Examination by a gynecologist is a mandatory and regular procedure for every woman. It is used both for the prevention of disorders of the genitourinary system, and in order to identify serious abnormalities in it.
Gynecological examination helps to find out the state of the genitourinary system
What is a gynecological examination for?
An important procedure for maintaining women's health is examination.
At a doctor's appointment, a woman must visit:
- for preventive purposes - at least 1 visit every 6–12 months (even if there are no complaints);
- during pregnancy (the schedule of visits is individual) - at least once every 3-4 weeks for the first 2 trimesters, and starting from 7-8 months, visits to the doctor are carried out almost weekly;
- after childbirth, be sure to undergo an examination after 2-3 days, then after 1.5-2 months and, if there are no complaints, regularly once every six months or a year.
The procedure allows the doctor to assess the external and internal state of the vagina.
With a superficial examination, the specialist pays attention to:
- skin (degree of dryness or greasy epidermis);
- hairline (hair growth, the presence of lep);
- labia (seals, growths, bulges);
- color of the mucous membrane of the genitals.
During the examination, the doctor checks in detail the genital structures - the clitoris, the labia (internal), the urethra, the cervix, the hymen (if any).
Gynecological examination involves the mandatory delivery of biological material - a smear for flora. This is done both for prevention and to identify the source of negative disorders in the genitourinary system.
Gynecological examination provides for a smear on the flora
An experienced doctor with an external examination can immediately determine the existing pathological abnormalities:
- inflammation, eczema, ulcerative processes, warts, papillomas, warts, tumors;
- hypoestrogenism (labia are pale, increased dryness of the mucous membrane of the uterus and vagina);
- high levels of estrogen in the body (discoloration of the vulva, profuse vaginal discharge);
- pregnancy (bright red genitals, which is associated with increased blood flow to the pelvic organs and hormonal changes in the body);
- hyperandrogenism (the clitoris is enlarged and distant from the urethra, the labia (internal) are poorly developed).
How to prepare for an examination by a gynecologist?
Before going to the gynecologist, you need to properly prepare.
- Avoid sexual intercourse 3 days before visiting a doctor.
- Do not douche or use a deodorant hygiene medium on the day of your doctor's appointment.
- Carry out the hygiene of the genitals with plain water without strong pressure on the genitals.
- The bladder and rectum should be empty before being examined.
Thorough preparation for the gynecological procedure allows the doctor to assess the real state of the genitourinary system and obtain reliable smear results on the flora.
Perform genital hygiene before going to the gynecologist
How is the examination by the gynecologist going?
An examination by a female doctor begins with a survey of the patient:
- complaints are studied (pain when visiting the toilet, during sex, the presence of rashes, the nature of the discharge);
- the doctor asks about the menstrual cycle (at what age it began, are there any failures, how many days, what abundance, the date of the last menstruation);
- data on reproductive function is collected (presence of pregnancies, childbirth, abortions, miscarriages);
- the sexual aspect is being studied (the presence of a sexual partner, the use of contraception);
- the doctor is interested in the previous diseases of the genitourinary system.
The next step is examination on the gynecological chair. It includes 2 stages - with the help of mirrors and bimanual (palpation with both hands). For each category of women (children, pregnant women, virgins, after childbirth), the procedure is different.
During pregnancy
A doctor's examination begins early in the gestation period (the first time at 8-12 weeks). At this time, an internal examination of the cervix and perineum with a mirror is performed. The purpose of the procedure is to find out the general condition of the genital organ and exclude an ectopic pregnancy. A smear for flora (bacteriological culture) and a cytological smear (for detecting malignant changes) must be taken. To do this, you need to bring with you a gynecological kit (sold in any pharmacy).
In addition to manipulating the gynecological chair, the doctor measures the patient's weight and height, pressure, pulse, studies the position of the uterus and the width of the pelvis. The survey will include information about hereditary diseases, chronic pathologies and bad habits.
From week 15, internal examinations are not performed on the chair. Now, at each visit, the doctor measures the patient's abdominal circumference, the standing of the fundus, and listens to the baby's heartbeat with a stethoscope. Pressure, pulse and weight remain mandatory parameters.
Up to 29 weeks, visits to the gynecologist are limited to 1 time in 3 weeks. Further, visits to the doctor become more frequent - 1 visit every 14 days. Starting from 36 weeks - visits every 7 days. 10-15 days before delivery, there is a need for a gynecological examination again. It is important to check the readiness of the birth canal through which the child will pass, as well as the state of the pharynx - the opening of the cervix.
For the entire period of gestation, a woman needs to lie on a gynecological chair at least 5-6 times. It all depends on the course of pregnancy and possible deviations.
After childbirth
Natural childbirth and a normal postpartum period require a visit to the doctor, when the discharge will take on a natural character - it will not be profuse and bloody. The purpose of the examination is to check the condition of the birth canal, the formation of the uterus - whether the organ is in place, the degree of its contraction to normal size, to examine the seams (if any), their healing.
