every year, or every 2 years. √ The patient is draped properly

Then try to assess if there are palpable lymph nodes,

because lymph nodes should not be palpable, unless
there is infection, or mass causing inflammation.

√ Breast palpation -- supine with one hand above her head

√ Use finger pads in continuous rolling, gliding, circular
motion

External genitalia (Inspection)

√ Inspect mons pubis, labia majora, labia minora,
perineal body and anal region for characteristics of
the skin, hair distribution, contour and swelling

√ Inspect the epidermal and mucosal characteristics
and anatomic configuration of: labia minora, clitoris,
urethral orifice, vaginal outlet, hymen, perineal body,
anus

INCIDENCE OF BREAST CANCER √ Disease of Skene’s gland

and Bartholin’s gland if
disease is suspected

Introitus – opening of the vagina

- Instruct the patient to bear down to rule out:
√ Cystocele
√ Rectocele
ALL 4 √ Uterine prolapse- ask the
quadrants:
patient to cough or strain
√ Systemic
approach –
e.g.
clockwise

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 GYNECOLOGY
Papaniculao Smear (Pap smear)
Vagina and Cervix

√ For detection of carcinoma of the cervix and its
√ Inspect using a speculum (internal exam is palpation) precursors, as well as viral, bacterial, fungal or protozoal
√ Proper insertion of speculum – sideways, bec introitus pathogens
is slit-like, once inside, that’s when you will rotate it,
√ Has reduced incidence of invasive cervical CA by 50%
press then open.
√ Initial screening to assess cervical cancer, at age 18
(USA), in Ph or other countries, at age 21, regardless
√ Instrument is warmed with tap water, not lubricated – can
if there is sexual intercourse or not
potentially contaminate the areas
√ Annual screening for high risk patients
√ Select proper size speculum
√ 1-2 years screening for low risk patients
√ Insert with blades in vertical position, closed and pressed
against the perineum
√ Supplies
√ When fully inserted, - Cervical scraper: cotton pledgets, Ayre’s spatula,
rotate blades into cervical brush
horizontal position - Glass slides
- Fixative: 95% alcohol (in the exams, eto daw
√ Open blades until sinusunod, but for doc, mas convenient gamitin
cervix is exposed ang spray net), spray net
√ Instructions:
√ Gently rotate
- No douche for 48 hours before procedure (insertion
speculum until all
of probe, makes the tissues inflamed, exposure to
surfaces are
a strong soap)
visualized
- No vaginal creams 1 week before
- No coitus for 24 hours in advance (in practice, 3
√ Inspect the vagina for the following days)
- Presence of blood - The patient must not be menstruating when doin
- Discharge – any purulence should be cultured get pap smear
samples
- Mucosal characteristics – color, lesions, superficial √ Technique:
vascularity, edema - Samples from both endocervix and exocervix
- Saline moistened cotton-tipped swab
- Structural abnormalities
1. No lubricant
√ Pap smear, gram stain, NSS smear, KOH smear, Whiff 2. Place the endocervical brush or cotton swab inside
test the endocervix and roll it firmly against canal
√ Inspect the cervix for the same factors listed for the 3. Remove the brush (best yield) or swab and place
vagina sample on slide
- Unusual bleeding 4. Place the spatula on cervix with longer protrusion in
- Inflammatory cervical canal
lesions 5. Rotate spatula clockwise 360o firmly on the cervix;
- Polyps rotate it enough to cover entire transformation zone
- Carcinoma
6. Immediately place the sample from spatula onto the
glass slide by rotating spatula on the slide in a
clockwise manner

7. Immediately fix the slide with either spray fixative or

95% ethanol fixative
MINOR DIAGNOSTIC PROCEDURES

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 GYNECOLOGY
4 sources of error: 3. Tenderness
1. Improper collection 4. Mobility
2. Poor transfer from collecting device to slide √ Follow the bimanual examination with a recto-vaginal
3. Air drying abdominal examination
4. Contamination with lubricant - Insert index finger into the vagina and middle finger
into the rectum
Identification: - Place other hand on infraumbilical region
- Assess the cul-de-sac
1. Name, age, pregnancy status, LMP
2. Pertinent history: hormonal therapy, radiation therapy,
√ In virgins → rectal-abdominal technique
recent surgery, postpartum state, IUD

