The gynaecological history and examination pdf

A history that is taken withsensitivity will often encourage the patient to revealmore details that are relevant to future management.Before proceeding to abdominal examination, ageneral

When interviewing a patient to obtain her history, the

consultation should ideally be held in a closed room

with no one else present Enough time should be

allowed for the patient to express herself, and the

doc-tor's manner should be one of interest and

under-standing It is important that a template is used for

history taking, as this prevents the omission of

import-ant points A sample template is given on page 2

Examination

It is important that the examiner smiles, introduces

her/himself by name and, if appropriate, asks the

patient's name A handshake often helps to put the

patient at ease

Important information about patients can beobtained by watching them walk into the examinationroom; poor mobility may affect decisions regardingsurgery While obtaining a history, it is possible toassess the patient's affect A history that is taken withsensitivity will often encourage the patient to revealmore details that are relevant to future management.Before proceeding to abdominal examination, ageneral examination should be performed Thisincludes examining the hands and mucous mem-branes for evidence of anaemia The supraclavicularnode should always be examined, particularly on theleft side, where, in cases of abdominal malignancy,one might palpate the enlarged Virchow's node (this

is also known as Troissier's sign) The thyroid glandshould be palpated

The chest and breasts should always be examined;this is particularly relevant if there is a suspected ovarianmass, as there may be a breast rumour with secondaries

2 The gynaecological history and examination

I Symptoms

History-taking template

The following outline is suggested.

• Name, age, occupation

• A brief statement of the general nature and duration ot

the main complaints

History ol presenting complaint

This section should focus on the presenting complaint,

But certain important points should always be enquired

about

• Abnormal menstrual loss.

• Pattern of bleeding - regular or irregular.

• Intermenstrual bleeding.

• Amount of blood loss - greater ot less than usual

• Number of sanitary towels or tampons used.

• Passage of clots or flooding.

• Pelvic pain - site of pain, nature and relation to periods

• Anything that aggravates or relieves the pain

• Vaginal discharge - amount, colour, odour, presence

of blood.

Obviously if the presenting complaint is one ot subfertility or

is u re-gynaecological, the history mus! be appropriately

tailored (see Chapters 7 and 16).

Usual menstrual cycle

• Age of menarche

• Usual duration of each period and length of cycle.

• First day ot the last period

Previous gynaecological history

This section should include any previous gynaecological

treatments or surgery Trie date of the last cervical smear

should also be recorded.

Previous obstetric history

• Number of children with ages and birth weights

• Any abnormalities with pregnancy, labour or the puerpenum.

• Number of miscarriages and gestation at which theyoccurred

• Any termination of pregnancy with record of gestation age and any complications.

Sexual and contraceptive history

• History of discomfort, pain or bleeding during intercourse

• The use of contraception and type of contraception used.

Previous medical history

• Any serious illnesses or operations with dates.

• Family history.

Enquiry about other systems

• Appetite, weight loss, weight gain

• Bowels

• Micturition.

• Other systems.

Social historyThe history regarding smoking and alcohol intake should be obtained It is important to ascertain whether the woman is married or has a sexual partner Any family problems should

be discussed, and it is especially important in the case of a frail patient to enquire about home arrangements if surgery

is being considered.

Summary

It is important to summarize the history in one or two sentences before proceeding to examination to alert the examiner io the salient features

in the ovaries known a"s Krukenburg tumours In

addition, a pleural effusion may be elicited as a

conse-quence of abdominal ascites The next step should be to

proceed to abdominal and pelvic examination

Abdominal examination

The patient should empty her bladder before the

abdominal examination She should be comfortable

and lying semi-recumbent, with a sheet covering

her from the waist down, but the area from the

xiphisternum to the symphysis pubis should be left

exposed It is usual to examine the woman from herright-hand side Abdominal examination comprisesinspection, palpation, percussion and, if appropriate,auscultation

Inspection

The contour of the abdomen should be inspected andnoted There may be an obvious distension or mass(Fig 1.1)

The presence of surgical scars, dilated veins orstriae gravidarum (stretch marks) should be noted It

is important specifically to examine the umbilicus forlaparoscopy scars and just above the symphysis pubis

Examination 3

Figure 1.1 Abdominal distension.

