1. Pelvic Examination
& Rectal Examination

3. Pelvic Examination
Also known as Vaginal Examination, Per Vaginal Examination, Pap Smear, and PV.
Indications:
As a screening test for pre-malignant or malignant lesions of the cervix.
To assist in the diagnosis of intra-abdominal pathology in the female patient with abdominal pain.
To obtain specimens to diagnose vaginal and uterine infections.
Part of a female complete physical examination.
George N. Papanicolaou was the founder of the Pap smear in 1920s.

4. Human Papillomavirus -HPV
Attacks the surface epithelial cells of the skin and the mucosa.
Lesions of HPV infection may involve the vulva, vaginal introitus, anus, cervix and the perineum.
High Risk Types: 16, 18, 31, and 35
Intermediate Risk Types: 33, 35, 39, 51, 52, 56, 58, 59, and 68
75% of cervical cancers are caused by the High Risk Types.
Gardisil vaccine.

5. Contraindications and Cautions
Warm water should be used on the speculum instead of lubricant if cultures or other specimens are to be obtained.
Gloves should be changed before a rectal exam. This prevents the spread of infection from the vagina to the rectum.
Female chaperone require, especially if the examiner is a male.

6. Equipment Light source Vaginal Speculum (appropriate size per patient)
Papanicolaou smear/ThinPrep Method
Lubricating jelly (water based)
Sterile cotton swabs, cytobrush, wooden or plastic spatula
Specimen slide with cover slips
KOH
NS solns
Gonorrhea and chlaymdia transport media
Drape or sheet

7. Cytobrush, Miltex plastic sampler, and tongue blade

8. Risk Factors & Historical Characteristics Correlated with Abnormal Paps
Tobacco smoking
Early age of 1st intercourse( <age 16)
Multiple sex partners (> 3)or vice versa
Hx of sexual abuse
STD Hx , Condyloma, and HIV
Illicit drug abuse (IV and Oral)
Hx of Abnl Paps
Diethylstilbestrol (DES): Rare Now

9. ThinPrep Method Latest papsmear technology
Relies on “liquid-based samples.”
More sensitive and specific
Another advantage is that the residual cytologic material left over after the Pap is completed can be used for HPV-DNA typing when Pap smears are equivocal (atypical). This is termed “Reflex DNA typing.”
The endocervical sample obtained is not spread on a slide as before, instead it is ‘swished’ in a vial of liquid that is spun and processed to eliminate blood and other debris. Those with High Risk HPV- evaluated with Colposcopy.
Those without High risk is evaluated at 6mths if some abnormalities or annually if Nl pap.

10. Patient Preparation
For a woman’s 1st Pelvic exam, time should be spent explaining what will occur. Models and illustrations may be used as adjuncts to the discussion.
Have the patient empty her bladder.
Assist the patient into the lithotomy position with her buttocks at the edge of the table and place a pillow under her head. Do not place the patient into this position until the actual commencement of the pelvic examination.
Pap is best performed during midcycle. Pt. should avoid douching, vaginal medications, and intercourse for 24hrs prior to pap.
Reschedule if pt is menstruating

11. Procedural Steps
First obtain Hx (especially sexual aspects of age at 1st intercourse, number of sexual partners, and Hx of sexual abuse or rape).
The pelvic exam should be carried out in a comfortable fashion for both the patient and physician.
To avoid startling the patient, advise her she will feel you touching her.

12. General Inspections
Inspect the external genitalia and perineum for swelling, ulcers, condylaomata, inflammation, bleeding, color changes and discharges.
Pay close attention to the clitoris, the vestibule, labias, Bartholin’s gland ( at 4 or 8 o’clock)
Inspect the vaginal orifice for d/c, or protrusions of the walls by asking the pt to bear down (cystocele, rectocele, urethral prolapse).

13. Speculum Examination
Use appropriate size speculum moistened with warm water Not with lubricant because it will interfere with cytology testing.
Insert one or two fingers into the introitus and press downward on the posterior or lower edge.
Insert the speculum at a 45 degree angle to the floor of the vagina and gently rotated pressing posteriorly.

14. Speculum Exam Cont’d
Then remove your fingers. The cervix should pop into view with some manipulation as the speculum is opened and then tightened.
Inspect the cervix and the vagina for color, lacerations, nabothian cysts and other lesions, and evidence of atrophy.
Inspect the cervical os for size, shape, color, and d/c. Obtain the Pap smear by using an endocervical sampling device, first insert into the canal and rotate 90 to 180 degrees with a cytobrush.

15. Speculum Exam Cont’d
With other devices (eg. Cervex-brush) rotate 360 degrees one or a few times.
Obtain adequate sampling from ectocervix with a plastic or wooden spatula by rotating 360 degrees or more.
Inspect the vagina for secretions and obtain specimen for cultures and other smears.
Gradually withdraw the speculum while rotating it to allow the visualization of the walls and the entire canal.

17. Bimanual Examination
While standing, place 2nd and 3rd lubricated glove fingers of the dominant hand inside the introitus .
Palpate the cervix note the size, shape, consistency, motility, and test for tenderness (the chandelier’s sign) or cervical motion tenderness, which is suggestive of PID or ruptured ectopic pregnancy.
With your fingers in the vagina posterior to the cervix and your hand on the abdomen place just above the symphysis, force the corpus of the uterus between the two examining hands. Note size, shape, consistency, position, and motility.

18. Bimanual Exam Cont.
Move the fingers in the vagina to one or the other fornix, and place the hand on the abdomen in a more lateral position to bring the adnexal areas under the examination. Palpate the ovaries, if possible, for any masses, consistency, and motility.
Unless, the fallopian tubes are diseased they are usually not palpable.

