Table 8: Genital Exam
| Physical Sign / Manoeuvre | Rationale | Technique(s) | Interpretation | Evidence | Pre-Clerkship | Clerkship |
|---|---|---|---|---|---|---|
| Female Genitalia | ||||||
| Inspection: External genitalia (pubic hair, labia majora, labia minora, clitoris, urethra meatus, hymen) | A variety of pathological processes may present with visible changes to external genitalia (e.g. condylomata, HSV, fungal vulvitis, Bartholin’s cyst, vulvar cancers, prolapse) | With patient in lithotomy position, appropriately draped, adequate lighting, explain procedure to patient – direct inspection, fingers may be used to spread labia to aid inspection. Inspection of anus can be performed simultaneously Male students should have a female chaperone present. All patients should be offered a chaperone. Consider particular comfort issues in patients who may have a history of sexual abuse | Be aware of range of normal human variation in external genitalia appearance. Be aware of appearance of common STIs and benign, pre-malignant and malignant skin changes. Be aware of cultural practices that may alter appearance of external genitalia. | Consensus opinion | 2 (model patient volunteer or teaching associate) | 3 (patient examined) |
| Inspection: Speculum examination(vaginal walls, cervix) | Speculum examination assists in identifying a variety of abnormalities (e.g. vaginal wall trauma, atrophy, abnormal discharge, polyps, growths, cervicitis, rectocele and cystocele), as well as being used in certain procedures (e.g. PAP smear) | Lubricate speculum with warm water. Retract labia laterally with gloved index and middle fingers. Insert closed blades of speculum in the vagina, either with blades horizontal, or vertical then rotate to horizontal once inside the introitus. Once blades inserted, angle speculum 30-45 degrees posteriorly, separate blades until cervix is viewed and lock open. | Be aware of normal age-specific appearance of vaginal walls and cervix. Be aware of common variations from normal and pathological features. | Consensus opinion – important for inspection to identify abnormalities Speculum exam essential for other evidence-based procedures (e.g PAP, other specimen collection) and IUD insertion Use of water-soluble lubricant on the outer inferior speculum blade does not affect cytology results on Pap smears Amies, 2002. Look for evidence re horizontal vs vertical | 2 (model, patient volunteer or teaching associate) | 3 (patient examined) |
| Bimanual Examination (vagina, cervix, uterus, adnexae) | Palpation assists with identifying abnormalities that may not be visible on inspection; as a component of prenatal care (e.g. gestational size) | Consistently use same hand for bimanual examination. Generally use two fingers (consider single finger in constricted vagina). Insert gloved, lubricated index and middle fingers into introitus with thumb widely abducted and 4th and 5th fingers folded into palm. Palpate vaginal wall, cervix, uterus and adnexae, with opposite hand on anterior abdominal wall simultaneously palpating same structure. Other manoeuvres may be indicated (e.g. palpation of Bartholin’s glands, base of bladder and urethra, cervical motion tenderness) | Normal size and position of pelvic structures; abnormalities of deeper pelvic structures; and as a component of prenatal care (e.g. gestational size) | Bimanual examination detects abnormalities 57-70% of the time compared to surgery – it is much more sensitive at detecting uterine masses than adnexal masses Padilla, 2005. Pelvic Examination agrees with Uls 75-92% of the time in assessing gestational age in first trimester Nichols, 2002. 87% of pre-menopausal women and 30% of post-menopausal women have palpable ovaries Granberg, 1988. | 2 (model, patient volunteer or teaching associate) | 3 (patient examined) |
| Female Clinical Breast Examination (CBE) | ||||||
| Inspection | CBE can identify both non-malignant and malignant breast changes | Usual technique is to have patient disrobe to waist and face examiner with arms at sides. Normal breasts may not be symmetrical. Left breast is commonly larger than right. | Abnormalities may be indicated by colour change, discharge, elevation of level of nipple, dimpling, bulging, dilated superficial veins and peau d’orange | Use of combined screening CBE and mammography demonstrated reduced mortality. CBE alone detected 3-45% of breast cancers found that screening mammography missed. Utility of inspection is currently unproven. In asymptomatic women, emphasis should be on palpation. In symptomatic women, careful inspection should be added to detailed palpation. No evidence for inspection with other positions ie: leaning forward all Barton, 1999. | 2 (as above) | 3 (as above) |
