INTRODUCTORY CLERKSHIP : CLINICAL SIKILL TEACHING

IB CSL O&G

P/E GYNAE
Dr Cheung

O&G
Tue 24-09-02
INTRODUCTION

Greet Pt

Take Hx

GENERAL EXAMINATION

General appearance

H&N

Supraclavicular areas

Breast

Thyroid

Extremities

Weight

Groin

Ab exam ® (1) Inspection ® scar, umbilicus, striae, distension, etc (2) Auscultation ® bruit, bowel sounds

BREAST EXAMINATION

Inspect

Pt position: hands at side ® raised ® on hips (chest fwd, pec tensed)

Contour - symmetry

Nipple - retraction (tumour under areola), pointing in different directions

Pt lying - hands behind head

Uncover one breast at a time

Hair growth - chest wall, around areola

Palpation

Use flat of fingers

nodularity during menstruation (\ best to examine at end of 1^st week of cycle)

Breast tissue - fat, fibrous, glandular/ ductal

RADIAL ® From nipple out ; Press breast tissue against chest wall ; Check axilla - enlarged LN, breast tissue ; Squeeze nipple - discharge?

SPIRAL ® Ever enlarging circles from nipple ; Axilla - LN, breast tissue ; Squeeze nipple - galactorrhoea? Unusual discharge?

Gynaecological examination

Utmost gentleness

Order: inspect ® speculum ® digital (bimanual) ® rectovaginal ® rectal

Equipment: Speculum, Gloves, Glass slide, Swab, Cover slip, KY jelly, Test-tube/ rack, Saline, KOH

Pt position

Lithotomy position - legs apart, buttocks at end of table, keep Pt informed (so she can relax)
Left lateral - if (1) Pt cannot spread legs (2) Prolapse in elderly (3) Very shy Pt

Genital inspection

Inspect

Mons

Labia majora - fat, sebaceous glands, hair follicles ® lesions?

Labia minora - sebaceous glands, nerve endings

Clitoris - do not touch

Urethral opening/ meatus

Skene's glands (aka paraurethral ducts of female urethra) - inconstantly present ducts in the female, which drain a group of the urethral glands into the vestibule

Hymeneal ring

Bartholin's gland (aka greater vestibular gland) - either of 2 small reddish-yellow bodies in the vestibular bulbs, one on each side of the vaginal orifice ® palpable if infected/ abnormal

Vestibule

Posterior fourchette

Pub hair distribution - diamond, triangle-shaped

Vulva - swelling, inflammation, ulceration, atrophy

Urethra - urethritis, caruncle

Prolapse

Speculum examination

Aim

Enable direct vision of the vagina and cervix.
A cervical smear can be obtained for cytology
High vaginal or endocervical swab for culture and sensitivity in case of abnormal vaginal discharge

Procedure

Lithotomy or left lateral position

Bivalve speculum (Cusco’s) or Sims’ speculum, lubricated

Sims' - 'U'-shaped; blades different lengths, for viewing genital prolapse

Paediatric/ Virginal - narrower, shorter

Metal - must sterilise between Pt's with autoclave

Plastic - ¯ coldness, can visualise vaginal wall, can attach light, disposable (use if suspect venereal disease), ¯ size available, hinge not good

Type ® (1) Age (2) Purpose (3) Parity (4) Method of delivery

NO speculum exam if not sexually active/ intact hymen (may do gentle 1 finger digital exam, only if consent given) - note: cannot view cervix + vagina without tearing intact hymen

Size important - (1) Too small - vaginal wall falls back and cannot see anything (2) Too large - painful!

Contraindications

Not menstruating

No immediately after menstruation

Not after vaginal pessary

Not during vaginal infection (most common ® Candida + Trichomonas vaginalis)

Not after vaginal douche

BEST - mid-cycle

Procedure

Warn Pt
Warm speculum (if metal)
Right hand gloved
Left hand separate the labia minora and inspect
Hold blades together between 2^nd and 3^rd fingers
Downward pressure on perineum
Insert at 45^o to vaginal opening + directed at 45° angle toward the floor (do not insert vertical as may catch urethral opening)
Open speculum (AP) - lock self-retaining screw
May need gentle manipulation to bring the cervix into view

Pap/ Cervical/ Endocervical smear

Recommended in females > 25yo

Ayre spatula - insert external os, rotate 360^o, wipe on slide

Swab - endocervical canal, rotate 360^o, wipe on same slide

Spray slide with fixative

Examine vaginal wall (may need to turn to view ant + post wall)

Remove slightly - release screw (otherwise may clamp cervix) then remove slowly

If contact bleedings ® must (1) Tell Pt (2) Mark in records [Pt with microerosion? May be cause of post-coital bleeding]

Tell Pt most uncomfortable procedure is finished!

