Gynecology examination according to bereks and Novak. Book

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Here is a comprehensive overview of the Gynecologic Examination as presented in Berek & Novak's Gynecology (Chapter 1: Initial Assessment and Communication).

Gynecologic Examination — Berek & Novak's Gynecology

Overview

A thorough gynecologic physical examination is performed at the initial visit, periodically, and as needed throughout the course of treatment. The scope of the examination is dictated by the patient's primary concerns and symptoms. For healthy adolescents without symptoms requesting contraception before sexual activity, a pelvic exam is not necessarily required.

The ACOG continues to recommend an annual visit as an opportunity for shared decision-making about whether a pelvic examination is appropriate.

1. History

The history precedes any physical examination and includes:

Chief complaint and present illness (using the structured technique in Table 1-5)
Complete medical and surgical history
Reproductive history (menstrual and obstetric)
Current medications (including OTC and complementary/alternative)
Family and social history

2. Physical Examination

A. General Examination

A complete physical examination includes assessment of vital signs, height, weight, and BMI. Body habitus, signs of endocrine or metabolic disease, skin changes, hair distribution, and breast examination are all components.

B. Abdominal Examination

The abdomen is inspected, auscultated, and palpated for:

Organomegaly, masses, ascites
Tenderness (direct and rebound)
Surgical scars and hernias

3. Pelvic Examination

A. External Genitalia (Vulvar Inspection)

The patient is placed in the dorsal lithotomy position. The vulva, perineum, and perianal area are inspected systematically:

Mons pubis, labia majora and minora, clitoris, urethral meatus, introitus
Look for lesions, ulcers, condylomata, erythema, discharge, or atrophic changes
The urethra and Skene glands are palpated; the Bartholin glands are evaluated for enlargement or tenderness

B. Urethral and Bartholin Gland Assessment

Skene (paraurethral) glands are palpated for tenderness or discharge
Bartholin glands (posterolateral walls of the introitus) are assessed for cysts or abscesses

C. Vagina and Cervix — Speculum Examination

A bivalve speculum (Graves or Pederson) is inserted to visualize:

Structure	What to Assess
Vaginal walls	Color, discharge, lesions, rugae, atrophy
Cervix	Color, position, os (size/shape), discharge, lesions, ectropion
Fornices	Masses, tenderness

Procedures performed at this stage:

Cervical cytology (Pap smear) — technique and frequency per Chapter 16
Cultures — for any purulent discharge from vagina or cervix (STI screening is routine in adolescents and young adults per CDC guidelines)
Biopsy — for any visible lesions on the cervix or vaginal walls
Endometrial biopsy — performed with a flexible cannula when indicated

D. Bimanual Palpation

After removing the speculum, a lubricated gloved hand is used:

One or two fingers (index ± middle) inserted into the vagina
The opposite hand placed on the lower abdomen to provide counter-pressure

Uterus assessment:

Size, shape, contour, consistency, position, and mobility
Presence of tenderness (patient provides verbal feedback; facial expressions are observed)

Adnexal assessment:

Both adnexa palpated gently
Note any enlargement, mass, tenderness, or irregularity
Document size, shape, mobility, and consistency

For patients with pelvic pain, a structured "functional pelvic examination" is performed — sequential palpation of:

Vaginal introitus
Pelvic floor muscles (spasm is a common concomitant of pelvic pain)
Bladder
Rectum
Cervix
Cul-de-sac

Bimanual examination showing two vaginal fingers elevating the uterus toward the abdominal hand

Figure 1-3 — The bimanual examination (Berek & Novak's Gynecology)

E. Rectovaginal Examination

Performed when indicated — one finger in the vagina, one in the rectum:

Structures assessed:

Rectovaginal septum
Posterior uterine surface
Uterosacral ligaments → nodularity suggests endometriosis
Posterior cul-de-sac → implants of ovarian cancer
Adnexal structures (palpable from behind)
Rectum: hemorrhoids, fissures, sphincter tone, polyps, carcinoma

A single stool fecal occult blood test obtained during rectal exam is not adequate for colorectal cancer screening and is not recommended.

Figure 1-4 — The rectovaginal examination (Berek & Novak's Gynecology)

4. Special Populations

Pediatric Patients

The approach is modified based on age, symptoms, and the indication for examination
A chaperone/parent is present
Non-invasive techniques are preferred; vaginoscopy may be used under anesthesia when necessary

Adolescent Patients

Pelvic examination is not required before prescribing contraception in asymptomatic adolescents
STI screening is performed per CDC recommendations
Confidentiality should be addressed

5. After the Examination

At the completion of the examination, the patient should be informed of findings:

Normal results → reassure the patient
Possible abnormality → discuss with the patient clothed after the examination, in clear understandable language
Outline a plan for evaluation, explain proposed procedures (e.g., biopsy), and inform the patient when results will be available

Key Points Summary

Component	Key Action
External genitalia	Systematic vulvar inspection (labia, clitoris, urethra, introitus)
Speculum exam	Visualize vaginal walls, cervix; collect Pap, cultures, biopsy as needed
Bimanual exam	Assess uterine size/position/mobility; palpate adnexa bilaterally
Rectovaginal exam	Evaluate uterosacral ligaments, posterior uterus, cul-de-sac; indicated for suspected endometriosis or malignancy
Communication	Inform patient of findings at conclusion; discuss abnormalities with patient clothed

— Berek & Novak's Gynecology, Chapter 1: Initial Assessment and Communication

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