Gynaecology Examination

1. Handwash
2. Introduce
3. Confirm patient’s name & age
4. Explain & gain consent –
o Today I will be examining your private parts.
o This will involve me looking & commenting on your vagina, and placing 2
fingers into the vagina.
o And I will also be inserting a metal speculum into your vagina later .
o It shouldn’t be painful but, if at any point you are uncomfortable or want to
stop, just say so.
o I hope you are alright with the procedures.
o A female chaperone will be present throughout the examination & this is
my examiner.
o All that we discuss today is for exam purposes only

5. Provide the patient with the opportunity to pass urine before the examination.
Would you like to empty your bladder before we begin?

6. Exposure
You will need to undress from waist down .
Ideally will expose from nipple line to mid-thigh .But for the modesty of this patient will
expose from just below umbilicus to mid thigh

7. Position-patient should be lying flat in lithotomy position but cover up untilneeded

“You will need to put your heels together and touching your bottom then flop your
knees down”
I’m happy with the exposure & position of the patient.
General Inspection

1) Patient is alert, conscious & not in any obvious pain or distress.

2) Not pale, jaundiced or flushed
3) Ideally will check for vital signs temperature, BP, pulse, BMI & RR

Closer inspection of vulva

1) Scars
Scarring: may relate to previous surgery (e.g. episiotomy) or lichen sclerosus
(destructive scarring with associated adhesions).
2) Symmetrical
3) Well estrogenized skin
4) Even distribution of hair
5) Masses
 causes include Bartholin’s cyst and vulval malignancy.
6) Vulval skin lesions (eczema,psoariasis,ulceration)
 Ulcers: typically associated with genital herpes.
 White lesions: may be patchy or in a figure of eight distribution around the vulva and
anus, associated with lichen sclerosus.
7) Vaginal atrophy
 Vaginal atrophy: most commonly occurs in postmenopausal women
8) Vaginal discharge / bleeding
 Abnormal vaginal discharge: causes include candidiasis, bacterial vaginosis,
chlamydia and gonorrhoea.

8. Signs of vaginal prolapse

 Inspect for evidence of vaginal prolapse (a bulge visible protruding from the
vagina). Asking the patient to cough as you inspect can exacerbate the lump
and help confirm the presence of prolapse.
Speculum Examination
I’m using a bi-valve self retaining speculum for this examination. Put gel on body .
Tell the patient “ this may feel slightly uncomfortable. Do let me know if you want me to
stop”. Insert the speculum at 30 degrees, turn upwards & then open up & screw.
1) Multiparous or nulliparous cervix
2) Bleeding
3) Discharge
4) Obvious lesions
5) No vaginal wall atrophy
6) Tell if cervix has polyp or ectropion or anteriorly displaced (indicates retroverted
uterus)
Visualising the cervix----Inspect the cervix:

1. Identify the cervical os: if open, this may indicate an inevitable or incomplete
miscarriage.
2. Inspect for erosions around the os: most commonly associated with ectropion
however early cervical cancer can have similar appearances.

3. Cervical masses: typically associated with cervical malignancy.

4. Ulceration: most commonly associated with genital herpes.
5. Abnormal discharge/bleeding: several possible causes including bacterial
vaginosis, vaginal candidiasis, trichomonas, chlamydia and gonorrhoea.
Cervical Smear

1. Open the bottle & keep in the beginning itself okay.

2. So later when doing the smear just take the endocervical brush, twirl it 360 degrees 3
times ( say 1,2,3 ) .
3. Swirl the brush 3 times in the liquid-based cytology container/bottle , nip the tip , close
the bottle.
4. Shake the bottle vigorously &
5. say “cervical smear labelled & sent to lab” and
6. place the bottle FAR AWAY IF NOT IT WILL FLY OFF THE TABLE. LIKE WHAT I DID .
Imagine cervical smear all over the place ..ugh
Removing the speculum
7. 1. Loosen the locking nut on the speculum and partially close the blades.
8. 2. Rotate the speculum 90°, back to its original insertion orientation.
9. 3. Gently remove the speculum, inspecting the walls of the vagina as you do so.
10. 4. Cover the patient with the sheet, explain that the examination is now
complete and provide the patient with privacy so they can get dressed. Provide
paper towels for the patient to clean themselves.
11. 5. Dispose of the used equipment into a clinical waste bin.
12. Release speculum , make sure it's closed.
13. Gently turn it back and pull out gently. Upon pulling the speculum out, say there is no
blood or discharge found on speculum.

