Health Assessment in Female Genetalia

Physical Assessment
of Male & Female

Genitalia, Anus &
Rectum
Professor Rhyan G. Tiopianco, RN, MAN

Instructor I, College of Nursing and Allied Health Sciences
Manuel S. Enverga University Foundation
Female Genitalia
Anatomy
Physical Assessment
Abnormalities
Anatomy
Female External Reproductive
Organs
PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

Female Internal Accessory
Organs
• uter ine tubes

• uter us
• vagina

Uterus
22-38
Assessment
Good News!!!
 Deaths due to uterine and cervical cancers

have declined by more than 50% since
1960s

Why?
 Because of early detection
 Physical Assessment
 Papanicolau test (Pap Smear)
 Increase patient knowledge

History taking
Physical Examination
Physical Examination
1. Inspection and Palpation of the

External Genitalia
2. Speculum assessment of Internal
Genitalia
3. Collection of Specimens for
Laboratory Analysis.
4. Inspection of the Vaginal walls
5. Bimanual Examination
6. Rectovaginal Assessment
Preparation for the exam
Preparation for the exam
• Instruct the patient while she is

dressed
• Instruct her to empty her bladder
prior to the exam (depending on
the history and complaints of
client)
• Close the door and curtain
• Ask for an assistant
External Genitalia
•Mons Pubis and Pubic Hair

•Vulva
•Clitoris
•Urethral Meatus
•Vaginal Introitus
•Perineum and Anus

External Genitalia
•Mons Pubis and Pubic Hair

•Vulva
•Clitoris
•Urethral Meatus
•Vaginal Introitus
•Perineum and Anus

Mons Pubis
& Pubic Hair
Inspection
Inspection
• Observe the pattern of pubic
hair distribution
• Note the presence of nits or
lice
Normal Findings
Skin over Mons Pubis:
• Clear with normal hair
distribution

Normal Findings (cont’d)
 Pubic Hair
 Distribution – inverse triangle
• There may be some growth on

abdomen and upper inner thigh
• Note: Diamond- shaped pattern
from the umbilicus may be due to
cultural or familial differences
 No nits or lice

Geriatric Variation:
 Gray and sparse

Abnormal Finding
Pediculosis Pubis
Crab lice, Pthirus pubis

Vulva
Inspection
Palpation
Inspection
• Observe the skin

coloration and
condition of
the mons
pubis and vulva
• Inform the patient that you will
touch the inside of her thigh
before you touch
the genitals
Inspecting the Vulva
•With gloved
hands, separate
the labia majora
using the thumb
and the index
finger of the
dominant hand.

Inspecting the Vulva (cont’d)
•Observe both
the labia majora
and the labia
minora for
discoloration,
lesions, trauma.

Normal Findings
 Labia majora and
minora
 Symmetrical
 Smooth to
somewhat
wrinkled,
unbroken,
slightly pigmented
skin surface.

Normal Findings
 Labia majora and minora (cont’d)
 No ecchymosis, excoriation, nodules,

swelling, rash, lesions.
•Occasional sebaceous cyst is within normal limits

•Sebaceous cysts are nontender, yellow nodules
that are less than 1 cm.

Skene’s glands
and Bartholin’s
glands

Normal Findings
 Skene’s glands and Bartholin’s glands are

not normally seen by naked eye

Normal Deviations
 Geriatric: atrophied- appears

flatter and smaller
 Multiparrous women: majora are
separated and minora more
prominent

Abnormal Findings Vulva
Bartholin’s Cyst Skene’s Gland Cyst
Vulvar epidermal cyst Edema,
Swelling
Rash (contact dermatitis, infestation)
Chancre (Syphilis)
Wartlike papules (condyloma latum)
Ulcer (Herpes)
Venous prominence (varicose veins)
Carcinoma
Inflammation of Bartholin Glands

Skene Gland Cyst

 Vulvar epidermal
 Vulvar hypertrophy cysts develop from sebaceous
glands.
Multiple, bilateral vulvar epidermal

inclusion cysts, previously referred to as
Sebaceous cyst are shown.
Benign vulvar lesions. Pemphigus vulgaris
mucosal involvement vulvar involvement

Benign vulvar
lesions
 Allergic Vulvitis  Psoriasis

Benign vulvar
lesions
 Vulvar Melanosis  Hemangioma

 Condyloma Latum  Condyloma
(Secondary Syphilis) Acuminatum
(Genital Or Venereal
Wart)

Herpes genitalis

 Well-  Advanced
differentiated carcinoma of vulva ,
involving entire vagina,
carcinoma of urethra and rectum
vulva

Palpating the Labia
Palpating the Labia
 Palpate each labium between the

thumb and the index finger of your
dominant hand.
 Observe for swelling, induration, pain,
or discharge from a Bartholin’s gland
duct.

