GENITOURINARY MEDICINE
Bimanual + Speculum Examination
1. “Today I examined Mrs Smith, a 28-year-old female who verbally consented for a bimanual + speculum exam. On general inspection, patient was comfortable at rest.
2. Vulva and vaginal inspection found no abnormalities (scars, redness, ulcers, masses, discharge, rash)
3. Cervix appeared (1) closed/open, (2) soft/firm, (3) short/long
4. Bimanual vaginal exam revealed no masses + speculum examination revealed a healthy cervix with closed external os (? Mass, ?bleed, ?ulcers, ? discharge?)
5. In summary, these findings are consistent with a normal speculum examination, cervical entropion/cancer, STI,
• Gain consent ® explain rationale + guide throughout entire process (will only take a few mins)
Introduction • Will have a chaperone with me
• Close curtain (allow for privacy) + allow to get undressed
• Don pair of sterile gloves
• Bum @ edge of bed
Positioning
• Modified lithotomy position ® Bring heels towards bottom and allow knees to fall to the side ® are there stirrups?
critical
o Get one knee to touch one side of the wall and the other leg to lie as flat as possible
• Put hands underneath her bum OR (If cannula on hand) è Roll up towel and place under bum to prop it up
• Check for any masses in between:
o endometriosis?,
o uterine fibroids?
o Cystic
Bimanual
o Pregnancy?
exam
• Ante-verted – above cervix (uterus felt anteriorly)
• Retroverted – below cervix (uterus felt posteriorly)
Cystic swelling:
1) Congenital cysts (wolffian
duct remnant) =
anterolateral
2) Vaginal inclusion cyst
(episiotomy scars)
3) Solid benign tumours
(myoma, papilloma,
adenomyoma)
Cause Smell Itchy Inflamed Key Features Rx
Bacterial Gardenella, Thin profuse fishy • inflamed vaginal • Metronidazole(400mg)
vaginosis mycoplasma, smelling No No mucosa
VULVA • Clindamycin (300mg)
(non-STI) haemophilus discharge • Wet prep = clue cells
Inspection
• Dyspareunia
Candidiasis Curd-like non • DM
C. albicans Yes Yes Fluconazole (150mg)
(non-STI) offensive charge • KOH prep =
psuedohyphae
Multi-sex
Doxycycline (chlamydia)
C+G partners Symptomatic + Post-coital bleed,
No Cef PLUS azithro
(STI) UNPROTECTED purulent dyspareunia (PID)
(Gonorrhea)
sex
strawberry cervix
Trichomoniasis Flagellated Smelly yellow- Metronidazole (500mg)
Yes Yes wet prep (trichomoniasis
(STI) protozoa green frothy “flagyl”
flagella)
Bartholin’s cyst Lichen sclerosis Vaginal Candidiasis Vaginal Prolapse
• Bartholin’s glands (4 + 8 o’clock) secrete • Chronic itchy + inflamed Chronic itchy moist curd-like lesions that Asking patient to cough ®
to maintain moist vagina white patches in anogenital cannot be scraped off exacerbate the lump
• Glands may become blocked/infected area
® cysts (unilateral fluctuant mass +/- • DDx: psoriasis (itchy, red and
tender) not well-demarcated plaques)
Itchy Vulva Red flags:
• Lichen sclerosis (thinner skin) • Female genital mutilation (FGM) = partial or total removal of external
female genitalia e.g. clitoris, labia, narrowed vaginal introitus for non-
• Vulva vestibulitis (painful) medical reasons ® FGM cases in girls < 18 need to be reported to police
• Vulva leukoplakia (precancer mucosal membrane) • Ulcers (HSV)
• Chronic lichen simplex • Scarring (PREVIOUS surgery e.g. episiotomy or lichen sclerosis)
Rx: refer to dermatologist if any signs of lichen sclerosis or ulceration • Vaginal atrophy (post-menopausal women)
, STEP 1: PALPATE ABDOMEN + WARM SPECULUM
1. Warn patient that your are going to insert the speculum – double check it is ok ® obtain 2nd consent
2. Lubricate speculum
3. Left hand (index, finger + thumb) separates labia
Inserting the
4. Insert speculum SIDEWAYS (BLADE CLOSED, angled DOWNWARDS ® down deep) - rest on forchette
