female intro short

female intro short - Introduction to the Female Exam...

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Unformatted text preview: Introduction to the Female Exam Anatomy Pelvic Exam Hormonal cycles Uterine conditions Ovarian conditions Breast evaluations So, who should have a pelvic exam and why? Annually for all women who are sexually active, or as a baseline, women at the age of 21. Important issues related to this exam: Cultural issues Patient modesty Anxiety about exam History of rape, molestation or abuse Office environment Office environment ALWAYS have another person in the room ALWAYS while examining female genital area or breasts. breasts. Explain what you are going to be doing, Explain before you do each step/manuever before Insure patient comfort, and modesty…. Patient comfort/modesty Use gowns AND sterile drapes over pt legs Allow patient to wear socks, bra (if no Allow breast exam is being done), sweater, etc. breast Foot of exam table does not face the door Door is clearly marked to avoid interruption Another person in the room all the time, taking notes or somehow attentive taking 3 Parts to the Pelvic Exam 1. Observation and the speculum exam 1. speculum 2. Bimanual exam 3. Recto-Vaginal Exam (includes DRE) But first, we ask history, inspect and palpate. Pubic hair-triangle pattern Lymph nodes Orifices Palpate: Urethral meatus-incontinence Labia Skene’s, then Bartholin’s glands Perineum The Speculum Exam Performed prior to the bi-manual exam so Performed prior as not to disturb the tissues/samples as Performed without lubricant jelly Performed without Always inserted with the speculum blades Always warmed with warm water and closed warmed closed Inserted at a 45 degree angle posteriorly Inserted 45 Proper position of speculum Visual Observation of the Cervix Position—is it anteverted, deviated, etc The position of the cervix gives clues to The the position of uterus the Color—should be flesh-colored, but ranges Color—should from pink to dark brown (blue or pale??) from Surface characteristics—cysts, erythema Discharge Size and shape of os Nulliparous cervix Multiparous cervix Everted cervix Nabothian cysts aka: retention cysts The Papanicolaou Exam (“Pap”) Developed over 50 years ago by Dr. George Developed Papanicolaou Papanicolaou A minimum of two samples will be taken: Cervical cells Vaginal secretion Other tests may be done to screen for STDs What are the three most common STDs among What women? women? HPV, Herpes, Chlamydia, (Now 10’s of millions of existing cases) millions The Quad Cities has the highest incidences of The STDs in Iowa In women, often no visible symptoms Protect Yourself! Protect What’s the goal of a Pap Smear? The “Pap smear” evaluates the condition of The the cervical cells (taken with cervical brush or spatula) or SCREENS FOR CERVICAL CANCER Assessing “transitional zone” of the cervix Accuracy of the Pap Smear It is estimated that the Pap Smear has It decreased the death rate due to cervical CA decreased by 75% 75% “False-positives” range from 10% to 40% “False-negatives” range from 1% to 15% (This is good) Vaginal Secretion Samples In addition to the cell sample, additional In information can be gained from the surrounding secretions Sampling methods are dependent upon the Sampling goal of the screening goal Bacterial Vaginosis aka: Vulvovaginitis General description for anything that causes General symptomatic discharge (an irritant) symptomatic May be due to bacteria, viruses, fungi, or May protozoans protozoans Patient may talk to you about: vaginal or vulvar Patient itching, burning, or change in color, texture or odor of discharge odor The Bimanual Exam The bimanual exam is the second part of a The complete pelvic exam complete Necessary to evaluate the cervix, uterus, and Necessary adenexal regions (ovaries, fallopian tubes, surrounding areas) surrounding Move the cervix to assess for PID/Endometriosis Important even if patient is not sexually active Recto-Vaginal Exam; DRE The Recto-Vaginal exam is the 3rd and final part of the pelvic exam part May help evaluate the posterior aspect of May the uterus (esp. if retroverted) the Allows exam of rectal walls (initial screen Allows for colo-rectal cancer or polyps) for Uterine Fibroids AKA: myoma, leiomyoma, fibroma Very, very common (40% of women > 40) The most common tumor of the pelvis The most common reason for a hysterectomy 33% of 600,000/yr. Benign, benign, benign! Risk Factors Nulliparity or delayed childbearing African American women have 2-3 times African the incidence the Locations Uterine