1. Menstrual history. Menstrual history is usually nonthreatening; thus it is a good place to start history.

2. Obstetric history. Have you ever been pregnant?

3. Menopause. Have your periods slowed down or stopped?

4. Self-care practices. How often do you have a Pap (Papanicolaou) smear or breast examination? Have you been immunised against human papillomavirus?

5. Urinary symptoms. Any problems with urinating? Frequently and small amounts? Cannot wait to urinate?

6. Vaginal discharge. Any unusual vaginal discharge? Increased amount? Normal discharge is small, clear or cloudy, and always nonirritating.

Occurs as a result of irritation from discharge.

Dyspareunia occurs with vaginitis of any cause.

• Taking any medications?

Factors that increase risk of vaginitis:

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

• Broad-spectrum antibiotics alter balance of normal flora.

• Diabetes increases glycogen content which predisposes the woman to fungal infection.

• Menses, post partum, menopause have a more alkaline vaginal pH.

7. Past history. Any other problems in the genital area? Sores or lesions—now or in the past? How were these treated?

8. Sexual activity. Often women have a question about their sexual relationship and how it affects their health. Do you?

9. Contraceptive use. Are you currently planning a pregnancy, or avoiding pregnancy?

10. Sexually transmitted infection (STI) contact. Have you had any sexual contact with partner who had a sexually transmitted disease, such as gonorrhoea, herpes, AIDS, chlamydial infection, venereal warts, syphilis? When? How was this treated? Were there any complications?

11. STI risk reduction. What measures do you take to reduce the risk of STIs? Does your partner use condoms at each episode of sexual intercourse?

1. Does your child have any problem urinating? Pain with urinating, crying, holding genitals? Urinary tract infection?

2. Problem with genital area: itching, rash, vaginal discharge?

3. Questions related to suspected child abuse. Registered nurses in Australia have a legal requirement to report suspected cases of child abuse and neglect. This is known as mandatory reporting. All Australian states and territories possess mandatory reporting requirements of some description. You should make sure that you understand the requirements within your area—http://www.aifs.gov.au/nch/pubs/sheets/rs3/rs3.html

Where appropriate, you need to make a judgment about the specific situation; however, examples of possible questions include:

3. Who in your family do you talk to about your body changes and about sex information? How do these talks go? Do you think you get enough information? What about sex education classes at school? Is there a teacher, a nurse or doctor, a minister, a counsellor to whom you can talk?

Often girls your age have questions about sexual activity. Do you have questions? Are you going out with someone?

Do you and your boyfriend have intercourse? Are you using condoms? What kind of protection did you use the last time you had sex? Avoid the term ‘sexually active’, which is ambiguous.

4. Has anyone ever talked to you about sexually transmitted infections, such as chlamydia, herpes, gonorrhoea or AIDS?

5. Questions related to suspected child abuse. See information above about your legal responsibilities regarding mandatory reporting of sexual abuse.

Where appropriate, you need to make a judgment about the specific situation; however, examples of possible questions include:

1. After menopause, have you 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?

S: Postmenopausal vaginal itching, dryness, burning sensation, dyspareunia, mucoid discharge (may be flecked with blood).

O: Pale mucosa with abraded areas that bleed easily; may have bloody discharge.

An opportunistic infection related to chronic oestrogen deficiency.

S: Intense pruritus, thick whitish discharge.

O: Vulva and vagina are erythematous and oedematous.

Discharge is usually thick, white, curdy, ‘like cottage cheese’.

Diagnose by microscopic examination of discharge on potassium hydroxide wet mount.

Predisposing causes–use of oral contraceptives or antibiotics, more alkaline vaginal pH (as with menstrual periods, postpartum, menopause), also pregnancy from increased glycogen and diabetes.

S: Pruritus, watery and often malodorous vaginal discharge, urinary frequency, terminal dysuria. Symptoms are worse during menstruation when the pH becomes optimal for the organism’s growth.

O: Vulva may be erythematous. Vagina diffusely red, granular, occasionally with red raised papules and petechiae (‘strawberry’ appearance). Frothy, yellow-green, foul-smelling discharge. Microscopic examination of saline wet mount specimen shows characteristic flagellated cells.

S: Profuse discharge, ‘constant wetness’ with ‘foul, fishy, rotten’ odour.

O: Thin, creamy, grey-white, malodorous discharge. No inflammation on vaginal wall or cervix because this is a surface parasite. Microscopic view of saline wet mount specimen shows typical ‘clue cells’.

S: (Mimics gonorrhoea.) Three of four infected women have no symptoms. May have urinary frequency, dysuria or vaginal discharge, postcoital bleeding.

