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Breast and pelvic exam History Setting: ○ Quiet, private, well-lit room interview/history first with patient dressed intimidating instruments covered ○ Be welcoming ○ Family members can be an impediment to an honest interview ○ Interpret...

Breast and pelvic exam History Setting: ○ Quiet, private, well-lit room interview/history first with patient dressed intimidating instruments covered ○ Be welcoming ○ Family members can be an impediment to an honest interview ○ Interpreter if necessary ○ When history is done, allow the patient to change PRIVATELY and use the bathroom ○ LMP= last menstrual period ○ Ask “what was the first day of your period” ○ Included in HPI ○ EXAMPLE: Pt is a 31 yoG0 LMP 5/15/20 who presents to the office for an annual GYN examination. The patient is without complaints today OB/GYN history and ROS components ○ Pap Smear history– date and results of most recent, prior abnormal results including evaluation, treatment and follow-up ○ Infections- vaginal, pelvic ○ Sexually transmitted diseases (STD) ○ Contraceptive history– dates, methods, complications, reasons for changes ○ Sexual history – sexual activity, types of relationships, satisfaction and dysfunction ○ Infertility history evaluation, treatment, outcome ○ Urinary or fecal incontinence– eval, treatment, outcome ○ Abdominal or pelvic symptoms– pain, bloating, bowel, bladder, weight gain or loss, vaginal discharge, irregular bleeding, dyspareunia ○ Abdominal or gynecologic surgery (e.g., tubal ligation, dilation and curettage, termination of pregnancy, laparoscopy, hysterectomy, pelvic reconstruction, office biopsies) ○ History of assault, or domestic violence ○ Breast disorder/surgery Obstetrics history ○ Duration and year of pregnancy, weight of baby, gender, type of delivery, current condition of the baby, complications ○ Termination of pregnancy – gestational age, type of procedure, complications, associated medial conditions (maternal disease, fetal chromosomal abnormalities) ○ Spontaneous abortions – gestational age, need for uterine instrumentation (D ad C), complications  ○ Ectopic pregnancies – location of pregnancy, treatment Common Terms ○ Gravity (G)-- number of pregnancies including present pregnancy ○ Parity (P)-- pregnancy outcome of prior pregnancies ○ Nulligravida – never been and not now pregnant ○ Primipara – delivered one beyond 20 weeks ○ Parturient – currently in labor ○ Puerpera– has recently given birth Summary of history/example questions ○ Menstrual history Age at menarche (onset of menstruation) and/ or menopause (end of menstruation)? Last menstrual period (LMP)? Frequency, duration and quantity of menses Any specific premenstrual symptoms or pain with menses (Dysmenorrhea) Any vaginal discharge or discomfort? ○ Sexual history Engagement in sexual activity? If so, with partners of same sex, opposite or both? Pain with sexual activity (dyspareunia)? Level of sexual satisfaction? Number of sexual partners Any history of sexually transmitted infections (STIs), including: gonorrhea, chlamydia, syphilis, HIV, Hepatitis B, HPV, HSV, Trichomonas ○ Contraception (if/when sexually active) Any specific method used in the past or currently? Any specific method to protect against STIs? ○ History of pap smear screening- recognizing that this might have been done in a different health system with results otherwise unknown to you Last pap smear and frequency of exams? Any previous abnormal pap smears? If so, what was done? ○ History of breast cancer screening – recoginizeing that this might have been done in a different health system with results otherwise unknown to you. Mammogram screening done? If so, when? What frequency? Results? Any previous abnormal mammograms? Any history of breast biopsies? Self breast examination? If yes, with what frequency? ○ Obstetric history Terminology (GTPAL): Gravida (G)= total number of pregnancies;  Term delivered (T)= total number of deliveries after 37 weeks; Preterm deliveries (P)= number deliveries prior to 37 weeks; Abortions (A)= spontaneous miscarriage or elective termination prior to 20 weeks; Living children (L)= live births Previous pregnancies? Any complications? Outcomes? If prior pregnancies, mode of delivery (vaginal or cesarean section?) ○ Family history Should include specific questions about breast cancer and gynecologic cancers (i.e., uterus, ovaries, vulva, and vagina) – as these have a