The vagina and cervix should be inspected with an appropriately sized bivalve speculum (Figure 2-2), which should be warmed and lubricated with warm water only, so as not to interfere with the examination of cervical cytology or any vaginal exudate. After gently spreading the labia to expose the introitus, the speculum should be inserted with the blades entering the introitus transversely, then directed posteriorly in the axis of the vagina with pressure exerted against the relatively insensitive perineum to avoid contacting the sensitive urethra. As the anterior blade reaches the cervix, the speculum is opened to bring the cervix into view. As the vaginal epithelium is inspected, it is important to rotate the speculum through 90 degrees, so that lesions on the anterior or posterior walls of the vagina ordinarily covered by the blades of the speculum are not overlooked. Vaginal wall relaxation should be evaluated using either a Sims’ speculum or the posterior blade of a bivalve speculum. The patient is asked to bear down (Valsalva’s maneuver) or to cough to demonstrate any stress incontinence. If the patient’s complaint involves urinary stress or urgency, this portion of the examination should be carried out before the bladder is emptied.

FIGURE 2-2 A: Pediatric speculum. B: Pederson speculum.C: Graves speculum. The Pederson speculum has narrower blades and is more appropriate for examining a nulliparous patient.D: Parts of a speculum.

The cervix should be inspected to determine its size, shape, and color. The nulliparous patient generally has a conical, unscarred cervix with a circular, centrally placed os; the multiparous cervix is generally bulbous, and the os has a transverse configuration (Figure 2-3). Any purulent cervical discharge should be cultured. Plugged, distended cervical glands (nabothian follicles) may be seen on the ectocervix. In premenopausal women, the squamocolumnar junction of the cervix is usually visible around the cervical os, particularly in patients of low parity. Postmenopausally, the junction is invariably retracted within the endocervical canal. A cervical cytologic smear (Papanicolaou, or Pap, smear) should be taken before the speculum is withdrawn. The exocervix is gently scraped with a wooden spatula, and the endocervical tissue is gently sampled with a Cytobrush.

FIGURE 2-3 Cervix of a nulliparous patient (A) and a multiparous patient (B). Note the circular os in the nulliparous cervix and the transverse os, owing to lacerations at childbirth, in the multiparous cervix.

Bimanual Examination

The bimanual pelvic examination provides information about the uterus and adnexa (fallopian tubes and ovaries). During this portion of the examination, the urinary bladder should be empty; if it is not, the internal genitalia will be difficult to delineate, and the procedure is more apt to be uncomfortable for the patient. The labia are separated, and the gloved, lubricated index finger is inserted into the vagina, avoiding the sensitive urethral meatus. Pressure is exerted posteriorly against the perineum and puborectalis muscle, which causes the introitus to gape somewhat, thereby usually allowing the middle finger to be inserted as well. Intromission of the two fingers into the depth of the vagina may be facilitated by having the patient bear down slightly.

The cervix is palpated for consistency, contour, size, and tenderness to motion. If the vaginal fornices are absent, as may occur in postmenopausal women, it is not possible to appreciate the size of the cervix on bimanual examination. This can be determined only on rectovaginal or rectal examination.

The uterus is evaluated by placing the abdominal hand flat on the abdomen with the fingers pressing gently just above the symphysis pubis. With the vaginal fingers supinated in either the anterior or the posterior vaginal fornix, the uterine corpus is pressed gently against the abdominal hand (Figure 2-4). As the uterus is felt between the examining fingers of both hands, the size, configuration, consistency, and mobility of the organ are appreciated. If the muscles of the abdominal wall are not compliant or if the uterus is retroverted, the outline, consistency, and mobility must be determined by ballottement with the vaginal fingers in the fornices; in these circumstances, however, it is impossible to discern uterine size accurately.

FIGURE 2-4 Bimanual evaluationof the uterus by exerting gentle pressure on the uterus with thevaginal fingers against the abdominal hand.

By shifting the abdominal hand to either side of the midline and gently elevating the lateral fornix up to the abdominal hand, it may be possible to outline a right adnexal mass (Figure 2-5). The left adnexa are best appreciated with the fingers of the left hand in the vagina (Figure 2-6). The examiner should stand sideways, facing the patient’s left, with the left hip maintaining pressure against the left elbow, thereby providing better tactile sensation because of the relaxed musculature in the forearm and examining hand. The pouch of Douglas is also carefully assessed for nodularity or tenderness, as may occur with endometriosis, pelvic inflammatory disease, or metastatic carcinoma.

FIGURE 2-5 Bimanual examination of the right adnexa. Note that fingers of the right hand are in the vagina.

FIGURE 2-6 Bimanual examination of the left adnexa. Note that fingers of the left hand are in the vagina.

It is usually impossible to feel the normal tube, and conditions must be optimal to appreciate the normal ovary. The normal ovary has the size and consistency of a shelled oyster and may be felt with the vaginal fingers as they are passed across the undersurface of the abdominal hand. The ovaries are very tender to compression, and the patient is uncomfortably aware of any ovarian compression or movement during the examination.

