FEMALE GENITALIA ASSESSMENT

The physical examination of the female genitalia may create client anxiety. The client
may be embarrassed about exposing her genitalia and nervous that an infection or
disorder will be discovered. Be sure to explain in detail what will be doing throughout the
examination and to explain the significance of each portion of the examination.

Encourage the client to ask question. Begin by sitting on a stool at the end of the
examination table and draping the client so only the vulva is exposed. These help to
preserve the client’s modesty. The nurse should shine the light source so it illuminates
the genital area, allowing the nurse to see all structures clearly.

Preparing the Clent

1. The client should be told ahead of time not to douche for 48 hours before
gynaecological examination
2. Ask the client to urinate before examination, so she will not experience bladder
discomfort. If a clean-catch urine specimen is needed, provide a container and a
vaginal wipes
3. Ask the client to remove her underwear and bra (if breast examination will also
perform) and to put on a gown with the opening in the back. The nurse should
leave the room while the client changes
4. Put the client in a lithotomy position
5. Ask the client to just put her arms on the side instead of putting it over the head
(it mat tightens the abdominal muscles)
6. Allow the nurse to maintain eye contact with the client during examination and
enables the client to see what the nurse doing or offer the client a mirror so she
can view the examination

Equipments and Supplies

 Stool
 Light
 Speculum
 Water-soluble lubricant
 Cotton-tipped applicators
 Chlamydia culture tube
 Culturette
 Test tube with water
 Sterile disposable gloves
 Ayre spatula (plastic)
 Endocervical broom
 ph paper
 Feminine napkins
 Mirror

Key points during examination :

a) Respect the client privacy
b) Wash hands, don gloves, be sure equipment is between room and body
temperature
c) Inspect and palapate female external and internal structures correctly
d) Use examination and laboratory equipment properly
e) Recognize the difference between common variations and abdominal findings

EXTERNAL GENITALIA
Assessment procedure
Inspection
Inspect the mons pubis.  Pubic hair is distributed  Absence of pubic hair in
Wash your hands and put
on gloves. As you begin the
examination, note the
distribution of pubic hair.
Also be alert for signs of
infestation.
Observe and palpate  There should be no  Enlarged inguinal lymph
inguinal lymph nodes
Inspect for labia majora and  It must be equal in size  Lesion may be form of
perineum. Observe for
lesion, swelling, excoriation
Inspect the labia minora,  It appear symmetrical,  Asymmetric labia may
clitoris, urethral meatus,
and vaginal opening. Used
your gloved hand to
separate the labia majora
and inspect for lesion,
excoriation, swelling and/or
discharges
Palpation
Palpate Bartholin’s glands.  It is usually soft, non  Swelling,
Place your index finger inthe
vaginal opening and your
thumb on the labia majora.
With a gentle pinching motion,
palpate from the inferior
portion of the posterior labia
majora to the anterior portion.
Repeat on the opposite side
PHYSICAL EXAMINATION
Normal findings Abnormal findings
in an inverted triangular
pattern and there are no
sign of infestation  Nice or nits at the base
enlargement or swelling
of the lymph nodes
and free of lesion,
swelling and excoriation.
A healed tear or
episiotomy scar may be
visible on the perineum
if the client has given
birth. The perineum
should be smooth
dark pink, and moist.
The clitoris is a small
mound of erectile tissue,
sensitive to touch. The
normal size of the
clitoris varies. The
urethral meatus is a
small and slitlike. The
vaginal opening is
positioned below the
urethral meatus. Its size
depends on sexual
activity or vaginal
delivery; it may covered
partially or completely
by a hymen.
tender , and drainage
free
the adult client is
abnormal
of the pubic hairs
indicate infestation with
pediculosis pubis. This
condition, commonly
reffered to as “crabs” is
most often transmitted
by sexual contact
nodes may indicate a
vaginal infection or may
be a result of irritation
from shaving pubic hairs
infection such as herpes
or syphilis. Excoriation
and swelling may be
from scratching or self-
treatment of the lesions.
All lesions must be
evaluated and the client
referred for treatment
indicate abscess.
Lesion, swelling, bulging
in the vaginal opening,
and the discharge are
abnormal findings.
Excoriation may result
from the client
scratching or self
treating a perineal
irritation
painand
discharges may result
from infection and
abscess. If you detect
abscess obtain a
specimen to send to the
laboratory for culture
 Palpate the urethra. Insert  No drainage should be 
your gloved index finger noted from the urethral
into the superior portion of meatus. The area
the vagina and milk the usually soft and
urethra from the inside, nontender
pushing up and out
Drainage from the
urethra indicates
possible urethritis. Any
discharge should be
cultured. Urethritis may
occur with infection with
Neisseria gonorrhoea or
Chlamydia trachomatis