Bimanual examination

Preparation

Empty bowels (enema if necessary)
Empty UB

Aim

To detect pelvic pathology eg. ovarian tumour

Procedure

Lithotomy or left lateral position

LOOK at Pt for signs of discomfort (remember, you are feeling \ do not need to look at genital region) - look at Pt's face instead

Left hand: open the labia minora

Right hand: gloved and lubricant on index (and middle) finger(s), introduced gently into the vagina (palm facing up)

Note vaginal wall condition

Cervix palpated for consistency

Do not touch os ® contact bleeding

Can gently feel rim of cervical ox + cervical lip (ant/ post)

Note any cervical excitation ® indicates pelvic infection (mainly at tubes) [move cervix ® moves uterus ® moves tubes \ painful]

Fingers slightly behind cervix to elevate uterus

Left hand placed on lower abdomen

Uterus : palpated between 2 hands for its size, consistency, shape, mobility, tenderness and tumour

Size of uterus - compare non-pregnant with pregnant size

Eg. Uterus size equivalent to 14 week gravid size

Bulky - 6-8 week-sized uterus

Nulliparous uterus usually smaller than multiparous (\ can allow size for multiparous and still be normal)

Irregularity - uterine fibroid myoma most common cause

Solid tumour of myometrial/ fibrous tissue

Benign

Commonest uterine mass/ cause of irregular uterus

The fingers in vagina is shifted into first one and then the other lateral fornix and the hand on the abdomen follows it to explore for any enlargement of tenderness of the fallopian tubes and ovaries (adnexa)

Ovarian mass - cystic (most common), solid

Cannot feel < 3cm Æ (\ if feel mass, must be ³ 3cm)

Size of normal ovary = 3x2 cm

Cannot differentiate between mass and body

Thin Pt - can sometime feel normal ovary (compression ® painful)

The fingers are then passed into the posterior fornix to detect any swelling or tenderness in the Pouch of Douglas (posterior vaginal wall, ovarian mass, nodularity may indicate endometriosis)

The fingers are moved into the anterior fornix to detect any swelling or tenderness.

The fingers are withdrawn and inspected for any bleeding or discharge

Note

Uterus position wrt axis of vagina

90^o - normal/ most usual, anteverted
More in line with axis of vagina - 1^st degree retroversion
Directly in line with axis of vagina - 2^nd degree retroversion
Uterus resting on rectum - 3^rd degree retroversion (can cause urinary retention if uterus 12w size/ pain)

Uterus corpus wrt axis of cervix

Anteflexion - bend anterior to cervix
Retroflexion - bend posterior to cervix

Rectal examination

Aim

Permits bimanual examination of uterus, tubes and ovaries when vaginal examination is impossible or undesirable, e.g. in sexually inactive woman

Enable to feel a retroverted uterus or swelling in Pouch of Douglas

Detect thickening in parametria

Detect rectal tumour (50% can be detected by DRE)

NOTE: routine gynae exam does NOT include rectal exam

Use 1 finger only (palm to sky)

Bimanual exam

Cervical ca - spreads to parametrium (aka cardinal ligament) - can only feel nodularity via rectal exam \ ca Pt always perform vaginal then rectal exam

Note: parametrium - from uterus to sidewall - give clinical assessment (eg. Half involved, spread to side wall)

Rectovaginal examination

Aim

Enable to palpate for nodularity, tenderness or abnormalities of the posterior surface of the uterus, broad ligament, uterosacral ligaments and rectovaginal septum

Procedure

Middle finger ® rectum

Index finger ® vagina

PROCEDURES

UTERINE SOUND

Has markings - measure size of uterus (from fundus to external os)

Before IUCD (most common use)

Determine direction of uterus ® ante/ retroverted

Before D&C

Endometrial sampling

Made of metal (hard) \ can negotiate through internal os

Can cause pain/ vasovagal attack

Lock speculum ® use ring forceps/ folsellum (?) to pull cervix out slightly (straightens uterus)

Insert sound

Leave folsellum (?) for next procedure (eg. IUCD insertion)

ENDOMETRIAL BIOPSY/ SAMPLING

Fine tube with holes at tip and suction device/ syringe/ -ve pressure
No need to dilate cervical canal

Endocervical curette (scraping)

Get endometrial cells for histology ® hyperplasia, ca (eg. Pt with abnormal bleeding)

Hormonal appearance (change with hormones) ® hormone assessment, day 22 of cycle

IUCD

'T'-shaped ($100 each)

Change every 3-5 years (if leave too long ® ¯ contraceptive effect + may become embedded)

'T' shape inserted into applicator (flattens out) - has nylon thread

Applicator has guard (stops at cervix) and plunger

Method: sound uterus ® steady plunger ® remove applicator (withdrawal method - safer - tip of applicator at top of uterus) - also insertion method (tip of applicator at internal os)

Complication rate depends on skill of insertion ® pain

Perforate uterus

Translocation - partially embeds in myometrium and squeezes through

Expulsion - spontaneously comes out (due to uterine contractions)

Note: uterus is opposed AP \ plane of IUCD in same plane as uterus ® if insert wrong plane - cramps, bleeding, perforate, infection, expulsion

IUCD - rate of ectopic pregnancy (due to ¯ intrauterine pregnancy)

Insert immediately after menstruation (sure that Pt is not pregnant)

Luteal phase pregnancy - no missed period \ Pt says that IUCD didn't work because she is pregnant, when in fact Pt pregnant before IUCD insertion (also occurs in tubal ligation)

Insertion by - (1) Gynaecologist (2) Family planning (3) MCH (4) GP if experienced (don't need specialist - need training!)

Thread - cut after insertion, on speculum exam if thread still there then IUCD still there too (thread will not separate from IUCD)

If pregnant and see thread, pull out (if no thread - (1) Continue pregnancy - change infection (2) Termination)

If no thread - (1) Expelled (2) Perforated - use US (3) Hiding in endocervical canal (thread too short)

At follow-up as if any problems during sex? Pricking sensation? May need to cut thread

Note: IUCD adjusts position after insertion \ leave thread longer at first until final position reached, then cut thread as necessary