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Questions and Answers
What is the recommended maximum number of people allowed in the room during the consultation?
What is the key purpose of introducing students and nurses during the consultation?
When can additional people be included in the consultation?
What approach is suggested for history taking during the consultation?
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What demeanor should the doctor maintain during the consultation to facilitate patient communication?
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What significant change does the nineteenth edition of Gynaecology by Ten Teachers feature compared to earlier editions?
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Which of the following features remains consistent in the nineteenth edition of Gynaecology by Ten Teachers as in previous editions?
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What is a primary benefit of the updates in the nineteenth edition of Gynaecology by Ten Teachers?
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What distinguishes the structure of the chapters in the nineteenth edition of Gynaecology by Ten Teachers?
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How does Gynaecology by Ten Teachers cater to its audience of students, lecturers, and practitioners in its nineteenth edition?
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Study Notes
Consultation
- The consultation should take place in a private environment and be conducted sensitively.
- The examiner should introduce themself, be courteous and explain the process to the patient.
- One person, besides the doctor, should be present for support, unless otherwise agreed by the patient.
- A standardised template for taking the history ensures all important points are covered.
Pelvic Examination
- The patient should lie in the dorsal lithotomy position for the pelvic examination.
- The vaginal walls are normally in apposition, except at the vault where they are separated by the cervix.
- The vagina is divided into four fornices: posterior, anterior, and two lateral.
- The mid-vagina is a transverse slit, while the lower vagina is an H-shape in transverse section.
- The upper posterior wall forms the anterior peritoneal reflection of the pouch of Douglas.
Examining the Vaginal Walls
- The vaginal walls are lined with transverse folds and have no glands.
- The vagina is kept moist by secretions from the uterine and cervical glands, as well as transudation from its epithelial lining.
- The epithelium is thick and rich in glycogen, particularly in the post-ovulatory phase of the cycle.
- Before puberty and after menopause, the vagina lacks glycogen due to a lack of estrogen.
- Doderlein's bacillus, a normal commensal of the vaginal flora, helps maintain a pH of 4.5 in the vagina by breaking down glycogen.
- This acidic environment protects the vagina by inhibiting the growth of pathogenic bacteria.
Bimanual Examination
- The bimanual examination allows for palpation of the uterus, cervix, and ovaries.
- One hand is inserted into the vagina to palpate the cervix and surrounding tissue.
- The other hand is placed on the abdomen to press down into the pelvis and palpate the fundus of the uterus.
- The size, shape, position, mobility, consistency, and tenderness of the uterus are noted.
- The normal uterus is pear-shaped and approximately 9 cm long, usually anterior.
- The normal ovaries are not usually palpable, except in very thin women.
Examining the Uterus
- The uterus is shaped like an inverted pear, tapering inferiorly to the cervix.
- The uterus has thick muscular walls and is situated entirely within the pelvis in the non-pregnant state.
- The upper part of the uterus is called the body or corpus.
- The cervix is the lower constricted portion of the uterus, projecting obliquely into the vagina.
- The uterus is usually tilted forward (anteversion) and flexed forward on itself at the isthmus (antiflexion).
- Approximately 20% of women have a uterus tilted backwards (retroversion and retroflexion), which is not usually a cause for concern.
- The cavity of the uterus is shaped like an inverted triangle, with the Fallopian tubes opening at the lateral angles.
Other Examinations
- A rectal examination can be used as an alternative to a vaginal examination in children or women who have never had sex.
- It is less sensitive than a vaginal examination and may be uncomfortable, but it can help identify pelvic masses.
- The vaginal walls are not well developed before puberty and atrophy after menopause.
- Both the labia minora and labia majora become engorged during sexual arousal.
- The clitoris is an erectile structure measuring 0.5–3.5 cm in length, made up of paired columns of erectile tissue called the corpora cavernosa.
Clitoral Bulbs
- The clitoral bulbs are extensive erectile and vascular tissues located on either side of the distal vaginal wall.
- They are thought to be part of the clitoris and may play a role in supporting the distal vaginal wall.
- Their exact function is unknown.
Rectal Examination
- A rectal examination is an alternative to a vaginal examination in children and women who have never had sex.
- It can help in identifying pelvic masses.
Key Points
- The consultation should take place in a private environment and be conducted sensitively.
- The examiner should introduce themself, be courteous and explain the process to the patient.
- One person, besides the doctor, should be present for support, unless otherwise agreed by the patient.
- A standardised template for taking the history ensures all important points are covered.
The Cervix
- The cervix is the lower constricted part of the uterus, projecting obliquely into the vagina.
- The internal os is the point where the mucous membrane of the isthmus transitions to the cervix.
The Uterosacral Ligaments
- The uterosacral ligaments may be tender or scarred in women with endometriosis.
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