Exame Ginecológico

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GYNECOLOGICAL EXAM
Carlos Miranda, MD, PhD 
UEL, UNINGÁ
Do a Complete Physical Assessment
• HEENT 
• CV 
• Lungs 
• Breasts 
• Abdomen 
• Pelvic/rectal 
• Neuro 
• Musculoskeletal
Essentials for an Adequate Examination--
Relaxation
• Patient should be given an opportunity to 
empty her bladder prior to the exam-- 
Routine UA specimen may be obtained at this 
time 
• Explain what is to take place during the exam 
• Drape her appropriately, cover extending at 
least over her knees 
• Arms should be at her side or folded across 
her chest.
Essentials for an Adequate Examination
• Examiner's hands should be warmed, also 
warm the speculum before the exam 
• Have eye to eye contact with the patient 
during the exam 
• Explain in advance each step in the 
examination, avoiding any sudden or 
unexpected movements
Correct Examining Position of the Patient
• The Lithotomy Position/or Semi-Sitting 
Lithotomy Position 
– Lying in supine position 
– Thighs flexed and abducted 
– Feet resting in stirrups 
– Buttocks extended slightly beyond edge of 
exam table 
– Head supported with a pillow
Male examiners should always be 
attended by female assistants
• Hx should be taken prior to patient 
disrobing. 
• Do not enter the room with an unclothed 
patient unless you have a female chaperone.
 Breast Examination (note the 
following):
• Breast development 
• Size, symmetry, contour and appearance 
of the skin (Variation in breast contour 
may include the presence of masses, 
dimpling, or flattening.)
Supernumerary Nipple
 Breast Examination (note the 
following):
• Nipples 
– Direction of the nipples may provide a clue to 
masses when there is asymmetry 
– Discharge may indicate disease or may merely 
occur with the hormonal fluctuation of the 
menstrual cycle 
– Ulcerated areas and other nipple lesions require 
further exploration 
– Lymph node, have patient press hands against hip 
contracting pectoral muscles, palpate lateral group 
of axillary lymph nodes
Nipple Laceration
Paget’s Disease
Inverted Nipple
Sequence of Breast Exam
• Patient sitting or standing--press hands on 
hips to contract pectoral muscles (This 
maneuver accentuates any existing tissue 
retraction.) 
• Observe size and contour and appearance 
of the skin 
• Observe direction of nipples
Sequence of Breast Exam 
• Palpate 
axillary 
region
Sequence of Breast Exam
• Have patient lying flat with arm abducted 
and hand under head (This helps flatten 
breast tissue evenly over the chest wall.) 
• Palpate entire breast and lymph nodes, 
(axillary and infraclavicular) 
• Palpation is performed in a rotary motion 
using an organized approach
Sequence of Breast Exam
• Some examiners start in 
the upper outer quadrant 
where tumors develop 
most frequently 
• Breasts of young clients 
are firm and elastic 
• Older clients, the tissue 
may feel stringy and 
nodular.
Sequence of Breast Exam
• Palpating large pendulous breasts, use a 
bimanual technique. The inferior portion 
of the breast is supported in one hand 
while the other hand palpates breast tissue 
against the supporting hand 
• Special attention is given to palpate the 
nipples, and areola 
– Entire surface is gently palpated 
– With thumb and index finger compress the 
nipple; note any discharge.
NOTE: If client complains of a mass or tenderness of one 
breast, examine the opposite breast first to ensure an 
objective comparison of normal and abnormal tissue.
PELVIC EXAM
Sequence of a Pelvic Examination
• Inspect the client's external genitalia 
– Perineal area must be well illuminated 
– Both hands are gloved to prevent the spread 
of infection 
– Perineum is sensitive and tender, warn the 
client by touching the neighboring thigh first 
before advancing to the perineum.
NOTE: A client suffering pain or deformity of the joints may be unable to 
assume a Lithotomy position. It may be necessary to have the client abduct 
only one leg or have another person assist in separating the client's thighs.
