Office Gynecology iii.

Mucosal characteristics-color, lesions, superficial

Gynecology vascularity, edema
iv. Structural abnormalities
 Pap smear, gram stain, Normal Saline Solution (NSS) smear (for
HISTORY AND PHYSICAL EXAMINATION Dx of Trichomoniasis or bacterial vaginosis), KOH smear (for
fungal infection), Whiff test (differentiate presence of bacterial
 After a dialogue has been established vaginosis from fungal infection, it’s positive for Trichomonas
 Will rely on good doctor-patient relationship or interchange and bacterial vaginosis-how: put specimen on a slide then drop
 Attention to details KOH, if it exudes amide like odor: (+) for Whifft test)
 Risk factors identified  Inspect cervix for unusual bleeding, inflammatory lesions,
 History polyps and carcinoma
i. Chief complaint, present illness
ii. Complete medical and surgical history, reproductive
history (including menstrual history) Bimanual palpation:
iii. A thorough family and social history
 Chief complaint and history of present illness  The pelvic organs can be outlined by bimanual palpation.
i. Allow patient to talk about her chief complaint i. Introduce the well lubricate index and middle finger into
i.i Temporal relation to total duration of the illness the vagina at its posterior aspect near the
perineumadvance fingers until cervix is encountered
ii. Associated symptoms ii. Press the abdominal hand very gently downward, pushing
ii.i Put in chronological order, character of each symptom the pelvic structures toward the palpating vaginal fingers
 Evaluate the body of uterus for:
ii.ii Pertinent negative and positive symptoms i. Position: anteverted (if uterus is directed anteriorly with
the fundus of the uterus pressing against the urinary
iii. Differential diagnosis bladder) or retroverted (uterus is directed posteriorly with
 Thorough the fundus of the uterus towards the rectum)
i. Vital signs ii. Architecture, size, shape, symmetry, tumor
ii. Breast examination iii. Consistency
iii. Abdomen iv. Tenderness
 Intra-abdominal mass v. Mobility
 Organomegaly  Evaluate the cervix for position, architecture, consistency and
 Distention of bowels tenderness especially on the mobility of cervix, then explore
iv. Pelvic examination the anterior, posterior and lateral fornices
 Place the “vaginal” fingers in the right lateral fornix and the
“abdominal“ hand on the right lower quadrant
Method of Female Pelvic Examination i. Outline the adnexa: palpate fallopian tube and ovary w/c
signifies enlarge ovary and fallopian tube
 The patient is instructed to empty the bladder ii. A normal tube and ovary are not palpated
 She is placed in dorsal lithotomy position: patient’s feet should iii. Adnexal mass is evaluated for its:
rest comfortably in the stirrups with the edge of the buttocks at o Location relative to the uterus and cervix
the lower end of the table o Architecture
 The patient is draped properly o Consistency
 External genitalia o Tenderness
i. Inspect mons pubis, labia majora, labia minora, perineal o Mobility
body and anal region for characteristics of the skin, hair  Palpate the left adnexal region, repeating technique described
distribution, contour and swelling above
ii. Inspect the epidermal and mucosal characteristics and  If a mass is fixed near the adnexal and mass is not movable, it is
anatomic configuration of: labia minora, clitoris, urethra more of a malignant process
orifice, vaginal outlet, hymen, perineal body, anus  Follow the bimanual examination with a rectovaginal
iii. Disease of Skene’s gland (palpate anterior vaginal wall) abdominal examination: commonly done with post menopausal
and Bartholin’s gland (palpate posterior part of labia and pre menopausal women
majora) if disease is suspected i. Insert index finger into the vagina and middle finger into
 Introitus: instruct the patient to bear down to rule out the rectum
i. Cystocele ii. Place other hand on infraumbilical region pushing the
ii. Rectocele structure
iii. Uterine prolapse iii. Assess the cul-de-sac
 Vagina and Cervix  In virginsrectal-abdominal technique: both fingers inserted in
i. Inspect using a speculum the rectum
ii. Proper insertion of speculum
o Instrument is warmed with tap water, not lubricated Rectal Examination
o Select proper size speculum
o Insert with blades in vertical position, closed and  Inspect the perineal and anal area, the pilonidal
pressed against the perineum (sacrococcygeal) region and perineum for: a. color b.
o When fully inserted, rotate blades into horizontal lesions
position (can see cervix and lateral vaginal wall)  Instruct the patient to “strain down”
o Open blades until cervix is exposed  Palpate the pilonidal area, ischiorectal fossa, perineum
o Gently rotate speculum until all surfaces are and the perianal region before inserting the gloved finger
visualized into the anal canal
o Multigravida and used a smaller speculum-won’t see  Palpate the anal canal and rectum with a well lubricated
the vagina gloved index finger
 Inspect the vagina for the following  Evaluate the anal canal for
i. Presence of blood o Sphincter tone
ii. Discharge-any purulence should be cultured to identify o Tenderness
Neisseria gonorrhea and Chlamydia trachomatis i. Tight sphincter
ii. Anal fissure

