PHYSICAL ASSESSMENT OF THE

FEMALE GENITALIA, ANUS & RECTUM

Structure and Function External
Genitalia or Vulva
External Genitalia or Vulva
❑Mons Pubis –is the flat pad located
over the symphysis pubis.
-functions to absorb
force and to protect the
symphysis pubis during coitus.
❑ Labia Majora – The main function of the labia majora along
with the coarse hairs on it is to keep away germs and bacteria
from entering the inner parts of the vagina and the urethra.

❑ Labia minora – labia minora close together, protecting

their inner mucous membrane and closing off the vaginal
entrance.

❑ Frenulum - is a small fold of tissue that secures or restricts

the motion of a mobile organ in the body.
❑ Clitoris –The clitoris is the center of sexual sensation
in women.

❑ Urethral meatus –Urethra meatus is the transport tube

leading from the bladder to which brings urine outside
the body. It is shorter in female than in the male. The
opening of the female urethra is beneath the vaginal
opening.
❑ Paraurethral (Skene’s) glands -
are glands located on the anterior wall of the vagina,
around the lower end of the urethra. They drain into the
urethra and near the urethral opening and may be near or
a part of the G-spot.

❑ Hymen -it tends to keep germs and dirt out of the vagina. In
infants and children, the hymen can serve a protective
purpose by helping to prevent things from being pushed into
the vagina
❑ Vestibular (Bartholin’s) glands –They secrete
mucus to provide vaginal lubrication. And secrete
relatively minute amounts (one or two drops) of fluid
when a woman is sexually aroused.
 Function of Internal Genitalia
❑ Vagina -this passage leads from the
opening of the vulva to the uterus (womb),
but the vaginal tract ends at the cervix

❑ Cervix -The function of the cervix is to allow

flow of menstrual blood from the uterus into
the vagina, and direct the sperms into the
uterus during intercourse.
❑ Anterior fornix and posterior fornix -Stimulation of the
fornices has been reported to enhance sexual pleasure for
some women.

❑ Rectouterine pouch or cul-de-sac of Douglas –Can serve

as a drainage point for fluids in the cavity.

❑ Uterus –A uterus is the place that a fetus develops.

Uterus also supplies antibodies to protect the young
one from infectious diseases,

❑ Fallopian tubes - The fallopian tubes connect the ovaries

to the uterus.
Objective Data: Physical Exam
• The physical exam of the female genitalia may create client
anxiety.
• The client may be very embarrassed about exposing her
genitalia and nervous that an infection or disorder will be
discovered.
• Be sure to explain in detail what you will be doing throughout
the examination.
• Encourage the client to ask questions. Begin by sitting on
a stool at the end of the examination table and draping the
Preparing the client:
• The client should be told ahead of time not to douche for 48 hours before
a gynecologic examination
• When the client arrives for the examination, ask her to urinate before the
examination so she does not experience bladder discomfort.
• When the client is back in the examination room ask her to remove her
underwear and bra and to put on a gown with the opening in the back
• After the client has changed and the nurse has returned to the room, the
nurse should help the patient into the dorsal lithotomy position.
• The client’s hip should be positioned toward the bottom of the examination
table.
• Ask the client to put her hands over her head. She should relax her
hands at her sides.
Physical Assessment:
External Genitalia Normal Findings Abnormal Findings
Inspection: Inspect -pubic hair is distributed in an -Absence of pubic hair in the
the Mons Pubis. inverted triangular pattern and adult client is abnormal.
Wash your hands and there are no signs of -Lice or nits(eggs) at the base
put on infestation. of the pubic hairs indicate
gloves. As you begin the -Older clients may have gray, manifestation with pediculosis
examination note the thinning pubic hair. pubis.
distribution of the pubic -Some clients shave or This condition, commonly
hair. Also be alert of the pluck the pubic hair. Piercing reffered to as “crabs”, is most
signs of infestation. of the mons pubis are for often transmitted by sexual
aesthetics and do not contact.
enhance sexual pleasure.

