Assessment of the Female Genitourinary System – Advanced (Nursing)

by Stephen Holt, MD, MS

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    00:00 So before we move on to the genital exam itself, it's really important to maintain open lines of communication with your patient, this is a very sensitive exam. And especially if your patient has never had a pelvic exam performed in the past, you really want to make sure that your patient is aware of what's happening and what the specific sequence of events are going to be. So for the purposes of this session, we're going to pretend that our patient has never had this exam performed in the past. "So, my understanding is this is the first time you've had a pelvic exam and a Pap smear. Is that correct?" "Yes." "Okay." "So it's really important that we have an open line of communication. I want you to feel comfortable during this exam. You may need to have it again in the future so it's important that it is a fine experience for you. So, I'm going to preserve your modesty as best as I can throughout and only expose parts of your anatomy that need to be when I'm examining them and I'll also make sure that you're comfortable throughout." First off let me explain to you what the sequence of events is going to be. So, the first part is an external genital exam, just visually taking a look in the area then we're going to move on to an internal exam which is called the bimanual exam. "So I'm going to insert 2 fingers into your vagina and I'm going to be examining the cervix, examining the anterior and posterior wall of the vagina, etc."And then once we have completed that, I'm going to move on and use the speculum part of the exam. Now the speculum is here, I'm going to take this out of the bag now. So depending upon where one is having the exam performed, there are different types of specula that are out there. This is a typical disposable specula and importantly this is the bill of the specula and this is the part that's going to be inserted into your vagina. This is simply the handle and I'm going to have a light attached to it so you will see a black cable attached of the back here and that's in order to best visualize the cervix. So, that's the speculum or direct visualization part of the exam. In addition, when I performed that part of the exam, I want to be looking at the cervix so that I can collect cellular tissue. And so this is a Papanicolaou or Pap brush, and I'm basically going to be placing this right at the entrance of your cervix and spinning it several times in order to get cervical tissue that is then useful for screening for cervical cancer. Okay? And lastly, I have some other specimen tools here if in the event that we were concerned about a sexually transmitted infection I can swab for any discharge in the vagina and send it off for microbiology studies and similarly if I was concerned about trying to evaluate for a new vaginal discharge I can collect some of that discharge and then plate it out on a slide and do what's called either a wet mount or a KOH prep to try and figure out exactly what the cause of the change in vaginal discharge is. The last piece of equipment is actually a piece of equipment for you, and it's actually just this hand mirror. I found and it's been shown that it's useful for the patient to actually be able to see what is going on "because otherwise I'm on one end of the bed and you can't really see what's happening.

    03:07 So you having some control being able to see the exam itself with a mirror is something that we encourage. So, I'll hand that to you once we're all set." Language, as you might imagine, is really important for this exam so you will note that I'm trying to avoid using overly clinical language like the word palpate which doesn't mean much to a lay audience, but I'm also trying to avoid words that can have particular connotations like I'm not going to use the word "I'm going to feel this area or touch this area." Instead, I'm going to use fairly neutral language like "I'm going to examine, I'm going to inspect, etc." "With that, I'm going to step out of the room and let you get into a gown and we will proceed with the exam." "Okay." "Okay, now that we've got your feet in this foot rest, I'm going to ask you now to simply just relax your legs and move them out to the side for me. Great. And we can lift up this drape now. Okay?" "Great. You can hold that. Perfect." She's got her mirror in position so that she can see what we're doing. So now we are doing the external inspection of the pelvis and this starts off by first taking a look at the labia majora, also called the mons pubis area. There are different techniques here, but oftentimes you wanted to just use one hand to separate the labia so that you have one hand free, but for the purposes of this educational session I'm going to use both of my hands. Ideally you want to minimize contact with the patient's skin when you can, but in this case we'll use both hands. "So, you're going to feel me touching the outside of your vagina now." By doing that, I can now plainly see the labia minora on the inside there. Above it, we can see the clitoral hood and the clitoris. And then just inside the labia minora is the urethral orifice, right back there. "Pardon me. Can you relax your legs just a little bit more? Okay, great." And in this case, what I'm looking for is any evidence of any skin lesions, for example condyloma acuminata, evidence of a chancre. Certainly a patient with candidal vulva vaginitis may have evidence of excoriations from scratching, a whitish discharge or some flaky scale on the outside of the vagina as well. And of course at this point I could also be looking to see if there is any excess discharge in the area. That essentially completes the external part of the exam.

    About the Lecture

    The lecture Assessment of the Female Genitourinary System – Advanced (Nursing) by Stephen Holt, MD, MS is from the course Assessment of the Genitourinary System (Nursing).

    Included Quiz Questions

    1. Speculum
    2. Pap brush
    3. Sterile gloves
    4. Urinary catheter
    5. Forceps
    1. “Please don’t try to look while I am performing the exam, I will walk you through what I am doing”
    2. “Please let me know if you feel uncomfortable at any time”
    3. “My preceptor will be in the room during the exam”
    4. “I am going to start by examining the outside of your vagina”
    1. Cervical cancer
    2. Chlamydia
    3. Pregnancy
    4. Gonorrhea

    Author of lecture Assessment of the Female Genitourinary System – Advanced (Nursing)

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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