Many clinicians now use a plastic brush tipped with a broomlike fringe for collection of a single specimen containing both squamous and columnar epithelial cells. Rotate the tip of the brush in the cervical os, in a full clockwise direction, then stroke each side of the brush on the glass slide. Promptly place the slide in solution or spray with a fixative as described above.
Inspect the Vagina. Withdraw the speculum slowly while observing the vagina. As the speculum clears the cervix, release the thumb screw and maintain the open position of the speculum with your thumb. Close the speculum as it emerges from the introitus, avoiding both excessive stretching and pinching of the mucosa. During withdrawal inspect the vaginal mucosa, noting its color and any inflammation, discharge, ulcers, or masses.
Perform a Bimanual Examination. Lubricate the index and middle fingers of one of your gloved hands, and from a standing position insert them into the vagina, again exerting pressure primarily posteriorly. Your thumb should be abducted, your ring and little fingers flexed into your palm. Pressing inward on the perineum with your flexed fingers causes little if any discomfort and allows you to position your palpating fingers correctly. Note any nodularity or tenderness in the vaginal wall, including the region of the urethra and the bladder anteriorly.
°alpate the cervix, noting its position, shape, consistency, regularity, mobil-ty, and tenderness. Normally the cervix can be moved somewhat without ?ain. Feel the fornices around the cervix.
Palpate the uterus. Place your other hand on the abdomen about midway between the umbilicus and the symphysis pubis. While you elevate the
Stool in the rectum may simulate a rectovaginal mass, but unlike a tumor mass can usually be dented by digital pressure. Rectovaginal examination confirms the distinction.
Pain on movement of the cervix, together with adnexal tenderness, suggests pelvic inflammatory disease.
and uterus with your pelvic hand, press your abdominal hand in and down, trying to grasp the uterus between your two hands. Note its size, shape, consistency, and mobility, and identify any tenderness or masses.
See Table 11-6, Abnormalities and Positions of the Uterus (pp. ___-_).
Uterine enlargement suggests pregnancy or benign or malignant tumors.
Now slide the fingers of your pelvic hand into the anterior fornix and palpate the body of the uterus between your hands. In this position your pelvic fingers can feel the anterior surface of the uterus, and your abdominal hand can feel part of the posterior surface.
If you cannot feel the uterus with either of these maneuvers, it may be tipped posteriorly (retrodisplaced). Slide your pelvic fingers into the posterior fornix and feel for the uterus butting against your fingertips. An obese or poorly relaxed abdominal wall may also prevent you from feeling the uterus even when it is located anteriorly.
Palpate each ovary. Place your abdominal hand on the right lower quadrant, your pelvic hand in the right lateral fornix. Press your abdominal hand in and down, trying to push the adnexal structures toward your pelvic hand. Try to identify the right ovary or any adjacent adnexal masses. By moving your hands slightly, slide the adnexal structures between your fingers, if possible, and note their size, shape, consistency, mobility, and tenderness. Repeat the procedure on the left side.
Normal ovaries are somewhat tender. They are usually palpable in slender, relaxed women but are difficult or impossible to feel in others who are obese or poorly relaxed.
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