Female Genitalia and the Pelvis

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Chapter 17 Female Genitalia and the Pelvis

Salvatore Mangione, MD

“A child of our grandmother Eve, a female; or, for thy more sweet understanding, a woman.”

Shakespeare, Love’s Labour’s Lost, Act I

1 What is the role of the pelvic exam?

To provide an essential component of the female exam, which, when well performed, allows for “low-tech” cancer screening plus the detection of various obstetric-gynecologic conditions—including pregnancy.

2 How can I make my patient as comfortable as possible during the pelvic exam?

By following a few simple steps:

Instruct her to void prior to the exam, since a full bladder can often be confused for a pregnant uterus or an ovarian cyst.

Ideally have her empty her bowels, too.

Raise the table back to a comfortable height so that you can maintain eye contact at all time.

Offer a pillow for her back.

Place a drape over her abdomen, thighs, and knees.

Before performing each step of the exam, inform her about it.

Instruct her to relax the perineal muscles through appropriate breathing.

Always wash your hands in the presence of the patient.

Warm the speculum before using it.

Watch your terminology during the exam. Never say you are going to “feel” something since this has sexual connotations. Use instead “check.” Also, do not refer to “foot rests” as “stirrups.” And more importantly, keep them out of sight until you are ready to use them.

Always explain your findings, even if normal.

Continuous communication is paramount. Provide your patient with a sense of control by reassuring her that she will be able to stop the exam at any time if it were to become too uncomfortable. Also, offer her a hand-held mirror so that she can become more of a participant. By following these guidelines, pelvic exams should cause minimal discomfort or embarrassment. They should never be painful, except for tenderness from underlying pathology.

3 When should a chaperone attend the pelvic exam?

Whenever the examiner is male

If the patient is a minor

If the patient requests it

At the examiner’s discretion when the patient is particularly anxious

4 What circumstances can make pelvic exams difficult for women?

For one, it may be their very first exam and, hence, totally unfamiliar. In this case, explain very clearly what you are going to do, and show the equipment you will use. Secondly, the patient might have never had intercourse and thus presents with a small vaginal opening that makes speculum insertion rather difficult. Postmenopausal women, especially if not sexually active, also may present with a small (and atrophic) introitus. In addition, women from various cultures might have undergone some type of “circumcision” that altered their anatomy and rendered the examination more difficult. Finally, the patient might have a background of childhood/adult sexual abuse—even rape. This can often cause panic (or dissociation) during the exam. Hence, it is essential that you elicit information of this sort during history-taking, especially while the patient is still clothed and comfortably seated—not while she is on the exam table.

5 What are some techniques that can assist you in a difficult exam?

The most valuable, definitely, is communication—and observation, too. For example, if at the beginning of the exam you see the patient bring her knees together, immediately stop and allow her to sit up comfortably. Put a drape on her lap, and then ask about her concerns. If the exam is not urgently needed, reschedule it. For women who are anxious because they are undergoing their first evaluation, ask them to return, but also instruct them to practice by inserting tampons or a disposable speculum. Instruct postmenopausal women with atrophy to apply an estrogen vaginal cream during the week preceding the rescheduled exam. Ask sexual abuse survivors if they feel safe about undergoing a pelvic exam. In fact, you may even want to offer them preparatory counseling. Finally, ask patients who have experienced “female circumcision” (i.e., female genital mutilation [FGM]) to contact the RAINBO Foundation, which can provide them with useful information.

6 Who is qualified to perform a pelvic exam for sexual assault victims?

Only individuals with training in forensic techniques, because an incomplete exam might prevent law enforcement authorities from arresting (and convicting) the perpetrator. Hence, when confronted with these situations, immediately contact local officials, who will provide you with qualified examiners, evidence-collecting kits, and appropriate forms for documenting the history and pelvic exam. Always be as supportive of the victim as possible—yet, do not allow her to change (or bathe) until the forensic exam has been completed. Otherwise, valuable evidence might get lost, including fibers, hairs, fingernail scrapings, blood, or body fluids.

