Female Genitalia

Phase

Physiologic Change

Excitement

Reduced amount of vaginal secretion and lubrication

Plateau

Less expansion of vagina

Labia majora do not elevate against perineum No color change in labia minora (was from pink to cardinal-red or dark red)

Size of clitoris decreases after age 60

Orgasm

Shorter duration

Resolution

Occurs more rapidly

Examiner Asks

Rationale

1. Menstrual history.

•Tell me about your menstrual periods:

•Date of your last menstrual period?

•Age at first period?

•How often are your periods?

•How many days does your period last?

•Usual amount of flow: light, medium, heavy? How many pads or tampons do you use each day or hour?

•Any clotting?

•Any pain or cramps before or during period? How do you treat it? Inter­fere with daily activities? Any other associated symptoms: bloating, cramping, breast tenderness, moodiness? Any spotting between periods?

Menstrual history is usually nonthreat-ening, thus it is a good place to start history.

LMP—last menstrual period.

Menarche—onset between 12 and 14 years indicates normal growth; onset between 16 and 17 years suggests an en­docrine problem.

Cycle—normally varies every 18 to 45 days.

Amenorrhea—absent menses.

Duration—average 3 to 7 days.

Menorrhagia—heavy menses.

Clotting indicates heavy flow or vaginal pooling.

Dysmenorrhea

.2. Obstetric history.

•Have you ever been pregnant?

•How many times?

•How many babies have you had?

•Any miscarriage or abortion?

•For each pregnancy, describe: duration, any complication, labor and delivery, baby’s sex, birth weight, condition.

•Do you think you may be pregnant now? What symptoms have you noticed?

Obstetric history.

Gravida—number of pregnancies.

Para—number of births.

Abortions—interrupted pregnancies, including elective abortions and sponta­neous miscarriages

3. Menopause.

•Have your periods slowed down or stopped?

•Any associated symptoms of menopause, e.g., hot flash, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, itching? Any treatment?

•If hormone replacement, how much? How is it working? Any side effects?

•

•How do you feel about going through menopausi

Menopause—cessation of menstruation.

Perimenopausal period, from 40 to 55 years of age, has hormone shifts, result­ing in vasomotor instability.

Side effects of estrogen replacement therapy include fluid retention, breast pain or enlargement, vaginal bleeding.

Although this is a normal life stage, re­action varies from acceptance to feelings of loss.

4. Self-care behaviors.

•How often do you have a gynecologic checkup?

•Last Papanicolaou smear? Results?

•Has your mother ever mentioned taking hormones while pregnant with you?

Assess self-care behaviors.

Maternal ingestion of DES (diethyl-stilbestrol) causes cervical and vaginal abnormalities in female offspring requir­ing frequent follow-up.

5. Urinary symptoms

•Any problems with urinating? Frequently and small amounts? Cannot wait to urinate?

•Any burning or pain on urinating?

•Awaken during night to urinate?

•      Blood in the urine?

••Urine dark, cloudy, foul smelling?

•      Any difficulty controlling urine or wetting yourself?

•

•

• Urinate with a sneeze, laugh, cough, bearing down?

Urinary symptoms. Frequency. Urgency.

Dysuria.

Nocturia.

Hematuria.

Bile in urine or urinary tract infection.

True incontinence—loss of urine without warning.

Urgency incontinence—sudden loss, as with acute cystitis.

Stress incontinence—loss of urine with physical strain due to muscle weakness.

6. Vaginal discharge.

•Any unusual vaginal discharge? Increased amount?

••Character or color: white, yellow-green, gray, curdlike, foul smelling?

•

•When did this begin?

•Is the discharge associated with vaginal itching, rash, pain with intercourse?

•

•

•Taking any medications?

•

•

•

•

•

•Family history of diabetes?

•What part of your menstrual cycle are you iow?

•Use a vaginal douche? How often?

•Use feminine hygiene spray?

•Wear nonventilating underpants, pantyhose?

•Treated the discharge with anything? Result?

Normal discharge is small, clear or cloudy, and always nonirritating.

Suggests vaginal infection; character of discharge often suggests causative organ­ism (see Table 26-6).

Acute versus chronic problem.

Occurs secondary to irritation from discharge.

Dyspareunia occurs with vaginitis of any cause.

Factors that increase risk of vaginitis:

Oral contraceptives increase glycogen content of vaginal epithelium, provid­ing fertile medium for some organisms.

Broad-spectrum antibiotics alter balance of normal flora.

Diabetes increases glycogen content.

Menses, postpartum, menopause have a more alkaline vaginal pH.