The specialist examines the woman first with a mirror, then takes a smear. Then he palpates - 2 fingers sticks into the vagina, and with the fingers of the second hand presses on the stomach closer to the groin area. This allows you to determine the density of tissues, check the appendages, find out if there are any extraneous seals or scarring on the uterus and its neck,
Medical examination at school
For the first time, girls' genitals are examined in the maternity hospital, then at 1 year old and before entering the kindergarten. At school, visits to a gynecologist for the first time begin at the age of 12-14. Girls are examined exclusively by a pediatric gynecologist.
The examination process consists of a survey (complaints, first menstruation) and examination of the genitals. The girls sit on a couch, where the doctor palpates through the rectum. With the other hand, the specialist presses on the peritoneum. In the absence of complaints about the sexual sphere, such manipulation may not occur.
Before the examination, the pediatric gynecologist conducts a survey
In adolescents who are not sexually active, a smear is taken with a special thin device, which allows not to injure the hymen. The examination of underage girls who already have intimate relationships is carried out similarly to the usual preventive visit of adult women.
Virgin at the gynecologist
The examination of a virgin is carried out in the same way as for a little girl - through the anus. The doctor checks the condition of the external genital organs, palpates the abdomen, and probes the uterus with his finger through the anus. The smear is taken with a thin instrument, the examination with a mirror is not performed.
Virgin examination goes through the anus
Before the onset of sexual activity and in the absence of complaints from the genital area, it is enough to visit a doctor once every 1-2 years.A gynecological examination helps to identify pathological changes in the early stages of development, monitor the course of pregnancy and regularly monitor the state of the reproductive organs. For prevention purposes, a woman needs to visit a doctor at least 1 time per year. If there are complaints, do not hesitate to visit a specialist - a timely examination can prevent dangerous diseases.
BIMANUAL RESEARCH TECHNIQUE
General information: bimanual examination is the main method for recognizing diseases of the uterus, appendages, pelvic peritoneum and cellulose, determining the duration of pregnancy.
Indications:
1) preventive examination;
2) examination of gynecological patients, pregnant women.
Workplace equipment:
1) gynecological chair;
2) gloves;
3) containers with a disinfectant;
4) an individual card of a pregnant and postpartum woman;
5) medical card of an outpatient patient;
6) antiseptic;
7) rags.
Inform a pregnant or gynecological patient about the necessity and essence of manipulation.
Suggest the patient to empty the bladder.
Cover the chair with an individual diaper or a disposable napkin.
Lay on a gynecological chair in a supine position, legs bent at the hip and knee joints and divorced.
Produce a toilet for the external genitalia according to indications.
Wash hands and wear sterile gloves.
The main stage of the manipulation.
With your left hand, push the large and small labia apart.
Insert the second and third fingers of the right hand into the vagina along the back wall.
Find out the state of the vagina: volume, folding, extensibility, the presence of pathological processes, swelling, scars, narrowing, the state of the vaginal vaults.
10. Find out the state of the cervix, determine its shape, consistency, mobility, sensitivity when displaced.
11.To determine the state of the uterus, put the left hand on the lower abdomen, the right - in the anterior fornix, while it is possible to determine the position, shape of the uterus, size, consistency, mobility, soreness.
12.To determine the condition of the uterine appendages, the fingers of the outer and inner hands are transferred from the corners of the uterus to the lateral surfaces of the pelvis (the ovaries and fallopian tubes are examined, size, shape, soreness, mobility). Normally, the appendages are not palpable.
13. With the help of the inner hand, palpate the inner surface of the pelvis (sciatic spines, sacral cavity, presence of exastoses).
14. Removing the right hand from the vagina, carefully examine it for the presence of discharge, their nature.
The final stage of the manipulation:
15. Remove gloves, wash hands, place gloves in a container with a disinfectant.
16. Record the received data in the medical documentation.
17. Put on gloves, remove the diaper.
18. Treat the chair with disinfectant.
3. Examination of the cervix
Equipment. Sterile: Sims spoon mirror and Ott's flat lift or Cusco double mirror, 2 forceps, rubber gloves, cotton balls, diaper; other: gynecological chair, patient's individual diaper, antiseptics.
Note. Be sure to warn the patient so that, on the eve of the manipulation, she empties the bladder, rectum and performs the toilet of the external genital organs.
1. Wash and dry your hands. 2. Remove the sterile diaper from the bix with sterile tweezers, put it on the table near the gynecological chair and unfold. 3. Observing the rules of asepsis, place on the diaper: vaginal speculum, 2 forceps, rubber gloves, cotton balls. 4. Conduct psychological preparation of the patient. 5. Suggest the patient to put an individual diaper on the gynecological chair and undress to the waist from below. 6. Help the patient to lie down on the gynecological chair (see practical skills "Toilet of the external genital organs"). 7. Wear sterile rubber gloves. 8. Go to the gynecological chair and stand at the woman's feet. 9. Treat the external genital organs with an antiseptic solution in accordance with the practical skills "Toilet of the external genital organs".
Note. The study is carried out with a Cusco bivalve mirror or with a Sims spoon mirror and an Ott flat lift.
Inspection with a mirror Cusco
10. Fold the Cuzco mirror closed, holding it in your right hand. 11. With the thumb and forefinger of the left hand, part the labia in the lower third. 12. The Cuzco speculum should be carefully inserted into the vagina up to half, placing the closed flaps parallel to the genital slit. 13. In the vagina, turn the mirror 90 ° with the ratchet down and insert, directing it to the posterior fornix. 14. Carefully open the mirror, pressing on the parts of the rack, expose the cervix so that it is located between the shutters of the mirror. 15. If necessary, fix the mirror with the lock screw. 16. Examine the cervix.
