The system of examination described in Chapter 12 is recommended, but should focus on inspection and palpation; percussion and auscultation are less important in gynaecological practice. The presence or absence of scars should be noted. Laparoscopic scars can be subtle, particularly if tucked within the umbilicus. Occasionally (usually to avoid the risk of perforation through adhesions in the lower abdomen) the entry point for laparoscopic surgery may be via Palmer’s point in the mid-clavicular line, under the rib cage. Transverse suprapubic (Pfannenstiel’s) incisions may also be difficult to see in the suprapubic crease unless specifically looked for.

Suprapubic examination is particularly important as gynaecological masses arise out of the pelvis and the examining hand cannot get below it. Do this part of the abdominal palpation with the ulnar border of the left hand, starting at or around the umbilicus, and work your way down. When an abdominopelvic mass is present, its characteristics and size, either in centimetres measured from the symphysis pubis upwards, or estimated as weeks’ gestation of an equivalent-size pregnancy, are recorded (see Fig. 4.1). Note its consistency (hard if a fibroid, usually soft if a pregnancy), regularity (subserosal fibroids and ovarian masses are usually irregular) and the presence of any tenderness. It can sometimes be difficult to elicit such signs if there is a scar in the lower abdomen or if the patient is obese. If nothing is palpable arising out of the pelvis, it is reasonable to conclude that any pelvic swelling is less than the size of a 12-week pregnancy. If ascites is suspected, check the supraclavicular and inguinal lymph nodes and look for an associated hydrothorax.

Figure 4.1 Approximate fundal height with changing gestation.

Pelvic examination

In gynaecology, pelvic examination (PE) is usually undertaken vaginally but it may also be performed rectally. The instruments used are shown in Figure 4.2. PE should always be preceded by abdominal examination. Patients will often be anxious and tense, so it is crucial to explain every step sensitively but clearly. Medical students should only undertake a PE in the presence of a supervisor; the same applies to trainees in gynaecology, except where specific permission has been granted by the trainer. In many centres, students begin to learn the technique of PE using simulated models.

Figure 4.2 Equipment for the gynaecological examination.

PE commences with inspection of the perineum in the dorsal or left lateral position and is followed by internal digital examination, using the index and middle fingers (one finger only may be possible if the vagina does not accommodate two). Generally, but not always, a speculum examination precedes the digital examination (if it is important to visualize any discharge, take swabs or take a cervical smear, the speculum should always be passed first; Fig. 4.3). In the event of the patient experiencing undue discomfort (be it speculum or digital), the examination should cease immediately. Make note of any inflammation, swelling, soreness, ulceration or neoplasia of the vulva, perineum or anus (Fig. 4.4). Small warts (condylomata acuminata) appearing as papillary growths may occur scattered over the vulva; these are due to infection with the human papilloma virus (HPV). Inspect the clitoris and urethra and ask the patient to strain and then cough to demonstrate any uterovaginal prolapse or stress incontinence (Fig. 4.5). If the patient has given a history of involuntary incontinence, it is important that the bladder is reasonably full and that more than one substantial cough is taken, as the first cough frequently fails to demonstrate leakage of urine. It is kind to press on the anus with a tissue or swab to reduce the risk of involuntary flatus, indicating to the patient the reason for doing so.