Frequent douching alters pH.

Spray has risk of contact dermatitis.

Local irritation.

7. Past history

•Any other problems in the genital area? Sores or lesions-now or in the past? How were these treated?

•Any abdominal pain?

•Any past surgery on uterus, ovaries, vagina?

Assess feelings. Some fear loss of sexual response following hysterectomy, which may cause problems in intimate relationships.

8. Sexual activity

•Often women have a question about their sexual rela­tionship and how it affects their health. Do you?

•Are you in a relationship involving sex now?

•Are aspects of sex satisfactory to you and your partner?

•Satisfied with the way you and partner communicate about sex?

•Satisfied with your ability to respond sexually?

•Do you have more than one sexual partner?

•

•

•

•What is your sexual preference: relationship with a man, with a woman, both?

Begin with open-ended question to assess individual needs. Include appro­priate questions as a routine part of history:

Communicates that you accept individual’s sexual activity and believe it is important.

Your comfort with discussion prompts person’s interest and possibly relief that the topic has been introduced.

Establishes a data base for comparison with any future sexual activities.

Provides opportunity to screen sexual problems.

Lesbians and bisexual womeeed to feel acceptance to discuss their health concerns.

9. Contraceptive use.

•Currently planning a pregnancy, or avoiding pregnancy?

•Do you and your partner use a contraceptive? Which method? Is this satisfactory? Do you have any questions about method?

•Which methods have you used in the past? Have you and partner dis-” cussed having children?

•Have you ever had any problems becoming pregnant?

If oral contraceptives are used, assess smoking history. Cigarettes increase cardiovascular side effects of oral contraceptives.

Infertility is considered after 1 year of engaging in unprotected sexual inter­course without conceiving

10. Sexually transmitted disease (STD) contact.

•Any sexual contact with partner having a sexually transmitted disease, such as gonorrhea, herpes, AIDS, chlamydial infection, venereal warts, syphilis? When? How was this treated? Were there any complications?

11. STD risk reduction

Any precautions to reduce risk of STDs? Use condoms at each episode of sexual intercourse?

Additional History for Infants and Children

•1. Does your child have any problem urinating? Pain with urinating, crying, holding genitals? Urinary tract infection?

•(If the child is older than 2 to 2V₂ years of age) Has toilet training started? How is it progressing?

·  Does the child wet bed at night? Is this a problem for child or you (parents)? What have you (parents) done?

2. Problem with genital area: itching, rash, vaginal discharge?

Occurs with poor perineal hygiene or insertion of foreign body in vagina.

3. {To child) Has anyone ever touched you in between your legs and you did not want them to? Sometimes that happens to children. They should remem­ber they have not been bad. They should try to tell a big person about it. Can you tell me three different big people you trust who you could talk to?

Screen for sexual abuse. For preven­tion, teach the child that it’s not okay for someone to look at or touch their private parts while telling them it’s a secret. Naming three trusted adults will include someone outside the family— important since most molestation is by a parent (Brown, 1997).

Additional History for Preadolescents and Adolescents

•Use the following questions, as appropriate, to assess sexual growth and devel­opment and sexual behavior. First

•Ask questions that seem appropriate for girl’s age but be aware that normsvary widely. When in doubt, it is better to ask too many questions than to omit something. Children obtain information, often misinformation, from the media and from peers at surprisingly early ages. You can be sure your information will be more thoughtful and accurate.

•Ask direct, matter-of-fact questions. Avoid sounding judgmental.

•Start with a permission statement, “Often girls your age experience …” This conveys that it is normal to think or feel a certain way.

·  Try the open-ended, “When did you …” rather than “Do you …” This is less threatening because it implies that the topic is normal and unexceptional

1. Around age 11, but sometimes earlier, girls start to develop breasts and pubic hair. Have you ever seen charts and pictures of normal growth patterns for girls? Let us go over these now.

2. Have your periods started? How did you feel? Were you prepared or surprised?

Assess attitude of girl and parents. Note inadequate preparation or attitude of distaste.

•3. Who in your family do you talk to about your body changes and about sex information? How do these talks go? Do you think you get enough informa­tion? What about sex education classes at school? Is there a teacher, a nurse or doctor, a minister, a counselor to whom you can talk?

•Often girls your age have questions about sexual activity. Do you have questions? Are you dating? Someone steady?

Do you and your boyfriend have intercourse? Are you using condoms?

What method of protection did you use the last time you had sex?

Avoid the term “sexually active,” which is ambiguous

4. Has anyone ever talked to you about sexually transmitted diseases, such as herpes, gonorrhea, or AIDS?

Teach STD risk reduction.