Note. If the cervix is covered with mucus and this interferes with its examination, remove the mucus with a cotton ball on the forceps.
17.Using the screw, loosen the lock so that the mirror shutters move freely and do not compress the cervix. 18. Examine the walls of the vagina, removing the speculum, having previously squeezed to a semi-closed state.
Inspection with Sims mirror and Ott lift
19. Take Sims's spoon-shaped mirror with your right hand. 20. With the thumb and forefinger of the left hand, part the labia in the lower third. 21. Insert the speculum into the vagina up to half, placing it obliquely to the genital slit. 22. In the vagina, turn the speculum with the handle down and push it forward. 23. With a mirror, gently press on the back wall of the vagina, expanding the opening. 24. In parallel to the rear mirror, insert the front mirror - Ott's lift and raise the front wall of the vagina with it. 25. Remove the cervix so that it is located between the mirrors. 26. Examine the cervix. 27. Examine the vagina by removing the mirrors in the reverse order: first, remove the lifter by examining the front wall of the vagina. 28. Then remove the rear mirror, examining the back and side walls of the vagina. 29. Remove the rubber gloves and place them in the waste container. 29. Remove the rubber gloves, put them in the container for the material worked. 30. Help the woman to get up from the chair and offer to get dressed. 31. Disinfect used equipment. 32. Wash and dry hands. 33. Make a note in the appropriate medical document.
General information: colposcopy - examination of the vaginal part of the cervix, the border of the stratified squamous and cylindrical epithelium of the surface of the endocervix, vagina and external genital organs with an optical device (colposcope) with an illuminator at 4-30 times magnification. Distinguish between simple and extended and simple colposcopy. With the help of a simple colposcopy, the shape and size of the cervix, external os, the color and relief of the mucous membrane, the transition zone of the squamous and cylindrical epithelium, and the vascular pattern are determined. Extended colposcopy is based on the use of pharmacological agents (3% acetic acid solution, Lugol's solution) to detect structural changes in tissues at the level of the cell and its components. It allows you to examine a specific area with sufficient optical magnification, as well as to produce targeted biopsy.
Indications:
1) diagnostics of diseases of the cervix and vagina; 2) examination of a gynecological patient before abdominal gynecological operations.
Contraindications:
1) bleeding;
2) menstruation.
Workplace equipment:
1) colposcope;
2) 3% acetic acid solution;
3) cotton balls, tweezers;
4) Lugol's solution;
5) ethyl alcohol 70 º;
6) vaginal speculum;
7) sterile gloves;
gynecological chair;
9) individual diaper.
Sequence of execution:
The preparatory stage for performing the manipulation.
The patient is placed on a gynecological chair covered with an individual diaper, a toilet of the external genital organs is performed.
The midwife prepares the necessary instruments, material, solutions.
Washes hands, dries, puts on sterile gloves.
The main stage of the manipulation.
The midwife assists the doctor
The final stage of the manipulation.
Place used tools and gloves in different containers with disinfectant.
In most cases, one of the signs of a normal structure and intact functions of the reproductive system is, as you know, the appearance of the external genital organs. In this regard, it is important to determine the nature of the pubic hair, the amount and type of hair distribution. Examination of the external and internal genital organs provides significant information, especially in women with menstrual irregularities and infertility. The presence of hypoplasia of small and large lips, pallor and dryness of the vaginal mucosa are clinical manifestations of hypoestrogenism. "Juicy", cyanotic color of the vulvar mucosa, abundant transparent secretion are considered signs of an increased level of estrogen. During pregnancy, due to congestive plethora, the color of the mucous membranes acquires a cyanotic color, the intensity of which is the more pronounced, the longer the gestation period. Hypoplasia of the small lips, an increase in the head of the clitoris, an increase in the distance between the base of the clitoris and the external opening of the urethra (more than 2 cm) in combination with hypertrichosis indicate hyperandrogenism. These signs are characteristic of congenital virilization, which is observed only in one endocrine pathology - VHKN (adrenogenital syndrome). Such changes in the structure of the external genital organs with pronounced virilization (hypertrichosis, coarsening of the voice, amenorrhea, atrophy of the mammary glands) make it possible to exclude the diagnosis of a virilizing tumor (both of the ovaries and adrenal glands), since the tumor develops in the postnatal period, and OHCI is a congenital pathology that develops antenatally, during the formation of the external genital organs.
In giving birth, attention is paid to the condition of the perineum and genital fissure. In normal anatomical relationships of the perineal tissues, the genital slit is usually closed, and only with a sharp straining does it slightly open. With various violations of the integrity of the pelvic floor muscles, developing, as a rule, after childbirth, even a slight tension leads to a noticeable gaping of the genital fissure and prolapse of the vaginal walls with the formation of cysto and rectocele. Often, when straining, prolapse of the uterus is observed, and in other cases, involuntary urination.
