Basic clinical skills in gynaecology

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Chapter 15

Basic clinical skills in gynaecology

Ian Symonds

Learning outcomes

After studying this chapter you should be able to:

Knowledge criteria

• Recognize the logical sequence of eliciting a history and physical signs in gynaecology

• Describe pathophysiological basis of symptoms and physical signs in obstetrics and gynaecology

• List the relevant investigations used in the management of common conditions in gynaecology

Clinical competencies

• Elicit a history from a gynaecology patient

• Perform an abdominal examination in women in the non-pregnant state and in early pregnancy (under 20 weeks) and recognize normal findings and common abnormalities

• Perform a vaginal examination (bimanual, bivalve speculum) and recognize normal findings and common abnormalities

• Recognize the acutely unwell patient in gynaecology (pain, bleeding, hypovolaemia, peritonitis)

• Perform, interpret and explain the following relevant investigations: genital swabs (high vaginal swab, endocervical swab), cervical smear

• Summarize and integrate the history, examination and investigation results; formulate a management plan in a clear and logical way and make a clear record in the case notes

Professional skills and attitudes

• Conduct an intimate examination in keeping with professional guidelines, e.g. Royal College of Obstetricians and Gynaecologists and the General Medical Council

• Appreciate the need for a chaperone

• Demonstrate an awareness of the importance of empathy

• Acknowledge and respect cultural diversity

• Demonstrate an awareness of the interaction of social factors with the patient’s illness

• Maintain patient confidentiality

• Provide explanations to patients in language they can understand

The term ‘gynaecology’ describes the study of diseases of the female genital tract and reproductive system. There is a continuum between gynaecology and obstetrics so that the division is somewhat arbitrary. Complications of early pregnancy (less than 20 weeks) such as miscarriage and ectopic pregnancy are generally considered under the title of gynaecology.

History

When taking a history, start by introducing yourself and explaining who you are. Details of the patient’s name, age and occupation should always be recorded at the beginning of a consultation. The age of the patient will influence the likely diagnosis for a number of presenting problems. Occupation may be relevant both to the level of understanding that can be assumed and the impact of different gynaecological problems on the patient’s life. The history should be comprehensive, but not intrusive in a manner that is not relevant to the patient’s problem. For example, whilst it is essential to obtain a detailed sexual history from a young woman presenting with a genital tract infection, it would be both irrelevant and distressing to ask the same questions of an 80-year-old widow with a prolapse. The history must, therefore, be geared to the presenting symptom.

Ten percent of patients presenting to gynaecological services have psychiatric morbidity, and there is a significant association between adverse life events, depression and gynaecological symptoms. Remember: the presenting symptom may not always be related to the main anxiety of the patient and that some time and patience may be required to uncover the various problems that bring the patient to seek medical advice.

Examination

A general examination should always be performed at the first consultation, including assessment of pulse, blood pressure and temperature. Careful note should be taken of any signs of anaemia. The distribution of facial and body hair is often important, as hirsutism may be a presenting symptom of various endocrine disorders. Body weight and height should also be recorded.

The intimate nature of gynaecological examination makes it especially important to ensure that every effort is made to ensure privacy and that the examination is not interrupted by phone calls, bleeps or messages about other patients. The examination should ideally take place in a separate area to the consultation. The patient should be allowed to undress in privacy and if necessary empty her bladder first. After undressing there should be no undue delay prior to examination. Before starting the examination explain what will be involved in vaginal examination and verbal consent should be obtained and documented. The woman should be informed that she can ask for the examination to be stopped at any stage. A chaperone should generally be present irrespective of the gender of the gynaecologist.

Breast examination

Breast examination should be performed if there are symptoms or at the first consultation in women over the age of 45 years. The presence of the secretion of milk at times not associated with pregnancy, known as, galactorrhoea may indicate abnormal endocrine status. Systematic palpation with the flat of the hand should be undertaken to exclude the presence of any lumps in the breast or axillae (Fig. 15.1).

Fig. 15.1 Systematic examination of the four quadrants of the breasts.