5. Sometimes it happens that a person touches a girl in a way that she does not  want them to. Has that ever happened to you? If that happens, the girl should remember it is not her fault. She should tell another adult about it.

Screen for sexual abuse.

Additional History for the Aging Aduit

• After menopause, noted any vaginal bleeding?

• Any vaginal itching, discharge, pain with intercourse?

• Any pressure in genital area, loss of urine with cough or sneeze, back pain, or constipation?

•4. Are you in a relationship involving sex now? Are aspects of sex satisfactory to you and your partner? Is there adequate privacy for a sexual relationship?

Postmenopausal bleeding warrants further workup and referral.

Associated with atrophic vaginitis.

Occurs with weakened pelvic muscula­ture and uterine prolapse.

NORMAL RANGE OF FINDINGS

Abnormal Findings

EXTERNAL GENITALIA

Inspection

Note:

·  • Skin color (Fig. 26-6)

· 

·  Hair distribution is in the usual female pattern of inverted triangle, although it normally may trail up the abdomen toward the umbilicus.

·  Labia majora normally are symmetric, plump, and well formed. In the nulli-parous woman, labia meet in the midline; following a vaginal delivery, the labia are gaping and slightly shriveled.

·  No lesions should be present, except for occasional sebaceous cysts. These are yellowish, 1-cm nodules that are firm, nontender, and often multiple.

·  With your gloved hand, separate the labia majora to inspect:

·  Clitoris (Fig. 26-7).

·  Labia minora are dark pink and moist, usually symmetric

·  Urethral opening appears stellate or slitlike and is midline.

·  Vaginal opening, or introitus, may appear as a narrow vertical slit or as a larger opening.

·  Perineum is smooth. A well-healed episiotomy scar, midline or mediolateral, may be present following a vaginal birth.

·  Anus has coarse skin of increased pigmentation (see Chapter 25 for assessment).

Refer any suspicious pigmented lesion for biopsy

Consider delayed puberty if no pubic hair or breast development has occurred by age 13.

Nits or lice at the base of pubic hair.

Swelling.

Excoriation, nodules, rash, or lesions (see Table 26-3).

Inflammation or lesions.

Polyp.

Foul-smelling, irritating discharge.

Palpation

Assess the urethra and Skene’s glands (Fig. 26-8). Dip your gloved finger in a bowl of warm water to lubricate. Then insert your index finger into the vagina, and gently milk the urethra by applying pressure up and out. This procedure should produce no pain. If any discharge appears, culture it.

Assess Bartholin’s glands. Palpate the posterior parts of the labia majora with your index finger in the vagina and your thumb outside (Fig. 26-9). Normally, the labia feel soft and homogeneous.

Assess the support of pelvic musculature by using these maneuvers:

1. Palpate the perineum. Normally, it feels thick, smooth, and muscular in the nulliparous woman, and thin and rigid in the multiparous woman.

2. Ask the woman to squeeze the vaginal opening around your fingers; it should feel tight in the nulliparous woman and have less tone in the multiparous woman.

3. Using your index and middle fingers, separate the vaginal orifice and ask the woman to strain down. Normally, no bulging of vaginal walls or urinary in­continence occurs

Tenderness.

Induration along urethra.

Urethral discharge.

Swelling (see Table 26-3).

Induration.

Pain with palpation.

3.Erythema around or discharge from duct opening

Tenderness.

Paper-thin perineum.

Absent or decreased tone may diminish sexual satisfaction.

Bulging of the vaginal wall indicates cystocele, rectocele, or uterine prolapse (see Table 26-4).

Urinary incontinence.

INTERNAL GENITALIA

Speculum Examination

Select the proper-sized speculum. Warm and lubricate the speculum under warm running water. Avoid gel lubricant at this point because it is bacteriostatic and would distort cells in the cytology specimen you will collect.

A good technique is to dedicate one hand to the patient and the other hand to picking up equipment in the room. For example, hold the speculum in your left hand (the equipment hand), with the index and the middle fingers sur­rounding the blades and your thumb under the thumbscrew. This prevents the blades from opening painfully during insertion. With your right index and mid­dle fingers (the patient hand), push the introitus down and open to relax the pubococcygeal muscle (Fig. 26-10). Tilt the width of the blades obliquely and insert the speculum past your right fingers, applying any pressure downward. This avoids pressure on the sensitive urethra above it

Ease insertion by asking the woman to bear down. This method relaxes the perineal muscles and opens the introitus. (With experience, you can combine speculum insertion with assessing the support of the vaginal muscles.) As the blades pass your right fingers, withdraw your fingers. Now change the hand holding the speculum to your right hand and turn the width of the blades hor­izontally. Continue to insert in a 45-degree angle downward toward the small of the woman’s back (Fig. 26-11). This matches the natural slope of the vagina.

