The appropriate technique and frequency for cervical cytology testing is presented in Chapter 19. Biopsy should be performed on any obvious lesions on the cervix or in the vagina. An endometrial biopsy usually is performed with a ﬂexible cannula or a Novak curette (see Chapter 14). Any purulence in the vagina or cervix should be cultured (see Chapter 18). Testing for sexually transmitted diseases should be performed routinely in adolescents and young adults as recommended by the Centers for Disease Control and Prevention.
After the speculum is removed and the pelvis palpated, lubrication is applied to the examination glove, and one or two (the index or index and middle) fingers are inserted gently into the vagina. In general, in right-handed physicians, the fingers from the right hand are inserted into the vagina and the left hand is placed on the abdomen to provide counter-pressure as the pelvic viscera are moved (Fig. 1.3). In patients with pelvic pain, a stepwise “functional pelvic examination” involves the sequential palpation of anatomic structures, including the pelvic ﬂoor muscles, bladder, rectum, cervix, and cul-de-sac. These areas are assessed for tenderness and a specific source of pain. Pelvic ﬂoor muscle spasm is a common concomitant of pelvic pain. The vagina, its fornices, and the cervix are palpated carefully for any masses or irregularities. One or two fingers are placed gently into the posterior fornix so the uterus can be moved. With the abdominal hand in place, the uterus usually can be palpated just above the surface pubis. In this manner, the size, shape, mobility, contour, consistency, and position of the uterus are determined. The patient is asked to provide feedback about any areas of tenderness, and her facial expressions are observed during the examination.
Figure 1.3 The bimanual examination.
The adnexa are palpated gently on both sides, paying particular attention to any enlargements. Again, the size, shape, mobility, and consistency of any adnexal structures should be carefully noted.
When indicated, a rectovaginal examination should be performed to evaluate the rectovaginal septum, the posterior uterine surface, the adnexal structures, the uterosacral ligaments, and the posterior cul-de-sac. Uterosacral nodularity or posterior uterine tenderness associated with pelvic endometriosis or cul-de-sac implants of ovarian cancer can be assessed in this manner. Hemorrhoids, anal fissures, sphincter tone, rectal polyps, or carcinoma may be detected. A single stool sample for fecal occult blood testing obtained in this manner is not adequate for the detection of colorectal cancer and is not recommended (55) (Fig. 1.4).
At the completion of the physical examination, the patient should be informed of the findings. When the results of the examination are normal, the patient can be reassured accordingly. When there is a possible abnormality, the patient should be informed immediately; this discussion should take place after the examination with the patient clothed. A plan to evaluate the findings should be outlined brieﬂy and in clear, understandable language.
Figure 1.4 The rectovaginal examination.
The implications and timing of any proposed procedure (e.g., biopsy) should be discussed, and the patient should be informed when the results of any tests will be available.
Pediatric Patients A careful examination is indicated when a child presents with genital symptoms such as itching, discharge, burning with urination, or bleeding. The examiner should be familiar with the normal appearance of the prepubertal genitalia. The normal unestrogenized hymenal ring and vestibule can appear mildly erythematous. The technique of examination is different from that used for examining an adult and may need to be tailored to the individual child based on her age, size, and comfort with the examiner.