Female Genitalia and the Pelvis

A

Inspection/Palpation of External Genitalia: Vulva and Perineum

• 9.

  What is the anatomy of the vulva?

  The vulva comprises several anatomic structures: (1) the mons veneris (or pubis), (2) the labia majora and minora, (3) the clitoris, (4) the urethral meatus, (5) the Skene’s glands, (6) the vaginal vestibule and introitus, and (7) the vestibular (Bartholin’s) glands. All should be inspected. Any lesion should be palpated.

• 10.

  What should you look for in the external genitalia?

  It depends on the structure. Inspect (1) the vulvar skin (for redness, nodules, swellings, excoriations, ulcerations, and changes in pigmentation/leukoplakia); (2) the mons veneris (for lesions and swelling); and (3) the hair (for lice and nits). By gently spreading the labia majora and minora, you will then get access to the vaginal vestibule. Inspect (and palpate) the urethral meatus (for purulent discharge) and the Skene’s glands. Inspect the clitoris, perineum , and anus . Look for masses, scars, fissures, and fistulas. Finally, check for hemorrhoids, and palpate any visible lesions.

• 11.

  Where are the openings of Skene’s (paraurethral) glands?

  On either side of the urethral meatus. Inspect them and palpate them. Then, insert your index finger into the vagina, press up onto the urethra, and milk it for possible discharge.

• 12.

  Who was Skene?

  Alexander J. Skene (1838–1900) was a Scot, who at the age of 18 moved to Canada and then to New York, where he obtained his medical degree in the midst of the American Civil War. He did serve in that war (even planning an army ambulance corps), eventually going back to the practice of gynecology and becoming one of the founders of the American Gynecological Society. Still, his call to fame was the 1880 description of the homonymous glands, which was nothing new, since they had already been reported in 1672 by Reiner de Graaf, in an observation that (as often happens in medicine) had been totally forgotten.

• 13.

  What important information can be gained by inspecting the vulva?

  Mostly the degree of estrogenization of the urogenital tract, which is reflected by the presence of mucus and by the thickness and rugation of the vulvar/vaginal mucosae.

• 14.

  What is the female escutcheon?

  It is the triangular pattern of pubic hair that is unique to adult females (i.e., with apex pointing down toward the pubis). The male escutcheon is instead a reverse triangle, with apex pointing up toward the umbilicus. A masculine escutcheon in a woman is usually a sign of virilization, even though it also may be a normal variant.

• 15.

  What are Tanner’s stages of sexual maturation?

  They are a way to assess sexual maturation by following the growth of breast and pubic hair . They are mostly used in pediatric and adolescent medicine, but also can be helpful in evaluating patients with primary amenorrhea ( Table 15.1 ).

  Table 15.1

  Tanner Stages of Sexual Maturation in Girls

  (From Polin RA, Ditmar MF. Pediatric Secrets . 2nd ed. Philadelphia: Hanley & Belfus; 1997.)

  STAGE	DESCRIPTION	MEAN AGE	AGE RANGE (5%–95%)
  Pubic Hair
  I	None	—	—
  II	Countable; straight; increased pigmentation and length; primarily on medial border of labia	11.25	9–13.5
  III	Darker; begins to curl; increased quantity on mons pubis	12	9.5–14.25
  IV	Increased quantity; coarser texture; labia and mons well covered	12.5	10.5–15
  V	Adult distribution with feminine triangle and spread to medial thighs	14	12–16.5
  Breast Development
  I	None	—	—
  II	Breast bud present; increase areolar size	11	9–13
  III	Further enlargement of breast; no secondary contour	12	10–14
  IV	Areolar area forms secondary mound on breast contour	13	10.5–15.5
  V	Mature; areolar area is part of breast contour; nipple projects	15	13–18
  Menarche		12.8	11–14.5

• 16.

  What is the differential diagnosis of enlarged inguinal nodes?

  The major one is infection of the genital area, lower extremities, or nodes per se. Cancer should also be ruled out, either primary (lymphoma) or metastatic.

• 17.

  What is the significance of white vulvar lesions?

  They may be benign, premalignant, or malignant.

• 18.

  What are the benign white lesions of the vulva?

  They are mostly vitiligo and inflammatory dermatitis, like psoriasis.