After the blades are fully inserted, open them by squeezing the handles to­gether (Fig. 26-12). The cervix should be in full view. Sometimes this does not occur (especially with beginning examiners), because the blades are angled above the location of the cervix. Try closing the blades, withdrawing about halfway, and reinserting in a more downward plane. Then slowly sweep upward. Once you have the cervix in full view, lock the blades open by tightening the thumbscrew.

Inspect the cervix and its os

Note:

·  Color. Normally the cervical mucosa is pink and even. During the 2nd month of pregnancy it looks blue (Chadwick’s sign), and after menopause it is pale.

·  Position. Midline, either anterior or posterior. Projects 1 to 3 cm into the vagina.

·  Size. Diameter is 2.5 cm (1 inch).

·  Os. This is small and round in the nulliparous woman. In the parous woman, it is a horizontal irregular slit and also may show healed lacerations on the sides (Fig. 26-13).

·  Surface. This is normally smooth, but cervical eversion, or ectropkm, may oc­cur normally after vaginal deliveries. The endocervical canal is everted or “rolled out.” It looks like a red, beefy halo inside the pink cervix surrounding the os. It is difficult to distinguish this normal variation from an abnormal condition (e.g., erosion, or carcinoma), and biopsy may be needed.

NORMAL VARIATION OF CERVIX

Nulliparous                                         Parous (after childbirth)

LACERATIONS

Cervical eversion                                      Nabothian cysts

Nabothian cysts are benign growths that commonly appear on the cervix after childbirth. They are small, smooth, yellow nodules that may be single or multiple. Less than I cm, they are retention cysts due to obstruction of cervi­cal glands.

Note the cervical secretions. Depending on the day of the menstrual cycle, se­cretions may be clear and thin, or thick, opaque, and stringy. Always they are odorless and nonirritating. If secretions are copious, swab the area with a thick-tipped rectal swab. This method sponges away secretions, and you have a better view of the structures.

Redness, inflammation.

Pallor with anemia.

Cyanotic other than with pregnancy (see Table 26-5).

Lateral position may be due to adhe­sion or tumor. Projection of more than 3 cm may be a prolapse.

Hypertrophy of more than 4 cm occurs with inflammation or tumor.

Surface reddened, granular, and asym­metric, particularly around os.

Friable, bleeds easily.

Any lesions: white patch on cervix; strawberry spot.

Refer any suspicious red, white, or pig-mented lesion for biopsy (see erosion, ul-ceration, and carcinoma, Table 26-5).

Cervical polyp—bright red growth pro­truding from the os (see Table 26-5).

Foul-smelling, irritating, with yellow, green, white, or gray discharge {see Table 26-6)

Obtain cervical smears and cultures

The Papanicolaou, or Pap, smear screens for cervical cancer. Do not obtain dur­ing the woman’s menses or if a heavy infectious discharge is present. Instruct the womaot to douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens. Obtain the Pap smear before other specimens so you will not disrupt or remove cells. Laboratories may vary in method, but usually the test consists of three specimens:

Vaginal Pool. Gently rub the blunt end of an Ayre spatula over the vaginal wall under and lateral to the cervix (Fig. 26-14). Wipe the specimen on a slide and spray with fixative immediately. If the mucosa is very dry (as in a post-menopausal woman), moisten a sterile swab with normal saline to collect this specimen.

Cervical Scrape (Fig. 26-15). Insert the bifid end of the Ayre spatula into the vagina with the more pointed bump into the cervical os. Rotate it 360 to 720 degrees, using firm pressure. The rounded cervix fits snugly into the spatula’s groove. The spatula scrapes the surface of the squamocolumnar junction and cervix as you turn the instrument. Spread the specimen from both sides of the spatula onto a glass slide. Use a single stroke to thin out the specimen, not a back-and-forth motion. This specimen is important for the adolescent whose endocervical cells have not yet migrated into the endocervical canal.

Endocervical Specimen (Fig. 26-16). Insert a Cytobrush (instead of a cot­ton applicator) into the os. A Cytobrush gives a higher yield of endocervical cells at the squamocolumnar junction, or SCJ, and safety for use during pregnancy has been shown (Stillson, Knight, and Elswick, 1997). The woman may feel a slight pinch with the brush and scant bleeding may occur. For this reason, col­lect the endocervical specimen last so that bleeding will not obscure cytologic evaluation.