Palpating the Labia
Labium:
•Feel soft
and uniform
instructure
•No swelling,
pain,
induration,
or purulent
discharge
Palpating around the
vaginal introitus
(Bartholin glands)

If discharge is
present ,
obtain a
specimen and
change the
gloves into
clean ones.

Abnormal Findings
Painless mass indicates

malignancy
 Painful mass indicates hernia
Hernia or
not?  If hernia is suspected,
re-palpate the mass with
the patient in a standing
position
 (+) hernia: If increase in
bulging when standing
and ask patient to cough

Clitoris
Inspection
Inspection
 Using the
dominant hand
and index
finger,
separate the
labia minora
laterally to
expose the
prepuce of
the clitoris
Normal Findings
•Approximately 2 cm in length and 0. 5

cm in diameter
•Without lesions
Abnormal Findings
Hypertrophy
(clitoromegaly,
pseudohermaphroditism)
Chancre
Clitoromegaly
 A 22- year- old  1 9- year- old
gravida O gravida O
 20 mm  30 mm
clitoroplasty PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

Urethral Meatus
Inspect
Palpate
Inspection
 Using the dominant hand and index
finger, separate the labia minora to
expose the urethral meatus.
 Do not touch the urethral meatus.
 may cause pain and urethral spasm
 Observe
 shape, color, and size of urethra

Normal Findings
 Slitlike in appearance
 Midline
 Free from discharge, swelling, or
redness
About the size of a pea
Abnormal Findings
Discharge or swelling
Urethral caruncle Urethral
carcinoma
Prolapse of urethral mucosa
Urethral
caruncle

Palpation
Milking the urethra and

paraurethral glands
Palpation
 Insert your dominant
index finger into the
vagina
 Apply pressure to the
anterior aspect of the
vaginal wall and milk
the urethra
 Observe for discharge
and client discomfort

Milking the urethra and
paraurethral glands

Normal Findings
 Should not cause pain
 Or result in any urethral
discharge

 If urethral discharge
is present, obtain a
specimen and change
to a clean pair of
gloves

Vaginal Introitus
Inspect
Palpate
Inspection
 Keep labia minora retracted
laterally to inspect the vaginal
introitus.
 Ask the patient to bear down.
 Observe for patency and bleeding.

Normal Findings
 Introitus Mucosa
 Pink and moist
 Patent
 Without Bulging

Nulliparous Multiparous with
with intact remaining hymen
hymen

 Normal Vaginal Discharge – white and
free of foul odor (some white clumps
may be seen—mass clamps of epithelia
cells)

Palpation
 Insert your dominant finger in the
vagina, ask the client to squeeze the
vaginal muscles around your finger.
 Evaluate muscle strength and tone
Normal Findings
 Vaginal muscle tone
 In nulliparous woman: tight and
strong
 In a parrous woman; it is diminished

Abnormal
Findings
Pale color and dryness (atrophy, aging)
Tear, fissure
Bulging Discharge
Pelvic Organ
Prolapse
Cystocele
Cystourethrocele
Rectocele
Uterine Prolapse
Cystocele

Rectocele

Degrees of Uterine Prolapse

Second degree uterine prolapse

Symptomatic
posthysterectomy
vault prolapse in
60- year- old
patient.

Perineum
Inspect
Palpate
Inspection
• Observe texture and color of the
perineum
• Observe for color and shape of the anus
Normal Findings
 Perineum
 Smooth
 Slightly darkened
 Well- healed episiotomy scar is normal
after vaginal delivery.

