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The adolescent gynecologic examination: An overview
The Adolescent Gynecologic . An Overview Carol
L. Gemberling,
MN,
RN, OB/GYN
Examination: . NP, PNP
The adolescent gynecologic examination is one area of pediatric medicine that is frequently overlooked. This article reviews suggestions for working with adolescent patients, as well as equipment and historical data necessary before the examination and indications for performing a pelvic examination. The examination is reviewed, including the techniques for some of the more common diagnostic tests performed as part of a routine examination. Suggestions for making the interaction a positive educational experience are provided. ] PEDIATR HEALTH CARE. (1987). I, 141-l 50.
Jenny was fifteen when I first met her at the Adolescent Ambulatory Clinic with her mother. Her chief complaint was a sore throat and stomacbacbe for the past 3 days. It was not unusual to see an adolescent in OUYsetting with this tpe of a problem. It was also not unusual fey the real reason for the adolescent’s visit to become apparent only after the adolescent entered the examination room unaccompanied by a parent orguardian. Jenny’s questions were sz&ntficant clues to the fmt that the real reason fey bev viiit was to talk about birth control, which appeared to be a current concern. I spent a fm minutes mentally mganizing the things I’d want to evaluate and the equipment I’d need to perform the examination efficiently. It was my hope that this first pelvic examination would prove to be a positive and valuable learning experience. SUGGESTIONS FOR WORKING ADOLESCENT PATIENTS
WITH
Sensitivity for the adolescent’s needs, concerns, and feelings can set the tone for her examination and have a profound influence on her attitudes about gynecologic health care for the rest of her lift. Whcncvcr possible, an environment that is private and comfortablc for the adolescent should be created. Confidentiality is a crucial concern that needs to bc discussed at the very beginning of the paticntpractitioner interaction. Not discussing it first ma) limit the amount and accuracy of information obtained. Reassurance must be provided that whatcvcr is disclosed will not be discussed with her parents Carol L. Cemberling 15 a Pediatric Nurse Practitioner and ObiCyn Nurse Practitioner. She is an Assistant Professor at California State University. Long Beach, in the Graduate Nurse Practitioner Program. She also is III private practice in Manhattan Beach and Redondo Beach, Califorma. Reprmt requests: Carol L. Gemberimg, MN, RN, NP, Assistant Proiessor, Department of Nursing, California State University, Long Beach, 1250 Bellflower Blvd., Long Beach, CA 90840. IOURNAL
OF PEDIATRIC
HEALTH
CARE
without her permission, unless this information is potentially harmful to her (cg, suicidal thoughts). It should never be assumed that the adolescent undcrstands this fact without discussing it explicitly.
s ensitivity for the adolescent’s needs, concerns, and feelings can set the tone for her examination and have a profound influence on her attitudes about gynecologic health care for the rest of her life.
Most women approach the gynccologic cxamination with some apprehension; this is particularlv true with the adolescent bcforc her first examination. Recognizing and discussing these feelings will help the patient to relax while also discovering the parts of the examination that may product the most anxicn or fear. The development of both primary and sccondary sexual characteristics may bc very anxiety provoking for an adolescent. The most common concerns that adolescents express arc the issues of pain or discomfort during the examination, being normal or different than other women, embarrassment or disgust during the examination, or fear of criticism for their sexual behavior. A nonjudgmcntal attitude provides an open and honest atmosphcrc where the adolescent will feel free to discuss her innermost concerns and questions. Explanations regarding the pelvic examination arc aided by using illustrations, diagrams, and models. With thcsc aids, a brief description of what the tccnager will see, feel, hear, and expericncc during the pelvic examination should be discussed. Ample time should bc allowed for questions during this prcex141
142
Gemberling
lubricant will be used during the the bimanual cxamination and the rcctovaginal examination. Tissues, tampons, and sanitary napkins arc useful and much appreciated after the examination has been completed. Another valuable item is a hand-held mirror to allow the adolescent to view her genitals as shown in Figure 1. This mav promote learning the names of various structures .and help her understand her anatomy. It also helps a teen bccomc comfortable with her own normal anatomv and assists her in the future should she notice anything different from this examination.
A
nonjudgmental attitude provides an open and honest atmosphere where the adolescent will feel free to discuss her innermost concerns and questions.
. n
FIGURE 1 Adolescent
viewing
genitals.
amination dialogue. Listening rather than lecturing conveys cart about her and that her worries are rcgardch as important. Any concerns she has about her body and how it functions should bc explored. She should bc instructed in relaxation techniques such as slow, deep breathing or visual imagery. These approaches will help to make the pelvic examination remain a nonpainful procedure, as it should be, in the absence of a pathologic condition. It should be emphasized that she will feel pressure but should not experience pain and if at any time she feels pain or needs to stop the examination for anv reason, the examiner will oblige her. EQUIPMENT NECESSARY FOR A CYNECOLOGIC EXAMINATION
n
The equipment necessary to perform a gynccologic examination includes an examination table with stirrups, gowns, sheets, and a good light source. Various types of small or pediatric plastic or metal speculums should be available. Warm water or (if you will be performing many examinations) a heating pad will be helpful for warming metal speculums. Nonsterile, well-fitting examination gloves and a water-soluble
The remainder of the equipment nccdcd to pcrform a pelvic examination will dcpcnd on which spccific tests arc indicated. In scxuallv active adolcsccnts, regardless of their age, an annual pelvic examination with a Pap smear is recommended by the American College of Obstetrics and Gynecology (ACOG) (1985). Cancer screening frequency is dctcrmincd b! the risk status of the woman. Beginning at 18 years of age, younger if she is sexually active, most women should undergo cervical cytologic cvraluation annually. It is particularly important that high-risk women (ic, those who have had carlv sexual intcrcourse and those who have had scvcral sexual partners or multiple marriages) should be screened annually. It is now common practice that hvo cytologic samplcs be taken. The first sample is taken from the endoccrvical canal using an cndocervical aspirator or a saline-soaked cotton swab that is introduced into the cndocervix and smeared onto a Pap smear slide A second more commonly taken sample comes from the outer portion of the cervix, the cxoccrvix. A spatula of either plastic or wood is inserted into the cervix and rotated 360 degrees in a firm but gcntlc manner and quickly applied to a labeled glass slide. Both the cndocervical and exoccnical spccimcns may bc placed on either the same or separate slides, depcnding on laboratory procedures. An open bottle filled with a special fixative solution such as 40% alcohol or a spray can with a fixative preparation needs to be in close proximity so that the sample may be treated within 10 to 15 seconds of obtaining the specimen to avoid a drying artifact. A pack is com-
~0~rnaloi Pediatric
The
Health Care
n
FIGURE
n
FIGURE
W FIGURE
2 Trichomonads
and
3 Clue cell with 4 Normal vaginal
white
blood
cells
clumps of bacteria epithelial cell.