SCJ

Rotate the brush 720 degrees in ONE direction in the endocervical canal, ei­ther clockwise or counterclockwise. Then rotate the brush gently on a slide to deposit all the cells. Rotate in the opposite direction from the one in which you obtained the specimen. Avoid leaving a thick specimen that would be hard to read under the microscope. Immediately (within 2 seconds) spray the slide with fixative to avoid drying.

For the woman following hysterectomy whose cervix has been removed, col­lect a scrape from the end of the vagina and a vaginal pool.

Immediately spray the slides with fixative. The frosted ends of the slides should be labeled with the woman’s name. Send these to the laboratory with the following necessary data:

·        Date of specimen

·        Woman’s date of birth

·        Date of last menstrual period

·        Hormone administration if any

·        If pregnant, with estimated date of delivery

·        Known infections

·        Prior surgery or radiation

·        Prior abnormal cytology

·        Abnormal findings on physical examination

These data are important for accurate interpretation; e.g., a specimen maybe in­terpreted as positive unless the laboratory technicians know the woman has had prior radiation treatment.

To screen for STDs, or if you note any abnormal vaginal discharge, obtain the following samples:

SALINE MOUNT, or “Wet Prep.” Spread a sample of the discharge onto a glass slide and add one drop of normal saline and a coverslip.

KOH Prep. To a sample of the discharge on a glass slide, add one drop potas­sium hydroxide and a coverslip.

GONORRHEA (GC) CHLAMYDIA CULTURE. Insert a sterile cotton applicator into the os, rotate it 360 degrees, and leave it in place 10 to 20 seconds for com­plete saturation. Insert into specimen container and label immediately. Note that newer specimen containers from many laboratories combine the GCIChlamydia culture and do not require incubation.

ANAL CULTURE. Insert a sterile cotton swab into the anal canal about 1 cm. Rotate it, and move it side to side. Leave in place 10 to 20 seconds. If the swab collects feces, discard it and begin again. Insert into specimen container.

FIVE PERCENT ACETIC ACID WASH. Acetic acid (white vinegar) screens for asymptomatic human papilloma virus (HPV), which causes genital warts. After all other specimens are gathered, soak a thick-tipped cotton rectal swab with acetic acid and “paint” the cervix. Acetic acid dissolves mucus and temporarily causes intracellular dehydration and coagulation of protein. A normal response (indicating no HPV infection) is no change in the cervical epithelium.

Rapid acetowhitening or blanching, es­pecially with irregular borders, suggests HPV infection (see Table 26-3).

Inspect the vaginal wall

Loosen the thumbscrew but continue to hold the speculum blades open. Slowly withdraw the speculum, rotating it as you go, to fully inspect the vaginal wall. Normally, the wall looks pink, deeply rugated, moist and smooth, and is free of inflammation or lesions. Normal discharge is thin and clear, or opaque and stringy, but always odorless.

When the blade ends near the vaginal opening, let them close, but be careful not to pinch the mucosa or catch any hairs. Turn the blades obliquely to avoid stretching the opening. Place the metal speculum in a basin to be cleaned later and soaked in a sterilizing and disinfecting solution; discard the plastic variety. Discard your gloves and wash hands

Inflammation or lesions.

Leukoplakia, appears as spot of dried white paint.

Vaginal discharge: thick, white, and curd-like with candidiasis; profuse, watery, gray-green, and frothy with trichomoniasis; or any gray, green-yellow, white, or foul-smelling discharge (see Table 26-6).

Bimanual Examination

Rise to a stand, and have the woman remain in lithotomy position. Drop lubri­cant onto the first two fingers of your gloved intravaginal hand (Fig. 26-17). As­sume the “obstetric” position with the first two fingers extended, the last two flexed onto the palm, and the thumb abducted. Insert your fingers into the vagina, with any pressure directed posteriorly. Wait until the vaginal walls relax, then insert your fingers fully.

You will use both hands to palpate the internal genitalia to assess their loca­tion, size, and mobility, and to screen for any tenderness or mass. One hand is on the abdomen while the other (often the dominant, more sensitive hand) in­serts two fingers into the vagina (Fig. 26-18). It does not matter which you choose as the intravaginal hand; try each way, and settle on the most comfort­able method for you

Palpate the vaginal wall. Normally, it feels smooth and has no area of induration or tenderness

Cervix. Locate the cervix in the midline, ofteear the anterior vaginal wall. The cervix points in the opposite direction of the fundus of the uterus. Palpate using the palmar surface of the fingers. Note these characteristics of a normal cervix:

Consistency—feels smooth and firm, as the consistency of the tip of the nose. It softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell’s sign).

