successful pelvic examinations

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SUCCESSFUL PELVIC

EXAMINATIONS

How SANE’s Succeed in challenging situations.

Minnesota Forensic Nurses Education Conference

September 14, 2018

Fridley MN

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Barbara Kern-Pieh, RN CNM MSN SANE-A SANE-P

Questions from SANE’s ahead of time

• How to keep competence and confidence when long spaces between exams?

• How do you find the “Hiding cervix”?

• What are the normal colors for:• the cervix?

• vagina?

• Discharge?

• When to use the petite vs x-large speculum?

• What to do if surplus tissue seems to cave in vaginal walls?

• Help us problem solve difficult situations:

• Positioning

• Elderly

• Immobile

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First steps to successful exams

• Promote excellence in forensic nursing through education and collaborative partnerships.

• Improve care and long-term health outcomes for victims of violence in Minnesota.

• Practice.

• Find joy in your work

• Share support

• Find joy in learning!

• Vote at end for the most joyful speculum story

Ways to practice on your own

• Practice words that will reassure patient

• State the expected

• You tube teaching videos – also humorous

• My beautiful cervix

• One video recommended masturbate prior to exam – increased lubrication and opened up vagina

• Humor “JoJo Head” “pinch grunt”

• “No Kids for You” Humorous use of duct tape, umbrella…

• Find joy

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SUCCESSFUL PELVIC EXAMINATIONS

• Maximize comfort

• Know what your challenges will be• Position

• Speculum choice

• Patient characteristics

• What are Normal cervix vs. STI

• Recent trauma

• General categories

• Adolescent

• Post menopausal

• Chronic medical conditions

• Developmental disability

• Genital surgery

• Specific cases

• Sent in

• From the audience

SUCCESSFUL PELVIC EXAMINATIONS

• Potential challenges• Patients feel exposed and lack control

• Emotional distress and fear of pain – patient reluctant

• Racial and ethnic groups fear how they will be treated

• Sexual minority groups

• Obese women

• Women with other disabilities

• Victims of sexual assault

• Trauma victims • Challenging Pelvic Exam , Bates, Carroll, Potter J Gen Intern Med 26(6)651-7

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Solutions for Success• Empower the patient

• Explain / demonstrate

• Elicit details about past experiences with pelvic exam and strategize together

• Plan / explain exam while clothed and before recline.

• Void before exam

• Chaperone

• Policy for chaperone per institution/ gender of provider

• Advocate for emotional support

• Educate advocate

Recommendations for exam after trauma

• Acknowledge patients anxiety

• Accommodate requests

• Do what is necessary in time constraints

• Supportive person/ object

• Keep clothed respectfully as much as possible

• Assure patient that examiner will stop if asked – negotiate what next

• Include patient in plans for best positioning

• Keep informed using positive language

• Anxiolytic medication if appropriate.

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Disassociate

• Some patients methods for coping

• Child like voice

• Startle to ambient sounds

• Continue with your evaluation of best practice.

Positions

• Maximize comfort

• Maximize information

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Dorsal lithotomy using stirrups

• Practitioner has good visibility and access for evidence collection

• Patient able to lie on back

• Uses foot supports (stirrups) for lower limb support

• Moves to edge of exam bed

• Speculum handle down

Side Lying Knee-Chest

• Does not require stirrups

• For woman who is comfortable and balanced on side

• Top leg closer to chest,

• Bottom leg straightened

• Speculum handle pointed either direction

• Angle speculum toward small of back – not toward patients head

• Assistant may elevate leg

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V-shaped Position

• May or may not need stirrups

• Patient must be able to lie on back

• Speculum inserted with handle up

• May be more comfortable with support pillow in small of back.

Diamond-shaped position

• Stirrups not needed

• Must be able to lie flat on back

• Speculum with handle up

• Assistant may be needed to hold feet together

• Wedge, Pillow, or bath blanket may be used under small of back to elevate

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Use of Obstetric Stirrups

• Offer more support

• Not likely available in ED setting

• If position is best choice, try using support staff to position legs.

M-shaped position

• Does not require use of stirrups

• Entire body supported by table

• Patient lies on back, knees apart, feet resting close to buttocks

• Speculum inserted with handle up

• If patient needs support, assistant may hold feet in place

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External genital evaluation

• Evaluate structures

• Document injuries

• Photo-documentation

• Evidence collection

laceration

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Laceration

Laceration and erythema

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Lichen Sclerosis

Speculum

• Speculum is just one tool to help you maximize information

• Now lets review how to maximize comfort

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Our tools can be mistaken

Photograph speculums Shoes arrived by mail

Our tools can be mistaken

• Several years ago, my husband thought that my speculum collection was a collection of shoe horns.

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Speculum selection

• Based on history of patient previous experiences

• History of assault

• Size

• Available selection at your institution

Pederson- or - Graves

Vaginal length and width vary by age, race, parity and height, and weight.

Narrow speculum may be more comfortable, Wide speculum may provide better visuilzation

op1

Slide 28

op1 office pc, 9/6/2018

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Ultra-narrow vs. Medium Pederson

Fiber optic lighted transparent

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Insertion technique – make your own video

• Hand separate labia

• Initial insertion oblique

• Avoid sensitive anterior structures

• Angle speculum depends on anatomy• If anteverted, direct toward spine

• If retroverted direct toward sacrum

• See rugae? – anterior or lateral

• Smooth? Posterior

• Reinsert if needed to find cervix

• Lock open NO distressing clicks

Cant find cervix?

