Gynecologic Procedures

Preparation for a Pelvic Examination

Before beginning an internal pelvic examination assemble the appropriate equipment. This equipment includes: a stretcher with stirrups or knee holders, various sizes of vaginal speculums, gloves, surgical lubricant, appropriate lighting, swabs, ring forceps or a Kelly clamp for the removal of foreign bodies or products of conception, transport medium for chlamydia and gonorrhea testing, pH paper, slides, coverslips, “eye dropper” bottles of 10% potassium hydroxide (KOH), and normal saline for testing vaginal discharge ( Fig. 57.2 ). Speculums may be plastic and disposable, or may be metal (warmed to body temperature before insertion), but must be sized to the patient; a pediatric speculum for women with a narrow introitus (elderly women and young adolescents), a Smith-Pederson speculum for virginal women, a standard speculum for most, and a Graves speculum for obese women and multiparous women. Note that if stirrups or leg supports are not available, the patient can have a padded bedpan under her buttocks with the bottoms of her feet together and her knees separated. When examination in a lithotomy position is not possible, an examination may be performed with the patient in a knee-chest position.

A pelvic examination should be done with the patient in a lithotomy position. She should be gowned and should have an empty bladder. Privacy should be assured and the patient should be fully informed by the examiner. Chaperones are commonly used during the examination. The examiner should glove and should touch the patient, reassuring her prior to each phase of the pelvic examination.

Performance of the Pelvic Examination

The vulva is examined visually for any lesions, and then by palpation. Women with a BA have acute, painful swelling of the posterior vulva that usually has developed over 2 to 3 days, making it difficult for them to sit or walk. The abscess appears erythematous, swollen, and forms a tender, spherical (3 to 4 cm in diameter) mass just lateral to the posterior fourchette. A Bartholin cyst is usually not tender and there is no associated erythema or swelling, differentiating it from an abscess. The treatment of a BA is similar to other abscesses in that incision and drainage is often required.

After examination of the vulva, separate the labia majora to expose the introitus and look for lesions, discharge, or blood. Next, insert a speculum with good lighting. If cervical cancer screening is anticipated, lubricate the speculum with water only. Otherwise, use surgical lubricant. Spread the labia, insert the speculum to its full length, and open the speculum. If the cervix is not seen, withdraw the speculum and palpate the location of the cervix with one finger, remove the finger, and follow with a second redirected speculum insertion. Inspect the cervix for blood, discharge and any lesions, particularly at the squamocolumnar junction (where the red columnar tissue of the endocervix changes to the reddish-pink squamous epithelium of the vagina). If there is a white lesion at the squamocolumnar junction that does not wipe off with a swab, consider dysplasia, carcinoma in situ, or condyloma accuminatum. Collect samples for STD and vaginitis prior to withdrawal of the speculum (see later section on Vaginal Discharge and Suspected STD Sampling ). Additionally, remove any foreign body or material found (see later section on Vaginal Foreign Body Removal ). Withdraw the speculum slowly while inspecting the walls of the vagina. Close the speculum just prior to exiting the introitus.

A bimanual examination of a woman with a small vagina can be accomplished with one gloved, lubricated index finger. Two fingers can be used when the introitus is larger. Gently place your opposite hand on the patient's abdomen. After palpating the labia majora, separate them, and inspect the introitus. Insert the fingers to locate the cervix. When using two fingers, place one on each side of the cervix. Pain with side to side cervical motion may indicate pelvic inflammatory disease (PID). Using the hand on the abdomen and the intravaginal fingers, evaluate the size and shape of the uterus. An asymmetric uterus may be an indication of a fibroid tumor. After moving both fingers to one side of the cervix, palpate the adnexa of that side between the intravaginal fingers and the abdominal hand. Gently palpate the pelvic adnexa since firm palpation of normal organs may cause pain and can be misleading to the examiner. If an adnexal mass is found, try to estimate a 3-D size in centimeters along with the degree of firmness, the degree of fixation to adjoining organs, and the degree of tenderness. Masses that can be detected with the bimanual examination include pedunculated fibroids, paraovarian cysts, tuboovarian abscesses (TOAs), and ectopic pregnancies.