speculum
5. ROTATE speculum back 90o so handle is facing upwards ® BEWARE OF PUBIC HAIR (GO STRAIGHT IN)- rest on forchette
6. OPEN SPECULUM blades until optimal view of cervix achieved
7. TIGHTEN LOCKING NUT to fix position
Cervical cancer
Cervical ectropion • Persistent HPV infection ® causing
• Metaplasia of columnar dysplasia (i.e . cervical intra-
epithelial cells found epithelial neoplasia -CIN)
outside of vaginal • Often asymptomatic but may
cervix (usu. Squamous). present w/ IMB, post-coital bleed,
• Red areas = columnar cells increased vaginal
+ higher bleeding risk discharge/discomfort
(more vascular) + post- • Early stage: White/red patches on
coital bleed cervix
• Pink areas = normal cervix • Advanced stage: cervical ulcer,
tumour
1. Cervical os
a. if open? ® may indicate incomplete miscarriage
b. Erosions around os ® ectropion, early cervical cancer
2. Cervical masses
3. Ulceration – genital herpes (HSV)
4. Abnormal discharge
Swabbing guidelines (NAAT = snapping swab vs charcoal swab)
1. Double swabs (NAAT (endocervical or vulvovaginal) + high
vaginal charcoal
2. Triple swab NAAT (endocervical or vulvovaginal) + high vaginal
Visualising the charcoal + endocervical charcoal
cervix
+ pap smear Endocervical - gently Vulvovaginal - swab Method
swab cervical os posterior fornix
NAAT Swab C+G Rotate for 10-15 s ® open NAAT tube ® place swab in
(snap) NAAT test tube (snap off at black) ® seal tube + label
Charcoal media M/C/S for High vaginal = Remove swab from tube ® passby speculum ® swab
(neutralises bact. Toxins gonorrhoea (only bacterial vaginosis, posterior fornix ® rotate 10-15s
and inhibitory after +ve NAAT) syphilis, candida, GBS Unlike NAAT (charcoal swab give sensitivities) ®
substance to prolong needed to guide ABx choice
viability or pathogens)
Blue smear Cervical cancer TWIRL repeatedly ® there will be bleeding (warn
woman to have extra pads)
1. LOOSEN locking nut + PARTIALLY close blades
ADDITIONAL THINGS TO DO
2. ROTATE speculum 90O back to original insertion orientation
Removing • Bimanual exam to check for any adnexal masses
3. REMOVE speculum + INSPECT vaginal walls while exiting • Cervical motion tenderness ® PID, peritonitis
speculum
4. COVER patient with sheet ® Close curtain ® Allow patient to redress
5. Dispose equipment into clinical waste bin
Bimanual + Speculum Examination
1. “Today I examined Mrs Smith, a 28-year-old female who verbally consented for a bimanual + speculum exam. On general inspection, patient was comfortable at rest.
2. Vulva and vaginal inspection found no abnormalities (scars, redness, ulcers, masses, discharge, rash)
3. Cervix appeared (1) closed/open, (2) soft/firm, (3) short/long
4. Bimanual vaginal exam revealed no masses + speculum examination revealed a healthy cervix with closed external os (? Mass, ?bleed, ?ulcers, ? discharge?)
5. In summary, these findings are consistent with a normal speculum examination, cervical entropion/cancer, STI,
• Gain consent ® explain rationale + guide throughout entire process (will only take a few mins)
Introduction • Will have a chaperone with me
• Close curtain (allow for privacy) + allow to get undressed
• Don pair of sterile gloves
• Bum @ edge of bed
Positioning
• Modified lithotomy position ® Bring heels towards bottom and allow knees to fall to the side ® are there stirrups?
critical
o Get one knee to touch one side of the wall and the other leg to lie as flat as possible
• Put hands underneath her bum OR (If cannula on hand) è Roll up towel and place under bum to prop it up
• Check for any masses in between:
o endometriosis?,
o uterine fibroids?
o Cystic
Bimanual
o Pregnancy?
