Learning_objectives

To understand the indications for performing a female genitalia examination.

To understand what is an appropriate environment for this examination

To understand the need to request a chaperone.

To be able to demonstrate a female genitalia examination on a model.

Theory_and_background

Underpinning a female examination is knowledge of anatomy & physiology together with applying the basics of the examination.

 

Indications

The following list of reasons for performing a female genitalia examination is by no means exhaustive

  • Persistent vaginal discharge
  • Lower abdominal tenderness
  • Excessive vaginal bleeding – menorrhagia
  • Minimal or no vaginal bleeding – amenorrhea
  • Urinary symptoms
  • Well woman clinic

The right environment

The room that the examination is taking place in should be private with the examination couch off set from the centre of the room and an additional barrier between the couch and the patient. This prevents anyone being unnecessarily exposed if somebody inadvertently enters the room.

There should be a good light source that will adequately illuminate the area being examined.

There should be screens offering privacy to the patient whilst they disrobe with a clean gown or blanket available to preserve modesty.

If any samples or swabs are being taken, ensure you know how to complete the paperwork and forward those samples etc. to the correct lab.

Handwashing facilities.

Chaperone

Given the level of intimacy of this examination a chaperone should be present. If not, this should risk assessed, and please ensure that it is in accordance with Trust policy (CQC 2017). The chaperone should be someone who is familiar with the procedure and can therefore recognise anything that is inappropriate.

The purpose of the chaperone is as much to protect the patient as well as offering protection to the clinician, hence the need to be familiar with the procedure.

The chaperone can also be in a position to explain to the patient anything that is pertinent, above all their role is to offer reassurance.

Please document clearly the presence of a chaperone, and also ensure that it is documented if a chaperone is suggested, and any subsequent discussion regarding chaperones, is clearly recorded, in accordance with GMC guidance (2013). See links below;

https://www.cqc.org.uk/guidance-providers/gps/nigels-surgery-15-chaperones

https://www.gmc-uk.org/Maintaining_boundaries_Intimate_examinations_and_chaperones.pdf_58835231.pdf

Procedure

Preparing & conducting a female genital examination.

The following is a suggested list of equipment.

  • Couch, with sheet and covering blanket
  • Alcohol hand wash solution or access to a sink
  • Gloves
  • Apron
  • Light source
  • Tissues
  • Clinical waste bin
  • Water based lubricant (if using a tube a small amount should be put on a piece of gauze or tissue to prevent contaminating lubricant tube once examination begins).
  • Tray/ trolley

Patient safety

Also;

Ask the patient to empty their bladder (voiding), as this avoids discomfort when pressing on the lower abdomen. Only expose the patient as much as needed and cover the lower abdomen to the mons pubis. Patient should be in a supine position with their hips and knees flexed and their ankles closed together, then abducting the thighs to reveal the external genitalia.

Inspection

Inspect the Mons pubis and labia majora, then gently separate the labia minora. Inspect the clitoris, urethra and vaginal orifice. Ask the patient to bear down and observe for any bulging or prolapse, if the history indicates. If the history suggests urinary incontinence ask the patient to cough and observe for any leakage of urine.

Internal examination

Gently introduce the lubricated right index finger, followed by the middle finger.

Pass downwards and backwards in line with the vagina.

Cervix will be felt as a semi-hard dome with a dimple in the middle (the external os)

The normal cervix is mobile and movement does not cause pain.

Assess the fornices surrounding the cervix.

“Nulliparous” by definition means “a female who has never borne offspring”, therefore as this implies, a nulliparous os is the os of a female who has never given birth vaginally, (but may have had a caesarean section).

“Multiparous” by definition means “a female who has borne more than one child”, however a multiparous os could be from any female who has given birth vaginally.

Bimanual examination

Apply upward pressure on the cervix and uterus by pressing in the posterior fornix

Fingers of the abdominal hand are applied flat to abdominal wall below umbilicus and gradually moved towards pubic bone.

Estimate distance between both examination hands to estimate uterine size or compare size and shape to a piece of fruit, for example a pear

 

A normal uterus may be palpable just above the pubic symphysis during bimanual examination.

To palpate this you may have to place your fingertips above the pubis and gently push down.

The uterus should be assessed for size, shape, mobility and consistency as well as for any masses or irregularities.

Adnexae

Adnexae of uterus is the fallopian tubes and ovaries. Ovaries are not always palpable in patients unless they are enlarged or patient is thin. Ovaries are generally firm, ovoid in shape (like an olive) and approximately 2-3cms in length. Fallopian tubes are not palpable in health

Palpating the adnexae

Place your abdomen hand over the iliac fossa whilst readjusting the vaginal fingers into the corresponding lateral fornix, position the finger pulps to face the abdominal fingers

Gently but firmly oppose the fingers of either hand by pressing the abdominal hand inward and downward, and the vaginal fingers upward and laterally.

Feel for adnexal structures as the interposed tissues slip between your fingers, then repeat the examination on the other side

The movement should be relatively painless, although palpation of the ovaries might elicit some tenderness,

If adnexal structures are felt describe:

Size, shape, position, consistency, mobility and tenderness

Completing the examination

Rotate your examining hand back to the midline before removing your fingers gently from the vagina. Inspect your fingers for signs of blood or mucus etc.

Offer the patient tissues to wipe any excess lubricant etc. away. (If patient is unable to do this for themselves, ensure you explain what you are doing before doing this for the patient)

Remove gloves from at least one hand before covering the patient up (to avoid contaminating bedding or clothing).

Dispose of your gloves and apron in clinical waste and then discuss your findings with the patient.