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Women's Physical Exam

 

The Pelvic and Breast Exam

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During a pelvic exam, your doctor visually and manually assesses your reproductive organs. A pelvic exam usually is done as part of a woman's regular checkup, or your doctor may recommend a pelvic exam if you're having symptoms such as unusual vaginal discharge or pelvic pain.

A pelvic exam is a relatively short procedure. In the course of a pelvic exam, your doctor checks your vulva, vagina, cervix, uterus, rectum and pelvis, including your ovaries, for masses, growths or other abnormalities. A Pap test, which screens for cervical cancer, may be performed during a pelvic exam.

You may need a pelvic exam to assess your gynecologic health. A pelvic exam often is part of a routine physical exam for women to find possible signs of a variety of disorders, such as ovarian cysts, sexually transmitted infections, uterine fibroids or early-stage cancer. Your doctor can recommend how frequently you need to be examined, but many women have a pelvic exam once a year.

To diagnose a medical condition. Your doctor may suggest a pelvic exam if you're experiencing gynecologic symptoms, such as pelvic pain, unusual vaginal bleeding, skin changes, abnormal vaginal discharge or urinary problems. A pelvic exam can help your doctor diagnose possible causes of these symptoms and determine if other diagnostic testing or treatment is needed.

No special preparation is required for a pelvic exam, although your doctor may recommend that you schedule your pelvic exam on a day when you don't have your period.

If you have questions about the exam or its possible results, write them down and bring them with you to the appointment so that you don't forget to ask about them during the visit with your doctor.

A pelvic exam is performed in your doctor's office and takes only a few minutes.

You'll be asked to change out of your clothes and into a gown. You may also be given a sheet to wrap around your waist for added comfort and privacy. Before performing the pelvic exam, your doctor may listen to your heart and lungs and perform a breast exam.

During the pelvic exam, you lie on your back on an examining table, with your knees bent and your feet placed on the corners of the table or in supports called stirrups. You'll be asked to slide your body toward the end of the table and let your knees fall to the sides.

First, your doctor visually inspects your vulva, looking for irritation, redness, sores, swelling or any other abnormalities.

Next, your doctor uses a speculum a plastic or metal-hinged instrument shaped like a duck's bill to spread open your vaginal walls and view your vagina and cervix. Often, the speculum is warmed before it's inserted. Inserting and opening the speculum can cause pressure or discomfort for some women. Relax as much as possible to ease discomfort, but tell your doctor if you're in pain.

If your pelvic exam includes a Pap test (Pap smear), your doctor collects a sample of your cervical cells before removing the speculum. After the speculum is removed, your doctor examines your other pelvic organs for signs of abnormalities.

Because your pelvic organs, including your uterus and ovaries, can't be seen from outside your body, your doctor needs to feel (palpate) your abdomen and pelvis for this part of the exam. To do this, your doctor inserts two lubricated, gloved fingers into your vagina with one hand, while the other hand presses gently on the outside of your lower abdomen. This is to check the size and shape of your uterus and ovaries and identify tenderness and unusual growths. After the vaginal examination, your doctor also inserts a gloved finger into your rectum to check for tenderness, growths or other irregularities.

Usually, at each step along the way, your doctor tells you exactly what he or she is doing, so nothing comes as a surprise to you.

After the pelvic exam is over, you can get dressed and then discuss with your doctor the results of your exam.

A breast examination consists of inspection and palpation of the breasts to identify abnormalities. Some breast examinations are focused on specific issues while others are more general.

The breasts may be examined while the patient is sitting or reclining. Sometimes it may be desirable to do both.

With the patient in a sitting position, inspect the breasts visually. While generally symmetrical, most breasts are slightly asymmetrical in respect to size, shape, orientation, and position on the chest wall. Inspect for:

Visible masses (change in contour)

Skin dimpling

Nipple retraction

Redness

Have her raise her arms while you continue to watch the breasts.

An underlying malignancy can fix the skin in place.

Raising the arms will accentuate these changes.

