Examination by a gynecologist: everything about a gynecological examination. Examination of the external genital organs Examination of the external sex organs of women

Examination of the genitals in girls presents significantly greater difficulties than adult women, for many reasons. Firstly, children react much more painfully to the study and resist the doctor's actions more. Secondly, the internal genital organs in girls are much less accessible for manual and instrumental examination than in most adults, since the former, as a rule, exclude the possibility of a two-handed vaginal examination and wide opening of the vagina with mirrors, as is done in women who have had sex. Thirdly, in children, especially in small children, palpation is also difficult because their pelvic floor is dense, spatial relationships are sharply limited, the genitals are small and often indistinctly contoured; and these difficulties, in turn, are aggravated by the fact that the examination is usually carried out rectally and that the child often cries, strains, and makes sudden movements. Finally, fourthly, children do not have those established sizes and shapes and that stable position of the internal genital organs that adult women have, which is why in each individual case it is necessary to take into account the age characteristics of the girl under study (for example, when assessing the size of the uterus, the condition of her vaginal parts, etc.).

All this creates certain difficulties in the study of the genitals in girls and requires the doctor to have special experience and skill, a careful and skillful approach to sick children, patience and endurance. It should be noted one more feature of a psychological nature, which the doctor has to meet when examining the reproductive system in girls of different ages, and which is very important to consider when approaching the child or adolescent being examined. The fact is that girls of an earlier age and older years react differently in some respects to the study of the genital organs.

Until about 4 years of age, girls respond to examination of the genitals in the same way as to examination of any other area. They experience a feeling of fear, fear of pain, and this alone is the reason for their desire to avoid examination and their active resistance to the doctor's actions. The attitude of middle-aged and older girls to medical manipulations on their genitals is determined not only by the fear of pain.

Here we are already confronted with a specific reaction, which is not observed in the study of other areas of the body and which, presumably, is the result of an awakened instinct of sexual self-defense, as it were. Girls unconsciously seek to protect their immature genitals from any touch. In some girls, this is even expressed in the form of a protest or an angry reaction, which differs from the behavior of the child in connection with the fear of the expected pain. One more psychological feature should also be noted: the older the girl, the more pronounced the natural feeling of embarrassment, awkwardness, and shame she experiences during gynecological examinations, which is especially pronounced in the puberty period.

The behavior and specific psychological attitude of girls and adolescents to the study of their genital organs are, of course, individually different and depend on many factors: temperament, emotional and mental tone, upbringing of the girl, her interest in sexual issues, etc. In more rare cases, the corresponding The attitude of a girl or adolescent is also determined to a certain extent by former attempts at self-exploration or abnormal satisfaction of sexual feelings (masturbation), which sometimes take place with incorrect education or bad influences.

The doctor who, for one reason or another, has to investigate the reproductive system in girls and adolescents must be, to a certain extent, a psychologist. He must learn to subtly understand the peculiar and sometimes quite complex psychological reactions and emotional experiences of the studied girls and show due tact, cordial attention and restraint towards them. The slightest tactlessness, and even more rude ignoring of these psychological characteristics, callousness or violent actions of the doctor, in addition to difficulties for himself, harm the girls under study, and in especially excitable, sensitive or impressionable adolescents, they can cause severe mental trauma with all its unpleasant consequences, sometimes quite remote. For example, we admit that true (psychogenic) vaginismus can sometimes manifest itself as a trace reaction associated with this kind of mental trauma in puberty.

Starting an objective examination of the genital organs in a girl, the doctor must also take care of creating the appropriate conditions for the general environment of the examination. First of all, it is necessary, as in a general examination, to remove all unnecessary people and not to allow simultaneous examinations or any manipulations and procedures on other persons, especially adults, in the same room. When examining girls on an outpatient basis, as well as during the initial examination in a hospital, it is necessary that the mother or another person close to the subject be present. If the girl is in the hospital without a mother, then it is desirable that, during the examination, there should be a sister or a nurse near the examined girl, to whom the girl is accustomed. It is very important that all staff serving sick children be friendly, affectionate with children and pleasant to them.

Before examination, the girl should urinate, the intestines should also be free; hygienic washing of the external genitalia is performed. In special cases, the preparation for the examination is done differently (for example, if you need to take smears to determine the gonococcus).