Contour—evenly rounded.

Mobility—With a finger on either side, move the cervix gently from side to side. Normally, this produces no pain (Fig. 26-19).

Palpate all around the fornices; the wall should feel smooth.

Next, use your abdominal hand to push the pelvic organs closer for your in­travaginal fingers to palpate. Place your hand midway between the umbilicus and the symphysis; push down in a slow, firm manner, fingers together and slightly flexed. Brace the elbow of your pelvic arm against your hip, and keep it horizontal. The woman must be relaxed.

Uterus. With your intravaginal fingers in the anterior fornix, assess the uterus. Determine the position, or version, of the uterus (Fig. 26-20). This com­pares the long axis of the uterus with the long axis of the body. In many women, the uterus is anteverted; you palpate it at the level of the pubis with the cervix pointing posteriorly. Two other positions occur normally {midposition and retroverted), as well as two aspects of flexion, where the long axis of the uterus is not straight but is flexed.

Anteverted

Midposition

Anteflexed

Retroflexed

Retroverted

Palpate the uterine wall with your fingers in the fornices. Normally, it feels firm and smooth, with the contour of the fundus rounded. It softens during pregnancy. Bounce the uterus gently between your abdominal and intravaginal hand. It should be freely movable and nontender.

Adnexa. Move both hands to the right to explore the adnexa. Place your ab­dominal hand on the lower quadrant just inside the anterior iliac spine and your intravaginal fingers in the lateral fornix (Fig. 26-21). Push the abdominal hand in and try to capture the ovary. Often, you cannot feel the ovary. When you can, it normally feels smooth, firm, and almond shaped, and is highly movable, slid­ing through the fingers. It is slightly sensitive but not painful. The fallopian tube is not palpable normally. No other mass or pulsation should be felt.

A note of caution—Normal adnexal structures often are not palpable. Be careful not to mistake an abnormality for a normal structure. To be safe, con­sider abnormal any mass that you cannot positively identify, and refer the woman for further study.

Move to the left to palpate the other side. Then, withdraw your hand and check secretions on the fingers before discarding the glove. Normal secretions are clear or cloudy and odorless.

Nodule

Tenderness.

Hard with malignancy. Nodular.

Irregular.

Immobile with malignancy.

Painful with inflammation or ectopic pregnancy

Enlarged uterus (see Table 26-7).

Lateral displacement.

Nodular mass. Irregular, asymmetric uterus. Fixed and immobile.

Tendeness

Enlarged adnexa. Nodules or mass in adnexa.

Immobile.

Markedly tender (see Table 26-8).

Pulsation or palpable fallopian tube suggests ectopic pregnancy; this warrants immediate referral.

Rectovaginal Examination

Use this technique to assess the rectovaginal septum, posterior uterine wall, cul-de-sac, and rectum. Change gloves to avoid spreading any possible infection. Lu­bricate the first two fingers. Instruct the woman that this may feel uncomfort­able and will mimic the feeling of moving her bowels. Ask her to bear down as you insert your index finger into the vagina and your middle finger gently into the rectum (Fig. 26-22).

While pushing with the abdominal hand, repeat the steps of the bimanual ex­amination. Try to keep the intravaginal finger on the cervix so the intrarectal fin­ger does not mistake the cervix for a mass. Note:

•Rectovaginal septum should feel smooth, thin, firm, and pliable.

•Rectovaginal pouch, or cul-de-sac, is a potential space and usually not palpated.

•Uterine wall and fundus feel firm and smooth.

Rotate the intrarectal finger to check the rectal wall and anal sphincter tone. (See Chapter 25 for assessment of anus and rectum.) Check your gloved finger as you withdraw; test any adherent stool for occult blood.

Give the woman tissues to wipe the area and help her up. Remind her to slide her hips back from the edge before sitting up so she will not fall

Nodular or thickened

DEVELOPMENTAL CONSIDERATIONS

Infants and Children

Preparation

•Infant—place on examination table.

•Toddler/preschooler—place on parent’s lap.

Frog-leg position—hips flexed, soles of feet together and up to bottom.

Preschool child may want to separate her own labia.

No drapes—the young girl wants to see what you are doing.

•        School-age child—place on examination table, frog-leg position, no drapes.

