The standard gynaecological examination includes the examination and palpation of the lower abdomen, the external genitalia, the vulva – vagina – cervix, the perineum, the groin and the anus, as well as the two mass glands – the mammary glands and the two axillary cavities. The examination is completed by palpation and ultrasound examination of the bladder, internal genitals, uterus, ovaries and fallopian tubes as well as the area around the organs of the anterior and posterior Douglas space and areas next to the uterus and the ovaries.
In adolescents and women who have not yet had sexual intercourse, the gynaecological examination is not performed vaginally; in case of suspicion of serious diseases, it can potentially be manually done by the rectal by palpating the internal genitals between the two hands and by palpating the intestine and lower abdomen. For the past 20 years, this examination has been replaced by imaging techniques such as abdominal ultrasound with a full bladder for better imaging of the organs and magnetic resonance imaging of the lower abdomen.
In an upright or sitting position, with the arms raised, behind the head or in the middle, the breasts are examined-observed; we pay attention to the size, shape and color of the breasts, the areola and the nipple as well as the armpits. We look for any skin changes, retractions locally or in the nipple, the deletion and course of superficial veins as well as for inflammations and skin diseases.
This is followed by palpation of the breasts and axillary cavities, in an upright or sitting position as well as in a supine position to compare the findings.
Palpation includes each part of the breast and armpit from outside to inside in a clockwise direction. We are looking for semi-hard, hard or soft lumps and masses that may have clear or unclear boundaries and may be painful or painless.
Self-examination – self-palpation of the woman every month after the end of the period is recommended because the breast at this time of the cycle is not swollen and does not hurt, thus facilitating the examination by the woman herself.
EXAMINATION OF THE LOWER ABDOMEN
We observe the lower abdomen for any changes in the skin and the shape of the abdomen. We gently feel the lower abdomen to find lumps, masses or formations painful or painless in the skin, muscles, or intestine and the internal genitals and lymph nodes.
EXAMINATION OF THE EXTERNAL GENITALS
We observe the perineum, the lower part of the pelvis, the external genitalia (vagina – entrance of the vagina) and the anus, the end of the intestine.
In the perineum we can see skin changes, such as eczema, nevi, papillomas or dermatitis, foliculitis or pustules, swollen lymph nodes or scars and deformities from surgery.
In the vulva and at the entrance of the vagina, dermatological inflammations such as dermatitis, eczema, cystic formations such as foliculitis, pustules, papillomas, warts, atrophic lichen, atrophic sclerosing lichen, epithelial cysts, haemangiomas, microbial inflammations, herpes, and lesions following systematic diseases or sexually transmitted diseases.
In the anus at the end of the intestine the examination can detect microbial and viral inflammations as well as haemorrhoids and stretch marks.
With the help of a disposable medical tool – the vaginal dilator – which is placed vaginally and opens in the correct position, the vagina, the cervix, and the beginning of the uterus become visible.
Vaginally we observe the texture and structure of the vagina and cervix.
Known hernias that protrude into the anterior and posterior vaginal wall are found or ruled out, such as cystic hernias and rectal hernias after surgery or vaginal delivery. Inflammation of the vagina by germs and fungi and lesions of the vaginal walls or ruptures after unintentional or voluntary sexual intercourse.
We observe the height and position of the cervix and detect or rule out possible prolapse or anatomical structural pathology, congenital anomaly or diseases of the cervix, inflammation – cervicitis, precancerous or cancerous lesions.
During the gynaecological examination, a vaginal and cervical secretion can be taken for culture and a cytological examination, the well-known Smear test.
INSPECTION OF THE INTERNAL GENITALS
In the past, with the two-handed gynaecological examination, i.e. the placement of two fingers of one hand in the vagina and by using the free hand to palpate the lower abdomen, the uterus and the accessories (ovarian tubes) were examined, palpating these organs between the two hands to examine the physiology or pathology of the organs. The palpation of the shape, size, and of any pathological findings of painless or painful formations – tumours. For several years now, this test has been replaced by the use of ultrasound for both the abdomen and the vagina or a combination of both.
With the new generation of both two-dimensional and three-dimensional ultrasound, the imaging of the lower abdomen and internal genitals is flawless with very little chance of error.