Bimanual Palpation:
RECTAL EXAMINATION
Dominant hand inside the vagina and non-dominant hand 1. Inspect the perineal and anal area, the pilonidal
in the abdomen, because this way, you can delineate (sacrococcygeal) region and perineum for: a. color b.
structures. lesions
1. The pelvic organs can be outlined by bimanual
palpation. 2. Instruct the patient to “strain down” – painful
2. Introduce the well lubricated index and middle finger because sphincter is tonically closed
into the vagina at its posterior aspect near the
perineum → advance fingers until cervix is 3. Palpate the pilonidal area, ischiorectal fossa,
encountered perineum and the perianal region before inserting the
3. Press the abdominal hand very gently downward, gloved finger into the anal canal
pushing the pelvic structures toward the palpating
vaginal fingers 4. Palpate the anal canal and rectum with a well
√ Evaluate the body of the uterus for: lubricated gloved index finger
- Position
- Architecture, size, shape, symmetry, tumor 5. Evaluate the anal canal for:
- Consistency - Sphincter tone
- Tenderness - Tenderness
a) tight sphincter
- Mobility
b) anal fissure
√ Evaluate the cervix for position, architecture, c) Painful hemorrhoids
consistency and tenderness especially on the mobility of
cervix, then explore the anterior, posterior and lateral - Tumor or irregularities especially at pectinate line
fornices. - Superior aspect
√ Place the “vaginal” fingers in the right lateral fornix and
6. Evaluate the rectum
the “abdominal” hand on the right lower quadrant.
√ Outline the adnexa- palpating the ovaries and - Anterior wall
fallopian tubes a) Cervix size, shape, symmetry, consistency,
tenderness
b) Uterine or adnexal masses
c) Rectouterine fossa for tenderness or
implants

- Right lateral wall, left lateral wall, posterior wall

7. Examine the finger after it is withdrawn:

- Gross blood, pus or other alterations in color or

consistency
- A normal tube and ovary are not palpable - Smear stool to test for occult blood
- Adnexal masses are evaluated as to:
- Location relative to the uterus and cervix EXAMINATION OF THE PEDIATRIC PATIENT

1. Architecture
√ Careful examination
2. Consistency

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 GYNECOLOGY
√ Familiarity with normal appearance of prepubertal
genitalia → mildly erythematous MINOR PELVIC PROCEDURES
√ Positions:
MINOR DIAGNOSTIC PROCEDURES
Vulvar biopsy
- Young child – frog-leg position
√ If a vulvar lesion has failed to respond therapy
- Toddler or infant – held in their mother’s arms.
Mother (clothed) on examination table (feet in √ Suspicion of malignant or premalignant condition
stirrup) with child in her lap. Others:
√ Careful inspection with colposcope
a) Knee-chest position
b) Use of anesthesia √ Infiltration with local anesthesia
c) Hysteroscope, cystoscope, etc.
√ Keyes punch biopsy (preferred- bec you just
press and rotate you get good chunks of tissue
for examination) with gentle rotation until full
thickness of skin has been reached

√ Pressure over biopsy area to stop bleeding – check

for clotting time and bleeding time of patient if
prolonged

FROG-LEG POSITION- toddlers; frog-leg on her

own 3-4 years old; to check for the vulva/ external
genitalia

KNEE-CHEST POSITION- vaginal examination; in Colposcopy

children, common complaint is discharge. If blood
tinged- suspect first foreign-body √ Visualization of the vulva, vagina and cervix using a
binocular microscope of low magnification (10 – 40x)
and strong light
EXAMINATION OF THE ADOLESCENT PATIENT
√ Uses:
√ Earn patient’s trust, explain components of examination,
use careful and gentle technique - To supplement cytology – after pap smear and
suspicious of pre-cancer lesion
√ Indications for pelvic examination: lithotomy position;
request for urinalysis and include pregnancy test, - To direct biopsy
especially if the child is already menstruating
- Used before cones or hysterectomy for CIN III
- She has had intercourse
- Positive pregnancy test - Evaluation of lesions of the vagina and vulva
- With abdominal pain
- Marked anemia - Used in follow-up: cervical carcinoma, adenosis, CIN
- Heavy bleeding
√ Technique:
√ Rectal examination is done if she is a virgin
- With the patient in dorsal lithotomy position, an
√ Confidentiality is an important issue in adolescent health
unlubricated vaginal speculum is inserted
care