When assessing the condition of the skin and mucous membranes of the external genitals, various pathological formations are revealed, for example, eczematous lesions and condylomas. In the presence of inflammatory diseases, the appearance and color of the mucous membranes of the external genital organs can be sharply changed. In these cases, the mucous membrane can be intensely hyperemic, sometimes with purulent deposits or ulcers. All altered areas are carefully palpated, determining their consistency, mobility and soreness. After examination and palpation of the external genital organs, they proceed to the examination of the vagina and cervix in the mirrors.
Examination of the cervix using mirrors
When examining the vagina, the presence of blood, the nature of the discharge, anatomical changes (congenital and acquired) are noted; condition of the mucous membrane; pay attention to the presence of inflammation, masses, vascular pathology, trauma, endometriosis. When examining the cervix, attention is paid to the same changes as when examining the vagina. But at the same time, you need to keep in mind the following: with bloody discharge from the external uterine pharynx outside of menstruation, exclude malignant tumor the cervix or body of the uterus; at cervicitis there are mucopurulent discharge from the external uterine pharynx, hyperemia and sometimes erosion of the cervix; cervical cancer is not always possible to distinguish from cervicitis or dysplasia, therefore, at the slightest suspicion of malignant tumor biopsy is shown.
For women who are sexually active, the vaginal self-contained mirrors of Pederson or Grave, Cuzco, as well as a spoon-shaped mirror and a lift are suitable for examination. Folding self-contained mirrors of the Cuzco type are widely used, since when using them you do not need an assistant and with their help you can not only inspect the walls of the vagina and the cervix, but also carry out some medical procedures and operations
To examine the patient, choose the smallest mirror that allows a full examination of the vagina and cervix. Folded mirrors are inserted into the vagina in a closed form obliquely in relation to the genital slit. Having advanced the mirror to half, turn it with the screw part down, at the same time move it inward and push the mirror apart so that the vaginal part of the cervix is between the separated ends of the flaps. With the help of a screw, the desired degree of vaginal expansion is fixed
During the study, using mirrors, the state of the vaginal walls is determined (the nature of folding, the color of the mucous membrane, ulceration, growth, tumors, congenital or acquired anatomical changes), the cervix (size and shape: cylindrical, conical; shape of the external pharynx: round in nulliparous, in the form of a transverse slit in those giving birth; various pathological conditions: ruptures, ectopia, erosion, ectropion, tumors, etc.), as well as the nature of the discharge.
Examining the walls of the vagina and the cervix when detecting bleeding from the external uterine pharynx outside of menstruation should be excluded malignant tumor cervix and body of the uterus. At cervicitis observe mucopurulent discharge from the cervical canal, hyperemia, erosion of the cervix. Polyps can be located both on the vaginal portion of the cervix and in its canal. They can be single or multiple. Also, when visually assessing the cervix with the naked eye, closed glands (ovulae nabothi) are determined. In addition, when examining the cervix in the mirrors, one can find endometrioid heterotopies in the form of "eyes" and linear structures of cyanotic color. In differential diagnosis with closed glands, a distinctive feature of these formations is considered the dependence of their size on the phase of the menstrual cycle, as well as the appearance of bleeding from endometrioid heterotopies shortly before and during menstruation.
Cervical cancer during a gynecological examination can not always be distinguished from cervicitis or dysplasia, therefore it is imperative to make smears for cytological examination, and in some cases - to make a targeted biopsy of the cervix. Particular attention is paid to the fornices of the vagina: it is difficult to examine them, however, there are often volumetric formations and genital warts. After removing the mirrors, a bimanual vaginal examination is performed.
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Introduction
The examination of the male genital organs differs from the examination of other organs or systems in that it is not difficult to examine and palpate the male genital organs. However, many doctors perform only the most superficial examination of the genitals. This is a mistake, because a significant number of the most common malignant diseases of the male genital organs can be detected already on physical examination.
Testicular cancer, the most common type of malignant tumor in men aged 25-30, is easily detected by palpation. Prostate cancer can also be easily detected by palpation. In this regard, male external genitalia must be examined carefully and gently. If significant pathological changes or deviations in the development of this area are detected, the patient should be referred to a urologist.
1. Pubic region
Examination of the external genitalia can be performed with the patient in a vertical or horizontal position.
It should be noted the nature of hair growth in the pubic region, in adolescents - to characterize the stage of sexual development according to Tanner.
It is necessary to describe the obvious pathological changes in the skin in this area (the presence of venereal warts, rash or signs of scabies). To detect a pathologically enlarged bladder (which indicates its inadequate emptying), an examination of the suprapubic region should be carried out by examination, percussion and palpation.
2. Penis
The penis consists of two paired, erectile corpus cavernosum, and a smaller, unpaired, erectile corpus spongiosum (corpus spongiosum penis), located ventrally in the midline and surrounding the urethra.
The distal part of the penis is covered, like a cap, by the formation of a conical shape - the head of the penis. The proximal, rounded edge of the head is called the crown. On examination, the presence or absence of the foreskin (preputium penis) should be noted. In adults, the foreskin should be easily retracted behind the head, thus exposing the surface of the inner layer of the foreskin and the head. Any difficulty indicates the presence of acute or chronic inflammation or scarring of the foreskin.