mercially available that contains the needed equipment and instructions to perform a Pap smear. If a sexually transmitted disease is suspected, special equipment and laboratory services need to be available. The examiner must use precautions and wear gloves. A gonorrhea culture is obtained from the endocervical canal with a sterile cotton swab. This sterile swab should be streaked on a Thayer-Martin culture plate and immediately placed in an incubating
on
Adolescent
Gynecologic
microscopic
on epithelial
Examination
143
examination.
cell
surface
environment (rich in carbon dioxide). If this is not available, a transport medium can be used, but this method may miss a significant number of positive cultures (Neinstein & Stewart, 1984). If the chief complaint is vaginitis or if during the examination an abnormal discharge, odor, or appearance of the vaginal walls or the cervix is detected, a wet mount preparation may be needed. A sample of the vaginal discharge is obtained using one or two
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Volume 1, Number 3 May-June 1987
Gemberling
n
FIGURE
5
Candida
with
branching
hyphae
Jenny said she and her mother have spent little time discus&g the physical changes that have been takirlg place in her body over the past 2 years. These changes have made her feel a little awkward a.sshe has bgun to outgrow adolescence
microscopic
examination
and fmt approach the young adult period of her life. This period of her life proved to be a vevely“teachable moment.” Based on my initial impYession of Jenny, I believed that her level ofpwtb and devebment was well within the ran5e of normal and her expectations wwe in line with her own perceptions m to what being a woman meant to her. As Jenny and I continued to talk, it became clear that her questions seemed to center around the areas ofsex, mensteal periods, dating, and birth control. She and her boyj-it-nd were having intercouvre about twice a month and she wanted to know about birth control method. She was aware of the duys of her menstrual cycle when she was most likely to 5et pregnant. The issue of sexually transmitted diseases did come up as a concern but wm a low risk in this mono5amow ‘tfim time to have intercourse” couple. This decreased but did not eliminate my need to talk about the use of condoms, safe sex pactices, and what it means to both of them. Her openness to talk about her sexuality and her sexual health need5 made the intewiew 50 very smoothly. Her menswud period had been fairly regular fi over R year, but she bad about two period per year that were later than she had expected them to be. I instructed her in the use of a menstrual calendar and told her how important it was to bring this oy a reasonable substitute to each of her 5yvtewlogic examinations to vetifi any iryeBuhr per%&.
nonsterile cotton swabs placed in a few drops of normal saline and potassium hydroxide solution. These specimens are placed on a clean glass slide with a cover slide used to visualize the specimen under the microscope. The normal saline side of the slide may reveal Tricbomonas parasites with their characteristic flagella. These can be seen along with a few round white blood cells and larger epithelial cells in Figure 2. The characteristic “clue cell” of Gardnerella vaginalis vaginitis can be seen in Figure 3 and compared with a normal epithelial cell as seen in Figure 4. The borders of a normal epithelial cell are clear and easy to see compared with the “clue cell’s” surface, which is ladden with bacteria. Pseudohyphae characteristic of Candida vaginitis may be best seen on the potassium hydroxide side of the slide. These branches with budding can be seen in Figure 5. A Chlamydia culture may also be performed if indicated by a history of exposure or lower abdominal pain. In Chlamydia many white blood cells are seen in a vaginal sample viewed with a microscope. If there are signs of cervicitis, a tender adnexa, uterus, or both during the bimanual examination, a specimen needs to be sent to determine the presence of Chlamydia.
on
INDICATIONS FOR PERFORMING A PELVIC EXAMINATION IN AN ADOLESCENT
n
In an adolescent the following are indications for performing a pelvic examination (Neinstein St Stewart, 1984). The adolescent:
Journal of Pediatric Health
n
FIGURE 6 Relaxation
(Redrawn examination.
. . . . . . . .
. .
The
Care
of pubococcygeal from Bates, B. [19831. A guide Philadelphia: ]. B. Lippincott.)
n
muscle. to physical
FIGURE 7 Gliding
from Bates, Philadelphia:
Requests a pelvic examination Is sexually active Needs birth control Complains of symptoms of vaginal and/or uterine infection Has a history of exposure to a sexually transmitted disease Has undiagnosed abdominal pain Has a suspected pelvic mass Has symptoms of a menstrual disorder (including amenorrhea, dysfunctional uterine bleeding, mild to moderate dysmenorrhea unresponsive to therapy, or severe dysmenorrhea) Discloses a history of diethylstilbestrol (DES) exposure Is a rape victim
The exact age at which a pelvic examination should be performed without a history of any of the above is an area of controversy. ACOG Standards for Obstetric and Gynecologic Services (1985) recommend that the first pelvic examination be performed at age 18 unless sexual activity begins earlier. The final decision depends on the feelings and background of the patient, her family, and the health care provider. HISTORICAL DATA NECESSARY BEFORE PERFORMING A GYNECOLOGIC EXAMINATION
n
.
. .
The reason for the clinic visit Age of onset and progression of puberty . Age of menarche, cycle length and regularity,
. . n
.
n
n
q
dura-
Gynecologic
speculum B. [1983]. A guide J. B. Lippincott.)
FIGURE 8 Opening
(Redrawn examination.
n
The gynecologic history is most important in ascertaining whether a significant abnormality exists in an adolescent. The areas to be assessedbefore performing a gynecologic examination on an adolescent includc the following:
Adolescent
from
Examination
145
over fingers. (Redrawn to physical examination.
speculum to view Bates, B. [ 19831. A guide Philadelphia: J. B. Lippincott.)
the cervix. to physical
tion of menses, amount of flow, last normal menstrual period, and previous menstrual period when indicated Delay or absence of menstrual periods, including an abnormal pattern or amount of vaginal bleeding as estimated by the number of tampons or pads she saturates in a day, any recent changes in the amount of flow, or the presence of spotting Premenstrual symptoms or dysmenorrhea Sexual knowledge, source of information, and level of sophistication Sexual activity and sexual concerns or questions Contraceptive needs Previous sexually transmitted disease or a current concern regarding vaginal discharge, pain, burning, or sores on the external genitalia Previous pregnancy and outcome if applicable Concerns or questions regarding body development or reproductive functioning
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Volume 1, Number 3 May-June 1987
Gemberling
n
FIGURE
9 Cervix
posterior
. Pelvic or lower abdominal pain or discomfort and whether it is present at all times or, if she is sexually active, only with intercourse A history of abnormal vaginal discharge should bc explored more fully. It is important to ascertain whether she knows what normal vaginal discharge is in terms of color, quantity, and relationship to the menstrual cycle. Any variation of normal should be assessed in terms of abnormal color, quantity, odor, pruritus, erythema, dysuria, lower abdominal pain, inguinal lymphadenopathy, or vulvar excoriation. These signs and symptoms are all indicative of a possible vaginitis or pelvic infection, which requires further diagnostic testing and evaluation. For some health care providers a sexual history is the most difficult aspect of an adolescent’s gynecologic history. Often this is gathered after the less invasive questions and the same manner and tone of voice used earlier should be used. Careful phrasing of the questions so that they are nonjudgmental will make it easier for the adolescent to give honest responses. For example, asking “Are you having sex” is much preferable to ‘Why are you having sex” and “Do you need some birth control information” can be asked rather than ‘Why aren’t you using birth control.” Eye-to-eye contact without taking notes will lead to a more comfortable and open atmosphere. Areas that need to be explored include usual sexual practices, gender and number of sexual partners, frequency of intercourse, type of contraception
with
anteflexed
uterus.