Observe and palpate There should be no -Enlarged inguinal nodes may

inguinal lymph nodes. enlargement or swelling in indicate a vaginal infection or
the lymph nodes. may be the result of irritation
fromshaving pubic hairs.
Physical Assessment:
External Genitalia
Normal Findings Abnormal Findings
Inspect the Labia -The Labia majora are equal in size and -Lesions may be from an
majora and perineum. free of lesions, swelling, and excoriation. A infectious disease such as
Observe the labia majora healed tear or episiotomy scar may be serps or syphilis. Excoriation
and perineum for visibleon the perineum if the clienthas and swelling may be from
lesions, swelling, given birth. The perineum should be scratching or self-treatment
excoriatio n. smooth. of the lesions. All lesions
must be evaluated and the
client referred for treatment.
Inspect the labia minora, -The labia minora appear symmetric, dark -Asymmetric labia may
clitoris, urethral meatus, pink, and moist. The clitoris is a small indicate abscess. Lesions,
and vaginal opening. Use mound or erectile tissue, sensitive of touch. swelling, bulging in the
your gloved hand to The normal size of the clitoris varies. The vaginal opening, and
separate the labia majora discharge are abnormal
and inspect for lesions, urethral meatus is small and slitlike. The findings. Excoriation may
excoriation, swelling and/or vaginal opening is positioned belowthe result from the client
discharge. urethral meatus. Its siz depends on sexual scratching or self-treating a
activity or vaginal delivery; may be covered perineal irritation.
partially or completely by hymen.
Physical Assessment:
External Genitalia
Normal Findings Abnormal Findings
Palpation: -Bartholin’s glands are Swelling, pain and discharge
Palpate Bartholin’s glands. If the client has usually soft, non tender, and may result from infection and
labial swelling or a history of it, palpate drainage free. abscess. If you detect a
Bartholin’s glands for swelling, tenderness discharge, obtain a
and discharge. Place your index finger in specimen to send to the
the vaginal opening and your thumb on the laboratory for culture.
labia majora. With a gentle pinching
motion, palpate from the inferior portion of
the posterior labia majora to the anterior
portion. Repeat on the opposite side.
Palpate the urethra. if the client repots -No drainage should be noted Drainage from the urethra
urethral symptoms of urethritis, or if you from the urethral meatus. The indicates possible urethritis.
suspect inflammation of Skene’s glands, area is normally soft and non- Any discharge should be
insert your gloved index finger into the tender. cultured. Urethritis may occur
superior portion of the vagina and milk the with infection with Neisseria
urethra from the inside, pushing up and out. gonorrhoeae or Chlamydia
trachomatis.
Physical Assessment:
Internal Genitalia
Normal Findings Abnormal Findings
Inspection: - The normal vaginal - Cervical enlargement or
Inspect the size of the vaginal opening opening varies in size projection into the vagina
and the angle of the vagina. Insert your according to the client’s age, more than 3cm may be from
gloved index finger into the vagina, noting sexual history and whether prolapse or tumor, and
the size of the opening. Then attempt to she has given birth further evaluation is
touch the cervix. This will help you vaginally. The vagina is needed.
establish the size of the speculum you typically tilted posteriorly at
need to use for the examination and the a 45-degree angle.
angle at which to insert it.
Inspect the vagina. Unlock the -The vagina should appear -Reddened areas, lesions,
speculum and slowly rotate and pink, moist, smooth and free and colored, malodorous
remove it. Inspect the vagina as you of lesions and irritation. It discharge are abnormal
remove the speculum. Note the vaginal should also be free of any and may indicate vaginal
color, surface, consistency, and any colored malodorous infections.
discharge. discharge. STD’s or cancer.
Physical Assessment:
Internal Genitalia
Normal Findings Abnormal Findings
Inspect the vaginal -the client should be -absent or decreased ability to squeeze
musculature. Keep your index able to squeeze the examiner’s finger indicates decreased
finger inserted in the client’s around the examiner’s muscle tone. Decreased tone may
vaginal opening. Ask the client to finger. Typically, the decrease sexual satisfaction.
squeeze around your finger. nulliparous woman Bulging of the anterior wall may
Use your middle and index can squeeze tighter indicate a cystocele. Bulging of the
fingers to separate the labia thann the posterior wall may indicate rectocele. If
minora. Ask the client to bear multiparous woman. the cervix or uterus protrudes down, the
down. No bulging and no client may have uterine collapse. If urine
urinary discharge. leaks out, the client may have stress
incontinence.
Inspect the cervix. Follow the -the surface of the In a pregnant woman, a bluish cervix
guidelines for using a speculum in cervix is normally may indicate cyanosis.
equipment. With the speculum smooth, pink and In a non menopausal woman, a pale
inserted in position to visualize even. Normally, it is cervix may indicate anemia. Redness
the cervix, observe cervical color, midline position and may be from inflammation.
size, and position. projects 1 to 3cm
into the vagina.
Physical Assessment:
Internal Genitalia Normal Findings Abnormal Findings
Palpation:
Palpate the vaginal wall. Tell -the vaginal wall should feel -tenderness or lesions may
the client that you are going to do a smooth and the client should not indicate infection.
manual examination and explain its report any tenderness.
purpose. Apply water soluble lubricant
to the gloved index and middle fingers
of your dominant hand. Then stand and
approach the client at the correct at the
correct angle. Placing your
nondominant hand on the client’s lower
abdomen, insert your index and middle
fingers into the vaginal opening. Apply
pressure to the posterior wall and wait
for the vaginal wall to relax before
palpating the vaginal walls.
Palpate the cervix. Advance your -The cervix should feel firm and -A hard immobile cervix may
fingers until they touch the cervix and soft. It is rounded, and can be indicate cancer. Pain with
run fingers around the circumference. moved somewhat from side to movement of the cervix may
Palpate for: contour, mobility, side without eliciting tenderness. indicate infection.
consistency, tenderness.
Physical Assessment:
Internal Genitalia Normal Findings Abnormal Findings
Palpate the ovaries. Slide -Ovaries are approximately -Enlarged size, masses,
your intravaginal fingers 3x2x1cm and almond shape. immobility and extreme
toward the left ovary in the tenderness are abnormal and
left lateral fornix and place should be evaluated.
your abdominal hand on the
left lower abdominal
quadrant. Press your
abdominal hand toward your
intravaginal fingers and
attempt to palpate the ovary.
 Guidelines for Using a Speculum
1. Before using the speculum, choose the instrument 2. Encourage the client to take deep breaths and to
that is the correct size for the client. Vaginal speculums maintain her feet in the stirrups with her knees resting
come in two basic types: in an open, relaxed fashion.
• Graves speculum—appropriate for most adult women 3. Place two fingers of your nondominant hand against
and available in various lengths and widths. the posterior vaginal wall and wait for relaxation to
• Pederson speculum—appropriate for virgins and occur.
some postmenopausal women who have a narrow 4. Insert the fingers of your nondominant hand about
vaginal orifice. Speculums can be metal with a thumb 2.5 cm into the vagina and spread them slightly while
screw that is tightened to lock the blades in place or pushing down against the posterior vagina.
plastic with a clip that is locked to keep the blades in
place. (Plastic speculums are shown in Figure A.)
Guidelines for Using a Speculum