| Palpation of breast tissue | CBE can identify both non-malignant and malignant breast changes and palpation is the most sensitive part of this examination | Drape patient appropriately and explain examination to maximize patient comfort Patient should be lying supine. Alternate positioning may be used in large breasted women to flatten breast tissue. Use a vertical strip pattern to cover all the breast tissue, including nipple. Making circular motions, compress the breast tissue between the fingers and the chest wall, using the pads of 3 fingers to examine each breast area with 3 different pressures. Spend at least 3 minutes on each breast. | Malignant lumps are more likely to be fixed, hard, irregular and large (greater or equal to 2 cm) | Duration of palpation increases sensitivity – sensitivity 69% with 5-10 minute total exam. Vertical strip method has been validated on silicone models. Expression of discharge from nipple has not been shown to increase cancer detection. Barton, 1999. | 2 (as above) | 3 (as above) |
| Palpation of axillary, supraclavicular and infraclavicular lymph nodes | Lymph node examination is a standard part of CBE, and may detect lymphadenopathy | Using pads of the fingers of one hand, palpate the 5 groups of axillary lymph nodes and the supraclavicular abd infraclavicular nodes. Patient’s arm should be in a relaxed position. | Inspection - enlarged nodes may be visible Palpation – consider size, number, consistency, mobility, tenderness, temperature of any palpable nodes | Breast cancer was detected in a significant minority of women with abnormal axillary lymph node examinations and normal CBE Barton, 1999. | 3 | 4 |
| Male Genitalia Examination | ||||||
| Inspection (penis, scrotum, urethral meatus) | A variety of pathological processes may present with visible changes to external genitalia (e.g. STIs, balanitis, discharge, hydroceles, varicoceles, abnormal growths) | Wearing gloves, with patient appropriately draped, adequate lighting, and explaining procedure to patient. Inspect penis. In uncircumcised patient, ask patient to retract foreskin to view glans and urethral meatus. Inspect scrotal walls by spreading the layer of rugae. | Be aware of range of normal human variation in external genitalia appearance, including possible asymmetry. Be aware of appearance of common STIs and benign, pre-malignant and malignant skin changes. Be aware of cultural practices that may alter appearance of external genitalia. | Consensus opinion | 2 (model, patient volunteer or teaching associate) | 3 (patient examined) |
| Palpation (penis, scrotal contents) | A variety of pathological processes may present with palpable changes to external genitalia (e.g. malignant and non-malignant masses, infections, torsion, hormonal abnormalities) | Palpate penile shaft, compress the glans to open urethral meatus. Palpate scrotal contents in following sequence: testes, tunica vaginalis, epidydimis, spermatic cord), external ring and inguinal lymph nodes. Testes are sensitive and care should be taken to palpate gently Transillumination may be used to examine scrotal content in specific situations. Examination for hernias and prostate examination via rectal exam is described in GI. | Be aware of normal scrotal anatomy, normal variation and presentation of common and serious abnormalities, which may indicate a surgical emergency | Early detection of testicular torsion results in better outcomes: 80-100% of testes can be saved with surgery at 6 hr vs 20% at 24 hr Although commonly performed, there is no information on sensitivity, specificity or positive predictive value of the clinical testicular examination as a screening manoeuvre for testicular cancer in asymptomatic men U.S. Preventive Services Task Force Agency for Healthcare Research and Quality, 2005. | 2 (as above) | 3 (as above) |
| Rectovaginal Examination | Has been used to aid in diagnosis of upper genital tract masses or retroverted uterus | Insert gloved middle finger in rectum while simultaneously inserting index finger of same hand in vagina and palpate structures. Other hand is placed on lower abdomen and palpates pelvic structures | Posterior pelvic structures/ masses may be palpated through anterior rectal wall | Rectovaginal examination is shown to have marked limitation for detecting cul-de-sac disease even under ideal circumstances Dragisic, 2003. There may be little evidence to support routinely teaching this skill. | 1 | 1 |
References
- Amies AM, et al. The effect of vaginal speculum lubrication on the rate of unsatisfactory cervical cytology diagnosis. Obstet.Gynecol. 2002 Nov;100(5 Pt 1):889-892.
- Barton MB, et al. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA 1999 Oct 6;282(13):1270-1280.
- Dragisic KG, et al. The accuracy of the rectovaginal examination in detecting cul-de-sac disease in patients under general anaesthesia. Hum.Reprod. 2003 Aug;18(8):1712-1715.
- Granberg S, et al. A comparison between ultrasound and gynecologic examination for detection of enlarged ovaries in a group of women at risk for ovarian carcinoma. J.Ultrasound Med. 1988 Feb;7(2):59-64.
- Nichols M, et al. Comparing bimanual pelvic examination to ultrasound measurement for assessment of gestational age in the first trimester of pregnancy. J.Reprod.Med. 2002 Oct;47(10):825-828.
- Padilla LA, et al. Limitations of the pelvic examination for evaluation of the female pelvic organs. Int.J.Gynaecol.Obstet. 2005 Jan;88(1):84-88.
- U.S. Preventive Services Task Force Agency for Healthcare Research and Quality. Screening for testicular cancer: recommendation statement. Am.Fam.Physician 2005 Nov 15;72(10):2069-2070.