used if any, and whether contraception sistently. w THE
GYNECOLOCIC
is used con-
EXAMINATION
Befme perfmmin~ the pelvic examination, we reviewed the steps of the examination. Jenny bad the opportunity to look at and touch a vqinal speculum, and tbti seemed to allay much of her anxiety. We discussed what tests would be performed at this visit including a Pap smear for cervical cancer. I asked her to empty her bladder and while she was undressing, I checked be-r urine with a dipstick; no abnormalities were found. I carefilly positioned Jenny MZ the examination table b.11 be&n5 her to rest her feet comfmtllbly in the stirs-ups and assisted her while she moved her buttocks to the end of the table. I put a pillow under her bead fm comfort and 5avc her a mirror so that she could look at any pati of her anatowg that she wished. I placed the drape so that it was cover+ her knees and fEat on her abdumen, making it possible to have eye contact during the examination. I told her I would be touchin her before she felt my band to prevent her porn being surprired.
The first part of the examination includes inspection of the external genitalia including the mons pubis, labia, clitoris, urethral orifice, vaginal introitus, and surrounding areas. The examiner evaluates these structures for any signs of inflammation, infection, discharge, swelling, nodules, lesions, or signs of trauma. Palpation should begin by first touching the inner aspect of her thigh and then progressing to the inguinal area. Lymphadenopathy may be a clue to
Journal of Pediatric Health Care
The
n
FIGURE
10 Cervix
anterior
adjacent and regional abnormalities. The mons pubis is palpated next. Abnormal hair distribution, such as a male escutcheon or absent pubic hair, is checked. While examining the clitoris, the examiner can inform the patient that this structure is one of the sites that when stimulated leads to sexual arousal. The Skene’s glands are two small glands that are located adjacent to the urethra. If a gonococcal infection is present, it may be possible to milk the gland and have the exudate cultured to confirm the diagnosis. The Bartholin’s glands are located at the 4 : 30 and 7 : 30 positions adjacent to the border of the hymenal ring. The Bartholin’s glands are nonpalpable and nontender unless an infection is present.
F
or some health care providers a sexual history is the most difficult aspect of an adolescent’s gynecologic history.
Afier warming the speculum with water and checking the temperature, I helped Jenny to ia’entifjl and then relax the pubouq~eal muscle as I slowly and Jently inserted the speculum. She tolerated this procedure without dticomfmt.
The speculum examination is performed next. The size of the speculum will depend on the age of the adolescent, whether she is sexually active or not, if she has used tampons, and whether the hymenal ring is intact. Most sexually active adolescents can be cx-
with
Adolescent
retroflexed
Gynecologic
Examination
147
uterus.
amined easily using a small size Pederson or Grave’s speculum. In the case of a very tight vaginal opening, an otoscope, a cystoscope, or a special pediatric speculum can be used to visualize the cervix and vaginal mucosa. To ensure a comfortable insertion of the speculum, help the adolescent to identify the pubococcygeal muscle. With the examiners fingers in the vagina, press down on the posterior vaginal wall. When this muscle is relaxed, insertion of the speculum will progress more easily (Figure 6). Second, a speculum lubricated with warm water will make insertion smoother and will not interfere with culture or Pap smear results. Finally, keep in mind that the vaginal canal is tilted downward approximately 45 degrees below the horizontal plane as shown in Figure 7. This will aid the examiner in gliding the speculum over either the one or two fingers that are partially within the vagina. The fingers are gradually removed as the speculum takes their place. The continuous gentle downward pressure will prevent the speculum from coming in contact with the sensitive urethra. As the examiner’s fingers are being removed from the vagina, they can be used to prevent pinching the labia or trapping pubic hairs while the speculum is being advanced. While continuing a downward pressure, the speculum blades are slowly opened and the cervix and the vaginal walls become visible (Figure 8). The position of the cervix within the vagina is most often related to the position of the uterus within the pelvis.
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Volume 1, Number 3 May-June 1987
Gemberling
Pap smear. If the cervix is very erythematous and covered with exudate, this may be a sign of cervicitis caused by Neisseria~onorrhoeae, Tvichmonas, or Cblamydia. Cervical polyps may also be found. If an adolescent has a history of exposure to diethylstilbestrol while in utero, she may have a number of cervical or vaginal abnormalities that need to be evaluated on a regular basis by a specialist. As I took the Pap smear, I told Jenny that she m@tfeel a slight cramplasting onlya second and that zfsbefelt nothing that was normal too. I mentioned that she might notice a small spot of blood later that day and should not be alarmed, sincethis is normal afzer a Pap smear.
w FIGURE 11
Bimanual examination. Bates, B. [1983]. A guide to physical Philadelphia: 1. B. Lippincott.)
(Redrawn examination.
from
If the uterus is anteflexed, the cervix may be more easily visualized in the posterior portion of the cul-de-sac as shown in Figure 9. In a more retroflexed uterus the cervix may be more easily visualized in the upper portion of the vagina after the speculum is inserted (Figure 10). If a plastic speculum is being used, the examiner might want to inform the adolescent that a clicking sound will be heard as the speculum blades arc closed.
I
f the teenager reports that she has multiple sexual partners, Neisseria gonorrhoeae and Chlamydia cultures and a wet mount may be taken to rule out a sexually transmitted disease.