Examination of the abdomen

Inspection of the abdomen may reveal the presence of a mass. The distribution of body hair should be noted, and the presence of scars, striae and hernias. Palpation of the abdomen should take account of any guarding and rebound tenderness. It is important to ask the patient to outline the site and radiation of any pain in the abdomen, and palpation for enlargement of the liver, spleen and kidneys should be carried out. If there is a mass, try to determine if it is fixed or mobile, smooth or regular, and if it arises from the pelvis (you should not be able to palpate the lower edge above the pubic bone). Check the hernial orifices and feel for any enlarged lymph nodes in the groin. Percussion of the abdomen may be used to outline the limits of a tumour, to detect the presence of a full bladder or to recognize the presence of tympanitic loops of bowel. Free fluid in the peritoneal cavity will be recognized by the presence of dullness to percussion in the flanks and resonance over the central abdomen (Fig. 15.2).

Fig. 15.2 (A) Percussion over a large ovarian cyst: central dullness and resonance in the flanks. (B) Percussion in the presence of ascites: dullness in the flanks and central resonance.

Auscultation of bowel sounds is indicated in patients with postoperative abdominal distension or acute abdominal pain where obstruction or an ileus is suspected.

Remember to look, in particular, in the umbilicus for scars from previous laparoscopies and in the suprapubic region where transverse incisions from caesarean sections and most gynaecological operations are found.

Pelvic examination

Pelvic examination should not be considered an automatic and inevitable part of every gynaecological consultation. You should consider what information will be gained by the examination, whether this is a screening or diagnostic procedure and whether it is necessary at this time.

The patient should be examined resting supine with the knees drawn up and separated or in stirrups in the lithotomy position (Fig. 15.3). Gloves should be worn on both hands during vaginal and speculum examinations.

Fig. 15.3 Inspection of the external genitalia.

Parting the lips of the labia minora with the left hand, look at the external urethral meatus and inspect the vulva for any discharge, redness, ulceration and old scars. Speculum examination should be performed before digital examination to avoid any contamination with lubricant. A bivalve or Cusco’s speculum is most commonly used, and enables a clear view of the cervix to be obtained.

Holding the lips of the labia minora open with the left hand, insert the speculum into the introitus with the widest part dimension of the instrument in the transverse position as the vagina is widest in this direction. When the speculum reaches the top of the vagina gently open the blades and visualize the cervix (Fig. 15.4). Make a note of the presence of any discharge or bleeding from the cervix and of any polyps or areas of ulceration. Remember that the appearance of the cervix is changed after childbirth with the external os more irregular and slit like.

Fig. 15.4 View of normal cervix on speculum examination.

The commonest finding is of a so-called erosion or ectropion. This is an area of cervical epithelium around the cervical os that appears a darker red colour than the smooth pink of the rest of the cervix. It is not an erosion at all, but normal columnar epithelium extending from the endocervical canal onto the ectocervix. If the clinical history suggests possible infection, take swabs from the vaginal fornices and cervical os and place in transport medium to look for Candida, Trichomonas and Neisseria and take a separate swab from the endocervix for Chlamydia.

Where vaginal wall prolapse is suspected, a Sims’ speculum should be used, as it provides a clearer view of the vaginal walls. Where the Sims’ speculum is used, it is preferable to examine the patient in the semiprone or Sims’ position (Fig. 15.5).

Fig. 15.5 Examination in the lateral semiprone position with a Sims’ speculum enables inspection of the vaginal walls.

Taking a cervical smear (Fig. 15.6)

This should be done at least 3 months after pregnancy and not during menstruation. Explain the purpose of the test and warn the patient that she may notice some spotting afterwards.

Fig. 15.6 (A) A cervical smear is taken using an Ayres spatula. (B) A sample being taking for liquid based-cytology using the broom-like device. (C) The material obtained is plated onto a glass slide and fixed.

Record the patient’s name and hospital number on a suitable slide. After inserting a speculum as above wipe away any discharge or blood. Note the appearance of the cervix. A 360° sweep should be taken with a suitable spatula or brush pressed firmly against the cervix at the junction of the columnar epithelium of the endocervical canal and the squamous epithelium of the ectocervix and rotated in clockwise direction five times.