Abnormal Findings
Fissure or tear (trauma, abscess,

or unhealed episiotomy)
Keloid
Giant perineal keloid

Palpating the Perineum
 Place the
dominant index
finger posterior
to the perineum
and the thumb
anterior to the
perineum

(cont’d)
 Assess perineum
between the
dominant thumb
and index finger
for muscular tone
and texture

Normal Findings
 Smooth & Firm
 Homogenous in
nulliparous
 Thinner in parous
woman
 Well- healed
episiotomy scar is also
within normal
limits for parous woman

Abnormal Findings
Thin (atrophy)
Fissure or tear (trauma, abscess,
or unhealed episiotomy)
Speculum Examination of the
Internal Genitalia
Inspection
Cervical
Examination
 Select the appropriate- sized
speculum
 Based on client’s history, size
vaginal introitus, and vaginal
muscle
tone

 Lubricate and warm the
speculum by rinsing it with
warm water
 Do not use lubricant, may

be bacteriostatic and can
alter Pap test results

Holding the
Speculum
•Hold the
speculum by
your dominant
hand with the
closed blades
between the
index and
middle fingers

Insert your
nondominant
index and middle
fingers, ventral
sides down, just
inside the vagina
and apply
pressure to the
posterior vaginal
wall

 Encourage client to bear down
 This will help to relax the
perineal muscles
 Encourage client to relax by taking
deep breaths
 Be careful not to
pull on pubic hair

or pinch the labia

Preparing for the Apply
downward
insertion of the pressure in
speculum posterior
vaginal
opening
with two
fingers

Oblique insertion of the
speculum
When you feel the
muscles relax,
insert the speculum
at an oblique angle
on a plane parallel
to the examination
table until the
speculum reaches
the end of the
fingers that are in
the vagina.
Withdraw your nondominant
hand from the vagina
Directing speculum
downward Gently rotate
at 450 the speculum
angle. blades to a
horizontal angle
and advance
the speculum at
a 45- degree-
angle against
the posterior
vaginal wall
until it reaches
the end of the
vagina.

Final Adjustment of the
Speculum

Opening of •With your
the speculum dominant thumb,
blades
depress the lever
to open the blades
and visualize the
cervix.

 If the cervix is not visualized, close
the blades and withdraw the speculum
2 to 3 cm and reinsert it at a slightly
different angle to ensure that the
speculum is inserted far enough into
the vagina.
 Once the cervix is fully visualized,
lock the speculum blades into place.
 Adjust your light source so that it
shines through the speculum.
Speculum in place, locked, and
stabilized. Note cervix in full view.

Normal Findings
 Color
 Glistening pink
 Pale after menopause
 Blue (Chadwick’s sign) during
pregnancy
 Position
 Located midline in the vagina with an
anterior or posterior position relative to

the vaginal vault
 Size:
 2. 5 cm to 3 cm in young woman.
Smaller in elderly
 Surface characteristics:
 Covered by glistening pink squamous
epithelium, which is similar to
vaginal epithelium
 Discharge:
 Note characteristics of any
discharge
 Shape of cervical os
 In nulliparous woman: os is
small and either round or
oval.
In a parrous
woman: os is a
horizontal slit

Abnormal Findings
Lacerations Cyanosis
Redness or friable appearance
Reddish circle around os (ectropion
or eversion)
Small, round, yellow lesion
(nabothian cyst)
Abnormal Findings
Condyloma Acuminata Candidiasis

Cervicitis
Endocervical Gonorrhea
Strawberry spots (trichomonal
infection)
Cauliflower overgrowth (carcinoma)
 Cervical  Nabothian Cyst
Ectropion

 Condyloma
acuminata  Candidiasis
(venereal warts)
caused by "Human Papilloma Virus"

(HPV).

Chlamydial
cervicitis

Endocervical
gonorrhea

 “Strawberry”
cervix  Cervical Cancer
(Trichomonasis)

Collecting Specimens for
Cytological Smears and
Cultuu re
res
•Pap Smear
s•Gonococcal Culture Specimen
•Saline Mount or “Wet Prep”
•KOH Prep
•Five Percent Acetic Acid Wash
•Anal Culture
Pap Smear
Endocervical
Smear
Cervical Smear Vaginal
Pool Smear
Pap Smear
Equipments
Maria Carmela L. Domocmat, RN,

MSN
 A collection of three specimens
that are obtained from three sites
 Cervix
 Vaginal pool
 Posterior fornix of the

vagina

Endocervical Smear
 Using your nondominant hand,
insert the cytobrush through
the speculum into
the cervical os approximately 1
cm
 May cause cramping sensation,
so forewarn the patient.

Endocervical
Smear (cont’d)
 Rotate the cytobrush between your index
finger and thumb 3
degrees clockwise, 60then counterclockwise.
 Keep cytobrush in contact with the
cervical tissue
 If you have to use a cotton- tipped
applicator instead of cytobrush, leave
the applicator in the os for 30 seconds
to ensure saturation
Endocervical Smear
(cont’d)
 Remove the cytobrush and, using a
rolling motion, spread
the cells on the section of the slide
marked E, if a sectional slide is
being used.
 Do not press down hard or wipe
the cytobrush back and
forth. Doing so will destroy
the cells.
 Discard the brush.