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 GYNECOLOGY
perpendicular to the
- The cervix is exposed, taking care not to traumatize it surface

- The vagina and cervix are inspected with the surface √ Vessels in mosaic
moistened with normal saline pattern –
neovascularization
- Acetic acid solution (3 – 5%) is applied to the cervix
with moistened cotton balls √ White epithelium –
piling up of cells
CIN DETECTION with increased N:C
ratio
√ Pertinent area – transformation zone
√ Atypical vessels
√ Acetic acid wash
√ Abnormal colposcopic findings:
- Acetowhite epithelium
- Punctation
COLPOSCOPY
- Mosaic
- Leukoplakia
- Abnormal blood vessels
Schiller’s test
nd
√ After applying (2
step) Lugol’s
solution, normal Leukoplakia – normal white areas of the cervix prior to the
cells take up the application of acetic acid
iodine

√ Normal cells – ABNORMAL COLPOSCOPIC FINDINGS
dark brown,
alive tissues, if
cells revitalized,
glycogen-rich,
starch, take-up
the color of
iodine.

√ Abnormal – pale

SEVERE DYSPLASIA SQUAMOUS CELL CARCINOMA ADVANCED SCC

Acetic acid wash test

√ Abnormal cells have

increased amounts of
protein in the nucleus
and cytoplasm

√ These proteins are

coagulated by the
acetic acid, making
the cells look white
Do not immediately
biopsy the white areas,
confirm first with
schiller’s test

Abnormal tissues:
COLPOSCOPY WITH BIPOSY
√ Punctation –
capillaries

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Cryosurgery
CIN DETECTION
ENDOMETRIAL BIOPSY
√ For abnormal uterine bleeding
√ Easier, faster, more convenient, less costly
√ Can establish the diagnosis of a malignant or
premalignant lesion
√ Types of curette
- Randall-type suction biopsy curette
Technique:
- Novak curette
√ Depth and direction of endocervical and endometrial
canal ascertained by passing a blunt sound
√ Curette the different quadrants of the endometrium
from the fundus to the internal os
√ Indications:
- AUB / postmenopausal bleeding
- Endometrial dating
- Follow up of previously diagnosed endometrial
HYSTEROSALPHINGOGRAM
hyperplasia
- Evaluation of patient with 1 year amenorrhea o
Evaluation of infertility
- Pap smear with atypical cells favoring endometrial
origin
√ Contraindications:
- Pregnancy
- Acute pelvic inflammatory disease (PID)
- Clotting disorder (coagulopathy)
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GYNECOLOGY
- Acute cervical and vaginal infection
- Cervical cancer
- Morbid obesity
- Severe cervical stenosis
- Severe pelvic relaxation w/ uterine descensus
√ Use: ablation of benign and premalignant lesions of
cervix, vaginal and vulva – not for malignant bec risk of
recurrence
√ Criteria for patient selection: (MAKE SURE YOU READ
ON THIS)
- The entire lesion must be visible
- Invasive cervical cancer have been ruled out
- Endocervical canal is uninvolved
- The lesion must be well encompassed by the freeze
- There are no deep or excessive involvement of
cervical clefts
- The patient is reliable for follow-up
1. Choose an appropriate probe which will cover the
entire lesion
2. Freeze for 3 minutes, start timing when the edge of
ice ball has protruded 3 – 5 mm beyond the probe
(compressed nitrogen gas, bec freezing time is
faster)
3. Thaw for 3 minutes
4. Refreeze for 3 minutes
OTHER DIAGNOSTIC PROCEDURES
√ Part of evaluation of the patency of tubes in an infertile
couple
√ Similar to hysterosalpingogram
√ Done in the first half of the cycle after the menstrual flow
and before ovulation
√ Prophylactic antibiotics are given
 GYNECOLOGY
Technique: cough. If no urine spills, then surgery will stop the
1. Insert a vaginal speculum urinary incontinence
2. With the cervical os visualized, insert a small foley
catheter aseptically into uterine cavity and inflate balloon
with 3 cc of air or saline