Phimosis is a situation in which exposure of the head is impossible due to narrowing of the foreskin ring or scarring. The elasticity of the foreskin tissue in children changes until about 5 years of age, after which it acquires mobility close to that of adults. Any attempt to remove the glans penis from the preputial sac by force is categorically unacceptable.
Paraphimosis is a situation in which the foreskin cannot be pushed onto the glans penis, as a result of squeezing and swelling of the glans penis.
Hypospadias - the location of the external opening of the urethra on the ventral surface of the penis.
Epispadias is the location of the external opening of the urethra on the dorsal surface of the penis.
Slightly squeezing the external opening of the urethra in the anteroposterior direction, you can examine the scaphoid fossa. This technique is especially important for young men who are more likely to get a sexually transmitted infection. Any discharge from the external opening of the urethra must be examined bacteriologically to exclude infection.
After examining the distal part of the penis, the shaft should be examined and palpated. Any curvature and asymmetry of the corpora cavernosa and head should be noted. Painful erections due to ventral curvature of the shaft of the penis are often associated with hypospadias.
3. Scrotum
The skin of the scrotum is normally wrinkled and very elastic. If there is a thickening, induration or a decrease in its elasticity, the presence of a pathological process in the skin should be suspected. At the same time, some conditions (congestive heart failure, liver failure) can manifest as swelling of the scrotum without any pathological process in the skin.
The size of the scrotum depends on the physique and tone of the underlying muscles (tunika dartos) at rest. The scrotal cavity is divided into two communicating spaces by a median septum. Within each of these spaces (hemiscrotum) are the testicle, epididymis and spermatic cord. Normally, all of these formations move freely within the hemiscrotum.
Some benign skin growths are common. Infection with Candida albicans, located in the scrotum and in the area of the femoral fold, is very common. The specified infection usually occurs in combination with diabetes mellitus, against the background of the use of antibiotics, immunosuppression and when the skin of the genitals becomes more "hospitable" to infection with increased humidity and sweating. A striking sign of candidiasis of the skin is bright red hyperemia. Tinea cruris is also a common fungal infection of the genital skin. In this condition, dark, reddish-brown spots appear on the front of the thighs. If a thin red spot is visible in the area of the most active area of inflammation along its periphery, then you can think of ringworm. Candidiasis and tinea cruris respond to conventional antifungal drugs such as naftifine hydrochloride and imidazole derivatives, although tinea cruris responds poorly to nystatin.
Pathological formations that are not associated with infection are often noted on the skin. An epidermoid cyst can be located anywhere on the body, but its favorite localization is the skin of the scrotum. These cysts stain the skin whitish, they are dense, 1-2 cm in diameter, and may be multiple. No special treatment is required until the patient seeks help for cosmetic reasons. Benign angiokeratomas are also often found. This lesion of the superficial tissues of the scrotum is observed in 20% of adult men and represents papular hemangiomas 1-2 mm in size, painted in colors from red to purple. Scattered over the surface of the scrotum. They are usually asymptomatic and do not require treatment. However, when bleeding occurs, electrocoagulation and treatment with a laser beam are indicated.
When examining the testicles, gently palpate between 1 and 2 fingers. The size, shape and consistency of the testicle should be described. The shape of the testicle is ovoid, its dimensions are about 4 cm or more in length and 2.5 cm in width. The testicles are dense and somewhat elastic in consistency. They are symmetrical in shape, size and consistency. When examining the testes in adolescents and men suffering from infertility, it is especially important to characterize the size of this paired organ.
Orchidometry instruments (ASSI. Westburn, NY) are available that can be used to quantify and compare testicular volume. The testicles should have a smooth surface and should be positioned in the scrotum. If the testicle is not palpable, the inguinal canal should be examined to rule out cryptorchidism. The presence of abnormalities on a flat, smooth surface of the testicles or a detected excess of tissue is an indication for an urgent referral of the patient to a urologist to exclude a tumor.
When palpating the testicles, difficulties are possible due to an increase in the scrotum, this may be due to the presence of dropsy of the testicular membranes (hydrocele). The testicle is covered with visceral and parietal sheets of the peritoneum (tunica vaginalis testis).
The accumulation of fluid between these two leaves leads to the formation of dropsy. Transillumination in a darkened room (using a fountain pen or similar light source) allows one to differentiate a fluid-filled mass (positive transillumination effect) from a dense mass of tissue. Sometimes, with auscultation of an enlarged scrotum, a peristalsis noise can be detected, which will indicate the presence of an inguinal-scrotal hernia.
examination urological genital prostate
5. Epididymis
The examination of the epididymis is directly related to the examination of the testicle, since the epididymis is usually located on the top and back of the testicle. The epididymis on both sides are located symmetrically and are accessible to direct palpation. The consistency of the epididemis is softer than the testicle, and on palpation is felt as a raised edge of the testis located behind. Examine the epididymis with extreme caution due to its great sensitivity.
Anatomically, the appendage can be divided into three segments: head, body, and tail. Each of the segments corresponds to the upper, middle and lower parts of the formation. An enlarged epididymis or pain on palpation is usually associated with an inflammatory process (epididymitis). A cystic formation in epididymal tissue, such as a spermatocele, transmits light and can therefore be detected by transillumination.
