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

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

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?

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