Female Genitourinary Examination

A female genitourinary exam is performed either as a preventative screening exam or a problem-focused exam to evaluate complaints such as itching, pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, lesions, or infection. The investigation includes inspection, palpation, speculum exam, and bimanual exam. In combination with the subject’s history, the clinician uses exam findings to diagnose genital and pelvic conditions or to screen for cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer (Pap smear).

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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Introduction

Initial steps

  • Build a good therapeutic relationship with the subject. Meet them for history-taking while dressed.
  • Ideally, have the subject empty their bladder before a pelvic exam.
  • Ensure good lighting and privacy.
  • Explain each step of the examination and obtain consent.
  • Drape the subject from the mid abdomen to the knees and depress the drape between the knees to maintain eye contact.
  • Use a chaperone during genital examination.

Components of the examination

  • Abdominal examination Abdominal examination The abdominal examination is the portion of the physical exam evaluating the abdomen for signs of disease. The abdominal examination consists of inspection, auscultation, percussion, and palpation. Abdominal Examination
  • External genitourinary examination:
    • Inspection
    • Palpation
  • Internal examination:
    • Speculum examination
    • Bimanual examination

Equipment needed

  • Examination table with stirrups
  • For preventative pelvic exam:
    • Speculum of appropriate size
    • Materials to obtain cervical cytology if a preventative exam is performed (Pap vial, broom)
    • Water-soluble lubricant
  • For problem-focused exams (e.g., vaginal infection):
    • pH indicator paper (to test for bacterial vaginosis (BV) or candidiasis Candidiasis Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis)
    • Dropper bottles of saline and KOH for performing wet preps
    • Specimen-collection equipment to identify STIs (lab assessment for gonorrhea Gonorrhea Gonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea/ chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia/trichomonas)

External Examination

Anatomy

Components of the external female genitalia include the mons pubis, vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor (labia minora and majora), clitoris, urethral orifice, vestibule, and external glands.

Anatomy of the external genitalia

Anatomy of the external genitalia

Image by Lecturio.

Inspection of the external genitalia

  • Inspect the mons pubis, labia, and perineum for abnormal skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin findings:
    • Rashes Rashes Rashes are a group of diseases that cause abnormal coloration and texture to the skin. The etiologies are numerous but can include irritation, allergens, infections, or inflammatory conditions. Rashes that present in only 1 area of the body are called localized rashes. Generalized rashes occur diffusely throughout the body. Generalized and Localized Rashes
    • Vaginal discharge
    • Vulvar skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lesions:
      • Cysts
      • Pigmented nevi Nevi Nevi (singular nevus), also known as "moles," are benign neoplasms of the skin. Nevus is a non-specific medical term because it encompasses both congenital and acquired lesions, hyper- and hypopigmented lesions, and raised or flat lesions. Nevus/Nevi
      • Warts
      • Ulcers
      • Herpetic lesions (vesicles)
    • Discoloration (e.g., with lichen sclerosis)
  • Separate the labia majora and inspect the labia minora, clitoris, urethral meatus, and vaginal opening; inspect for abnormal findings:
    • Urethral caruncle: small, red, benign swelling visible at the posterior urethral meatus
    • Prolapse of the urethral mucosa: swollen erythematous ring around the urethral meatus
    • Note any vaginal discharge or bleeding:
      • Color
      • Consistency
      • Odor
    • Swelling of labia
    • Nodules or masses
Inspection of the external genitalia

Inspection of the external female genitalia

Image by Lecturio.