Fibroids: Symptoms Heavy menstrual bleeding Abdominal distortion Pelvic pressure Low back pain; dyspareunia Infertility Frequent urination Constipation Miscarriage or premature labor Plain Film Findings: Cauliflower-like radio-opaque mass seen in the pelvic cavity, in the area of the uterus. Is it any wonder problems include low back pain, urinary frequency, constipation, infertility? Treatment Options (from least to most invasive) “Wait and see” Drug therapy (GnRH agonists) Uterine Artery Embolization (UAE) Myomectomy Hysterectomy Pelvic Arteriogram Used to identify blood vessels feeding the myoma. Polyvinyl particles block blood flow Endometriosis Endo=inner metr=layer osis=condition Normal endometrium found in abnormal places Therefore, “ectopic tissue” responds to hormone Therefore, levels just like the inner layer of the uterus levels How? How? Retrograde menstrual flow, fallopian tubes, Retrograde abdomen abdomen Lymphatic or circulatory systems cause spread Risk Factors Young age: 10-15% of women ages 25 to Young 44 have endometriosis 44 Family History (6 - 12% of cases) Nuliparity or delayed childbearing Asians and Caucasians are at highest risk When? Onset of endometriosis is at onset of menses Delay in seeking care = 4.67 years Delay in diagnosis = 4.61 years Delay for ages 15-19 years is 8.3 years Symptoms confused with “typical” dysmenorrhea Symptoms or UTIs or 1/3 of women say doctor took symptoms “not at all 1/3 seriously” and 1/4 said “not very seriously” seriously” Signs and Symptoms Pain, pain, pain (low back and pelvic) Pelvic mass Alterations of menses Dysmenorrhea (pattern = pain just prior to Dysmenorrhea menses) menses) Infertility Dyspareunia Pain with defecation, urination Pattern of Menstruation Women with endometriosis have: earlier onset of menses regular cycles shorter intervals between periods (less shorter than 27 days) than more severe menstrual cramps prolonged menstrual flow (> 1 week) What do the lesions look like? Endometrial deposits can occur anywhere in pelvis Ovary—most common (75%); an ideal site for growth Posterior cul-de-sac—70% Between the uterus and bowel—35% Uterosacral ligament—30% Ureters Uterus Bowel Also known to occur on appendix, gall bladder, Also stomach, spleen, liver, lung stomach, Red Endometrial Lesions Endometrial Deposits on Appendix Complications Remember—this normal uterine tissue in an Remember—this abnormal location responds to fluctuations in hormone levels just as the rest of the uterus. So… hormone Bleeding lesions inflammatory response Bleeding fibrin deposition adhesion formation distortion of the peritoneal surfaces Peritoneal Adhesions Adhesions, caused by inflammation around site of endometriosis, cause uterus and cervix to be “fixed”, and the cervix is very painful upon movement (during female exam, and during intercourse). Confirming the Diagnosis Suspected by case history Visible lesions on the vulva or cervix Red, brown, black (remember—may bleed) Speculum exam (“shotty nodules”) Definitive Diagnosis The definitive diagnosis can only be made The by direct visualization of the lesions direct Presently, confirmed by laparoscopy Treatment Options Keep in mind that these patients typically suffer a Keep prolonged course of multiple therapies/surgeries prolonged “Leave it alone” Drug therapy Laparotomy Hysterectomy Child-bearing (or pseudo-pregnancy conditions) FAQs How successful is laparotomy? 70-90% pain How Does it recur after treatment? 10-20% within 3 yrs Can tubal ligation help? Theoretically Does intercourse during menses risks? No Does use of tampons risks? No Does early pregnancy protect against it? Maybe C-sections and endometriosis? A possibility Infertility and Endometriosis? Peritoneal fluid normally acts as a lubricant. Endometriosis causes changes in the volume and cellular Endometriosis content of the peritoneal fluid. content Fluid level is increased Leukocytes are increased Prostaglandin levels are increased Enzyme levels are increased These all cause a localized inflammatory reaction These around the lesions around The peritoneal fluid can then act as a toxin to the embryo The and/or can alter the normal function of the ovaries and fallopian tubes. fallopian www.bioscience.org/books/endomet/ end34-65.htm Great website for FAQs of Great endometriosis endometriosis Other Pelvic Conditions that Deserve Your Attention Uterine sarcoma (endometrial carcinoma) Cervical carcinoma Cervical Ovarian carcinoma Hint: I often ask about risk factors and CA Ovarian cysts Uterine, vaginal prolapse ...
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