Bimanual examination.pptx

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1. Bimanual examination-PV Lecture N7

2. A  bimanual vaginal examination  may need to be performed in a number of different clinical scenarios including unexplained pelvic pain, irregular vaginal bleeding, abnormal vaginal discharge and as part of the assessment of a pelvic mass.

3. Gather equipment Gather the appropriate  equipment : Gloves Lubricant Paper towels

4. Introduction: Wash your hands  and  don PPE  if appropriate. Introduce yourself to the patient including your  name  and  role . Confirm the patient’s  name  and  date of birth . Explain  what the examination will involve using  patient-friendly   language. Ask the patient if they have any  pain  or if they think they may be  pregnant  before proceeding with the clinical examination. Provide the patient with the opportunity to  pass   urine  before the examination. Explain to the patient that they’ll need to  remove their underwear  and  lie on the clinical examination  couch,  covering themselves  with the  sheet  provided. Provide the patient with  privacy  to undress and  check it is ok to re-enter the room before doing so .

5. Abdominal examination An  abdominal examination   should  always  be performed before moving onto  vaginal   examination . This may be less thorough than a full abdominal examination, but should at least include  inspection  and  palpation  of the abdomen.

6. Vulval inspection Position 1 . Don a pair of non-sterile gloves. 2 . Position the patient in the  modified lithotomy position :  “Bring your heels towards your bottom and then let your knees fall to the sides.”

7. Inspect the vulva . Inspect the vulva for abnormalities: Ulcers : typically associated with genital herpes. Abnormal vaginal discharge : causes include candidiasis, bacterial vaginosis, chlamydia and gonorrhoea . Scarring : may relate to previous surgery (e.g. episiotomy) or lichen sclerosus (destructive scarring with associated adhesions). Vaginal atrophy : most commonly occurs in postmenopausal women. White lesions : may be patchy or in a figure of eight distribution around the vulva and anus, associated with lichen sclerosus . Masses : causes include Bartholin’s cyst and vulval malignancy. Varicosities : varicose veins secondary to chronic venous disease or obstruction in the pelvis (e.g. pelvic malignancy). Female genital mutilation : total or partial removal of the clitoris and/or labia and/or narrowing of the vaginal introitus. 2 . Inspect for evidence of vaginal prolapse (a bulge visible protruding from the vagina). Asking the patient to  cough  as you inspect can exacerbate the lump and help confirm the presence of prolapse.

8. Vaginal examination Warn the patient you are going to  examine the vagina  and ask if they’re still ok for you to do so. If the patient consents  to the continuation of the examination: 1. Lubricate  the gloved index and middle fingers of your dominant hand. 2.  Carefully  separate   the   labia  using the thumb and index finger of your non-dominant hand. 3.  Gently  insert  the  gloved   index  and  middle   finger  of your dominant hand into the vagina. 4.  Enter the vagina with your  palm   facing   laterally  and then  rotate   90   degrees  so that your palm is facing upwards.

9. Equipment Non sterile gloves

10. Equipment Water-soluble lubricant

11. Equipment Two drape

12. Equipment Kidney shape dish

13. Equipment Forceps

14. Equipment 3 cotton ball

15. Equipment Antiseptic solution

16. Vaginal walls Palpate the  walls of the vagina  for any  irregularities  or  masses . Cervix Examine the  cervix  to assess: Position  (e.g. anterior or posterior) Consistency  (e.g. irregular, smooth) Cervical motion tenderness:  involves severe pain on palpation of the cervix and may suggest pelvic inflammatory disease or ectopic pregnancy. Fornices The  fornices  are the superior portions of the vagina, extending into the recesses created by the vaginal portion of the cervix. Gently palpate lateral  fornices  for any  masses .

17. Uterus Bimanually   palpate  the  uterus : 1.  Place your  non-dominant hand  4cm above the  pubis symphysis . 2.  Place  two of your dominant hand’s fingers  into the  posterior   fornix . 3.   Push upwards with the internal fingers  whilst simultaneously  palpating the lower abdomen  with your  non-dominant hand . You should be able to feel the  uterus   between your hands . You should then assess the various  characteristics  of the uterus: Size:  the uterus should be approximately orange-sized in an average female. Shape:  may be distorted by masses such as large fibroids. Position:  the uterus may be anteverted or retroverted. Surface characteristics:  note if the uterus feels smooth or nodular. Tenderness:  may suggest inflammation (e.g. pelvic inflammatory disease, ectopic pregnancy).

18. Uterine position The  position  of the  uterus  can be described as: Anteverted:  the uterus is orientated forwards towards the bladder. This is the most common position of the uterus. Retroverted:  the uterus is orientated posteriorly, towards the spine. This is a less common uterine position present in approximately 1 in 5 women.

19. Ovaries and uterine tubes The term  adnexa  refers to the area that includes the  ovaries  and  fallopian   tubes . Bimanually   palpate  the  adnexa : 1.  Position your  internal fingers  in the  left lateral fornix . 2.  Position your  external hand  onto the  left iliac fossa . 3.  Perform  deep palpation  of the  left iliac fossa  whilst moving your  internal fingers upwards  and  laterally  (towards the left). 4.  Feel for any  palpable   masses , noting their  size  and  shape  (e.g. ovarian cyst, ovarian tumour , fibroid). 5.   Repeat   adnexal   assessment  on the  right . 6. Withdraw your fingers  and inspect the glove for  blood  or  abnormal   discharge . 7. Cover the patient  with the sheet,  explain that the examination is now complete  and provide the patient with  privacy  so they can get dressed. Provide paper towels for the patient to clean themselves. 8. Dispose  of the used equipment into a  clinical   waste   bin .

20. Thank you for attention….