The vagina and cervix are inspected for signs of inflammation or infection, lesions, cyanosis, or any gross anatomic abnormalities. The cervix will appear smooth in comparison with the ruguated vagina. Usually the cervix is a smooth pink structure that is covered with stratified squamous epithelium. In some adolescents a darker pink erythematous area may surround the arca of the external OS. This is columnar epithelium and represents a normal variation. The junction between these two types of tissue, if it is visible, is called the squamocolumnar junction. This is the arca that needs to be sampled when taking a
A Pap smear, culture or wet mount, is taken if indicated by history or physical examination findings. If an adolescent reports a history of an abnormal Pap smear in the past, previous lesions or cervical disease, multiple partners, or early age of first intercourse, the Pap smear may need to be taken on a more frequent basis. Individual risk factors are the best determinant of frequency of cytologic evaluation (American College of Obstetrics and Gynecology, 1985). If the teenager reports that she has multiple sexual partners, Neikeria ~onorrhoeae and Chlamydia cultures and a wet mount may be taken to rule out a sexually transmitted disease. As the speculum is removed, the blades are rotated slightly, keeping a gently downward pressure. This maneuver allows for full visualization of the vaginal mucosa as the speculum is removed and the blades are slowly closed. The last part of the pelvic examination is the bimanual evaluation of the cervix, uterus, and ovaries. The adolescent should be instructed to place her arms at her side or across her upper abdomen because this helps to relax the abdominal muscles. Relaxation techniques can now be used as a lubricated index finger of the gloved hand is slowly and gently inserted into the vagina. She should be reminded that she will feel pressure and that if she experiences discomfort, she should let the examiner know so that the cxamination can either be stopped or progress more slowly. If no discomfort is experienced and relaxation is adequate, a second finger can be introduced in the vaginal canal. The examiner’s other hand is placed on the abdomen to provide a counterpressure and to assist the internal fingers in locating and palpating first the cervix, then the uterus, and finally the adnexa (Figure 11). The cervix should be smooth and nontender when moved gently from side to side. The uterus is pal-
Journal of Pediatric Health Care
pated next and should also be smooth and nontender. The size and ratio of mndus to cervix will vary depending on whether the adolescent is pubertal or an older adolescent. As the adolescent matures, the proportion will approximate that of an adult woman; that is, the cervix is approximately one third the size of the uterine fimdus. The size, shape, position, consistency, mobility, and any masses or tenderness should be noted by the examiner. The size, if enlarged, is estimated in centimeters. If the uterus is irregular in shape, tender on palpation, or immobile within the pelvis, these are cause for further evaluation by a specialist. A soft, enlarged uterus and a cvanotic cervix are indicative of pregnancy. The areas around and behind the cervix should be evaluated for any masses or tenderness.
R eassurance that the adolescent is normal helps alleviate concern and can positively affect her body image.
The adnexal areas are evaluated next. Normally the ovaries are small, round, or slightly ovoid, and may be slightly tender when palpated. The fallopian tubes should be nonpalpable and nontender; any thickening or masses in this area also need further evaluation. Feeling ovaries is a skill that takes practice to develop and is easier to do in a relaxed, nonobese patient. To increase the likelihood of palpating these structures, the examiner must relocate the internal examining fingers into the lateral fornix while sweeping the abdominal hand downward and inward in an attempt to trap the ovaries between the two examining hands. This same procedure is repeated on the other side. The rectovaginal examination is frequently performed to confirm previous examination findings, to evaluate the rectum and the rectovaginal septum, and to confirm the vaginal examination findings. Any masses or tenderness are noted. To prevent crosscontamination, a cZean&ve is used. A liberal amount of lubricant is used on the middle finger. This finger is placed at the rectum and the examiner waits for the usual contraction response to subside. The patient is asked to bear down as if having a bowel movement, since this relaxes the sphincter and facilitates the examination. The rectal examining finger is gently inserted and almost simultaneously the first finger is inserted into the vagina. Using the bimanual approach, the examiner should briefly reach as high
The
Adolescent
Cynecologic
149
Examination
as possible to note any abnormal masses or tenderness. If no abnormalities exist, the pelvic examination is now complete. The adolescent is offered a tissue or a minipad if this is necessary. She is asked to move back on the table and then to sit up; this prevents her from falling off the table if she sits up first. n
POSTEXAMINATION
CONSULTATION
After the examination was completed, I asked Jenny to come to my ofice so that we could discuss the findinfls. I reassured her that the entire examination was normal and that she could call the clinic in a week toget the results of the Pap smear. We reviewed the various birth control methods includin8 bow they prevent conception. At her request, IJave her written information on the various metbodr fh her to discuss with her partner. She decided that she and her partner would use condoms and felt comfortable using this mletbod to prevent pregnancy as well a.s a sexual& transmitted disease. She wasn’t interested in birth control pills at this time but would call our clinic when her fiequenc?, of intercourse increased. She was undecided whether to discuss any of this information with her mother and asked me to keep our discussion con$dential. I assured her that I would but did enwuraged her to discuss our visit with her mother.
Alter the examination is completed, the health care provider should spend a few minutes reviewing normal as well as abnormal findings. Reassurance that the adolescent is normal helps alleviate concern and can positively affect her body image. If an abnormality exists, the diagnostic, therapeutic, and cducational plan should be discussed. Written instructions help to remind the adolescent what therapy is indicated. The adolescent needs time to express her concerns and to have any questions answered. If the adolescent gives her consent, the parent or partner can be asked to join the discussion. The adolescent and health care provider should have previously dctided which aspects of the historv or the examination may be discussed so that confidentiality can be maintained to the extent desired. The gynecologic examination can be a valuable educational experience and is an essential component of health care to adolescents. Time and attention to their unique health care needs relays a message that they are special, which in turn may foster a more positive self-image and attitude toward health promotion practices. n REFERENCES American
College
of Obstetrics and Gynecology ( 1985). se&m (6th ed.). Washington,
for obstetric-gyneco&& thor. 53-55. Bates, B. (1983). J. B. Lippincott.
A au4tlide
to p&ti
Stanah& DC:
Au-
examination. Philadelphia:
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Gemberling
N&stein, L. S. ( 1984). Adolescent health Baltimore: Urban and Schwarzenberg.
we:
a practicalguide.
RESOURCES Adams, B. N. (1983). Adolescent health care: Needs, priorities and services. Nursinfl Clinics of North America, 18, 237-247. Hawkins, J. W. (1981). Self-care health maintenance and contraccptive use. information needs. and knowledge of a selected group of universitv women. Issues in Health Care of Women, 3, 287-305.
Health assessment hana’bwk. (1985). Nursing 85 Books. Springhouse, PA: Springhouse. Dery, G. K. (1982). An approach to health assessment of women. Nursing Clinics ofNorth America, 17, 127.135. Martin, L. M., (1978). Health care of wM1zcx Philadelphia: J. B. Lippincott. Nichols, D. H., & Evrard, J. R. (1985). Ambulatoyr~necolu~~. Philadelphia: Harper Kc Row.
CORRECTIONS Gaunder, B. N., & Plummer, E. (1987). Diaper rash: Managing and controlling infants and toddlers. Journal of Pediatric Health Care, 1, 26-34.
a common
problem
in
The legend for Figure 1 on page 27 should read: Diaper rash grading scale. The following scale was used to grade diaper rash. 0, No evidence of rash; 1, slight rash (detectable erythema); 2, mild rash (moderate to severe erythema and/or scaling, slight edema, and papules); 3, moderate rash (moderate to severe erythema and scaling; slight to moderate ulceration(s), moderate to severe papules and edema); 4, severe rash (severe ulceration, papules, edema, and erythema). (From Jordan, W. E., Lawson, K. D., Berg, R. W., Franxman, J. J., & Marrer, A. M. [1986]. Diaper dermatitis: Incidence and severity among a general infant population. Pediatric Dwmatolugy, 3, 198207.)
The legend for Figure 2 on page 32 should read: Diaper rash model. (Courtesy Gamble Company.)