O: May have yellow or green mucopurulent discharge, friable cervix, cervical motion tenderness. Signs are subtle, easily mistaken for gonorrhoea. The two are important to distinguish because antibiotic treatment is different; if the wrong drug is given or if the condition is untreated, chlamydia can ascend the reproductive tract to cause pelvic inflammatory disease (PID), and result in infertility.

S: Variable: vaginal discharge, dysuria, abnormal uterine bleeding, abscess in Bartholin’s or Skene’s glands; the majority of cases are asymptomatic.

O: Often no signs are apparent. May have purulent vaginal discharge. Diagnose by positive culture of organism. If the condition is untreated, it may progress to acute salpingitis, pelvic inflammatory disease (PID).

Gloves

Goose-necked lamp with a strong light

• Skin colour (Fig 25.3).

• Hair distribution is in the usual female pattern of inverted triangle, although it normally may trail up the abdomen towards the umbilicus.

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.

• Labia majora normally are symmetrical, plump and well formed. In the nulliparous (woman who has never had a baby) woman, labia meet in the midline; after a vaginal delivery, the labia are usually gaping and slightly shrivelled.

• No lesions should be present, except for occasional sebaceous cysts. These are yellowish, 1-cm nodules that are firm, nontender and often multiple.

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

• Clitoris (Fig 25.4).

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

• Urethral opening appears stellate or slit-like 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 Ch 20 for assessment). If this is the extent of the examination you need to perform, make sure that you give the woman some tissues to clean herself and allow time for her to redress before completing the assessment.

• Infant—place on examination table.

• Toddler/preschooler—place on parent’s lap.

Frog-leg position—hips flexed, soles of feet together and up to bottom.

Preschool child may want to separate her own labia.

No drapes—the young girl wants to see what you are doing.

• School-age child—place on examination table, frog-leg position, no drapes.

During childhood, a routine screening is limited to inspection of the external genitalia to determine that (1) the structures are intact, (2) the vagina is present and (3) the hymen is patent.

Ambiguous genitalia are rare but are suggested by a markedly enlarged clitoris, fusion of the labia (resembling scrotum), and palpable mass in fused labia (resembling testes) (see Table 25.8).

Imperforate hymen warrants referral.

Poor perineal hygiene.

Excoriations.

During and after toddler age, foul-smelling discharge occurs with lodging of foreign body, pinworms or infection.

Absence of pubic hair by 13 years indicates delayed puberty.

Amenorrhoea in adolescent, together with bluish and bulging hymen, indicates imperforate hymen and warrants referral.

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 localised 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, oedema. 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.

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-coloured, soft, pointed, moist, warty papules.

Single or multiple in a cauliflowerlike 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.

A strong association of HPV infection and abnormal cervical cytology exists.

S: Local pain, can be severe.

O: Overlying skin red and hot. Posterior part of labia swollen; palpable fluctuant mass and tenderness. Mucosa shows red spot at site of duct opening; can express purulent discharge. Often secondary to gonococcal infection.

S: Dysuria.

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, haematuria, dyspareunia or asymptomatic.

O: Small, deep red mass protruding from meatus; usually secondary to urethritis or skenitis; lesion may bleed on contact.

In addition to the equipment listed previously you will require:

Vaginal speculum of appropriate size (Fig 25.6)

Materials for cytological study–this is dependent on the preference of the laboratory. Make yourself familiar with the equipment and how to collect, prepare and transport the specimen.

Specimen containers for specific STI cultures if needed

Lubricant jelly

In addition to the detailed inspection described previously, you may need to assess for pelvic organ prolapse and stress incontinence. While observing the perineum, ask the woman to cough and note any loss of urine when coughing. Observe for any sign of bulging of the vaginal walls at the introitus and bulging of the urethral meatus.

There should be no prolapse of the vaginal walls and no urine loss during coughing.

Loss of urine when coughing is an indicator of stress incontinence.

Bulging of the anterior vaginal wall is termed a cystocele where the pelvic musculature fails to support the bladder and it falls posteriorly into the vagina. This can cause voiding dysfunction and incontinence. Similarly, a bulge in the posterior vaginal wall is termed a rectocele. A rectocele can cause defecatory dysfunction and can contribute to constipation.

Any degree of pelvic organ prolapse should be referred to a medical practitioner for further assessment.

Tenderness.

Induration along urethra.

Urethral discharge.

Swelling (see Table 25.2).

Induration.

Pain with palpation.

Erythema around or discharge from duct opening.

Tenderness.

Paper-thin perineum.

Tenderness.

Descent of cervix into vagina.

Anterior or posterior prolapse.

• Establish a baseline of neuromuscular function and contractility of the pelvic floor muscles;

• Assess the woman’s ability to identify isolate, contract and relax the pelvic floor muscles (Gray and Moore, 2009).