3. Do a baseline transvaginal ultrasound to visualize the In exams:

uterus, endometrial stripe and adnexa
√ initial assessment for cervical cancer- Pap
4. Instill 10 cc of normal saline into catheter to visualize
smear bec universal screening.
endometrial canal
√ If problems present with pap smear- proceed
5. Instill additional 10 – 20 cc of fluid until patency of both
tubes is established. Fluid may be seen coursing with colposcopy
through the tubes, or fluid is seen in the cul-de-sac on
both sides of the uterus (antibiotic prophylaxis before √ Colposcopy- acetic acid, schiller’s test- make
instilling normal saline to prevent PID) sure to know the normal and abnormal
UROLOGIC EVALUATION findings in both tests (ginawa ko exam nyo

√ For women with urinary incontinence common in

kagabi, dito ako nagfocus)
menopausal women √ Indications and contraindications for doing
√ Differentiate if urinary symptoms are sensory or
endometrial biopsy
functional
√ Sensory disorders are characterized by dysuria, √ cryosurgery- what is it for?
frequency, urgency and sometimes incontinence.
√ Check on normal values of cytometry
These are usually treated medically
√ Functional disorders are mainly manifested as
difficulty in voiding control …and you’ll do just fine, perfect ang plating

TECHNIQUE OF OFFICE CYSTOMETRY at exam, okay?

1. Before examination, the patient is asked to void

2. If the bladder remains palpable, it is catheterized and
residual urine is measured
3. A 50 ml asepto syringe is attached to the catheter and
BLUE- RECORDINGS
held just above the level of the pubis
BLACK- PPT
4. 50 ml increments of saline is infused
5. The bladder volume at the first urge to void is noted
6. The patient’s bladder capacity is determined by
instilling more saline until the patient feels unable to
hold anymore
Normal results are:
√ Residual urine < 50 ml
√ First desire to void: 150 – 200 ml
√ Bladder capacity: 400 - 500 ml
7. Bonney test
The fluid is drained from the bladder until only 250 ml
remains. The patient is asked to cough. If urine spills,
urinary incontinence is present. Then the examiner’s
finger is applied against the anterior vaginal wall at
the pubovesical angle. The patient is again asked to

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OFFICE GYNECOLOGY
Sheryl Santiago-Millares, MD,FPOGS
INITIAL ASSESSMENT OF THE GYNECOLOGIC PATIENT
• Communication
Good communication is essential to patient assessment and
treatment
Key skills:
Empathy
Attentive listening capabilities
Rapport
Expert knowledge
Interviewing techniques
Trust
INITIAL ASSESSMENT OF THE GYNECOLOGIC PATIENT
• Variables that affect patient status
Patient’s “significant others”
Psychologic, genetic, biologic, social and economic issues
Patient’s education, attitudes, understanding of human
reproduction and sexuality
Cultural factors, socioeconomic status, religion, ethnicity, sexual
preference

