What are the key takeaways in the examination of female genitalia?

Key Takeaways for Female Genitalia Examination

The examination of female genitalia should be systematic, starting with external inspection and progressing to internal assessment only when clinically indicated—routine screening pelvic examinations in asymptomatic women are not recommended. 1, 2

When to Perform Pelvic Examination

Perform pelvic examination for symptomatic patients only, including those with:

• Vulvar complaints, vaginal discharge, or abnormal bleeding 2
• Pelvic pain, dyspareunia, or suspected pelvic inflammatory disease 2
• Pelvic organ prolapse symptoms or urinary incontinence 2
• Suspected sexual abuse or assault 2
• Infertility evaluation 2

Do NOT perform routine screening pelvic examinations in asymptomatic, nonpregnant adult women—this is a strong recommendation as it provides no mortality or morbidity benefit and causes unnecessary anxiety, discomfort, and false-positive findings leading to unneeded procedures. 1, 2

External Genitalia Assessment

Systematic Inspection Sequence

Evaluate pubic hair distribution for Tanner staging and look for folliculitis (common with shaving), hidradenitis suppurativa (larger, tender, draining lesions), pubic lice, or nits. 1, 3

Assess skin for inflammatory changes: Look for erythema, swelling, hypopigmentation (lichen sclerosus, vitiligo), or hyperpigmentation. 1

Examine the clitoris after retracting the clitoral hood—normal width should be <10 mm; enlargement suggests hyperandrogenism from ovarian or adrenal pathology. 1, 3

Inspect the hymen for patency and configuration:

• Imperforate, microperforate, or cribriform hymen requires urgent gynecology referral in pubertal females to prevent hematocolpos 1, 3
• Use saline-soaked cotton swab to gently demonstrate patency if uncertain 1
• Vertical or transverse vaginal septum warrants evaluation for other genital tract anomalies 1

Check Bartholin glands (4 and 8 o'clock positions in posterior vestibule) for swelling, erythema, or tenderness—infection commonly involves STI pathogens including gonorrhea and chlamydia. 1

Examine Skene glands (lateral to urethra) for erythema; apply anterior pressure with vaginal finger to express discharge from ducts if infection suspected. 1

Lesion Recognition

Document all lesions systematically: papules, vesicles, pustules, ulcers, fissures, warts, or trauma. 1

Ulcers are most commonly caused by herpes simplex virus or syphilis in the United States—obtain HSV viral culture and syphilis serology for any genital ulcer. 1

Genital warts (condylomata acuminata) appear as flesh-colored or white papules that cannot be removed with swab, caused by HPV types 6 or 11; HPV types 16,18,31,33, and 35 are associated with neoplasia. 1, 3

Cervical Assessment (When Speculum Exam Indicated)

Normal cervix appears pink, smooth, and uniform. 2

Ectropion (cervical eversion with visible squamocolumnar junction) is normal in adolescents and regresses with age—do not misinterpret as pathology. 2

Friability and hyperemia indicate possible STI. 2

"Strawberry cervix" (red punctate lesions) is characteristic of Trichomoniasis. 2

Cervical cyanosis (Chadwick's sign) is an early pregnancy sign. 2

Diagnostic Testing Priorities

Test simultaneously for Chlamydia, Gonorrhea, and Trichomonas in symptomatic women—this optimizes detection of the most common treatable STIs. 1

Screen high-risk individuals (especially men who have sex with men) at extragenital sites (rectal, oropharyngeal) for gonorrhea and chlamydia. 1

Use reverse syphilis screening algorithm: treponemal-specific test first (EIA/chemiluminescence), then nontreponemal (RPR) to confirm. 1

For bacterial vaginosis, Gram stain and microbiome-based assays are more specific than culture for Gardnerella vaginalis alone. 1

Critical Preparation Steps

Have patient empty bladder before examination to minimize pain and discomfort. 1, 3

Ensure proper environment: room with locked door/curtain, adequate adjustable lighting, examination table with stirrups, nonlatex gloves, water-soluble lubricant. 1, 3

Never force a pelvic examination—this is always contraindicated. 1, 3

For adolescents, use anatomic models, pictures, and educational materials to reduce anxiety before first examination. 2

Common Pitfalls to Avoid

Do not misinterpret normal ectropion in adolescents as cervical pathology—this is a developmental finding. 2

Do not perform routine screening pelvic exams—35% of women experience pain, discomfort, fear, or anxiety during examination, and screening provides no proven benefit in asymptomatic women. 1, 2

Do not miss reinfection from untreated partners—25-40% of persistent symptoms or positive STI tests result from partner reinfection; always ensure partner testing and treatment. 1

Do not rely on pelvic examination alone for ovarian cancer detection—positive predictive value is only 0-3.6%, and the PLCO trial found no mortality benefit from screening with bimanual examination. 1

Women with PTSD or history of sexual violence experience more pain and anxiety during examination—provide trauma-informed care and consider alternative testing methods when possible. 2