exam
• Ante-verted – above cervix (uterus felt anteriorly)
• Retroverted – below cervix (uterus felt posteriorly)
Cystic swelling:
1) Congenital cysts (wolffian
duct remnant) =
anterolateral
2) Vaginal inclusion cyst
(episiotomy scars)
3) Solid benign tumours
(myoma, papilloma,
adenomyoma)
Cause Smell Itchy Inflamed Key Features Rx
Bacterial Gardenella, Thin profuse fishy • inflamed vaginal • Metronidazole(400mg)
vaginosis mycoplasma, smelling No No mucosa
VULVA • Clindamycin (300mg)
(non-STI) haemophilus discharge • Wet prep = clue cells
Inspection
• Dyspareunia
Candidiasis Curd-like non • DM
C. albicans Yes Yes Fluconazole (150mg)
(non-STI) offensive charge • KOH prep =
psuedohyphae
Multi-sex
Doxycycline (chlamydia)
C+G partners Symptomatic + Post-coital bleed,
No Cef PLUS azithro
(STI) UNPROTECTED purulent dyspareunia (PID)
(Gonorrhea)
sex
strawberry cervix
Trichomoniasis Flagellated Smelly yellow- Metronidazole (500mg)
Yes Yes wet prep (trichomoniasis
(STI) protozoa green frothy “flagyl”
flagella)
Bartholin’s cyst Lichen sclerosis Vaginal Candidiasis Vaginal Prolapse
• Bartholin’s glands (4 + 8 o’clock) secrete • Chronic itchy + inflamed Chronic itchy moist curd-like lesions that Asking patient to cough ®
to maintain moist vagina white patches in anogenital cannot be scraped off exacerbate the lump
• Glands may become blocked/infected area
® cysts (unilateral fluctuant mass +/- • DDx: psoriasis (itchy, red and
tender) not well-demarcated plaques)
Itchy Vulva Red flags:
• Lichen sclerosis (thinner skin) • Female genital mutilation (FGM) = partial or total removal of external
female genitalia e.g. clitoris, labia, narrowed vaginal introitus for non-
• Vulva vestibulitis (painful) medical reasons ® FGM cases in girls < 18 need to be reported to police
• Vulva leukoplakia (precancer mucosal membrane) • Ulcers (HSV)
• Chronic lichen simplex • Scarring (PREVIOUS surgery e.g. episiotomy or lichen sclerosis)
Rx: refer to dermatologist if any signs of lichen sclerosis or ulceration • Vaginal atrophy (post-menopausal women)
, STEP 1: PALPATE ABDOMEN + WARM SPECULUM
1. Warn patient that your are going to insert the speculum – double check it is ok ® obtain 2nd consent
2. Lubricate speculum
3. Left hand (index, finger + thumb) separates labia
Inserting the
4. Insert speculum SIDEWAYS (BLADE CLOSED, angled DOWNWARDS ® down deep) - rest on forchette
speculum
5. ROTATE speculum back 90o so handle is facing upwards ® BEWARE OF PUBIC HAIR (GO STRAIGHT IN)- rest on forchette
6. OPEN SPECULUM blades until optimal view of cervix achieved
7. TIGHTEN LOCKING NUT to fix position
Cervical cancer
Cervical ectropion • Persistent HPV infection ® causing
• Metaplasia of columnar dysplasia (i.e . cervical intra-
epithelial cells found epithelial neoplasia -CIN)
outside of vaginal • Often asymptomatic but may
cervix (usu. Squamous). present w/ IMB, post-coital bleed,
• Red areas = columnar cells increased vaginal
+ higher bleeding risk discharge/discomfort
(more vascular) + post- • Early stage: White/red patches on
coital bleed cervix
• Pink areas = normal cervix • Advanced stage: cervical ulcer,
tumour
1. Cervical os
a. if open? ® may indicate incomplete miscarriage
b. Erosions around os ® ectropion, early cervical cancer
2. Cervical masses
3. Ulceration – genital herpes (HSV)
4. Abnormal discharge
Swabbing guidelines (NAAT = snapping swab vs charcoal swab)
1. Double swabs (NAAT (endocervical or vulvovaginal) + high
vaginal charcoal
2. Triple swab NAAT (endocervical or vulvovaginal) + high vaginal
Visualising the charcoal + endocervical charcoal
cervix
+ pap smear Endocervical - gently Vulvovaginal - swab Method
swab cervical os posterior fornix
NAAT Swab C+G Rotate for 10-15 s ® open NAAT tube ® place swab in
(snap) NAAT test tube (snap off at black) ® seal tube + label
Charcoal media M/C/S for High vaginal = Remove swab from tube ® passby speculum ® swab
(neutralises bact. Toxins gonorrhoea (only bacterial vaginosis, posterior fornix ® rotate 10-15s
and inhibitory after +ve NAAT) syphilis, candida, GBS Unlike NAAT (charcoal swab give sensitivities) ®
substance to prolong needed to guide ABx choice
viability or pathogens)
Blue smear Cervical cancer TWIRL repeatedly ® there will be bleeding (warn
woman to have extra pads)
1. LOOSEN locking nut + PARTIALLY close blades
ADDITIONAL THINGS TO DO
2. ROTATE speculum 90O back to original insertion orientation
Removing • Bimanual exam to check for any adnexal masses
3. REMOVE speculum + INSPECT vaginal walls while exiting • Cervical motion tenderness ® PID, peritonitis
speculum
4. COVER patient with sheet ® Close curtain ® Allow patient to redress
5. Dispose equipment into clinical waste bin