For examination of girls, a regular table of gynecological rooms can be used. After a general examination and examination of the abdomen, the girl is given the usual position with knees bent and legs brought to the stomach. It is not recommended to use foot holders or other similar devices either for older or, especially, for little girls. It is better if the legs are supported by one of the assistants. The examination instruments must be covered so that the examined girl cannot see them. Tools, fluids and other items needed for inspection should be warm. During the examination, especially careful observance of the rules of asepsis and antisepsis is required, given the special susceptibility of children's genitals to infection.

We give an approximate list of tools and other items that the doctor may need during the study, from which he, of course, chooses what suits him best in each individual case.

1) Bix with sterile material (cotton balls, gauze tufters, wooden sticks with wound cotton wool, etc.); 2) Esmarch's mug; 3) rubber gloves and rubber fingertips; 4) anatomical and surgical tweezers; 5) Playfair probes; 6) catheters for children (preferably elastic and metal); 7) grooved and eye probes; 8) spoons for taking swabs such as Volkmann or Mazhbits, a platinum loop for the same purpose; 9) long glass pipettes (20-30 cm) with a rubber bulb for washing out secretions from the vagina and intestines; 10) Brown syringe (for the same purpose); 11) special forceps or a long probe (15-20 cm) with a blunt hook at the end - to remove pieces of cotton wool and other foreign bodies from the vagina; 12) a set of ear and nasal mirrors; 13) forehead reflector; 14) vaginoscope with a set of tubes with obturators and a transformer to it; 15) cups (or bottles) and watch glass (laboratory) for collecting washing water from the vagina and rectum; 16) glass slides for smears; 17) sterile test tubes for secretions subject to inoculation or bacteriological examination; 18) a thin metal tip with a reverse current or a thin glass cannula for washing the vagina and intestines; 19) a sufficient source of artificial lighting; 20) sterilizer for instruments.

It is recommended to have on hand some antiseptic solutions, penicillin, iodine tincture (5%), sterile petroleum jelly or sulfidine (streptocid) fish oil emulsion, (10-20%), sterile saline, purified alcohol, chloroethyl and ether for anesthesia , a mask for inhalation anesthesia with all the necessary accessories that may be required during anesthesia (tongue holder, mouth expander, kidney coxa, etc.).

In most cases, one of the signs of a normal structure and undisturbed functions of the reproductive system is, as you know, the appearance of the external genital organs. In this regard, the determination of the nature of the pubic hair, the amount and type of hair distribution is important. Examination of the external and internal genital organs provides significant information, especially in women with menstrual irregularities and infertility. The presence of hypoplasia of the small and large lips, pallor and dryness of the vaginal mucosa are clinical manifestations of hypoestrogenism. "Juiciness", cyanosis of the color of the mucous membrane of the vulva, an abundant transparent secret are considered signs of an increased level of estrogens. During pregnancy, due to congestive plethora, the color of the mucous membranes acquires a cyanotic color, the intensity of which is all the more pronounced, the longer the gestational age. 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,  CAH (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 ovaries and adrenal glands), since the tumor develops in the postnatal period, and CAH is a congenital pathology that develops antenatally, during the formation of the external genital organs.

In giving birth, pay attention to the condition of the perineum and genital gap. With normal anatomical relationships of the tissues of the perineum, the genital slit is usually closed, and only with a sharp straining slightly opens. With various violations of the integrity of the pelvic floor muscles, which develop, as a rule, after childbirth, even slight tension leads to a noticeable gaping of the genital slit and the descent of the vaginal walls with the formation of a 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 genitalia, various pathological formations are detected, for example, eczematous lesions and warts. In the presence of inflammatory diseases, the appearance and color of the mucous membranes of the external genital organs are sharply changed. In these cases, the mucous membrane can be intensely hyperemic, sometimes with purulent deposits or ulcerative formations. 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 with 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, mass formations, vascular pathology, injuries, endometriosis. When examining the cervix, pay attention to the same changes as when examining the vagina. But at the same time, the following must be borne in mind: with bloody discharge from the external uterine os outside of menstruation, malignant tumor cervix or body of the uterus; at cervicitis mucopurulent discharge from the external uterine os, hyperemia and sometimes erosion of the cervix are observed; cervical cancer is not always possible to distinguish from cervicitis or dysplasia, therefore, at the slightest suspicion of malignant tumor biopsy is indicated.

