THE

GYNAECOLOGICA
L EXAMINATION
 CONTEN
TS
• Introduction
• General examination
• Chest examination- heart, lungs and breast
examination
• Abdominal examination
• Pelvic examination - Digital and
speculum examination
 INTRODUCTI
ON
• Gynaecological examination confirms presence of
pathology suspected from the gynaecological history.
• Always explain to the patient the need and the nature
of the proposed examination.
• Obtain an informed verbal consent.
• The examiner (male or female) should be accompanied
by another female (chaperone).
• Examination performed in a private setting, respecting
patient's privacy at all times.
• Patient should be covered at all times and only
relevant parts of her anatomy exposed.
 GENERAL
• EXAMINATION
Observe general appearance, state of nutrition, gait,
demeanour, level of consciousness, responsiveness
etc.
•
Height and weight - BMI
•
Hands and arms- assess tobacco-stained fingers,
clubbing, pulse, blood pressure, temperature.
• Head and neck- facial hair distribution (also other
secondary sexual development and hair distribution),
anaemia, jaundice, cyanosis, acne, lymphadenopathy,
thyroid disease (enlarged thyroid gland, tremor etc)
Legs - ankle swelling
•
 CHEST
EXAMINATION
• Assess the heart and lungs for signs of disease
 BREAST
EXAMINATION
Position patient reclining at 45 degrees with
arms at the sides
Inspection – positions at rest, arms above head, on
hips
1) Development and symmetry of breasts and
nipples.
2) Reddening of skin, ulceration or dimpling (peau
d'orange)
3) Retraction of nipple (CA breast)
4) Nipple discharge- blood, serous or milky
Palpation- palpate systematically for lumps with the flat part of the
fingers, through all 4 quadrants. If present, describe the
characteristics of the lump- location, size, shape, surface, edge,
consistency and mobility in relation to deep and superficial structures.
Palpate the axillae for lymph nodes – describe if present.
 ABDOMINAL
EXAMINATION
Ensure patient lying supine, with a pillow for head rest, arms
by the sides and bladder emptied.

••Inspection: Assess for distension, scars (operative,

traumatic or scarification), distended veins, striae, pubic
hair distribution.
Palpation: Palpate the abdomen systematically in all 9
regions
1) Superficial palpation- assess for tenderness, guarding and
rebound tenderness
2) Deep palpation- assess any enlargement of intra-abdominal
organs (uterus, liver, spleen etc) and for any abnormal
masses.
•
•
Describe any abnormal mass in terms of:
Size, shape
Position- e.g central arising out of the pelvis, or left iliac fossa
Mobility- e.g can it move from side-to-side and up-and-down or is it fixed to
surrounding structures?
Surface - e.g smooth or nodular
Consistency - e.g solid or cystic
Tenderness (pain on palpation)

Percussion: Assess for ascites using shifting dullness and fluid thrill
Auscultation: Listen for bowel sounds or for foetal heart rate in pregnancy
 PELVIC
•
EXAMINATION
Bear in mind the comments on
privacy, respect and a female
chaperone before this examination
is performed.
• Best performed with patient supine
in the lithotomy position (legs up in
stirrups) and examiner working from
• the foot of the bed.
The examination can also be done
on an examination couch with
patient supine, knees and hips
flexed, hips abducted and feet
together .The examiner stands on
• the patient's right side.
A good and adjustable light source
needed for inspection of the vulva
• and for the speculum examination.
Examiner to wear gloves.
 PELVIC
EXAMINATION
• Inspection and palpation of the vulva

• Speculum examination

• Bimanual digital
examination
 INSPECTION AND
PALPATION OF
VULVA
Assess all structures from anterior to posterior:
1) Mons pubis- Describe pubic hair
distribution Female pattern-upside-down
triangle
Male pattern- diamond shaped
Look for skin lesions, discolouration, excoriation, lice,
ulcers and abscesses
2) Labia majora - lateral to the introitus (opening of vagina),
covered with pubic hair. They meet anteriorly as the mons
pubis.
As above.
FEMALE EXTERNAL
GENITALIA
 INSPECTION AND
PALPATION OF
VULVA
3) Labia minora- Medial to labia majora with no
pubic hair covering. They meet anteriorly to
cover the clitoris.
Palpate deep to the labia for enlargement of the
Bartholin's gland.
4) The perineum - area between the fourchette
and the anus (The labia minora meet posteriorly
at the fourchette.)
Inspect for lesions, scars, old third degree
perineal tears.
 INSPECTION AND
PALPATION OF
VULVA
5) The introitus - Separate the labia minora to expose
the introitus, or vaginal opening.
•Examine from anterior to posterior
• Inspect the clitoris ( size, trauma, ulcers)