The physician must avoid being judgmental with respect to

questions about sexual practices and preferences
Medical History and PE
The gynecologist often serve both as specialist and generalist, hence is
given the opportunity to prevent and treat a wide variety of diseases
Hence, a complete history and PE is a must
The intimate and highly personal nature of many gynecologic conditions
requires particular sensitivity to evoke an honest response
HISTORY AND PHYSICAL EXAMINATION
• Chief Complaint and History of present illness
Allow patient to talk about her chief complaint
o Temporal relation to total duration of the illness
Associated symptoms
o Put in chronological order, character of each symptom
o Pertinent negative and positive symptoms
Differential diagnosis
HISTORY AND PHYSICAL EXAMINATION
• Chief Complaint and History of present illness
Review of systems
Consider:
a. Probable cause of symptoms or illness
b. Severity of patient’s illness
c. Patient’s psychological reaction to her illness
Physical Examination
• Thorough
Vital signs
Breast examination
Abdomen
o Intra-abdominal mass
o Organomegaly
o Distension of the bowels
Pelvic examination
Breast Examination
• Clinical breast examination (CBE)
Identify small portion of malignancies
which may not be identified on
mammography
Identify cancer in young women who
are not typically candidates for
mammography
Breast Examination
• Inspection – woman sits on edge
of table with hands pushing
against her hips to flex the
pectoralis muscle
Assymetry
Erythema
Retraction
Scaling
Edema
Breast Examination
• Lymph node evaluation
Cervical
Supraclavicular
Infraclavicular
Axillary
• Sentinel node – located just
behind the midportion of the
pectoralis major muscle
Breast Examination
• Breast palpation -- supine
with one hand above her
head
• Use finger pads in
continuous rolling, gliding,
circular motion
Incidence of Breast Cancer
 Method of Physical Examination
• Abdominal examination
Supine position
o Relaxed position
o Pillow under the head
Inspect for signs of intra-abdominal
mass, organomegaly or distention
Initial palpation
o Liver
o Spleen
o Other abdominal contents,
mass effect
Method of Physical Examination
• Abdominal examination
All 4 quadrants
Systemic approach – e.g.
clockwise
Percussion to measure the
liver
Auscultation – bowel sounds
o Intestinal obstruction – “rushes”
or “high-pitched” sound
o Ileus – less frequent but same
pitch as normal bowel sound
Pelvic Examination
Method of Female Pelvic Examination
• She is placed in dorsal lithotomy position:
• The patient is instructed to empty the bladder
• Patient’s feet should rest comfortably in the stirrups with the edge of
the buttocks at the lower end of the table
• The patient is draped properly
 Method of Female Pelvic Examination
• External genitalia (Inspection)
1. Inspect mons pubis, labia majora, labia
minora, perineal body and anal region for
characteristics of the skin, hair distribution,
contour and swelling
2. Inspect the epidermal and mucosal
characteristics and anatomic configuration
of: labia minora, clitoris, urethral orifice,
vaginal outlet, hymen, perineal body, anus
3. Disease of Skene’s gland and Bartholin’s
gland if disease is suspected
 Method of Female Pelvic Examination
• Introitus
Instruct the patient to bear down to rule out
o Cystocele
o Rectocele
o Uterine prolapse
 Method of Female Pelvic Examination
• Vagina and Cervix
Inspect using a speculum
Proper insertion of speculum
o Instrument is warmed with tap water, not lubricated
o Select proper size speculum
o Insert with blades in vertical position, closed and
pressed against the perineum
o When fully inserted, rotate blades into horizontal
position
o Open blades until cervix is exposed
o Gently rotate speculum until all surfaces are visualized
Method of Female Pelvic Examination
• Vagina and Cervix
Inspect the vagina for the following
o Presence of blood
o Discharge – any purulence should be cultured
o Mucosal characteristics – color, lesions, superficial vascularity, edema
o Structural abnormalities
Pap smear, gram stain, NSS smear, KOH smear, Whiff test
 Method of Female Pelvic Examination
• Vagina and Cervix
Inspect the cervix for the same factors listed for
the vagina
o Unusual bleeding
o Inflammatory lesions
o Polyps
o Carcinoma
MINOR DIAGNOSTIC PROCEDURES
• Papaniculao Smear (Pap smear)
For detection of carcinoma of the cervix and its precursors, as well
as viral, bacterial, fungal or protozoal pathogens
Has reduced incidence of invasive cervical CA by 50%
Initial screening at age 18 CDC DATA AND FOR FILIPINOS 21 years old