There are two methods by which cells are transferred onto a slide for staining and inspection by a cytologist or pathologist. In a conventional Pap smear the specimen is spread immediately on to a clear glass slide in a thin even layer. The slide is fixed with 95% alcohol alone or in combination with 3% glacial acetic acid. Fixation requires 30 minutes in solution. In liquid-based cytology (LBC) the sampling device is transferred into the preservative solution vial by pushing the broom into the bottom of the vial 10 times, forcing the bristles apart. The solution is then passed through a filter that traps the large squamous cells but allows smaller red cells, debris and bacteria to pass through. The squamous cells are then transferred to a slide. The sensitivity of both methods for the detection of abnormal cells is similar, although the rate of unsatisfactory smears is lower in LBC. LBC also allows for testing for human Papilloma virus and Chlamydia infection.

Finally, complete the cytology request form with details of previous smears, last period, contraception and results of previous smears.

Taking vaginal swabs

The indications are for symptoms of vaginal discharge, irregular bleeding and pelvic inflammatory disease. Swabs may also be taken to screen for sexually transmitted infection in asymptomatic women.

A high vaginal swab is taken as part of speculum examination by dipping the tip of a culture swab moistened in culture media in the posterior vaginal fornix and then placing the swab immediately back into a suitable culture medium. This is used mainly to identify organisms such a Candida or Trichomonas and in the assessment of bacterial vaginosis.

Endocervical swabs are taken by inserting the tip of the swab into the external cervical os and rotating two or three times. Using standard culture media as for the high vaginal swab this can be used to test for Neiserra Gonorrhoea. Testing for Chlamydia infection is also done by swabbing the endocervix. Instead of culturing the organism the presence of chlamydial DNA is tested using polymerase chain reaction by placing the swab in specialized collection fluid in a plastic vial.

Bimanual examination is performed by introducing the middle finger of the examining hand into the vaginal introitus and applying pressure towards the rectum (Fig. 15.7). As the introitus opens, the index finger is introduced as well. The cervix is palpated and has the consistency of the cartilage of the tip of the nose. It must be remembered that the abdominal hand is used to compress the pelvic organs on to the examining vaginal hand. The size, shape, consistency and position of the uterus must be noted. The uterus is commonly pre-axial or anteverted, but will be postaxial or retroverted in some 10% of women. Provided the retroverted uterus is mobile, the position is rarely significant. It is important to feel in the pouch of Douglas for the presence of thickening or nodules, and then to palpate laterally in both fornices for the presence of any ovarian or tubal masses. An attempt should be made to differentiate between adnexal and uterine masses, although this is often not possible. For example, a pedunculated fibroid may mimic an ovarian tumour, whereas a solid ovarian tumour, if adherent to the uterus, may be impossible to distinguish from a uterine fibroid. The ovaries may be palpable in the normal pelvis if the patient is thin, but the Fallopian tubes are only palpable if they are significantly enlarged.

Fig. 15.7 (A) Bimanual examination of the pelvis. (B) Examination of the lateral fornix.

In a child or in a woman with an intact hymen, speculum and pelvic examination is usually not performed unless as part of an examination under anaesthesia. It should always be remembered that a rough or painful examination rarely produces any useful information and, in certain situations such as tubal ectopic pregnancy, may be dangerous. Throughout the examination remain alert to verbal and non-verbal indications of distress from the patient. Any request that the examination be discontinued should be respected (Box 15.1).