• External urethral meatus (discharge, prolapse) and

2 paraurethral gland openings at 3 and 9 o'clock.
Remnants of the hymenal
•
ring below. Vaginal canal -
Vaginal mucosa
•
Well-oestrogenised - pink colour, thick texture and
rugae (folds) present. Poorly oestrogenised - thin,
pale colour and absent rugae

Vaginal discharge- colour, texture, odour

Older women- ask to cough to demonstrate urinary
incontinence or utero-vaginal prolapse
 SPECULUM
EXAMINATION
• Inform patient that the
speculum will be passed to
visualize the vaginal canal
and the cervix.
• A sterile
duck-billed/bivalve Cusco
speculum checked to
• ensure in working order.
Speculum assembled with
blades in closed position and
lock mechanism fully
• loosened.
Speculum should be
lubricated with KY jelly
or lukewarm water
before insertion (Note
Pap)
 TECHNIQUE OF SPECULUM
•INSERTION
Inform patient and ask her to gently bear down while speculum is
passed, to relax the levator ani muscles.
• The labia are separated with the index finger and thumb of left hand.
• The lubricated closed speculum (correct size) is inserted through the
introitus into the vaginal canal in one of the following ways:
Nulliparous, young woman: closed speculum blades inserted vertically
with speculum handles on patients right side. Rotate through 45 degrees,
bringing the speculum handles to the posterior position if using
lithotomy position, or the anterior position if using the examination
couch.
Multiparous women: The introitus is more patulous as they have given
birth previously. The speculum may be inserted without any rotation i.e.
closed blades are horizontal with speculum handles pointing posteriorly
in the lithotomy position or anteriorly if using the examination couch.
 SPECULUM
EXAMINATION
1) Visualisation of the cervix

• The full length of speculum is inserted up the

length of the vaginal canal. Pushing the handles
together opens the blades of the speculum
which is manoeuvered so that the cervix is fully
visualized.
• The screw adjuster on the handle is then
locked so that the speculum is maintained in
place.
• The cervix is then inspected.
SPECULUM EXAMINATION – NOTE THAT
SPECULUM IN ILLUSTRATION IS
NOT A CUSCO….
Inspect the cervix:
Type of cervical os- small round
dimple (nulliparous os) or os in the
shape of a smile (multiparous os)
Colour- normally pink, may be a
redder area around the os, known as
cervical ectropion, or tinged blue if
pregnant, red in cervicitis
Secretions/ discharge - observe
colour (eg cervical mucus if
ovulating, blood if menstruating)
Presence of growths/ tumours-
usually cauliflower-like and friable,
i.e. bleeds on touch ( indicates
malignancy)
Ulcerations, scars and retention
cysts (Nabothian follicles)
The cervical smear/“Pap" smear is
taken at this stage
 SPECULUM
EXAMINATION
Papanicolau/“Pap" smear:
Indications:
Cervical cancer screening-
Within 5years of becoming sexually active Annually
in high-risk groups such as patients
with recurrent STI's and HIV
Post-coital bleeding
Postmenopausal bleeding 1st
trimester of pregnancy

Additional equipment required

- Ayres spatula or an endocervical
brush eg Craigbrush
- Swabs
- Fixative spray
- Two glass slides labeled with
patient's name
 PAP
Procedure (Pap smear): SMEAR
• Gently clean discharge or blood from • Within 20 seconds of taking it,
the cervix, if present, with a cotton apply the smear onto the glass
swab.
slide with a light sweeping
•Insert the spatula with the motions. Spray immediately with
endocervical tip ( the longest part), one spray of fixative, holding the
into the endocervical canal and turn
spray bottle upright at about 30cm
360 degrees. This allows removal of
from the slide, to prevent drying
the surface cells from the whole of • and decay of the cells.
the squamocolumnar junction. Apply
the smear onto the slide – 2 strokes. Complete the pathology request
The Craigbrush is superior to the form, recording any findings about
spatula if the transition zone is high the appearance of the cervix and
•and you cannot see it. Turn it gently • send the smear to the laboratory.
in five complete circles and apply It is crucial to contact the patient
the smear to the slide in gentle with the results, hence ensure her
strokes. address and contact tel. nos are
complete and correct.
PAP SMEAR – THIS IS NOT AN
AYRE’S SPATULA…
 SPECULUM
EXAMINATION
2) Inspecting the vagina

