1. Menstrual history.

•Date of your last menstrual period?

•Age at first period?

•How often are your periods?

•How many days does your period last?

 •Usual amount of flow: light, medium, heavy? How many pads or tampons do you use each day or hour?

•Any clotting?

 •Any pain or cramps before or during period? How do you treat it?

Interfere with daily activities? Any other associated symptoms:

 bloating,

breast tenderness,

moodiness?

Any spotting between periods?

Menstrual history

LMP—last menstrual period.

Menarche—mean age at onset at 12 to 13 years; delayed onset suggests endocrine or underweight problem.

Cycle—normally every 18 to 45 days.

Amenorrhea—absent menses.

Duration—average 3 to 7 days.

Menorrhagia—heavy menses.

Clotting indicates heavy flow or vaginal pooling.

Dysmenorrhea.

2. Obstetric history.

•How many times?

•How many babies have you had?

•Any miscarriage or abortion?

•For each pregnancy, describe: duration, any complication, labor and delivery, baby's sex, birth weight, condition.

•Do you think you may be pregnant now? What symptoms have you noticed?

Gravida—number of pregnancies.

Para—number of births.

Abortions—interrupted pregnancies,

including elective abortions and spontaneous miscarriages.

3. Menopause.

•Any associated symptoms of menopause

(e.g., hot flash,

night sweats,

numbness and tingling,

headache,

palpitations,

drenching sweats,

mood swings,

vaginal dryness,

 itching)?

Any treatment?

•If hormone replacement, how much? How is it working? Any side effects?

•How do you feel about going through menopause?

Menopause

Perimenopausal period from 40 to 55 years has hormone shifts, resulting in vasomotor instability.

Side effects of HRT include

fluid retention,

breast pain,

vaginal bleeding,

 and breast cancer risk.

Although a normal life stage, reaction varies from acceptance to feelings of loss.

4. Self-care behaviors.

•Last Pap smear? Results?

•Has your mother ever mentioned taking hormones while pregnant with you?

Begin cervical cancer screening within 3 years after first vaginal intercourse or age 21 years,

and continue annually until age 30.

After age 30, if have three consecutive normal Pap tests, women may be screened every 2 to 3 years.

Maternal ingestion of diethylstilbestrol (DES) causes cervical and vaginal abnormalities in female offspring requiring frequent follow-up.

5. Urinary symptoms.

•Any burning or pain on urinating?

•Awaken during night to urinate?

•Blood in the urine?

•Urine dark, cloudy, foul smelling?

 •Any difficulty controlling urine or wetting yourself?

•Urinate with a sneeze, laugh, cough, bearing down?

Urgency.

dysuria

nocturia

hematuria

Bile in urine or urinary tract infection.

Urge incontinence—involuntary urine loss from overactive detrusor muscle in bladder. It contracts, causing urgent need to void.

Stress incontinence—involuntary urine loss with physical strain, sneezing, or coughing.

6. Vaginal discharge.

vaginal discharge?

•Character or color: white, yellow-green, gray, curdlike, foul smelling?

 •When did this begin?

•Is the discharge associated with vaginal itching, rash, pain with intercourse?

•Taking any medications?

 •Family history of diabetes?

•What part of your menstrual cycle are you in now?

•Use a vaginal douche? How often?

•Use feminine hygiene spray?

•Wear nonventilating underpants, pantyhose?

 •Treated the discharge with anything? Result?

Normal discharge is small, clear or cloudy, and always nonirritating.

Suggests vaginal infection; character of discharge often suggests causative organism

Acute versus chronic problem.

Rash is result of irritation from discharge. Dyspareunia

occurs with vaginitis of any cause.

Factors that increase risk for vaginitis:

• Oral contraceptives increase glycogen content of vaginal epithelium, providing fertile medium for some organisms.

• Broad-spectrum antibiotics alter balance of normal flora.

• Menses, postpartum, menopause have a more alkaline vaginal pH.

• Frequent douching alters pH.

• Spray has risk for contact dermatitis.

• Local irritation.

7. Past history.

•Any abdominal pain?

•Any past surgery on uterus, ovaries, vagina?

