Vaginal examination
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knees flexed, does not afford such a good view of the ***** and does not permit the easy introduction of a speculum, but is a convenient position for bimanual palpation.
4. Lithotomy position If the examination is made under anaesthesia, this is the best position. The patient lies on her back, with the buttocks drawn to the edge of the table and the thighs abducted and flexed on the abdomen, and kept in position by supports. Because of the extent of the exposure, unanaesthetized patients do not like this position; nevertheless it is routinely used in other countries and in departments of genito-urinary medicine.
For vaginal examination the bladder must be empty. The examination is made in a methodical manner. First the presence or absence of vaginal discharge is noted, then the ***** and ******** are examined for signs of infection, ulceration, new growths or swellings. The ***** are separated and the urethral orifice is inspected; the urethra is compressed from behind forwards to see if there is any urethral discharge. The patient is asked to strain and cough; the presence of any stress incontinence is noted. The orifices of Bartholin’s ducts are examined.
To make a visual examination of the ****** a speculum is employed. Care must be taken to avoid hurting the patient. A sterile lubricant is used. This should be presented from a tube, so that it cannot become contami- nated and cause cross-infection of one patient by another. It should be transparent, so that discharge can be distinguished, and should not contain antiseptics which will interfere with bacteriological examination or the search for other organisms such as trichomonads.
Two forms of specula are in common use. (Fig. 6.1). 1. Sims’ speculum. This was devised to display vesicovaginal fistulae. It consists of two concave blades of different sizes, with a handle connecting
them.
2. Cusco’s or bivalve speculum. This consists of two blades fixed together by a hinge at the vulval end of the instrument. I t gives an excellent view of the cervix, and when screwed open remains steady in the ****** without being held.
Examination of discharge. The amount and nature of any discharge should be noted. Patients will occasionally complain of discharge when little or none exists, or alterna- tively deny all knowledge of an obviously copious discharge. A discharge may be mucoid; thick and white with infection with Candida albicans; purulent and offensive with infection with Trichomonas vaginalis; or blood-stained with a malignant ulcer or with a foreign body.
Although it is often possible to make a diagnosis of the probable cause of the discharge by clinical examination, diagnosis cannot be fmal without examining the discharge by the methods described in Chapter 13 (p. 108).
