Gynecology Examination Part 1 - Physical, Speculum, Vaginal Examination for Medical Students

Pelvic exam

Preparation
After explaining the details of the procedure and obtaining the patient's verbal consent, ask the patient to empty their bladder.
Allow the patient to remove all clothes and underwear below the waist in privacy, and provide sheets for cover if necessary.
Ask the patient to lay back in the lithotomy position on the examination chair.
Ensure that all the equipment and instruments used during the procedure are warmed.
External genital exam
Check the vulva for any abnormalities (e.g., swelling, irritation, ulcers, warts).
Examine the skin for the presence of scars, discoloration, and hair distribution.
Inspect the vaginal introitus for discharge or swelling.
Ask the patient to perform the Valsalva maneuver and examine the vaginal introitus for organ prolapse or urinary incontinence.
Palpate the labia majora for any masses or tenderness.
Vulvar lichen sclerosusVaginal discharge in gonococcal infectionBartholin cystStage III uterine prolapse

Bimanual pelvic exam

Lubricate the index and middle fingers of one hand and slowly insert them into the vaginal canal.
Use the other hand to simultaneously palpate the abdomen.
This procedure allows for palpation of both the uterus and adnexa (e.g., their localization, size, tenderness during manipulation, presence of masses).
Bimanual pelvic examination

Rectovaginal pelvic exam
Lubricate the index and middle fingers of one hand and slowly insert them into the vaginal canal and rectum respectively.
Use the other hand to push the uterus posteriorly by pressing on the anterior abdominal wall.
This procedure allows for the palpation of the rectovaginal septum, cul-de-sac tenderness, or masses.
The rectovaginal exam is usually reserved for patients with suspected pelvic masses (e.g., colorectal cancer).
Bimanual rectal and rectovaginal exams

Sterile speculum exam
Before proceeding to the speculum exam, remind the patient about the procedure and ensure they are comfortable before beginning.
Choose the appropriately sized speculum and lubricate it.
Separate the labia majora with the index and middle fingers and gently introduce the speculum inside the vaginal canal with the blades facing down and the handle pointing to the side.
After fully advancing the speculum, carefully rotate it to 90° so that the blades are in a horizontal position, with the handle pointing down.
Only after the speculum has been placed in its final position, remove the fingers and slowly open the speculum.
Lock the screws on the speculum after getting a good visualization of the cervix.
Inspect the cervix and the cervical os for the following:
Position (e.g., anteriorly displaced cervix in a patient with a retroverted uterus)
Color (e.g., ectocervical reddening due to the development of cervical ectropion )
Abnormal discharge (e.g., mucopurulent discharge in gonococcal cervicitis)
Erosions and ulcerations (e.g., HSV infection)
Hemorrhages (e.g., strawberry cervix in trichomoniasis)
Cervical masses (e.g., polyps, cervical cancer)
Take a cervical swab/Pap smear if necessary.
Loosen the screws, close the speculum partially , and slowly return it to its original position at insertion (i.e., with the blades facing down and the handle pointing to the side).
Carefully extract the speculum and inspect the vaginal introitus.