Assess feelings.

Some fear loss of sexual response after hysterectomy,

which may cause problems in intimate relationships.

8. Sexual activity.

sexual relationship

 •Are you in a relationship involving sex now?

•Are aspects of sex satisfactory to you and your partner?

 •Satisfied with the way you and partner communicate about sex?

 •Satisfied with your ability to respond sexually?

 •Do you have more than one sexual partner?

•What is your sexual preference: relationship with a man, with a woman, both?

Begin with open-ended question to assess individual needs. Include appropriate questions as a routine:

• Communicates that you accept individual's sexual activity and believe it is important.

• Your comfort with discussion prompts person's interest and possibly relief that the topic has been introduced.

• Establishes a database for comparison with any future sexual activities.

• Provides opportunity to screen sexual problems.

The practice environment must be welcoming and respectful of lesbians and bisexual women to discuss their health concerns.

9. Contraceptive use. Currently planning a pregnancy, or avoiding pregnancy?

•Do you and your partner use a contraceptive?

Which method? Is this satisfactory? Do you have any questions about method?

 •Which methods have you used in the past? Have you and partner discussed having children?

 •Have you ever had any problems becoming pregnant?

Assess smoking history.

Oral contraceptives, together with cigarette smoking, increase the risk for vascular problems.

Infertility is considered after 1 year of engaging in unprotected sexual intercourse without conceiving.

10. Sexually transmitted infection (STI) contact.

11. STI risk reduction.

Use condoms at each episode of sexual intercourse?

Additional History for the Aging Adult

1. After menopause, noted any vaginal bleeding?

2. Any vaginal itching, discharge, pain with intercourse?

3. Any pressure in genital area, loss of urine with cough or sneeze, back pain, or constipation?

4. Are you in a relationship involving sex now?

Are aspects of sex satisfactory to you and your partner?

Is there adequate privacy for a sexual relationship?

Postmenopausal bleeding warrants further workup and referral.

Associated with atrophic vaginitis.

Occurs with weakened pelvic musculature and uterine prolapse.

EXTERNAL GENITALIA

Inspection

Note:

• Skin color is even; labia minora are a darker pink

• Hair distribution is in the usual female pattern of inverted triangle,

although it normally may trail up the abdomen toward the umbilicus.

• Labia majora normally are symmetric, plump, and well formed.

In the nulliparous woman, labia meet in the midline; after a vaginal delivery, the labia are gaping and slightly shriveled.

• No lesions should be present, except for occasional sebaceous cysts.

These are yellowish, 1-cm nodules that are firm, nontender, and often multiple.

Note any pigmented nevus or lesion that the woman cannot see.

Refer any suspicious lesion for biopsy.

Consider delayed puberty if no pubic hair or breast development has occurred by age 13 years.

Nits or lice at the base of pubic hair.

Swelling.

With your gloved hand, separate the labia majora to inspect:

• Clitoris

• Labia minora are dark pink and moist, usually symmetric.

• Urethral opening appears stellate or slitlike and is midline.

• Vaginal opening, or introitus, may appear as a narrow vertical slit or as a larger opening.

• Perineum is smooth. A well-healed episiotomy scar, midline or mediolateral, may be present after a vaginal birth.

• Anus has coarse skin of increased pigmentation (see Chapter 25 for assessment).

Excoriation, nodules, rash, or lesions

Inflammation or lesions.

Polyp.

Foul-smelling, irritating discharge.

Palpation

Assess the urethra and Skene's glands (Fig. 26-8).

Dip your gloved finger in a bowl of warm water to lubricate.

Then insert your index finger into the vagina, and gently milk the urethra by applying pressure up and out.

This procedure should produce no pain.

If any discharge appears, culture it.

Tenderness.

Induration along urethra.

Urethral discharge.

Assess Bartholin's glands.

Palpate the posterior parts of the labia majora with your index finger in the vagina and your thumb outside (Fig. 26-9).

Normally, the labia feel soft and homogeneous.

Swelling (see Table 26-2).

Induration.

Pain with palpation.

Erythema around or discharge from duct opening.