7 What are the tools needed for a pelvic exam?

Padded exam table with padded foot rests (quilted oven mitts do nicely)

Good and adjustable light source (gooseneck or fiberoptic lamp)

Examination gloves

Plastic (or metal) vaginal specula of various sizes and types, including Pedersen’s, Graves’, and pediatric

Water-soluble lubricant

Tissues

Although a simple direct exam can provide lots of information, a few bedside diagnostic procedures are routinely added. These include occult blood testing, microbiologic assessment, and performance of the Papanicolaou smear (which provides a simple cytologic exam for cervical inflammation, atypia, or dysplasia). To carry out these procedures you will need:

Glass slides for Pap smear and wet mount

Cytological fixative

A small test tube with a few drops of normal saline for the wet mount

pH paper

Cytobrush and wooden spatula for collecting the Pap smear

Cotton-tipped applicators and specimen collection tubes for gonococcal and chlamydial testing by DNA probe analysis

Fecal occult blood testing card and hemoccult developer

8 What are the components of the pelvic exam?

Inspection and palpation of external genitalia

Examination with speculum

Bimanual palpation

Rectovaginal palpation

A. Inspection/Palpation of External Genitalia: Vulva and Perineum

9 What is the anatomy of the vulva?

The vulva comprises several anatomic structures: (1) the mons veneris (or pubis), (2) the labia majora and minora, (3) the clitoris, (4) the urethral meatus, (5) the Skene’s glands, (6) the vaginal vestibule and introitus, and (7) the vestibular (Bartholin’s) glands. All should be inspected. Any lesion should be palpated.

10 What should you look for in the external genitalia?

It depends on the structure. Inspect (1) the vulvar skin (for redness, nodules, swellings, excoriations, ulcerations, and changes in pigmentation/leukoplakia); (2) the mons veneris (for lesions and swelling); and (3) the hair (for lice and nits). By gently spreading the labia majora and minora, you will then get access to the vaginal vestibule. Inspect (and palpate) the urethral meatus (for purulent discharge) and the Skene’s glands. Inspect the clitoris, perineum, and anus. Look for masses, scars, fissures, and fistulas. Finally, check for hemorrhoids, and palpate any visible lesions.

11 Where are the openings of Skene’s (paraurethral) glands?

On either side of the urethral meatus. Inspect them, and palpate them. Then, insert your index finger into the vagina, press up onto the urethra, and milk it for possible discharge.

12 Who was Skene?

Alexander J. Skene (1838–1900) was a Scot, who at the age of 18 moved to Canada and then to New York, where he obtained his medical degree in the midst of the American Civil War. He did serve in that war (even planning an army ambulance corps), eventually going back to the practice of gynecology and becoming one of the founders of the American Gynecological Society. Still, his call to fame was the 1880 description of the homonymous glands, which was nothing new, since they had already been reported in 1672 by Reiner de Graaf, in an observation that (as often happens in medicine) had been totally forgotten.

13 What important information can be gained by inspecting the vulva?

Mostly the degree of estrogenization of the urogenital tract, which is reflected by the presence of mucus and by the thickness and rugation of the vulvar/vaginal mucosae.

14 What is the female escutcheon?

It is the triangular pattern of pubic hair that is unique to adult females (i.e., with apex pointing down toward the pubis). The male escutcheon is instead a reverse triangle, with apex pointing up toward the umbilicus. A masculine escutcheon in a woman is usually a sign of virilization, even though it also may be a normal variant.

15 What are Tanner’s stages of sexual maturation?

They are a way to assess sexual maturation by following the growth of breast and pubic hair. They are mostly used in pediatric and adolescent medicine, but also can be helpful in evaluating patients with primary amenorrhea (Table 17-1).

