TECHNIQUES OF EXAMINATION

EXAMPLES OF ABNORMALITIES

majus. On each side in turn, palpate between your finger and thumb for
swelling or tenderness. Note any discharge exuding from the duct opening
of the gland. If any is present, culture it.

INTERNAL EXAMINATION
Assess the Support of the Vaginal Walls.

With the labia Bulging

separated
from a cystocele or rectoby your middle and index fingers, ask the patient to strain down. Note any
cele. See Table 11-2, Bulges and
bulging of the vaginal walls.
Swelling of Vulva, Vagina, and Ure-

Insert the Speculum.

thra (p. ___).

Select a speculum of appropriate size and shape,

and lubricate it with warm water. (Other lubricants may interfere with cytologic studies and bacterial or viral cultures.) You can enlarge the vaginal introitus by lubricating one finger with water and applying downward pressure
at its lower margin. (You may also wish to check the location of the cervix to
help angle the speculum more accurately.) Enlarging the introitus greatly
eases insertion of the speculum and the patients comfort. With your other
hand (usually the left), introduce the closed speculum past your fingers at a
somewhat downward slope. Be careful not to pull on the pubic hair or pinch
the labia with the speculum. Separating the labia majora with your other hand
can help to avoid this.

SMALL
INTROITUS
392THE
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BATES
GUIDE
TO
EXAMINATION
HISTORY

TECHNIQUES OF EXAMINATION

EXAMPLES OF ABNORMALITIES

Two methods help you to avoid placing pressure on the sensitive urethra.
(1) When inserting the speculum, hold it at an angle (shown below on the
left), and then (2) slide the speculum inward along the posterior wall of
the vagina.

ENTRY ANGLE ANGLE AT FULL INSERTION

After the speculum has entered the vagina, remove your fingers from the introitus. You may wish to switch the speculum to the right hand to enhance
maneuverability of the speculum and subsequent collection of specimens.
Rotate the speculum into a horizontal position, maintaining the pressure
posteriorly, and insert it to its full length. Be careful not to open the blades
of the speculum prematurely.

Inspect
the
Cervix.
speculum
light
the
ing
ent
cotton
cervix
slope.
the
until
swab.
cervix,
If
until
you
points
discharge
withdraw
itFEMALE
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the
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Rotate
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findtheretroversion
See
p. ___.
of the uterus,
393
s can
GENITALIA

CHAPTER 11

TECHNIQUES OF EXAMINATION

EXAMPLES OF ABNORMALITIES

Inspect the cervix and its os. Note the color of the cervix, its position, the
See Table 11-3, Variations in the
characteristics of its surface, and any ulcerations, nodules, masses, bleeding,
Cervix (p. ___), and Table 11-4,
or discharge.
Abnormalities of the Cervix
(p. ___).

Maintain the open position of the speculum by tightening the thumb screw.

Obtain Specimens for Cervical Cytology (Papanicolaou Smears). A yellowish discharge on the
Obtain one specimen from the endocervix and another from the ecto- endocervical swab suggests a
mucopurulent
cervicitis, commonly
cervix, or a combination specimen using the cervical brush (broom).
For
best results the patient should not be menstruating. She should avoid inChlamydia
caused
trachomatis,
by
Neisseria gonorrhoeae,
or herpes
tercourse and use of douches or vaginal suppositories for 24 to 48 hours
simplex (p. ___).
before the examination.

OBTAINING THE PAP SMEAR:

OPTIONS FOR SPECIMEN COLLECTION
Cervical Scrape and Endocervical Brush
Cervical Scrape. Place the longer end of
the scraper in the cervical os. Press,
turn, and scrape in a full circle, making
surespecimen
to
include
the
transformation
zone
394endocervical
and
the
slide
Note
reduces
which
the
in
that
sometimes
aobscuring
safe
doing
squamocolumnar
brush.
on
spot
the
a appears
glass
cells
that
cervical
iswith
slide.
easy
with
junction.
scrape
blood,
Set
to
use
reach.
the
of
first
the
Smear

BATES GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING

TECHNIQUES OF EXAMINATION

EXAMPLES OF ABNORMALITIES

Endocervical Brush. Now take the endocervical brush and place it in the cervical os.
Roll it between your thumb and index finger, clockwise and counterclockwise. Remove the brush and pick up the slide you
have set aside. Smear the slide with the
brush, using a gentle painting motion to
avoid destroying any cells. Place the slide
into an etheralcohol solution at once, or
spray it promptly with a special fixative.
Note that for pregnant women, a
cotton-tip applicator, moistened with
saline, is advised in place of the endocervical brush.

Cervical Broom
Many clinicians now use a plastic brush
tipped with a broomlike fringe for collection of a single specimen containing both
squamous and columnar epithelial cells.
Rotate the tip of the brush in the cervical
os, in a full clockwise direction, then
stroke each side of the brush on the glass
slide. Promptly place the slide in solution
or spray with a fixative as described
above.

Inspect the Vagina.

Withdraw the speculum slowly while observing

the11-5, Vaginitis (p. ___).
See Table
vagina. As the speculum clears the cervix, release the thumb screw and maintain the open position of the speculum with your thumb. Close the speculum as it emerges from the introitus, avoiding both excessive stretching and
pinching of the mucosa. During withdrawal inspect the vaginal mucosa, noting its color and any in ammation, discharge, ulcers, or masses.
Cancer of the vagina

Perform a Bimanual Examination.

Lubricate the index and

middle
Stool
in the rectum may simulate a
fingers of one of your gloved hands, and from a standing position insert
them mass, but unlike a
rectovaginal
into the vagina, again exerting pressure primarily posteriorly. Your thumb
tumor mass can usually be dented
should be abducted, your ring and little fingers exed into your palm.
by Pressdigital pressure. Rectovaginal exing inward on the perineum with your exed fingers causes little if any
dis- confirms the distinction.
amination
comfort and allows you to position your palpating fingers correctly. Note
any nodularity or tenderness in the vaginal wall, including the region of the
urethra
ity,
pain.
Palpate
tween
and
Feel
the
and
tenderness.
theumbilicus
the
the
cervix,
uterus.
bladder
Normally
noting
Place
and
around
anteriorly.
the
your
itssymphysis
position,
the
the
other
cervix
cervix.
hand
shape,
pubis.
can
onbe
the
consistency,
While
moved
abdomen
you
somewhat
elevate
regularity,
about midway
the
without
cervix
mobiltogether
Painbesuggests
on with
movement
adnexal
pelvic
disease.
of
intenderness,
the
ammatory
cervix,
395
CHAPTER
11
s fornices
FEMALE
GENITALIA