for Pfannenstiel scars (used for Caesarcan section,

hysterectomy, etc.) The patient should be asked to

raise her head or cough and any herniae or

divarica-tion of the rectus muscles will be evident

Palpation

First, if the patient has any abdominal pain, she

should be asked to point to the site This area should

not be examined until the end of palpation It is usual

to get the patient to cough, as she may show signs of

peritonism Palpation using the right hand is

per-formed, examining the left lower quadrant and

pro-ceeding in a total of four steps to the right lower

quadrant of the abdomen Palpation should include

examination for masses, liver, spleen and kidneys If a

mass is present but it is possible to palpate below it, it

is more likely to be an abdominal mass rather than a

pelvic mass It is important to remember that one of

the characteristics of a pelvic mass is that one cannot

palpate below it

If the patient has pain, her abdomen should be

pal-pated gently and the examiner should look for signs

of peritonism, i.e guarding and rebound tenderness

The patient should also be examined for inguinal

her-niae and lymph nodes

Percussion

Percussion is particularly useful if free fluid is

sus-pected In the recumbent position, ascitic fluid will

settle down into a horseshoe shape and dullness in the

flanks can be demonstrated

As the patient moves over to her side, the dullness

will move to her lowermost side; this is known as

'shifting dullness' A fluid thrill can also be elicited

An enlarged bladder due to urinary retention will also

be dull to percussion and this should be demonstrated

to the examiner (many pelvic masses have peared after catheterization)

disap-Auscultation

This method is not specifically useful for the logical examination However, a patient will sometimespresent with an acute abdomen with bowel obstruc-tion or a postoperative patient with ileus, and there-fore listening for bowel sounds may be appropriate

gynaeco-Pelvic examination

Before proceeding to a vaginal examination, thepatient's verbal consent should be obtained and afemale chaperone should be present tor any intimateexamination

The external genitalia are first inspected under

a good light with the patient in the dorsal position,the hips flexed and abducted and the knees flexed.The left lateral position is used for examination

of prolapse or to inspect the vaginal wall with aSims' speculum (Fig 1.2) The patient is asked tostrain down to enable the detection of any prolapseand also to cough, as this will show the sign of stressincontinence After this, a bivalve (Cusco's) speculum

is inserted to visualize the cervix (Fig 1.3) It is usual

to warm the speculum to make the examination morecomfortable for the patient If taking a smear test, this

is performed at the same time

Bimanual digital examination is then performed(Fig 1.4) This technique requires practice It is cus-tomary to use the fingers of the right hand in thevagina and to place the left hand on the abdomen In

a virgin or a child, only a rectal examination should

be performed The left hand is used to separate thelabia minora to expose the vestibule and the examin-ing fingers of the right hand are inserted The cervix ispalpated and any hardness or irregularity noted Thehand on the abdomen is placed just below the umbil-icus and the fingers of both hands are then used to pal-pate the uterus The size, shape, position, mobilityand tenderness of the uterus are noted The tips of thevaginal fingers are then placed into each lateral fomixand the adnexae are examined on each side Except in

a very thin woman, the ovaries and Fallopian tubes are

not palpable The uterosacral ligaments can be

pal-pated in the posterior fornix and may be scarred or

shortened in women with endometriosis

4 The gynaecological history and examination

'.'

Figure 1.2 (a) Sims' speculum (b) Sims' speculum exposing anterior vaginal wall

Figure 1.3 (a) Cusco's speculum (b)Cusco's speculum in position with the blades opened exposing the cervix

(a) (b)

Investigations 5

Rectal examination

A rectal examination may be used as an alternative to

vaginal examination in a virgin or a child In addition,

it may be useful to differentiate between enterocele

and rectocele and can be used to assess the size of a

rectocele

Investigations

The appropriate investigation should be performed,e.g swabs for discharge or cervical smear

Other investigations are discussed in Appendix 1

The consultation should be performed in a private

environment in a sensitive fashion

The student should introduce him/herself to the patient and

be courteous

The student should be familiar with a template and use it

regularly to avoid omissions

A chaperons should always be present for an intimate

When presenting the history to the examiner, it should besuccinct and should be summarized before presenting theexamination.

Remember the examiners will usually ask for a differentialdiagnosis

Development of the genital organs

^^•••^•^•^•^••^^•^•••^•^ii^se^^^^Bte-:

During the fifth week of embryonic life the

nephro-genfc cord develops from the mesoderrn and forms

the urogenilal ridge and mesonephrie duct (later to

form the Wolffian duct) (Fig 2.1) The mesonephros

consists of a corn para lively large ovoid organ on each

side of the midline, with the developing gonad on the

medial side of its lower portion The paramesonephric

duct later forms the Miillerian system The fate of the

mesonephrie and paramesonephric duets is dependent

on gonadal secretion Assuming female development>

the two paramesonephric ducts extend caudally

to project into the posterior wall of the urogenital

sinus as the Miillerian tubercle The Wolffian system

degenerates

tf ^Genitalridge

Mesonephros

Figure 2.1 Cross-sectional diagram of the posterior abdominalwall showing the genital ridge

bee oi gynaecology Both

tototrtinal wall Although

Mnember lhat congenital

~- = :r= c t e r serves as a

Development of the uterus and Fallopian tubes

The lower end of the Miillerian ducts come together

in the midline, tu.se and develop into the uterus andcervix (Tig 2.2) At first there is a septum separatingthe lumina ol the two ducts, but later this disappears

and a single cavity is formed, i.e the uterus.

