Chapter 2 Examination of the gynaecological patient
Examination of the gynaecological patient Gynaecological history
Taking a good history will go a long way towards arriving at the correct diagnosis. In order to do this it is important to develop a good rapport with the patient.
Greeting the patient with a proper introduction, an explanation of the purpose of the consultation and guaranteeing privacy and confidentiality are all vital. Having a model for history taking can help to ensure that all aspects are covered but the need to be flexible and sensitive to individual patients and their problems should be appreciated. An outline is given below.Current history
Name, age, and parity.
Presenting symptom(s). Three examples of common gynaecological complaints:
• Pelvic pain: site, onset, duration, character, radiation, exacerbating, relieving factors, any relationship to the menstrual cycle, dyspareunia, associated symptoms such as vaginal discharge, dysuria, vomiting.
• Abnormal menstrual bleeding: regular/irregular including post coital or intermenstrual, quantification of loss (does she report flooding or use of double sanitary protection?), dysmenorrhoea, dyspareunia, any previous treatments and their effects.
• Vaginal discharge: onset, colour, odour, itchiness, presence of blood, use of over-the-counter remedies, relation to the menstrual cycle, concurrent symptoms from sexual partner.
Menstrual history
First day of last menstrual period (LMP), length of cycle and days of bleeding, age of menarche/menopause as appropriate.
Contraceptive and sexual history
Current method of contraception and previous methods with any side-effects. Dyspareunia—superficial/deep/positional, libido, vaginal dryness, problems with orgasm, recent change in partner, vaginal discharge.
Past gynaecological history
Details that have not yet been covered such as details of last cervical smear, previous gynaecological conditions and relevant treatments or operations (e.g.
pelvic inflammatory disease, endometriosis, use of hormone replacement therapy (HRT) and laparoscopies.)Past obstetric history
Details of previous pregnancies and their outcomes (gestation, mode of delivery, any complicating factors e.g. haemorrhage, perforation of uterus at time of evacuation of retained products of conception (ERPC)) in chronological order.
Past medical and surgical history
This is important as accurate information may help lead to a diagnosis (e.g. thyroid disorders and menstrual disturbances, colorectal carcinoma and endometrial carcinoma), planning management with regard to anaesthetic assessment preoperatively (cardiovascular and respiratory conditions) and multidisciplinary input and follow up (e.g. haematologist involvement when managing a thrombophilic patient).
Drug history and allergies
Current medication should be noted and specific drug allergies clearly marked on the notes. Thought must always be given to any current medication to avoid drug interactions, e.g. enzyme-inducing action of antiepileptic drugs leading to higher failure rate of the combined oral contraceptive.
Social and family history
This should include how the current complaint impacts on the patient’s life. Enquiry into smoking, drinking, recreational drug use and living conditions may be relevant to the condition and impact on the future management of the patient. Ascertaining a family history of conditions such as malignancies and venous thrombolic disease may also direct diagnoses or influence therapeutic options. Clinical examination
This will start with a general examination of the patient, including blood pressure and weight to calculate body mass index. Initial inspection of the woman will include her general wellbeing, but attention to detail such as the presence of a goitre, acne and hirsuitism may be relevant before moving on to the actual gynaecological examination.
It is essential that the woman be put at ease and every effort to ensure that the woman remains as comfortable as possible throughout the examination, e.g.
given a clean sheet to cover herself to protect some modesty, a female chaperone present for all patients, and curtains providing full privacy. The doctor must ensure that interruptions (e.g. pagers, mobile phones) are avoided throughout the examination.Abdominal examination
This should follow the routine examination of any system: inspection, palpation, percussion, and auscultation. The emphasis will be guided by the patient’s history but in the gynaecological patient particular attention to pubic hair distribution, striae, surgical scars including laparoscopy scars are worth noting. Palpation should allow description of any maximal site of tenderness with associated signs of peritonism and define any palpable mass in terms of site, size consistency and, importantly, mobility. Percussion can be a useful sign to differentiate between a solid mass, full bladder or distended bowel as well as the presence of fluid within the peritoneal cavity, e.g. blood from a ruptured ectopic or ascites from an ovarian malignancy. Auscultation is not routinely used in gynaecological practice but can be important for the initial assessment of a patient presenting with an acute abdomen and postoperatively to guide commencing oral intake or to rule out paralytic ileus.
