Neurological & Genitalia

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Chapter 27

Female Genitourinary System

External structures

Vulva, or pudendum

Mons pubis

Labia majora

Labia minora

Frenulum or fourchette

Clitoris

Vestibule

Urethral meatus

Skene’s glands

Vaginal orifice

Hymen

Bartholin’s glands

Female Genitourinary System: External Structures

External Female Genitalia

Internal structures

Vagina

Cervix

Squamocolumnar junction

Anterior fornix

Posterior fornix

Rectouterine pouch, or cul-de-sac of Douglas

Uterus

Fallopian tubes

Female Genitourinary System: Internal Structures

Internal Female Genitalia

Structure: External Genitalia (1 of 2)

Known as vulva, or pudendum

Mons pubis is a round, firm pad of adipose tissue covering the symphysis pubis.

Labia majora are two rounded folds of adipose tissue extending from mons pubis down and around to perineum.

Labia minora: inside labia majora as two smaller, darker folds of skin

Clitoris: small, pea-shaped erectile body homologous with male penis and highly sensitive to tactile stimulation

Structure: External Genitalia (2 of 2)

Vestibule: a boat-shaped space, or cleft encircled by the labial structures

Vaginal orifice: posterior to urethral meatus

Hymen: thin, circular or crescent-shaped fold that may cover part of the vaginal orifice or may be absent completely

Vestibular or Bartholin’s glands: on either side and posterior to vaginal orifice, secrete clear lubricating mucus during intercourse

Structure: Internal Genitalia (1 of 2)

Vagina: flattened, tubular canal extending from the orifice up and backward into the pelvis

Uterine cervix: at end of the canal, projects into the vagina

Cervical epithelium is of two distinct types:

Anterior fornix in front and the posterior fornix in back form a continuous recess around cervix

Behind the posterior fornix is another deep recess called the rectouterine pouch, or cul-de-sac of Douglas.

Structure: Internal Genitalia (1 of 2)

Uterus: pear-shaped, thick-walled, muscular organ, flattened anteroposteriorly, not fixed, and freely movable, and usually tilts forward and superior to the bladder

Fallopian tubes: two pliable, trumpet-shaped tubes, 10 cm in length, extending from the uterine fundus laterally to the brim of the pelvis

Ovaries: located one on each side of the uterus at the level of the anterior superior iliac spine

Developmental Competence: Infants and Adolescents

At birth, external genitalia are engorged because of the presence of maternal estrogen.

At puberty, estrogens stimulate growth of cells in the reproductive tract and development of secondary sex characteristics.

First signs of puberty are breast and pubic hair development, beginning between ages 8 and 10.

Menarche occurs during latter half of this sequence, just after peak of growth velocity.

Ovaries are now in pelvic cavity.

Developmental Competence

Tanner staging

Five stages of pubic hair development, sex maturity rating (SMR) helpful in teaching girls expected sequence of sexual development

Data may not necessarily generalize to all racial groups as research was based on Caucasian girls.

National Health and Nutrition Examination Survey (NHANES) results:

Provides cross-sectional snapshot of US health characteristics

Reproductive milestones

Overweight and obesity

Developmental Competence: Pregnant Woman

Greatest change is in uterus.

Increases in shape and size and becomes an abdominal organ with advancing gestation

Increase in cervical and vaginal secretions

Change in pH becoming more acidic

Increase in glycogen increases risk for candidiasis infection.

Women who have sex with women (WSW)

Lesbian and bisexual

Access to care

Myths and misconceptions

Risk for cancer

Cervical screening guidelines

Developmental Competence: Sexual Identity

Developmental Competence: Aging Woman (1 of 2)

Female’s hormonal milieu decreases rapidly in contrast with slow decline in aging male.

Menopause: cessation of menses

Uterus shrinks in size because of decreased myometrium.

Uterus droops as sacral ligaments relax and pelvic musculature weakens.

Sometimes it may protrude, or prolapse, into vagina

Ovaries atrophy to 1 to 2 cm and are not palpable after menopause.

Cervix shrinks, looks paler, thick, glistening epithelium

Vagina becomes shorter, narrower, and less elastic because of increased connective tissue.

Atrophy of tissues with increased alkalinity

Developmental Competence: Aging Woman (2 of 2)

Externally, mons pubis looks smaller because fat pad atrophies.

Labia and clitoris gradually decrease in size.

Pubic hair becomes thin and sparse.

Changes in female sexual response cycle

Declining estrogen levels produce some physiologic changes in the female sexual response cycle.

Reduced amount of vaginal secretion and lubrication during excitement.

Shorter duration of orgasm; and rapid resolution

However, these changes do not affect sexual pleasure and function.