Have her flex the pectoralis major muscles. A simple way to do this is have her place her hands on her hips and squeeze inward. Another way is have her place her palms together (praying position) and squeeze the palms together.

With flexion of the underlying muscle, areas of breast tissue that are fixed in place will move with the muscle, while the rest of the breast will not.

Suspicious areas will appear as a dimpling of the skin while she flexes these muscles.

Ask her to raise her arm over her head.

This has the effect of stretching and tightening the pectoralis major muscle that lies directly undeneath the breast.

Functionally, this places the breast on a fairly solid, fairly flat surface, making it easier to palpate abnormalities.

With the patient's arm raised over her head, palpate for lumps, masses or thickenings.

Breast tissue is normally somewhat nodular or "lumpy," particularly in the upper outer quadrant.

You are looking for a dominant mass.

Some have suggested that you are looking for "a marble in a bag of rice."

Palpate the breast using the proximal and middle phalanges of the fingers.

The palm of the hand is too insensitive to detect subtle changes in breast texture.

The fingertips are too sensitive and will focus on the normal granularity of the breast tissue rather than the more worrisome masses.

Move your hand in a circular motion while pressing into the breast substance.

Making these small circles will help you identify mass occupying lesions.

Cover the entire breast in a systematic fashion, including the tail of the breast that extends up into the axilla.

With smaller breasts, palpation with one hand will give good results.

When breasts are larger or pendulous, it may be useful to use two hands, compressing the breast tissue between them.

Some examiners have the woman raise both arms above the head during the examination. Others have her raise only one arm, leaving the other arm down.

Many patients feel exposed a vulnerable during this examination. It is not a comfortable feeling for them. They may feel more comfortable if only one arm is raised as they will feel less vulnerable.

Similarly, leaving one breast covered while you examine the other breast will often make the patient feel more comfortable during the exam. In cases where you are going back and forth, comparing findings from one side to the other, one-sided draping may not be practical.

Check the axilla for masses or palpable lymph nodes.

It is relatively common to find palpable lymph nodes in the axilla of normal patients.

These most often are the result of trauma to the arm, such as small cuts or scrapes

They usually disappear by themselves over a 1-2 month period of time.

Palpable axillary lymph nodes that are present because of an underlying malignancy will not gradually regress over time.

Check the supraclavicular area for palpable masses.

The supraclavicular area can be an area of spread of breast malignancy.

Palpable masses or lymph nodes in this area can be a sign of underlying malignancy.

Stripping the ducts toward the nipple will cause any secretions to be expressed.

This should be done firmly, but not so hard as to cause discomfort or pinching.

With effort, you will almost always be able to bring a drop or two of breast secretions to the surface. This is normal and the secretions will be clear, milky, or have a slight greenish tinge.

Bloody discharge is always considered a danger sign.

Large amounts (many drops) of secretions are not considered normal and usually require further investigation.

After completing the examination on one side, move to the other breast and repeat the examination.

Experienced examiners will frequently go back to the first breast to compare findings from one side to the other.

A thickening that is symmetrically present in both breasts is usually of no significance.

A thickening that is present in only one breast is more worrisome.

The patient may be flat, or semi-reclining with the head and trunk partially raised.

Sometimes, lumps or masses are better appreciated in the reclining or semi-reclining position.


The Rectal Exam

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A digital (finger) rectal examination is done to check for problems with organs or other structures in the pelvis and lower belly. During the examination, the doctor gently puts a lubricated, gloved finger of one hand into the rectum. He or she may use the other hand to press on the lower belly or pelvic area.

A digital rectal exam is done for men as part of a complete physical examination to check the prostate gland. It is done for women as part of a gynecological examination to check the uterus and ovaries. Other organs, such as the bladder, can sometimes also be felt during a digital rectal exam.

A digital rectal exam (DRE) is done to:

Check for growths in or enlargement of the prostate gland in men. A tumor in the prostate can often be felt as a hard lump. This may be done as part of a regular examination or to check on symptoms, such as a change in urination. Not all problems of the prostate can be felt through the rectum.