Sequence of a Pelvic Examination 
• Mons pubis--note quantity 
and distribution of hair 
growth 
• Labia--usually plump and 
well-formed in adult female 
• Perineum--slightly darker 
than the skin of the rest of 
the body. Mucous 
membranes appear dark 
pink and moist
Sequence of a Pelvic Examination
• Separate the labia and inspect the labia 
minora: 
– Labia minora 
– Clitoris 
– Urethral orifice 
– Hymen 
– Vaginal orifice
Sequence of a Pelvic Examination
• Note the following: 
– Discharge 
– Inflammation 
– Edema 
– Ulceration 
– Lesions
Sequence of a Pelvic Examination
• Note abnormalities such 
as: 
– Bulges and swelling of 
vulva and vagina 
– Enlarged clitoris 
– Syphilitic chancres 
– Sebaceous cyst
Primary Syphilis
Sequence of a Pelvic Examination 
• Skene's glands 
– Near the urethra 
– Suspect inflammation; check for urethral 
discharge (Dc = Infxn Most likely GC) 
• Insert index finger with palm facing you into the 
vagina up to the 2d joint. Apply pressure upwards 
and milk the Skene's gland by moving your fingers 
outward 
• Do this on both sides and note any discharge. 
Obtain specimen for culture. 
• Change glove if discharge is found.
Sequence of a Pelvic Examination
• If there is history or appearance of labial 
swelling check Bartholin's glands 
– Insert index finger up to first knuckle 
– With your index finger and thumb, palpate 
the posterolateral area of the labia majora 
noting any: 
• Swelling 
• Tenderness 
• Masses 
• Heat or discharge
Sequence of a Pelvic Examination 
• Bartholin's glands (CONT) 
– A painful abscess is pus filled and usually 
staphylococcal or gonococcal in origin and 
should be incised and drained to perform 
C+S.
 Sequence of a Pelvic Examination 
• Assess the support of the vaginal outlet: 
– With the labia separated by middle and index 
finger 
– Ask patient to strain down 
– Note any bulging of the vaginal walls 
(cystocele and rectocele).
Sequence of a Pelvic Examination
• Inspect the anus at this time, note 
presence of lesions and hemorrhoids
Speculum Examination of Internal 
Genitalia
• Select a speculum of appropriate size, 
lubricate and warm with warm water 
(Commercially prepared lubricants 
interfere with pap smear studies) 
– Small--not sexually active female 
– Medium--sexually active 
– Large--women who have had children 
• Medium to large speculum may be used if 
female has had children.
Speculum Examination of Internal 
Genitalia
• Hold speculum in right hand 
• Place two fingers just inside or at the 
introitus and gently press down, this will help 
guide the speculum into the vagina opening 
• The speculum has to be closed 
• Insert closed speculum obliquely into vagina 
at a 45 degree angle rotating 50 degrees 
counterclockwise
Speculum Examination of Internal 
Genitalia
• Avoid trauma to the urethra 
• Care is taken to avoid pulling pubic hair or 
pinching the labia 
• Maintaining downward pressure, open blades 
slowly after full insertion and position the 
speculum so that the cervix can be visualized 
• When the cervix is in full view, the blades are 
locked in the open position
Examination/Collection Specimen of the 
Cervix
• Inspect the cervix 
– Color should be uniformly pink 
• Erythema around os: 
• Ectropion--expressed columnar epithelium 
• Erosion--term has been used to describe both the 
exposed columnar epithelium and the erythema 
seen with cervicitis 
– Pale--anemia 
– Bluish--Chadwick's sign, presumptive sign ofpregnancy.
Examination/Collection Specimen of the 
Cervix
• Inspect the cervix 
– Lesions/cysts: 
• Nabothian cyst--endocervical retention cysts usually 
secondary to cervical infection/inflammation 
• Friable, granular, red or white patchy areas--be 
suspicious of dysplasia, needs to be evaluated with 
colposcopy 
• Ulcerative lesions--may be herpetic; do viral culture 
of lesions and refer for colposcopy 
• Polyps--soft, friable mass protruding through os; 
may bleed if traumatized; refer for eval/removal
Examination/Collection Specimen of the 
Cervix
• Inspect the cervix 
– Discharge: 
• Endocervical vs. from vaginal vault 
• Physiological discharge--odorless, colorless 
• Culture any discharge.