Annual screening for high risk patients

1-2 years screening for low risk patients
MINOR DIAGNOSTIC PROCEDURES
• Papaniculao Smear (Pap smear)
Supplies
1. Cervical scraper: cotton pledgets, Ayre’s spatula, cervical brush
2. Glass slides
3. Fixative: 95% alcohol, spray net
Instructions:
1. No douche for 48 hours before procedure
2. No vaginal creams 1 week before
3. No coitus for 24 hours in advance
MINOR DIAGNOSTIC PROCEDURES
• Papniculao Smear (Pap smear)
Technique:
• Samples from both endocervix and exocervix
• Saline moistened cotton-tipped swab
1. No lubricant
2. Place the endocervical brush or cotton swab inside the endocervix and
roll it firmly against canal
3. Remove the brush or swab and place sample on slide
4. Place the spatula on cervix with longer protrusion in cervical canal
5. Rotate spatula clockwise 360o firmly on the cervix; rotate it enough to
cover entire transformation zone
6. Immediately place the sample from spatula onto the glass slide by
rotating spatula on the slide in a clockwise manner
7. Immediately fix the slide with either spray fixative or 95% ethanol fixative
MINOR DIAGNOSTIC PROCEDURES
MINOR DIAGNOSTIC PROCEDURES

PAP SMEAR
MINOR DIAGNOSTIC PROCEDURES
• Papaniculao Smear (Pap smear)
4 sources of error:
1. Improper collection
2. Poor transfer from collecting device to slide
3. Air drying
4. Contamination with lubricant
Identification:
1. Name, age, pregnancy status, LMP
2. Pertinent history: hormonal therapy, radiation therapy,
recent surgery, postpartum state, IUD
Method of Female Pelvic Examination
• Bimanual Palpation:
The pelvic organs can be outlined by
bimanual palpation.
Introduce the well lubricated index
and middle finger into the vagina at
its posterior aspect near the
perineum → advance fingers until
cervix is encountered
Press the abdominal hand very gently
downward, pushing the pelvic
structures toward the palpating
vaginal fingers
 Method of Female Pelvic Examination
• Bimanual Palpation:
Evaluate the body of the uterus for:
o Position
o Architecture, size, shape,
symmetry, tumor
o Consistency
o Tenderness
o Mobility
Evaluate the cervix for position,
architecture, consistency and tenderness
especially on the mobility of cervix, then
explore the anterior, posterior and lateral
fornices.
Method of Female Pelvic Examination
• Bimanual Palpation:
Place the “vaginal” fingers in the right lateral
fornix and the “abdominal” hand on the right
lower quadrant.
Outline the adnexa
o A normal tube and ovary are not palpable
o Adnexal masses are evaluated as to:
o Location relative to the uterus and cervix
a. Architecture
b. Consistency
c. Tenderness
d. Mobility
Method of Female Pelvic Examination
• Bimanual Palpation:
Follow the bimanual examination
with a recto-vaginal abdominal
examination
o Insert index finger into the
vagina and middle finger into
the rectum
o Place other hand on
infraumbilical region
o Assess the cul-de-sac
In virgins → rectal-abdominal
technique
Method of Female Pelvic Examination
• Rectal Examination
1. Inspect the perineal and anal area, the pilonidal
(sacrococcygeal) region and perineum for: a. color b.
lesions
2. Instruct the patient to “strain down”
3. Palpate the pilonidal area, ischiorectal fossa, perineum
and the perianal region before inserting the gloved
finger into the anal canal
Method of Female Pelvic Examination
• Rectal Examination
4. Palpate the anal canal and rectum with a well lubricated gloved
index finger
5. Evaluate the anal canal for:
 Sphincter tone
 Tenderness
o tight sphincter
o anal fissure
o Painful hemorrhoids
 Tumor or irregularities especially at pectinate line
 Superior aspect
 Method of Female Pelvic Examination
• Rectal Examination
6. Evaluate the rectum
Anterior wall
o Cervix size, shape, symmetry, consistency, tenderness
o Uterine or adnexal masses
o Rectouterine fossa for tenderness or implants
Right lateral wall, left lateral wall, posterior wall
7. Examine the finger after it is withdrawn:
Gross blood, pus or other alterations in color or consistency
Smear stool to test for occult blood
Examination of the Pediatric Patient
• Careful examination
• Familiarity with normal appearance of prepubertal genitalia → mildly
erythematous
• Positions:
Young child – frog-leg position
Toddler or infant – held in their mother’s arms. Mother (clothed) on
examination table (feet in stirrup) with child in her lap. Others:
o Knee-chest position
o Use of anesthesia
o Hysteroscope, cystoscope, etc.
Examination of the Pediatric Patient