6. Seed cord
After completing the examination of the epididymis, it is necessary to palpate the spermatic cord. If the patient is in a horizontal position, then it is necessary for him to stand up, since this part of the examination with an upright position is more convenient to carry out. Usually, palpation begins in the middle of the distance between the outer ring of the inguinal canal and the testicle. It is not difficult to recognize the vas deferens (ductus deferens). In shape and consistency, it resembles a cord and is a bit like a braided electrical wire, but more elastic and slightly larger in diameter. If the vas deferens cannot be palpated, further special studies are indicated.
Other components of the spermatic cord are felt on palpation as a small ball of round helminths. Indeed, greatly enlarged and varicose veins of the vas deferens can give this impression. However, in most cases, varicocele is felt as a more tender mass. For more accurate identification, each spermatic cord is taken between the first three fingers of one hand. After palpation of the spermatic cord from other tissues, any increase in its vascular component is well felt. The patient is then asked to perform the Valsalva test (take a deep breath, hold his breath and strain). An increase in the palpable spermatic cord indicates the presence of a small varicocele. If the patient has a cremasteric reflex, then the result of the test may be less distinct. Although more often varicocele develops on the left side, a bilateral process is also quite possible.
Elastic, fleshy inclusions in the cord tissue may turn out to be a lipoma or, less commonly, a liposarcoma. Cystic formations of the cord, which lend themselves to transillumination, are most often small, local hydrocele. If the patient does not complain, then such findings do not require treatment. If the diagnosis is unclear, the patient should be referred to a urologist. The examination of the scrotum is completed after the exclusion of an inguinal hernia. The second finger of the hand is moved along the surface of the skin of the scrotum and along the spermatic cord proximally to the external inguinal ring. After a clear sensation of the external inguinal ring, the patient is asked to cough and perform a Valsalva test. The feeling of bulging or jolting at this point indicates the presence of an inguinal hernia. As a result, during the examination of the scrotum, the testicle, its epididymis, the spermatic cord and, finally, the external inguinal ring are sequentially palpated. Testicular enlargement is usually caused by a malignant tumor and requires careful differential diagnosis. Excess tissue in the area of the epididymis or spermatic cord is benign, but, nevertheless, requires the consultation of a urologist. A patient over 16 years of age should be given instructions for self-examination. Acute scrotal pain and other emergencies will be discussed separately in other sections.
7. Prostate gland
A complete examination of the male external genital organs includes examination of the per rectum with palpation of the prostate gland. It is recommended that all men over 50 undergo an annual rectal examination to examine the prostate gland, as well as an examination for the presence of prostate-specific antigen in blood serum (PSA). In young men, the prostate gland reaches 3.5 cm in diameter and 2.5 cm in length with a mass of 18-20 g. In configuration, it is similar to a chestnut. The prostate gland is usually enlarged in men over 50, although the normal size of the prostate varies greatly at different ages. Normally, the consistency of the prostate gland is comparable to the consistency of thenar when 1 toe is opposed to 5.
During digital examination of the prostate gland, the patient may be in different positions. Lying on your side (legs bent at the knee and hip joints and pulled up to the chest) provides an opportunity for a full examination. Another position is also possible, when the patient stands with his back to the doctor with a belt tilt at 90 °, leaning his elbows on the examination table. The doctor puts on a surgical glove, dips 2 fingers into a water-soluble lubricant. Spreads the patient's buttocks and initially examines the anus. Then 2 finger in a glove is placed in the anus and gently presses on it. This technique promotes relaxation of the anal sphincter, which allows rectal examination in the most favorable conditions and allows the doctor to assess the tone of the anal sphincter. After relaxation of the latter, the lubricated finger is carried to the fornix of the rectum above the prostate gland. The finger should be inserted as deep as possible to palpate the free posterior surface of the prostate gland.
Usually, the examination begins with palpation of the apex (located closer to the anal sphincter) of the gland and continues at its base. Wide finger movements allow the doctor to assess the size and characteristics of the lateral lobes of the gland and its central groove. Describing the detected changes, one should indicate their localization (right, left, apex, base, midline or lateral). The seminal vesicles originate from the base of the gland and are not normally palpable. On palpation of the prostate gland, its size is determined. Although urologists tend to express the size of the prostate gland in grams or in relative units from 0 to 4, it is still better to estimate the size in centimeters, specifying its width and length. In addition to the size of the organ, its symmetry should also be characterized. Asymmetry should be highlighted, as well as suspicion of malignant growth, inflammation or infection, which may arise if any irregularities or compaction is found in the gland. In acute inflammation of the prostate gland, pathological softness (tissue softer than normal) and pain on palpation can be felt. The presence of fluctuations indicates the occurrence of an abscess. Vigorous massage is contraindicated for acute inflammation of the prostate gland.
Before removing the finger, it is necessary to make a wide circular motion along the fornix of the rectum to exclude any pathological changes. After the examination, the patient should be offered a large gauze pad to remove excess lubricant from the perineum. After the examination of the prostate gland is completed, the discharge from the penis and prostatic juice must be examined microscopically.
8. Urine analysis
Urinalysis is an important part of the urological examination.
