Physical Examination
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
General assessment & vital signs
Points about pelvic examination
General assessment & vital signs
Note the general condition, e.g. well or not, comfortable or not, & the vitals – heart rate, temperature, blood pressure, respiratory rate & colour of mucous membranes. Remember stigmata of HIV-related illnesses, such as wasting, rash, oral thrush, general lymphadenopathy, & chest signs of TB.
Systematic examination
Examine the head & neck including thyroid, heart, lungs, breasts, & do a basic neurological assessment.
Abdominal examination
Use a systematic approach exactly as for a surgical patient:
- First inspection: scars, distension, hernias etc.
- Then palpation: start with touch, then gentle palpation, after which deep palpation. Organomegaly: liver, spleen, kidneys, uterus, ovaries
- Tenderness: location, presence/site, guarding, & rebound
- Masses: site, size, regular/irregular, solid/cystic, fixed, tender
- Ascites: shifting dullness or fluid thrill
- Inguinal & supraclavicular lymph nodes
Points about pelvic examination
- Explain the examination to the patient. Ask for consent to perform a pelvic examination
- Ensure that the bladder is empty before proceeding
- Move slowly & gently with speculum/fingers to minimize discomfort
- Do not do a bimanual examination without passing a speculum first (unless you know the patient and have done a speculum before)
- A considerate & careful abdominal examination often ensures an easier & informative pelvic examination
Speculum examination
- A good light source is vitally important
- Remember to note the visual findings of the vulva first
- Avoid making loud metallic noises with the speculum
- Do not wave the speculum in front of the patient, keep it low
- Put a little bit of lubricant jelly on the outside of the blades, even when taking a smear
- When inserting, part the labia gently with one hand, aim slightly downwards, and insert the speculum with the blades horizontal. If it does not pass easily, be gentle, turn and insert the speculum with the blades vertical, then turn horizontal, but not quite to the midline vertical
- If there is resistance, wait a few seconds; do not force the speculum in
- Never push the lock/handle against the clitoris as this can be very painful
- Warn the patient just before opening the speculum that she will feel stretching
- If the cervix cannot be found, take the speculum out & feel for the cervix with one finger, then re-insert, aiming the speculum slowly to that spot
- Note the appearance of the cervix – normal, ectropion, irregular, cancerous, os open or not etc.
- If an ulcer or mass is seen on the cervix, biopsy, & omit the Pap smear
- Note bleeding (amount, clots) or discharge (appearance, smell)
- Turn the screw to fix the speculum open before taking a cervical smear
- When withdrawing the speculum, open it slightly to release the cervix and allow the blades to collapse as you withdraw the speculum
- Note the appearance of the vaginal walls
Bimanual examination
- First ensure that the bladder is empty
- Two fingers (or one) are in the vagina, & the other hand is on the abdomen. With gentle pressure, try to bring the two hands together to feel what is between
- Press the abdominal hand towards the vagina, not straight down
- An examination using gentle pressure is more informative
- The following information must be sought & recorded (+/-):
- Cervical dilatation (in pregnancy), consistency,
- Products (in pregnancy) & whether offensive/not
- Irregularity of the cervix or masses
- Presence of cervical excitation tenderness
- Uterine axis, size, regularity, tenderness & mobility
- Adnexal masses & tenderness
- If a mass is present beyond the vagina does the cervix move with it (more likely uterus, or adherent ovarian cyst)
- If endometriosis expected, is there tender uterosacral beading
Rectal Examination
- If any pelvic or vaginal mass is palpable, do a rectal examination
Rectal examination is mandatory if any gynaecological cancer is present or endometriosis expected. You cannot assess the parametrium, the true mobility of a mass, recto-vaginal endometriosis, a rectal mass without it. The anal sphincter has a distinct axis. Enter the sphincter slowly with plenty of jelly, as you push the anal ‘sling’ slowly inwards you can feel further, upwards & to left & right. Gentle pressure relaxes the sphincters.