Assess the support of pelvic musculature by using these maneuvers:

1.Palpate the perineum.

Normally, it feels thick, smooth, and muscular in the nulliparous woman

and thin

and rigid in the multiparous woman.

2.Ask the woman to squeeze the vaginal opening around your fingers;

it should feel tight in the nulliparous woman

and have less tone in the multiparous woman.

3.Using your index and middle fingers,

separate the

vaginal orifice and ask the woman to strain down.

Normally, no bulging of vaginal walls or urinary incontinence occurs.

Tenderness.

Paper-thin perineum.

Absent or decreased tone may diminish sexual satisfaction.

Bulging of the vaginal wall indicates cystocele, rectocele, or uterine prolapse (see Table 26-3, p. 754).

Urinary incontinence.

INTERNAL GENITALIA

Speculum Examination

Select the proper-size speculum.

Warm and lubricate the speculum under warm running water.

Regarding Pap test cytology, evidence shows applying a small amount (dime size) of water-soluble gel lubricant on the outer inferior blade

increases patient comfort and yields no more unsatisfactory slides than does water-only lubricant.³,¹⁷

However, the effect of gel lubricant on interference with bacterial or viral cultures has not been tested.

A good technique is to dedicate one hand to the patient and the other hand to picking up equipment in the room.

For example, hold the speculum in your left hand (the equipment hand), with the index and the middle fingers surrounding the blades and your thumb under the thumbscrew.

 This prevents the blades from opening painfully during insertion.

With your right index and middle fingers (the patient hand), push the introitus down and open to relax the pubococcygeal muscle (Fig. 26-10).

Tilt the width of the blades obliquely and insert the speculum past your right fingers, applying any pressure downward.

This avoids pressure on the sensitive urethra above it.

Ease insertion by asking the woman to bear down.

 This method relaxes the perineal muscles and opens the introitus.

(With experience, you can combine speculum insertion with assessing the support of the vaginal muscles.)

As the blades pass your right fingers, withdraw your fingers.

Now change the hand holding the speculum to your right hand and turn the width of the blades horizontally.

Continue to insert in a 45-degree angle downward toward the small of the woman's back (Fig. 26-11).

This matches the natural slope of the vagina.

After the blades are fully inserted, open them by squeezing the handles together (Fig. 26-12).

The cervix should be in full view.

Sometimes this does not occur (especially with beginning examiners)

because the blades are angled above the location of the cervix.

Try closing the blades, withdrawing about halfway, and reinserting in a more downward plane.

Then slowly sweep upward.

Once you have the cervix in full view, lock the blades open by tightening the thumbscrew.

Inspect the Cervix and Its Os

Note:

• Color. Normally the cervical mucosa is pink and even (Fig. 26-13, A).

During the 2nd month of pregnancy, it looks blue (Chadwick sign),

and after menopause, it is pale.

• Position. Midline, either anterior or posterior. Projects 1 to 3 cm into the vagina.

• Size. Diameter is 2.5 cm (1 inch).

• Os. This is small and round in the nulliparous woman.

In the parous woman, it is a horizontal, irregular slit and also may show healed lacerations on the sides

Redness, inflammation.

Pallor with anemia.

Cyanotic other than with pregnancy

Lateral position may be due to adhesion or tumor.

Projection of more than 3 cm may be a prolapse.

Hypertrophy of more than 4 cm occurs with inflammation or tumor.

cervix cont.

• Surface. This is normally smooth, but cervical eversion, or ectropion, may occur normally after vaginal deliveries (Fig. 26-13, B).

The endocervical canal is everted or “rolled out.” It looks like a red, beefy halo inside the pink cervix surrounding the os.

It is difficult to distinguish this normal variation from an abnormal condition (e.g., erosion or carcinoma), and biopsy may be needed.

Nabothian cysts are benign growths that commonly appear on the cervix after childbirth.

They are small, smooth, yellow nodules that may be single or multiple.

Less than 1 cm, they are retention cysts caused by obstruction of cervical glands.

• Note the cervical secretions. Depending on the day of the menstrual cycle, secretions may be clear and thin, or thick, opaque, and stringy.

Always they are odorless and nonirritating.