INTERNAL EXAMINATION
Assessment procedure
Inspection
Inspect the size of the  The normal vaginal
vaginal opening and the
angle of the vagina. Insert
your gloved index finger
into the vagina, noting the
size of the opening, then
attempt to touch the cervix.
Inspect the vaginal  The client should be
musculature. Keep your
index finger inserted in the
client’s vagina opening. Ask
the client to squeeze
around your finger.
Use your middle and index  No bulging and no
fingers to separate the labia
minora. Ask the client to
bear down
Inspect the cervix. Follow 
the guidelines for using the
speculum.
Inspect the vagina. Unlock 
the speculum and slowly
rotate and remove it.
Inspect the vagina as you
remove the speculum. Note
the vaginal color, surface,
consistency and any
discharges
Normal findings Abnormal findings
 Any loss of hymenal
opening varies in size
according to the client’s
age, sexual history, and
whether she has given
birth vaginally. The
vagina is typically tilted
posteriorly at a 45-
degree angle.
 Absent or decrease
able to squeeze around
the examiner’s finger.
Typically, the nulliparus
woman can squeeze
tighter than the
multiparous woman
 Bulging of the anterior
urinary discharges
It is normally smooth, 
pink, and even.
Normally it is midline in
position and projects 1
to 3 cm into the vagina
It should appear pink, 
moist, smooth and free
of lesion and irritation. It
should be free of any
colored, malodorous
discharge
tissue between the 3
o’clock position and the
9 o’clock position
indicates trauma. This
findings is not as
relevant in adult
ability to squeeze the
examiner’s finger
indicates decrease
muscle tone. Decreased
tone may decrease
sexual satisfaction
wall may indicate a
cystocele. Bulging of the
posterior wall may
indicate rectocele. If the
client cervix or uterus
protrudes down, the
client may have uterine
prolapse
In non pregnant woman,
a bluish cervix may
indicate cyanosis; in a
non menopausal
woman, a pale cervix
may indicate anemia.
Redness may be from
inflammation
Reddened areas, lesion
and colored,
malodorous discharges
are abnormal and may
indicate vaginal
infection, STD’s, or
cancer
Guidelines for using a Speculum
1. Choose the correct size of speculum for the client
2 basic type of speculum :
a. Graves speculum – appropriate for most adult women and available in
various lengths and widths
b. Pederson speculum – appropriate for virgins and some postmenopausal
women who have a narrowed vaginal orifice
2. Encourage the client to take a deep breaths and to maintain her feet in the
stirrups with her knees resting in an open, relaxed fashion
3. Place two fingers of your non dominant hand against the posterior vaginal wall
and wait for relaxation to occur
4. Insert the finger of your dominant hand about 2.5cm into the vagina and spread
them slightly while pushing them down against the posterior vagina
5. Lubricate the blades of the speculum with vaginal secretions from the client
6. Hold the speculum with two fingers around the blades and the thumb under the
screw or lock
7. Insert the speculum between your fingers into the posterior portion of the vaginal
orifice at a 45-degree angle downward.
8. Continue inserting the speculum until the base touches the fingertips inside the
vagina
9. Remove the fingers of your non dominant hand from the client’s posterior vagina
10. Press handle together to open blades and allow visualization of the cervix
11. Secure the speculum in place by tightening the thumb screw or locking the
plastic clip

BIMANUAL EXAMINATION
Assessment procedure Normal findings Abnormal findings
Palpation
Palpate the vaginal wall.  Vaginal wall should feel  Tenderness or lesion
Tell the client that you are smooth and the client may indicate infection
going to do a manual should not report any
examination and explain its tenderness
purpose. Apply water
soluble lubricant to the
gloved index and middle
fingers of your dominat
hand. Then stand and
approach the client at the
correct angle. Placing your
non dominant hand on the
client’s lower abdomen,
insert your index and
middle fingers into the
vaginal opening. Apply
pressure to the posterior
wall, and wait for the
vaginal opening to relax
before palpating the vaginal
walls for texture and
tenderness.
Palpate the cervix.  It should be feel firm  Hard, immobile cervix
Advance your fingers until and soft (like the tip of may indicate cancer.
they touch the cervix and your nose). It is Pain with movement of
run fingers around the rounded, and can be the cervix may indicate
circumference. moved somewhat from infection
Palpate for : contour; side to side without
consistency; mobility; eliciting tenderness
 tenderness
Palpate the uterus. Move  The fundus is normally  Enlarged uterus above
your finger intravaginallly round, firm and smooth. the level of the pubis is
into the opening above the It is usually at the level abnormal; irregular
cervix and gently press the of the pubis; the cervix ahape suggest
hand resting on the is aimed posteriorly. abnormalities such as
abdomen downward, However several other myomas (fibroid tumor)
squeezing the uterus position are considered or endometriosis
between the two hands. normal
Note uterine size, position,
shape and consistency

Attempt to bounce the
uterus between your two
hands to assess mobility
and tenderness
Palpate the ovaries. Slide
your intravaginal fingers
toward the left ovary in the
left lateral fornix and place
your abdominal hand on
the left lower abdominal
quadrant. Press your
abdominal hand toward
your intravaginal fingers
and attempt to palpate the
ovary.
Slide your intravaginal
fingers to the right fornix
and attempt to palpate the
right ovary
 The normal uterus  Fixed and tender uterus
moves freely and is non may indicate fibroids,
tender infection, or massess
 Ovaries are  Enlarge size, masses,
approximately 3x2x1 immobility and extreme
cm(size of a walnut) tenderness are
and almond shaped abnormal and should
be evaluated
 They are firm, smooth,  Large amount of
mobile and somewhat colourful, frothy, or
tender on palpation malodorous secretions
 A clear, minimal amount are abnormal. Ovaries
of drainage appearing that are palpable 3 to 5
on the gloves from the years after menopause
vagina is normal are also abnormal.