Sexual desire and need for full sexual expression continue.

Culture and Genetics

Cervical cancer: Racial/geographic disparity

Black women have higher cervical cancer incidence rates and lower relative survival rates than whhite women.

Factors leading to this occurrence: stage of diagnosis, access to care, patient refusal, inappropriate physician recommendation, poorer health and presence of comorbidities.

HPV vaccine: American Cancer Society Recommendations

For all boys and girls starting at 11 and 12 years of age

Female circumcision, known as infibulation or female genital mutilation

Invasive surgical procedure (removal partial or total of the clitoris) usually performed on girls before puberty—social custom

Practiced within Aboriginal, Christian, and Muslim families who have emigrated to US from western and southern Asia, Middle East, and large areas of Africa

Menstrual history

Obstetric history

Menopause

Patient-centered care

Acute pelvic pain

Urinary symptoms

Vaginal discharge

Past history

Sexual activity

Contraceptive use

Sexually transmitted infection (STI) contact

Subjective Data

Menstrual History Questions

Menstrual history: Ask about

age at first period and date of your last menstrual period.

frequency, cycle, and duration.

usual amount of flow—use of pads and/or tampons.

whether there is any clotting.

pain characteristics and treatment.

impact on ADLs.

associated clinical symptoms—bloating, breast tenderness, or moodiness.

having any spotting between periods.

Obstetric History Questions

Obstetric history: Ask about

gravida, parity, and abortion/miscarriages.

pregnancy history: Gestation, any complications, labor and delivery, and infant’s gender, birth weight, and condition.

whether the person thinks she may be pregnant now any symptoms she has noticed.

Menopause History Questions

Menopause history: Ask about

Have your periods slowed down or stopped?

Associated symptoms of menopause, such as hot flashes, night sweats, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, or itching

Treatment: Rx or OTC

If you are using hormone replacement therapy (HRT), how much? How is it working? Do you have any side effects?

Feelings about going through menopause

Patient-Centered Care Questions

Ask about

how often does the person have a gynecologic checkup.

compliance with recommended screening guidelines based on age and history.

last pap smear and results.

yearly screening for STI—chlamydia.

presence of acute pelvic pain.

Description of onset, frequency, duration, location and severity

Associated with menses

Urinary Symptom History Questions

Urinary symptom: Ask about

any problems with urinating—frequency or urge.

burning or pain upon urination.

nocturia.

presence of blood.

color or odor.

problems with control.

loss of urine associated with activities—sneezing, laughing, coughing or bearing down.

Vaginal Discharge History Questions

Vaginal discharge: Ask about

type, amount, color, odor, and onset.

whether it is associated with vaginal itching, rash, or pain with intercourse.

Medications—Rx and OTC.

family history of diabetes.

what part of the menstrual cycle is the person in now.

use of vaginal douche—type and frequency.

use of feminine hygiene spray—type and frequency.

Clothes—nonventilating underpants or pantyhose.

treatment and response.

Past History Questions

Past history: Ask about

any other problems in genital area.

having any sores or lesions, now or in past.

treatment and response.

Presence of any abdominal pain

Surgical procedures: any surgery on uterus, ovaries, or vagina

Sexual Activity History Questions

Sexual activity: Ask about

Often women have a question about their sexual relationship and how it affects their health. Do you?

Are you in a relationship involving sex now?

Are aspects of sex satisfactory to you and your partner?

Satisfied with the way you and partner communicate about sex?

Are you satisfied with your ability to respond sexually?

Do you have more than one sexual partner?

What is your sexual preference: do you prefer a relationship with a man, with a woman, or with both?

Contraceptive Use and STI Contact Questions

Contraceptive use: Ask about

Currently planning a pregnancy or avoiding pregnancy?

Do you and your partner use a contraceptive? Which method? Is this satisfactory? Do you have any questions about this or other methods?

Which methods have you used in the past?

Have you and your partner discussed having children?

Have you ever had any problems becoming pregnant?

STI contact: Ask about

any sexual contact with a partner who has STI.

occurrence and treatment.

complications.

precautions taken to reduce incidence of occurrence—condoms.

Additional History: Infants and Children

Does your child have any problem urinating? Pain with urinating, crying, holding genitals? Urinary tract infection?

If child is older than 2 to 2½, has toilet training started? How is it progressing?

Does the child wet bed at night? Is this a problem for child or you (parents)? What have you (parents) done?

Problem with genital area: itching, rash, vaginal discharge?

To child: Has anyone ever touched you between your legs and you did not want them to?