Table 17-1 Tanner Stages of Sexual Maturation in Girls

16 What is the differential diagnosis of enlarged inguinal nodes?

The major one is infection of the genital area, lower extremities, or nodes per se. Cancer should also be ruled out, either primary (lymphoma) or metastatic.

17 What is the significance of white vulvar lesions?

They may be benign, premalignant, or malignant.

18 What are the benign white lesions of the vulva?

They are mostly vitiligo and inflammatory dermatitis, like psoriasis.

19 What are the most common premalignant white lesions?

Vulvar dystrophies, such as hyperplastic dystrophy (squamous cell hyperplasia) and lichen sclerosus et atrophicus (LS&A). LS&A is an atrophic condition of the vulva and perianal skin that can occur alone or in association with other cutaneous lesions. It presents as patches of reddened and thin skin, which evolve into yellowish-bluish papules/macules, eventually coalescing into areas of atrophic, grayish, and crinkling mucosa—smooth, thin, fragile. Itching and burning are common, and so is secondary infection. Other symptoms may include dyspareunia (pain during intercourse) and skin splitting and bleeding. The condition may eventually lead to resorption of the clitoris and labia minora. It also may progress to malignancy, usually squamous cell carcinoma. Although LS&A may occur in all age groups, it is more common in postmenopausal women (especially Caucasian and Latino), where extensive lesions can even narrow the introitus. Hyperplastic dystrophy can present quite similarly, as a pruritic grayish-whitish plaque, but it does not lead to resorption of the labia and clitoris. Moreover, it is microscopically differentiated from LS&A because of its squamous cell hyperplasia/atypia. Vulvar dystrophies represent a continuum from benign to malignant, with white lesions of both kinds frequently coexisting in the vulva. Hence, the need to biopsy any white and dystrophic area.

20 What are malignant white lesions?

Mostly two: vulvar intraepithelial neoplasia and Bowen’s disease.

21 What are other vulvar malignancies?

The most common is squamous cell carcinoma. Of interest, melanoma is the next most common. Hence, both patients and physician should be quite attentive to vulvar “moles” and include this area in their regular examination for nevi. Other histologic types include adenocarcinoma (of Bartholin’s gland), basal cell carcinoma, and sarcoma.

22 What is the differential diagnosis of a painful vulvar ulceration?

A painful (and multiple) vulvar ulceration is usually due to ruptured and coalescent herpes simplex lesions or chancroid.

23 What is the differential diagnosis of a painless vulvar ulceration?

A painful (and solitary) vulvar ulceration is usually due to syphilis. A painless but longstanding ulcer should raise the suspicion for a vulvar carcinoma.

24 What is a labial hernia?

The uncommon occurrence of the herniation of a bowel loop into one of the labia majora, analogous to an inguinal hernia in a male.

25 Where are Bartholin’s glands located?

Deep in the lateral walls of the vulva, close to the posterior fornix.

26 How do you examine them?

By placing a gloved index finger just inside the vaginal opening (near the posterior end of the introitus) and the thumb on the outside. Then, to examine the right Bartholin’s gland, grasp the posterior portion of the right major labium between the index finger and the thumb. Palpate gently for enlargement or tenderness. Do the same for the contralateral gland. Note that in the absence of disease, Bartholin’s glands should be neither visible nor palpable.

27 What is the differential diagnosis of a mass or swelling of the Bartholin’s gland?

The most common is cysts or abscesses of the glands. These are quite common and present as indurated (and often tender) enlargement of one or both labia majora. More rarely, adenocarcinoma of the gland also can be responsible.

28 Who was Bartholin?

Caspar Bartholin (1655–1738) was a Danish physician and the son of a famous anatomist (who provided the first description of intestinal lymphatics and their drainage into the thoracic duct). Caspar managed to outdo his dad, not only because of his description of the homonymous glands (and their possible cystic degeneration), but also because of his discovery of the sublingual glands and their ducts, which still carry his name. During the last part of his life, he left medicine for politics, becoming Denmark’s procurator general and deputy of finance.