• 19.

  What are the most common premalignant white lesions?

  Vulvar dystrophies , such as hyperplastic dystrophy (squamous cell hyperplasia) and lichen sclerosus et atrophicus (LS&A). LS&A is an atrophic condition of the vulva and perianal skin that can occur alone or in association with other cutaneous lesions. It presents as patches of reddened and thin skin, which evolve into yellowish-bluish papules/macules, eventually coalescing into areas of atrophic, grayish, and crinkling mucosa – smooth, thin, fragile. Itching and burning are common, and so is secondary infection. Other symptoms may include dyspareunia (pain during intercourse) and skin splitting and bleeding. The condition may eventually lead to resorption of the clitoris and labia minora. It also may progress to malignancy, usually squamous cell carcinoma. Although LS&A may occur in all age groups, it is more common in postmenopausal women (especially Caucasian and Latino), where extensive lesions can even narrow the introitus. Hyperplastic dystrophy can present quite similarly, as a pruritic grayish-whitish plaque, but it does not lead to resorption of the labia and clitoris. Moreover, it is microscopically differentiated from LS&A because of its squamous cell hyperplasia/atypia. Vulvar dystrophies represent a continuum from benign to malignant, with white lesions of both kinds frequently coexisting in the vulva. Hence, the need to biopsy any white and dystrophic area.

• 20.

  What are malignant white lesions?

  Mostly two: vulvar intraepithelial neoplasia and Bowen’s disease.

• 21.

  What are other vulvar malignancies?

  The most common is squamous cell carcinoma. Of interest, melanoma is the next most common. Hence, both patients and physician should be quite attentive to vulvar “moles” and include this area in their regular examination for nevi. Other histologic types include adenocarcinoma (of Bartholin’s gland), basal cell carcinoma, and sarcoma.

• 22.

  What is the differential diagnosis of a painful vulvar ulceration?

  A painful (and multiple) vulvar ulceration is usually due to ruptured and coalescent herpes simplex lesions or chancroid.

• 23.

  What is the differential diagnosis of a painless vulvar ulceration?

  A painful (and solitary) vulvar ulceration is usually due to syphilis. A painless but long-standing ulcer should raise the suspicion for a vulvar carcinoma.

• 24.

  What is a labial hernia?

  The uncommon occurrence of the herniation of a bowel loop into one of the labia majora , analogous to an inguinal hernia in a male.

• 25.

  Where are Bartholin’s glands located?

  Deep in the lateral walls of the vulva, close to the posterior fornix.

• 26.

  How do you examine them?

  By placing a gloved index finger just inside the vaginal opening (near the posterior end of the introitus) and the thumb on the outside. Then, to examine the right Bartholin’s gland, grasp the posterior portion of the right major labium between the index finger and the thumb. Palpate gently for enlargement or tenderness. Do the same for the contralateral gland. Note that in the absence of disease, Bartholin’s glands should be neither visible nor palpable.

• 27.

  What is the differential diagnosis of a mass or swelling of the Bartholin’s gland?

  The most common is cysts or abscesses of the glands. These are quite common and present as indurated (and often tender) enlargement of one or both labia majora. More rarely, adenocarcinoma of the gland also can be responsible.

• 28.

  Who was Bartholin?

  Caspar Bartholin (1655–1738) was a Danish physician and the son of a famous anatomist (who provided the first description of intestinal lymphatics and their drainage into the thoracic duct). Caspar managed to outdo his dad, not only because of his description of the homonymous glands (and their possible cystic degeneration) but also because of his discovery of the sublingual glands and their ducts, which still carry his name. During the last part of his life, he left medicine for politics, becoming Denmark’s procurator general and deputy of finance.

• 29.

  What is the hymen? What are the myths surrounding it?

  From the Greek humen (membrane), the hymen is a ring of tissue around the vaginal opening. Contrary to popular belief, a normal hymen does not completely occlude the introitus (see Question 30) but simply surrounds it as an annular structure. Hymens also can be septate (with one or more bands across the opening) or cribriform (completely stretching across the opening but with several perforations). After pregnancy, they are usually reduced to a few remnants around the vaginal opening or to a ragged and irregular outline. Yet completely intact hymens have been reported after delivery. They also have been reported after intercourse. In fact, bleeding may not occur at all after the first vaginal penetration, and if it does, it may not be due to laceration of the hymen but to trauma of nearby tissues. Finally, the infamous straddle injuries of old (such as horseback riding or falling on the horizontal bar of a bicycle) do not traumatize the hymen.