Procter
&
Table 1 on pages 30 and 31: The column ‘Treatment” for primary candidiasis should read as follows: Nystatin cream or lotion, 2-3 times per day; 1% hydrocortisone cream alternated with Nystatin at each diaper change for extremely inflamed skin; basic diaper and skin care. I
I
L. Gemberling,
MN,
RN, OB/GYN
Examination: . NP, PNP
The adolescent gynecologic examination is one area of pediatric medicine that is frequently overlooked. This article reviews suggestions for working with adolescent patients, as well as equipment and historical data necessary before the examination and indications for performing a pelvic examination. The examination is reviewed, including the techniques for some of the more common diagnostic tests performed as part of a routine examination. Suggestions for making the interaction a positive educational experience are provided. ] PEDIATR HEALTH CARE. (1987). I, 141-l 50.
Jenny was fifteen when I first met her at the Adolescent Ambulatory Clinic with her mother. Her chief complaint was a sore throat and stomacbacbe for the past 3 days. It was not unusual to see an adolescent in OUYsetting with this tpe of a problem. It was also not unusual fey the real reason for the adolescent’s visit to become apparent only after the adolescent entered the examination room unaccompanied by a parent orguardian. Jenny’s questions were sz&ntficant clues to the fmt that the real reason fey bev viiit was to talk about birth control, which appeared to be a current concern. I spent a fm minutes mentally mganizing the things I’d want to evaluate and the equipment I’d need to perform the examination efficiently. It was my hope that this first pelvic examination would prove to be a positive and valuable learning experience. SUGGESTIONS FOR WORKING ADOLESCENT PATIENTS
WITH
Sensitivity for the adolescent’s needs, concerns, and feelings can set the tone for her examination and have a profound influence on her attitudes about gynecologic health care for the rest of her lift. Whcncvcr possible, an environment that is private and comfortablc for the adolescent should be created. Confidentiality is a crucial concern that needs to bc discussed at the very beginning of the paticntpractitioner interaction. Not discussing it first ma) limit the amount and accuracy of information obtained. Reassurance must be provided that whatcvcr is disclosed will not be discussed with her parents Carol L. Cemberling 15 a Pediatric Nurse Practitioner and ObiCyn Nurse Practitioner. She is an Assistant Professor at California State University. Long Beach, in the Graduate Nurse Practitioner Program. She also is III private practice in Manhattan Beach and Redondo Beach, Califorma. Reprmt requests: Carol L. Gemberimg, MN, RN, NP, Assistant Proiessor, Department of Nursing, California State University, Long Beach, 1250 Bellflower Blvd., Long Beach, CA 90840. IOURNAL
OF PEDIATRIC
HEALTH
CARE
without her permission, unless this information is potentially harmful to her (cg, suicidal thoughts). It should never be assumed that the adolescent undcrstands this fact without discussing it explicitly.
s ensitivity for the adolescent’s needs, concerns, and feelings can set the tone for her examination and have a profound influence on her attitudes about gynecologic health care for the rest of her life.
Most women approach the gynccologic cxamination with some apprehension; this is particularlv true with the adolescent bcforc her first examination. Recognizing and discussing these feelings will help the patient to relax while also discovering the parts of the examination that may product the most anxicn or fear. The development of both primary and sccondary sexual characteristics may bc very anxiety provoking for an adolescent. The most common concerns that adolescents express arc the issues of pain or discomfort during the examination, being normal or different than other women, embarrassment or disgust during the examination, or fear of criticism for their sexual behavior. A nonjudgmcntal attitude provides an open and honest atmosphcrc where the adolescent will feel free to discuss her innermost concerns and questions. Explanations regarding the pelvic examination arc aided by using illustrations, diagrams, and models. With thcsc aids, a brief description of what the tccnager will see, feel, hear, and expericncc during the pelvic examination should be discussed. Ample time should bc allowed for questions during this prcex141
142
Gemberling
lubricant will be used during the the bimanual cxamination and the rcctovaginal examination. Tissues, tampons, and sanitary napkins arc useful and much appreciated after the examination has been completed. Another valuable item is a hand-held mirror to allow the adolescent to view her genitals as shown in Figure 1. This mav promote learning the names of various structures .and help her understand her anatomy. It also helps a teen bccomc comfortable with her own normal anatomv and assists her in the future should she notice anything different from this examination.
A
nonjudgmental attitude provides an open and honest atmosphere where the adolescent will feel free to discuss her innermost concerns and questions.
. n
FIGURE 1 Adolescent
viewing
genitals.
amination dialogue. Listening rather than lecturing conveys cart about her and that her worries are rcgardch as important. Any concerns she has about her body and how it functions should bc explored. She should bc instructed in relaxation techniques such as slow, deep breathing or visual imagery. These approaches will help to make the pelvic examination remain a nonpainful procedure, as it should be, in the absence of a pathologic condition. It should be emphasized that she will feel pressure but should not experience pain and if at any time she feels pain or needs to stop the examination for anv reason, the examiner will oblige her. EQUIPMENT NECESSARY FOR A CYNECOLOGIC EXAMINATION
n
The equipment necessary to perform a gynccologic examination includes an examination table with stirrups, gowns, sheets, and a good light source. Various types of small or pediatric plastic or metal speculums should be available. Warm water or (if you will be performing many examinations) a heating pad will be helpful for warming metal speculums. Nonsterile, well-fitting examination gloves and a water-soluble
The remainder of the equipment nccdcd to pcrform a pelvic examination will dcpcnd on which spccific tests arc indicated. In scxuallv active adolcsccnts, regardless of their age, an annual pelvic examination with a Pap smear is recommended by the American College of Obstetrics and Gynecology (ACOG) (1985). Cancer screening frequency is dctcrmincd b! the risk status of the woman. Beginning at 18 years of age, younger if she is sexually active, most women should undergo cervical cytologic cvraluation annually. It is particularly important that high-risk women (ic, those who have had carlv sexual intcrcourse and those who have had scvcral sexual partners or multiple marriages) should be screened annually. It is now common practice that hvo cytologic samplcs be taken. The first sample is taken from the endoccrvical canal using an cndocervical aspirator or a saline-soaked cotton swab that is introduced into the cndocervix and smeared onto a Pap smear slide A second more commonly taken sample comes from the outer portion of the cervix, the cxoccrvix. A spatula of either plastic or wood is inserted into the cervix and rotated 360 degrees in a firm but gcntlc manner and quickly applied to a labeled glass slide. Both the cndocervical and exoccnical spccimcns may bc placed on either the same or separate slides, depcnding on laboratory procedures. An open bottle filled with a special fixative solution such as 40% alcohol or a spray can with a fixative preparation needs to be in close proximity so that the sample may be treated within 10 to 15 seconds of obtaining the specimen to avoid a drying artifact. A pack is com-
~0~rnaloi Pediatric
The
Health Care
n
FIGURE
n
FIGURE
W FIGURE
2 Trichomonads
and
3 Clue cell with 4 Normal vaginal
white
blood
cells
clumps of bacteria epithelial cell.