particularly strong heritable component Gynecologic exam ○ In 2018, ACOG discontinued the recommendation for an annual routine pelvic- examination and advised shared decision making with the patient ○ They recommended the Obstetrician- gynecologists and other gynecologic care ○ Providers counsel asymptomatic, nonpregnant women about the benefits, harms and lack of data regarding routine pelvic examinations. The patient and gynecologic care provider should then decide together if an examination will be performed ○ They also advised that, regardless of whether a pelvic exam is performed, a woman should see her obstetrician-gynecologist at least once a year for well-woman care Complaints that would warrant a gynecological exam: ○ STI testing ro screening ○ Screening exams in females above the age of 21 ○ Pain ○ Discharge ○ Pregnancy or postpartum ○ Infection ○ Itching ○ Swelling ○ Bleeding ○ Menstrual abnormalities ○ Sexual development abnormalities ○ Sexual or physical trauma ○ Neurological conditions ○ Incontinence ○ Pelvic floor disorders Consent  ○ Patient consent – the clinician should request permission before starting a pelvic examination. Written consent is not required with the exception of examination under anesthesia ○ Lack of consent is a contraindication for the exam ○ Chaperone Clinical Pearls ○ Allow adequate time ○ Be prepared to answer questions ○ Ensure patients have sense of control during the exam Thoroughly explain the procedure first Allowing the patient to participate in decision making Reassure the patient that the exam can be discontinued at any point ○ Talk to the patient during the exam Silence can cause the patient to think something is wrong Explain what is coming next Comment on findings ○ Maintain eye contact as much as possible ○ Warming instruments and trying to be as gentle as possible during the exam are good habits Equipment ○ The basic equipment needed to perform a pelvic exam includes: An examining table with stirrups (or means for elevating the buttocks when stirrups aren’t available (when patient is on a stretcher or in bed) Good light source (perferably cold light) Speculum of appropriate size Graves speculum Pederson Speculum ○ Materials to obtain cervical cytology ○ Materials to test for common infections– chlamydia, gonorrhea, herpes simplex virus ○ Cotton swabs for obtaining samples of vaginal discharge ○ pH indicator paper ○ Dropper bottles of saline and potassium hydroxide for performing wet preps ○ Large cotton swabs to absorb excess vaginal discharge or blood ○ Water soluble lubricant, disposable gloves, material to drape the patient Gynecologic exam ○ Abdomen Exam of the abdomen should be performed using the standard techniques of inspection, auscultation, palpation, and percussion  The examiner should observe for abnormalities of skin color and intestinal peristalsis, hernias, organomegaly, masses, fluid collection, and tenderness Tips for a successful exam Patient ○ Avoids intercourse, douching, or use of vaginal suppositories for 24 to 48 hours before exam ○ Empties her bladder before the exam ○ Lies supine, with head and shoulders elevated, and arms at her sides or folded across the chest to enhance eye contact and reduce tightening of abdominal muscles Examiner ○ Obtains permission; selects chaperone ○ Explains each step of the exam in advance ○ Drapes the patient from the mid abdomen to knees; depresses the drape between the knees to provide eye contact with patient ○ Avoids unexpected or sudden movements ○ Chooses a speculum that is the correct size ○ Warms the speculum with tap water ○ Monitors the comfort of the examination by watching the patient’s face and obtaining verbal feedback ○ Uses excellent but gentle technique, especially when inserting the speculum Patient positioning ○ Positioning: dorsal lithotomy with head raised about 30 degrees ○ Extend the foot rests, ask the patient to place their feet in them, and then have them scoot towards the end of the table so that their bottom reaches the edge (you can put your hand there so that they have a target to reach) ○ Arrange the sheet so that it covers up to their knees ○ Ask the patient to position their legs (so that there is space for you to sit and perform the exam) Say: “go ahead and relax your knees out to the side” ○ Use verbal cues to assist them in positioning their legs and avoid pushing them open with your hands Pelvic exam: 3 steps ○ 1. Observation and visual