In non-concentrated urine, by immersing a tester stick in it, pH, glucose, protein, nitrite and leukocyte esterase are determined. After that, the urine sample is centrifuged for 3-5 minutes at a speed of 2500 rpm. The supernatant is discarded and the remainder is mixed with a small amount of urine remaining in the tube. Then carry out microscopy at low and high magnification (tab. 1-2).
In one field of view (FOV) of the microscope at high magnification, the number of leukocytes, erythrocytes, bacteria, salt crystals, yeast and cylinders is identified and counted. Bacteriological examination of urine is carried out in cases where, according to other urine tests or according to clinical data, it can be assumed that the patient has a urinary tract infection. If a test with a stick tester is positive for both nitrates and leukocyte estarase, then this is a strong argument in favor of the patient having a urinary tract infection. The same can be said if 4-5 bacteria are found in the centrifuged urine residue in the PZ.
9. Self-examination of the scrotum and testicles
Examination of the male external genitalia is an important part of any comprehensive physical examination of a patient with urologic symptoms. It is advisable to carry out it not only with a doctor. Every man aged 20-35 should have his own testicles examined monthly. Every year, a urologist should conduct a digital rectal examination in men over 50 years old, and in case of an unfavorable family history of prostate cancer, at the age of 40 years and older.
Regular (monthly) testicular self-exam is important because testicular cancers often affect young men, but if detected early, the disease is usually curable. The examination is simple and takes a few minutes.
The testicles in the scrotum feel like small, dense, hard-boiled eggs without a shell. On their posterior surface and apex is the epididymis, which is felt separately, like a ridge rising along the posterior surface of the testicle. In the epididymis, two parts are distinguished: the body and the tail, which is sometimes felt separately. The spermatic cord is attached to the upper pole of the testicle and goes up into the inguinal canal. It consists of muscle fibers, blood vessels and the vas deferens. The cord has a spongy structure, with the exception of the vas deferens, which is firm to the touch (like a twig) and feels like "macaroni".
First of all, examine the entire scrotum and the surface of the surrounding skin, note the presence of any rash, other painful formations, tumors. Then, gently feel the scrotum and its contents. After several such examinations, you will become familiar with the sensation of the healthy tissues that make up the testes, their epididymis, the vas deferens, and any abnormality will be immediately detected. Any changes that you see or feel should be addressed to your doctor.
It is advisable to conduct such a self-examination once in the doctor's office so that he can answer any questions that arise.
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External examination of patients begins with an assessment of the type of constitution. The infantile body type is characterized by small stature, proportional build, evenly narrowed pelvis. The mammary glands are small, with flat and small nipples, and there is insufficient development of hair on the genitals. The first menstruation in such women often occurs later than usual, and menstruation is characterized by irregularity and soreness. For women of the hypersthenic type, average height is characteristic, the length of the legs is insignificant in comparison with the length of the body. The subcutaneous fat layer is usually well developed. The specific functions of the female body are usually not changed. The asthenic type of women is characterized by anatomical and functional weakness of the muscular and connective tissue systems. Often there is an increase, lengthening and soreness of menstruation. After childbirth, they easily have prolapse of the vagina and uterus due to the weakness of the ligamentous apparatus and the muscles of the pelvic floor. Prolapse of the uterus is sometimes observed in nulliparous women with a pronounced asthenic constitution. Intersex women are usually quite tall, with a massive skeleton, and a wide shoulder girdle; the shape of the pelvis is close to that of the male. There is a growth of male pubic hair, hair growth on the legs. Hypoplasia of the genitals, menstrual dysfunction, infertility are often observed. There are various transitional options between the indicated basic types of constitution.
It is necessary to pay attention to the nature of hair growth, (especially excessive), the time of its appearance. It should be noted the presence of stretch stripes on the skin, their color. Pay attention to skin color. Pallor of the skin is most often due to anemia. Hyperpigmentation or depigmentation of the skin is associated with dysfunction of the endocrine glands.
The mammary glands are part of the reproductive system, a hormone-dependent organ, a target for the action of sex hormones. Examination of the mammary glands is carried out in a standing and lying position, followed by palpation of the outer and inner quadrants of the gland. It is necessary to take into account the structure and size of the mammary gland. In all patients, attention should be paid to the presence or absence of discharge from the nipples, its color, consistency. Discharge brown or mixed with blood indicates a possible malignant process. The presence of milk or colostrum allows for the diagnosis of galactorrhea. The discharge from the mammary gland must be subjected to cytological examination. Palpation of the mammary glands makes it possible to establish the diagnosis of fibrocystic mastopathy, which can occur in 40% of gynecological patients. If it is detected, it is necessary to perform an ultrasound examination of the mammary gland and mammography. Patients with this disease must be referred to an oncologist to perform special research methods
The state of the internal organs is examined by systems. The blood pressure is measured, the nature of the pulse, the respiratory rate in 1 min are determined. Percussion and auscultation of the heart and lungs are performed.
When examining the abdomen, attention is paid to its configuration, bloating, symmetry, participation in the act of breathing, the presence of free fluid in the abdominal cavity. If necessary, measure the abdominal circumference with a centimeter tape.
