Periodic examinations and routine cancer screening are important for all women. An annual breast and pelvic examination is im-portant for all women age 18 or older and for those who are sex-ually active, regardless of age. The patient deserves understanding and support because of the emotional and physical considerations associated with gynecologic examinations. Women may be sensi-tive or embarrassed by the usual questions asked by a gynecologist or women’s health care provider. Because gynecologic conditions are of a personal and private nature to most women, such infor-mation is shared only with those directly involved in patient care (as is true with all patient information).
Throughout the examination, the nurse explains the proce-dures to be performed. This not only encourages the woman to relax but also provides an opportunity for her to ask questions and minimizes the negative feelings that many women associate with gynecologic examinations.
The first pelvic examination is often anxiety-producing for women; the nurse can alleviate many of these feelings with expla-nations and teaching (Chart 46-5). Before the examination begins, the patient is asked to empty her bladder and to provide a urine specimen if urine tests are part of the total assessment. Voiding en-sures patient comfort and eases the examination because a full bladder can make palpation of pelvic organs uncomfortable for the patient and difficult for the examiner.
Although several positions may be used for the pelvic examination, the supine lithotomy position is used most commonly, although the upright lithotomy position (in which the woman assumes a semisitting posture) may also be used. This position offers several advantages:
· It is more comfortable for some women.
· It allows better eye contact between patient and examiner.
· It may provide an easier means for the examiner to carry out the bimanual examination.
· It enables the woman to use a mirror to see her anatomy (if she chooses) to visualize any conditions that require treatment or to learn about using certain types of contraceptive methods.
In the supine lithotomy position, the patient lies on the table with her feet on foot rests or stirrups. She is encouraged to relax so that her buttocks are positioned at the edge of the examination table, and she is asked to relax and spread her thighs as widely apart as possible.
If the patient is too ill, disabled, or neurologically impaired to lie safely on the examination table or cannot maintain the supine litho-tomy position, the Sims’ position may be used. In Sims’ position, the patient lies on her left side with her right leg bent at a 90-degree angle. The right labia may be retracted to gain adequate access to the vagina. Other positions for pelvic examination for disabled women make the examination easier for the woman and the clini-cian. The presence of a disability does not justify skipping any parts of the physical assessment, including the pelvic examination.
The following equipment is obtained and readily available: a good light source; a vaginal speculum; clean examination gloves; lubricant, spatula, cytobrush, glass slides, fixative solution or spray; and diagnostic testing supplies for screening for occult rectal blood if the woman is older than 40. Latex-free gloves should be avail-able if the patient or clinician is allergic to latex. This allergy is be-coming more prevalent in nurses and other health care providers and patients and is potentially life-threatening. Patients should be questioned about previous reactions to latex.
After the patient is prepared, the examiner inspects the labia ma-jora and minora, noting the epidermal tissue of the labia majora; the skin fades to the pink mucous membrane of the vaginal in-troitus. Lesions of any type (eg, venereal warts, pigmented lesions [melanoma]) are evaluated. In the nulliparous woman, the labia minora come together at the opening of the vagina. In women who have delivered children vaginally, the labia minora may gape and vaginal tissue may protrude.
Trauma to the anterior vaginal wall during childbirth may have resulted in incompetency of the musculature, and a bulge caused by the bladder protruding into the submucosa of the an-terior vaginal wall (cystocele) may be seen. Childbirth trauma may also have affected the posterior vaginal wall, producing a bulge caused by rectal cavity protrusion (rectocele). The cervix may descend under pressure through the vaginal canal and be seen at the introitus (uterine prolapse). To identify such protrusions, the examiner asks the patient to “bear down.”
The introitus should be free of superficial mucosal lesions. The labia minora may be separated by the fingers of the gloved hand and the lower part of the vagina palpated. In virgins, a hymen of variable thickness may be felt circumferentially within 1 or 2 cm of the vaginal opening. The hymenal ring usually permits the insertion of one finger. Rarely, the hymen totally occludes the vaginal entrance (imperforate hymen).