inspection ○ 2. Speculum exam ○ 3. Bimanual exam Perform an external exam: ○ Assess sexual maturity (if adolescent) ○ Inspect the mons pubis, labia, perineum (inflammation, ulceration, discharge, swelling, nodules, any lesions)  Perform an internal exam: ○ Inspect the cervix (color, position, surface characteristics, any ulcerations, nodules, masses, bleeding, discharge) ○ Inspect the vagina (masses, lesions, or abormal discharge or bleeding) Perform a bimanual exam: ○ Palpate the cervix (position, shape, consistency, regularity, mobility, tenderness) ○ Palpate the uterus (size, shape, consistency, mobility, and tenderness or masses) ○ Palpate the ovaries (size, shape, consistency, mobility any tenderness) ○ Assess the pelvic floor muscles (Strength and tenderness) Perform a rectovaginal exam (if indicated) Observation and visual inspection: external genitalia ○ Explain what you’re doing at each step ○ Identify the following external structures: Mons pubis Labia majora Labia minora (has no hair) Clitoris and clitoral hood Urethral opening Vaginal opening (introitus) Bartholin glands Perineum Anus ○ Evaluate for developmental abnormalities, skin lesions (e.g., discoloration, ulcers, plaques, verrucous changes, excoriation), masses and evidence of trauma or infection ○ Palpation of discrete structures can be done as indicated by the presence of observed abnormalities or symptoms ○ Visible vulvar lesions may need to be cultured or biopsied. Bartholin and paraurethral glands ○ The bartholin gland openings are located at the 4 and 8 o'clock positions just outside the hymenal ring ○ The glands are not palpable when healthy ○ The paraurethral glands, the largest of which are Skene’s glands, are adjacent to the distal urethra; the gland ducts open into the urethra or just outside the urethral orifice ○ If enlarged or tender, an attempt should be made to express exudate, which suggests infection External exam– common abnormalities  ○ Mucosal appearance can be thin, reflecting atrophy that can be postmenopausal. Also level of lubrication, which can also decrease postmenopausal ○ Any discharge, noting that a small to moderate amount of discharge, without strong odor is normal ○ Evidence of HSV infection → typically clusters of vesicles on a red base Often associated with itching or burning sensation Typically genital or perianal area Can be isolated or clusters of bumps which often have cauliflower-like appearance ○ Any other ulcers, masses, skin or mucosal findings Speculum exam ○ Gain comfort with the speculum prior to using it with a patient. Show it to the patient and describe what you’re going to do prior to starting ○ The light sourced attached to the plastic version should make for easy visualization ○ For metal specula, use an external light (especially on a goose-neck) to visualize the inside of the vagina and cervix 1. Prior to starting the exam, lubricate the specula with a water-soluble agent. Metal specula should be warmed with water prior to use if not in a warming drawer 2. Make sure that you’ve fully explained the process to the patient and continue to explain the steps prior to initiating each one. Inform them that youre going to start and touch their inside thigh (say: “you’re going to feel my hand on your leg”) as a way of getting started and preparing them for the beginning of the exam 3. Use a finger of your non-dominant hand in the distal vagina to apply downward pressure, and then gently place the speculum over that finger and into the vagina (or you can use 2 fingers of that hand in an upside-down peace sign to spread the labia and expose the introitus in this fashion) 4. Insert speculum sideways. Apply steady downward pressure and downward angling while placing the specula in the vagina. Keeping away from the clitoris and urethra, which are highly innervated. Follow the path of least resistance! 