notes by dr Claudio Italiano
Vaginal exploration is the most important part of gynecological examination. It
is also called "combined exploration" or "abdominal-pelvic exploration." The
examination begins with the inspection of the vulva, for the description of
possible skin lesions (inflammatory, parasitic, neoplastic or traumatic), which
document the presence of fistulae and possible swelling (also in the seat of the
Bartolino glands) By gently introducing the gloved finger, the characteristics
of the vaginal mucosa are appreciated: in healthy women it is smooth and flowing,
and free of swelling.The tone of the sphincter apparatus (which could be
increased: vaginism) is appreciable: the vaginal fund is then evaluated, with
the cervix and vaginal arches.
With the palpation of the posterior vaginal fornix the existence of possible painful tumefactions of the Douglas switch is sought: in the event of intense pain, the sign indicates the presence of a collection (mostly infected) endoperitoneal. During vaginal exploration, it is possible to find the existence of specific pathologies of the hernia (cystoceles, rectoceles, elitrocele and eocele) that are most appreciated if the patient performs the Valsalva maneuver, or making cough, as well as existence ( and the relative degree) of a uterine prolapse. Vaginal exploration is performed in women who do not have the hymen intact, while in virgins excretion is generally performed rectally. Vaginal exploration must be done with great delicacy, so that you can appreciate the objective discovery in all its details during the visit. On the gynecological table the woman must be completely released and should therefore be invited to make sure that her back adheres to the sofa and does not have an arched attitude. It is also advised not to keep the arms raised towards the head, always to avoid a counterproductive abdominal tension.
After wearing gloves, the gynecologist spreads the big and small lips with one hand, and introduces the index of the other hand and, if the genitals are large, also the center, through the vulvar ovule and along the vaginal canal. Your finger or fingers must advance into the vagina until it reaches the neck of the uterus and the arches. It is helpful to lubricate the fingers before introducing them into the vagina. First of all, exploration must allow us to appreciate the state of the vulva and vagina, the consistency of the tissues present at this level, the presence of swelling (cysts of Bartolini's gland, cysts of the vagina), the resistance that opposes the perineal plane to the his depression at the time of the introduction of the scouting finger or fingers, the possible painfulness awakened by these maneuvers. In some women, particularly sensitive or heretic or affected by vaginismus, the introduction of a single finger is painful.
Once the finger has reached the portio, one must appreciate:
- the shape of the uterine neck (conical, squat, irregular, etc.) and its
volume;
- if the external uterine orifice is punctiform or beante or irregular for scars
on its contour, and if the cervical canal is patent to the same finger;
- the possible presence of polyps or any other material expelling, protruding
into the vagina from the uterine cavity. It is also important to specify the
consistency of the portio, which will be turgid in normal conditions, softened in
case of pregnancy, friable in case of cancer, etc. The fingers must run through
the four arches and appreciate its depth and softness. It will be necessary to
investigate whether there are any infiltrative facts or adhesions, with a
reduction in the width of the arches and if the pressure in the arches awakens
pain. With the help of the external hand resting on the abdominal wall, the
characteristics of the uterine body and the annexes can be appreciated. This
perception is more difficult in women with a very developed adipose tissue and
is practically useless in high-grade obese. It is usually noted first of all if
the uterus is in axis or not and what is its shape, its mobility, its volume (if
it is normal, higher or lower than normal in relation to the patient's age).
Having diagnosed a retroversion, we will see if the uterus can be shown on the
axis or not. If the uterus can be returned to the axis, it must be observed
whether its lifting is easy or difficult. However, we must not insist on this
maneuver if it awakens pain. After specifying the volume and position of the
uterus, check whether the surface of the bowel is regular or irregular (presence
of fibrous nodes). It is important to know the uterine consistency, whether it
is normal or whether it has decreased (as happens, for example, during pregnancy)
or if it has increased (such as fibromatosis or adenomyosis). We must also
ascertain whether the various movements on the bowels awaken pain or not. We
then move on to the examination of the parameters and annexes. Going through the
archway in a medium-lateral direction, one notices whether the parametrio is
free, soft, or if it is retracted or if there is an infiltration, whose
character (smooth and hard, nodular, etc.) must be specified. The characters of
the parameters are however better evaluated with rectal exploration.
The appreciation of the anexes is easy in women who have thin abdominal walls and can easily release during the visit, while it is more difficult and sometimes
impossible in obese women. We will try to evaluate the volume of the annexes, to see if they are in normal position, or stretched up or down, or prolapsed in
Douglas, if the pressure on them awakens pain or not, if they are fixed or mobile. The shape and the consistency of the tuba and the ovary (retortal tuba,
rosary-shaped tuba) are very important for orienting on the type of pathology present (sactosalpinge, outcomes of tubercular forms, etc.). The combined
maneuver is also essential for the examination of the annexes. The outer hand moves the appendages downwards until they come into contact with the inner
fingers placed in the furnace of the corresponding side. Then we examine the pelvic floor and the Douglas, their state of softness, the possible pain that
the pressure on them awakens, the conditions of the uterus-sacral ligaments (if they are stretched or painful, if they have gnarled formations along their
course ). In special cases, where the presence of endoabdominal neoformations is
suspected, but because of the obesity or intolerance of the patient the normal gynecological examination can not clarify the doubt, it is better to perform the
abdominal-vaginal exploration by placing the patient in narcosis.
The gynecological examination constantly requires that a speculum examination be performed. which can provide extremely interesting and valuable data for diagnosis. They are usually used: the bivalve speculum of Cusco or that of Collin. Today also transparent, sterile plastic speculum types are used, to be eliminated after use. It is necessary to have a series of vaginal speculum, from the smallest, which can also be introduced through an intact hymen, but sufficiently elastic (speculum for virgins), to the larger ones, to be used in cases of very wide vagina of vagina.