29 What is the hymen? What are the myths surrounding it?

From the Greek humen (membrane), the hymen is a ring of tissue around the vaginal opening. Contrary to popular belief, a normal hymen does not completely occlude the introitus (see question 30) but simply surrounds it as an annular structure. Hymens also can be septate (with one or more bands across the opening) or cribriform (completely stretching across the opening, but with several perforations). After pregnancy, they are usually reduced to a few remnants around the vaginal opening or to a ragged and irregular outline. Yet completely intact hymens have been reported after delivery. They also have been reported after intercourse. In fact, bleeding may not occur at all after the first vaginal penetration, and if it does, it may not be due to laceration of the hymen, but to trauma of nearby tissues. Finally, the infamous straddle injuries of old (such as horseback riding or falling on the horizontal bar of a bicycle) do not traumatize the hymen.

30 What is an imperforate hymen?

A congenital abnormality that often goes unrecognized until puberty, when the patient becomes symptomatic from retained menses. On exam, the hymen appears as an intact and completely closed membrane, bulging with retained menstrual products. If untreated, this can lead to hematometrium and hematosalpinx. Treatment is hymenotomy, which also is the treatment of choice for unusually thick hymens, another congenital abnormality, often responsible for dyspareunia.

31 What is the normal size of the glans clitoris?

Around 3–4 mm.

32 What is the clitoral index (CI)? How do you calculate it?

The CI is a “poor man’s” bioassay of androgenic stimulation since it reflects the stimulation of the clitoris by both testosterone and 17-ketosteroids. It is calculated by multiplying the sagittal and transverse diameters of the glans, with the normal range being 9–35 mm. A CI of 36–99 mm is usually borderline, whereas one >100 mm is considered abnormal. Enlargement of the clitoris indicates virilization and thus should prompt a search for sources of androgenization.

33 What is the appearance of the clitoris and vulva in congenital adrenal hyperplasia?

Virilized. This is usually apparent from birth, including clitoral hypertrophy and fused labia. In untreated females, secondary sex characteristics fail to develop.

34 What is congenital adrenal hyperplasia?

The generic term for hereditary deficiency of a number of enzymes of glucocorticoid synthesis—the most common being 21-hydroxylase and 11-B-hydroxylase. The resulting decrease in hydrocortisone levels leads to greater adrenocorticotropic hormone (ACTH) production, which, in turn, causes a secondary increase in adrenal androgens. Hence, the virilization. A very famous patient with this condition was probably Queen Christina of Sweden, whose sexuality has been a subject of speculation from the very day of her birth, when she was indeed mistaken for a boy (the cannons at the royal palace saluted her as such). Some have even suggested that she may have been a female pseudohermaphrodite. Christina was the cultured and intellectual daughter of Gustavus Adolphus, a war-mongering Protestant king and the Catholics’ scourge during the Thirty Years War. After her father got himself killed in battle, young Christina invited Descartes to Stockholm to spruce up the local cultural scene. Unfortunately, he soon caught pneumonia and died, which convinced the queen that it was finally time to move to more southern and warmer climates. In a few months, she abdicated, became a Catholic, and relocated in Rome. Some historians have even speculated that the real reason behind this surprising decision was that she did not want to take a husband, possibly as a result of her congenital adrenal hyperplasia. Either way, she spent the rest of her life in Italy, pursuing culture, beauty, and romantic liaisons—mostly with women. After her death, she was buried in St Peter’s Basilica, not too far from Michelangelo’s Pietà—the only woman (?) to this day to have had such an honor. Of interest, she also was portrayed in a homonymous movie by another enigmatic Swede, Greta Garbo, who also was rumored to like women better than men. In 1965, Christina’s body was disinterred and examined, but because of decomposition (and the fact that the embalmers had removed the internal organs), no final conclusions could be drawn on her sexuality. She remained as elusive in death as she had been in life.