A.
 Guidelines for Using a Speculum
5. Lubricate the blades of the speculum with When the blades pass your fingers inside the vagina,
vaginal secretions from the client. Do not use rotate the closed speculum so the blades are in a
horizontal position (Figure B).
commercial lubricants on the speculum. Lubricants
➤ Clinical Tip • Be careful during the speculum insertion
are typically bacteriostatic and will alter vaginal pH not to pinch the labia or pull the pubic hair. If the vaginal
and the cell specimens collected for cytologic, orifice seems tight or you are having trouble inserting the
speculum, ask the client to bear down. This may help relax
bacterial, and viral analysis. the muscles of the perineum and promote opening.
6. Hold the speculum with two fingers around the 8. Continue inserting the speculum until the base
blades and the thumb under the screw or lock. This touches the fingertips inside the vagina.
is important for keeping the blades closed. Position 9. Remove the fingers of your nondominant hand
from the client’s posterior vagina.
the speculum so the blades are vertical.
10. Press handles together (Figure C) to open blades
7. Insert the speculum between your fingers into
and allow visualization of the cervix.
the posterior portion of the vaginal orifice at a 45-
11. Secure the speculum in place by tightening the
degree angle downward.
thumb screw or locking the plastic clip (Figure D).
Guidelines for Using a Speculum
HEALTH PROBLEMS OF GENITOURINARY SYSTEM
❑ Amenorrhea –is an abnormal absence of menstruation.
-There are two types of amenorrhea: primary amenorrhea and secondary
amenorrhea. Primary amenorrhea is when a young woman has not had
her first period by the age of 16. Secondary amenorrhea is when a
woman who has had normal menstrual cycles stops getting her monthly
period for three or more months.

