Summary Final year MD notes - genitourinary medicine
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Course
Institution
Macquarie University (MQ
)
A collection suite of final obstetrics and gynaecology MD notes to ace your penultimate and final year exams!
Look no further and save the stress of accessing multiple resources as this PDF collates and summarises information from several resources including but not limited to:
-Talley and O�...
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)
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
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