5. DON’T OPEN THE BILLS UNTIL THE SPECULUM IS FULLY INSERTED. Once fully inserted, use the thumb lever to open the bills while observing thru the opening of the speculum. The cervix should hopefully be visible 6. If the cervix is visible you’ll need to tighten the thumb screw to keep the bills in place 7. If the cervix is not visible, you are either off to one side or not deep enough. To address this situation, close the bills, withdraw the speculum slightly/reposition and then open again 8. If finding the cervix remains challenging, consider performing the bimanual exam first which allows you to feel the position of the cervix. Then go back to perform the  speculum exam, using the information gained from the bimanual to assist in locating the cervix. The cervix ○ The squamocolumnar junction in the transformation zone is the area at risk for later dysplasia which is sampled by the Papanicolaou, or Pap smear Once the cervix is visualized, pay attention to: ○ General appearance of cervix. Look for lesions or discharge Following a vaginal delivery, the os will appear transverse. Otherwise, the os has a round appearance ○ Discharge that’s thin and without significant odor is normal ○ Vaginal lesions, anomalies, or atrophic mucosa are noted. If abnormal discharge is identified, the volume, color, consistency and odor should be noted and a sample taken with a cotton swab The pH of physiologic vaginal discharge is less than 4.5; an elevated pH may be due to infection (e.g., bacterial vaginosis) or exogenous substances (eg, semen) ○ A few common types of abnormal discharge (and their causes) include: Blood Most commonly from menstruation (in correct age population) Other considerations: infection, cancer (cervical, endometrial, vaginal), vulvar), fibroids, polyps, perimenopausal, coagulopathy, pregnancy related (e.g., ectopic, threatened abortion, spontaneous abortion, placenta previa, placenta accreta), others. Candida: white, cottage cheese consistency Causes itching, soreness, and sometimes pain with intercourse Trichomonoas: yellowish/green, frothy, malodorous discharge Can cause itching and pain with intercourse Bacterial vaginosis: thin, grayish, malodorous discharge Can cause pain with intercours Cervicitis/PID: yellowish discharge. Cervix may appear red/inflamed. Pain on manipulation of cervix may also be present ○ The degree of vaginal wall relaxation and uterine prolapse is evaluated, if indicated, by removing the top blade of the speculum and using the posterior blade as a retractor ○ It is helpful to ask the patient to bear down to determine the degree of uterovaginal descensus Additional testing can be performed in patients with complaints of urinary incontinence ○ Cervical cultures and cervical cancer screening are performed as indicated Pap test collection  ○ From the transformation zone of the cervix ○ Gynecologic spatula ○ Endocervical brush ○ Liquid cytology (pap, HPV PCR, gc/chl) ○ Conventional methods ○ Blood, discharge, lubrication Obtaining the Pap Smear: options for specimen collection ○ Cervical broom ‘ Many clinicians use a plastic brush tipped with a broomlike fringe for collection of a single specimen containing both squamous and columnar epithelial cells. Rotate the tip of the brush in the cervical os, in a full clock-wise direction, then place the sample directly into preservative so that the lab can prepare the slide (liquid based cytology) Alternatively, stroke each side of the brush on the glass slide. Promptly place the slide in solution or spray with fixative ○ Cervical scrape Place the longer end of the scraper in the cervical os. Press, turn and scrape in a full circle, making sure to include the transformation zone and the squamocolumnar junction. Smear the specimen on a glass slide. Set the slide aside in a safe spot that is easy to reach. Note that first doing the cervical scrape reduced obscuring the cells with blood, which sometimes appears after use of the endocervical brush. ○ Endocervical brush Take the endocervical brush and place it in the cervical os. Roll it between your thumb and index finger, clockwise and counterclockwise. Remove the brush and pick up the slide you have set aside. Smear the slide with the brush, using a gentle painting motion to avoid destroying any cells. Place the slide into an ether-alcohol solution at once, or spray it promptly with a special fixative Note that for pregnant women, a cotton tipped applicator, moistened with saline, is advised in place of the endocervical brush Gonorrhea and chlamydia testing ○ PCR amplification of either a urine or cervical discharge sample ○ Nucleic acid amplification testing (NAAT) Herpes: Culture or PCR and typing Removing the speculum 1. Do this with care so as not to cause discomfort  2. First pull the speculum back a bit, so that the cervix is no longer between the bills. This will prevent you from pinching the cervix 3. Once you’ve cleared the cervix, close the speculum halfway 4. Observe the walls of the vagina as you withdraw the speculum, noting any