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from Section 4 - Pelvis and perineum
Published online by Cambridge University Press: 05 July 2015
Checklist
WIPER
• Patient lying down, undressed from the waist down. Chaperone as required.
Physiological parameters
Inspection
• Hair distribution: measure of sexual development
• Rash/coloured areas: infection, atrophy
• Ulcers: see notes below for differential diagnosis
• Lumps: painful or painless
• Sinus openings: fistula
• Scars/asymmetry: previous surgery
Gently separate the labia.
• Inspect for all the above: do not forget to look at the medial aspect of the labia
• Size and shape of clitoris
• Urethra: urethral caruncle/prolapse
• Presence of discharge from urethral orifice and/or vaginal outlet
Ask the patient to bear down.
• Presence of lump/bulge: cystocoele/rectocoele/uterine prolapse
Ask the patient to cough.
• Leakage of urine: stress incontinence
Cusco's and Sims' speculum examination
• To visualise the vaginal walls and cervix
• To obtain specific samples (for cytology, microbiology)
Palpation/digital bimanual examination
• Lumps: Bartholin's cyst or abscess
• Vaginal walls
• Cervix: shape, consistency, regularity, mobility, tenderness
• Uterus: size, shape, consistency, position, mobility
• Adnexae: presence of any masses; if any determine characteristics
• Uterosacral ligaments in the pouch of Douglas: regularity, tenderness
To complete the examination…
• Examine the abdomen: remember, if an enlarged pelvic organ is palpable abdominally, you cannot get below it.
• Examine the groins: lymphadenopathy (if vulval pathology is present).
• Perform a rectal examination: identify pelvic masses/tenderness and distinguish between enterocoele and rectocoele.
Examination notes
Essential history points
A focused gynaecological history should be obtained prior to examination. As an absolute minimum, the examining clinician ought to determine:
• LMP (first day of last menstrual period)
• Parity
• Pregnancy status in women of childbearing age
• Vaginal discharge or bleeding
• Abdominal pain
• Methods of contraception
How do you prepare for the gynaecological examination?
Any internal examination is potentially frightening for the patient, so it is imperative to ensure privacy, explain in simple language what you are going to do and ask for the patient's permission.
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