Many examiners follow the bimanual examination with a rectal examination looking for firmness or nodules between the uterus and rectum, suggestive of tumors or uterosacral ligamentous endometriosis. Rectal material should be guaiac tested for blood, which may be falsely positive for gastrointestinal bleeding if blood is present in the vagina.

Bartholin Abscess (BA)

As stated previously, the BA is an acute painful swelling located in the posterior part of the vaginal introitus ( Fig. 57.3 ). The inflammatory swelling can be small or quite large and painful. BA occurs in about 2% of women, usually in the reproductive years. The pathogenesis of the abscess is unclear, but is thought to be the result of a blocked or partially obstructed Bartholin duct leading to accumulation of material with subsequent infection. As with any abscess, the evaluation must include consideration of the patient's comorbidities and willingness to consent for the procedure.

In most cases, a BA can be treated in the ED, but close follow-up with gynecology is needed. These abscesses can recur and the gynecologist may elect to do a marsupialization of the area which reduces the recurrence rate. If the abscess is very large, if the diagnosis is uncertain, or if there are other masses, significant cellulitis, or significantly distorted tissue, involvement of the gynecologist is warranted. In addition, if the patient has significant comorbidities, has unstable vital signs, has a bleeding dyscrasia, or is immunocompromised, the patient should be seen by the consulting gynecologist to manage the abscess.

Incision and Drainage ( Fig. 57.4 )

Incision and drainage of a BA can be painful and anxiety-provoking for many patients.

It is an invasive procedure that requires a written, witnessed, and signed consent form from the patient, parent, or guardian and should be witnessed with a notation made in the medical record documenting that the procedure was described, complications were discussed, and any alternatives such as antibiotics or warm compresses were offered when appropriate.

Once written consent is obtained, place the patient in the lithotomy position. Place the patient's feet in stirrups. Generously premedicate with intravenous opioids, or sedatives when appropriate. Administration of nitrous oxide analgesia is also an accepted practice. Procedural sedation with propofol, etomidate, or benzodiazepines can be considered, especially for those patients who are extremely uncomfortable.

• 1.

  Use universal precautions with gown, gloves, and mask. The contents of the abscess may be under pressure and can spray when incised.

• 2.

  Clean the affected area in the usual sterile way.

• 3.

  Apply topical analgesia to the mucosal surface of the introitus where the swelling is most evident. Note that the abscess incision is made on the mucosal, not on the skin surface. Applying viscous lidocaine to this area for 10 minutes can help reduce discomfort.

• 4.

  Administer a local anesthetic using a 25- or 27-gauge needle and 2% lidocaine. Note that the abscess contents may be under pressure and may leak during this step.

• 5.

  Approach the abscess from the vaginal introitus and, using an 11-blade scalpel, make a 5-mm stab incision through the mucosal surface, not the skin, to evacuate the contents of the abscess. If the abscess is larger, the incision can be lengthened to the diameter of the abscess, but in most cases 5 mm is sufficient ( Fig. 57.5 ).

  

• 6.

  After irrigating and cleaning the area, the wound can be packed or left open. Iodoform strips can be used to pack the wound. Do not pack the wound too tightly and leave just enough material to fill the base of the wound with a small tail (0.5 to 1 cm) extending from the cavity.

• 7.

  Some authors recommend inserting a small balloon catheter into the wound rather than packing. The Word catheter (Cook Medical Inc., Bloomington, IN) is often recommended ( Fig. 57.6 ). Insert the Word catheter cautiously and fill it with 3 mL of saline. Be careful not to fill it too much because the resulting pressure in the abscess cavity can be uncomfortable. This should be sufficient to hold the catheter in place. On rare occasions, it is necessary to suture the catheter in place. The Word catheter is usually left in place for 2 to 4 weeks.

  

• 8.

  Close follow-up with gynecology is recommended for a repeat examination and evaluation within the next 3 days.

• 9.

  Antibiotics are usually not necessary unless there is fever, significant cellulitis, multiple comorbidities, or the patient is immunocompromised in any way. If these conditions are present, the patient may need observation and gynecology consultation prior to performing the procedure.

• 10.

  Counsel the patient that the Word catheter is usually left in place for up to 4 weeks, but close gynecology follow-up and monitoring is needed throughout that time.

• 11.

  If the patient is well enough to be discharged, prescribe analgesics, including nonsteroidal antiinflammatory medications. Advise patients that they can resume most of their normal activities pending repeat follow-up evaluation by gynecology.