Palpation of the abdomen must be performed in a horizontal position of the patient after emptying the bladder and intestines. With the help of palpation, the condition of the abdominal wall is determined (tone, muscle protection, divergence of the rectus abdominis muscles), painful areas on it, the presence of tumors in the abdominal cavity, infiltrates. Palpation allows you to determine with a certain accuracy the size, shape, boundaries, consistency and tenderness of tumors and infiltrates emanating from the genitals and located outside the small pelvis.
Percussion of the abdomen complements palpation and helps to clarify the boundaries and contours of tumors, as well as large infiltrates and exudates formed in inflammatory diseases of the genital organs.
Percussion when changing the position of the body reveals the presence of ascitic fluid in the abdominal cavity, poured out blood (disturbed ectopic pregnancy, rupture of the ovary), the contents of cysts when their walls rupture. Percussion can be used in the differential diagnosis between parametritis and pelvioperitonitis. When parametrizing the boundaries of the infiltrate, determined by percussion and palpation, coincide, with pelvioperitonitis - the percussion border of the infiltrate seems smaller due to gluing of the intestinal loops above its surface.
Auscultation of the abdomen allows you to determine the nature of peristalsis (intestinal paresis, violent peristalsis). It helps in the differential diagnosis between genital tumors and pregnancy. With the help of auscultation, the patency of the fallopian tubes is determined when they are blown through.
Gynecological examination includes examination of the external genital organs, examination using gynecological mirrors, vaginal examination, two-handed (bimanual) examination; rectal and vaginal-rectal studies. The study is carried out in rubber sterile gloves in a horizontal position of the patient on a gynecological chair after emptying the bladder and intestines.
When examining the external genital organs, the degree and nature of the hairline (for female or male type) is taken into account; development of small and large labia, the state of the perineum, the presence of pathological processes - inflammation, tumors, ulceration, condylomas, pathological discharge) Pay attention to whether there is a prolapse or prolapse of the vagina and uterus, whether there is a pathological condition in the anal area (varicose nodes , cracks, condylomas, blood discharge, pus from the rectum). An examination of the vulva and the entrance to the vagina is performed, taking into account their color, the nature of the secretion, the presence of pathological processes (inflammation, cysts, ulceration), the state of the external opening of the urethra and excretory ducts of the Bartholin glands, and the hymen.
Examination using gynecological mirrors (Figure 1, 2) is performed after examining the external genitalia. Introducing the speculum into the vagina, examine the mucous membrane of the vagina and cervix. At the same time, the color of the mucous membrane, the nature of the secretion, the size and shape of the cervix, the state of the external pharynx, the presence of pathological processes in the cervix and vagina (inflammation, trauma, ulceration, tumors, fistulas, etc.) are determined.
a - spoon-shaped Sims, b - bivalve Cusco, c - lift
Rice. 2
(a) and exposure of the cervix in the mirrors (b)
With a vaginal examination, the condition of the pelvic floor is determined, the area of the location of the Bartholin glands is palpated. On the side of the anterior wall of the vagina, the urethra is palpated. The state of the vagina, volume, folds of the mucous membrane, extensibility, the presence of pathological processes (infiltrates, scars, stenoses, tumors, malformations) are determined. Reveal the features of the vaginal vaults (depth, mobility, soreness). Next, the vaginal part of the cervix is examined, the size (hypertrophy, hypoplasia), shape (conical, cylindrical, deformed by scars, tumors, condylomas), the presence of ruptures, surface (smooth, bumpy), consistency (normal, softened, dense), position relative to the pelvic axis (directed anteriorly, posteriorly, left or right), the state of the external pharynx (closed or open, round shape, transverse slit, gaping); mobility of the neck (excessively mobile, immobile or limitedly mobile).
Two-handed vaginal-abdominal examination (Fig. 3, a) is the main method for recognizing diseases of the uterus, appendages, pelvic peritoneum and cellulose. First, examine the uterus. On palpation, determine its position, size, shape, consistency, mobility, pain. After completing the examination of the uterus, an examination of the appendages is carried out. The fingers of the outer and inner hands are gradually moved from the corners of the uterus to the lateral walls of the pelvis. Normal tubes are usually not identified; healthy ovaries can be found with sufficient experience. They are defined on the side of the uterus in the form of small oblong formations. The unaltered ligaments of the uterus are usually not defined. With inflammation, tumors, you can palpate the round, main, sacro-uterine ligaments. After palpation of the uterus and appendages, pathological processes in the pelvic peritoneum and tissue (infiltrates, scars, adhesions, etc.) are revealed.
Rectal-peritoneal (Fig. 3, b) and vaginal-rectal examinations are performed in the following cases: in girls with atresia or stenosis of the vagina, in addition to vaginal-abdominal examination for tumors of the genital organs (especially cervical cancer), with inflammatory diseases, the presence of discharge from the rectum. During the study, it is determined whether there are tumors, polyps, narrowings and other processes in the rectum. Palpation of the cervix, pelvic tissue, sacro-uterine ligaments is performed. With the rectal-abdominal method, the body of the uterus and the appendages are examined.
In the presence of pathological processes in the wall of the vagina, intestine and surrounding tissue, a rectovaginal examination is performed. With its help, tumors, infiltrates and other changes in the wall of the vagina, intestine and surrounding tissue are easily identified.
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