abnormalities (e.g. growths or ulcers suggestive of cancer, appearance of mucosa) 5. Before you fully remove the speculum, close the bills and take pressure off the thumb piece, otherwise it will snap open when it exits the vagina. Avoide touching the urethral or clitoral area. Bimanual exam 1. Explain what is going to occur next 2. Place a small amount of lubricant on the middle and first finger of your dominant hand 3. Touch the patient’s inner thigh as a way of preparing for the start of this exam 4. Separate the introitus and introduce the lubricated fingers of the dominant hand into the vagina. Apply posterior pressure to keep your fingers away from the urethra and clitoral areas 5. Place your fingers under/on the sides of the cervix and gently move it, noting if this causes any pain. You should also note the general consistency of this structure 6. Then, with your fingers beneath the cervix (in the posterior fornix), gently lift up. At the same time, place your other hand on the lower abdomen, immediately above the symphysis pubis. Imagine that you are pushing the uterus up from the vaginal hand to the abdominal hand. Try to move the uterus between your two hands. Note its size, shape, consistency, mobility and if manipulation causes any pain. The position of the normal uterus is variable and can be: ○ Anteverted (tipped towards the abdominal wall), in which case the fundus will be palpated along the abdominal wall ○ Mid-position ○ Retroverted, in which case the fundus will be palpated behind the cervix in the posterior fornix Pull your hand back slightly (to clear your fingers of the cervix) and then move the fingers into the right fornix (the space on the side of the cervix). Use the external hand to try to sweep the ovary toward the inner hand, as you try to identify the ovary/adnexal structures. Recognize that the ovary is quite small and learning to identify it takes practice. Also note that palpation of the ovary can cause discomfort. After palpating on one side, slightly withdraw your hand and move the fingers into the left fornix. Repeat your efforts, this time trying to palpate the left ovary and adnexa. The adnexal areas are checked for the presence of appropriately sized, mobile ovaries (eg, approximately 2 by 3 cm) which are normally somewhat tender When adnexal masses are detected, they should be described as to location, size, consistency, mobility and degree of tenderness. Findings on Bimanual exam:  ○ Pain on palpation/movement of the cervix might indicate cervical infection. There is often discharge noted during the speculum exam. If the infection ascends (PID, tubo-ovarian abscess), there will also be discomfort upon examining the adnexa and the patient typically is more ill. ○ The uterus becomes palpable during normal pregnany, with the top emerging above the pelvic brim at approximately 12-14 weeks gestation ○ Large fibroids can sometimes be identified during palpation of the uterus ○ Large uterine cancers may also be palpable and may also cause vaginal bleeding ○ Ovarian masses (e.g., cysts, cancer) can sometimes be identified during palpation of the adnexal region Cervical motion tenderness is concerning for pelvic inflammatory disease (uterus is inflamed, infection) Rectovaginal examination ○ Allows optimal palpation of the posterior cul-de-sac and uterosacral ligaments, as well as the uterus and adnexa Known or suspected cancer Endometriosis Colorectal cancer screening in a patient >50 who has not had a colon/sigmoidoscopy Rectocele or symptoms attributable to rectal area ○ Anorectal findings should be documented (eg, hemorrhoids, rectal mass) ○ Stool on the examining glove can be tested for occult blood, but: screening is better accomplished by home collection of stool samples ○ When performing the rectovaginal examination, using a lubricated examining glove and asking the patient to bear down against the examiners finger will usually allow the sphincter to relax and decrease discomfort ○ The same finger should not be used to examine both the vagina and rectum to avoid transmission of HPV or contamination with blood, which may alter fecal occult blood testing, if performed. Concluding the exam ○ At the end of the exam, provide the patient with privacy so that they can clean themselves up (e.g., wipe any excess lubricant) and get dress. Then return to answer questions, review findings and discuss next steps (if any) Expected lifespan variations ○ Ovarian