Discharge. This should be studied to detect trichomoniasis, monilia, and clue cells and to obtain cultures, primarily for gonococci and chlamydia.
c.
Mucosal characteristics (i.e., color, lesions, superficial vascularity, and edema) The lesion may be: 1.
Inﬂammatory—redness, swelling, exudates, ulcers, vesicles 2.
3.
4.
Pigmented—bluish discoloration of pregnancy (Chadwick’s sign) 5.
Miscellaneous (e.g., endometriosis, traumatic lesions, and cysts) d.
Table 1.6 (Continued ) 2. Inspect the cervix for the same factors listed above for the vagina. Note the following comments relative to the inspection of the cervix: a.
Unusual bleeding from the cervical canal, except during menstruation, merits an evaluation for cervical or uterine neoplasia.
b.
Inﬂammatory lesions are characterized by a mucopurulent discharge from the os and redness, swelling, and superficial ulcerations of the surface.
c.
Polyps may arise either from the surface of the cervix projecting into the vagina or from the cervical canal. Polyps may be inﬂammatory or neoplastic.
d.
Carcinoma of the cervix may not dramatically change the appearance of the cervix or may appear as lesions similar in appearance to an inﬂammation. Therefore, a biopsy should be performed if there is suspicion of neoplasia.
D.
The pelvic organs can be outlined by bimanual palpation; the examiner places one hand on the lower abdominal wall and the finger(s) (one or two) (see Fig. 1.3) of the other hand in the vagina (or vagina and rectum in the rectovaginal examination) (see Fig. 1.4). Either the right or left hand may be used for vaginal palpation. The number of fingers inserted into the vagina should be based on what can comfortably be accommodated, the size and pliability of the vagina, and the weight of the patient. For example, adolescent, slender, and older patients might be best examined with a single finger technique.
1.
Introduce the well-lubricated index finger and, in some patients, both the index and the middle finger into the vagina at its posterior aspect near the perineum. Test the strength of the perineum by pressing downward on the perineum and asking the patient to bear down. This procedure may disclose a previously concealed cystocele or rectocele and descensus of the uterus.
Advance the fingers along the posterior wall until the cervix is encountered. Note any abnormalities of structure or tenderness in the vagina or cervix.
2.
Press the abdominal hand, which is resting on the infraumbilical area, very gently downward, sweeping the pelvic structures toward the palpating vaginal fingers. Coordinate the activity of the two hands to evaluate the body of the uterus for: a.
b.
Architecture, size, shape, symmetry, tumor c.
d.
e.
Tumors, if found, are evaluated for location, architecture, consistency, tenderness, mobility, and number.
3.
Continue the bimanual palpation, and evaluate the cervix for position, architecture, consistency, and tenderness, especially on mobility of the cervix. Rebound tenderness should be noted at this time. The intravaginal fingers should then explore the anterior, posterior, and lateral fornices.
4.
Place the “vaginal” finger(s) in the right lateral fornix and the “abdominal” hand on the right lower quadrant. Manipulate the abdominal hand gently downward toward the vaginal fingers to outline the adnexa.