Check for problems in a woman's reproductive organs , such as the uterus and ovaries. It is often done during a regular pelvic examination and Pap test. It may also be done to check on symptoms, such as pelvic pain or vaginal bleeding.

Help find the cause of symptoms such as rectal bleeding (blood in the stool), belly or pelvic pain, a change in urination, or a change in bowel habits.

Collect a stool sample to test for blood in the stool.

Check for hemorrhoids or growths, such as cancer, in the rectum. DRE alone is not used to diagnose colorectal cancer. Also, a DRE may not find internal hemorrhoids because they are soft and hard to feel. A sigmoidoscopy may be needed to diagnose internal hemorrhoids.

How To Prepare

If you have hemorrhoids, tell your doctor before the examination begins. Your doctor will try not to bother your hemorrhoids.

How It Is Done

For a digital rectal exam, you will take off your clothes below the waist. You will be given a gown to wear.

A man is often examined while he stands, bending forward at the waist. A man can also be examined while lying on his left side, with his knees bent toward his chest.

A woman is often examined while lying on her back on an examination table, with her feet raised and supported by stirrups. A rectovaginal exam is often done for women so that organs in the pelvic area can be checked.

Your doctor gently puts a lubricated, gloved finger into the rectum. He or she may use the other hand to press on the lower belly or pelvic area to feel for tenderness or problems, such as enlargement, hardness, or growths.

Men may feel some discomfort or pain during a digital rectal exam (DRE). Your doctor must press firmly on the prostate to feel for problems. This pressure may make you feel the need to urinate. The examination may be painful if the prostate gland is swollen or irritated.

Most women do not find a DRE painful. You may feel some pressure or discomfort when your doctor presses on your belly to feel the internal organs.

People with hemorrhoids, breaks in the skin around the anus (called anal fissures), or other anal sores may find a DRE more painful than people without these problems.

Risks

A small amount of bleeding from the rectum may occur after an examination, especially if hemorrhoids or anal fissures are present.

In rare cases, you may feel lightheaded and faint. This feeling is called vasovagal syncope and is caused by fear or pain when your doctor puts a finger into the rectum. Vasovagal syncope is more likely to happen if you are standing up.

Results

A digital (finger) rectal examination is done to check for problems of organs or other structures in the pelvis and lower belly. During the examination, the doctor gently puts a lubricated, gloved finger of one hand into the rectum.

Digital rectal exam

Normal:

No problems such as organ enlargements or growths are felt.

Abnormal:

Problems such as organ enlargements or growths are felt.

For men, the prostate gland may be enlarged. This may mean benign prostatic hypertrophy (BPH) or inflammation of the prostate gland (prostatitis). Tumors are felt.

For women, growths such as tumors of the cervix, uterus, or ovaries are felt.

Growths such as hemorrhoids, polyps, tumors, or abscesses may be found in the lower rectum. Breaks in the skin around the anus (anal fissures) may be found. Problems of the bladder may also be felt.

What Affects the Test

Hemorrhoids or anal fissures may cause discomfort during a digital rectal exam.

What To Think About

If a digital rectal exam (DRE) is being done to screen for prostate cancer, the examination may be combined with a blood test for prostate-specific antigen (PSA). The two tests are often done together to check for prostate cancer. For more information, see the topic Prostate-Specific Antigen (PSA).

Other tests may need to be done after a DRE if problems are felt. You may need a test for blood in the stool or a visual examination of the anus and rectum (anoscopy). For more information, see the topics Sigmoidoscopy and Fecal Occult Blood Test (FOBT).

A transrectal ultrasound and a prostate biopsy may be done if the DRE or PSA test shows that prostate cancer may be present. For more information, see the topics Pelvic Ultrasound and Prostate Biopsy.

DRE alone is not used to check for colorectal cancer. If problems are found during a DRE, more tests may be needed, such as a sigmoidoscopy, colonoscopy, or stool test. For more information, see the topics Sigmoidoscopy, Colonoscopy, or Fecal Occult Blood Test (FOBT).

    
       

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