19. Rectovaginal Exam
Insert your index finger into the vagina, and place the well lubricated middle finger into the rectum.
Palpate the posterior surface of the uterus and the broad ligament for nodularity, tenderness, or other masses. Exam the uterosacral and rectovaginal septum. Nodularity here may represent endometriosis.
If stool specimen is available, do a occult blood test (guaiac).

20. Wet Mount/ Vaginal Saline Prep
Helpful in Dx of Trichomonas or BV
Mix a drop of discharge with a drop of NS on a glass slide and cover with a cover slip.
Observe the slide while still warm to see the flagellated, motile trichomonads. BV is diagnosed by the presence of “clue cells,” which represent polymorphonuclear white cells (PMNs).
Lactobacillus are normally the predominant bacteria in the vagina in the absence of specific infections .
the normal pH is usually <4.5.

21. KOH Prep BV gives a fishy amine odor with the addition of KOH
For thick white, curdy discharge the patient may have Candida albicans (Yeast Infection). Prepare a slide with one drop of discharge and one drop of aqueous 10% KOH soln.
The KOH dissolves the epithelial cells and debris and facilitates viewing of the hyphae and mycelia of the fungus that cause the infection.

22. GC and Chlamydia Cx
Use a sterile cotton swab to obtain specimen from the endocervical canal and plate it out on Thayer-Martin medium for GC.
Chlamydia testing varies but can include DNAprobe, EIA, or DFA testing.
A herpes Cx can be done for suspicious vesicular lesions.

24. Pap Report (Bethesda 2001) Atypical Squamous Cells (ASC)
ASC-US ( undetermined significance)
Three follow-up approaches are possible:
(1) Do DNA typing
(2) Immediately refer to colposcopy if risks factors are present.
(3) If repeated pap is abnormal then refer for colposcopy.
1) If high risk then Colposcopy, if not repeat pap in 6mths to 1yr.

25. Pap Report ASC-H ( cannot rule out High-grade dysplasia)
All require colposcopy
Evidence of SIL of any degree ( LGSIL and HGSIL): All require Colposcoy with ECc.
Evidence of Malignant cells: Colposcopy with ECC
Evidence of glandular atypia/atypical glandular cells (AGS) : Colposcoy with ECC.
Endocervical Adenocaricinoma In Situ: Oncologist referral
ECC: Endocervical Curettage

26. Colposcopy
Nothing more than the observation of a cervix under magnification after it has been stained with acetic acid to identify the most abnormal areas for Bx.
Heard so much about Colposcopy. What is a Colposcopy?

27. Colposcopic Exam Serves to : Identify normal landmarks
Identify abnormal areas in relation to these landmarks
Facilitate directed Bx of abnormal areas for histologic Dx
R/O Invasive cancer
Colposcopy also used in Rape and sexual assault victims.
Acetowhite : epithelium that transiently whitens following the application of acetic acid. Areas of acetowhite correlate with higher nuclear density. The white staining fades within minutes.

28. Self-Breast Exam (SBE)
Educate the patient:
That the best time to do a SBE is just after or up to a week after her menses.
To Inspect skin for any color changes, obvious lesions, changes in the nipple, and the areola.
Why?

29. SBE
Lying Supine:
Lie down with pillow under right shoulder and right arm behind your head.
Use the “Strip” pattern or Circular or Wedge pattern techniques with the finger pads.
Check the entire breast area, and remember how your breast feels from month to month
Repeat exam with the left breast.

30. SBE Standing in Shower: Follow same technique as supine
Upright position makes it easier to check the UOQ (toward the armpit). This is where about half of breast cancers are found.
Standing In front of the Mirror:
Especially for pendulum breasts, hands on hips and leaning forward with breast dangling.
Look for mirror reflections of dimpling or retractions of breast tissue and or nipples.
Other techniques: “Arms over Head” and “ Hands pressed against Hips”

31. Rectal Exam –DRE
As a screening test for CRC, anorectal Ds and for Prostate exam.
Positions:
Left lateral decubitus position
Lithotomy position
Standing with upper body leaning over table.

32. External Anal Exam
Look for signs of perianal inflammation that may suggest Pruritus ani or other dermatologic conditions.
Gently separate the buttocks; looking for fissures, fistulas, sentinel skin tag, perianal abscess, and external hemorrhoids.
condylomas/warts.
What are Hemorrhoids? Hemorrhoids are collections of arteries and veins that, if not enlarged, represent normal anatomy and are not considered varicosities.

33. Digital Anorectal Exam
Inform Pt. that anus will be touched with a lubricated gloved finger.
Gently pressure at the anal verge and ask the pt. to bear down to enter the anal canal.
Assess the prostate in males
Sweep the rectal vault and extend the examining finger as far as possible for any palpable lesion or mass.
Internal Hemorrhoids are generally not palpable. Check sample of stool for occult blood (guaiac).
Stool Studies: Cx, WBC, O&P x3, Giardia, Entamoeba, C.difficile, FOBT x3

34. Continence & Anal Sphincter function
Flex index finger slightly posterior and ask pt. to “squeeze down” as if trying to stop a BM.
If NL anatomic sphincter function, you feel the tightening of the distal extent of the External Sphincter at the base of your finger.

35. Removal of IUD Strings No need for Sterile technique.
Insert Speculum and visualize the IUD strings.
Using forceps, grasp the strings and pull toward the introitus.
Can pre-medicate with Motrin 800mg for possible momentary discomfort.

36. If Strings are not Visible
Use a cytobrush or similar instrument and insert it (the brush portion) the full depth into the cervical canal (2cm)
Rotate and extract the brush in a repeated, continuous motion .
There are other methods like inserting hemostat like instrument into the os , with this instrument opened as much as the os will allow. Close the jaws in hopes that the strings are grasped.