If secretions are copious, swab the area with a thick-tipped rectal swab.

This method sponges away secretions, and you have a better view of the structures.

Surface reddened, granular, and asymmetric, particularly around os.

Friable, bleeds easily.

Any lesions: white patch on cervix; strawberry spot.

Refer any suspicious red, white, or pigmented lesion for biopsy

Cervical polyp—bright red growth protruding from the os

Foul-smelling, irritating, with yellow, green, white, or gray discharge

Obtain Cervical Smears and Cultures

The Papanicolaou, or Pap, test screens for cervical cancer and not for endometrial or ovarian cancer.

Do not obtain during the woman's menses or if a heavy infectious discharge is present.

Instruct the woman to not douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens.

Obtain the Pap smear before other specimens so you will not disrupt or remove cells.

Most U.S. clinics have changed from conventional cytology collection using glass slides to liquid-based cytology vials.

Using liquid-based cytology, the cervical specimens are dipped into a vial with preservative rather than being smeared on a slide.

Conventional glass slides can come back from the laboratory as “unsatisfactory”

because of obscuring by blood or inflammation or clumped distribution of cells.

Thus evidence shows that just stirring off the cells into the liquid vial results in

fewer unsatisfactory tests and is more sensitive in detecting cervical neoplasia.⁷

Using liquid-based cytology, microscopic evaluation is made clearer

by the uniform spread of epithelial cells in a thin layer.

Also, after cytology examination,

pathologists can perform further studies on the liquid remnant such as testing for high-risk HPV types.⁴,³⁶

Whichever collection method you are using, collect the cellular specimens from the following three locations.

Vaginal Pool.

Cervical Scrape: Insert the bifid end of the Ayre spatula into the vagina with the more pointed bump into the cervical os.

Rotate it 360 to 720 degrees, using firm pressure. The rounded cervix fits snugly into the spatula's groove.

The spatula scrapes the surface of the squamocolumnar junction (SCJ) and cervix as you turn the instrument.

Spread the specimen from both sides of the spatula onto a glass slide.

Use a single stroke to thin out the specimen, not a back-and-forth motion.

This specimen is important for the adolescent whose endocervical cells have not yet migrated into the endocervical canal.

Endocervical Specimen: Insert a cytobrush (instead of a cotton applicator) into the os.

 A cytobrush gives a higher yield of endocervical cells at the SCJ and is safe for use during pregnancy.

The woman may feel a slight pinch with the brush, and scant bleeding may occur.

For this reason, collect the endocervical specimen last so that bleeding will not obscure cytologic evaluation.

cervical smears and cultures cont.

Rotate the brush 720 degrees in ONE direction in the endocervical canal, either clockwise or counterclockwise.

Then rotate the brush gently on a slide to deposit all the cells.

 Rotate in the opposite direction from the one in which you obtained the specimen.

 Avoid leaving a thick specimen that would be hard to read under the microscope.

 Immediately (within 2 seconds) spray the slide with fixative to avoid drying. Or stir the cytobrush gently into the liquid vial.

For the woman after hysterectomy whose cervix has been removed, collect a scrape from the end of the vagina and a vaginal pool.

Label the frosted ends of the slides or the vial with the woman's name.

Send specimens to the laboratory with the following necessary data:

_ Date of specimen

_ Woman's date of birth

_ Date of last menstrual period

_ Any hormone medication

_ If pregnant, estimated date of delivery

_ Known infections

_ Prior surgery or radiation

_ Prior abnormal cytology

_ Abnormal findings on physical examination

These data are important for accurate interpretation

(e.g., a specimen may be interpreted as positive unless the laboratory technicians know the woman has had prior radiation treatment).

To screen for STIs and if you note any abnormal vaginal discharge, obtain the gonorrhea (GC)/chlamydia culture.

 Insert a sterile cotton applicator into the os, rotate it 360 degrees, and leave it in place 10 to 20 seconds for complete saturation.

Insert into labeled container.

Occasionally you will need the following samples:

Saline Mount, or “Wet Prep.” Spread a sample of the discharge onto a glass slide and add one drop of normal saline solution and a coverslip.