For women who are sexually active, Pederson's or Grave's, Cusco's self-supporting vaginal mirrors, as well as a spoon-shaped mirror and a lift, are suitable for examination. Folding self-supporting 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 examine the walls of the vagina and cervix, but also carry out some medical procedures and operations

For examination, the patient chooses the smallest mirror, which allows a full examination of the vagina and cervix. Folding mirrors are inserted into the vagina in a closed form obliquely with respect to the genital slit. Having advanced the mirror to half, turn it with the screw part down, at the same time move it deeper and push the mirror so that the vaginal part of the cervix is between the parted ends of the valves. With the help of a screw, the desired degree of expansion of the vagina is fixed

During the study, using mirrors, the condition of the vaginal walls is determined (the nature of folding, the color of the mucous membrane, ulceration, growths, tumors, congenital or acquired anatomical changes), the cervix (size and shape: cylindrical, conical; shape of the external os: 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.

When examining the walls of the vagina and the cervix, if blood discharge from the external uterine os is detected outside of menstruation, it should be excluded malignant tumor cervix and 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, with a visual assessment of the cervix with the naked eye, closed glands (ovulae nabothi) are determined. In addition, when examining the cervix in the mirrors, endometrioid heterotopias in the form of "eyes" and linear structures of cyanotic color can be detected. In differential diagnosis with closed glands, a distinctive feature of these formations is the dependence of their size on the phase of the menstrual cycle, as well as the appearance of blood discharge from endometrioid heterotopias shortly before and during menstruation.

Cervical cancer during a gynecological examination can not always be distinguished from cervicitis or dysplasia, so 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 vaults of the vagina: it is difficult to examine them, but volumetric formations and genital warts are often located here. 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 do 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 during a physical examination.

Testicular cancer, the most common type of malignant tumor in men aged 25-30 years, is easily detected by palpation. Prostate cancer can also be easily detected by palpation. In this regard, the male external genitalia must be examined carefully and gently. If significant pathological changes or abnormalities in the development of this area are detected, the patient should be referred to a urologist.

1. Pubic area

Examination of the external genital organs can be performed with the patient in a vertical or horizontal position.

It should be noted the nature of the hair growth of the pubic region, in adolescents - to characterize the stage of sexual development according to Tanner.

It is necessary to describe obvious pathological changes in the skin in this area (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 performed by examination, percussion and palpation.

2. Penis

The penis consists of two paired, capable of erection cavernous bodies, and a smaller, unpaired, capable of erection spongy body (corpus spongiosum penis), located ventrally in the midline and surrounding the urethra.

The distal part of the penis is covered, like a cap, with a conical formation - 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, while the surface of the inner leaf of the foreskin and the head are exposed. 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 its scarring. The elasticity of the tissue of the foreskin in children changes until about 5 years of age, after which it acquires mobility close to that of adults. Any attempt to remove the head of the penis from the preputial sac by force is categorically unacceptable.

Paraphimosis - a situation in which the foreskin cannot be pushed over the glans penis, as a result of compression and swelling of the glans penis.

Hypospadias - the location of the external opening of the urethra on the ventral surface of the penis.

Epispadias - 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 navicular fossa. This technique is especially important in young men, who are more likely to contract a sexually transmitted infection. Any discharge from the external opening of the urethra should be examined bacteriologically to rule out infection.

After examining the distal part of the penis, its trunk should be examined and palpated. Any curvature and asymmetry of the cavernous bodies and head should be noted. Painful erection due to ventral bending of the penis shaft is often associated with hypospadias.

3. Scrotum

The skin of the scrotum is normally wrinkled and highly elastic. With the appearance of 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) may present with 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 the mentioned spaces (hemiscrotum) are the testis, the epididymis and the spermatic cord. Normally, all of these formations move freely within the hemiscrotum.

Some benign neoplasms on the skin are noted quite often. A very common infection is Candida albicans, located on the scrotum and in the area of the femoral crease. This infection usually occurs in combination with diabetes mellitus, against the background of the use of antibiotics, immunosuppression and when the skin of the genital organs becomes more "hospitable" to infection with increased humidity and sweating. A striking sign of skin candidiasis is bright red hyperemia. Tinea cruris is also a common fungal infection of the genital skin. With this disease, dark, red-brown spots appear on the front of the thighs. If in the area of the most active site of inflammation along its periphery a thin red spot is visible, then one can think of ringworm. Candidiasis and tinea cruris respond to common 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 in a whitish color, 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 occurs in 20% of adult men and is a papular hemangiomas 1-2 mm in size, colored 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 laser beam treatment are indicated.