function usually starts to diminish during a woman’s 40s, and menstrual periods cease on the average between ages 45 and 52, sometimes earlier and sometimes later ○ Pubic hair becomes sparse as well as gray ○ As estrogen stimulation falls, the labia and the clitoris become smaller ○ The vagina narrows and shortens and its mucosa becomes thin, pale, and dry  ○ The uterus and ovaries diminish in size ○ Once menopause has occurred, the ovaries may no longer be palpable ○ The suspensory ligaments of the adnexa, uterus and bladder may also relax Tanner staging ○ Tanner staging, also known as sexual maturing rating, is an onjective classification system that providers use to document and track the development and sequence of secondary sex characteristics of children using puberty ○ Stage 1: Preadolescent, no sexual hair ○ Stage 2: sparse, pigmented, long, straight, mainly along labia and at base of penis ○ Stage 3: darker, coarser, curlier ○ Stage 4: adult, but decreased distribution ○ Stage 5: adult in quantity and type with spread to medial thighs History “red flags”/disease-related findings ○ The dates of previous periods may alert you to possible pregnancy or menstrual irregularities ○ Unlike the normal dark red menstrual discharge, excessive flow tends to be bright, red and may include “clots” ○ Postmenopausal bleeding raises the question of endometrial cancer, although it has other causes ○ Other causes of secondary amenorrhea include low body weight from any cause, including malnutrition and anorexia nervosa, stress, chronic illness, and hypothalamic-pituitary-ovarian dysfunction ○ Increased frequency, increased flow, or bleeding between periods may have systemic causes or may be dysfunctional ○ Postcoital bleeding suggests cervical disease (e.g., polyps, cancer) or in an older woman, atrophic vaginitis ○ Amenorrhea followed by heaving bleeding suggests a threatened abortion or dysfunctional uterine bleeding related to lack of ovulation Pelvic exam “red flags”/disease-related findings ○ Delayed puberty is often familial or related to chronic illness. It may also be due to abnormalities in the hypothalamus, anterior pituitary gland or ovaries. ○ Excoriations or itchy, small, red macules papules suggest pediculosis pubis (lice or “crabs”). Look for nits or lice at the bases of the pubic hairs. ○ Clitormegaly ○ An imperforate hymen occasionally delays menarche. Be sure to check for this possibility when menarche seems unduly late in relation to the development of a girl’s breasts and pubic hair ○ Sexual dysfunctions are classified by the phase of sexual response. A woman may lack desire, she may fail to become aroused and to attain adequate vaginal lubrication, or despite adequate arousal, she may be unable to reach orgasm much  or all of the time. Causes include lack of estrogen, medical illness and psychiatric conditions ○ Superficial pain suggests local inflammation, atrophic vaginitis, or inadequate lubrication; deeper pain may be due to pelvic disorder or pressure on a normal ovary. The cause of vaginismus may be physical or psychological ○ A yellowish discharge on endocervical swab suggests a mucopurulent cervicitis, commonly caused by chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex ○ Stool in the rectum may stimulate a rectovaginal mass, but unlike a tumor mass can actually be dented by digital pressure. Rectovaginal examination confirms the distinction ○ Pain on movement of the cervix, together with adnexal tenderness, suggests pelvic inflammatory disease ○ Uterine enlargement suggests pregnancy or benign or malignant tumors ○ Nodules on the uterine surfaces suggest myomas ○ Three to five years after menopause, the ovaries have usually atrophied and are no longer palpable. If you can feel an ovary in a postmenopausal woman, consider an abnormality such as a cyst or a tumor ○ Adnexal masses include ovarian cysts, tumors, and abscesses, also the swollen fallopian tube(s) of pelvic inflammatory disease and a tubal pregnancy. A uterine myoma may stimulate an adnexal mass. ○ Impaired pelvic muscle strength may be due to age, vaginal deliveries, or neurologic deficits. Weakness may be associated with urinary stress incontinence ○ Urethritis (redness or discharge from the urethral meatus) may arise from infection with Chlamydia trachomatis or Neisseria gonorrhoeae ○ Nodularity, and thickening of the uterosacral ligaments occur in endometriosis; also pain with uterine movement