Which examination position is used for gynecologic examinations?

History

The approach to both the history and physical examination of a child is often a collaborative effort that involves the child, her caregiver, and the provider. With a preverbal or very young patient, clinicians obtain the majority of the history from a parent or caregiver. Even for the very young patient, developmentally appropriate social questions directed to the patient can put her at ease and help to develop cooperation and rapport that will facilitate a subsequent examination. Specific patient, caregiver, or provider concerns about vaginal discharge or bleeding, pruritus, external genital lesions, or abnormalities should direct a problem-focused history. In a patient presenting with vaginal bleeding, questions should focus on recent growth and development, signs of pubertal progression, trauma, vaginal discharge, medication exposure, and any history of foreign objects in the vagina. For complaints of vulvovaginal irritation, pruritus, or discharge, questions should concentrate on perineal hygiene, the onset and duration of symptoms, the presence and quality of discharge, exposure to skin irritants, recent antibiotic use, travel, presence of medical comorbidities or infections in the patient and her family members, and other systemic symptoms of illness or skin conditions. Throughout the history, the patient should be encouraged to ask her own questions. Occasionally, the child is brought to the clinician because she or her parents have concerns about anatomic findings, developmental changes, or congenital anomalies. It helps to understand the family's concerns and if a specific reason, event, or family history raised the need for a gynecologic consultation.

Examining adolescent girls

Gynecologic examination of an adolescent girl begins with the interview. If a young girl is uncomfortable being interviewed alone and requests her parent's presence, make sure to phrase the questions so that the girl is aware that she, and not her parent, is the patient and is the person controlling the interview. If it is difficult to separate the parent from the child, defer confidential personal questioning to another visit, when the youngster may be more relaxed. Some physicians establish ground rules with the teenager and her parents, telling them that at a predetermined age, such as 12 years, you will spend some time talking with the young girl alone. It is very important, when dealing with adolescents, to convey to them a sense of self and to reassure them that everything they tell you is confidential and will not be conveyed to their parents without their consent. You also must establish with a young patient that if she is pursuing life-threatening behaviors, you will be compelled to involve other health care providers and her parents, even without her consent.

Gynaecological examination

Full awareness of the privacy of the examination is mandatory. A chaperone should be present during any intimate examination (breast or pelvic examination) whether the person performing the examination is male or female. General, abdominal and peripheral examination can be carried out without a chaperone, although it is preferable to have one present. Breast examination is not part of the gynaecological assessment in UK practice unless there is a specific complaint related to the breasts. It is important to ensure that the patient gets undressed in privacy without the doctor or student present, and that she has a suitable covering for the lower half of her body.

For a new consultation, a general examination is necessary and particularly relevant if an anaesthetic is anticipated. Details of the general physical examination are covered in other chapters. In the context of gynaecology, measurements of height and weight (giving the body mass index, BMI) and an assessment of body proportions (e.g. general or central obesity) are important. In ‘gynaecological endocrinological’ cases, the presence or absence of signs associated with hyperandrogenaemia (hirsutism, male pattern baldness, acne, increased muscle bulk) should be documented.

Pelvic Examination

A complete gynecologic examination, including speculum examination, bimanual examination, and rectovaginal examination, should be performed on all incontinent patients. Gynecologic examination should begin with inspection of the external genitalia. The pelvic structures should be evaluated for any abnormality. Vaginal discharge, estrogen status, and excoriation of skin should be noted. On occasion vaginal discharge may mimic urinary incontinence. If no objective evidence for urinary incontinence is found in this patient, she should be treated for vaginal discharge. Signs suggestive of atrophic vaginitis, such as thin and friable vaginal mucosa and vulvar skin, loss of vaginal rugae, and urethral caruncle, indicate a hypoestrogenic state in the lower urinary tract. Although controversial, estrogen may have some role in the treatment of certain lower urinary tract symptoms. (This discussion is beyond the scope of this chapter, but the interested reader can review two meta-analyses by Cardozo et al6 and Al-Badr.7) After a thorough examination of the vulva, the vagina should be inspected and examined. Vaginal atrophy should be noted. The anterior vaginal wall should be palpated for pain and masses. Painful urethra and bladder may suggest conditions such as urinary tract infection or interstitial cystitis. A suburethral mass with expression of pus from the urethra may suggest urethral or bladder diverticulum. The presence of a mass on the anterior vaginal wall necessitate ruling out carcinomas, Gartner's duct cyst, and other inflammatory conditions of the urethra.