When examining the testicles, it is necessary to carefully palpate between 1 and 2 fingers. The size, shape and consistency of the testis 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 consistency of the testicles is dense and somewhat elastic. They are symmetrical in shape, size and texture. When examining the testicles in adolescents and men suffering from infertility, it is especially important to characterize the size of this paired organ.

Orchidometry instruments are available (ASSI, Westburn, NY) that can be used to quantify and compare testicular volume. The testicles should have a smooth surface, they should occupy a certain position in the scrotum. If the testicle is not palpable, then the inguinal canal should be examined to rule out cryptorchidism. The presence of abnormalities on a flat, smooth surface of the testicles or detected excess tissue is an indication for an urgent referral of the patient to a urologist to rule out a tumor.

On palpation of 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 (the vaginal membrane of the testicle, tunica vaginalis testis).

The accumulation of fluid between these two sheets leads to the formation of dropsy. Transillumination in a darkened room (using a pen-flashlight or other similar light source) allows you to differentiate a fluid-filled formation (positive transillumination effect) from a dense mass of tissue. Sometimes with auscultation of an enlarged scrotum, a noise of peristalsis can be detected, which will indicate the presence of an inguinal-scrotal hernia.

examination urological genital prostatic

5. Epididymis

Examination of the epididymis is directly related to the examination of the testicle, since the epididymis is usually located on its upper and posterior surface. The epididymis is located symmetrically on both sides and is accessible to direct palpation. The consistency of the epididemis is softer than that of the testicle, and on palpation it is felt as a raised edge of the testis located behind. Examine the epididymis should be extremely careful 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. Enlargement of the epididymis or pain on palpation is usually associated with an inflammatory process (epididymitis). A cystic mass in epididymal tissue, such as a spermatocele, is translucent and therefore can be detected by transillumination.

6. The spermatic 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 that he stand up, since this part of the examination is more convenient to carry out in a vertical position. Usually, palpation begins from the middle of the distance between the outer ring of the inguinal canal and the testicle. Recognize the vas deferens (ductus deferens) is not difficult. In shape and consistency, it resembles a cord and is a bit like braided electrical wire, but more elastic and slightly larger in diameter. If the vas deferens cannot be palpated, then 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 create such an impression. However, in most cases, a varicocele feels more tender. For more accurate identification, each spermatic cord is taken between the first three fingers of one hand. After palpation separation of the spermatic cord from other tissues, any increase in its vascular component is well felt. The patient is then asked to perform a Valsalva maneuver (take a deep breath, hold your breath, and strain). An increase in the palpable spermatic cord indicates the presence of a small varicocele. If the patient has a pronounced cremaster 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 be a lipoma or, less commonly, a liposarcoma. Cystic formations of the funiculus, which are amenable to transillumination, are most often small, localized hydroceles. 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 study 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 maneuver. A sensation of bulging or pushing at this moment 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 epididymis of the fovea or spermatic cord is a benign formation, but, nevertheless, requires a consultation with a urologist. A patient over 16 years of age should be given instructions for self-examination. Acute pain in the scrotum and other emergencies will be discussed separately in other sections.

7. Prostate gland

A complete examination of the male external genitalia includes examination per rectum with palpation of the prostate gland. It is recommended that all men over 50 years of age have an annual rectal examination to examine the prostate gland, as well as an examination for the presence of prostate-specific serum antigen (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. It is similar in configuration to a chestnut. The prostate gland is usually enlarged in men older than 50 years, although the normal size of the gland varies greatly at different ages. Normally, the consistency of the prostate gland is comparable to that of thenar, when 1 finger is opposed to 5.

During digital examination of the prostate gland, the patient may be in a different position. The lying position on the 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 90 ° inclination in the belt, resting his elbows on the examination table. The doctor puts on a surgical glove, dips his 2nd finger in a water-soluble lubricant. Pushes the buttocks of the patient and initially examines the anus. Then the 2nd finger in a glove is placed in the anus and gently presses on it. This technique promotes relaxation of the anal sphincter, which allows for rectal examination in the most favorable conditions and allows the doctor to assess the tone of the anal sphincter. After relaxing the latter, a lubricated finger is passed to the arch 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.