KOH Prep. To a sample of the discharge on a glass slide, add one drop of potassium hydroxide and a coverslip.

Anal Culture. Insert a sterile cotton swab into the anal canal about 1 cm.

Rotate it, and move it side to side. Leave in place 10 to 20 seconds.

If the swab collects feces, discard it and begin again. Insert into specimen container.

Acetic Acid Wash.

Inspect the Vaginal Wall

Loosen the thumbscrew but continue to hold the speculum blades open.

Slowly withdraw the speculum, rotating it as you go, to fully inspect the vaginal wall.

Normally, the wall looks pink, deeply rugated, moist and smooth, and free of inflammation or lesions.

Normal discharge is thin and clear or opaque and stringy but always odorless.

When the blade ends are near the vaginal opening, let them close, but be careful not to pinch the mucosa or catch any hairs.

Turn the blades obliquely to avoid stretching the opening.

Place the metal speculum in a basin to be cleaned later and soaked in a sterilizing and disinfecting solution; discard the plastic variety.

Discard your gloves, and wash hands.

Inflammation or lesions.

Leukoplakia, appears as spot of dried white paint.

Vaginal discharge: thick, white, and curdlike with candidiasis;

profuse, watery, gray-green, and frothy with trichomoniasis;

or any gray, green-yellow, white, or foul-smelling discharge

Bimanual Examination

Rise to a stand, and have the woman remain in lithotomy position.

Drop lubricant onto the first two fingers of your gloved intravaginal hand

Assume the “obstetric” position with the first two fingers extended, the last two flexed onto the palm, and the thumb abducted.

Insert your fingers into the vagina, with any pressure directed posteriorly.

Wait until the vaginal walls relax, and then insert your fingers fully.

You will use both hands to palpate the internal genitalia to assess their location, size, and mobility and to screen for any tenderness or mass.

 One hand is on the abdomen while the other hand (often the dominant, more sensitive hand) inserts two fingers into the vagina (Fig. 26-18).

It does not matter which you choose as the intravaginal hand; try each way, and settle on the most comfortable method for you.

Palpate the vaginal wall. Normally, it feels smooth and has no area of induration or tenderness.

Nodule.

Tenderness.

Cervix.

• Consistency—feels smooth and firm, as the consistency of the tip of the nose. It softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell sign).

• Contour—evenly rounded.

• Mobility—with a finger on either side, move the cervix gently from side to side. Normally, this produces no pain (Fig. 26-19).

Palpate all around the fornices; the wall should feel smooth.

Hard with malignancy.

Nodular.

Irregular.

Immobile with malignancy.

Painful with inflammation or ectopic pregnancy.

Uterus.

version,

Palpate the uterine wall with your fingers in the fornices.

Normally, it feels firm and smooth, with the contour of the fundus rounded.

It softens during pregnancy. Bounce the uterus gently between your abdominal and intravaginal hand.

It should be freely movable and nontender.

Enlarged uterus (see Table 26-6, pp. 757-758).

Lateral displacement.

Nodular mass. Irregular, asymmetric uterus.

Fixed and immobile.

Tenderness.

Adnexa.

A note of caution—normal adnexal structures often are not palpable.

Be careful not to mistake an abnormality for a normal structure.

To be safe, consider abnormal any mass that you cannot positively identify, and refer the woman for further study.

Move to the left to palpate the other side.

Then, withdraw your hand and check secretions on the fingers before discarding the glove.

 Normal secretions are clear or cloudy and odorless.

Enlarged adnexa.

Nodules or mass in adnexa.

Immobile.

Markedly tender (see Table 26-7, Adnexal Enlargement, p. 759).

Pulsation or palpable fallopian tube suggests ectopic pregnancy;

this warrants immediate referral.

Rectovaginal Examination

Use this technique to assess the rectovaginal septum, posterior uterine wall, cul-de-sac, and rectum.

 Change gloves to avoid spreading any possible infection.

Lubricate the first two fingers. Instruct the woman that this may feel uncomfortable and will mimic the feeling of moving her bowels.