mercially available that contains the needed equipment and instructions to perform a Pap smear. If a sexually transmitted disease is suspected, special equipment and laboratory services need to be available. The examiner must use precautions and wear gloves. A gonorrhea culture is obtained from the endocervical canal with a sterile cotton swab. This sterile swab should be streaked on a Thayer-Martin culture plate and immediately placed in an incubating
on
Adolescent
Gynecologic
microscopic
on epithelial
Examination
143
examination.
cell
surface
environment (rich in carbon dioxide). If this is not available, a transport medium can be used, but this method may miss a significant number of positive cultures (Neinstein & Stewart, 1984). If the chief complaint is vaginitis or if during the examination an abnormal discharge, odor, or appearance of the vaginal walls or the cervix is detected, a wet mount preparation may be needed. A sample of the vaginal discharge is obtained using one or two
144
Volume 1, Number 3 May-June 1987
Gemberling
n
FIGURE
5
Candida
with
branching
hyphae
Jenny said she and her mother have spent little time discus&g the physical changes that have been takirlg place in her body over the past 2 years. These changes have made her feel a little awkward a.sshe has bgun to outgrow adolescence
microscopic
examination
and fmt approach the young adult period of her life. This period of her life proved to be a vevely“teachable moment.” Based on my initial impYession of Jenny, I believed that her level ofpwtb and devebment was well within the ran5e of normal and her expectations wwe in line with her own perceptions m to what being a woman meant to her. As Jenny and I continued to talk, it became clear that her questions seemed to center around the areas ofsex, mensteal periods, dating, and birth control. She and her boyj-it-nd were having intercouvre about twice a month and she wanted to know about birth control method. She was aware of the duys of her menstrual cycle when she was most likely to 5et pregnant. The issue of sexually transmitted diseases did come up as a concern but wm a low risk in this mono5amow ‘tfim time to have intercourse” couple. This decreased but did not eliminate my need to talk about the use of condoms, safe sex pactices, and what it means to both of them. Her openness to talk about her sexuality and her sexual health need5 made the intewiew 50 very smoothly. Her menswud period had been fairly regular fi over R year, but she bad about two period per year that were later than she had expected them to be. I instructed her in the use of a menstrual calendar and told her how important it was to bring this oy a reasonable substitute to each of her 5yvtewlogic examinations to vetifi any iryeBuhr per%&.
nonsterile cotton swabs placed in a few drops of normal saline and potassium hydroxide solution. These specimens are placed on a clean glass slide with a cover slide used to visualize the specimen under the microscope. The normal saline side of the slide may reveal Tricbomonas parasites with their characteristic flagella. These can be seen along with a few round white blood cells and larger epithelial cells in Figure 2. The characteristic “clue cell” of Gardnerella vaginalis vaginitis can be seen in Figure 3 and compared with a normal epithelial cell as seen in Figure 4. The borders of a normal epithelial cell are clear and easy to see compared with the “clue cell’s” surface, which is ladden with bacteria. Pseudohyphae characteristic of Candida vaginitis may be best seen on the potassium hydroxide side of the slide. These branches with budding can be seen in Figure 5. A Chlamydia culture may also be performed if indicated by a history of exposure or lower abdominal pain. In Chlamydia many white blood cells are seen in a vaginal sample viewed with a microscope. If there are signs of cervicitis, a tender adnexa, uterus, or both during the bimanual examination, a specimen needs to be sent to determine the presence of Chlamydia.
on
INDICATIONS FOR PERFORMING A PELVIC EXAMINATION IN AN ADOLESCENT
n
In an adolescent the following are indications for performing a pelvic examination (Neinstein St Stewart, 1984). The adolescent:
Journal of Pediatric Health
n
FIGURE 6 Relaxation
(Redrawn examination.
. . . . . . . .
. .
The
Care
of pubococcygeal from Bates, B. [19831. A guide Philadelphia: ]. B. Lippincott.)
n
muscle. to physical
FIGURE 7 Gliding
from Bates, Philadelphia:
Requests a pelvic examination Is sexually active Needs birth control Complains of symptoms of vaginal and/or uterine infection Has a history of exposure to a sexually transmitted disease Has undiagnosed abdominal pain Has a suspected pelvic mass Has symptoms of a menstrual disorder (including amenorrhea, dysfunctional uterine bleeding, mild to moderate dysmenorrhea unresponsive to therapy, or severe dysmenorrhea) Discloses a history of diethylstilbestrol (DES) exposure Is a rape victim
The exact age at which a pelvic examination should be performed without a history of any of the above is an area of controversy. ACOG Standards for Obstetric and Gynecologic Services (1985) recommend that the first pelvic examination be performed at age 18 unless sexual activity begins earlier. The final decision depends on the feelings and background of the patient, her family, and the health care provider. HISTORICAL DATA NECESSARY BEFORE PERFORMING A GYNECOLOGIC EXAMINATION
n
.
. .
The reason for the clinic visit Age of onset and progression of puberty . Age of menarche, cycle length and regularity,
. . n
.
n
n
q
dura-
Gynecologic
speculum B. [1983]. A guide J. B. Lippincott.)
FIGURE 8 Opening
(Redrawn examination.
n
The gynecologic history is most important in ascertaining whether a significant abnormality exists in an adolescent. The areas to be assessedbefore performing a gynecologic examination on an adolescent includc the following:
Adolescent
from
Examination
145
over fingers. (Redrawn to physical examination.
speculum to view Bates, B. [ 19831. A guide Philadelphia: J. B. Lippincott.)
the cervix. to physical
tion of menses, amount of flow, last normal menstrual period, and previous menstrual period when indicated Delay or absence of menstrual periods, including an abnormal pattern or amount of vaginal bleeding as estimated by the number of tampons or pads she saturates in a day, any recent changes in the amount of flow, or the presence of spotting Premenstrual symptoms or dysmenorrhea Sexual knowledge, source of information, and level of sophistication Sexual activity and sexual concerns or questions Contraceptive needs Previous sexually transmitted disease or a current concern regarding vaginal discharge, pain, burning, or sores on the external genitalia Previous pregnancy and outcome if applicable Concerns or questions regarding body development or reproductive functioning
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Volume 1, Number 3 May-June 1987
Gemberling
n
FIGURE
9 Cervix
posterior
. Pelvic or lower abdominal pain or discomfort and whether it is present at all times or, if she is sexually active, only with intercourse A history of abnormal vaginal discharge should bc explored more fully. It is important to ascertain whether she knows what normal vaginal discharge is in terms of color, quantity, and relationship to the menstrual cycle. Any variation of normal should be assessed in terms of abnormal color, quantity, odor, pruritus, erythema, dysuria, lower abdominal pain, inguinal lymphadenopathy, or vulvar excoriation. These signs and symptoms are all indicative of a possible vaginitis or pelvic infection, which requires further diagnostic testing and evaluation. For some health care providers a sexual history is the most difficult aspect of an adolescent’s gynecologic history. Often this is gathered after the less invasive questions and the same manner and tone of voice used earlier should be used. Careful phrasing of the questions so that they are nonjudgmental will make it easier for the adolescent to give honest responses. For example, asking “Are you having sex” is much preferable to ‘Why are you having sex” and “Do you need some birth control information” can be asked rather than ‘Why aren’t you using birth control.” Eye-to-eye contact without taking notes will lead to a more comfortable and open atmosphere. Areas that need to be explored include usual sexual practices, gender and number of sexual partners, frequency of intercourse, type of contraception
with
anteflexed
uterus.