The upper parts of both ducts retain their identityand form the Fallopian tubes The lower end of thefused Mullerian ducts beyond the uterine lumenremains solid, proliferates and forms a cord

Development of the vagina

During the ninth week of embryonic life, the corddoes not open out into the sinus but makes contactwith the sinovaginal bulbs, which are solid out-growths from the sinus As the pelvic region of thefetus elongates, the sinus and Miillerian tuberclebecome increasingly distanced from the tubular por-tions, the ducts The solid epithelial cord provides thelength of the future vagina The current view is that

Embryology '

most of the upper vagina is of Mullerian origin The solid sinovaginal bulbs also have to canalize to form a lower vagina and this occurs above the level of the eventual hymen, so that the epithelia of both surfaces

of the hymen are of urogenital sinus origin Complete canalization of the vagina is a comparatively late

event, occurring in the sixth and seventh months

Development of the external genitalia

There is overlap in the timing of the formation of theexternal genitalia and the internal duct system.There is a common indifferent stage consisting oftwo genital folds, two genital swellings and a midlineanterior genital tubercle The female development is asimple progression Irom-these structures;

• genital tubercle —> clitoris

• genital folds -> labia minora

• genital swellings —> labia major a

A male phenotype is dependent on the production

of fetal testosterone Agents or inborn errors that vent the synthesis or action of androgens inhibit theformation of male external genitalia and the femalephenotype will develop

_ Paramesonephric ducts

Fallopian tube Gubernaculum

Degenerating mesonephric - duct

Developing uterus

Mullerian tubercle Urogenital

sinus

Figure 2.2 Caudal growth of paramesonephric ducts (top).

Fusion to form trie uterus and Fallopian tubes (below).

Development of the ovary

The primitive gonad is first evident in embryos at 5weeks It forms as a bulb on the medial aspect of themesonephric ridge and is of triple origin, from thecoelomic epithelium of the genital ridge, the underlyingmesoderm and the primitive germ cells There is pro-liferation of cells in and beneath the coelomic epithe-lium of the genital ridge By 5-6 weeks these cells areseen spreading as ill-defined cords (sex cords) intothe ridge, breaking up the mesenchyrne into loosestrands The primitive germ cells are seen at first lyingbetween the cords and then within them (Fig 2.3).Morphological development of the ovary occursabout 2 weeks later than the testes and proceeds moreslowly The sex cords develop extensively and epithe-lial cells in this area are known as pregranulosa ceDs.The germ cells decrease in size by 14—16 weeks Theactive growth phase causes enlargement of the gonad.The next stage involves the primitive germ cells (nowknown as oocytes) becoming surrounded by a ring ofpregranulosa cells; stromal cells develop from the

ovarian mesenchyme Mitotic division, by whkh di

5 Embryology and anatomy

germ cells have been increasing in numbers, then

ceases and they enter the first stage of meiosis and

prophase arrest The number of oocytes is greatest

before birth and thereafter declines Approximately 7

million gerrn cells arc present at 5 months, but at birth

this has fallen to 2 million, half of which are atretic

At the same time as the ovary descends

extraperi-toneally into the abdominal cavity, two ligaments

develop and these appear to help control its descent,

guiding it to its final position and preventing its

Mesoriephricduct

Mesonephricswelling

Coelomic

epithelium

Mesonephricswelling

Primitive

follicles

Figure2.3 Development of the ovary

complete descent through the inguinal ring, in trast to the testes

con-ANATOMY

Anatomy is covered in some depth in the pre-clinicalyears This is intended as a brief review

External penitalia The vulva

The female external genitalia, commonly referred to asthe vulva, include the mons pubis, the labia majgraand minora, the vestibule, the clitoris and the greatervestibular glands (Fig 2.4) The mons pubis is com-posed of fibrofatty tissue, which covers the body of thepubic bones Inferiorly it divides to become continuouswith the labium majus on each side of the vulva In theadult, the skin that covers the mons pubis bears pubichair, the upper limit of which is usually horizontal,The labia majora are two folds of skin with under-lying adipose tissue bounding either side of the vaginalopening They contain sebaceous and sweat glandsand a few specialized apocrinc glands In the deepestpart of each labium is a core of fatty tissue continuouswith that of the inguinal canal and the fibres of theround ligament terminate here

Mons pubisClitorisUrethraloriliceVestibuleLabia majoraLabia minoraVaginalorificeHymen