In women who are not virgins, a rim of scar tissue represent-ing the remnants of the hymenal ring may be felt circumferen-tially around the vagina near its opening. The greater vestibular glands (Bartholin’s glands) lie between the labia minora and the remnants of the hymenal ring. An abscess of the Bartholin’s gland can cause discomfort and requires incision and drainage.
The bivalved speculum, either metal or plastic, is available in many sizes. Metal specula are soaked, scrubbed, and sterilized be-tween patients. Some clinicians and some patients prefer plastic specula, which permit one-time use. The speculum should be warmed with a heating pad or warm water to make insertion more comfortable for the patient. The speculum is not lubricated because commercial lubricants interfere with cervical cytology (Papanicolaou [Pap] smear) findings.
The metal speculum has two set-screws. The one along the handle, holding the two valves of the speculum together, is kept tightened. The screw that holds the thumb rest in place is loos-ened. The speculum is grasped in the dominant hand, with the thumb against the back of the thumb rest to keep the tips of the valves closed. The speculum is rotated slightly counterclockwise, and the vaginal orifice is held open by the thumb and the fore-finger of the gloved nondominant hand by some examiners. Other examiners find that straight insertion of a speculum with downward pressure on the vagina is more comfortable for the pa-tient. The speculum is gently inserted into the posterior portion of the introitus and slowly advanced to the top of the vagina; this should not be painful or uncomfortable for the woman. The tip of the speculum may then be elevated and the speculum rotated to a transverse position. The speculum is then slowly opened and the set-screw of the thumb rest is tightened to hold the speculum open (Fig. 46-4).
The cervix is inspected. In nulliparous women, the cervix usually is 2 to 3 cm wide and smooth. Women who have borne children may have a laceration, usually transverse, giving the cervical os a “fishmouth” appearance. Epithelium from the endocervical canal may have grown onto the surface of the cervix, appearing as beefy-red surface epithelium circumferentially around the os. Occasion-ally, the cervix of a woman whose mother took DES has a hooded appearance (a peaked aspect superiorly or a ridge of tissue sur-rounding it); this is evaluated by colposcopy when identified.
Malignant changes may not be obviously differentiated from the rest of the cervical mucosa. Small, benign cysts may appear on the cervical surface. These are usually bluish or white and are called nabothian cysts. A polyp of endocervical mucosa may protrude through the os and usually is dark red. Polyps can cause irregular bleeding; they are rarely malignant and usually are removed eas-ily in an office or clinic setting. A carcinoma may appear as a cauliflower-like growth that bleeds easily when touched. Bluish col-oration of the cervix is a sign of early pregnancy (Chadwick’s sign).
During the pelvic examination, a Pap smear is obtained by rotat-ing a small spatula at the os, followed by a cervical brush rotated in the os. The tissue obtained is spread on a glass slide and sprayed or fixed immediately, or inserted into a liquid. A small broom-like device can also be used to obtain specimens for the Pap smear.
A specimen of any purulent material appearing at the cervical os is obtained for culture. A sterile applicator is used to obtain the specimen, which is immediately placed in an appropriate medium for transfer to a laboratory. In patients at high risk for infection, routine cultures for gonococcal and chlamydial organisms are rec-ommended because of the high incidence of both diseases and the high risk for pelvic infection, fallopian tube damage, and sub-sequent infertility.
Vaginal discharge, which may be normal or may result from vaginitis, may be present. Discharge caused by bacteria (bacterial vaginosis) usually appears gray and purulent. Discharge caused by Trichomonas species infection is usually frothy, copious, and mal-odorous. Discharge caused by Candida species infection is usu-ally thick and white-yellow and has a cottage-cheese appearance. Table 46-3 summarizes the characteristics of vaginal discharge found in different conditions.
The vagina is inspected as the examiner withdraws the specu-lum. It is smooth in young girls and thickens after puberty, with many rugae (folds) and redundancy in the epithelium. In meno-pausal women, the vagina thins and has fewer rugae because of decreased estrogen.
