2025 Female Genitalia PD2 Richards - Tagged.pdf

Female Genitalia Bates Chapter 21 Jessa Richards, MMS, PA-C 1 Instructional Objectives Describe the anatomy and physiology of the female genitalia Obtain a through patient history specifically regarding complaints of changes in menstruation, vaginal bleeding and/or discharge,...

Female Genitalia Bates Chapter 21 Jessa Richards, MMS, PA-C 1 Instructional Objectives Describe the anatomy and physiology of the female genitalia Obtain a through patient history specifically regarding complaints of changes in menstruation, vaginal bleeding and/or discharge, or vulvovaginal lesions Describe the risk factors for cervical cancer, STD’s, and HIV Describe the principles of the pelvic examination Helpful Definitions Menarche-onset of menses Dysmenorrhea-pain with menses, often with bearing down, aching, or cramping sensation in the lower abdomen or pelvis Premenstrual syndrome (PMS)-a cluster of emotional, behavioral, and physical symptoms occurring 5 days before menses for three consecutive cycles Abnormal uterine bleeding-bleeding between menses; includes infrequent, excessive, prolonged, or postmenopausal bleeding Menopause-absence of menses for 12 consecutive months, usually occurring between ages 48 and 55 years Postmenopausal bleeding-bleeding occurring after menopause Helpful Definitions Menorrhagia-periods where the bleeding is quite heavier, or the duration is longer than usual Metrorrhagia-bleeding or spotting in between menstruation Menometrorrhagia-combination of moth menorrhagia and metrorrhagia Polymenorrhea-less than 21-day intervals between menses Oligomenorrhea-infrequent bleeding Amenorrhea-absence of menses Helpful Definitions Gravidity- # of times a woman has been pregnant Primigravida-a woman who is pregnant now or has been pregnant once Multigravida-pregnant more than once Nulligravida-never been pregnant more than once Parity- # of times a woman has given birth to a baby of viable age (≥24 weeks) regardless of birth outcome Primipara (Primip)-pregnant for the first time (and has made it beyond viable age) OR has given birth to only 1 child Multipara (Multip)-Given birth 2 or more times Nullipara (Nullip)-a woman who has never given birth or who has never had a pregnancy progress beyond viability Miscarriage (spontaneous abortion)-fetal demise before the 20th week of gestation History: Chief Complaint CC: Yearly well-woman Menarche and menstruation Premenstrual syndrome (PMS)  Depression, angry outbursts, irritability, anxiety, confusion, crying spells, sleep disturbance, poor concentration, social withdrawal, bloating, weight gain, swelling of hands and feet, generalized aches and pains  Criteria: o 1. Must be present in the 5 days prior to menses for at least three consecutive cycles. o 2. Cessation of symptoms and signs within 4 days after onset of menses. o 3. Interfere with daily activities Amenorrhea  Primary-Absence of ever initiating periods  Secondary-Cessation of periods after they have been established Abnormal bleeding  Menorrhagia, metrorrhagia, and menometrorrhagia  Polymenorrhea, oligomenorrhea, post coital bleeding History: Chief Complaint CC: Dysmenorrhea  Abnormal when interfering with ADLs (activities of daily living)  Primary-Increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline  Secondary-Endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease (PID), and endometrial polyps History: Chief Complaint CC: Menopause and Postmenopausal bleeding Pelvic pain-acute and chronic  Dysmenorrhea, dyspareunia, etc Vulvovaginal symptoms  Discharge, pruritis, and rash/lesions STIs Sexual health Pregnancy Urinary symptoms  Dysuria, frequency, urgency, incontinence History HPI: OLDCARTS Pertinent positives/negatives PMH Reproductive health history/STI’s  Important to assess impact on fertility, risk for ectopic pregnancy, best contraceptive to prescribe, etc. History urinary tract infections, glomerulonephritis, etc Previous urinary catheterization/dilation History spina bifida (risk factor for recurrent UTI) History of trauma/spinal cord injury Medications/form of birth control Surgical history Reproductive Health History Obstetric History Gyn History Ovarian cyst Onset of #Pregnancies Endometriosis Menarche #Losses/ Infertility/ Abortions treatments LNMP Delivery hx- Fibroids Salpingitis vaginal vs c- Tubo-ovarian section abscess PID Screenings Last pap Sexual smear History Last mammogra m Sexually  Reproductive Health History/Sexual History The 5 “Ps+” Partners