 Ask her to bear down as you insert your index finger into the vagina and your middle finger gently into the rectum

While pushing with the abdominal hand, repeat the steps of the bimanual examination.

Try to keep the intravaginal finger on the cervix so the intrarectal finger does not mistake the cervix for a mass.

Note:

• Rectovaginal septum should feel smooth, thin, firm, and pliable.

• Rectovaginal pouch, or cul-de-sac, is a potential space and usually not palpated.

• Uterine wall and fundus feel firm and smooth.

Rotate the intrarectal finger to check the rectal wall and anal sphincter tone. (See Chapter 25 for assessment of anus and rectum.)

Check your gloved finger as you withdraw; test any adherent stool for occult blood.

Give the woman tissues to wipe the area, and help her up.

Remind her to slide her hips back from the edge before sitting up so she will not fall.

Nodular or thickened.

(regarding the rectovaginal pouch, or cul-de-sac)

The Aging Adult

Natural lubrication is decreased; to avoid a painful examination,

take care to lubricate instruments and the examining hand adequately.

Use the Pedersen speculum (rather than the Graves) because its narrower,

flatter blades are more comfortable in women with vaginal stenosis or dryness.

Menopause and the resulting decrease in estrogen production cause numerous physical changes.

 Pubic hair gradually decreases, becoming thin and sparse in later years.

The skin is thinner and fat deposits decrease, leaving the mons pubis smaller and the labia flatter.

 Clitoris size also decreases after age 60 years.

aging adult

Internally, the rugae of the vaginal walls decrease and the walls look pale pink because of the thinned epithelium.

The cervix shrinks and looks pale and glistening. It may retract, appearing to be flush with the vaginal wall.

In some, it is hard to distinguish the cervix from the surrounding vaginal mucosa.

Or, the cervix may protrude into the vagina if the uterus has prolapsed.

Refer any suspicious red, white, or pigmented lesion for biopsy.

Vaginal atrophy increases the risk for infection and trauma.

aging adult

With the bimanual examination, you may need to insert only one gloved finger if vaginal stenosis exists.

The uterus feels smaller and firmer, and the ovaries are not palpable normally.

Be aware that older women may have special needs and will appreciate the following plans of care: for those with arthritis, taking a mild analgesic or

anti-inflammatory before the appointment may ease joint pain in positioning;

schedule appointment times when joint pain or stiffness is at its least;

allow extra time for positioning and “unpositioning” after the examination; and be careful to maintain dignity and privacy.

Women should continue cervical cancer screening up to age 70 years if they have an intact cervix and are in good health.³⁷

 After age 70, women may decide to stop screening if

(1) they have had no abnormal cytology tests in the previous 10 years and

(2) if the three most recent Pap tests are documented as technically satisfactory and with normal results.³⁷

Women who have had a total hysterectomy for benign gynecologic disease do not need cervical cancer screening.

 But if the hysterectomy was for cervical neoplasia,

 Pap tests should continue until a 10-year history of no abnormal results.

S:Severe perineal itching.

O:Excoriations and erythematous areas.

May see little dark spots (lice are small),

nits (eggs) adherent to pubic hair near roots.

 Usually localized in pubic hair,

occasionally in eyebrows or eyelashes.

S:Episodes of local pain,

dysuria,

fever.

O:Clusters of small, shallow vesicles with surrounding erythema;

erupt on genital areas and inner thigh.

Also, inguinal adenopathy, edema.

Vesicles on labia rupture in 1 to 3 days, leaving painful ulcers.

Initial infection lasts 7 to 10 days.

Virus remains dormant indefinitely;

recurrent infections last 3 to 10 days with milder symptoms.

O:Begins as a small, solitary silvery papule

that erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge.

Palpation—nontender indurated base;

can be lifted like a button between thumb and finger.

Nontender inguinal lymphadenopathy.

S:History of skin contact with allergenic substance in environment,

intense pruritus.

O:Primary lesion—red, swollen vesicles.

Then may have weeping of lesions,

crusts,

scales,

thickening of skin,

excoriations from scratching.

May result from reaction to feminine hygiene spray or

synthetic underclothing.

S:Painless warty growths, may be unnoticed by woman.