Bimanual Examination
Put gel on index & middle finger. Part labia with left hand. Insert two fingers inside gently & feel
the vestibule & rugae . Then go posteriorly until your fingers are behind the cervix. Use the ulnar
part of left hand to palpate the uterus .
Warn the patient you are going to examine the vagina and ask if they’re still ok for you to
do so.

If the patient consents to the continuation of the examination:

1. Lubricate the gloved index and middle fingers of your dominant hand.

2. Carefully separate the labia using the thumb and index finger of your non-dominant

hand.

3. Gently insert the gloved index and middle finger of your dominant hand into the

vagina.

4. Enter the vagina with your palm facing laterally and then rotate 90 degrees so that

your palm is facing upwards.
1) Vestibule -Vestibule – the area enclosed by the labia minora. It contains the openings
of the vagina (external vaginal orifice, vaginal introitus) and urethra.

No Swellings of the vulva – tumours, cysts (sebaceous, Bartholin’s)

- No lumps
- No cyst

2) Vaginal wall

- Rugae can be felt

- Smooth
- Non-tender

3. Fornix
 The fornices are the superior portions of the vagina, extending into the recesses
created by the vaginal portion of the cervix.
Gently palpate lateral fornices for any masses
4. Cervix The cervix is the lower portion of the uterus, an organ of the female reproductive
tract. It connects the vagina with the main body of the uterus, acting as a gateway
between them.

a) Position (e.g. anterior or posterior)

b) Size-normal
c) Consistency (e.g. irregular, smooth)

a.
d) Cervical motion tenderness/Cervical excitation tenderness: 
 Gently move the cervix from side to side to check for cervical tenderness (important
sign with ectopic pregnancy or pelvic inflammatory disease).
 involves severe pain on palpation of the cervix and may suggest pelvic inflammatory
disease or ectopic pregnancy
 4. Uterus

Place fingers in the posterior fornix to lift the uterus whilst simultaneously pushing the fundus
down by placing the left hand above the symphysis pubis.
Bimanually palpate the uterus:

1. Place your non-dominant hand 4cm above the pubis symphysis.

2. Place two of your dominant hand’s fingers into the posterior fornix.

3. Push upwards with the internal fingers whilst simultaneously palpating the lower

abdomen with your non-dominant hand. You should be able to feel the uterus between
your hands. You should then assess the various characteristics of the uterus:

 Size: the uterus should be approximately orange-sized in an average female.

 Shape-mass: may be distorted by masses such as large fibroids.
 Position: the uterus may be anteverted or retroverted.

 Surface characteristics: note if the uterus feels smooth or nodular.

 Tenderness: may suggest inflammation (e.g. pelvic inflammatory disease, ectopic
pregnancy
 Mobility

- Palpable
- Position : Anteverted/Retroverted
- Size
- Mass
- Mobility
- Tenderness
 5. Adnexal
Place the fingers in the lateral fornix and press lateral to the umbilicus to feel for any
adnexal tenderness or masses (repeat on the other side)
The term adnexa refers to the area that includes the ovaries and fallopian tubes.

Bimanually palpate the adnexa:

1. Position your internal fingers in the left lateral fornix.

2. Position your external hand onto the left iliac fossa.

3. Perform deep palpation of the left iliac fossa whilst moving your internal fingers upwards and
laterally (towards the left).

4. Feel for any palpable masses, noting their size and shape (e.g. ovarian cyst, ovarian
tumour, fibroid).

5. Repeat adnexal assessment on the right.

- Mass(e.g. ovarian cyst, ovarian tumour, fibroid).
- Tenderness

End of examination

6. Withdraw your fingers and inspect the glove for blood or abnormal discharge.

7. Cover the patient with the sheet, explain that the examination is now

complete and provide the patient with privacy so they can get dressed. Provide paper
towels for the patient to clean themselves.