Vaginal examination
Vaginal examination is normally carried out with the patient lying on her back with her knees flexed and hips abducted and includes
• inspection of the external genitalia
• speculum examination of the cervix and vagina
• bimanual examination of the uterus and adnexae.
Inspection of the external genitalia: mons pubis and pubic hair distribution. Any obvious lesions of the labia majora, minora, clitoris, urethral meatus, vaginal introitus, and perianal region should be documented. Further visualization of the perineal region and introitus may be aided by gently separating the labia further with the thumb and index finger of the examiner’s left hand. This may reveal the presence of a cystourethrocoele or rectocoele.
Alternatively, at this stage, asking the patient to cough or ‘bear down’ may unmask the presence of urinary stress incontinence or other uterovaginal prolapse. On occasion it may be necessary to ask the patient to use her own hands to localize any particular area of tenderness in this area.Speculum examination
After explanation to the patient, the labia are parted by the examiner’s finger and thumb as above and a warm lubricated Cuscoe’s speculum is inserted gently in one smooth movement into the vagina directed at approximately 45° as if towards the coccyx, i.e. along the axis of the vagina. When the speculum can be advanced no further the blades are opened to visualize the cervix. If the cervix is not in view at this stage, closing the blades and drawing the instrument back before reopening them again may help. It is wise to tell the patient that you are gently going to move the speculum slightly within the vagina and the purpose of doing so. If the cervix remains out of view, occasionally it can be visualized with a Cuscoe’s speculum, performed with the patient in the left lateral position.
Documentation of the appearance of the cervix and any vaginal discharge is important. Under direct vision of the cervix a cervical smear, high vaginal and endocervical swabs can be obtained as appropriate. Taking care with removal of the speculum can allow further visualization of the vagina and is essential to prevent unnecessary discomfort to the patient. The blades should be allowed to close slightly after the cervix has disappeared from view. Care should be taken not to entrap lax vaginal wall within the blades and complete the closure of the blades before final withdrawal of the instrument through the introitus is advisable.
A Sim’s speculum examination, of the patient lying in the left lateral position can allow full visualization of uterovaginal prolapse and is also appropriate when suspecting vesicovaginal fistulae.
Omission of vaginal examination
It may be appropriate not to proceed with a vaginal examination during an outpatient consultation, either due to patient’s request/virgo intacta/an adult unable to give consent/paediatric patient.
Consideration should be given to whether examination under anaesthesia is going to add to the management of the patient. In the case of women who are virgo intacta, some are happy to be examined and a small Cuscoe’s can be introduced if the patient is suitably relaxed and then proceeding to a one finger vaginal examination.Bimanual examination
Ensure the bladder is empty prior to this examination to prevent discomfort to the patient and maximize correct identification of the pelvic organs. The index and middle fingers of the right hand are inserted into the vagina with the palmar aspect facing anteriorly until the cervix is felt. The left hand presses gently on the lower abdomen to bring the abdominal wall close to the pelvic organs, which are simultaneously being pushed upwards by the ‘vaginal hand’. The uterus is palpated first between the two hands, followed by the adnexae, by moving the vaginal fingers into the lateral fornices and the abdominal hand over the respective iliac fossae. The pouch of Douglas is then felt by feeling in the posterior fornix. The size, consistency and mobility of any pelvic mass(es) detected are documented.
Rectal
This may be indicated in specific circumstances and may need to be performed simultaneously with a digital vaginal examination such as in women with suspected cervical carcinoma to asses the pelvic side walls to aid staging, severe endometriosis where involvement of the rectum is likely, urogynaecological conditions such as urinary/faecal incontinence and rectocoele where there are also defaecatory difficulties.