Genders of sexual partners, recent sexual intercourse, # of partners in the last 6 months, 5 years, and lifetime, any new partners in the last 6 months Practices Types of sex (oral, vaginal, anal, etc) Protection from STIs Use of condoms Past history of STIs What kind, when, what treatment, last screening Pregnancy Plans Any plans or desire to have (more) children? Discuss concerns, birth control, etc Plus Encompasses an assessment of trauma, violence, sexual satisfaction, sexual health concerns/problems, and support for sexual orientation and gender identify (SOGI)  Reproductive Health History/OB History Gravidity and Parity Can be documented succinctly as G and P Ex: A woman who is gravida 2, para 2 (G2P2) has had two pregnancies and two deliveries after 24 weeks. Ex: A women who is gravida 2, para 0 (G2P0) has had two pregnancies, neither of which survived to a gestational age of 24 weeks  Reproductive Health History/OB History Parity can be broken down even further G,P(TPAL) Gravidity - # of pregnancies Parity T-Term- # of term pregnancies/deliveries 37-40 weeks P-Premature- # of premature pregnancies/deliveries 20-36 weeks A-Abortions/miscarriages Elective abortions and spontaneous abortions L-Living children Reproductive Health History/OB History Practice! Your patient: A woman with two spontaneous losses prior to 20 weeks gestation, 3 living children who were delivered at term, and currently pregnant Reproductive Health History/OB History How many times has she been pregnant? 2 spontaneous losses+3 living children at term+currently pregnant=6 G6 How many times has she had full term pregnancies? 3 children born at term T=3 How many times has she had pre-term pregnancies? 0 P=0 How many times has she had an abortion/miscarriage? Two spontaneous losses prior to 20 weeks A=2 How many living children does she have? 3 living children L=3 Reproductive Health History/OB History Practice! A woman with two spontaneous losses prior to 20 weeks gestation, 3 living children who were delivered at term, and currently pregnant G6P3023 Reproductive Health History/OB History Practice! What about twins? Important to note that for gravidity, it’s about number of pregnancies, not number of babies This also goes for T, P, and A (term/pre-term pregnancies and abortions/miscarriages) Try this one: A woman has only had one pregnancy, she had twins that were delivered at term. She has had no miscarriages or abortions Reproductive Health History/OB History How many times has she been pregnant? Once G1 How many times has she had full term pregnancies? 1 full term pregnancy T=1 How many times has she had pre-term pregnancies? 0 P=0 How many times has she had an abortion/miscarriage? 0 A=0 How many living children does she have? 2 living children L=2 Reproductive Health History/OB History Practice! What about twins? Important to note that for gravidity, it’s about number of pregnancies, not number of babies This also goes for T and P (term and pre-term pregnancies) Try this one: A woman has only had one pregnancy, she had twins that were delivered at term. She has had no miscarriages or abortions G1P1002 History FH History of renal disease Polycystic Kidney dz Renal failure Cancer SH Sexual history ROS General Skin Pulm Cardiac GI GU Physical Exam Vital signs General Skin Pulm Cardiac GI Rectal when indicated GU Pelvic exam Female Anatomy Female Anatomy Female Anatomy Female Anatomy Before preparing for the exam…  Is the patient younger than 21 years old? Pelvic exams should only be performed on patients under 21 years old if indicated by the medical history, such as menstrual disorders, pelvic pain, discharge, etc. NO EVIDENCE SUPPORTS THE ROUTINE INTERNAL EXAMINATION OF THE HEALTHY, ASYMPTOMATIC PATIENT BEFORE AGE 21 YEARS.  Male examiners should be accompanied by female chaperones, and female examiners should be accompanied by a chaperone as well. Tips for Successful Female Genitalia Exam Prep for the Pelvic Exam Assemble equipment Moveable light source Gloves Vaginal speculum of appropriate size Water-soluble lubricant Pap smear equipment (if indicated) Specimen/culture Make Sure The Patient is Comfortable Positioning Assist the patient into lithotomy position She may be warmer and feel less exposed with socks on Ask her to slide all the way down the exam table until her buttocks extend slightly beyond the edge. Her hips should be flexed, abducted, and externally rotated Make sure her head is supported with a pillow Touching the Patient Give