Cervical
Smear
 Insert the bifurcated end of
Ayre spatula through
the speculum base.
 Place the longer projection of
the
bifurcation into the cervical os.

Cervical
Smear
(cont’d)
 The shorter projection should be snug
against the ectocervix
 Rota te the spa tula 360 degrees one
time only
 Remove the spatula and gently spread
the specimen on the section of the
slide labeled C, if a sectional slide is
being used.

Vaginal Pool
Smear
 Reverse the
Ayre spatula and
insert the
rounded end into
the posterior
fornix and gently
scrape the area

Vaginal Pool
Smear
 Cotton- tipped applicator
may be the preferred vehicle for
obtaining specimen if vaginal
secretions are
viscous or dry.
 By moistening the cotton- tipped
applicator with normal saline solution,

viscous secretions can be removed
with less trauma to the surrounding
membranes.
Vaginal Pool
Smear
 Remove the spatula and gently spread
the specimen on the section of the
slide marked V, if a sectional slide is
being used.
 Dispose of the spatula cotton- tipped
applicator .
 Spray the entire slide or the slides
with cytological fixative.
 Submit the specimens to the
laboratory.
Normal
findings
 Normal classifications for all
cervicovaginal cytology should read
“within normal limits” (WNL) using
Bethesda system.
 Denotes lack of pathogenesis

Inspection of the
Vaginal Wall
Inspection
 Disengage the locking device of the
speculum
 Slowly withdraw the speculum but do
not close the blades
 Rotate the speculum into oblique
position as you retract it
 to allow full inspection of the vaginal
walls
 Observe vaginal wall color and texture
Normal
findings
 Vaginal walls
 Pink
 Moist
 Deeply ruggated
 Without lesions or
redness

Geriatric Variation
 Thinner
 Drier
 Less vascular

Abnormal Findings
Vaginitis
Adenosis
Carcinoma
Atrophic vaginitis
 External genitalia of a
67- year- old woman who
is naturally menopausal
for two years and is not
on estrogen replacement
therapy. Note loss of
labial and vulvar fullness,
pallor of urethral and
vaginal epithelium, and
decreased vaginal
moisture.

 Vaginal inclusion  Bacterial
cysts contain epithelial Vaginosis
tissue

 Vaginal adenosis  Vaginal
Carcinoma

Bimanual Examination
•Vagina •Fornices •Adnexa

•Cervix •Uterus
Steps of Bimanual
Exam:
1. Observe the client’s face for
signs of discomfort
during the assessment
process.
2. Inform the client of the
steps of the bimanual
assessment, and tell her that
the lubricant gel may be cold.

Steps of Bimanual Exam:
(cont’d)
3. Squeeze the lubricant onto
the fingertips
of your dominant hand.
4. Stand between the legs of
the client as
she remains in the lithotomy
position, and place your non-
dominant hand on
her abdomen and below the
umbilicus.PROFESSOR RHYAN G. TIOPIANCO, RN, MAN
(cont’d)
5. Insert your lubricated index and

middle fingers
1 cm into the vagina. The fingers
should be extended with the
palmer
side up. Exert gentle
posterior pressure.

(cont’d)
6. Inform the client

that pressure from
palpation may be
uncomfortable.
Instruct the patient
to relax the
abdominal muscles by
taking deep breaths.

Steps of Bimanual Exam
(cont’d)
7. When you feel the client’s

muscles relax, insert your
fingers slowly to their full
length into the vagina. Simultaneously
palpate
the vaginal walls.

Steps of Bimanual Exam
(cont’d)
8. Remember to keep your thumb

widely abducted and
away from the urethral
meatus and clitoris throughout
the palpation in order
to prevent pain or
spasm.

Vagina
 Complete steps 1 - 8 of
the bimanual exam.
Rotate the wrist so that
the fingers are able to
palpate all surface
aspects of the vagina.

Vagina
 Normal Findings
 Vaginal wall non tender

 Smooth or ruggated surface
 No lesions, masses, or cysts

Cervix
1. Position the dominant hand so

that the palmar surface face
upward. s
2. Place the nondominant hand on the

abdomen approximately 1 /3 of the
way down between the umbilicus and
the symphysis pubis.