• With the speculum in this position, inspect the vaginal side-

walls for any ulcers, discolouration, discharge or growths.
• The handles of the speculum are then unlocked and the
blades allowed to close but not completely, leaving a 1cm
gap between the tips.
•
Withdraw the speculum gently whilst inspecting the
anterior and posterior walls of the vagina, again looking for
• any ulcers, discolouration, discharge or growths.
The speculum is placed in a bowl with disinfectant, for
later cleaning and re-sterilization (autoclave).
 BIMANUAL DIGITAL
EXAMINATION
• Explain every step to the patient and reassure her -inform
her that an internal examination is to be performed.
• The labia are gently parted with the gloved index finger
and thumb of the left hand.
• Initially the lubricated index finger of the examiner's right
hand is inserted through the introitus into the vaginal
canal.
• If patient is comfortable with this, the lubricated middle
finger of the same hand is also inserted. If not, due to pain,
a limited bimanual examination with one finger can be
performed.
•
The full length of the finger is introduced, assessing the
vaginal walls in transit until the cervix is located.
 BIMANUAL DIGITAL
EXAMINATION
1) Assessing the cervix:
Vaginal fingers locate the cervix and the external
cervical os:
- Determine whether it is open or closed
Determine the length of the cervix
- Directed posteriorly when the uterus is
- anteverted
Consistency usually firm when normal, but
- hard due to fibrosis or carcinoma, and soft
in pregnancy
Gently and minimally move the cervix from
- side-to-side while watching patient's face to
ascertain whether this is painful = cervical
excitation tenderness - positive in the
presence of pelvic inflammation and ectopic
pregnancy.
 BIMANUAL DIGITAL
2)
EXAMINATION
Assessing the uterus:
The vaginal fingers then push on or behind the
cervix to elevate the uterus upwards towards
the anterior abdominal wall, while the left
hand is placed supra-pubically to palpate the
uterus between the two hands(bimanual).

- Assess size of uterus (in gestational weeks)

- Shape (globular is almost round and smooth,
while bossellated means lumpy as in a tumour)
- Consistency (normally firm, soft in early
pregnancy, hard if a tumour present)
- Position of uterus (if anteverted it is angled/
tipped towards the ant. abdominal wall, while if
retroverted, it is angled backwards away from
the ant. abdominal wall)
Presence of any tenderness
- Mobility (mobile or fixed)
-
 BIMANUAL DIGITAL
3)EXAMINATION
Assessing the adnexae:
The vaginal fingers are now moved into one of the
lateral fornices with the abdominal hand moving to
the corresponding iliac fossa.
Assess for any adnexal masses (ovaries and
fallopian tubes) on both sides - size, shape,
tenderness, etc.
 BIMANUAL DIGITAL
EXAMINATION
4) Assessing the Pouch of Douglas
(recto-uterine pouch):
-The vaginal fingers now placed into the
posterior fornix of the vagina and its
shape is assessed (normally concave
away from the fingers, but may be
convex towards the fingers if there is a
mass in the Pouch of Douglas).

-The fingers are now removed from

the vagina.
-Clean the vulva, cover and help the
patient to sit up.
-Thank her and make her
comfortable.
RECORD YOUR FINDINGS
IN THE CHART
Vaginal examination – often abbreviated as PV (per
vaginum) or VE (vaginal examination) Describe each of
the following, plus any abnormalities noted:
1. Vulva and Vagina
2. Cervix
3. Uterus
4. Adnexae
5. Any Additional significant findings
Example – for a routine check-up may see notes recorded as follows:
PV: V&V: NAD
Cervix: Closed, non-tender, no visible abnormality (Pap taken)
Uterus: Bulky, non-tender, approximately 6 week size
Adnexae: NAD
 REFEREN
CES
• Skills protocol from Dept of Obstetrics and
Gynaecology
• Hutchison's Clinical Methods, Michael Swash
• South African Family Practice Manual,Mash
& Lindeque Google Images