FROG-LEG POSITION
Examination of the Pediatric Patient

KNEE-CHEST POSITION
Examination of the Adolescent Patient
• Earn patient’s trust, explain components of examination, use careful
and gentle technique
• Indications for pelvic examination:
She has had intercourse
positive pregnancy test
With abdominal pain
Marked anemia
Heavy bleeding
• Rectal examination is done if she is a virgin
• Confidentiality is an important issue in adolescent health care
Minor Pelvic Procedures
MINOR DIAGNOSTIC PROCEDURES
• Vulvar biopsy
If a vulvar lesion has failed to respond therapy
Suspicion of malignant or premalignant condition
Careful inspection with colposcope
Infiltration with local anesthesia
Keyes punch biopsy with gentle rotation until full thickness of skin has been
reached
Pressure over biopsy area to stop bleeding
MINOR DIAGNOSTIC PROCEDURES

VULVAR BIOPSY
MINOR DIAGNOSTIC PROCEDURES
• Colposcopy
Visualization of the vulva, vagina and cervix using a binocular microscope of
low magnification (10 – 40x) and strong light
Uses:
1. To supplement cytology
2. To direct biopsy
3. Used before cones or hysterectomy for CIN III
4. Evaluation of lesions of the vagina and vulva
5. Used in follow-up: cervical carcinoma, adenosis, CIN
MINOR DIAGNOSTIC PROCEDURES
• Colposcopy
Technique:
1. With the patient in dorsal lithotomy position, an
unlubricated vaginal speculum is inserted
2. The cervix is exposed, taking care not to traumatize it
3. The vagina and cervix are inspected with the surface
moistened with normal saline
4. Acetic acid solution (3 – 5%) is applied to the cervix
with moistened cotton balls
CIN - Detection
• Colposcopy
• Pertinent area – transformation
zone
• Acetic acid wash
MINOR DIAGNOSTIC PROCEDURES

COLPOSCOPY
MINOR DIAGNOSTIC PROCEDURES
• Colposcopy
Abnormal colposcopic findings:
1. Acetowhite epithelium
2. Punctation
3. Mosaic
4. Leukoplakia
5. Abnormal blood vessels
CIN - Detection
• Schiller’s test
After applying Lugol’s
solution, normal cells take
up the iodine
Normal cells – dark brown
Abnormal - pale
CIN - Detection
• Acetic acid wash test
Abnormal cells have
increased amounts of protein
in the nucleus and cytoplasm
These proteins are
coagulated by the acetic acid,
making the cells look white
CIN - Detection
•Abnormal tissues:
Punctation – capillaries
perpendicular to the surface

Vessels in mosaic pattern –

neovascularization

White epithelium – piling up of cells

with increased N:C ratio
Atypical vessels
Colposcopy
• Leukoplakia – normal white
areas of the cervix prior to the
application of acetic acid
Abnormal Colposcopic Findings

Severe dysplasia
Squamous cell carcinoma

Advanced squamous cell carcinoma

MINOR DIAGNOSTIC PROCEDURES

COLPOSCOPY WITH BIOPSY

CIN - Detection
MINOR DIAGNOSTIC PROCEDURES
• Endometrial Biopsy
• For abnormal uterine bleeding
• Easier, faster, more convenient, less costly
• Can establish the diagnosis of a malignant or premalignant
lesion
• Types of curette
• Randall-type suction biopsy curette
• Novak curette
• Depth and direction of endocervical and endometrial canal
ascertained by passing a blunt sound
• Curette the different quadrants of the endometrium from the
fundus to the internal os
MINOR DIAGNOSTIC PROCEDURES