It may be impossible to differentiate between an ovarian and tubal mass, and even a lateral uterine mass. Generally, left adnexal masses are more difficult to evaluate than those on the right because of the position of the sigmoid colon on the left side of the pelvis. An ultrasonic examination should be helpful for delineating these features.

RECTAL EXAMINATION

The anus should be inspected for lesions, hemorrhoids, or inflammation. Rectal sphincter tone should be recorded and any mucosal lesions noted. A guaiac test should be performed to determine the presence of occult blood.

A rectovaginal examination is helpful in evaluating masses in the cul-de-sac, the rectovaginal septum, or adnexa. It is essential in evaluating the parametrium in patients with cervical cancer. Rectal examination may also be essential in differentiating between a rectocele and an enterocele (Figure 2-7).

FIGURE 2-7 Rectovaginal bimanual examination. During Valsalva’s maneuver, an enterocele will separate the two fingers.

LABORATORY EVALUATION

Appropriate laboratory tests normally include a urinalysis, complete blood count, erythrocyte sedimentation rate, and blood chemistry analyses. Special tests, such as tumor marker and hormone assays, are performed when indicated.

ASSESSMENT

A reasonable differential diagnosis should be possible with the information gleaned from the history, physical examination, and laboratory tests. The plan of management should aim toward a chemical or histologic confirmation of the presumptive diagnosis, and the appropriate therapeutic options, along with the rationale for each option, should be recorded.

Patients with Special Needs

THE PEDIATRIC AND ADOLESCENT PATIENT

Girls experience fewer gynecologic problems than do adult women, but their concerns need to be met effectively and skillfully in a way that will allay anxiety and create a positive attitude toward their gynecologic health. Unique complaints fall generally into a handful of categories: congenital anomalies, genital injuries, inflammation of the nonestrogenized genital tract, pubertal problems, and psychosexual concerns. Genital ambiguity, trauma, and vaginal bleeding in the prepubertal child are covered briefly in this chapter.

GENITAL AMBIGUITY

Dealing with genital ambiguity in the newborn requires a coordinated and timely response. The family’s psychological well-being must be addressed because they must feel confident in the gender identity of their child. Ambiguity can result from masculinization of a female child due to exogenous hormone ingestion or maternal or fetal overproduction of androgen. It may also result from incomplete virilization of a male infant, hormonal insensitivity, gonadal dysgenesis, or chromosomal anomalies (see Chapters 31 and 32). When assessing an infant with ambiguous genitals, fluid and electrolyte balance should be monitored and blood drawn for 17-hydroxyprogesterone and cortisol to rule out 21-hydroxylase deficiency. Life-threatening illness may be missed in children with the salt-losing form of congenital adrenal hyperplasia (see Chapter 32).

TRAUMA

Straddle injuries are the most common cause of trauma to the genitalia of a young girl, and the injuries have a seasonal peak when bicycles come out in the spring. Most of these injuries are to the labia. Penetrating vaginal injuries can cause major intraabdominal damage with minimal external findings. Sexual assault must always be considered. After a life-threatening condition is ruled out, an ice pack, chilled bag of intravenous solution, or cool compress may be applied to the injured area and the child allowed to rest quietly for 20 minutes before being assessed further. Extensive injuries usually require examination under anesthesia and surgical repair.

In any case of trauma, concurrent damage to the rectum or urinary tract should be considered. If there is any reason to suspect sexual or physical abuse, the child protection authorities must be notified, and the examination should include the collection of medicolegal evidence.

VAGINAL BLEEDING IN THE PREPUBERTAL CHILD

Vaginal bleeding is a frequent and distressing complaint in childhood. Although it will most often be of benign cause, more serious pathologic processes must always be ruled out. Vaginal bleeding in the newborn is most often physiologic as a result of maternal estrogen withdrawal. In such cases, there should be supportive evidence of a hormonal effect, such as the presence of breast tissue and pale, engorged vaginal epithelium. Bleeding disorders are uncommon in this age group but should be considered. Vitamin K is routinely given to the newborn, but some patients may refuse the medication.

Precocious puberty (see Chapter 31) may present with vaginal bleeding, although most commonly other evidence of maturation will have preceded the bleeding and will be evident on examination. At the very least, a pale, estrogenized vaginal epithelium will be seen, and cytologic analysis of the vagina will confirm the hormonal effect. Transient precocious puberty may occur in response to a functional ovarian cyst, and vaginal bleeding may be triggered by the spontaneous resolution of the cyst. Exogenous hormonal exposure should be considered because children have been known to ingest birth control pills. Ovarian tumors resulting in pseudoprecocious puberty should be ruled out.

Vulvovaginitis is common but is a diagnosis of exclusion. When bleeding is present, it is necessary to assess the vagina and to rule out a foreign body or vaginal tumor.

Vaginal tumors are the most serious possibility to be considered. Sarcoma botryoides classically presents with vaginal bleeding and grape-like vesicles. Fortunately, this is a rare tumor.

The Geriatric Patient