During childhood, a routine screening is limited to inspection of the external genitalia to determine that (1) the structures are intact, (2) the vagina is present, and (3) the hymen is patent

The newborn’s genitalia are somewhat engorged. The labia majora are swollen, the labia minora are prominent and protrude beyond the labia majora, the clitoris looks relatively large, and the hymen appears thick. Because of tran­sient engorgement, the vaginal opening is more difficult to see now than it will be later. Place your thumbs on the labia majora. Push laterally while pushing the perineum down, and try to note the vaginal opening above the hymenal ring. Do not palpate the clitoris because it is very sensitive.

A sanguineous vaginal discharge and/or leukorrhea (mucoid discharge) are normal during the first few weeks because of the maternal estrogen effect. (This also may cause transient breast engorgement and secretion.) During the early weeks, the genital engorgement resolves, and the labia minora atrophy and re­main small until puberty (Fig. 26-23)

Between the ages of 2 months and 7 years, the labia majora are flat, the labia minora are thin, the clitoris is relatively small, and the hymen is tissue-paper thin. Normally, no irritation or foul-smelling discharge is present.

In the young school-age girl (7 to 10 years), the mons pubis thickens, the labia majora thicken, and the labia minora become slightly rounded. Pubic hair ap­pears beginning around age 11, although sparse pubic hair may occur as early as age 8 years. Normally, the hymen is perforate.

Almost always in these age groups, an external examination will suffice. If needed, an internal pelvic examination is best performed by a pediatric gyne­cologist using specialized instruments.

Ambiguous genitalia are rare but are suggested by a markedly enlarged cli­toris, fusion of the labia (resembling scro­tum), and palpable mass in fused labia (resembling testes) (see Table 26-9).

Imperforate hymen warrants referral.

Lesions, rash.

Poor perineal hygiene.

Pest inhabitants. Excoriations.

During and after toddler age, foul-smelling discharge occurs with lodging of foreign body, pinworms, or infection.

Absence of pubic hair by 13 years indi­cates delayed puberty.

Amenorrhea in adolescent, together with bluish and bulging hymen, indicates imperforate hymen and warrants referral.

The Adolescent

The adolescent girl has special needs during the genitalia examination. Examine her alone, without the mother present. Assure her of privacy and confidentiality. Allow plenty of time for health education and discussion of pubertal progress. Assess her growth velocity and menstrual history, and use the SMR charts to teach breast and pubic hair development. Assure her that increased vaginal fluid (physiologic leukorrhea) is normal because of the estrogen effect

A pelvic examination is indicated when contraception is desired, when the girl’s sexual activity includes intercourse, or at age 18 years in virgins. Periodic Pap smears also are started when intercourse begins. Although the techniques of the examination are listed in the adult section, you will need to provide addi­tional time and psychological support for the adolescent having her first pelvic examination.

The experience of the first pelvic examination determines how the adolescent will approach future care. Your accepting attitude and gentle, unhurried approach are important. You have a unique teaching opportunity here. Take the time to teach, using the girl’s own body as illustration. Your frank discussion of anatomy and sexual behavior communicates that these topics are acceptable to discuss and not taboo with health care providers. This affirms the girl’s self-concept.

During the bimanual examination, note that the adnexa are not palpable in the adolescent.

Pelvic or aclnexal mass.

The Pregnant Female

Depending on the week of gestation of the pregnancy, inspection shows the en­larging abdomen (see Fig. 27-1 in the following chapter). The height of the fun-dus ascends gradually as the fetus grows. At 16 weeks, the fundus is palpable halfway between the symphysis and umbilicus; at 20 weeks, at the lower edge of the umbilicus; at 28 weeks, halfway between the umbilicus and the xiphoid; and at 34 to 36 weeks, almost to the xiphoid. Then close to term, the fundus drops as the fetal head engages in the pelvis.

The external genitalia show hyperemia of the perineum and vulva because of increased vascularity. Varicose veins may be visible in the labia or legs. Hemor­rhoids may show around the anus. Both are caused by interruption in venous re­turn from the pressure of the fetus.

Internally, the walls of the vagina appear violet or blue (Chadwick’s sign) be­cause of hyperemia. The vaginal walls are deeply rugated and the vaginal mucosa thickens. The cervix looks blue, feels velvety, and feels softer than in the nonpreg-nant state, making it a bit more difficult to differentiate from the vaginal walls.

During bimanual examination, the isthmus of the uterus feels softer and is more easily compressed between your two hands (Hegar’s sign). The fundus bal­loons between your two hands; it feels connected to, but distinct from, the cervix because the isthmus is so soft.

Search the adnexal area carefully during early pregnancy. Normally, the ad-nexal structures are not palpable

An ectopic pregnancy has serious con­sequences (see Table 26-8).