35 What should one look for when inspecting the labia?

For warts (see questions 36 and 37), ulcers, masses, discharge, atrophies, and swellings. Note that yellow-white asymptomatic papules may occasionally be noted on the inner aspect of the labia minora. They represent ectopic sebaceous glands (Fordyce’s spots), like those seen in the mouth and penile shaft (see Male Genitalia and HEENT chapters). They are entirely normal.

36 What are condylomata lata?

They are flat warts typical of secondary syphilis.

37 What are condylomata acuminata?

They are genital warts due to the human papillomavirus (HPV). They present as flesh-colored papules with cauliflower-like papillations that can degenerate into cervical cancer. There are more than 70 serotypes of HPV. Of these, serotypes 16, 18, 45, and 56 have the highest malignant potential.

38 How does genital herpes simplex present?

With clusters of small (<1 mm) fluid-filled vesicles on an erythematous base. These may rupture or coalesce, eventually resulting in a painful vulvar ulceration (see question 22).

B. Examination With Speculum—The Vagina

39 What is a speculum?

A metal (or plastic) tool that is used to hold back the walls of the vagina in order to visualize the cervix and collect specimens. Specula come as small, medium, and large, and all consist of a handle and two blades (or bills). Before using them, always practice with the handle mechanism, and always warm the blades with warm water. Never use jelly lubricant, since this may interfere with cytologic determination and gonococcal cultures (see questions 59–64).

40 What are Pedersen’s and Graves’? What are their differences?

They are the two main specula types. Pedersen’s is 0.5-inch narrower than Graves’ and with flat blades. Although it provides a more comfortable fit for women, it is mostly suited for patients with a small, (and at times) atrophic introitus, such as the young (nulliparous) and the elderly (menopausal). The Graves’ speculum is instead wider than Pedersen’s and with blades that are biconcave. It is more commonly used, especially in multiparous women, or women in whom Pedersen’s is unable to retract the vaginal wall adequately enough to visualize the cervix. Both Pedersen’s and Graves’ may be made of metal or clear plastic.

41 How do you insert the speculum?

Use your left index and middle fingers to separate the labia and depress the perineum. Ask the patient to take a deep breath, and then use your right hand to gently insert the closed speculum into the introitus, pointing the handle down at an oblique angle of 45 degrees (inserting it vertically may traumatize urethra or meatus). Slide the speculum over your left fingers, and while inserting it, rotate it downward to 90 degrees— eventually pointing the handle vertical to the floor. Gently open the blades by squeezing on the handle mechanism. This will open the vaginal walls and hold them apart, allowing you to inspect the lateral walls of the vagina and the cervix. If made of clear plastic, the speculum also will allow you to inspect the vaginal vault. Once in good position (i.e., with the cervix in clear view), keep the speculum open by tightening the set screw.

42 When do you withdraw the speculum? How?

The speculum can be withdrawn once you are done with cervical inspection and Pap sampling. To do so:

1. Hold the blades open while releasing the screw (otherwise the blades might painfully close on the cervix).

2. Once the speculum is safely away from the cervix, allow the blades to partially close, so that you can still inspect the vaginal walls. Look for bleeding, ulcers, tumors; also note the amount, color, and character of any discharge.

3. Finally, as you further withdraw the speculum, allow the blades to close completely.

43 What is a colpocele?

From the Greek kolpos (vagina) and kele (bulging), a colpocele is a vaginal prolapse, often the result of hysterectomy.

44 What is a cystocele? How can you detect it?

A cystocele is a bulge in the anterior wall of the vagina, caused by weakening of the wall and protrusion of the bladder. It can be detected by observing through the speculum the anterior vaginal wall with the patient either bearing down or coughing. In more severe cases, it can even be observed at the vestibule, after separating the minor labia. Finally, it can be palpated, too.

45 What is a rectocele? How can you detect it?

A rectocele is a bulge in the posterior wall of the vagina, caused by weakening of the wall and protrusion of the rectum. Like the cystocele, it can be detected through inspection or intravaginal palpation while the patient is bearing down or coughing.

