• Surveillance for cervical carcinoma
• Postmenopausal bleeding
• Symptoms of uterine prolapse
• Unexplained urinary tract obstruction
• Suspected tubal pregnancy
□ Position the patient comfortably either on her back or in the left lateral position with her head on a pillow, hips and knees flexed and thighs abducted.
P Use a lamp to illuminate the vulva adequately.
P Use suitable gloves and lubricate the examining fingers.
P Separate the labia minora with the forefinger and thumb of the left hand, bringing into view the clitoris anteriorly, then the urethra, the vagina and the anus posteriorly.
Tumour of testicle
Tumour of testicle
O Palpate each lateral fornix in turn bimanually.
O Note any tenderness or swelling of the Fallopian tubes or ovaries (adnexae), the bladder anteriorly and the pouch of Douglas posteriorly.
□ Supplement digital examination by inspection of the vagina and uterine cervix using a vaginal speculum.
Using a vaginal speculum and taking a cervical smear
□ Gently insert a lubricated, warmed speculum into the vagina; do not use a lubricant other than water if a cervical smear is being performed.
□ Rotate the blades through 90 degrees pointing the handles anteriorly if the patient is supine and posteriorly if in the left lateral position.
□ Gently open the blades and identify the cervix.
□ Use the notched end of a spatula and rotate through 360 degrees to scrape off a cytological sample from the cervical os.
□ Spread the sample thinly onto a labelled, cleaned glass slide and fix immediately with a 50/50 mixture of alcohol and ether.
□ Swab any discharge from the urethra, vagina and cervix.
□ Send one specimen for culture and smear another on to a glass slide for direct microscopy: unstained smears arc helpful to confirm trichomona! infection and stained smears to confirm gonorrhoea or thrush.
Fig, 5.20 MRI scan showing the contents of the female pelvis.
(Courtesy of Dr Andrew R. Wright.)
□ Look for any evidence of discharge, ulceration or abnormalities of Bartholin's glands.
□ Inspccl the vaginal walls for prolapse by asking the patient to strain down and then to cough.
□ Note the position and degree of any vaginal prolapse and the occurrence of any involuntary urinary incontinence on coughing.
□ Insert the index and middle fingers of the right hand into the vagina and rotate palm-upwards (Fig. 5.21). Use only one finger if vaginismus (spasm of the vaginal muscles) or atrophic vaginitis makes examination painful.
□ Palpate the cervix; the normal cervix points downwards and slightly backwards and feels like the tip of the nose.
□ Note any tenderness on movement of the cervix (.cervical excitation).
□ Now perform bimanual palpation: with two fingers in the anterior fornix, place the left hand flat on the abdomen above the pubis. \
□ Identify the size, position and surface characteristics of the uterus between the hands.
□ If the uterus is not palpable, palpate with the fingers in the posterior fornix as the ulerus may be retroverted.
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