Defects in pelvic organ support commonly coexist with urinary incontinence. Clinicians are expected to treat these two conditions concomitantly. Therefore, a complete examination evaluating all defects is mandatory. The choice of treatment for one condition will often guide the treatment for a coexisting condition. For example, a patient who seeks correction of prolapse via vaginal route may want to consider a vaginal procedure such as a suburethral sling to correct coexisting urodynamic stress urinary incontinence rather than an abdominal procedure such as the Burch procedure. The two halves of the vaginal speculum (Fig. 28-3) can be used sequentially to detect defects in the anterior compartment (cystocele, urethrocele), central compartment (uterine prolapse, enterocele, posthysterectomy vaginal vault prolapse), and posterior compartment (rectocele, enterocele). Prolapse is graded using a system as per personal preference. A complete speculum examination and a bimanual examination are also performed at this time, noting any vaginal scarring and/or reduction in vaginal length and/or calibration from previous surgical interventions. Any pelvic masses should be evaluated further.

Physical Examination

The physical examination is a crucial part of overall assessment of older adults with UI. In addition to routine aspects of physical examination including pelvic examination in women and genital and rectal examination in men, several unique components are also included for older adults with incontinence. The general physical examination should include identification of conditions associated with fluid overload and associated incontinence including peripheral edema, congestive heart failure, and pulmonary edema.

Neurologic examination includes gait and balance, mobility, and ability to transfer between positions. This includes ability to get on and off a chair, which can be similar to getting on and off the toilet. Clinical signs associated with common rheumatologic and neurologic disorders in older adults should also be evaluated. These include changes from arthritis and joint disorders, Parkinson disease, multiple sclerosis, prior stroke, spinal stenosis, cord compression, vertebral disc herniation, acute or chronic back pain, dementia, and delirium.

Perineal sensation should be tested and may be diminished or asymmetric, particularly in those with a history of underlying neurologic disease. For example, patients with a history of stroke and associated hemiparesis may have asymmetric perineal sensation. Tissue quality should be assessed, including presence or lack of rugation of the vaginal mucosa. Atrophic vaginitis is common in postmenopausal women and is usually due to lack of estrogen. This can also lead to fusion or agglutination of the labia minora or labia majora. In some cases this can cause voiding dysfunction and BOO (Chang et al., 2012). Vaginal narrowing or stenosis is another common finding on pelvic examination in elderly women. This is sometimes associated with a prior history of pelvic radiation therapy.

Pelvic examination in women should be performed with the bladder moderately full to evaluate for stress UI. Many older women wish to void before pelvic examination because it makes this more comfortable, and they may be used to doing so before routine gynecologic examinations. In some cases, women want to void before examination to avoid potential embarrassment with urine leakage in front of the clinician. However, if the patient voids to completion before the examination, determination of stress leakage with cough or Valsalva will be severely limited. Gentle reassurance of the importance of doing the examination with urine in the bladder and objective identification of stress leakage can be very useful and can help put the patient at ease.

Rectal examination may reveal signs associated with chronic constipation or fecal impaction. The bulbocavernosus reflex may be absent in older adults, although this change may or may not be associated with underling neurologic pathology. Prostate enlargement or nodularity may be palpable, although prostate size on rectal examination does not necessarily correlate with symptoms. Rectal cancers are more common among older adults, and the majority of lesions are palpable on digital rectal examination. Stool guaiac testing should also be considered and can help to identify otherwise silent pathology in some patients (Goetzl et al., 2008).

Diagnosis

The value of careful inspection of the vulva during routine gynecologic examinations cannot be overstated; this remains the most productive diagnostic technique. The entire vulva, perineum, and perianal area must be evaluated for multifocal lesions. It is not uncommon to find intraepithelial lesions on hemorrhoid tags. The use of acetic acid is very helpful in identifying subtle lesions. In contrast to the cervix, the vulva requires application of acetic acid for 5 minutes or longer before many lesions are apparent. Placement of numerous soaked cotton balls on the vulva for the desired length of time is an effective method. After a lesion has been diagnosed, colposcopic examination of the entire vulva and perianal area should follow to rule out multicentric lesions. A handheld magnifying glass can also be used which allows greater viewing area at one time compared with the colposcope. In general, multifocal lesions are more common in premenopausal patients, whereas postmenopausal patients have a higher rate of unifocal disease.

Some investigators prefer to use toluidine blue to identify vulvar lesions. A 1% aqueous solution of the dye is applied to the external genital area. After drying for 2–3 minutes, the region is then washed with 1–2% acetic acid solution. Suspicious foci of increased nuclear activity become deeply stained (royal blue), whereas normal skin accepts little or none of the dye. Regrettably, hyperkeratotic lesions, even though neoplastic, are only lightly stained, whereas benign excoriations are often brilliant, an observation that accounts for the high false-positive and false-negative rates.