46 What are the clues to the presence of a rectovaginal fistula?

A history of fecal contamination in the vagina. The fistula also may be palpable, as an indurated area in the posterior vaginal wall.

47 What is Chadwick’s sign?

The bluish-violet appearance of vagina or cervix. This is a sign of pregnancy (usually occurring after the seventh week of gestation), but it also may occur in association with a pelvic tumor. It results from mucosal congestion and is most notable in the anterior vaginal wall.

48 Who was Chadwick?

James R. Chadwick (1844–1905) was an American gynecologist. Born in Boston and schooled at Harvard, Chadwick traveled extensively in Europe after graduation, visiting the medical centers of Vienna, London, Paris, and Berlin. He eventually returned to his native Boston, where he went on to become one of the founding fathers of the Boston Medical Library and the president of the American Gynecological Society.

49 What is diethylstilbestrol (DES)? What is the vaginal appearance of women with prenatal exposure to it?

DES was an oral synthetic nonsteroidal estrogen, which was used from 1938 to 1972 to prevent miscarriage, until found to cause vaginal changes in women who had been exposed to it in utero. The most common of these is adenomyosis (90% of the cases), which consists of a glandular columnar epithelium of the vagina. This is not premalignant, but can be associated with clear cell adenocarcinoma. Hence, DES patients must be followed serially, with exams and colposcopy.

50 What is a Gartner’s duct cyst?

A benign tumor arising in the anterior or lateral wall of the vagina. It is a congenital lesion caused by retained epithelial remnants of the Wolffian duct.

51 Who was Gartner?

Hermann T. Gartner (1785–1827) was a Danish surgeon. A native of St. Thomas, West Indies (when this was still a Danish possession), Gartner eventually returned to Denmark, graduated from Copenhagen Medical School, and worked as an army surgeon for most of his professional life.

52 What is the normal vaginal pH?

Acid, because vaginal secretions are in the acidic range, with pH <4.5.

53 What is the significance of tenderness in the vaginal fornices?

It depends. Tenderness in either the left or right vaginal fornix usually indicates ipsilateral salpingitis, but tenderness of the right fornix also may represent a sign of retrocecal appendicitis.

C. Examination With Speculum—The Cervix

54 What is the best way to visualize the cervix?

Through the speculum. Note that cervical visualization may be difficult in patients with either retroverted uterus or displacement by prolapse. To improve vision, reposition the speculum by slowly pulling it back. You also may want to gently turn the bills in various directions. Yet, remember that the most common reason for not visualizing the cervix is an incomplete insertion of the speculum. If still unable to locate the cervix, perform first the bimanual exam by lubricating your gloved fingers with water (other lubricants may ruin the Pap smear). Once you have palpated the cervix, it will be easier to aim the speculum toward the correct direction.

55 How does a normal nonparous cervix appear?

It looks round, pink, and with a central os (this in the parous cervix is horizontal and possibly “fishmouthed”). A darker and reddish columnar epithelium at the os is a normal variation, as are the presence of small and yellowish nabothian cysts. Inspect the cervix for color, size, configuration, discharge, erosions, ulcerations, cysts, polyps, leukoplakia, and masses.

56 What are endocervical polyps? What is their significance?

They are small pedunculated masses that protrude from the endocervical canal and are composed of columnar epithelium. Although at times friable and bleeding, they are invariably benign.

57 What is the cause of cervical duplication?

Common in animals, a cervical (and uterine) duplication is usually due to failure of Müllerian duct fusion. It is often associated with a partially or fully septate vagina. On physical exam, the two cervices are often different in size, appearing side by side in the coronal plane.

