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


• 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

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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• 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



• 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



• 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

successful pelvic examinations

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