Sometimes that happens to children; they should remember they have not been bad; they should try to tell a big person about it

Additional History: Preadolescents and Adolescents (1 of 3)

Use following questions to assess sexual growth, development, and sexual behavior:

Ask questions that seem appropriate for girl’s age, but norms vary widely.

When in doubt ask too many questions rather than omit something.

Children obtain information, often misinformation, from media and peers at surprisingly early ages.

Ask direct, matter-of-fact questions; avoid sounding judgmental.

Start with a permission statement, “Often girls your age experience . . .” This conveys that it is normal to think or feel a certain way.

Try open-ended, “When did you . . .” rather than “Do you . . .” This is less threatening because it implies that the topic is normal and unexceptional.

Additional History: Preadolescents and Adolescents (2 of 3)

Around age 9 or 10, girls start to develop breasts and pubic hair

Have your periods started?

How did you feel? Were you prepared or surprised?

Who in your family do you talk to about your body changes and about sex information?

Do you think you get enough information?

What about sex education classes at school?

Is there a teacher, a nurse, a minister, to whom you can talk?

Often girls your age have questions about sexual activity

Do you have questions? Are you dating?

Additional History: Preadolescents and Adolescents (3 of 3)

Do you and your boyfriend have intercourse?

Are you using condoms?

What kind of protection did you use the last time you had sex?

Has anyone ever talked to you about sexually transmitted infections, such as chlamydia, herpes, gonorrhea, or AIDS?

Have you and your parents discussed the human papillomavirus vaccine?

It is recommended before girls become sexually active.

Sometimes a person touches a girl in a way that she does not want them to

Has that ever happened to you? If that happens, the girl should remember it is not her fault.

She should tell another adult about it.

Additional History: Aging Woman

After menopause, have you noted any vaginal bleeding?

Any vaginal itching, discharge, or pain with intercourse? Use of lubricants?

Any pressure in genital area, loss of urine with cough or sneeze, back pain, or constipation?

Are you in a relationship involving sex now? Are aspects of sex satisfactory to you and your partner? Is there adequate privacy for a sexual relationship?

Objective Data: Preparation and Equipment

Preparation

Assemble equipment before helping woman into position.

Familiarize yourself with vaginal speculum before examination.

Equipment

Gloves, lighting and speculums

Cotton tipped applicators and lubricant

Materials for cytologic study

Slide, specimen container, vials, pH tape, prep bottles (NS, KOH and acetic acid

Objective Data: Positioning (1 of 2)

Initially, the woman should be sitting up.

An equal-status position is important to establish trust and rapport before vaginal examination

For examination, the woman should be placed in lithotomy position, with examiner sitting on a stool.

Place arms at her sides or across chest, not over head, because this position only tightens abdominal muscles.

Traditional mode is to drape woman fully, covering stomach and legs, exposing only vulva to view.

Be sure to push down drape between woman’s legs and elevate her head so that you can see her face.

Lithotomy Position and Draping

Objective Data: Positioning (2 of 2)

You can help woman relax, decrease her anxiety, and retain a sense of control by using these measures

Have her empty bladder before examination.

Position examination table so that her perineum is not exposed to an inadvertent open door.

Ask if she would like a friend, family member, or chaperone present; position this person by woman’s head to maintain privacy.

You can help woman relax, decrease her anxiety, and retain a sense of control by using these measures

Explain each step in examination before you do it.

Assure woman she can stop examination at any point should she feel any discomfort.

Educational or Mirror Pelvic Examination

Routine examination with some modifications in attitude, position, and communication

First, woman considered active participant, one who is interested in learning and in sharing decisions about her own health care

Woman props herself up on one elbow, or head of table is raised; her other hand holds a mirror between her legs, above examiner’s hands.

Mirror works well for teaching normal anatomy and its relationship to sexual behavior.

Woman is more willing to comply with treatment when she shares in decisions.

External Genitalia: Inspection (1 of 2)

Skin color is even; labia minora are darker pink.

Hair distribution in usual female pattern of inverted triangle, although it normally may trail up abdomen

Labia majora normally are symmetric, plump, and well formed; in nulliparous woman, labia meet in midline; after a vaginal delivery, labia are gaping and slightly shriveled.

No lesions should be present, except for occasional sebaceous cysts.

External Genitalia: Inspection (2 of 2)

With your gloved hand, separate labia majora to inspect

Clitoris

Labia minora are dark pink and moist, usually symmetric.

Urethral opening appears stellate or slitlike and is midline.

Vaginal opening, or introitus, may appear as narrow vertical slit or as larger opening.

Perineum is smooth; a well-healed episiotomy scar, midline or mediolateral, may be present after vaginal birth.

Anus has coarse skin of increased pigmentation.

