Makindo Medical Notes

Related Subjects: | Causes of Abnormal Vaginal Bleeding | Vaginal Carcinoma | Cervical Cancer | Endometrial (Uterine) Cancer | Post Menopausal Bleeding | Anatomy of the Uterus | Anatomy of the Ovary | Gynaecological History Taking | Gynaecological Examination (OSCE) | Colposcopy | Premature Menopause | Polycystic Ovary Syndrome

💬 Introduction

Begin by introducing yourself (name and role) and confirming the patient’s identity. Explain the purpose of the pelvic examination clearly — whether for diagnosis, symptom investigation, or cervical screening. Ensure the patient understands what the examination involves and why it’s needed. Obtain explicit verbal consent and reassure them they can stop at any point. Offer to answer questions, maintain eye contact, and check understanding. Always offer a trained chaperone for all intimate examinations (per GMC guidance).

🧴 Preparation and Infection Control

• 🧼 Wash hands thoroughly and wear appropriate PPE (gloves and apron).
• 🪣 Ensure privacy with curtains or a closed door. Ask the patient to undress from the waist down and provide a sheet for modesty.
• 🪶 Position the patient comfortably in the dorsal lithotomy position (hips and knees flexed, feet together), or the left lateral position if prolapse or mobility issues are present.
• 💡 Adjust lighting and height of the couch to ensure good visibility.

👀 General Observation

• Assess whether the patient looks well, anxious, or in pain.
• If the patient appears unwell, prioritise Airway, Breathing, Circulation before proceeding.
• Observe the abdomen for scars (C-section, laparotomy), distension, or tenderness before touching.

🩺 Abdominal Examination

• Inspection: Look for distension, scars, visible masses, or discoloration.
• Palpation: Assess for tenderness or guarding.
  • Check for palpable masses (consider pregnancy, fibroids, or ovarian cysts).
  • If the abdomen is distended, percuss for ascites or bowel obstruction.
• Auscultation: Listen for bowel sounds — reduced sounds may suggest ileus or peritonitis.

🌸 Vaginal Examination

• External Inspection (Vulva): Observe for redness, swelling, ulceration, lesions, discharge, or signs of infection (e.g., candida, HSV).
• Speculum Examination: Allows inspection of the vaginal walls and cervix.
  • Use a Cusco’s speculum (bivalve) for general inspection or cervical smear; use a Sims’ speculum for prolapse assessment.
  • Lubricate with jelly (or warm water if doing a smear).
  • Insert the closed speculum with blades parallel to the labia, directed gently toward the sacrum at a 45° angle.
  • Open slowly to visualise the cervix — note colour, discharge, ectropion, or lesions.
  • If the cervix is not visible, adjust angle or repeat after a bimanual check of uterine position.
  • Take appropriate swabs (e.g. high vaginal, endocervical, or chlamydia) and ensure proper labelling.
  • Close under direct vision to avoid pinching cervical tissue.
• Bimanual Examination:
  • Insert two lubricated fingers into the vagina and place the other hand on the lower abdomen.
  • Assess uterine size, mobility, and tenderness (retroverted vs anteverted uterus).
  • Palpate for adnexal masses or tenderness (suggesting cyst, ectopic pregnancy, or infection).

🔧 Using a Cusco’s Speculum – Step by Step

• Warm and lubricate the speculum (unless performing cytology).
• Insert closed, with gentle posterior pressure along the vaginal canal.
• Angle toward the sacrum, open slowly once inside, and secure the position.
• Inspect the cervix for:
  • Colour, ulcers, ectropion, or cervical polyps.
  • Discharge (consider infection or malignancy).
  • Contact bleeding (possible cervical ectopy or CIN).
• Perform swabs or smear if indicated, then gently close and withdraw under vision.

🧭 End of Examination

• Remove gloves and wash hands.
• Reassure and thank the patient for their cooperation.
• Provide tissues and privacy to allow dressing.
• Assist the patient if needed and check that they feel well before standing.
• Explain findings (if appropriate) and outline next steps or follow-up tests.
• Document:
  • Consent obtained and chaperone present.
  • Findings: appearance of vulva, vagina, cervix, discharge, uterine/adnexal tenderness.
  • Samples taken and patient’s response.

💡 Clinical Pearls

• Always use a chaperone for intimate exams and record their name in the notes.
• Maintain constant communication — narrate each step to reassure the patient.
• Never continue if the patient feels pain or withdraws consent.
• Consider differential diagnoses for abnormal findings — infection, malignancy, prolapse, or trauma.
• Offer emotional support; pelvic exams can be distressing for survivors of trauma or sexual assault.