Palpation of the external genitalia

  • Palpate any abnormal lesions.
  • If labial swelling is noted, check Bartholin glands Bartholin glands Mucus-secreting glands situated on the posterior and lateral aspect of the vestibule of the vagina. Vagina, Vulva, and Pelvic Floor:
    • Insert a lubricated finger into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor.
    • Place the thumb outside the posterior part of the labia majora.
    • Palpate between the index finger and thumb for swelling or tenderness.
    • Note any discharge from the duct opening of the gland and send for culture.
Table: Lesions of the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor and vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor
Lesion Description
Epidermoid cyst
  • Small, firm, round cystic nodules in the labia
  • May be yellow
  • Inspect for dark punctum marks blocking the gland opening.
Genital warts Genital Warts Condylomata acuminata are a clinical manifestation of genital HPV infection. Condylomata acuminata are described as raised, pearly, flesh-colored, papular, cauliflower-like lesions seen in the anogenital region that may cause itching, pain, or bleeding. Condylomata Acuminata (Genital Warts) (condyloma acuminatum) Warty lesions on the labia, within the vestibule, or around the anus
Genital herpes Genital Herpes Genital herpes infections are common sexually transmitted infections caused by herpes simplex virus (HSV) type 1 or 2. Primary infection often presents with systemic, prodromal symptoms followed by clusters of painful, fluid-filled vesicles on an erythematous base, dysuria, and painful lymphadenopathy. Labial and Genital Herpes Shallow, small, tender ulcers on an erythematous base
Lichen sclerosus
  • Presents with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and pruritus
  • Marked inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, epithelial thinning, distinctive dermal changes
  • Usually does not involve the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor
Vulvar squamous intraepithelial lesions (previously called vulvar intraepithelial neoplasia)
  • Can be asymptomatic (40%), pruritic, or scaly
  • Difficult to distinguish clinically from lichen sclerosus or lichen planus Lichen planus Lichen planus (LP) is an idiopathic, cell-mediated inflammatory skin disease. It is characterized by pruritic, flat-topped, papular, purple skin lesions commonly found on the flexural surfaces of the extremities. Other areas affected include genitalia, nails, scalp, and mucous membranes. Lichen Planus; requires biopsy
  • Noninvasive squamous lesion and precursor of squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma of the vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor
Syphilitic chancre A firm, nontender ulcer
Secondary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis (condyloma lata) Slightly raised, flat, round, or oval papules covered by a gray exudate
Lichen planus
  • Presents with pruritus and loss of architecture
  • Usually involves the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor with inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and synechiae

Internal Examination

Speculum examination

  • Select a speculum of an appropriate size (small size for women with no previous vaginal births).
  • Lubricate the speculum with warm water or a water-soluble lubricant (lubricants do not interfere with sampling for cervical cytology as thought previously).
  • Let the subject know you are about to insert the speculum. Insert at an angle and slide inward along the posterior vaginal wall:
    • Rotate the speculum into a horizontal position, maintain the pressure posteriorly, and insert fully.
    • Be careful not to open the blades of the speculum prematurely.
    • Inspect vaginal walls for lesions/masses/discharge during the procedure.
  • Open the speculum carefully, and rotate and adjust until the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Posterior Abdominal Wall is well visualized.
  • Position your light source for adequate visualization of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Posterior Abdominal Wall and inspect for:
    • Cervical discharge or bleeding
    • Lesions:
      • Ulcerations
      • Nodules
      • Masses
Speculum examination

Speculum examination of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Posterior Abdominal Wall

Image by Lecturio.

Abnormal findings on speculum exam

  • Note any abnormal vaginal findings:
    • Discharge:
      • White curdy discharge due to candidal vaginitis (“yeast infection”); not sexually transmitted
      • Yellowish-green or gray discharge that may be malodorous; discharge due to STIs such as chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia, gonorrhea Gonorrhea Gonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea, trichomonas
      • Watery discharge with a “fishy” odor; discharge due to BV, usually not sexually transmitted
    • Mucosal abnormalities:
      • Erythema
      • Lesions (ulcers, papules, vesicles)
    • Protrusion from the anterior wall (bladder): cystocele
    • Protrusion from the posterior wall ( rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal): rectocele
  • Note any abnormal cervical findings:
    • Cervical polyp: tissue arising from the endocervical canal at the os
    • Mucopurulent cervicitis: purulent yellow discharge from the cervical os due to an STI STI Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections
    • Cervical cancer: an extensive, irregular “cauliflower-like” growth in the late stage

Obtaining specimens for cervical cytology (Pap smear)

  • Collect samples when the subject is not menstruating.
  • Ideally, subjects should avoid intercourse, douches, or vaginal suppositories 24–48 hours before the examination.
  • Use a cervical brush to obtain specimen from the endocervix/ectocervix.
Pap smear

Use of a cervical/Pap brush to obtain a cervical specimen for cytology/Pap smear

Image by Lecturio.

Bimanual examination

  • Lubricate the index and middle fingers of 1 of your gloved hands.
  • While standing, insert 1 or 2 fingers into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor (depending on the subject’s age, history, and size of introitus), exerting pressure posteriorly.
  • Palpate the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor to assess for nodules and tenderness.
  • Evaluate for cystocele or rectocele if there is a concern (ask the subject to bear down).
  • Palpate the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Posterior Abdominal Wall and document:
    • Position
    • Mobility
    • Tenderness
  • Palpate the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall:
    • Place your external hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand on the abdomen (midway between the umbilicus and the symphysis pubis) while 1 or 2 of your fingers are in the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor.
    • Elevate the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Posterior Abdominal Wall and uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall with your pelvic hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand, depress your abdominal hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand, and grasp the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall between both hands.
    • Document the position of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall (retroflexed, retroverted, anteflexed, anteverted).
    • Document any enlargement, masses, or tenderness.
  • Palpate each ovary:
    • Place your external hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand on the RLQ/LLQ of the abdomen and grasp the ovary between the external hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand and finger(s) in the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor.
    • Identify each ovary (or its absence) and adjacent adnexal masses.
    • Document any enlargement, masses, or tenderness (possible cysts or malignancy).
    • Repeat the procedure on the other ovary.
Bimanual examination

Bimanual examination: positioning of the hands during the exam, including the abdominal exam

Image by Lecturio.