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 sulcus. When describing the detected changes, one should indicate their localization (on the right, on the left, at the apex, at the base, along the midline or laterally). The seminal vesicles originate from the base of the gland and are not normally palpable. When palpation of the prostate determine its size. 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 should the suspicion of malignancy, inflammation, or infection, which may occur if any irregularities or indurations are found in the gland. In acute inflammation of the prostate gland, pathological softness (the tissue is softer than normal) and pain on palpation can be felt. The presence of fluctuation indicates the occurrence of an abscess. Vigorous massage with acute inflammation of the prostate gland is contraindicated.

Before removing the finger, it is necessary to make a wide circular motion along the fornix of the rectum to exclude any of its pathological changes. After the examination, the patient should be offered a large gauze pad to remove excess lubricant from the perineum. Upon completion of the examination of the prostate gland, discharge from the penis and prostatic juice should be examined microscopically.

8. Urinalysis

Urinalysis is an important part of the urological examination.

In non-concentrated urine, pH, glucose, protein, nitrite and leukocyte esterase are determined by immersing tester sticks in it. After that, the urine sample is centrifuged for 3-5 minutes at a speed of 2500 rpm. The supernatant is discarded and the residue is mixed with the small amount of urine remaining in the tube. Then microscopy is carried out at low and high magnification (Table 1-2).

In one field of view (PV) of the microscope at high magnification, the number of leukocytes, erythrocytes, bacteria, salt crystals, yeasts and cylinders is identified and counted. A bacteriological study of urine is performed in cases where other urine tests or clinical data suggest that the patient has a urinary tract infection. If the stick test is positive for both nitrate 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 checked monthly. Annually, a urologist should conduct a digital examination of the rectum in men over 50 years of age, and with an unfavorable family history of prostate cancer - at the age of 40 years and older.

Regular (monthly) testicular self-examination is important because testicular cancers often affect young men, but if detected early, the disease is usually treatable. The survey is easy and takes a few minutes.

The testicles in the scrotum feel like small, firm, hard-boiled eggs with no 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 appendage, two parts are distinguished: the body and the tail, which is sometimes felt separately. The spermatic cord is attached to the superior pole of the testis and extends upward into the inguinal canal. It consists of muscle fibers, blood vessels and the vas deferens. The cord is spongy except for the vas deferens, which is firm to the touch (twig-like) and feels like "macaroni".

First of all, inspect 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 feeling of healthy tissues that make up the testicles, their appendages, the vas deferens, and any abnormality will be immediately detected. Any changes you see or feel should be brought to the attention of 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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Objective research(status praesens)

Objective research includes:

Research by Systems

respiratory organs,
circulation,
digestion,
urinary system, etc.

Inspection

assessment of the position of the patient, her general condition, consciousness;
anthropometric studies: assessment of the type of constitution, measurement of height, weight, pelvic dimensions;
measurement of blood pressure, pulse, respiratory rate per minute.

Palpation(abdominal organs, mammary glands).

Percussion(abdomen, lungs)

Auscultation(lungs, intestinal peristalsis).

Gynecological examination (Status genitalis)

Applied when examining all patients without fail after emptying the bladder and preferably after defecation in the position of the patient on the gynecological chair.
Be sure to use sterile reusable or disposable instruments (mirrors, gloves, lined oilcloth).

examination of the external genital organs;
assessment of the nature and degree of development of sexual characteristics;
inspection with mirrors;
two-handed vaginal examination;
rectovaginal examination;
rectal examination.

Examination of the external genitalia

On examination, attention is paid to the severity of hair growth in the pubis and labia majora, possible pathological changes (swelling, tumors, atrophy, pigmentation, etc.), the height and shape of the perineum (high, low, trough-shaped), its breaks and their degree, condition genital fissure (closed or gaping), prolapse of the walls of the vagina (independent and when straining).
When pushing the genital slit, it is necessary to pay attention to the color of the mucous membrane of the vulva, examine the condition of the external opening of the urethra, paraurethral passages, excretory ducts of the large glands of the vestibule of the vagina, pay attention to the nature of the vaginal discharge.
After examining the external genital organs, the anal area should be examined (the presence of cracks, hemorrhoids, etc.).
Establish the state of the hymen (its integrity, the shape of the hole).

