CLINICAL SKILLS PROGRAM

of
REPRODUCTIVE SYSTEM

VENEREOLOGICAL EXAMINATION
 What is the clinical skills program?
 The clinical skills program is designed to
develop and refine the clinical techniques
of medical students:
 Human interaction skills
 Physical examination behaviors

education of a sensitive and effective physician

 Goals
 To prepare students for patient contact in
community office practice programs, clinical
clerkships, residency and future personal
office practice
 Objective
 After completing a practice of venereological
examination the students will be able to
perform the venereological examination
COMPREHENSIVE PATIENT MANAGEMENT OF SEXUALLY
TRANSMITTED INFECTION (STI)

 “Correct diagnosis”
 Effective treatment
 Counseling on risk reduction
 Partner notification & treatment
 Testing for other STIs
 Clinical follow up
 WHAT IS THE ESSENTIAL COMPONENTS IN
THE “DIAGNOSIS” of STI?

 History taking
 Genital/Venereological Examination
 Laboratory Examination
 HOW THE STI PATIENTS FEEL ABOUT THEIR
CONDITIONS?

 Emotionally disturbed
 Embarrassed
 To show the genital
 Done a multiple sexual behaviour
 WHAT SHOULD WE DO ?

EXAMINE THE PATIENT IN :

• Privacy & chaperon
• Comfortable
• Confidentially
• Non-judgmental
• Explained : the examination & test
SEXUALLY TRANSMITTED INFECTIONS (STI)

INFECTIONS BY A NUMBER OF
VIRUSES, BACTERIAS, FUNGI,
PROTOZOAS OR ARTHROPODS THAT ARE
TRANSMITTED PRIMARILY THROUGH
HETERO OR HOMOSEXUAL CONTACT
STI-ASSOCIATED PRESENTING PROBLEMS

 Urethral discharge
 Vaginal discharge
 Genital ulcer
 Scrotal swelling
 Inguinal swelling
 Lower abdominal pain
 Vegetations
URETHRAL DISCHARGE
 URETHRAL DISCHARGE
GONOCOCCAL URETHRITIS NON-GONOCOCCAL
URETHRITIS
ETIOLOGY N. gonorrhoeae C. trachomatis

INCUBATION PERIOD 2-5 DAYS 1-5 WEEKS

CLINICAL FEATURES
DYSURIA SEVERE MILD

DISCHARGE QUALITY PURULENT MUCOID

DISCHARGE QUANTITY MORE (abundant) LESS (scanty)

MICROSCOPY URETHRAL SMEAR: URETHRAL SMEAR:

> 5 PMNs/hpf > 5 PMNs/hpf
GRAM NEGATIVE STAIN:
INTRA-CELLULAR DIPLOCOCCI
VAGINAL DISCHARGE
 THE CAUSES OF VAGINAL DISCHARGE
1. PHYSIOLOGICAL
puberty, menstrual cycles, sexual arousal,
pregnancy

2. PATHOLOGICAL
 noninfective :
chemical, foreign body, gynecological
 infective : STI & non STI patogen
cervical infections, vaginal infections
THE SYMPTOMS & SIGNS OF ABNORMAL
VAGINAL DISCHARGE

 EXCESSIVE
 MALODOROUS
 YELLOW OR PURULENT
 INFLAMMATION
 VAGINAL DISCHARGE : cervical infection
DIAGNOSIS GONOCOCCAL NON-GONOCOCCAL GENITAL HERPES
CERVICITIS CERVICITIS
ETIOLOGY N. gonorrhoeae C. trachomatis Herpes simplex virus

INCUBATION 2-5 days 1-5 weeks 2-10 days

PERIOD
SYMPTOMS 50% asymptomatic, 70% asymptomatic, Symptomatic
vaginal discharge, vaginal discharge (>> primary infection)
vaginal bleeding or asymptomatic
CERVIX Erythema, bleeds Erythema, bleeds Erythema, erosions,
easily, purulent easily, ectopic cervix, necrosis, purulent
discharge, may purulent discharge discharge
appear normal (37%)
 VAGINAL DISCHARGE : vaginal infection

DIAGNOSIS NORMAL YEAST TRICHOMONAL BACTERIAL

VULVOVAGINITIS VAGINITIS VAGINOSIS
ETIOLOGY Lactobacilli Candida spp. T. vaginalis G. vaginalis,
M. hominis,
Mobiluncus sp,etc
TYPICAL none vulvar pruritus purulent discharge, vulvovaginal
SYMPTOMS and/or irritations, often profuse, malodor, slightly >
sometimes sometimes vulvar discharge
discharge >> pruritus
DISCHARGE-
- amount variable scant to moderate profuse scant to moderate
(usually scant)
- color clear or white white or yellow yellow, tan usually white
- consistency non- clumped, adherent homogeneous homogeneous, low
homogeneous, plaques viscosity,smoothly
floccular covers vaginal
mucous membrane
 VAGINAL DISCHARGE : vaginal infection

