Female Genitalia


image Speculum

image Gloves

image Water-soluble lubricant

image Lamp or light source

image Specimen collection equipment such as:
Sterile cotton swabs

Glass slides

Wooden or plastic spatula

Cervical brush devices

Cytologic fixative

Culture plates or media, if needed

DNA probe kits for chlamydia and gonorrhea, if needed


Have patient in lithotomy position, draped for minimal exposure.


Wear gloves on both hands
Ask patient to separate or drop open her knees. Tell patient you are beginning the examination, then touch either lower thigh and—without breaking contact—move hand along thigh to external genitalia.
Inspect and palpate mons pubis
imageCharacteristics EXPECTED:Skin smooth and clean.
UNEXPECTED:Improper hygiene.
imagePubic hair EXPECTED:Regularly distributed female pubic hair.
UNEXPECTED:Nits or lice.

From Lowdermilk and Perry, 2004.

Inspect and palpate labia
imageLabia majora EXPECTED:Gaping or closed, dry or moist, shriveled or full, tissue soft and homogeneous, usually symmetric.
  UNEXPECTED:Swelling, redness, tenderness, discoloration, varicosities, obvious stretching, or signs of trauma or scarring. If excoriation, rashes, or lesions are present, ask patient whether she has been scratching.

image Labia minora

Separate labia majora with fingers of one hand. With other hand, palpate labia minora between thumb and second finger.

EXPECTED:Moist, dark pink inner surface. Tissue soft and homogeneous.
UNEXPECTED:Tenderness, inflammation, irritation, excoriation, caking of discharge in tissue folds, discoloration, ulcers, vesicles, irregularities, or nodules. Hyperemia of fourchette not related to recent sexual activity.
Inspect clitoris
imageSize and length EXPECTED:Length 2 cm or less; diameter 0.5 cm.
UNEXPECTED:Enlargement, atrophy, inflammation, or adhesions.
Inspect urethral meatus and vaginal opening
imageUrethral orifice EXPECTED:Slit or irregular opening, close to or in vaginal introitus, usually midline.
UNEXPECTED:Discharge, polyps, caruncles, fistulas, lesions, irritation, inflammation, or dilation.
imageVaginal introitus EXPECTED:Thin vertical slit or large orifice with irregular edges. Tissue moist.
UNEXPECTED:Swelling, discoloration, discharge, lesions, fistulas, or fissures.
Milk Skene glands
Tell patient you will be inserting one finger into her vagina and pressing forward with it. With palm up, insert index finger to second joint, press upward, and milk Skene glands by moving finger outward. Perform on both sides of urethra and directly on urethra. UNEXPECTED:Discharge or tenderness. Note color, consistency, odor of any discharge; obtain culture.
Palpate Bartholin glands
Tell patient she will feel you pressing around the entrance to her vagina. Palpate lateral tissue between index finger and thumb, then palpate entire area bilaterally, particularly posterolateral portion of labia majora. EXPECTED:No swelling.
UNEXPECTED:Swelling, tenderness, masses, heat, fluctuation, or discharge. Note color, consistency, odor of any discharge; obtain culture.
Test vaginal muscle tone if indicated
Ask patient to squeeze vaginal opening around your finger. EXPECTED:Fairly tight squeezing by some nulliparous women, less so by some multiparous women.
UNEXPECTED:Protrusion of cervix or uterus.
Locate the cervix
With your finger still in place you can reach in farther to locate the cervix and note the direction in which it points. This may help you locate the cervix when you insert the speculum. EXPECTED:Midline, may point horizontally, anteriorly, or posteriorly.
UNEXPECTED:Deviates to right or left.
Inspect for bulging and urinary incontinence if indicated
Ask patient to bear down. EXPECTED:No bulging.
UNEXPECTED:Bulging of anterior or posterior wall, or urinary incontinence.
Inspect and palpate perineum
Compress perineal tissue between finger and thumb. EXPECTED:Perineum surface smooth—generally thick and smooth in a nulliparous woman, thinner and rigid in a multiparous woman. Possible episiotomy scarring in women who have borne children.
UNEXPECTED:Tenderness, inflammation, fistulas, lesions, or growths.
Inspect anus
image Skin characteristics EXPECTED:Skin darkly pigmented and possibly coarse.
UNEXPECTED:Scarring, lesions, inflammation, fissures, lumps, skin tags, or excoriation.
If you touched the perineum or anal skin while examining the external genitalia, change gloves before beginning internal examination.
Lubricate speculum and gloved fingers with water or water-soluble gel lubricant. Water is preferred if obtaining a Pap smear.
Insert speculum
Tell patient she will feel you touching her again, then insert two fingers of hand not holding the speculum just inside vaginal introitus and gently press downward. Ask patient to breathe slowly and try to consciously relax her muscles. image
Use fingers of that hand to separate labia minora widely so that the vaginal opening becomes clearly visible. Then slowly insert speculum along path of least resistance, often slightly downward, avoiding trauma to urethra and vaginal walls. Some clinicians insert speculum blades at an oblique angle; others prefer to keep blades horizontal. In either case avoid touching clitoris, catching pubic hair, or pinching labial skin. Insert speculum the length of the vaginal canal. Maintaining downward pressure, open speculum by pressing on thumb piece. Sweep speculum slowly upward until cervix comes into view. Adjust light, then manipulate speculum farther into vagina so that cervix is well exposed between anterior and posterior blades. Stabilize distal spread of blades, and adjust proximal spread as needed.  
Inspect cervix
imageColor EXPECTED:Evenly distributed pink. Symmetric, circumscribed erythema around os can be expected.