Algorithm of actions during a gynecological examination

Treat the chair with disinfectant.
Put a disinfected oilcloth on the chair.
Invite the patient to lie down on a chair.
Put on sterile gloves.
Examine the external genital organs visually (pubis, the nature and degree of hair growth; labia majora - cover the labia minora or not).
Separate the large labia with the index and thumb of the left hand.
Examine visually: clitoris, labia minora, vestibule, hymen.

Inspection with mirrors

After examining the external genitalia, they begin to study with the help of mirrors, which is of great importance in gynecology for detecting pathological changes in the vagina and cervix.
Examination with the help of vaginal mirrors helps to timely detect precancerous diseases of the cervix and the initial manifestations of cancer, as well as diagnose a number of other forms of pathology. Therefore, the study of women with the help of mirrors is an obligatory part of every gynecological examination.

Algorithm for conducting an inspection using mirrors

Put an oilcloth on the chair.
Invite the patient to lie down on the gynecological chair.
Treat your hands in one of the ways.
Put on sterile gloves.
Take the mirror in your right hand.
Dilute with your left hand, index and thumb, large labia.
Insert a mirror into the genital slit to the middle of the vagina in a straight size.
Translate the mirror into a transverse dimension and advance to the posterior fornix, slightly pressing on the perineum.
Take the lift in your left hand.
Insert the lift into the vagina along a spoon-shaped mirror to the middle in a straight size, then transfer to a transverse size.
Advance the lifter to the end of the anterior vaginal fornix, applying slight pressure to the anterior vaginal wall.
Open up the mirror. Examine the walls of the vagina and cervix.
Remove the mirror in reverse order: first the lifter, then the spoon-shaped mirror.

Vaginal examination

Produced by inserting the 2nd and 3rd fingers into the vagina. At the same time, it seems possible to determine the width of the entrance to the vagina, the condition of the perineum, the muscles of the pelvic floor, the length of the vagina, the depth of the vaginal vaults, the length and condition of the vaginal part of the cervix. This study can also give an idea of the condition of the pelvic walls (bone exostoses).

Bimanual study

It is carried out with two hands. The 2nd and 3rd fingers of the inner hand are inserted into the vagina, the outer hand is placed on the anterior abdominal wall above the pubis. Palpation of organs and tissues is carried out with the help of two hands, while examining the uterus and uterine appendages, their size, shape, consistency, mobility and soreness. Then, a study of periuterine tissue is carried out, which is palpable only if there are infiltrates and exudate in it.

Bimanual vaginal examination

Put an oilcloth on the gynecological chair.
Lay the patient on the gynecological chair.
Treat your hands in one of the ways.
Put on sterile gloves.
Separate the large and small labia with the index and thumb of the left hand.
Bring the fingers of the right hand into the obstetric position: move the thumb to the side, press the ring and little fingers to the palm, straighten and close the middle and index fingers.
Insert the middle and index fingers of the right hand into the vagina, pressing on the perineum.
Place the fingers of the right hand in the anterior fornix of the vagina.
Place your left hand slightly above the pubic joint on the anterior abdominal wall.
Bring the fingers of both hands together, find the uterus by palpation.
Determine the position, size, shape, consistency, mobility and sensitivity of the uterus.
Move the fingers of the outer and inner hands alternately into the lateral fornix of the vagina.
Determine the condition of the appendages.
Remove the fingers of the right hand from the vagina.

Rectal examination

Produced by the 2nd finger of the right hand. It helps to get an idea of the state of the cervix, paravaginal and pararectal tissue, to establish changes in the rectum (narrowing, compression by the tumor, infiltration of the walls, etc.).

Rectovaginal examination

This study is resorted to in patients who do not live sexually (with preserved hymen). It is performed by inserting the 2nd finger into the vagina, and the 3rd finger into the rectum. It is advisable to use this combined study if there is a suspicion of pathological changes in parametric fiber and recto-uterine muscles. The study is performed in a gynecological chair.

An 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

Why is a gynecological examination necessary?

An important procedure for maintaining women's health is an examination.

