Gynaecology examination

Vulval inspection
1. Done gloves
2. Inspect the vulva:
• Ulcers (e.g. genital herpes)
• Abnormal vaginal discharge (e.g. chlamydia or gonorrhoea)
• Scars from previous surgery (e.g. episiotomy)
• Vaginal atrophy (secondary to post-menopausal changes)
• Masses (e.g. Bartholin’s cyst)
• Varicosities (varicose veins secondary to venous disease/obstruction in the
pelvis)
3. 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.

Inserting the speculum

1. Warn the patient you are about to insert the speculum
2. Use your left hand (index finger and thumb) to separate the labia
3. Gently insert the speculum sideways (blades closed, angled downwards and
backwards)
4. Once inserted, rotate the speculum back 90 degrees (so that the handle is facing
upwards)
5. Open the speculum blades until an optimal view of the cervix is achieved
6. Tighten the locking nut to fix the position of the blades and hold in place with
your non-dominant hand (otherwise, it can slide out)

Inspect the cervix

• Cervicitis (e.g. gonorrhoea or chlamydia)
• Cervical erosions (e.g. ectropion)
• Masses (e.g. cervical malignancy)
• Ulcers (e.g. genital herpes)
• Abnormal discharge (e.g. bacterial vaginosis)

Taking the vaginal swabs

Swab technique
• Pick up the swab’s sample tube using your dominant hand and pass it to your
non-dominant hand (which should also be stabilising the speculum)
• Remove the lid of the sample tube using your dominant hand and place in the
tray
• Pick up the swab itself with your dominant hand and take the sample (see be-
low for specifics depending on the swab being used)
• Place the used swab back into its tube, which should still be in your non-domi-
nant hand and tighten the lid
• Place the completed swab into the tray
Vaginal examination

Entering the vagina

1. Lubricate the gloved index and middle fingers on your dominant hand
2. Carefully separate the labia using the thumb and index finger of your non-domi-
nant 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 it is facing upwards

Uterus
Palpate the uterus
1. Place your non-dominant hand 4cm above the pubis symphysis
2. Place your dominant hand’s fingers into the posterior fornix
3. Push upwards with the internal fingers whilst simultaneously palpating the low-
er 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:
Assess the uterus
• Size – approximately orange sized in an average female
• Shape – may be distorted by masses such as fibroids
• Position  – anteverted vs retroverted
• Surface characteristics – smooth vs nodular
• Note any tenderness during palpation

Ovaries and uterine tubes

Assess the adnexa
1. Place your internal fingers into the left lateral fornix
2. Place your external fingers onto the left iliac fossa
3. Perform deep palpation of the left iliac fossa whilst moving your internal fin-
gers upwards and laterally (towards the left)
4. Feel for any palpable masses, noting their size and shape (e.g. ovarian cyst/ovari-
an tumour/fibroid)
5. Repeat adnexal assessment on the opposite side

To complete the examination…

• Withdraw your fingers – inspect the glove for blood or abnormal discharge
• Re-cover the patient – allow the patient time to re-dress in private