Examination/Collection Specimen of the 
Cervix
• Inspect the cervix 
– Os: 
• Nulliparous--small, 
round, oval 
• Parous/
multiparous--linear, 
irregular, stellate
Examination/Collection Specimen of the 
Cervix 
• Obtain specimens 
– Chlamydia culture--most prevalent STD 
– GC culture--gram stain not reliable, done for 
screening, must do Thayer-Martin for 
confirmation 
– PAP smear for cytology--sites of collection: 
• Endocervical brush--all patients 
• Endocervical scrape with spatula--all patients 
• Posterior fornix--all 
• Vaginal cuff and area of former posterior fornix for 
post-hysterectomy patient.
Examination/Collection Specimen of the 
Cervix 
• Obtain specimens 
– Wet mount of normal saline: 
• WBCs--evidence of infection/inflammatory 
process 
• Flagellated trichomonads--trichomonas 
• Granulated epithelial cells,"clue cells"--
Gardnerella
Examination/Collection Specimen of the 
Cervix 
• Obtain specimens 
– KOH prep--budding yeast--candidiasis + 
"whiff" (fishy odor)--Gardnerella 
– Viral cultures of suspected lesions 
– Others: 
• STS (VDRL)--if suspected STDs 
• Beta HCG--if pregnancy suspected.
Examination/Collection Specimen of the 
Cervix 
• Obtain specimens 
– Collect during routine PAP smear/pelvic 
exam: 
• Wet mount if suspicious discharge 
• KOH prep if suspicious discharge 
• Thayer-Martin of Transgrow cultures 
• Chlamydia cultures
Inspection of the Vagina
• Withdraw the speculum slowly while 
observing the vaginal wall 
• Close blades as the speculum emerges 
from the introitus 
• Inspect vaginal mucosa as the speculum is 
withdrawn
Perform a Bimanual Examination
• From a standing position, introduce the 
index finger and middle finger of your 
gloved hand into the vagina 
• Exert pressure posteriorly 
• Your thumb should be adducted with the 
ring finger and little finger into your palm 
to avoid touching the clitoris.
Perform a Bimanual Examination
• Palpate the vaginal walls as you insert your fingers 
for tenderness, cysts, nodules, masses or growths 
• Identify the cervix, noting the following: 
– Position--anterior or posterior 
– Shape--pear-shaped 
– Consistency--firm or soft 
– Regularity 
– Mobility--move from side to side 1-2 cm in each 
direction 
– Tenderness
Perform a Bimanual Examination
• Palpate the fornix around the cervix 
• The os should admit your fingertip 0.5 cm 
• Place your free hand on the patient's 
abdomen midway between the umbilicus 
and symphysis pubis and press downward 
toward the pelvic hand
Perform a Bimanual Examination 
• Many vaginal orifices will readily admit a 
single examining finger. The technique can 
be modified so that the index finger alone 
is used. Special small speculum or nasal 
speculum may make inspection possible 
also. When the orifice is even smaller, a 
fairly good bimanual examination can be 
performed with one finger in the rectum.
Perform a Bimanual Examination
• Your pelvic hand should be kept in a 
straight line with your forearm and 
inward pressure exerted on the perineum 
by your flexed fingers. Support and 
stabilize your arm by resting your elbow 
either on your hip or on your knee which 
is elevated by placing your foot on a stool
(Bimanual Examination) Identify the 
Uterus Noting the Following:
• Size--uterine enlargement suggests 
pregnancy, benign or malignant tumors. 
The uterus should be 5.5-8.0 cm long 
• Shape--pear-shaped 
• Consistency--firm or soft.
(Bimanual Examination) Identify the 
Uterus Noting the Following:
• Mobility--should be mobile in the antero-
postero plane and deviation to the left or 
right is indicative of adhesions, pelvic 
masses of pregnancy 
• Tenderness--suggests PID process or 
ruptured tubal pregnancy 
• Masses.