Rectovaginal examination

  • A rectovaginal exam is indicated for:
    • Palpation of the retroverted uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall, uterosacral ligament, cul-de-sac, and adnexa
    • Screening for colorectal cancer Colorectal cancer Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the United States. Colorectal cancer is a heterogeneous disease that arises from genetic and epigenetic abnormalities, with influence from environmental factors. Colorectal Cancer in women ≥ 50 years of age
    • Assessing pelvic pathology
  • After withdrawing your fingers after the bimanual examination:
    • Change your gloves and lubricate your fingers.
    • Insert your index finger into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor and your middle finger into the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal.
    • Ask the subject to bear down to relax the anal sphincter as you perform this step.
    • Apply pressure against the anterior and lateral walls with the examining fingers, and downward pressure with the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand on the abdomen.
  • Wipe off the external genitalia and rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal after the exam, or offer a tissue to the subject so that they can wipe themselves.

Clinical Relevance

  • STIs:
    • Anogenital warts (condyloma acuminata): warty lesions on the external genitalia. Anogenital warts are caused by an HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV infection, most often types 6 and 11. Warts can be single or multiple, flat, dome shaped, cauliflower shaped, filiform, fungating, pedunculated, or cerebriform. After the initial appearance, warts may increase in number and size or regress spontaneously. Medical and surgical treatment options are available to treat symptomatic anogenital warts.
    • HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 & 2 (genital herpes): a mucocutaneous infection characterized by acute, localized appearance of clusters of small, painful vesicles on an erythematous base. There is now a significant overlap; in the past, HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 & 2-1 was classically associated with oropharyngeal lesions and HSV HSV Herpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals. Herpes Simplex Virus 1 & 2-2 with genital herpes, an STI STI Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections. Diagnosis is based on viral culture and treatment is with oral antiviral medications.
    • Syphilis: a bacterial infection caused by the spirochete Spirochete Treponema is a gram-negative, microaerophilic spirochete. Owing to its very thin structure, it is not easily seen on Gram stain, but can be visualized using dark-field microscopy. This spirochete contains endoflagella, which allow for a characteristic corkscrew movement. Treponema Treponema Treponema Treponema is a gram-negative, microaerophilic spirochete. Owing to its very thin structure, it is not easily seen on Gram stain, but can be visualized using dark-field microscopy. This spirochete contains endoflagella, which allow for a characteristic corkscrew movement. Treponema pallidum that spreads through sexual contact. Primary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis begins with a painless ulcer on the genitals and is called a chancre. Diagnosis is based on blood tests and treatment is with penicillin. Progression to secondary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis manifests as a generalized maculopapular rash, which includes the palms and soles. Tertiary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis can appear years later with cardiac and neurologic manifestations.
    • Gonorrhea: an STI STI Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections caused by the gram-negative bacterium, Neisseria Neisseria Neisseria is a genus of bacteria commonly present on mucosal surfaces. Several species exist, but only 2 are pathogenic to humans: N. gonorrhoeae and N. meningitidis. Neisseria species are non-motile, gram-negative diplococci most commonly isolated on modified Thayer-Martin (MTM) agar. Neisseria gonorrhoeae. Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis. Disseminated gonococcal infection is associated with fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, dermatitis, tenosynovitis, septic arthritis Septic arthritis Septic arthritis is an infection of the joint due to direct inoculation, contiguous extension, or hematogenous spread of infectious organisms into the joint space. This process causes an acute, inflammatory, monoarticular arthritis. Septic Arthritis, and rarely endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis or meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis. Diagnosis is made by microscopy, culture, or nucleic acid amplification test (NAAT). Management is with antibiotics for the subject and their partner(s).
    • Chlamydia: Chlamydia trachomatis is the most common cause of STIs. Chlamydia can be asymptomatic or produce urethral discharge. Diagnosis is with NAAT using a genital swab or urine sample. Treatment is with antibiotics for the subject and their partner(s). Untreated chlamydial infections Chlamydial infections Chlamydial infections are a group of infectious diseases caused by bacteria belonging to the Chlamydiaceae family. The 3 species that can infect humans are Chlamydia trachomatis, C. pneumoniae, and C. psittaci. The most common infection is an STI caused by C. trachomatis, which affects the genitourinary tract. Chlamydial Infections may have serious consequences including sterility, ectopic pregnancies, spontaneous abortions, and chronic pelvic inflammatory disease Pelvic inflammatory disease Pelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and Gardnerella vaginalis. Pelvic Inflammatory Disease.