DIAGNOSIS NORMAL YEAST TRICHOMONAL BACTERIAL

VULVOVAGINITIS VAGINITIS VAGINOSIS
Inflammation None Erythema of vaginal Erythema of vaginal None
of vulvar / epithelium, introitus; vulvar epithelium;
vaginal vulvar dermatitis << petechiae of
epithelium common ectocervix
(strawberry cervix)
pH of vaginal Usually < 4.5 Usually < 4.5 Usually > 5.0 Usually > 4.7
fluid

Amine None None Present Present

(fishy odor)
with 10% KOH
Microscopy Normal Epithelial cells, PMNs >>, motile Clue cells;
epithelial cells, yeasts or Trichomonads profuse mixed
Lactobacilli >> pseudomycelia (80-90% flora with few or no
(large Gram (up to 80%), symptomatic cases) Lactobacilli
positive rods) usually few PMNs << in asymptomatic
GENITAL ULCER
DIAGNOSIS CHANCROID SYPHILIS GENITAL HERPES

ETIOLOGY H. ducreyi T. pallidum Herpes simplex virus

(type 2 >>)
INCUBATION 1-14 days (+ 3-6 days) 10-90 days (21 days) 2-10 days
PERIOD
PREDILECTION Men : Men : Men :
SITES fraenulum, prepuce, sulcus coronarius, glans penis, prepuce,
coronal sulcus, glans glans penis & penile penile shaft
penis & penile shaft shaft, perianal area Women :
Women : Women : cervix, vagina, labia,
cervix, vagina, cervix, vagina, fourchette, clitoris
fourchette, labia, fourchette, labia
perianal area
NUMBER OF 1-3 (up to 10) 1, sometimes > 1 Multiple,
LESIONS Primary infection >>
recurrent infection
 GENITAL ULCER
DIAGNOSIS CHANCROID SYPHILIS GENITAL HERPES

ULCERS :
- Initial lesions Macules, papules, Papules Vesicles
pustules

- Diameter Variable, < 2 cm 0,5 -1,5 cm 1-2 mm

- Edge Ragged undermined, Well-defined border, erythematous
irregular elevated, round or
oval.
- Depth Excavated Superficial or deep Superficial
- Base Dirty, gray/yellow Clean, red, Bright red
necrotic, bleeds with clear serum
easily,
- Induration (-) Firm (-)
- Pain Usually very tender (-)/uncommon Frequently tender
DIAGNOSIS CHANCROID SYPHILIS GENITAL HERPES

Inguinal Unilateral/bilateral, Bilateral, multiple, Bilateral, firm,

adenopathy fluctuant, painful, firm, nonfluctuant, moderatelly tender,
overlying erythema (-) Painless, overlying nonfluctuant, overlying
suppuration (+) erythema (-) erythema (-)

Constitutional Seldom Seldom (primary Often (primary inf.)

symptoms syphilis) Seldom (recurrent inf.)
Microscopy Gram : Dark field micr : Giemsa :
Gram (-), parallel- Treponemal Multinucleated giant
arrays (‘rail-track’ or movement cells
‘school of fish’)
 Greet client
 Explain the patient
 Wash your hand
 Voiding prior examination
 • Venereological examination :
The patient should be examined in
privacy, preferably by chaperon with the
same gender
VENEREOLOGICAL
EXAMINATION
IN FEMALE
• CASE

Mrs. Vadis 22 years old, single, working in

massage parlor with many sexual partners,
visiting STI Clinic with the chief complain of
increased vaginal discharge for 1 week. The
last sexual intercourse was 2 weeks ago
without condom.
 EXPLAIN THE PURPOSE OF EXAMINATION

• Mrs. Vadis, after I asked you all about your signs

and symptoms, now I will examine your genital.
• The purpose of this procedure is to find the
causes of your problem.
• During examination, I will inserting the speculum
& taking the specimen collection from the cervix
and vagina, its often painful, but don’t worry, I
will try to perform it gently.
• Verbal consent : do you mind ?
• Dr : have you urinate Mrs. vadis?
• Mrs. Vadis : Not yet doc!
• Dr : oke, for succesfull examination please
urinate.
Lithotomy Position
Put the Glove
Inguinal Region  Inspect
Inguinal Region  Palpate

Lymphadenopathy ? : size, consistency, mobility

& tenderness
Skin & Pubic Hair

Lesion, lice, nits ?

Papule  Molluscum
Contagiosum
 Nits

Pediculosis pubis
INSPECT LABIA MAJORA & MINORA

Lesions : erythema, oedema, fissuring,

erosion, ulcer or papules ?
Erythema & Edema  Candidosis Vulvovaginitis
Erosion  Genital Herpes
Ulcers  Syphilis
Ulcers  Chancroid
Papule  Condylomata
(syphilis 2)
Papules  Warts
 Labia minora  separated

Any discharge ?  amount, colour, consistency

 INSPECT
URETHRA & PERIURETHRAL

Any lesions : Erythema, oedema, or

discharge ? : amount, colour, consistency
If no discharge :
MILKING THE URETHTRA
by gentle presure
by forefinger from above downword
Urethtral Skene gland
milking
THE BARTHOLIN’S
GLAND : at 5 & 7 oclock
position
Palpate the Bartholin’s gland

Infected : tender & pus (+) at inflamed duct orifice

INSERTING THE SPECULUM
Insert a speculum
 vagina, at an angle
 hollow the sacrum
 opened to reveal
the cervix
 INSPECT VAGINAL WALL

Erythema, erosions, ulcers, papules or discharge ?