Cervix
3. U s e t h e p a l m a r sces urfa of the

dominant hand’ fingerpads, s which are
the vagina, to assess in
c e r v i x f o r c o n s i s t ethe
ncy, position
shape, and tenderness.
4. Grasp the cervix between the
fingertips and move the cervix from
side to side to assess mobility.

Cervix
 Normal Findings
 Mobile
 Without pain
 Smooth and
firm
 Symmetrically
rounded
 Midline Softening between 5th or 6th
week of pregnancy- Goodell’s sign

Abnormal Findings
Extreme pain on palpation

(Chandelier’s sign –PID)
Irregular surface (malignancy,
nabothian cyst, polyps)
Fornices
• With the fingertips

and palmar
surfaces of the
fingers, palpate
around the
fornices.
• Note nodules or
irregularities.
Fornices
 Normal Findings
 Walls should be
smooth
 No nodules

Uterus
1. With the dominant
hand, which is in the vagina, push
the pelvic
organs out of the pelvic
cavity and provide stabilization while
the nondominant
hand,
which is on the
abdomen, performs
the palpation.
Uterus
2. Press the hand

that is on the
abdomen inward
and downward
toward the vagina,
and try to grasp
the uterus between
your hands.

Uterus
2. Press the hand that

is on the abdomen
inward and downward
toward the vagina,
and try to grasp the
uterus between your
hands.

Bimanual palpation of Uterus

Uterus
 Normal Findings
 Size varies based on parity
 Nongravid client: Pear- shaped
 Parous: more rounded
 Smooth
 Without masses

Uterus
 Normal Findings (cont’d)
 May be non- palpable if it

is retroverted or
retroflexed (rectovaginal
assessment)
 Non palpable uterus is
normal in older women

 Due to secondary uterine
atrophy
Anteverted
uterus

Anteverted Anteflexed
uterus Uterus

 Retroverted  Retroflexed
Uterus Uterus

Abnormal Findings
 Enlargement and changes in shape
 Nodules or irregularities (leiomyomas)
 Non palpable uterus (hysterectomy)

Adnexa
1. Move the intravaginal hand to

the right lateralfornix,
andthe hand o the n
abdomen to the ght ri
lower quadrant just insidethe
anterior iliac spine.
2. Press deeply inward and upward
toward the abdominal hand.

Adnexa
3. Push inward and downward with
the abdominal hand and
try to catch the ovar between
your fingerti y
ps.
 Palpate for size, consistency,
and mobility of the adnex
 Repeat the above maneuvers on the
left side. a.

Palpation of Left
Adnexa

Adnexa
 Normal Findings
Ovaries
 Almond- shaped
 Firm
 Smooth
 Mobile
 Without
tenderness
Geriatric Variation
 Rarely palpable

Abnormal Findings
Enlarged, irregular, nodular,

painful, with decreased mobility
(ectopic pregnancy, ovarian cyst,
PID or malignancy)
Collecting
Specimens
Five Percent Acetic Acid
Wash
1 . After completing all other vaginal
specimens, swab the cervix with
cotton- tipped applicator that has
been soaked in 5% acetic acid.
2. Leave for one minute.
Normal Finding
 There should be no change in
the appearance of the cervix
(HPV)

Abnormal Findings
Rapid acetowhitening or blanching with
jagged borders (HPV)
Apparently normal
cervix

After application of acetic
acid

Rectovaginal
Examination
Rectovaginal Examination

Health Assessment in Female Genetalia

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Physical Assessment

of Male & Female

Professor Rhyan G. Tiopianco, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

• uter ine tubes

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

 Deaths due to uterine and cervical cancers

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

 Because of early detection

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

1. Inspection and Palpation of the

• Instruct the patient while she is

•Mons Pubis and Pubic Hair

•Perineum and Anus

•Mons Pubis and Pubic Hair

•Perineum and Anus

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

• There may be some growth on

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

 Gray and sparse

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

• Observe the skin

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

 No ecchymosis, excoriation, nodules,

•Occasional sebaceous cyst is within normal limits

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

 Skene’s glands and Bartholin’s glands are

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

 Geriatric: atrophied- appears

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

Multiple, bilateral vulvar epidermal

mucosal involvement vulvar involvement

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

 Palpate each labium between the

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

Painless mass indicates

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

•Approximately 2 cm in length and 0. 5

clitoroplasty PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

 Free from discharge, swelling, or

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

Milking the urethra and

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN

PROFESSOR RHYAN G. TIOPIANCO, RN, MAN