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Flashcards in Female GU Deck (24)
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1
Q

What are the 4 steps to properly ready a patient for examination of the external genitalia in a female?

A
  1. Drape the patient appropriately and then assist her into the lithotomy position.
  2. Place one heel, then the other into the stirrups. She may be more comfortable in socks or shoes than bare feet.
  3. Then ask her to slide all the way down the examining table until her buttocks extend slightly beyond the edge. Her thighs should be flexed, abducted, and externally rotated at the hips.
  4. Make sure her head is supported with a pillow.
2
Q

What is the proper technique for assessing the external genitalia in a female?

A

Seat yourself comfortably and warn the patient that you will be touching her genital area. Inspect the mons pubis, labia, and perineum. Separate the labia and inspect:

  • The labia minora
  • The clitoris
  • The urethral meatus
  • The vaginal opening, or introitus
  • *Note any inflammation, ulceration, discharge, swelling, or nodules. Palpate any
    lesions. **
3
Q

When and how do you properly assess the Bartholin glands?

A
  • When: If the patient reports labial swelling, examine the Bartholin glands.
  • How:Insert your index finger into the vagina near the posterior introitus (Fig. 14-8). Place your thumb outside the posterior part of the labium majus . Palpate each side in turn, at approximately the “4-o’clock” and “8-o’clock” positions, between your finger and thumb,checking for swelling or tenderness. Note any discharge
    exuding from the duct opening of the gland. If any is present, culture it.
4
Q

What is the proper technique when inserting the speculum into the vagina?

A
  1. Select a speculum of appropriate size and shape, and moisten it with warm water
  2. When inserting the speculum, hold it at a 45° angle
  3. Then slide the speculum inward along the posterior wall of the vagina, applying downward pressure to keep the vaginal introitus relaxed
  4. Rotate the speculum into a horizontal position, maintaining pressure posteriorly, and insert it to its full length (Fig. 14-12). Do not open the blades of the speculum prematurely.
5
Q

What is the proper technique used to examine the cervix?

A
  1. Open the speculum carefully. Rotate and adjust the speculum until it cups the cervix and brings it into full view (Fig. 14-13).
  2. Fix the speculum in its open position by tightening the thumbscrew.
  3. Note the color of the cervix; its position and surface characteristics; and any
    ulcerations, nodules, masses, bleeding, or discharge. Inspect the cervical os for
    discharge.
6
Q

How do you properly obtain a pap smear

A
  • For best results the patient should not be menstruating.
  • She should avoid intercourse and use of douches, tampons, contraceptive foams or creams, or vaginal suppositories for 48 hours before the examination.
  • Rotate the tip of the cervical brush in the cervical os, in a full clockwise direction, then place the sample directly into preservative so that the laboratory 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 a fixative as described on the next page
7
Q

What type of cells are collected with a pap smear?

A

Squamous and columnar epithelial cells.

8
Q

What is the proper technique used when inspecting the vagina?

A
  • Withdraw the speculum slowly while observing the vaginal walls.
  • During withdrawal, inspect the vaginal mucosa, noting its color and any inflammation, discharge, ulcers, or masses.
    • Vaginal discharge often accompanies infection from Candida, Trichomonas vaginalis, and bacterial vaginosis
  • Check for bulging in the vaginal wall. Remove either the upper or lower blade of the speculum (or use a single-blade speculum) and ask the woman to bear down so that you can assess the location of vaginal wall relaxation or the degree of uterine prolapse.
9
Q

Describe how you would perform a bimanual examination

A
  1. Lubricate the index and middle fingers of one of your gloved hands, and from a standing position, insert your lubricated fingers into the vagina, again exerting pressure primarily posteriorly
    • Your thumb should be abducted, your ring and little fingers flexed into your
      palm.
    • Note any nodularity or tenderness in the vaginal wall, including the region of the urethra and the bladder anteriorly.
  2. Palpate the cervix, noting its position, shape, consistency, regularity, mobility, and tenderness. Normally, the cervix can be moved somewhat without pain.
  3. Palpate the uterus. Place your other hand on the abdomen about midway between the umbilicus and the symphysis pubis. While you elevate the cervix and uterus with your pelvic hand, press your abdominal hand in and down, trying to grasp the uterus between your two hands (Fig. 14-14).
    • Note its size, shape, consistency, and mobility, and identify any tenderness or masses.
  4. Palpate each ovary. Place your abdominal hand on the right lower
    quadrant, and your pelvic hand in the right lateral fornix (Fig. 14-15). Press your abdominal hand in and down, trying to push the adnexal structures toward your pelvic hand. Try to identify the right ovary or any adjacent adnexal
    masses. By moving your hands slightly, slide the adnexal structures between your fingers
    • If possible, and note their size, shape, consistency, mobility, and tenderness. Repeat the procedure on the left side
    • Normal ovaries are somewhat tender. They are usually palpable in slender relaxed women, but are difficult or impossible to feel in women who are obese or tense.
10
Q

How do you asses the pelvic floor muscles for strength and tenderness?