patient power by your words: “This is the speculum I will use” “We will begin the examination now with your permission.” “You will feel the back of my hand”  GU Female Exam Inspection (and palpation if indicated) of the external genitalia  Mons pubis, labia majora and perineum  Labia minora, clitoris, urethral meatus, and introitus  Anus External Exam Mons pubis Inspect: Pubic hair pattern/distribution Labia majora Inspect: Color, symmetry, moisture, scarring, inflammation, swelling. Palpate for tenderness Labia minora Inspect: symmetry, moisture, inflammation, discharge, excoriations, lesions. Palpate for tenderness Clitoris Size, atrophy, inflammation, adhesions Urinary meatus Discharge, polyps, caruncles, inflammation Vaginal introitus Moisture, swelling, discoloration, discharge, lesions, fissures Skene and Bartholin glands Inspect: Discharge and swelling Palpate: Bartholin glands for tenderness External Exam Bartholin glands Palpate each side at approximate the 4- o’clock and 8-o’clock position between your finger and thumb Check for swelling or tenderness Note any discharge exuding from the duct opening of the gland Culture if present  Speculum Examination Understand mechanics of the speculum and make sure it’s in good working order Preferable to lubricate with warm water May use lubricant sparingly*** Can prevent accurate pap/culture results so use with caution!  Internal Exam-Speculum Exam Advise patient you will now place the speculum in the vagina Place 1-2 fingers in the posterior introitus and press downward If needed, locate the position of the cervix with your fingers to guide the direction of the speculum With speculum closed, insert at an oblique angle and gradually rotate to horizontal position Insert at a 30-degree downward angle towards the cervix Gradually open the speculum, bring cervix into view, and lock If having difficulty finding the cervix, withdraw slightly and reposition on a different slope  Internal Exam-Speculum Exam (cont) If discharge obscures the view, wipe away gently with a large cotton swab Note the color and symmetry of the cervix Note the surface characteristics Smooth, ectropion, Nabothian cysts, polyps, erythema Note the shape of the os Note the presence of any discharge Odor, consistency  Internal Exam-Speculum Exam (cont) Obtain pap smear and cultures if indicated Withdraw the speculum just until it clears the cervix, then inspect the vaginal walls Inspect for color, surface characteristics, lesions, secretions, or bleeding Have the patient bear down, and check for bulging in the vaginal wall or incontinence Ensuring the speculum has cleared the cervix, close the speculum and remove slowly at the same oblique angle The Speculum Exam Papanicolaou (Pap) Smear Once the cervix is clearly visualized: Obtain one specimen from the endocervix and another from the ectocervix If indicated/consented: Then take cultures from the cervical os TAKE CUTURES LAST!!!  GU Female Exam Bimanual Examination-Performed from standing position  Lubricate index and middle fingers  Inform patient you will insert fingers  Insert fingers exerting pressure posteriorly, with the thumb abducted and 4th and 5th fingers flexed into the palm.  Note any lesions or tenderness in the vaginal wall, including the region of the urethra and bladder anteriorly  Palpate the cervix, noting the size, contour/consistency, and assess for cervical motion tenderness  Palpate the uterus  Place your other hand on the lower abdomen just above the symphysis pubis while you elevate the cervix and uterus with your pelvic hand. Press the abdominal hand in and down, capturing the uterus between your two hands. Note its position, size, shape, contour/consistency, any masses present, mobility and identify any tenderness.  Palpate each ovary  Place your abdominal hand on the right lower quadrant and your pelvic hand in the right lateral fornix, pushing your abdominal hand in and down.  