• 30.

  What is an imperforate hymen?

  A congenital abnormality that often goes unrecognized until puberty, when the patient becomes symptomatic from retained menses. On exam, the hymen appears as an intact and completely closed membrane, bulging with retained menstrual products. If untreated, this can lead to hematometrium and hematosalpinx. Treatment is hymenotomy , which also is the treatment of choice for unusually thick hymens, another congenital abnormality, often responsible for dyspareunia.

• 31.

  What is the normal size of the glans clitoris?

  Around 3–4 mm.

• 32.

  What is the clitoral index (CI)? How do you calculate it?

  The CI is a “poor man’s” bioassay of androgenic stimulation since it reflects the stimulation of the clitoris by both testosterone and 17-ketosteroids. It is calculated by multiplying the sagittal and transverse diameters of the glans, with the normal range being 9–35 mm. A CI of 36–99 mm is usually borderline, whereas one >100 mm is considered abnormal. Enlargement of the clitoris indicates virilization and thus should prompt a search for sources of androgenization.

• 33.

  What is the appearance of the clitoris and vulva in congenital adrenal hyperplasia?

  Virilized. This is usually apparent from birth, including clitoral hypertrophy and fused labia. In untreated females, secondary sex characteristics fail to develop.

• 34.

  What is congenital adrenal hyperplasia?

  The generic term for hereditary deficiency of a number of enzymes of glucocorticoid synthesis – the most common being 21-hydroxylase and 11-β-hydroxylase. The resulting decrease in hydrocortisone levels leads to greater adrenocorticotropic hormone (ACTH) production, which, in turn, causes a secondary increase in adrenal androgens. Hence, the virilization.

• 35.

  What should one look for when inspecting the labia?

  For warts (see Questions 36 and 37), ulcers, masses, discharge, atrophies, and swellings. Note that yellow-white asymptomatic papules may occasionally be noted on the inner aspect of the labia minora. They represent ectopic sebaceous glands (Fordyce’s spots), like those seen in the mouth and penile shaft. They are entirely normal.

• 36.

  What are condylomata lata ?

  They are flat warts typical of secondary syphilis.

• 37.

  What are condylomata acuminata ?

  They are genital warts due to the human papillomavirus (HPV). They present as flesh-colored papules with cauliflower-like papillations that can degenerate into cervical cancer. There are more than 70 serotypes of HPV. Of these, serotypes 16, 18, 45, and 56 have the highest malignant potential.

• 38.

  How does genital herpes simplex present?

  With clusters of small (<1 mm) fluid-filled vesicles on an erythematous base. These may rupture or coalesce, eventually resulting in a painful vulvar ulceration (see question 22).

B

Examination with Speculum—The Vagina

• 39.

  What is a speculum?

  A metal (or plastic) tool that is used to hold back the walls of the vagina in order to visualize the cervix and collect specimens. Specula come as small, medium, and large, and all consist of a handle and two blades (or bills). Before using them, always practice with the handle mechanism, and always warm the blades with warm water . Never use jelly lubricant, since this may interfere with cytologic determination and gonococcal cultures (see Questions 59–64).

• 40.

  What are Pedersen’s and Graves’ ? What are their differences?

  They are the two main specula types. Pedersen’s is 0.5-inch narrower than Graves’ and with flat blades. Although it provides a more comfortable fit for women, it is mostly suited for patients with a small, atrophic introitus, such as the young (nulliparous) and the elderly (menopausal). The Graves’ speculum is instead wider than Pedersen’s and with blades that are biconcave . It is more commonly used, especially in multiparous women, or women in whom Pedersen’s is unable to retract the vaginal wall adequately enough to visualize the cervix. Both Pedersen’s and Graves’ may be made of metal or clear plastic.

• 41.

  How do you insert the speculum?