used if any, and whether contraception sistently. w THE
GYNECOLOCIC
is used con-
EXAMINATION
Befme perfmmin~ the pelvic examination, we reviewed the steps of the examination. Jenny bad the opportunity to look at and touch a vqinal speculum, and tbti seemed to allay much of her anxiety. We discussed what tests would be performed at this visit including a Pap smear for cervical cancer. I asked her to empty her bladder and while she was undressing, I checked be-r urine with a dipstick; no abnormalities were found. I carefilly positioned Jenny MZ the examination table b.11 be&n5 her to rest her feet comfmtllbly in the stirs-ups and assisted her while she moved her buttocks to the end of the table. I put a pillow under her bead fm comfort and 5avc her a mirror so that she could look at any pati of her anatowg that she wished. I placed the drape so that it was cover+ her knees and fEat on her abdumen, making it possible to have eye contact during the examination. I told her I would be touchin her before she felt my band to prevent her porn being surprired.
The first part of the examination includes inspection of the external genitalia including the mons pubis, labia, clitoris, urethral orifice, vaginal introitus, and surrounding areas. The examiner evaluates these structures for any signs of inflammation, infection, discharge, swelling, nodules, lesions, or signs of trauma. Palpation should begin by first touching the inner aspect of her thigh and then progressing to the inguinal area. Lymphadenopathy may be a clue to
Journal of Pediatric Health Care
The
n
FIGURE
10 Cervix
anterior
adjacent and regional abnormalities. The mons pubis is palpated next. Abnormal hair distribution, such as a male escutcheon or absent pubic hair, is checked. While examining the clitoris, the examiner can inform the patient that this structure is one of the sites that when stimulated leads to sexual arousal. The Skene’s glands are two small glands that are located adjacent to the urethra. If a gonococcal infection is present, it may be possible to milk the gland and have the exudate cultured to confirm the diagnosis. The Bartholin’s glands are located at the 4 : 30 and 7 : 30 positions adjacent to the border of the hymenal ring. The Bartholin’s glands are nonpalpable and nontender unless an infection is present.
F
or some health care providers a sexual history is the most difficult aspect of an adolescent’s gynecologic history.
Afier warming the speculum with water and checking the temperature, I helped Jenny to ia’entifjl and then relax the pubouq~eal muscle as I slowly and Jently inserted the speculum. She tolerated this procedure without dticomfmt.
The speculum examination is performed next. The size of the speculum will depend on the age of the adolescent, whether she is sexually active or not, if she has used tampons, and whether the hymenal ring is intact. Most sexually active adolescents can be cx-
with
Adolescent
retroflexed
Gynecologic
Examination
147
uterus.
amined easily using a small size Pederson or Grave’s speculum. In the case of a very tight vaginal opening, an otoscope, a cystoscope, or a special pediatric speculum can be used to visualize the cervix and vaginal mucosa. To ensure a comfortable insertion of the speculum, help the adolescent to identify the pubococcygeal muscle. With the examiners fingers in the vagina, press down on the posterior vaginal wall. When this muscle is relaxed, insertion of the speculum will progress more easily (Figure 6). Second, a speculum lubricated with warm water will make insertion smoother and will not interfere with culture or Pap smear results. Finally, keep in mind that the vaginal canal is tilted downward approximately 45 degrees below the horizontal plane as shown in Figure 7. This will aid the examiner in gliding the speculum over either the one or two fingers that are partially within the vagina. The fingers are gradually removed as the speculum takes their place. The continuous gentle downward pressure will prevent the speculum from coming in contact with the sensitive urethra. As the examiner’s fingers are being removed from the vagina, they can be used to prevent pinching the labia or trapping pubic hairs while the speculum is being advanced. While continuing a downward pressure, the speculum blades are slowly opened and the cervix and the vaginal walls become visible (Figure 8). The position of the cervix within the vagina is most often related to the position of the uterus within the pelvis.
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Volume 1, Number 3 May-June 1987
Gemberling
Pap smear. If the cervix is very erythematous and covered with exudate, this may be a sign of cervicitis caused by Neisseria~onorrhoeae, Tvichmonas, or Cblamydia. Cervical polyps may also be found. If an adolescent has a history of exposure to diethylstilbestrol while in utero, she may have a number of cervical or vaginal abnormalities that need to be evaluated on a regular basis by a specialist. As I took the Pap smear, I told Jenny that she m@tfeel a slight cramplasting onlya second and that zfsbefelt nothing that was normal too. I mentioned that she might notice a small spot of blood later that day and should not be alarmed, sincethis is normal afzer a Pap smear.
w FIGURE 11
Bimanual examination. Bates, B. [1983]. A guide to physical Philadelphia: 1. B. Lippincott.)
(Redrawn examination.
from
If the uterus is anteflexed, the cervix may be more easily visualized in the posterior portion of the cul-de-sac as shown in Figure 9. In a more retroflexed uterus the cervix may be more easily visualized in the upper portion of the vagina after the speculum is inserted (Figure 10). If a plastic speculum is being used, the examiner might want to inform the adolescent that a clicking sound will be heard as the speculum blades arc closed.
I
f the teenager reports that she has multiple sexual partners, Neisseria gonorrhoeae and Chlamydia cultures and a wet mount may be taken to rule out a sexually transmitted disease.