Try to identify the right ovary or any adjacent adnexal masses  Note the size, shape, consistency, mobility, and tenderness  Repeat on left side  DRE (Verbalize only that you will perform)  Note the sphincter tone and any scarring, fissures, lesions, rectal wall masses, polyps, tenderness, uterus position/size/tenderness, stool color, and presence of any blood. The Bimanual Examination Special Techniques Milking the urethra To evaluate possible urethritis or inflammation of the paraurethral glands, insert your index finger into the vagina and milk the urethra gently outward from the inside. Note any discharge from the urethral meatus. If discharge is present, culture it Common Abnormalities  Common Abnormalities Vulvar/Vaginal Lesions Herpes simplex Vesicles/ulcers Syphilis Cancer Bartholin cysts HPV Warts Common Abnormalities  Common Abnormalities Vaginal Pruritus/Pain Candidiasis Trichomoniasis Herpes simplex Vesicles  Common Abnormalities Vaginal discharge Urethritis/cervicitis Chlamydia/GC Mucopurulent discharge Bacterial Vaginosis Homogeneous white discharge which coats the vagina +clue cells Fishy odor, “whiff” test Candidiasis White clumped discharge Trichomoniasis Yellow/green, often malodorous discharge with vulvar itching Motile flagellated organisms Common Abnormalities Urethrocele-When a prolapsed urethra protrudes into the anterior vaginal wall Cystocele-A bulge of the upper two-thirds of the anterior Common Abnormalities Cystourethrocele-When the entire anterior vaginal wall, together with the bladder and urethra, produces the bulge. Rectocele-Herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia. Common Abnormalities Urethral abnormalities Caruncle-Small red benign tumor visible at the posterior urethral meatus. Most common in postmenopausal women Typically asymptomatic Important to avoid confusing with carcinoma of the urethra  Common Abnormalities Cervical abnormalities Mucopurulent discharge  Mucopurulent cervicitis produces purulent yellow drainage from the cervical os, usually from C. trachomatis, N. gonorrhoeae, or herpes infection. Carcinoma of the cervix  Earliest stages-cannot be distinguished from a normal cervix.  Later stages-an extensive, irregular, cauliflower-like growth may develop.  Early frequent intercourse, multiple partners, smoking, and infection with human papillomavirus increase the risk for cervical cancer. Fetal exposure to DES  Daughters of women who took DES during pregnancy are at greatly increased risk for several abnormalities  Columnar epithelium that covers most or all of the cervix  Vaginal adenosis (i.e extension of this epithelium to the vaginal wall)  A circular collar or ridge of tissue, between the cervix and vagina  Rare carcinoma of the upper vagina. Nabothian cysts (AKA Mucinous retention cysts)  Common Abnormalities Uterine abnormalities Fibroids (Myomas) Very common, benign tumors Vary in number and size Firm, irregular nodules Prolapse Weakness of supporting structures of the pelvic floor 1st degree-cervix is still well within the vagina 2nd degree-cervix is at the introitus 3rd degree-cervix and vagina are outside the introitus Common Abnormalities Adnexal masses and other causes of pelvic pain Ovarian cancer Ovarian cysts/tumors Cysts can be transient or suggestive of PCOS PCOS-Requires 2/3 factors to be present for diagnosis Androgen excess Ovulatory dysfunction Polycystic ovaries on U/S Ectopic pregnancy PID Dysmenorrhea Endometriosis Common Abnormalities Renal Conditions UTI and Pyelonephritis Nephrolithiasis Gross hematuria Glomerulonephritis Previous history of streptococcal infection Microscopic hematuria Nephrotic syndrome Facial edema/increased bp/> 3grams of protein in 24hours Documentation “External genitalia without erythema, lesions, or masses. Vaginal mucosa pink. Cervix parous, pink, and without discharge. Uterus anterior, midline, smooth, and not enlarged. No adnexal tenderness. Pap smear obtained. Rectovaginal wall intact. Rectal vault without masses. Stool brown and negative for fecal blood.” OR “External genitalia without erythema or lesions. Vaginal mucosa and cervix coated with white homogenous discharge with mild fishy odor. After swabbing cervix, no discharge visible in the cervical os. Uterus midline; no adnexal masses. Rectal vault without masses. Stool brown and negative for fecal blood.” Health Promotion and Education Question: Why should lubricant be used sparingly or not at all during a pap? A. Could cause an allergic reaction B. Could cause inaccurate results C. Could cause discomfort D. Could cause issues with the speculum Question: Which of the following is not an instrument used during a pelvic exam? A. Broom B. Spatula/Scrape C. Brush D. Cannula Question: Which of the following is the definition of metrorrhagia? A. Bleeding between menses B. Heavy bleeding C. Bleeding that occurs 1 year after cessation of periods D. Pain with menses Question: At what age should cervical cancer screening begin? A.18 B. 21 C. 30 D. When the patient becomes sexually active References Bates Guide to Physical Examination