ENDOMETRIAL BIOPSY
MINOR DIAGNOSTIC PROCEDURES
• Endometrial Biopsy
Indications:
o AUB / postmenopausal bleeding
o Endometrial dating
o Follow up of previously diagnosed endometrial hyperplasia
o Evaluation of patient with 1 year amenorrhea
o Evaluation of infertility
o Pap smear with atypical cells favoring endometrial origin
MINOR DIAGNOSTIC PROCEDURES
• Endometrial Biopsy
Contraindications:
o Pregnancy
o Acute pelvic inflammatory disease (PID)
o Clotting disorder (coagulopathy)
o Acute cervical and vaginal infection
o Cervical cancer
o Morbid obesity
o Severe cervical stenosis
o Severe pelvic relaxation w/ uterine descensus
MINOR DIAGNOSTIC PROCEDURES
• Cryosurgery
Use: ablation of benign and premalignant lesions of cervix,
vaginal and vulva
Criteria for patient selection:
1. The entire lesion must be visible
2. Invasive cervical cancer have been ruled out
3. Endocervical canal is uninvolved
4. The lesion must be well encompassed by the freeze
5. There are no deep or excessive involvement of cervical clefts
6. The patient is reliable for follow-up
MINOR DIAGNOSTIC PROCEDURES
• Cryosurgery
Technique:
1. Choose an appropriate probe which will
cover the entire lesion
2. Freeze for 3 minutes, start timing when
the edge of ice ball has protruded 3 – 5
mm beyond the probe
3. Thaw for 3 minutes
4. Refreeze for 3 minutes
MINOR DIAGNOSTIC PROCEDURES

CRYOSURGERY
OTHER DIAGNOSTIC PROCEDURES
• Hysterosonosalpingogram
Part of evaluation of the patency of tubes in an
infertile couple
Similar to hysterosalpingogram
Done in the first half of the cycle after the
menstrual flow and before ovulation
Prophylactic antibiotics are given
OTHER DIAGNOSTIC PROCEDURES
• Hysterosonosalpingogram
Technique:
1. Insert a vaginal speculum
2. With the cervical os visualized, insert a small foley catheter
aseptically into uterine cavity and inflate balloon with 3 cc of
air or saline
3. Do a baseline transvaginal ultrasound to visualize the uterus,
endometrial stripe and adnexa
4. Instill 10 cc of normal saline into catheter to visualize
endometrial canal
5. Instill additional 10 – 20 cc of fluid until patency of both
tubes is established. Fluid may be seen coursing through the
tubes, or fluid is seen in the cul-de-sac on both sides of the
uterus
OTHER DIAGNOSTIC PROCEDURES
• Urologic Evaluation
For women with urinary incontinence
Differentiate if urinary symptoms are sensory or functional
Sensory disorders are characterized by dysuria, frequency,
urgency and sometimes incontinence. These are usually
treated medically
Functional disorders are mainly manifested as difficulty in
voiding control
OTHER DIAGNOSTIC PROCEDURES
Technique of Office Cystometry
1. Before examination, the patient is asked to void
2. If the bladder remains palpable, it is catheterized and
residual urine is measured
3. A 50 ml asepto syringe is attached to the catheter and
held just above the level of the pubis
4. 50 ml increments of saline is infused
5. The bladder volume at the first urge to void is noted
 OTHER DIAGNOSTIC PROCEDURES
• Technique of Office Cystometry
6. The patient’s bladder capacity is determined by instilling more saline
until the patient feels unable to hold anymore
 Normal results are:
o Residual urine < 50 ml
o First desire to void: 150 – 200 ml
o Bladder capacity: 400 - 500 ml
7. Bonney test
• The fluid is drained from the bladder until only 250 ml remains.
The patient is asked to cough. If urine spills, urinary
incontinence is present. Then the examiner’s finger is applied
against the anterior vaginal wall at the pubovesical angle. The
patient is again asked to cough. If no urine spills, then surgery
will stop the urinary incontinence
THANK YOU