性器の内診 i: 評価
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Q1: How should you introduce a pelvic exam to make patients feel comfortable?
Establish an expectation of comfort at the start and invite patients to communicate questions and concerns throughout the visit. Ask about prior pelvic exam experiences and reassure them about what to expect. Use neutral, professional language—saying "assess" or "examine" instead of "touch" or "feel"—and refer to the "table" and "drape" rather than "bed" and "sheet." These strategies help patients feel empowered rather than vulnerable.
Q2: What anatomical structures are assessed during visual inspection of the external genitalia?
Visual inspection evaluates the mons pubis, labia majora and minora, clitoris, clitoral hood, urethral meatus, vaginal introitus, and perineum. The examiner assesses hair growth patterns, rashes, lesions, moles, masses, and discharge. The exam also screens for signs of domestic violence, female genital mutilation, hemorrhoids, skin tags, and fissures. A systematic approach ensures no potential findings are missed.
Q3: What is the modified lithotomy position and why is it used during a pelvic exam?
The modified lithotomy position involves raising the exam table back to 45-60 degrees with the patient's feet in footrests and knees extended sideways. This position allows the patient to see the examiner and facilitates the examination because the patient's internal organs sink into the pelvic basin, making them much easier to assess. It also enables better communication and patient control.
Q4: How do you perform digital assessment of the Bartholin's glands and Skene's glands?
To assess Bartholin's glands, lubricate your index finger and insert it into the vaginal introitus just beyond the first knuckle in palm-down position. Gently pinch tissue between your thumb and finger at five and seven o'clock positions. For Skene's glands, apply posterior pressure and rotate your palm up, then tap gently upward at one and eleven o'clock positions. Finish with a gentle beckoning motion at twelve o'clock to check for discharge.
Q5: What pelvic floor conditions are assessed using the Valsalva maneuver during digital vaginal examination?
The Valsalva maneuver—bearing down as if having a bowel movement—helps assess cystocele, which is anterior bladder prolapse, and rectocele, which is rectal herniation into the back wall of the vagina. The examiner applies downward pressure to assess cystocele and upward pressure to assess rectocele. These assessments help evaluate pelvic floor support and guide speculum selection.
Q6: How is pelvic floor muscle tone evaluated during the pelvic exam?
Pelvic floor muscle tone is assessed by asking the patient to squeeze around your inserted fingers as if stopping the flow of urine. This maneuver is called the Kegel exercise. A firm squeeze represents a healthy and toned pelvic floor, while weak or absent contraction may indicate pelvic floor dysfunction. This assessment provides important information about pelvic floor strength.
Q7: What preparation and setup steps should be completed before beginning the external genitalia assessment?
Ask the patient to change into a gown with underwear off and the gown open in the back, then provide a drape for their lap and step out for privacy. Set up all supplies beforehand, including lubricant squeezed onto a clean area before gloving. Ensure a trashcan, working light, and stool are near the exam table. Wash your hands, put on gloves, and establish non-invasive contact before beginning.