Some diseases ○ Epidermoid cyst → small, firm, round cystic nodule in the labia suggests an epidermoid cyst. These are yellowish in color. Look for the dark punctum marking the blocked opening of the gland ○ Venereal wart (condyloma acuminatum) → warty lesions on the labia and within the vestibule suggest condyloma acuminatum. These result from infection with human papillomavirus (HPV) ○ Genital herpes → shallow, small, painful ulcers on red bases suggests a herpes infection. Initial infection may be extensive. Recurrent infections usually are confined to a small local patch ○ Syphilitic Chancre→ a firm, painless ulcer suggests the chancre of primary syphilis. Because most chancres in women develop internally, they often go undetected  ○ Secondary syphilis (condyloma latum) → slightly raised, round, or oval, flat-topped papules covered by a gray exudate suggest condylomata lata. These constitute one manifestation of secondary syphilis and are contagious ○ Carcinoma of the vulva → an ulcerated or raised red vulvar lesion in an elderly woman may indicate vulvar carcinoma Bacterial ○ Trichomonal vaginitis Cause →a trichomonas vaginalis, a protozoan; often but not always acquired sexually Discharge → yellowish green or gray, possibly frothy; often profuse and pooled in the vaginal fornix; may be malodorous Other symptoms → pruritus (though not as severe as with candida infection); pain on urination (from skin inflammation or possibly urethritis); dyspareunia Vulva and vaginal mucosa → vestibule and labia minora may be reddened. Vaginal mucosa may be diffusely reddened, with small red granular spots or petechiae in the posterior fornix. In mild cases, the mucosa looks normal ○ Candidal vaginitis Cause → candida albicans, a yeast (normal overgrowth of vaginal flora); many factors predispose, including antibiotic therapy Discharge → white and curdy, may be thin but typically thick; not as profuse as in trichomonal infection; not malodorous Other symptoms → pruritus; vaginal soreness; pain on urination (from skin inflammation); dyspareunia Vulva and vaginal mucosa → the vulva and even the surrounding skin are often inflamed and sometimes swollen to a variable extent. Vaginal mucosa often reddened, with white, often tenacious patches of discharge. The mucosa may bleed when these patches are scraped off. In mild cases, the mucosa looks normal ○ Bacterial vaginosis Cause → bacterial overgrowth probably from anaerobic bacteria; may be transmitted sexually Discharge → gray or white, thin, homogeneous, malodorous; coats the vaginal walls; usually not profuse, may be minimal Other symptoms → unpleasant fishy or musty genital odor Vulva and vaginal mucosa → vulva usually normal. Vaginal mucosa usually normal Other stuff ○ Cystocele → a cystocele is a bulge of the upper 2/3s of the anterior vaginal wall, together with the bladder above it. It results from weakened supporting tissues ○ Cystourethrocele → when the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge, a cystourethrocele is present. A groove sometimes defines the border between urethrocele and cystocele, but is not always present ○ Urethral caruncle → a urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus. It occurs chiefly in postmenopausal women and usually causes no symptoms. Occasionally a carcinoma of the urethra is mistaken for a caruncle. To check, palpate the urethra through the vaginal thickening, nodularity or tenderness and feel for inguinal lymphadenopathy ○ Prolapse of the urethral mucosa → prolapsed urethral mucosa forms a swollen red ring around the urethral meatus. It usually occurs before menarche or after menopause. Identify the urethral meatus at the center of the swelling to make this diagnosis. ○ Bartholin’s gland infection → causes of a bartholin’s gland infection include trauma, gonococci anaerobes like bacteroides and peptostreptococcus, and Chlamydia trachomatis. Acutely, it appears as a tense, hot, very tender abscess. Look for pus coming out of the duct or erythema around the duct opening. Chronically a contender cyst is felt. It may be large or small ○ Rectrocele → a rectocele is a herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia ○ Mucopurulent cervicitis → mucopurulent cervicitis produces purulent yellow drainage from the cervical os, usually from chlamydia trachomatis, Neisseria gonorrhoeae, or herpes infection. These infections are usually sexually transmitted and may occur without