PELVIC EXAMINATION IN EXAMINATION OF THE FEMALE GENITALIA:
EXTERNAL GENITAL EXAMINATION:
The distribution of pubic hair note, as well as whether any anatomic abnormalities are present in the clitoris, labia and perineum. Presence of any vaginal discharge or blood is looked for and noted. The patient ask to cough/strain to elicit the presence of a genital prolapse or stress urinary incontinence. Labia separate using fingers and the external urethral meatus also character of hymen are noted. Usually, the openings of the Bartholin’s ducts cannot be visualized, but if they can seen, an inflammation of the ducts suspect.
VAGINAL EXAMINATION:
SPECULUM EXAMINATION
Speculum examination ideally done prior to a bimanual examination especially when a Pap smear needs to take or a specimen of any discharge needs to collect for bacteriological investigations. Also, if a lesion is present in the cervix, it may bleed on digital examination, making it difficult to visualize during a subsequent speculum examination.
The Cusco’s self-retaining speculum use for satisfactory inspection of the cervix and vaginal fornices and for collection of cervical and vaginal smears. The anterior vaginal wall, however, best visualize with a Sims’ speculum. It permits the evaluation of presence of cystocele or rectocele.
DIGITAL EXAMINATION
In brief, Digital examination always carried out using well-lubricated, gloved fingers.
Cervix
Two fingers of the right hand introduce in the vaginal introitus and moved up to the fornices. Whether the anterior or posterior lip of cervix felt first is noted. If the anterior lip felt first, it means that the cervix push downwards and hence the uterus anteverted. If the posterior lip felt first, the cervix upwards and the uterus retrovert. After making note of the position of cervix, its consistency note; in the pregnant state, the cervix feels soft, whereas in the non-pregnant state, it feels as firm as the tip of the nose. Movement of the cervix elicits pain in cases of ectopic pregnancy and acute salpingo-oophoritis .
Uterus
A bimanual examination done by placing the left hand over the hypogastrium. The fingers in the introitus are then used to push the fornices up so that the uterus (if anteverted) then palpated between both hands and its shape, size, tenderness and any pathology is noted. A retroverted uterus can examine using the fingers present internally only, through the posterior fornix.
Adnexa
Lateral fornices then felt and push up so that any swellings in the lateral part of the pelvis can palpate bimaually. A mass felt separate from the uterus (or a mass that does not move on movement of the cervix) indicative of an adnexal swelling, the most common of which are ovarian cyst, paraovarian cyst, ovarian tumour, chronic ectopic pregnancy or tubo-ovarian mass.
Fallopian tubes are non-palpable, unless they enlarge. Ovaries usually are non-palpable.
Pouch of Douglas
Generally, The pouch of Douglas palpate from the posterior fornix and swellings, if any, note. Additionally, Swelling felt in this area can indicated a retroverted uterus, loaded rectum, pelvic inflammatory masses, chocolate cyst of ovary, pelvic abscess or ovarian neoplasm.
RECTAL EXAMINATION
A rectal examination can do additionally to a vaginal examination or on its own. The lower bowel should ideally empty during a rectal examination and it always carry out with well-lubricated glove fingers.
A rectal examination carried out as part of a gynaecological work-up in cases of i.e.:
- Virgins also children
- Carcinoma of cervix to determine the extent of its spread posteriorly
- Pelvic endometriosis
- Vaginal atresia
- Rectocele to distinguish it from an enterocele
- Swelling in the pouch of Douglas (already determined by vaginal examination), for better appreciation
