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meticulous exam be performed in asymptomatic areas. Position the patient in low lithotomy. The head may
be elevated 30-60° to allow the patient visual access to the exam. If a lithotomy table with stirrups is not
available, the patient may flex her knees to her chest or an exam table can be improvised with a litter, litter
stands, IV poles and small battle dressings.
Figure 3-2
External Genitalia Examination:
Prior to touching the perineum inspect it visually. Observe for symmetry, bulges, rashes or lesions
If asymmetry or mass is noted these areas should be palpated to confirm mass, induration or other
abnormality.
Vaginal Examination:
Select the appropriate sized speculum. Speculum may be lubricated with warm water prior to insertion.
Remember to discuss the examination with the patient. Ask the patient to consciously relax the muscles at
the opening of the vagina. Gentle downward pressure with the tip of the speculum or with the finger may help
the patient relax, although many times this is not necessary. Place the speculum at the opening of the vagina
and gently push it in and downwards until the vaginal apex is reached. Insert the speculum obliquely through
the introitus and then rotated to the horizontal plane. Always control the speculum blades, holding them shut
with one hand until the blades are opened as the vaginal apex is reached. Observe the vaginal sidewalls
and the cervix. Inspect vaginal discharge for quantity, color, consistency and odor. Evaluate the cervix for
erosion, lesion, infection, laceration, polyps, ulceration and tumors. To perform cervical cultures for gonorrhea
and chlamydia, place each swab into the cervical os and allow to sit for 20-30 seconds. Replace in culture
tube. Assess vaginal pH by obtaining a sample of vaginal discharge from the sidewall or from any pooled
discharge in the posterior fornix using a small cotton swab. Touch the cotton swab to the pH paper and
look for color change. Obtain discharge samples for KOH and wet mount with a similar technique. Blood or
cervical mucus will be basic (high pH) and will give false readings, so avoid these while sampling.
Bulging of the bladder and/or rectum into the vagina may be seen in patients with pelvic relaxation. Women
who have had children vaginally will have some relaxation of the rectovaginal and vesicovaginal septum. The
cervix may descend into the vagina with Valsalva.
Bimanual Examination:
With a gloved hand, lubricated with water or gel, insert the index and middle fingers of the dominant hand
along the posterior wall of the vagina (Figure 3-3). Place the other hand on the patient’s abdomen in the
midline above the symphysis pubis. The vaginal fingers should encounter the cervix, which should feel firm
and circular. Push the cervix upward in the cervical canal. This will move the body of the uterus. If the
uterus is anteverted or midline it will be palpable with the abdominal hand. If the uterus is retroverted it will
move toward the rectum and the abdominal and vaginal hands will meet in the midline as they come together.
If possible feel the body of the uterus for shape, symmetry and mass. A nulliparous uterus will be quite small
(pear-sized). A parous uterus can be the size of a small grapefruit. Assess the uterus for mobility by moving