The diagnosis of VIN can be subtle. To avoid delay, the physician must exercise a high degree of suspicion. Vulvar biopsy should be used liberally. It is best accomplished under local anesthesia with a Keyes dermatologic punch (4–6 mm size). This instrument allows removal of an adequate tissue sample and orientation for future sectioning. After obtaining the biopsy specimen, we use the Keyes punch to cut out a piece of absorbable gelatin powder (e.g. Gelfoam); this is positioned in the skin defect and kept in place with a small dressing for at least 24 hours.

Adequate biopsy specimens can also be obtained with a sharp alligator-jaw instrument if one has proper traction on the skin. The problem with ordinary knife biopsies is that only superficial epithelium can be reached. If this technique is used, one must be careful to sample deeper layers.

Few reports have been made on untreated VIN (see previous section). Jones and McLean observed five of five untreated VIN lesions, which progressed to invasive cancer in 2–3 years. All had multiple focal lesions. Barbero and colleagues noted 3 of 55 patients treated with VIN whose condition progressed to carcinoma in 14 months–15 years. These three patients were 58–74 years of age. Adequate diagnosis is important. Chafe and associates noted that 19% of women who were thoroughly evaluated and thought to have only VIN had invasive cancer on the vulvectomy specimen.

Diagnosis

The value of careful inspection of the vulva during routine gynecologic examinations cannot be overstated; this remains the most productive diagnostic technique. The milder forms of VIN first appear clinically as pale areas that vary in density. More severe forms are seen as papules or macules, coalescent or discrete, or single or multiple. Lesions on the cutaneous surface of the vulva usually appear as lichenified or hyperkeratotic plaques—that is, white epithelium (Figures 2-9 and 2-10). By contrast, lesions of mucous membranes are usually macular and pink or red. Vulvar lesions are hyperpigmented in 10% to 15% of patients (Figure 2-11). These lesions range from mahogany to dark brown, and they stand out sharply when observed solely with the naked eye.

The entire vulva, perineum, and perianal area must be evaluated for multifocal lesions. It is not uncommon to find intraepithelial lesions on hemorrhoid tags. The use of acetic acid is helpful in identifying subtle lesions. In contrast to the mucous membrane of the cervix, the keratinized epithelium of the vulva requires application of acetic acid for 5 minutes or longer before many lesions become apparent. Placement of numerous soaked cotton balls or sponges on the vulva for the desired length of time is an effective method. After a lesion has been diagnosed, colposcopic examination of the entire vulva and perianal area should follow to rule out multicentric lesions. A handheld magnifying glass can also be used, which allows greater viewing area at one time compared with the colposcope. In general, multifocal lesions are more common in premenopausal patients, whereas postmenopausal patients have a higher rate of unifocal disease.

Some investigators prefer to use toluidine blue to identify vulvar lesions. A 1% aqueous solution of the dye is applied to the external genital area. After drying for 2 to 3 minutes, the region is then washed with 1% to 2% acetic acid solution. Suspicious foci of increased nuclear activity become deeply stained (royal blue), whereas normal skin accepts little or none of the dye. Regrettably, hyperkeratotic lesions, even though neoplastic, are only lightly stained, whereas benign excoriations are often brilliant, an observation that accounts for the high false-positive and false-negative rates.

The diagnosis of VIN can be subtle. To avoid delay, the physician must exercise a high degree of suspicion. Vulvar biopsy should be used liberally. It is best accomplished under local anesthesia with a Keyes dermatologic punch (4-6-mm size). This instrument allows removal of an adequate tissue sample and orientation for future sectioning. The biopsy site can be made hemostatic with silver nitrate, Monsel's, or a piece of absorbable gelatin powder (e.g., Gelfoam) cut with the Keyes punch; this is positioned in the skin defect and kept in place with a small dressing for at least 24 hours. Adequate biopsy specimens can also be obtained with a sharp alligator-jaw instrument if one has proper traction on the skin. The problem with ordinary knife biopsies is that only superficial epithelium can be reached. If this technique is used, one must be careful to sample deeper layers.

Assessment of the Breast

The breast examination is included as a routine part of the gynecologic examination. If the patient has complaints about discomfort or pain in a breast, the health care professional should begin by examining the nonaffected breast and axilla. Inspect the breasts with the patient in the supine and sitting positions, with her hands above her head and then on her hips. Care should be taken to observe the contour, symmetry, and vascular pattern of the breasts for signs of skin retraction, edema, or erythema. Then, the examiner should systematically palpate each breast, the axillae, and the supraclavicular areas using the pads of the fingers to feel for masses. This can be accomplished by going in a circle, dividing the breast into segments, or by going up and down. Regardless, care must be taken to examine the breast in its entirety. Finally, the nipple should be evaluated for discharge, crusting, or ulceration.