The Oxford grading system is used to quantify pelvic floor muscle strength:

0 = nil

1 = flicker

2 = weak

3 = moderate

4 = good

5 = strong

• Assess the duration of the contraction (in seconds)—normally 36 seconds

• Number of contractions that can be performed before the muscle fatigues

• Assess how fast the woman can contract the muscles. Make sure that you allow the woman to rest the muscles for a few seconds between contractions.

• Assess extent of muscle movement. Normally the contraction should lift the examiner’s fingers upwards. Note the evenness of the contraction (anterior-posterior, circumferential) (Dolman, 2007; Gray and Moore, 2009; Neuman and Laycock, 2008)

• Colour. Normally the cervical mucosa is pink and even. During the 2nd month of pregnancy it looks blue (Chadwick’s 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.

• 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 (Fig 25.12).

• Surface. This is normally smooth, but cervical eversion, or ectropion, may occur normally after vaginal deliveries. 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.

Surface reddened, granular and asymmetrical, particularly around os.

Friable, bleeds easily.

Any lesions: white patch on cervix; strawberry spot.

Refer any suspicious red, white or pigmented lesion for biopsy (see erosion, ulceration and carcinoma, Table 25.4).

• 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 odourless and nonirritating.

The Papanicolaou, or Pap, smear screens for cervical cancer. Do not obtain during the woman’s menses or if a heavy infectious discharge is present. Instruct the woman not to 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. Laboratories may vary in method, but usually the test consists of three specimens:

Vaginal pool. Gently rub the blunt end of an Ayre spatula (or cervical brush depending on the equipment required by the particular laboratory) over the vaginal wall under and lateral to the cervix (Fig 25.13). Wipe the specimen on a slide and spray with fixative immediately. If the mucosa is very dry (as in a postmenopausal woman), moisten a sterile swab with normal saline solution to collect this specimen.

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.

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

Immediately spray the slides with fixative. The frosted ends of the slides should be labelled with the woman’s name. Send these 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, with estimated date of delivery

• Known infections

• Prior surgery or radiation

• Prior abnormal cytology

• Abnormal findings on physical examination

Inflammation or lesions.

Leucoplakia, appears as spot of dried white paint.

Vaginal discharge: thick, white and curd-like with candidiasis; profuse, watery, grey-green and frothy with trichomoniasis; or any grey, green-yellow, white or foul-smelling discharge (see Table 25.5).

Nodule.

Tenderness.

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

Hard with malignancy.

Nodular.

• Contour—evenly rounded.

• Mobility—With a finger on either side, move the cervix gently from side to side. Normally, this produces no pain (Fig 25.18).

Enlarged uterus (see Table 25.6).

Lateral displacement.

Nodular mass. Irregular, asymmetrical uterus.

Fixed and immobile.

Tenderness.

Enlarged adnexa. Nodules or mass in adnexa.

Immobile.

Markedly tender (see Table 25.7).

Pulsation or palpable fallopian tube suggests ectopic pregnancy; this warrants immediate referral.

A note of caution—normal adnexal structures are often 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 odourless.

Following the examination make sure that you give the woman some tissues to clean herself and allow time for her to redress before completing the assessment.

For advanced practice: Perform pelvic examination when contraception is desired, when the girl’s sexual activity includes intercourse. Start periodic Pap smears when intercourse begins. Although the techniques of the examination are listed in the adult section, you will need to provide additional time and psychological support for the adolescent having her first pelvic examination.

The experience of the first pelvic examination determines how the adolescent will approach future care. Your accepting attitude and gentle, unhurried approach are important. You have a unique teaching opportunity here. Take the time to teach, using the girl’s own body as illustration. Your frank discussion of anatomy and sexual behaviour communicates that these topics are acceptable to discuss and not taboo with healthcare providers. This affirms the girl’s self-concept.

Depending on the week of gestation of the pregnancy, inspection shows the enlarging abdomen (see Fig. 28.1). The height of the fundus ascends gradually as the fetus grows. At 16 weeks, the fundus is palpable halfway between the symphysis and umbilicus; at 20 weeks, at the lower edge of the umbilicus; at 28 weeks, halfway between the umbilicus and the xiphoid; and at 34 to 36 weeks, almost to the xiphoid. Then, close to term, the fundus drops as the fetal head engages in the pelvis.

The external genitalia show hyperaemia of the perineum and vulva because of increased vascularity. Varicose veins may be visible in the labia or legs. Haemorrhoids may show around the anus. Both are caused by interruption in venous return from the pressure of the fetus.

Internally, the walls of the vagina appear violet or blue (Chadwick’s sign) because of hyperaemia. The vaginal walls are deeply rugated and the vaginal mucosa thickens. The cervix looks blue, feels velvety and feels softer than in the nonpregnant state, making it a bit more difficult to differentiate from the vaginal walls.