symptoms or signs ○ Carcinoma of the cervix → carcinoma of the cervix begins in an area of metaplasia. In its earliest stages, it cannot be distinguished from a normal cervix. In later stages, an extensive, irregular, cauliflower growth may develop. Early frequent intercourse, multiple partners, smoking and infection with HPV increase the risk of cervical cancer. ○ Myomas of the uterus (fibroids) → myomas are very common benign uterine tumors. They may be single or multiple and vary greatly in size, occasionally reaching massive proportions. They feel like firm, irregular nodules in continuity with the uterine surface. Occasionally, a myoma projecting laterally can be confused with an ovarian mass; a nodule projecting posteriorly can be mistaken for a retroflexed uterus. Submucous myomas project toward the endometrial cavity and are not themselves palpable, although they may be suspected because of an enlarged uterus. ○ Prolapse of the Uterus → prolapse of the uterus results from the weakness of the supporting structures of the pelvic floor and is often associated with a cystocele and rectocele. In progressive stages, the uterus becomes retroverted and descends down the vaginal canal to the outside: In first degree prolapse → the cervix is still well within the vagina In second degree prolapse → it is at the introitus In third degree prolapse (procidentia) → The cervix and vagina are outside the introitus ○ Adnexal masses most commonly result from disorders of the fallopian tubes or ovaries. Three examples –often hard to differentiate – are described. In addition, inflammatory disease of the bowel (such as diverticulitis), carcinoma of the colon, and a pedunculated myoma of the uterus may stimulate an adnexal mass Ovarian cysts and ovarian cancer Ovarian cysts and tumors may be detected as adnexal masses on one or both sides. Later they mey extend out of the pelvis. Cysts tend to be smooth and compressible, tumors more solid and often nodular. Uncomplicated cysts are usually not tender Small (equal to or < 6 in diameter), mobile, cystic masses in young women are usually benign and often disappear after the next menstrual period. Diagnosis of polycystic ovary syndrome rests on exclusion of several endocrine disorders and 2 of the 3 features listed: absent or irregular menses; hyperandrogenism (hirsutism, acne, alopecia, elevated serum testosterone); an confirmation of polycystic ovaries on ultrasounds. Obesity and absence of lactation outside pregnancy or childbirth are additional predictors Ovarian cancer is relatively rare and usually presents at an advanced age. Symptoms include pelvic pain, bloating, increased abdominal size and urinary tract symptoms; often there is a palpable ovary mass. Currently there are no reliable screening tests. A strong family history of breast or ovarian cancer is an important risk factor but occurs in only about 5% of cases. Ruptured tubal pregnancy A ruptured tubal pregnancy spills blood into the peritoneal cavity, causing severe abdominal pain and tenderness. Guarding and rebound tenderness are sometimes associated. A unilateral adnexal mass may be palpable, but tenderness often prevents its detection. Faintness, syncope, nausea, vomiting, tachycardia, and shock may be present, reflecting the hemorrhage. There may be a prior history of amenorrhea or other symptoms of pregnancy Pelvic inflammatory disease  Pelvic inflammatory disease is most often a result of sexually transmitted infection of the fallopian tubes (salpingitis) or of the tubes and ovaries (salpingo-oophoritis). It is caused by neisseria gonorrhoeae, chlamydia trachomatis, and other organisms. Acute disease is associated with very tender, bilateral adnexal masses, although pain and muscle spasm usually make it impossible to delineate them. Movement of the cervix produces pain. If not treated, a tubo-ovarian abscess of infertility may ensure Infection of the fallopian tubes and ovaries may follow delivery of a baby or gynecologic surgery Speculum ○ The blades of graves speculum are wider, higher and curved on the sides; they work better for parous women with loose vaginal walls ○ The pederson speculum works best for nulliparous women and menopausal women with atrophic vaginas; the blades are flat and narrow and barely curve on the sides ○ The graves and pederson speculums come in pediatric sizes to be used in virginal adults or young children (call GYN if need to do a spec exam on a child)