Box 15.1

General Medical Council guidelines for intimate examination – ethical practice

When conducting intimate examinations you should:

• Explain to the patient why an intimate examination is necessary and give the patient an opportunity to ask questions

• Explain what the examination will involve, in a way the patient can understand, so that the patient has a clear idea of what to expect, including any potential pain or discomfort

• Obtain the patient’s permission before the examination and be prepared to discontinue the examination if the patient asks you to

• You should record that permission has been obtained

• Keep discussion relevant and avoid unnecessary personal comments

• Offer a chaperone or invite the patient (in advance if possible) to have a relative or friend present. If the patient does not want a chaperone, you should record that the offer was made and declined. If a chaperone is present, you should record that fact and make a note of the chaperone’s identity. If, for justifiable practical reasons, you cannot offer a chaperone, you should explain to the patient and, if possible, offer to delay the examination to a later date

• Give the patient privacy to undress and dress and use drapes to maintain the patient’s dignity. Do not assist the patient in removing clothing unless you have clarified with them that your assistance is required

• You must obtain consent prior to anaesthetization, usually in writing, for the intimate examination of anaesthetized patients. If you are supervising students you should ensure that valid consent has been obtained before they carry out any intimate examination under anaesthesia

(Adapted from General Medical Council List of Ethical Guidance: Maintaining Boundaries http://www.gmc-uk.org/guidance/ethical_guidance/maintaining_boundaries.asp; accessed 18 September 2012)

Special circumstances

Except in an emergency situation, pelvic examination should not be carried out for non-English-speaking patients without an interpreter. You should be aware of, and sensitive to, factors that may make the examination more difficult for the woman with particular cultural or religious expectations.

Women who experience difficulty with vaginal examination should be given every opportunity to facilitate disclosure of any underlying sexual or marital difficulties or traumas. However, it must not be assumed that all women who experience difficulty with pelvic examination have a background history of sexual abuse, domestic violence or sexual difficulties.

The basic principles of respect, privacy, explanation and consent that apply to the conduct of gynaecological examinations in general apply equally to the conduct of such examinations in women who have temporary or permanent learning disabilities or mental illness.

When examining anaesthetized patients, all staff should treat the woman with the same degree of sensitivity and respect as if she were awake.

Exceptional gentleness should be displayed in the examination of victims of alleged sexual assault. The woman should be given a choice about the gender of the doctor and be allowed to control the pace of, and her position for, the examination.

Rectal examination

Rectal examination may be indicated if there are symptoms such as change of bowel habit or rectal bleeding, which may suggest bowel disease. It is occasionally used as a means of assessing a pelvic mass and in conjunction with a vaginal examination can provide additional information about disease in the rectovaginal septum.

Presenting your findings

Start by introducing the patient by name and age and give the main reason for admission. If there are several problems deal with each in turn. If the history consists of a long narrative of events try to summarize these rather than recap each event. Present the remainder of the history in a logical structured way, not skipping back and forward between items. At the end of your history give a summary in no more than one or two sentences.

Example of a typical history

This is Ms Smith, a 29 year-old housewife who has been referred by her general practitioner to the clinic because of bleeding and a positive pregnancy test. Ms Smith has had three episodes of painless vaginal bleeding over the last 3 days. Her last menstrual period was 7 weeks ago and prior to this she had a regular 28-day menstrual cycle. She has no previous gynaecological history of note and her last cervical smear was 2 years ago and was negative. This is a planned pregnancy and before conceiving she was using the combined oral contraceptive pill until 3 months ago. She has had two previous pregnancies with uncomplicated normal vaginal deliveries at term. She underwent an appendicectomy at the age of 14 and had no problems with the general anaesthetic at the time. She is currently taking folic acid and has no known allergies. She lives with her partner and two children. She does not smoke or drink.

In summary, Ms Smith is a 29-year-old lady with a history of painless vaginal bleeding at 7 weeks in her third pregnancy.

Unless you are asked only to discuss one particular part of the examination always start by commenting on the patient’s general condition including pulse and blood pressure. For abdominal examination, list the findings on inspection first followed by those on palpation and percussion (if there is abdominal distension or a mass). If there is a mass arising from the pelvis describe it in terms of a pregnant uterus, e.g. a mass reaching the umbilicus would be a 20 week size pelvic mass. If there are areas of tenderness specify whether they are associated with signs of peritonism (guarding and rebound). On pelvic examination, describe the findings on inspection of the vulva and then of the cervix (if a speculum examination was carried out). Describe the size, position and mobility of the uterus and any tenderness. Finally, say whether there were any palpable masses or tenderness in the adnexae.

Example of presentation of clinical findings