(Bimanual Examination) Identify Right 
Ovary and Masses in the Adnexa
• Place your abdominal hand on the right 
lower quadrant 
• Place your pelvic hand in the right lateral 
fornix 
• Maneuver your abdominal hand 
downward 
• Use your pelvic hand for palpation.
(Bimanual Examination) Identify Right 
Ovary and Masses in the Adnexa
• Felt with the vaginal hand. The ovary has 
the size and consistency of a shelled oyster 
• Note the size, shape, consistency, mobility 
and tenderness of any palpable organs or 
masses
(Bimanual Examination) Identify Right 
Ovary and Masses in the Adnexa
• Repeat the procedure on the left side 
• The normal ovary is somewhat tender 
when palpated 
• Withdraw Fingers from Vagina and 
Change Gloves
Techniques of a Rectovaginal 
Examination
• The rectovaginal exam allows the 
examiner to reach almost 1" higher into 
the pelvis 
• The rectovaginal exam is usually 
performed after the bimanual 
examination.
Techniques of a Rectovaginal 
Examination
• There is a risk of spreading infection between the 
vagina and rectum. Gonorrhea may infect the 
rectum, as well as the female genitalia. It is 
recommended that gloves be changed between 
bimanual and rectovaginal examination, in order 
to avoid spreading gonococcal infection. In order 
to avoid fecal soiling, gloves should always be 
changed, if for some reason the practitioner 
examines the vagina after the rectum.
Techniques of a Rectovaginal 
Examination
• Tell the patient that this may be somewhat 
uncomfortable, and will make her feel as 
if she has to move her bowels 
• Lubricate dominant gloved hand 
• Inspect the perianal area for lesions, 
discoloration, inflammation and 
hemorrhoids.
Techniques of a Rectovaginal 
Examination
• Client is instructed to bear down as though she 
as having a bowel movement, caution her; she 
will feel as though she must pass a bowel 
movement 
• As the anal sphincter relaxes, insert your 
fingertip of the second finger gently into the 
anal canal and the 1st finger into the vagina. 
• Sphincter tone is palpated
Techniques of a Rectovaginal 
Examination
• Palpate the anorectal junction. Tell the 
woman to bear down, palpate the anterior 
rectal wall and check for sphincter tone. 
A loose sphincter may be present due to 
neurologic deficit or 3d degree perineal 
laceration after childbirth
Techniques of a Rectovaginal 
Examination
• Insert fingers as far as they will go. Tell 
the woman to bear down, and that should 
bring another centimeter of palpation. 
Check the rectal walls, rotating your 
finger, checking for masses, polyps, 
irregularities or tenderness.
Techniques of a Rectovaginal 
Examination
• Palpate the rectovaginal septum for tone 
and thickness 
• With your vaginal finger in the posterior 
fornix, perform a bimanual exam and 
palpate the bottom of the uterus and 
adnexa completely. 
• Withdraw your fingers and evaluate the 
posterior rectal wall.
Techniques of a Rectovaginal 
Examination
• Prepare guaiac of rectal finger 
• Give the patient a towel or tissues to 
cleanse herself
Common Abnormalities
• Vulva 
–Bartholin's cyst 
– Condyloma acuminatum
Common Abnormalities
• Cervix 
– Polyps 
– Discharge 
– Discoloration
Common Abnormalities 
• Uterus--enlarged 
– Pregnancy 
– Fibroids
Common Abnormalities 
• Adnexa 
– Ectopic pregnancy 
– Ovarian tumor or cyst
SUMMARY
• Inspect 
• Palpate Axilla 
• Palpate Breast 
• Palpate Nipple
BREAST EXAM
SUMMARY
• Inspect Externally 
• Palpate Skene’s Glands 
• Palpate Bartholin’s Glands 
• Assess Outlet 
• Speculum Exam 
• Bimanual Exam 
– Vagina, Cervix, Uterus, Adnexa
PELVIC EXAM
SUMMARY
• Palpate sphincter tone 
• Palpate rectal wall 
• Palpate rectovaginal septum 
• Palpate Uterus 
• Palpate Adnexa 
• Guaiac 
RECTOVAGINAL EXAM
Obrigado