To complete the pelvic examination, the examiner performs a bi-manual examination from a standing position. The examination is performed with the forefinger and middle finger of the gloved and lubricated hand. These fingers are placed in the vaginal ori-fice, while the other fingers are held tightly out of the way, with the thumb completely adducted. The fingers are advanced verti-cally along the vaginal canal, and the vaginal wall is palpated. Any firm part of the vaginal wall may represent old scar tissue from childbirth trauma but may also require further evaluation.
The cervix is palpated and assessed for its consistency, mobility, size, and position. The normal cervix is uniformly firm but not hard. Softening of the cervix is a finding in early pregnancy. Hardness and immobility of the cervix may reflect invasion by a neoplasm. Pain on gentle movement of the cervix is called a pos-itive chandelier sign or positive cervical motion tenderness (recorded as +CMT) and usually indicates a pelvic infection.
To palpate the uterus, the examiner places the opposite hand on the abdominal wall halfway between the umbilicus and the pubis and presses firmly toward the vagina (Fig. 46-5). Movement of the abdominal wall causes the body of the uterus to descend, and the pear-shaped organ becomes freely movable between the ab-dominal examining hand and the fingers of the pelvic examining hand. Uterine size, mobility, and contour can be estimated through palpation. Fixation of the uterus in the pelvis may be a sign of endometriosis or malignancy.
The body of the uterus is normally twice the diameter and twice the length of the cervix, curving anteriorly toward the abdominal wall. Some women have a retroverted or retroflexed uterus, which tips posteriorly toward the sacrum, whereas others have a uterus that is neither anterior nor posterior but is midline.
Next, the right and left adnexal areas are palpated to evaluate the fallopian tubes and ovaries. The fingers of the hand examining the pelvis are moved first to one side, then to the other, while the hand palpating the abdominal area is moved correspondingly to either side of the abdomen and downward. The adnexa (ovaries and fallopian tubes) are trapped between the two hands and pal-pated for an obvious mass, tenderness, and mobility. Commonly, the ovaries are slightly tender, and the patient is informed that slight discomfort on palpation is normal.
Bimanual palpation of the vagina and cul-de-sac is accomplished by placing the index finger in the vagina and the middle finger in the rectum. To prevent cross-contamination between the vaginal and rectal orifices, the examiner puts on new gloves. A gentle movement of these fingers toward each other compresses the pos-terior vaginal wall and the anterior rectal wall and assists the ex-aminer in identifying the integrity of these structures. During this procedure, the patient may sense an urge to defecate. The nurse assures the patient that this is unlikely to occur. Ongoing expla-nations are provided to reassure and educate the patient about the procedure.
Yearly examinations can help prevent problems of the repro-ductive tract in aging women. Some older women do not have regular gynecologic examinations. If a woman delivered her chil-dren at home, she may never have had a pelvic examination. Some regard it as an embarrassing and unpleasant procedure. An im-portant role of the nurse is to encourage an annual gynecologic examination for all women. The nurse can make the examina-tion a time for education and reassurance rather than a time of embarrassment.
Perineal pruritus is common in elderly women and should be evaluated because it may indicate a disease process (diabetes or malignancy). It may also indicate vulvar dystrophy, a thickened or whitish discoloration of tissue that needs biopsy to rule out ab-normal cells. Topical cortisone and hormone creams may be pre-scribed for symptomatic relief.
With relaxing pelvic musculature, uterine prolapse and re-laxation of the vaginal walls can occur. Appropriate evaluation and surgical repair can provide relief if the patient is a candidate for surgery. After surgery, the patient needs to know that tissue repair and healing may require additional time. Pessaries (latex devices that provide support) are often used if surgery is con-traindicated or before surgery to see if surgery can be avoided. They are fitted by a health care provider and may reduce dis-comfort and pressure. Use of a pessary requires the patient to have routine gynecologic examinations to monitor for irritation or infection.
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