  Use your left index and middle fingers to separate the labia and depress the perineum. Ask the patient to take a deep breath, and then use your right hand to gently insert the closed speculum into the introitus, pointing the handle down at an oblique angle of 45 degrees (inserting it vertically may traumatize the urethra or meatus). Slide the speculum over your left fingers and, while inserting it, rotate it downward to 90 degrees – eventually pointing the handle vertical to the floor. Gently open the blades by squeezing on the handle mechanism. This will open the vaginal walls and hold them apart, allowing you to inspect the lateral walls of the vagina and the cervix. If made of clear plastic, the speculum also will allow you to inspect the vaginal vault . Once in good position (i.e., with the cervix in clear view), keep the speculum open by tightening the set screw.

• 42.

  When do you withdraw the speculum? How?

  The speculum can be withdrawn once you are done with cervical inspection and Pap sampling. To do so:

  Hold the blades open while releasing the screw (otherwise the blades might painfully close on the cervix).

  Once the speculum is safely away from the cervix, allow the blades to partially close, so that you can still inspect the vaginal walls. Look for bleeding, ulcers, tumors; also note the amount, color, and character of any discharge.

  Finally, as you further withdraw the speculum, allow the blades to close completely.

• 43.

  What is a colpocele ?

  From the Greek kolpos (vagina) and kele (bulging), a colpocele is a vaginal prolapse, often the result of hysterectomy.

• 44.

  What is a cystocele ? How can you detect it?

  A cystocele is a bulge in the anterior wall of the vagina, caused by weakening of the wall and protrusion of the bladder. It can be detected by observing through the speculum the anterior vaginal wall with the patient either bearing down or coughing. In more severe cases, it can even be observed at the vestibule, after separating the minor labia. Finally, it can be palpated, too.

• 45.

  What is a rectocele ? How can you detect it?

  A rectocele is a bulge in the posterior wall of the vagina, caused by weakening of the wall and protrusion of the rectum. Like the cystocele, it can be detected through inspection or intravaginal palpation while the patient is bearing down or coughing.

• 46.

  What are the clues to the presence of a rectovaginal fistula?

  A history of fecal contamination in the vagina. The fistula also may be palpable , as an indurated area in the posterior vaginal wall.

• 47.

  What is Chadwick’s sign ?

  The bluish-violet appearance of the vagina or cervix. This is a sign of pregnancy (usually occurring after the 7th week of gestation), but it also may occur in association with a pelvic tumor. It results from mucosal congestion and is most notable in the anterior vaginal wall.

• 48.

  Who was Chadwick?

  James R. Chadwick (1844–1905) was an American gynecologist. Born in Boston and schooled at Harvard, Chadwick traveled extensively in Europe after graduation, visiting the medical centers of Vienna, London, Paris, and Berlin. He eventually returned to his native Boston, where he went on to become one of the founding fathers of the Boston Medical Library and the president of the American Gynecological Society.

• 49.

  What is diethylstilbestrol (DES)? What is the vaginal appearance of women with prenatal exposure to it?

  DES was an oral synthetic nonsteroidal estrogen, which was used from 1938 to 1972 to prevent miscarriage, until found to cause vaginal changes in women who had been exposed to it in utero. The most common of these is adenomyosis (90% of the cases), which consists of a glandular columnar epithelium of the vagina. This is not premalignant but can be associated with clear cell adenocarcinoma. Hence, DES patients must be followed serially, with exams and colposcopy.

• 50.

  What is a Gartner’s duct cyst ?

  A benign tumor arising in the anterior or lateral wall of the vagina. It is a congenital lesion caused by retained epithelial remnants of the Wolffian duct.

• 51.

  Who was Gartner?

  Hermann T. Gartner (1785–1827) was a Danish surgeon. A native of St. Thomas, West Indies (when this was still a Danish possession), Gartner eventually returned to Denmark, graduated from Copenhagen Medical School, and worked as an army surgeon for most of his professional life.

• 52.

  What is the normal vaginal pH?

  Acid, because vaginal secretions are in the acidic range, with pH <4.5.

• 53.

  What is the significance of tenderness in the vaginal fornices?

  It depends. Tenderness in either the left or right vaginal fornix usually indicates ipsilateral salpingitis, but tenderness of the right fornix also may represent a sign of retrocecal appendicitis.