The labia minora ai

between the labia maitwo to form the prepuPosteriorly they fuse tfourchette They oonl

no adipose tissue Thepuberty, and atrophy;cularity allows them texcitement

The clitoris is a smalthe clitoris contains n«which are attached torami The clitoris is omuscle; bulbospongioThe clitoris is abouldeveloped nerve suppiecual arousal.The vestibule is theThe urethra, the ductsvagina open in the v«two oblong masses ofside of the vaginal (plexus of veins withiiBartholin's glands, ea<tie at the base of eachinto the vestibule betminora These are mious amounts during iThe hymen is a thacross the entrance bopenings in it to allov

is partially ruptured <3disrupted during chiltrapture are known as

Age changes

In infancy the vulva is

sderable adipose tissithat is lost during dpuberty, at which tinthe skin atrophies aiminora shrink, subcutorifice becomes small

Figure 2.4 The vulva afavirgin

internal repr

Figure 2-5 shows a

The labia minora arc two thin folds of skin that lie

between the labia major a Anteriorly they divide into

two to form the prepuce and frenulum of the clitoris

Posteriorly they fuse to form a fold of skin called the

fourchette They contain sebaceous glands but have

no adipose tissue They are not well developed before

puberty, and atrophy after the menopause Their

vas-cular ily allows them to become turgid during sexual

excitement

The clitoris is a small erectile structure The body of

the clitoris contains two crura, the corpora cavernosa,

which are attached to the inferior border of the pubic

rami The clitoris is covered by the ischiocavernosus

muscle; bulbospongiosus muscle inserts into its root

The clitoris is about 1cm long but has a highly

developed nerve supply and is very sensitive during

sexual arousal

The vestibule is the cleft between the labia minora

The urethra, the ducts of the Bartholin's glands and the

vagina open in the vestibule The vestibular bulbs are

two oblong masses of erectile tissue that lie on either

side of the vaginal entrance They contain a rich

plexus of veins within the bulbospongiosus muscle

Barlholin's glands, each about the size of a small pea,

lie at the base of each bulb and open via a 2 cm duct

into the vestibule between the hyrnen and the labia

minora These are mucus-secreting, producing

copi-ous amounts during intercourse to act as a lubricant

The hymen is a thin fold of mucous membrane

across the entrance to the vagina There are usually

openings in it to allow menses to escape The hymen

is partially ruptured during first coitus and is further

disrupted during childbirth Any tags remaining after

rupture are known as carunculae myrtiformes

Age changes

In infancy the vulva is devoid of hair and there is

con-siderable adipose tissue in the labia majora and pubis

that is lost during childhood but reappears during

puberty, at which time hair grows After menopause

the skin atrophies and becomes thinner The labia

minora shrink, subcutaneous fat is lost and the vaginal

orifice becomes smaller

The internal reproductive organs

Figure 2.5 shows a sagittal section of the human

female pelvis

The vagina

The vagina is a fibromuscular canal lined with fied squamous epithelium that leads from the uterus

strati-to the vulva It is longer in the posterior wall (around

9 crn) than anteriorly (approximately 7 cm) The vaginalwalls are normally in apposition, except at the vault,where they are separated by the cervix The vauk ofthe vagina is divided into four fornices: posterior,anterior and two lateral (Fig 2.6)

The midvagina is a transverse slit and the lowerportion is an H shape in transverse section Thevaginal walls are rugose, with transverse folds Thevagina is kept moist by secretions from the uter-ine and cervical glands and by some transudationfrom its epithelial lining It has no glands Theepithelium is thick and rich in glycogen, whichincreases in the postovulatory phase of the cycle.However, before puberty and after the menopause,the vagina is devoid of glycogen because of oestrogendeficiency

Doderlein's bacillus is a normal commensal of thevagina that breaks down the glycogen to form lacticacid, producing a pH of around 4.5 This has a pro-tective role for the vagina in decreasing the growth ofpathogenic organisms

The upper posterior vaginal wall forms the anteriorperitoneal reflection of the pouch of Douglas Themiddle third is separated from the rectum by pelvicfascia and the lower third abuts the perineal body,Anteriorly, the lip of the vagina is in direct contactwith the base of the bladder; the urethra runs downthe lower half in the midline to open to the vestibule.Its muscles fuse with the anterior vaginal wall.Laterally, at the fornices, the vagina is related to theattachment at the cardinal ligaments Below this arethe levator ani muscles and the ischiorectal fossae.The cardinal ligaments and the uterosacral ligaments,which form posteriorly from the parametrium, sup-port the upper part of the vagina

disap-10 Embryology and anatomy

Ovary

Recto-uterine-~" fold

Rectouterinerecess

\ Posterior part

of fornix

Cervixuteri

Rectalampulla

Posterior wall

(length 9 cm)

Posteriorfornix

Urethra

Figure 2.6 Sagittal section of the vagina

The uterus is shaped Inferiorly to the cervi

is situated entirety vri has thick muscular

dimensions are appro

and 3 cm thick I Fig 1

An adult uterus we

is termed the body or

each Fallopian tube