Early Pregnancy Bleeding

One fifth of pregnant women have vaginal bleeding during the first half of pregnancy, and 2% of women have an ectopic pregnancy, with the potential of hemorrhagic shock and maternal death. Evaluation of ectopic pregnancy is discussed in the later section on Culdocentesis .

One of the most common reasons to perform a speculum examination in early pregnancy bleeding is to evaluate a possible miscarriage, looking for cervical dilatation or the presence of products of conception. Some emergency physicians simply palpate the os intravaginally to determine the status of cervical dilatation and feel that speculum examination adds little to either the diagnosis or the plan of treatment, with the exception of early pregnancy bleeding associated with shock where the removal of obstructing products of conception is a resuscitative measure. Ultrasonography and β-hCG levels generally give the information needed to manage a patient with early pregnancy bleeding, and some practitioners feel that vaginal examination does not improve the accuracy of the diagnosis.

Pelvic and Lower Abdominal Pain

Pelvic examination, particularly bimanual examination, is often performed for pelvic and lower abdominal pain. The pain can be caused by problems in the urinary tract, intestinal tract and the reproductive tract (in both pregnant and nonpregnant patients). Urinary tract conditions include ureteral colic, cystitis and pyelonephritis. Intestinal tract conditions include appendicitis, diverticulitis, inflammatory bowel disease, bowel obstruction or ischemia, and a perforated viscus. Reproductive tract conditions include ectopic pregnancy, threatened abortion, endometritis, endometriosis, corpus luteal cyst, salpingitis (PID and TOA), ovarian cyst, ovarian torsion, round ligament pain, uterine fibroids, and uterine perforation. Later in pregnancy three conditions of importance are ectopic pregnancy, placenta previa (which is most often painless), and placenta abruption, all of which are suggested by vaginal bleeding. Conditions that may cause pain in the nonpregnant patient include salpingitis (PID), TOA, ovarian cyst, ovarian torsion, endometriosis, round ligament pain, uterine perforation, or uterine fibroids. Painless third trimester bleeding may be caused by placenta previa, in which a separated placenta is near or at the cervical os. Because manipulation of the uterus may further dislodge the placenta, defer rectal examination, speculum examination, and manual examination of the vagina to an obstetric professional. PID and TOA are often associated with vaginal discharge and fever. Endometriosis is often associated with dyspareunia and dysmenorrhea.

Vaginal Foreign Body Removal

Retained vaginal foreign bodies can cause pain or bleeding and may lead to a foul-smelling vaginitis. Common vaginal foreign bodies in adults include retained tampons, broken parts of condoms, pessaries, contraceptive diaphragms, drug smuggling devices, and sexual stimulation devices. Women with psychiatric illness sometimes insert vaginal foreign bodies (vaginal polyembolokoilamania). The removal of these foreign bodies, once located, may be accomplished using a speculum and ring forceps, or a Kelly clamp. Imbedded foreign bodies may require removal in an operating room. Once the foreign body is removed, the vaginal walls should be inspected for lacerations and infection. Bleeding vaginal lacerations can be tamponaded with surgical dressing prior to repair. Deep lacerations may require operative repair by a gynecologist.

It is not uncommon for a tampon to be lodged in a horizontal position in the upper vagina, commonly following intercourse. There is frequently a foul odor. The tampon can be removed by trapping it between two gloved examining fingers. Withdraw the tampon while inverting the examining glove with the tampon inside, placing the encased tampon in the palm of the opposite glove and then inverting the second glove over the first, followed by disposal.

Vaginal Discharge and Suspected STD Sampling

History and physical exam are critical for diagnosing infectious pathology of the external genitalia, vagina, cervix, or reproductive tract. However, given the often nonspecific symptoms, laboratory evaluation is mandatory to target appropriate therapy. Diagnostic options include Gram stain, culture, nucleic acid amplification tests (NAATs), and antigen-detecting immunochromatography. Culturing is done to assess the effectiveness of antibiotics on targeted bacteria, particularly when there has been treatment failure. According to the Centers for Disease Control and Prevention, “the performance of NAATs with respect to overall sensitivity, specificity, and ease of specimen transport is better than that of any of the other tests available for the diagnosis of chlamydial and gonococcal infections.”