58 What is the squamocolumnar junction?

It is the meeting of the columnar endothelium of the endocervical canal with the external pink mucosa of the ectocervix (which is covered by squamous cells). This transition zone is a crucial area, since 95% of all cervical cancers originate from it. Yet, the junction may or may not be visible on speculum examination. Note that for an adequate evaluation of the cervix, you must sample cells from all three layers: ectocervix, transition zone, and endocervix.

59 What is a Pap smear? What is the best way to obtain it?

The Pap smear is a preparation of endocervical canal cells. These are obtained by inserting a brush into the endocervical canal, and rotating it 180 degrees (a 360-degree rotation is more likely to cause bleeding). The brush is then withdrawn and either run across a slide (standard method) or agitated in a tube of medium (thin prep method). Squamous cells from the ectocervix are instead obtained by scraping the cervix circumferentially with a wooden spatula, and then spreading the sample on either a slide or a tube medium. Pap smear slides must be fixed with cytology fixative as quickly as possible.

60 Which patients benefit from regular Pap smear screening?

Mostly two groups of patients:

Women who are sexually active (since they are the ones mostly at risk for HPV infection). They should undergo vaginal Paps either yearly or biennially.

Women who have had hysterectomies for malignant disease. Conversely, women who have had hysterectomies for benign reasons (such as myomata) no longer need Pap screening.

61 Who was “Pap”?

George N. Papanicolaou (1883–1962) was an American pathologist. A native of Greece and a graduate of Athens University, Papanicolaou gained a medical degree only because of his father’s wishes and only as a prerequisite to then be free to pursue a career in history and philosophy. The Balkan Wars of 1912–1913 (and the outbreak of World War I) totally changed his plans, pushing him to emigrate to the United States, where he went on to become chair of pathology at Cornell. A soft-spoken and modest man, he always maintained a very thick Greek accent.

62 What is the significance of a purulent cervical discharge?

It is usually the harbinger of purulent cervicitis, most often caused by gonorrhea or chlamydia. If untreated, this may result in pelvic inflammatory disease and its various sequelae.

63 What is the significance of cervical motion tenderness?

It suggests pelvic inflammatory disease. Informally known as the “chandelier sign,” since patients “hit the chandelier” whenever their tender cervix is palpated.

64 What additional laboratory tests should be obtained from the cervix?

In high-risk populations, some clinicians routinely culture for gonorrhea and chlamydia because chlamydial infection may be relatively asymptomatic, and if undiagnosed, can lead to serious sequelae—such as infertility. Hence, the low threshold for screening, especially in cases of any of the aforementioned signs of purulent cervicitis.

D. Bimanual Palpation—The Uterine Corpus

65 What is the normal shape and location of the uterus?

The uterus has the shape and size of a small pear. It is anteverted and anteflexed in approximately 80% of women.

66 What is the best way to examine the uterus?

Bimanually—a technique used not only to palpate the uterus, but also the adnexa (see questions 77–82). Prepare the patient by first lowering the head of the exam table to 15 degrees or flat, and by then having her lay the arms on either the chest or sides (which will relax the abdominal muscles). While standing next to the patient, insert then the gloved middle finger and forefinger of one hand (usually your right) into the vagina, in a downward and posterior direction, with gentle pressure toward the posterior fornix. Try to avoid the periurethral area. With fingers half in, rotate your hand 90 degrees clockwise, so that your palm faces upward, the thumb is extended, and the fourth and fifth fingers are pushed against the palm. Continue to insert the fingers into the vagina until you reach the cervix. At this point, palpate the vaginal walls and rugae, looking for nodules, scarring, and induration. Also assess the cervix for configuration, consistency, and tenderness. Once done, place your other hand (usually the left) on the abdominal wall, starting from the umbilicus and moving downward to the symphysis. Reach through the wall for both the uterus and adnexa. Use your vaginal hand to push the pelvic organs up, making them accessible (and palpable) to the abdominal hand. Note size, position, configuration, consistency, and sensitivity of the uterus. Remember that throughout the exam you should keep your eyes on the patient, looking for any signs of discomfort.