The Aging Adult

Natural lubrication is decreased; to avoid a painful examination, take care to lu­bricate instruments and the examining hand adequately. Use the Pedersen speculum {rather than the Graves) because its narrower, flatter blades are more comfortable in women with vaginal stenosis or dryness.

Menopause and the resulting decrease in estrogen production cause numer­ous physical changes. Pubic hair gradually decreases, becoming thin and sparse in later years. The skin is thinner and fat deposits decrease, leaving the mons pu-bis smaller and the labia flatter. Clitoris size also decreases after age 60.

Internally, the rugae of the vaginal walls decrease, and the walls look pale pink because of the thinned epithelium. The cervix shrinks and looks pale and glis­tening. It may retract, appearing to be flush with the vaginal wall. In some, it is hard to distinguish the cervix from the surrounding vaginal mucosa. Alternately, the cervix may protrude into the vagina if the uterus has prolapsed.

With the bimanual examination, you may need to insert only one gloved fin­ger if vaginal stenosis exists. The uterus feels smaller and firmer, and the ovaries are not palpable normally.

Prior surgery for hysterectomy does not preclude the need for routine gyne­cologic care, including the Pap smear. The Pap smear can help detect gynecologic malignancies even when the cervix has been removed. Be aware that older women may have special needs and will appreciate the following plans of care: for those with arthritis, taking a mild analgesic or antiinflammatory before the appoint­ment may ease joint pain in positioning; schedule appointment times when joint pain or stiffness is at its least; allow extra time for positioning and “unposition-ing” after the examination; and be careful to maintain dignity and privacy.

Refer any suspicious red, white, or pig-mented lesion for biopsy.

Vaginal atrophy increases the risk of in­fection and trauma.

Refer any mass for prompt evaluation.

Summary Checklist: Female Genitalia Exam

1. Inspect external genitalia

2. Palpate labia, Skene’s and Bartholin’s glands

3. Using vaginal speculum, inspect cervix and vagina

4. Obtain specimens for cytologic study

5. Perform bimanual examination: cervix, uterus, adnexa

6. Perform rectovaginal examination

7. Test stool for occult blood

RELATED FACTORS (Etiology)

DEFINING CHARACTERISTICS (Symptoms and Signs)

DIAGNOSIS: Sexual dysfunction

Depression

Disturbance in self-esteem or body image

Lack of significant other

Lack of privacy

Effects of actual or perceived limitation imposed by disease and/or therapy

Substance abuse

Physical or psychosocial abuse

Dysfunctional interpersonal relationships

Ineffective or absent role models

Failure to identify satisfactorily with same-sex parent

Cultural norms regarding male/female roles

Values conflict

Knowledge deficit

Decreased or absent sexual desire

Impotence

Delayed development of secondary sex characteristics

Sexual promiscuity

Exhibitionism

Guilt

Alterations in achieving perceived sex role or sexual satisfaction

Verbalization about the problem

Conflicts involving values

Changes in interest in self and others

Seeking confirmation of desirability

Voyeurism

Transsexualism

Transvestism

Masochism/sadism

DIAGNOSIS: Functional Incontinence

Deficits

Cognitive

Motor

Sensory

Altered environment

Rape event

Unpredictable voiding pattern

Unrecognized signals of bladder fullness

Urge to void or bladder contractions sufficiently strong to result in loss of urine before reaching an appropriate site or receptacle

Acute Phase

Emotional reactions

Anger

Crying

Overcontrol

Panic

Denial

Self-blame

Emotional shock

Embarrassment

Fear of being alone

Humiliation

Fear of physical violence and death

Mistrust of the opposite sex

Desire for revenge

Change in sexual behavior

Multiple physical symptoms

Muscle tension

Pain

Sleep pattern disturbance

Gastrointestinal irritability

Genitourinary discomfort

Long-Term Phase

Mentally reliving rape

Depression

Loss of self-confidence

Changes in lifestyle

Changes in residence

Dealing with repetitive nightmares and phobias

Anxiety

Ambivalence about own sexuality

OTHER RELATED NURSING DIAGNOSES

ACTUAL

Ineffective Sexuality patterns (see Chapter 24)

Impaired Skin integrity (see Chapters 12 and 24)

Pain

Stress Incontinence

Reflex Incontinence

Total Incontinence

Urge Incontinence

RISK/WELUNESS

Risk

Risk for urinary urge incontinence Risk for infection Risk for post-trauma syndrome

Wellness

Health seeking behavior for information on STD risk reduction