From Edge and Miller, 1994.

  UNEXPECTED:Bluish, pale, or reddened cervix (especially if patchy or with irregular borders).
imagePosition EXPECTED:In midline, horizontal or pointing anteriorly or posteriorly. Protruding into vagina 1 to 3 cm.
UNEXPECTED:Deviation to right or left. Protrusion into vagina greater than 1 to 3 cm.
imageSize EXPECTED:3 cm in diameter.
UNEXPECTED:Larger than 3 cm.
imageShape EXPECTED:Uniform.
imageSurface characteristics EXPECTED:Surface smooth. Possible symmetric, reddened circle around os (squamocolumnar epithelium). Possible small, white, or yellow, raised round areas on cervix (nabothian cysts).
UNEXPECTED:Friable tissue, red patchy areas, granular areas, or white patches.

image Discharge

Note any discharge. Determine origin—cervix or vagina.

EXPECTED:Odorless, creamy or clear, thick, thin, or stringy (often heavier at midcycle or immediately before menstruation).
UNEXPECTED:Odorous and white to yellow, green, or gray.

image Size and shape of os

Follow standard precautions for safe collection of human secretions.

EXPECTED:Nulliparous woman: Small, round, oval. Multiparous woman: Usually a horizontal slit or irregular and stellate.
UNEXPECTED:Slit resulting from trauma from induced abortion, difficult removal of intrauterine device (IUD), or sexual abuse.
Withdraw speculum and inspect vaginal walls
Unlock speculum, and remove it slowly, rotating it so vaginal walls can be inspected. Maintain downward pressure, and hook index finger over anterior blade as it is removed. Note odor of any discharge pooled in posterior blade, and obtain specimen if not already obtained. EXPECTED:Vaginal wall color same pink as cervix or lighter; moist, smooth or rugated; and homogeneous. Thin, clear or cloudy, odorless secretions.
UNEXPECTED:Reddened patches, lesions, pallor, cracks, bleeding, nodules, swelling. Secretions that are profuse; thick, curdy, or frothy; gray, green, or yellow; or malodorous.
Change gloves, and then lubricate index and middle fingers of examining hand.
Tell patient you are going to examine her internally with your fingers. Prevent thumb from touching clitoris during examination.

Obtaining Vaginal Smears and Cultures

Vaginal specimens are obtained while the speculum is in place in the vagina but after the cervix and its surrounding tissue have been inspected. Collect specimens as indicated for a Papanicolaou (Pap) smear, sexually transmitted disease screening, and wet mount. Label the specimen with the patient’s name and a description of the specimen (e.g., cervical smear, vaginal smear, and culture). Be sure to follow standard precautions for the safe collection of human secretions.

Pap Smear

Brushes and brooms are now being used in conjunction with or instead of the conventional spatula to improve the quality of cells obtained. The cylindric-type brush (e.g., a Cytobrush) collects endocervical cells only. First, collect a sample from the ectocervix with a spatula. Insert the longer projection of the spatula into the cervical os. Rotate it 360 degrees, keeping it flush against the cervical tissue. Withdraw the spatula, and spread the specimen on a glass slide. A single light stroke with each side of the spatula is sufficient to thin out the specimen over the slide. Fix the specimen and label as ectocervical. Then introduce the brush device into the vagina, and insert it into the cervical os until only the bristles closest to the handle are exposed. Slowly rotate one half to one full turn. Remove and prepare the slide. A single light stroke with each side of the spatula is sufficient to thin out the specimen over the slide. Fix the specimen and label as ectocervical. Then introduce the brush device into the vagina, and insert it into the cervical os until only the bristles closest to the handle are exposed. Slowly rotate one half to one full turn. Remove and prepare the endocervical smear by rolling the brush with moderate pressure across a glass slide. Fix the specimen and label as endocervical. Alternatively, both specimens can be placed on a single slide.

The broom-type brush is used for collecting ectocervical and endocervical cells at the same time. The broom has flexible plastic bristles, which are reported to cause less blood spotting after the examination. Introduce the brush into the vagina, and insert the central long bristles into the cervical os until the lateral bristles bend fully against the ectocervix. Maintain gentle pressure, and rotate the brush by rolling the handle between the thumb and forefinger three to five times to the left and right. Withdraw the brush, and transfer the sample to a glass slide with two single “paint” strokes. Apply first one side of the bristle, then turn the brush over, and paint the slide again in exactly the same area. Apply fixative and label as the ectocervical and endocervical specimen.

For the liquid preparation technology, using the broom-type device, insert the central bristles of the broom into the endocervical canal deep enough to allow the shorter bristles to fully contact the ectocervix. Push gently, and rotate the broom clockwise five times. Rinse the broom into the solution vial by pushing the broom into the bottom of the vial 10 times, forcing the bristles apart. As a final step, swirl the broom vigorously to further release material. Discard the collection device. Alternatively, deposit the broom end of the device directly into the collection vial. With any collection device, be sure to follow the manufacturer’s and laboratory instructions to collect and preserve the specimen appropriately. Close the vial tightly to prevent leakage and loss of the sample during transport. The liquid sample is also used to test for the HPV virus.

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Mar 25, 2017 | Posted by in PHYSIOLOGY | Comments Off on Female Genitalia

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