Position of the Uterus

1. Anteverted
 Most typical position of the uterus
 Cervix is pointed posteriorly, and the body of the uterus is at the level of
the pubis over the bladder
2. Midposition
 A normal variation
 The cervix is pointed slightly more anterior, and the body of the uterus is
positioned more posterior than the anteverted position, midway between
the bladder and the rectum
 It may be difficult to palpate the body through the abdominal and rectal
walls with the uterus is this position
3. Anteflexed
 A normal variation that consists of the uterine body flexed anteriorly in
relation to the cervix
 The position of the cervix remain normal
4. Retroverted uterus
 Normal variation that consist of the cervix and the body of the uterus tilting
backward
 The uterine wall may not be palpable through the abdominal wall or the
rectal wall in moderate retrovertion
5. Retroflexed uterus
  Normal variation that consist of the uterine body being flexed posteriorly in
relation to the cervix.
 The position of the cervix remains normal
 The body of the uterus may be felt through the posterior fornix or the rectal
wall

RECTOVAGINAL EXAMINATION
Assessment procedure
Explain the purpose and  The
the procedure
Forewarn the client that she
may feel uncomfortable as
if she wants to move her
bowels but that she will not.
Encourage her to relax.
Change the gloves on your
dominant hand and
lubricate your index fingers
with water-soluble lubricant
Normal findings Abnormal findings
rectovaginal  Masses, thickened
septum is normally structures, immobility,
smooth, thin, movable, and tenderness are
and firm. The posterior abnormal
uterine wall is normally
smooth, firm, round,
movable and non tender

Ask the client to bear down

to promote relaxation of the
sphincter and insert your
index finger into the vaginal
orifice and your middle
finger into the rectum.
While pushing down on the
abdominal wall with your
other hand, palpate the
internal reproductive
structure through the
anterior rectal wall. Pay
particular attention to the
area behind the cervix, the
rectovaginal septum, the
cul-de-sac, and posterior
uterine wall. Withdraw your
vaginal finger and continue
with rectal examination.

DOCUMENTATION

Sample Objective Data

 Inspection discloses normal hair distribution, no lesions, masses, or swelling

 Labia majora pink, smooth, and free of lesions, excoriation, and swelling
 Labia minora dark pink, moist, and free of lesions, excoriation, swelling, and
discharge
 No bulging at vaginal orifice
 No discharge from urethral urethral opening
 Cervix slightly anterior, pink, smooth, slitlike os, mobile, nontender, and firm
without lesions or discharge. Vaginal walls smooth and pink
 Palpation indicates firm fundus located anteriorly at level of symphysis pubis,
without tenderness, lesions, or nodules
 Smooth, firm, almond-shaped, mobile ovaries approximately 3cm in size palpated
bilaterally, no excessive tenderness or masses noted
  No malodorous, colored vaginal discharge on gloved fingers
 Routine pap smear performed
 Firm, smooth, nontender, movable posterior uterine wall and firm, smooth, thin,
movable rectovaginal septum palpated during rectovaginal examination

Appropriate Nursing Diagnoses

Wellness Diagnoses
 Readiness for enhanced health management of genitalia
 Health-Seeking Behavior: Requests information on external genitalia examination
 Health-Seeking Behavior: Requests information on ways to prevent sexually
transmitted disease
 Health-Seeking Behavior: Requests information on ways to prevent yeast
infections
 Health-Seeking Behavior: Requests information on birth control
 Health-Seeking Behavior: Requests information on cessation of menses and
hormone replacement therapy

Risk Diagnoses
 Risk of ineffective therapeutic regimen management (monthly external genitalia
examination) related to lack of knowledge of the importance of the examination
 Risk for infection related to unprotected sexual intercourse
 Risk for disturbed body image related to perceived effects on feminine role and
sexuality

Actual Diagnoses
 Fear of ovarian cancer related to high incidence of risk factors
 Ineffective sexuality pattern related to decreased libido
 Ineffective therapeutic regimen management related to lack of knowledge of
external genitalia self-examination
 Acute pain: dysuria related to infection
 Anticipatory grieving related to impending loss of reproductive organs secondary
to gynecologic surgery
 Ineffective sexuality pattern related to perceptions of effects of surgery on sexual
functioning and attractiveness
 Acute pain related to surgical incision
 Acute pain: dyspareunia related to inadequate vaginal lubrication