O:Pink or flesh-colored, soft, pointed, moist, warty papules.

Single or multiple in a cauliflower-like patch.

Occur around vulva, introitus, anus, vagina, cervix.

HPV infection is common among sexually active women,

especially adolescents, regardless of ethnicity or socioeconomic status.

Risk factors include early age at menarche and multiple sexual partners.

The long incubation period (6 weeks to 8 months)

makes it difficult to establish history of exposure.

S:Local pain, can be severe.

O:Overlying skin red, shiny, and hot.

Posterior part of labia swollen;

palpable fluctuant mass and tenderness.

(Compare with wrinkled skin on the other, normal side.)

Mucosa shows red spot at site of duct opening.

Requires incision and drainage, antibiotic therapy.

S:Dysuria, burning sensation.

O:Palpation of anterior vaginal wall shows

erythema,

tenderness,

induration along urethra,

purulent discharge from meatus.

Caused by Neisseria gonorrhoeae,

chlamydia,

or staphylococcus infection.

S:Tender,

painful with urination,

urinary frequency,

hematuria,

dyspareunia,

or asymptomatic.

O:Small, deep red mass protruding from meatus;

usually secondary to urethritis or skenitis;

lesion may bleed on contact.

S:Feeling of pressure in vagina,

stress incontinence.

O:With straining, note introitus widening and the presence of a

soft, round anterior bulge.

The bladder, covered by vaginal mucosa, prolapses into vagina.

S:Feeling of pressure in vagina,

possibly constipation.

O:With straining, note introitus widening and the presence of a soft, round bulge from posterior.

Here, part of the rectum, covered by vaginal mucosa,

prolapses into vagina.

O:With straining or standing, uterus protrudes into vagina.

Nontender, non-fluctuant, smooth hemisphere; may cause a broad-based gait.

Prolapse is graded:

1st degree, cervix appears at introitus with straining;

2nd degree, cervix bulges outside introitus with straining;

3rd degree (in this case), whole uterus protrudes even without straining—

essentially, uterus is inside out.

O:Bluish discoloration of the mucosa occurs normally in pregnancy

(Chadwick sign at 6 to 8 weeks’ gestation)

and with any other condition causing hypoxia or venous congestion

(e.g., heart failure, pelvic tumor).

O:Cervical lips inflamed and eroded.

Reddened granular surface is superficial inflammation, with no ulceration (loss of tissue).

Usually secondary to purulent or mucopurulent cervical discharge.

 Biopsy needed to distinguish erosion from carcinoma;

cannot rely on inspection.

Human Papillomavirus (HPV, Condylomata

cervix

O:Virus can appear in various forms when affecting cervical epithelium.

Here, warty growth appears as abnormal thickened white epithelium.

Visibility of lesion is enhanced by acetic acid (vinegar) wash,

which dissolves mucus and temporarily causes

intracellular dehydration

and coagulation of protein.

polyp

cervix

S:May have mucoid discharge or bleeding.

O:Bright red, soft, pedunculated growth emerges from os.

It is a benign lesion, but this must be determined by biopsy.

May be lined with squamous or columnar epithelium.

Diethylstilbestrol (DES) Syndrome

cervix

S:Prenatal exposure to DES causes cervical and vaginal abnormalities not apparent until adolescence.

O:Red, granular patches of columnar epithelium extend

beyond normal squamocolumnar junction

onto cervix and into fornices (vaginal adenosis).

 Also cervical abnormalities:

circular groove,

transverse ridge,

protuberant anterior lip,

“cockscomb” formation.

Structural abnormalities cause

infertility,

ectopic pregnancy,

spontaneous abortion,

and preterm labor.

carcinoma

cervix

S:Bleeding between menstrual periods or after menopause, unusual vaginal discharge.

O:Chronic ulcer and induration are early signs of carcinoma,

although the lesion may or may not show on the exocervix.

(Here, lesion is mostly around the external os.)

Diagnosed by Pap smear and biopsy.

Risk factors for cervical cancer are

early age at first intercourse,

multiple sex partners,

cigarette smoking,

certain sexually transmitted infections.