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 iii. Painful hemorrhoids i. Young child:
o Tumor or irregularities especially at pectinate line ii. Toddler or infant: held in their mother’s arms. Mother
o Superior aspect (clothed) on examination table (feet in stirrup) with child
 Evaluate the rectum on her lap. Others:
o Anterior wall o Knee-chest position
i. Cervix size, shape, symmetry, consistency, o Use of anesthesia
tenderness o Hysteroscope, cystoscope, etc.
ii. Uterine or adnexal masses
iii. Rectouterine fossa for tenderness or implants
o Right lateral wall, left lateral wall, posterior wall Examination of the Adolescent Patient
 Examine the finger after its withdrawn:
o Gross blood, pus or other alterations in color or  Earn patient’s trust, explain components of examination, use
consistency careful and gentle technique
o Smear stool to test for occult blood  Indications for pelvic examination:
o She has had intercourse
o Positive pregnancy test
Abdominal examination o With abdominal pain
o Marked anemia
i. Supine position o Heavy bleeding
o Relaxed position  Rectal examination is done if she is a virgin
o Pillow under the head  Confidentiality is an important issue in adolescent health care
ii. Inspect for signs of intra-abdominal mass, organomegaly
or distention
iii. Initial palpation Follow up
o Liver
o Spleen  Routine care patients with no disease
o Other abdominal contents, mass effect  Further assessment, treatment plan for those with S/S
iv. All four quadrants  Referral to other specialists if needed
v. Systemic approach- e.g. clockwise
vi. Percussion to measure the liver
vii. Auscultation-bowel sounds MINOR DIAGNOSTIC PROCEDURES
o Intestinal obstruction- “rushes” or “high-pitched”
sound 1. Papaniculao Smear (Pap smear)
o Ileus-less frequent but same pitch as normal  For detection of carcinoma of the cervic and its precursors, as
bowel sound well as viral, bacterial, fungal or protozoal pathogens
 Has reduced incidence of invasive cervical CA by 50%
 Initial screening at age 18
Speculum Examination (Graves or Pederson)  Annual screening for high risk patients
 1-2 years screening for low risk patients
i. Smallest with adequate visualization  Supplies
ii. Speculum warmed with warm water i. Cervical scraper: cotton pledgets, ayre’s spatula, cervical
iii. Cervix and vagina carefully inspected brush
iv. PAP smear ii. Glass slides
v. Biopsy of any lesions iii. Fixative: 95% alcohol, spray net
vi. Endometrial biopsy  Instructions:
vii. Culture of purulent discharge i. No douche for 48 hrs before procedure
viii. A vaginal and cervical cytology done as screening tool for ii. No vaginal creams 1 wk before
cervical neoplasm iii. No coitus for 24 hrs in advance
 After speculum is removed1st and 2nd fingers are inserted  Technique:
gently into the vagina o Samples from both endocervix and exocervix
 Carefully palpate: o Saline moistened cotton-tipped swab
i. Vagina i. No lubricant
ii. Fornices ii. Place the endocervical brush or cotton swab inside the
iii. Cervix endocervix and roll it firmly against canal
 Opposite hand placed on patient’s abdomen (above symphysis iii. Remove the brush or swab and place sample on slide
pubis) iv. Place the spatula on cervix with longer protrusion in
 Uterus assessed well cervical canal
 Adnexa, gently palpated on both sides v. Rotate spatula clockwise 360o firmly on the cervix
 On postmenopausal and premenopausal women in whom there enough to cover the entire transformation zone
is difficulty in ascertaining adnexal structure vi. Immediately fix the slide with either spray fixative or
 Also to rule out possibility of concurrent rectal disease 95% ethanol fixative
 Check on
i. Sphincter muscles
ii. Support of pelvis  4 sources of error:
iii. Masses and hemorrhoids i. Improper collection
iv. At completion of examination, patient should be informed ii. Poor transfer from collecting device to slide
about the findings. iii. Air drying
iv. Contamination with lubricant
 Identification:
Examination of the Pediatric Patient i. Name, age, pregnancy status, LMP
ii. Pertinent history: hormonal therapy, radiation therapy,
 Careful examination recent surgery, postpartum state, IUD
 Familiarity with normal appearance of prepubertal
genitaliamildly erythematous
 Positions:

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2. Colposcopy ii. Invasive cervical cancer have been ruled out
iii. Endocervical canal is uninvolved
 Visualization of the vulva, vagina and cervix using a binocular iv. The lesion must be well encompassed by the freeze
microscope of low magnification (10-40x) and strong light v. There are no deep or excessive involvement of cervical
 Uses: clefts
i. To supplement cytology vi. The patient is reliable for follow-up
ii. To direct biopsy  Technique:
iii. Used before cones or hysterectomy for CIN III i. Choose an appropriate probe which will cover the entire
iv. Evaluation of lesions of the vagina and vulva lesion
v. Used in follow-up: cervical carcinoma, adenosis, CIN IIII ii. Freeze for 3 minutes, start timing when the edge of ice ball
 Technique: has protruded 3-5 mm beyond the probe
i. With the patient in dorsal lithotomy position, an iii. Thaw for 3 minutes
unlubricated vaginal speculum is inserted iv. Refreeze for 3 minutes
ii. The cervix is exposed, taking care not to traumatize it
iii. The vagina and cervix are inspected with the surface
moistened with normal saline Other Diagnostic Procedures
iv. Acetic acid solution (3-5%) is applied to the cervix with
moistened cotton balls 1. Hysterosonosalpingogram
 Abnormal colposcopic findings:
i. Acetowhite epithelium  Part of evaluation of the patency of tubes in an infertile couple
ii. Punctation  Similar to hysterosalpingogram
iii. Mosaic  Done in the first half of the cycle after the menstrual flow and
iv. Leukoplakia before ovulation
v. Abnormal blood vessels  Prophylactic antibiotics are given
 Technique
i. Insert a vaginal speculum
3. Vulvar biopsy ii. With the cervical os visualized, insert a small foley catheter
aseptically into uterine cavity and inflate balloon with 3 cc
 If a vulvar lesion has failed to respond to therapy of air or saline
 Suspicion of malignant or premalignant condition iii. Do a baseline transvaginal US to visualize the uterus,
 Careful inspection with colposcope endometrial stripe and adnexa
 Infiltration with local anesthesia iv. Instill 10 cc of normal saline into catheter to visualize
 Keyes punch biopsy with gentle rotation until full thickness of endometrial canal
skin has been reached v. Instill additional 10-20 cc of fluid until patency of both
 Pressure over biopsy area to stop bleeding tubes is established. Fluid may be seen coursing through
the tubes, or fluid is seen in the cul-de-sac on both sides of
the uterus
4. Endometrial biopsy

 For abnormal uterine bleeding 2. Urologic Evaluation

 Easier, faster, more convenient, less costly
 Can establish the diagnosis of a malignant or premalignant  For women with urinary incontinence
lesion  Differentiate if urinary symptoms are sensory or functional
 Types of curette  Sensory disorders are characterized by dysuria, frequency,
i. Randall-type suction of endoervical and endometrial canal urgency and sometimes incontinence. These are usually treated
ascertained by passing a blunt sound medically.
ii. Novak curette  Functional disorders are mainly manifeste as difficulty in
 Depth and direction of endocervical and endometrial canal voiding control.
ascertained by passing a blunt sound  Technique of office cystometry
 Curette the different quadrants of the endometrium from the i. Before examination, the patient is asked to void
fundus to the internal os ii. If the bladder remains palpable, it is catherized and
 Indications: residual urine is measured
i. Abnormal Uterine Bleeding/postmenopausal bleeding iii. A 50 ml asepto syringe is attached to the catheter and held
ii. Endometrial dating just above the level of the pubis
iii. Follow up of previously diagnosed endometrial hyperplasia iv. 50 ml increments of saline is infused
iv. Evaluation of patient with 1 yr amenorrhea v. The bladder volume at the first urge to void is noted
v. Evaluation of infertility
vi. Pap smear with atypical cells favoring endometrial origin
 Contraindications:
i. Pregnancy
ii. Acute pelvic inflammatory disease (PID)
iii. Clotting disorder (coagulopathy)
iv. Acute cervical and vaginal infection
v. Cervical cancer
vi. Morbid obesity
vii. Severe cervical stenosis
viii. Severe pelvic relaxation w/ uterine descensus

5. Cryosurgery

 Use: ablation of benign and pre-malignant lesions of cervix,

vaginal and vulva
 Criteria for patient selection:
i. The entire lesion must be visible

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