White clumped discharge  Candidosis
Yellow, homogen, frothy discharge 
Trichomoniasis
 INSPECT CERVIX

Erythema, oedema, any lesions or discharge ? 

amount, colour, consistency
 External os cervix is wiped clean
with cotton wool  inspect

Any lesions ?
Erosions, ulcers, papules,
Erytheme or ectopy
Any discharge ?
amount, colour, consistency
Cervicitis gonorrhoea
Petechiae “Strawberry cervix” 
Trichomoniasis
Erythema, erosions  Genital Herpes
 N. gonorrhoeae

Insert a cotton-tipped swab about 1-2 cm into

endocervix  firmly rotating 10 sec
Spread the smear thinly on slide
 Gram staining
Second swab  put in to the
transport medium
 C. Trachomatis : PCR

Rubbed cotton tip swab against the mucous membrane

of endoccervix  placed into transport medium
 Trichomonas vaginalis

A drop of saline sol. is added to the slide

Mixed with vaginal secretion from fornix posterior
Placed the cover slip on it, sealed the edge with vaseline to
prevent drying.
 Candida

• A drop of 10% KOH is added to the slide

• Mixed with vaginal secretion from vaginal wall
• Placed the cover slip on it, sealed the edge with vaseline to
prevent drying.
pH Determination of vaginal fluid

Held the pH paper with forcep 

Appled to the vaginal wall near the lateral fornix
 Whiff Test or Amine Test

A drop of 10% KOH is added to vaginal fluid pooling

in the speculum.
The test (+)  “fishy odor”
Insert the first two fingers into the vagina
 cervix is palpated and moved
Normally : NO painful
 Buttocks  separated

Inspection for any lesions

Papule  Condyloma
Accuminata
Papule  Condyloma lata
• Dr. : Okay Mrs. Vadis, the examination is
finished, please get dressed, and while I
recording the result of your genital
examination and performed the laboratory
examination, please wait in the waiting
room, thank you!
VENEREOLOGICAL
EXAMINATION
IN MALE
Supine Position
Put the Glove
Supra Pubic Palpation

Distanded bladder ?
 Inguinal Region

Lymphadenopathy ? : size, consistency, mobility

& tenderness
Lymphadenopathy
Skin & Pubic Hair

Lesion, lice, nit ?

 Nit

Pediculosis pubis
Molluscum contagiosum
Stand Up

Hernia ?
 INSPECT

Warts, vesicle, erosion or ulcer ?

 Uncircumcised Client

Retracted foreskin  balanitis, posthitis, warts or tumor

Balanitis
Posthitis
Papule

Warts
Vesicle
Ulcer

Chancroid
 Tumor

Squamous cell carcinoma

External Urinary Meatus

Meatitis, discharge, lesions, anomaly ?

 Discharge

Consistency, color & amount

Normal Meatitis
Hipospadia
Pinching the glans

Meatal stenosis, intra urethral lesion ?

Meatal Stenosis
Warts
 Shaft of the penis

Warts, vesicle, erosion, ulcer & Peyronie’s disease ?

Papule

Warts
Vesicle

Genital herpes
Erosion

Genital herpes
Ulcer

Syphilis
PEYRONIE’S DISEASE
 Transport Media

N. gonorrhoeae C. trachomatis
CLEAN THE MEATUS
 Inserted cotton swab for
specimen collection : Gram staining & culture
Swab is rolled onto the slide for Gram-stained
smear
Put the other specimen in to the transport
media for culture
 C. trachomatis : PCR

Gently scrape by rotating the swab 5-10sec.  placed

into transport medium
 Trichomonas vaginalis

A drop of saline sol. is added to the slide

Mixed with the specimen from urethra. Placed the cover slip
on it, sealed the edge with vaseline to prevent drying.
Normal Epididimoorchitis
Sebaceus Cyst
 TESTIS

Palpate : size, tenderness, induration, mass ?

Transillumination Test
Hydroceles
 Epididymis

Palpate : size, tenderness, induration ?

Groove testis-epididymis
 Spermatic Cord

Tenderness, thickening or asymmetry ?

Warts, vesicle, erosion, ulcer, lesion ?
 Hemorrhoids
 Fissures
 Fistula
 Any lesion
Sphincter tone, tenderness, induration
Size : 4 cm length and in width
Smooth
Mobile
Non tender
Rubbery
Soft & tubular
Extending oblique beneath base of the
bladder
Clear presence  pathologic