❑ Anuria -Failure of the kidneys to produce urine. Caused by failure in

the function of kidneys. It may also occur because of some severe
obstruction like kidney stones or tumors.
❑ Bacteriuria -The presence of bacteria in the urine. This is
typically an indication of a urinary tract infection

❑ Calculus/Calculi- A stone in the kidney (or lower down in

the urinary tract). Also called a kidney stone.

❑ Cryosurgery -Connective tissue separates the pelvic

organs. The tissue, called fascia, is attached to nearby
muscles. When healthy, the fascia and muscles support the
bladder, vagina and rectum. Defects in the fascia can cause
cystoceles and rectoceles.
❑ Dysuria -Painful or difficult urination.

❑ Hematuria -The presence of blood in urine.

❑ Hyperplasia - is a condition of excessive proliferation of the cells

of the endometrium, or inner lining of the uterus.

❑ Menorrhagia -Abnormally heavy bleeding at menstruation

❑ Metrorrhagia -Abnormal bleeding from the uterus.

❑ Nephrolithiasis -the presence of kidney stones (calculi) in the kidney.

❑ Nocturia -excessive urination at night.

❑ Oligomenorrhea -abnormally light or infrequent menstruation

❑ Oliguria -The production of abnormally small amounts of urine.

❑ Ovarian cyst -a cystic tumor (usually benign) of the ovary.

❑ Polyuria -Production of too much dilute urine.

❑ Pyuria -The presence of pus in the urine, typically from

bacterial infection.
❑ Retrograde menstruation -The backward flow of
menstrual blood up into the fallopian tubes, thought to
be a cause of endometriosis.

❑ Retroversion/retroflexion -is a uterus that is tilted

backwards instead of forwards.

❑ Toxic Shock Syndrome (TSS) -Acute septicemia in

women, typically caused by bacterial infection from a
retained tampon
❑ Urolithiasis -The formation of stony concretions in the
bladder or urinary tract.

❑ Uterine prolapse - Uterine prolapse occurs when

pelvic floor muscles and ligaments stretch and
weaken, providing inadequate support for the uterus.
The uterus then slips down into or protrudes out of
the vagina.
❑ Vesicoureteral reflux -is an abnormal movement of
urine from the bladder into ureter or kidneys.
• Abscess of the Bartholin’s gland- a
painful condition and common sign of
Neisseria gonorrhoeae infection.
• Syphilitic Chancre-often most
appear on the perianal area
as silvery white papules that
become superficial red ulcers.
Syphilitic chancr are painless.
They are sexually transmitted
and usually develop at the site
of initial contact with the
infecting organism.
• Genital Herpes Simples-
The initial outbreak of
herpes may have many
small, painful ulcers with
erythematous base.
Recurrent herpes lesions
are usually not as
extensive.
• Rectocele- is bulging in the posterior vaginal wall caused
by weakening of the pelvic musculature. Part of the rectum
covered by the vaginal mucosa protrudes into the vagina.
• Cystocele- is a bulging in the anterior vaginal wall
caused by the thickening of the pelvic musculature.
As a result, the bladder caused by vaginal mucosa,
prolapses into the vagina.
• Uterine Prolapse- It occurs when the uterus
protrudes into the vagina. It is graded according
to how far it protrudes into the vagina.
• Cervical Polyp- A polyp typically develops in the endocervical
canal and may protrude visibly at the cervical os. It is soft, red
and rather fragile. Cervical polyps are benign.
• Trichomoniasis- this type of vaginal infection is
caused by a protozoan organism and is usually
sexually transmitted. This infection causes
itching and urinary frequency in the client.