The vagina and cervix are inspected for signs of inflammation or infection, lesions, cyanosis, or any gross anatomic abnormalities. The cervix will appear smooth in comparison with the ruguated vagina. Usually the cervix is a smooth pink structure that is covered with stratified squamous epithelium. In some adolescents a darker pink erythematous area may surround the arca of the external OS. This is columnar epithelium and represents a normal variation. The junction between these two types of tissue, if it is visible, is called the squamocolumnar junction. This is the arca that needs to be sampled when taking a
A Pap smear, culture or wet mount, is taken if indicated by history or physical examination findings. If an adolescent reports a history of an abnormal Pap smear in the past, previous lesions or cervical disease, multiple partners, or early age of first intercourse, the Pap smear may need to be taken on a more frequent basis. Individual risk factors are the best determinant of frequency of cytologic evaluation (American College of Obstetrics and Gynecology, 1985). If the teenager reports that she has multiple sexual partners, Neikeria ~onorrhoeae and Chlamydia cultures and a wet mount may be taken to rule out a sexually transmitted disease. As the speculum is removed, the blades are rotated slightly, keeping a gently downward pressure. This maneuver allows for full visualization of the vaginal mucosa as the speculum is removed and the blades are slowly closed. The last part of the pelvic examination is the bimanual evaluation of the cervix, uterus, and ovaries. The adolescent should be instructed to place her arms at her side or across her upper abdomen because this helps to relax the abdominal muscles. Relaxation techniques can now be used as a lubricated index finger of the gloved hand is slowly and gently inserted into the vagina. She should be reminded that she will feel pressure and that if she experiences discomfort, she should let the examiner know so that the cxamination can either be stopped or progress more slowly. If no discomfort is experienced and relaxation is adequate, a second finger can be introduced in the vaginal canal. The examiner’s other hand is placed on the abdomen to provide a counterpressure and to assist the internal fingers in locating and palpating first the cervix, then the uterus, and finally the adnexa (Figure 11). The cervix should be smooth and nontender when moved gently from side to side. The uterus is pal-
Journal of Pediatric Health Care
pated next and should also be smooth and nontender. The size and ratio of mndus to cervix will vary depending on whether the adolescent is pubertal or an older adolescent. As the adolescent matures, the proportion will approximate that of an adult woman; that is, the cervix is approximately one third the size of the uterine fimdus. The size, shape, position, consistency, mobility, and any masses or tenderness should be noted by the examiner. The size, if enlarged, is estimated in centimeters. If the uterus is irregular in shape, tender on palpation, or immobile within the pelvis, these are cause for further evaluation by a specialist. A soft, enlarged uterus and a cvanotic cervix are indicative of pregnancy. The areas around and behind the cervix should be evaluated for any masses or tenderness.
R eassurance that the adolescent is normal helps alleviate concern and can positively affect her body image.
The adnexal areas are evaluated next. Normally the ovaries are small, round, or slightly ovoid, and may be slightly tender when palpated. The fallopian tubes should be nonpalpable and nontender; any thickening or masses in this area also need further evaluation. Feeling ovaries is a skill that takes practice to develop and is easier to do in a relaxed, nonobese patient. To increase the likelihood of palpating these structures, the examiner must relocate the internal examining fingers into the lateral fornix while sweeping the abdominal hand downward and inward in an attempt to trap the ovaries between the two examining hands. This same procedure is repeated on the other side. The rectovaginal examination is frequently performed to confirm previous examination findings, to evaluate the rectum and the rectovaginal septum, and to confirm the vaginal examination findings. Any masses or tenderness are noted. To prevent crosscontamination, a cZean&ve is used. A liberal amount of lubricant is used on the middle finger. This finger is placed at the rectum and the examiner waits for the usual contraction response to subside. The patient is asked to bear down as if having a bowel movement, since this relaxes the sphincter and facilitates the examination. The rectal examining finger is gently inserted and almost simultaneously the first finger is inserted into the vagina. Using the bimanual approach, the examiner should briefly reach as high
The
Adolescent
Cynecologic
149
Examination
as possible to note any abnormal masses or tenderness. If no abnormalities exist, the pelvic examination is now complete. The adolescent is offered a tissue or a minipad if this is necessary. She is asked to move back on the table and then to sit up; this prevents her from falling off the table if she sits up first. n
POSTEXAMINATION
CONSULTATION
After the examination was completed, I asked Jenny to come to my ofice so that we could discuss the findinfls. I reassured her that the entire examination was normal and that she could call the clinic in a week toget the results of the Pap smear. We reviewed the various birth control methods includin8 bow they prevent conception. At her request, IJave her written information on the various metbodr fh her to discuss with her partner. She decided that she and her partner would use condoms and felt comfortable using this mletbod to prevent pregnancy as well a.s a sexual& transmitted disease. She wasn’t interested in birth control pills at this time but would call our clinic when her fiequenc?, of intercourse increased. She was undecided whether to discuss any of this information with her mother and asked me to keep our discussion con$dential. I assured her that I would but did enwuraged her to discuss our visit with her mother.
Alter the examination is completed, the health care provider should spend a few minutes reviewing normal as well as abnormal findings. Reassurance that the adolescent is normal helps alleviate concern and can positively affect her body image. If an abnormality exists, the diagnostic, therapeutic, and cducational plan should be discussed. Written instructions help to remind the adolescent what therapy is indicated. The adolescent needs time to express her concerns and to have any questions answered. If the adolescent gives her consent, the parent or partner can be asked to join the discussion. The adolescent and health care provider should have previously dctided which aspects of the historv or the examination may be discussed so that confidentiality can be maintained to the extent desired. The gynecologic examination can be a valuable educational experience and is an essential component of health care to adolescents. Time and attention to their unique health care needs relays a message that they are special, which in turn may foster a more positive self-image and attitude toward health promotion practices. n REFERENCES American
College
of Obstetrics and Gynecology ( 1985). se&m (6th ed.). Washington,
for obstetric-gyneco&& thor. 53-55. Bates, B. (1983). J. B. Lippincott.
A au4tlide
to p&ti
Stanah& DC:
Au-
examination. Philadelphia:
150
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Gemberling
N&stein, L. S. ( 1984). Adolescent health Baltimore: Urban and Schwarzenberg.
we:
a practicalguide.
RESOURCES Adams, B. N. (1983). Adolescent health care: Needs, priorities and services. Nursinfl Clinics of North America, 18, 237-247. Hawkins, J. W. (1981). Self-care health maintenance and contraccptive use. information needs. and knowledge of a selected group of universitv women. Issues in Health Care of Women, 3, 287-305.
Health assessment hana’bwk. (1985). Nursing 85 Books. Springhouse, PA: Springhouse. Dery, G. K. (1982). An approach to health assessment of women. Nursing Clinics ofNorth America, 17, 127.135. Martin, L. M., (1978). Health care of wM1zcx Philadelphia: J. B. Lippincott. Nichols, D. H., & Evrard, J. R. (1985). Ambulatoyr~necolu~~. Philadelphia: Harper Kc Row.
CORRECTIONS Gaunder, B. N., & Plummer, E. (1987). Diaper rash: Managing and controlling infants and toddlers. Journal of Pediatric Health Care, 1, 26-34.
a common
problem
in
The legend for Figure 1 on page 27 should read: Diaper rash grading scale. The following scale was used to grade diaper rash. 0, No evidence of rash; 1, slight rash (detectable erythema); 2, mild rash (moderate to severe erythema and/or scaling, slight edema, and papules); 3, moderate rash (moderate to severe erythema and scaling; slight to moderate ulceration(s), moderate to severe papules and edema); 4, severe rash (severe ulceration, papules, edema, and erythema). (From Jordan, W. E., Lawson, K. D., Berg, R. W., Franxman, J. J., & Marrer, A. M. [1986]. Diaper dermatitis: Incidence and severity among a general infant population. Pediatric Dwmatolugy, 3, 198207.)
The legend for Figure 2 on page 32 should read: Diaper rash model. (Courtesy Gamble Company.)
Procter
&
Table 1 on pages 30 and 31: The column ‘Treatment” for primary candidiasis should read as follows: Nystatin cream or lotion, 2-3 times per day; 1% hydrocortisone cream alternated with Nystatin at each diaper change for extremely inflamed skin; basic diaper and skin care. I
I