    • Trichomoniasis: caused by the protozoa Trichomonas vaginalis and is the most common nonviral STI STI Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Overview: Sexually Transmitted Infections worldwide. More women than men are affected and the infection is often asymptomatic. Untreated infection may progress to urethritis or cervicitis, which present with malodorous discharge with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, burning, and pruritus. Diagnosis is made using NAAT, rapid antigen tests, or DNA DNA The molecule DNA is the repository of heritable genetic information. In humans, DNA is contained in 23 chromosome pairs within the nucleus. The molecule provides the basic template for replication of genetic information, RNA transcription, and protein biosynthesis to promote cellular function and survival. DNA Types and Structure hybridization probes. Treatment is with antibiotics for the subject and their partner(s).
  • Vulvar lichen sclerosus: a benign, chronic, progressive vulvar skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin condition characterized by marked inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, epithelial thinning, and distinctive dermal changes accompanied by pruritus and pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain. Exam findings include white atrophic papules that may coalesce into plaques on the labia minora and/or labia majora. Diagnosis is made using a vulvar punch biopsy. Management is by using topical or intralesional corticosteroids, topical calcineurin inhibitors, or UVA1 phototherapy.
  • Bartholin gland cyst: a growth that can obstruct the Bartholin duct orifice and result in abscess formation. The most commonly isolated pathogen is Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli, but the cause can also be polymicrobial. Examination findings include tense, warm, very tender, soft, or fluctuant labial swelling. Pus may drain from the duct opening. Diagnosis is clinical. Management is by incision and drainage.
  • Cervical cancer: related to persistent infection with the high-risk HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV strains 16 and 18 among others. Human papillomavirus Human papillomavirus Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV infections are asymptomatic, and screening with routine cervical cytology (Pap smear) plus cotesting for HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV are essential for early detection. Management depends on the stage and varies from excisional biopsy for microinvasive carcinoma in situ to radical hysterectomy for more advanced cases. Radiation may be recommended if there is extracervical spread.
  • Vulvovaginitis Vulvovaginitis The term vulvovaginitis is used to describe an acute inflammation of the vulva and vagina. Vulvovaginitis can be caused by several infectious and non-infectious etiologies, and results from disruption of the normal vaginal environment. Common signs and symptoms include pain, pruritus, erythema, edema, vaginal discharge and dyspareunia. Vulvovaginitis: acute inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation presenting with vulvovaginal itching and discharge. Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis species cause the typical “yeast infection.” Management is with topical or oral antifungal agents and varies for uncomplicated, complicated, and recurrent cases. Another common cause of vulvovaginitis is BV, which is due to an overgrowth of normal vaginal bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview. Treatment is with antibiotics. Both candida and BV are not usually sexually transmitted and partners do not need treatment.
  • Pelvic inflammatory disease: a complication of STIs involving the fallopian tubes Fallopian tubes The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The fallopian tubes receive an ovum after ovulation and help move it and/or a fertilized embryo toward the uterus via ciliated cells lining the tubes and peristaltic movements of its smooth muscle. Posterior Abdominal Wall and ovaries Ovaries Ovaries are the paired gonads of the female reproductive system that contain haploid gametes known as oocytes. The ovaries are located intraperitoneally in the pelvis, just posterior to the broad ligament, and are connected to the pelvic sidewall and to the uterus by ligaments. These organs function to secrete hormones (estrogen and progesterone) and to produce the female germ cells (oocytes). Ovaries. Pelvic inflammatory disease can be caused by N. gonorrhoeae, C. trachomatis, or other organisms. Acute disease is associated with very tender and bilateral adnexal masses. Movement of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Posterior Abdominal Wall produces pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain (called “cervical motion tenderness” on exam). Complications including tubo-ovarian abscess or infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility can occur if left untreated.

References

  1. Bickley, L.S. (2017). Female Genitalia. Bates’ Guide to Physical Examination and History Taking, 12th edition. pp. 565–603. Wolters Kluwer.
  2. Miranda, A.M. (2018). Pelvic Examination. In Isaacs, C., et al. (Ed.), Medscape. Retrieved October 8, 2021, from https://emedicine.medscape.com/article/1947956
  3. Carusi, D.A. (2021). The gynecologic history and pelvic examination. In Barbieri, R.L., et al. (Ed.), UpToDate. Retrieved October 8, 2021, from https://www.uptodate.com/contents/the-gynecologic-history-and-pelvic-examination

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