At the doctor's appointment, a woman must be:

for preventive purposes - at least 1 visit in 6-12 months (even if there are no complaints);
during pregnancy (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 evaluate the external and internal condition of the vagina.

During 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 on the flora. This is done both for prevention and to identify the source of negative disorders in the genitourinary system.

Gynecological examination includes 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 (pale lips, increased dryness of the uterine and vaginal mucosa);
high levels of estrogen in the body (change in color of the vulva, abundant 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).

If the doctor noticed negative deviations, he prescribes a detailed examination - ultrasound, blood tests, urine, cytological examination.

How to prepare for a gynecological examination?

Before going to the gynecologist, you need to properly prepare.

Exclude sexual intercourse 3 days before visiting the doctor.
Do not douche or use a deodorizing hygiene medium on the day of your visit to the doctor.
Perform genital hygiene with plain water without strong pressure on the genitals.
The bladder and rectum must be empty before examination.

Careful 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.

Before going to the gynecologist, perform genital hygiene

How is a gynecological examination carried out?

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 did they start, are there any failures, how many days, what profusion, the date of the last menstruation);
data are collected on reproductive function (the presence of pregnancies, childbirth, abortions, miscarriages);
the sexual aspect is being studied (the presence of a sexual partner, the use of contraceptives);
the doctor is interested in past 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 has its own differences.

During pregnancy

An examination by a doctor begins in the early stages of gestation (the first time at 8-12 weeks). At this time, an internal examination of the cervix, perineum with a mirror is carried out. The purpose of the procedure is to determine the general condition of the reproductive organ and exclude ectopic pregnancy. Be sure to take a smear on the flora (bacteriological culture) and a cytological smear (to detect malignant changes). To do this, you need to bring a gynecological kit with you (sold in any pharmacy).

In addition to manipulations on the gynecological chair, the doctor measures the weight and height of the patient, pressure, pulse, examines the position of the uterus and the width of the pelvis. The survey will include information about hereditary diseases, chronic pathologies and bad habits.

Starting from the 15th week, internal examinations on the chair are not carried out. Now, at each visit, the doctor measures the circumference of the patient's abdomen, the position of the uterine fundus, and listens to the baby's heartbeat with a stethoscope. Mandatory parameters are pressure, pulse and weight.

Until the 29th week, visits to the gynecologist are limited to 1 time in 3 weeks. Further trips to the doctor become more frequent - 1 visit in 14 days. Starting from 36 weeks - visits every 7 days. 10-15 days before the birth, the need for a gynecological examination again appears. It is important to check the readiness of the birth canal through which the child will pass, as well as the condition 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 the normal postpartum period involve a visit to the doctor when the discharge takes on a natural character - it will not be plentiful and bloody. The purpose of the examination is to check the condition of the birth canal, the formation of the uterus - whether the organ has become in place, the degree of its contraction to normal sizes, to examine the sutures (if any), their healing.

The specialist examines the woman first with a mirror, then takes a swab. Then he performs palpation - he puts 2 fingers into the vagina, and with the fingers of the second hand he presses on the stomach closer to the inguinal zone. This allows you to determine the density of tissues, check the appendages, find out if there are extraneous seals or scarring on the uterus and its neck,

Medical examination at school

For the first time, the genitals of girls are examined in the maternity hospital, then at 1 year and before entering the kindergarten. At school, visits to the gynecologist for the first time begin at the age of 12–14. Girls are examined exclusively by a pediatric gynecologist.

The examination process consists in a survey (complaints, first menstruation) and examination of the genital organs. The girls are located on the couch, where the doctor performs palpation through the rectum. With the second hand, the specialist presses on the peritoneum. In the absence of complaints about the genital area, 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. Examination of underage girls who already have intimate relationships is carried out in the same way as a regular preventive visit of adult women.

Virgin at the gynecologist

The examination of a virgin is carried out in the same way as in a little girl - through the anus. The doctor checks the condition of the external genital organs, palpates the abdomen, probes the uterus with a finger through the anus. The smear is taken with a thin instrument, examination with a mirror is not carried out.

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 detect pathological changes in the early stages of development, monitor the course of pregnancy and regularly monitor the condition of the reproductive organs. For prevention purposes, a woman should visit a doctor at least once a year. If there are complaints, do not hesitate to visit a specialist - a timely examination can prevent dangerous diseases.