• Use finger to sound vagina

• Estimate length

• Estimate location

• Change speculum size or type/shape

• Use condom to hold back lateral walls of vagina

• Avoid skimming cervix

• Open handle end of speculum

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Our tools can be mistaken

• En Route to Panama to provide Pap smears, my suitcase was packed with plastic speculae.

So I made sun glasses out of speculae!

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Vaginal Gallery

• Look for pink folds of rugae

• Color and texture of discharge

• Erythema

• History

• Document any injuries.

The Cervix

• Evaluate cervix

• Collect

• photograph

• Look at lateral vaginal walls

• Swab vagina for evidence

• Closing speculum• Care not to trap cervix or vaginal tissue

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Cervix Gallery

Cervix Gallery - fertile mucous, mid spot

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Cervix Gallery• Cervix has two cell types

• Squamous cells – flat light pink line vagina and face of cervix

• Columnar cells more red, appear rough, line the inner part of the cervical tube

• Transition zone changes with age

• Transition zone susceptible to HPV –cervical cancer

• This slide has a pap collection brush in the cervical os, transition zone clearly demarcated

Cervix Gallery – ectropian

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Cervix Gallery – healed lacerations

Cervix Gallery – polyp and polypectomy

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Cervix Gallery; Menses – os and rugae

Cervix Gallery normal variations

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Cervix Gallery

Cervix Gallery Herpes

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Cervix Gallery Herpes

Chancre Gallery –Chanre (syphyllis)

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Cervix Gallery petechiae

Cervix Gallery -Trichomonas

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Cervix Gallery Chlamydia

STI Gallery - Gonorrhea

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STI Gallery - HPV

Genital Gallery Yeast and BV

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Genital variations

• Female Genital Cutting

• Illegal in US and European Countries, still widely practiced .

• Piercings/ tatoos / implants

• Increasing in popularity, can alter the genital structures

• Trans with bottom surgery

• Post radiation

• Genital cancer/ vulvectomy

Female Genital Cutting

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Type 1

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Type III

Type III

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Why you should keep your training speculum in the glove box

• Can practice en route to the exam

• Can show it to the officer who pulls you over when you tell them that you are going to a SA case and you need to not make the victim wait.

• Self lighting feature could be used as a flashlight

Specific cases

• Atrophic Vaginitis

• Atrophy and stenosis, shortening and reduced elasticity following radiation

• Liberal use of lubricant

• Topical lidocaine

• Weigh benefit/risk of blind collection

• If internal injuries need to be evaluated, involve ED staff, consider conscious sedation if patient and staff agree to benefit.

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Specific cases – Vulvodynia/ vestibulitis/ vaginismus

• Tactile discomfort with touching Labia or area around the vagina

• Vaginismus – painful spasms

• Generous use of lubricant

• Discontinue exam, weigh risk –benefit to continue

Choosing positions/stirrup use

• Good visibility

• Examiner evaluation of injuries and evidence collection

• Patients perception

• Position can be perceived as disempowering, abusive and humiliating

• Don’t replicate position of assault if possible

• Physical comfort

• Language – “stirrups” vs. “foot supports”

• “Cold and hard” vs. “easy to clean”

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Gender non conforming

• Sensitivity to possibility of previous experiences with the system

• Concern for voyeurism on the part of health care providers

• Advocate present sensitive to circumstances

Patients with disabilities

• High prevalence of abuse with patients with disabilities

• Most victims are able to assent and cooperate with exam

• Plan for time - Let your back up know you will be longer with this exam

• Safe positioning/ transfer/

• Respectful etiquette• Include PCA, service animal, sign interpreter

• Screen for potential abuser to be Relative/ caregiver

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Side walls caving in?

• Use a condom to hold side walls back

• Used widest/ largest speculum available

• Open handle aperture slowly

I don’t have many opportunities

• Use your practice speculum

• Insert into your hand demo

• Cooking jars

• Review teaching tapes on internet

• Hand separate labia

• Initial insertion oblique

• Avoid sensitive anterior structures

• Angle speculum depends on anatomy• If anteverted, direct toward spine

• If retroverted direct toward sacrum

• See rugae? – anterior or lateral

• Smooth? Posterior

• Reinsert if needed to find cervix

• Lock open NO distressing clicks

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Color range –Pale pink to cyanotic blue

Specific Case

• Developmentally delayed Adult

• Unable to sit

• Use any assistance –How does PCA do peri care?

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Unable to Relax

• Use your confident positive words

• Share control with the patient

• Let patient know the benefit to seeing Cx, collection

• Offer time to relax

• Anti anxiety Rx

• Problem solve together – What has worked in past

• Engage advocate if appropriate

• Use smallest tools available

I have a long vagina

• Use longest tool available

• Roll hips up on bath blanket

• Raise hips on fists

• Separate Labia Majora to get more length from speculum blades

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Cant find the cervix

• Check surgical history

• Digital exam – how deep/ which direction

• Angle speculum depends on anatomy

• See rugae? – anterior or lateral

• Smooth? Posterior

• Reinsert large if needed

• Posterior pressure / rock handle

• Patient position – roll hips

Conclusion

• Pelvic exams are a challenge for the practitioner as well as the patient

• Improve the technical skills of the provider

• Acceptance and comfort of the diverse / traumatized patients

• With

• positive information,

• close collaboration,

• Modicum of creativity,

Even the most challenging pelvic examinations can be successful.

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So use your lenses and turn on those lights