During bimanual examination, the isthmus of the uterus feels softer and is more easily compressed between your two hands (Hegar’s sign). The fundus balloons between your two hands; it feels connected to, but distinct from, the cervix because the isthmus is so soft.

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

Vaginal atrophy increases the risk of infection and trauma.

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.

Prior surgery for hysterectomy does not preclude the need for routine gynaecological care, including the Pap smear. The Pap smear can help detect gynaecological malignancies even when the cervix has been removed. 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.

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.

S: Prenatal exposure to DES causes cervical and vaginal abnormalities.

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, ‘cocks-comb’ formation. Warrants frequent monitoring.

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 diseases.

Obviously a normal condition, pregnancy is included here for comparison.

S: Amenorrhoea, fatigue, breast engorgement, nausea, change in food tolerance, weight gain.

O: Early signs: cyanosis of vaginal mucosa and cervix (Chadwick’s sign). Palpation–soft consistency of cervix, enlarging uterus with compressible fundus and isthmus (Hegar’s sign at 10 to 12 weeks).

S: Varies, depending on size and location. Often no symptoms. When symptoms do occur, include vague discomfort, bloating, heaviness, pelvic pressure, dyspareunia, urinary frequency, backache or hypermenorrhoea if myoma disturbs endometrium. Heavy bleeding produces anaemia.

O: Uterus irregularly enlarged, firm, mobile and nodular with hard, painless nodules in the uterine wall.

They are usually benign. Highest incidence between the ages of 30 and 45 years and in African Americans. Myomas are oestrogen dependent; after menopause, the lesions usually regress but do not disappear. Surgery may be indicated.

S: Abnormal and intermenstrual bleeding before menopause; postmenopausal bleeding or mucosanguineous discharge. Pain and weight loss occur late in the disease.

O: Uterus may be enlarged.

The Pap smear is rarely effective in detecting endometrial cancer. Women with abnormal vaginal bleeding or at high risk should have an endometrial tissue sample. Risk factors for endometrial cancer are early menarche, late menopause, history of infertility, failure to ovulate, tamoxifen, unopposed oestrogen therapy (which continually stimulates the endometrium, causing hyperplasia) and obesity (which increases endogenous oestrogen).

S: Cyclic or chronic pelvic pain, occurring as dysmenorrhoea or dyspareunia, low backache. Also may have irregular uterine bleeding or hypermenorrhoea or may be asymptomatic.

O: Uterus fixed, tender to movement. Small, firm nodular masses tender to palpation on posterior aspect of fundus, uterosacral ligaments, ovaries, sigmoid colon. Ovaries often enlarged. Masses are aberrant growths of endometrial tissue scattered throughout pelvis as a result of transplantation of tissue by retrograde menstruation. Ectopic tissue responds to hormone stimulation; builds up between periods, sloughs during menstruation. May cause infertility from pelvic adhesions, tubal obstruction, decreased ovarian function.

S: Sudden fever >38°C, suprapubic pain and tenderness.

O: Acute-rigid board-like lower abdominal musculature. May have purulent discharge from cervix. Movement of uterus and cervix causes intense pain. Pain in lateral fornices and adnexa. Bilateral adnexal masses difficult to palpate because of pain and muscle spasm. Chronic–bilateral, tender, fixed adnexal masses. Complications include ectopic pregnancy, infertility and reinfection. PID usually caused by Neisseria gonorrhoeae and Chlamydia trachomatis.

S: Amenorrhoea or irregular vaginal bleeding, pelvic pain.

O: Softening of cervix and fundus; movement of cervix and uterus causes pain; palpable tender pelvic mass, which is solid, mobile, unilateral.

This has potential for serious sequelae; seek gynaecological consultation immediately before the mass ruptures or shows signs of acute peritonitis.

S: Usually asymptomatic.

O: Smooth, round, fluctuant, mobile, nontender mass on ovary. Some cysts resolve spontaneously within 60 days but must be followed closely.

S: Usually asymptomatic. May have abdominal enlargement from fluid accumulation.

O: Solid tumour palpated on ovary. Heavy, solid, fixed, poorly defined mass suggests malignancy; benign mass may feel mobile and solid.

Biopsy necessary to distinguish the two types of masses. The Pap smear does not detect ovarian cancer. Women over age 40 years should have a thorough pelvic examination every year.

S: Feeling of pressure in vagina, stress incontinence.

O: With straining or standing, note introitus widening and the presence of a soft, round anterior bulge. The bladder, covered by vaginal mucosa, prolapses into vagina, in this case with an extreme uterine prolapse.

S: Feeling of pressure in vagina, possibly constipation.

O: With straining or standing, 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.