C

Examination with Speculum—The Cervix

• 54.

  What is the best way to visualize the cervix?

  Through the speculum. Note that cervical visualization may be difficult in patients with either retroverted uterus or displacement by prolapse. To improve vision, reposition the speculum by slowly pulling it back. You also may want to gently turn the bills in various directions. Yet, remember that the most common reason for not visualizing the cervix is an incomplete insertion of the speculum . If still unable to locate the cervix, perform first the bimanual exam by lubricating your gloved fingers with water (other lubricants may ruin the Pap smear). Once you have palpated the cervix, it will be easier to aim the speculum toward the correct direction.

• 55.

  How does a normal nonparous cervix appear?

  It looks round, pink, and with a central os (this in the parous cervix is horizontal and possibly “fishmouthed”). A darker and reddish columnar epithelium at the os is a normal variation, as are the presence of small and yellowish nabothian cysts. Inspect the cervix for color, size, configuration, discharge, erosions, ulcerations, cysts, polyps, leukoplakia, and masses.

• 56.

  What are endocervical polyps ? What is their significance?

  They are small pedunculated masses that protrude from the endocervical canal and are composed of columnar epithelium. Although at times friable and bleeding, they are invariably benign.

• 57.

  What is the cause of cervical duplication?

  Common in animals, a cervical (and uterine) duplication is usually due to failure of Müllerian duct fusion. It is often associated with a partially or fully septate vagina. On physical exam, the two cervices are often different in size, appearing side by side in the coronal plane.

• 58.

  What is the squamocolumnar junction ?

  It is the meeting of the columnar endothelium of the endocervical canal with the external pink mucosa of the ectocervix (which is covered by squamous cells). This transition zone is a crucial area, since 95% of all cervical cancers originate from it. Yet, the junction may or may not be visible on speculum examination. Note that for an adequate evaluation of the cervix, you must sample cells from all three layers: ectocervix, transition zone, and endocervix.

• 59.

  What is a Pap smear? What is the best way to obtain it?

  The Pap smear is a preparation of endocervical canal cells. These are obtained by inserting a brush into the endocervical canal and rotating it 180 degrees (a 360-degree rotation is more likely to cause bleeding). The brush is then withdrawn and either run across a slide (standard method) or agitated in a tube of medium (thin prep method). Squamous cells from the ectocervix are instead obtained by scraping the cervix circumferentially with a wooden spatula and then spreading the sample on either a slide or a tube medium. Pap smear slides must be fixed with cytology fixative as quickly as possible.

• 60.

  Which patients benefit from regular Pap smear screening?

  Mostly two groups of patients:

  • Women who are sexually active (since they are the ones mostly at risk for HPV infection). They should undergo vaginal Pap smears either yearly or biennially.

  • Women who have had hysterectomies for malignant disease. Conversely, women who have had hysterectomies for benign reasons (such as myomata) no longer need Pap screening.

• 61.

  Who was “Pap”?

  George N. Papanicolaou (1883–1962) was an American pathologist. A native of Greece and a graduate of Athens University, Papanicolaou gained a medical degree only because of his father’s wishes and only as a prerequisite to then be free to pursue a career in history and philosophy. The Balkan Wars of 1912–1913 (and the outbreak of World War I) totally changed his plans, pushing him to emigrate to the United States, where he went on to become chair of pathology at Cornell. A soft-spoken and modest man, he always maintained a very thick Greek accent.

• 62.

  What is the significance of a purulent cervical discharge?

  It is usually the harbinger of purulent cervicitis, most often caused by gonorrhea or chlamydia. If untreated, this may result in pelvic inflammatory disease and its various sequelae.

• 63.

  What is the significance of cervical motion tenderness?

  It suggests pelvic inflammatory disease. Informally known as the “chandelier sign,” since patients “hit the chandelier” whenever their tender cervix is palpated.

• 64.

  What additional laboratory tests should be obtained from the cervix?

  In high-risk populations, some clinicians routinely test for gonorrhea and chlamydia because chlamydial infection may be relatively asymptomatic, and if undiagnosed, can lead to serious sequelae, such as infertility. Hence, the low threshold for screening, especially in cases of any of the aforementioned signs of purulent cervicitis.

D