A
  • Spread your fingers against the vaginal walls and ask the patient to squeeze around your fingers as long and as hard as she can.
  • Snug compression of your fingers, moving them upward and inward, that lasts 3 or more seconds is full strength.
  • Check for strength, tenderness during contraction, appropriate relaxation after contraction, and endurance in all four vaginal quadrants.
  • Then, with your fingers still placed against the vaginal walls inferiorly, ask the patient to cough several times or to bear down (Valsalva maneuver).
  • Look for any urinary leakage during increased abdominal pressure. Watch for abdominal muscle over recruitment or tightening of the adductor or gluteal muscles.
11
Q

According to the ACOG 2012 guidelines when should women begin having pap smears?

A
  • Younger than 21 should not be screened regardless of the age of sexual initiation or other risk factors
  • 21–29 years - Screening with cytology every 3 years
  • 30–65 years - Screening with cytology and HPV testing (“cotesting”) every 5 years (preferred) or cytology alone every 3 years (acceptable) is recommended.
  • Older than 65 years - Recommends against screening women who have had adequate prior screening¶ and are not otherwise at high risk for cervical cancer
12
Q

What causes and what type of discharge is associated with candidal vaginitis?

A
  • 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
13
Q

What are the symptoms and describe the appearance of the vulva and vaginal mucosa with candidal vaginitis

A
  • Symptoms: Pruritus; vaginal soreness; pain on urination (from skin inflammation); dyspareunia
  • Appearance: The vulva and even the surrounding skin are often
    inflamed and sometimes swollen to a variable extent; the vaginal mucosa is often reddened, with white tenacious patches of discharge; the mucosa may bleed when these patches are scraped off; in mild cases, the mucosa looks normal
14
Q

What causes and what type of discharge is associated with bacterial vaginitis?

A
  • Causes: Bacterial overgrowth probably from anaerobic bacteria; often transmitted sexually
  • Discharge: Gray or white, thin, homogeneous, malodorous;
    coats the vaginal walls; usually not profuse, may be minimal
15
Q

What are the symptoms and describe the appearance of the vulva and vaginal mucosa with bacterial vaginitis

A
  • Symptoms: Unpleasant fishy or musty genital odor; reported to occur after intercourse
  • Appearance: The vulva and vaginal mucosa usually appear normal
16
Q

What are the symptoms associated with atrophic vaginitis?

A

A long-term decrease in estrogen stimulation is generally required before symptoms of atrophic vaginitis arise:

  • Dryness
  • Itching
  • Burning
  • Dyspareunia
  • Burning leucorrhea
  • Vulvar pruritus
  • Feeling of pressure
  • Yellow malodorous discharge
17
Q

What are the physical examination findings associated with atrophic vaginitis

A

Genital:

  • Pale, smooth or shiny vaginal epithelium
  • Loss of elasticity or turgor of skin
  • Sparsity of pubic hair
  • Dryness of labia
  • Fusion of labia minora
  • Introital stenosis
  • Friable, unrugated epithelium
  • Pelvic organ prolapse
  • Rectocele
  • Vulvar dermatoses
  • Vulvar lesions
  • Vulvar patch erythema
  • Petechiae of epithelium

Urethral:

  • Urethral caruncle
  • Eversion of urethral mucosa
  • Cystocele
  • Urethral polyps
  • Ecchymoses
  • Minor lacerations at peri-introital and posterior fourchette
18
Q

What is pelvic organ prolapse?

A

It is a hernia of the pelvic organs to or through the vaginal opening. How does this happen? All of the pelvic organs (bladder, uterus, and rectum) are supported by a complex “hammock” of muscles, ligaments, and fibers that attach to the bony anatomy of the pelvis. When these are weakened, those organs can drop.

19
Q

What causes pelvic inflammatory disease?

A
  • PID is due to “spontaneous ascension of microbes from the cervix or vagina to the endometrium, fallopian tubes, and adjacent structures
  • 85% of cases involve STIs or bacterial vaginosis affecting the fallopian tubes (salpingitis) or the tubes and ovaries (salpingo-oophoritis), primarily N. gonorrhoeae and C. trachomatis.
  • Hallmarks of acute disease are adnexal, cervical, and uterine compression tenderness.
  • The diagnosis is imprecise, however—only 75% have confirmed pathogens on tubal laparoscopy. If not treated, a tubo-ovarian abscess may ensue; 18% of treated patients report infertility after 3 years. Infection of the fallopian tubes and ovaries may also follow childbirth or gynecologic surgery.
20
Q

Describe the stage 1 tanner stage in a female

A
  • Preadolescent—no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen
  • elevation of nipple only
21
Q

Describe the stage 2 tanner stage in a female

A
  • Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly along the labia
  • Breast bud stage: elevation of breast and nipple as a small mound; enlargement of areolar diameter
22
Q

Describe the stage 3 tanner stage in a female

A
  • Darker, coarser, curlier hair, spreading sparsely over the pubic symphysis
  • Further enlargement of elevation of breast and areola, with no separation of their contours
23
Q

Describe the stage 4 tanner stage in a female

A
  • Coarse and curly hair as in adults; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs
  • Projection of areola and nipple to form a secondary mound above the level of
    breast
24
Q

Describe the stage 5 tanner stage in a female

A
  • Hair adult in quantity and quality, spreads on the medial surfaces of the thighs but not up over the abdomen
  • Mature stage: projection of nipple only; areola has receded to general contour of the breast (although in some normal individuals the areola continues to form a secondary mound)