8. Dispose of the used equipment into a clinical waste bin.

Summary : Miss Fran a 37 year old female came in for her routine gynae check up. Upon
performing the gynaecological examination, no obvious abnormalities found.
“Abdominal examination was unremarkable and there were no abnormalities noted on
inspection of the vulva.
Bimanual examination revealed an anteverted uterus of normal size and shape.
There were no masses palpated in the vaginal canal or adnexa.”
( if got say what is the abnormality. Will most probably be a mass only) .
Will do further investigations such as TVUS, Blood Test .. etc etc
Cervical Screening

Start at 25 years old

25-44 : 3 years once

44-65 : 5 years once
65 > : Annually

PE findings of endometriosis

1) Fixed retroverted uterus - This why we can’t feel anything on the model during
examination because the uterus can’t move
2) Pelvic tenderness
3) Tender utero-sacral ligaments
4) Palpable nodules in Pouch of Douglas
5) Unilateral/Bilateral mass

Laparoscopic Findings

1) “Gun shot” powder

2) “Powder burn” lesions
3) Black-Bluish implants
4) Red implants
5) Endometriomas - Chocolate Cyst
6) Nodules or cysts

Prevention of endometrial carcinoma in a young girl

1) HPV vaccine
2) Barrier method during sex
3) Delaying first sexual intercourse until late teens
4) Avoid having sex with people who have genital warts
5) Avoid having sex with people who have had many partners
Management of endometriosis

MEDICAL MANAGEMENT

GnRH - Zoldex, Decapeptyl ( causes hypo-oestrogenic state)

Metoxyprogesterone Acetate - progesterone therapy
NSAIDS - Pain

SURGICAL MANAGEMENT

1) Conservative : Cystectomy for endometrioma ( chocolate cyst)

Ablation of all endometriosis lesions
Fenestration & drainage of all small ovarian cysts

2) Radical Surgery : Total Abdominal Hysterectomy & Bilateral Salphingo Oopherectomy

Difference between ovarian cyst & uterine fibroid

Uterine Fibroid

1) Midline
2) Mobility : side to side
3) Unable to get under
4) Lobulated surface

Ovarian Cyst

1) Located at the iliac fossa

2) Freely mobile
3) Able to get below
4) Smooth surface
5) Cystic consistency

Fibroid DDX

1) Adenomyosis
2) Pregnancy
3) Ovarian Tumor
4) Endometriosis
5) Endometrial carcinoma

Right & Left Adnexal Mass DDX

1) Ovarian cyst
2) Ovarian torsion
3) Tubo-Ovarian Abscess
4) Hydrosalpinx
5) Ectopic pregnancy
6) Endometrioma
7) Para-Tubal Cyst

*For any right or left adnexal mass must mention urine pregnancy test & ultrasound.
Causes of cervical excitation

Cervical Excitation A.K.A Chandelier Sign Positive

1) Ectopic Pregnancy
2) Ruptured Ovarian Cyst
3) PID
4) Endometriosis
5) Peritoneal infections
6) Adhesions
Management of Ectopic Pregnancy

Surgical

1) Laparoscopy Vs Laparotomy

Laparoscopy = Patient is stable

Laparotomy = Patient is unstable. Resuscitate first then conduct laparotomy

2) Salpingectomy VS Salpingostomy = Choose salpingostomy when there is contra-lateral

tube disease

Medical

1) Methotrexate

- Hemodynamically stable
- Unruptured ectopic pregnancy < 35 mm
- No fetal cardiac activity
- HCG between 1500-5000 IU

2) Regime

- 50 mg/m^2 IM
- Check HCG levels on day 4 & 7
- Repeat dose if HCG levels are rising

3) Follow up

- Weekly follow up until HcG < 5iu/L

- No intercourse until HCG returns to normal
- No conceiving until 3 months

Differential Diagnosis of fibroids ( basically causes of uterus enlargement)

1) Leiomyosarcoma
2) Adenomyosis
3) Endometrial carcinoma
4) Sarcoma
5) Molar pregnancy
6) Physometra
7) Haematometra
Menopause

What are the post-menopausal changes :

1. Vasomotor
a. Hot flushes
b. Night sweats
2. Urogenital
a. Atrophy
b. Dyspareunia
c. Incontinence, frequency, dysuria, nocturia
d. thinner/dryer skin at vulva & vagina
e. decreased secretions
f. bacterial vaginosis
3. Osteoporosis
a. Decreased bone strength
b. Increased fracture risk
4. Cardiovascular