External Genitalia: Palpation

Assess urethra and Skene’s glands

Procedure should produce no pain.

If any discharge appears, culture it.

Assess Bartholin’s glands

Palpate posterior parts of labia majora with index finger in vagina and your thumb outside; normally labia feel soft and homogeneous.

Assess support of pelvic musculature by using these maneuvers:

Palpate perineum.

Normally it feels thick, smooth, and muscular in nulliparous woman; thin and rigid in multiparous woman.

Speculum Examination

Internal genitalia

Select proper-sized speculum.

Warm and lubricate speculum under warm running water.

Lubricant decreases pain and may increase compliance with procedure if atrophy is present.

Good technique is to dedicate one hand to patient and other to picking up equipment.

Inspect vaginal wall after removing speculum.

Internal Genitalia (1 of 2)

Internal genitalia: inspect cervix and its os

Color: normally cervical mucosa is pink and even

During second month of pregnancy it looks blue

(Chadwick’s sign); after menopause it is pale.

Position: midline, either anterior or posterior; projects 1 to 3 cm into vagina

Size: diameter is 2.5 cm (1 inch)

Os: small and round in nulliparous woman; in parous woman, it is horizontal irregular slit and also may show healed lacerations on sides

Internal Genitalia (2 of 2)

Internal genitalia: inspect cervix

Surface: normally smooth, but cervical eversion, or ectropion, may occur after vaginal deliveries

Endocervical canal everted; looks like red, beefy halo inside pink cervix surrounding os

Difficult to distinguish this normal variation from an abnormal condition and biopsy may be needed

Nabothian cysts are benign growths that commonly appear on cervix after childbirth; they are small, smooth, yellow nodules that may be single or multiple; they are retention cysts caused by obstruction of cervical glands.

If secretions are copious, swab area with a thick-tipped rectal swab.

Variations of the Cervix

Pap Test

Pap smear

Pap smear screens for cervical cancer, but not for endometrial or ovarian cancer.

Do not obtain during woman’s menses or if a heavy infectious discharge present.

Instruct the woman not to douche, have intercourse, or put anything into vagina 24 hours before collecting specimen.

Obtain pap smear before other specimens so you will not disrupt or remove cells.

Obtain Cervical Tests and Cultures

Vaginal pool: gently rub blunt end of an Ayre spatula over vaginal wall under and lateral to cervix; wipe specimen on glass slide

Cervical scrape: insert bifid end of Ayre spatula into vagina with the more pointed bump into cervical os; rotate 360 to 720 degrees, using firm pressure; this specimen is important for the adolescent whose endocervical cells have not yet migrated into endocervical canal

Endocervical: insert a Cytobrush into os; Cytobrush gives a higher yield of endocervical cells at squamocolumnar junction, and is safe for use during pregnancy

Additional Testing Samples

Saline mount, or wet preparation: spread sample of discharge onto a glass slide and add one drop of normal saline solution and a coverslip

KOH preparation: add one drop of potassium hydroxide and a coverslip to a sample of discharge on slide

Anal culture: insert sterile cotton swab into anal canal about 1 cm; rotate and move it side to side

Acetic acid wash: acetic acid (white vinegar) screens for asymptomatic HPV, which causes genital warts

Specimen Documentation

Send specimens to laboratory with following necessary data:

Date of specimen

Woman’s date of birth

Date of last menstrual period

Any hormone medication

If pregnant, with estimated date of delivery

Known infections

Prior surgery or radiation

Prior abnormal cytology

Abnormal findings on physical examination

Bimanual Examination: Vaginal Wall

Rise to a stand, and have the woman remain in lithotomy position; drop lubricant onto first two fingers of your gloved intravaginal hand.

Assume “obstetric” position with first two fingers extended, last two flexed onto palm, and thumb abducted

Insert fingers into vagina, with any pressure directed posteriorly; wait until vaginal walls relax, then insert your fingers fully.

Use both hands to palpate internal genitalia.

Assess location, size, and mobility, and screen for any tenderness or mass.

One hand is on abdomen while other hand inserts two fingers into vagina.

Palpate vaginal wall; normally it feels smooth and has no area of induration or tenderness.

Bimanual Examination: Cervix

Locate cervix in midline, often near anterior vaginal wall.

Palpate using palmar surface of fingers; note these characteristics of normal cervix:

Consistency: feels smooth and firm; softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell’s sign)

Contour: evenly rounded

Mobility: with a finger on either side, move cervix gently from side to side; normally this produces no pain

Palpate all around fornices; the wall should feel smooth

Next, use abdominal hand to push pelvic organs closer for your intravaginal fingers to palpate.

Place your hand midway between umbilicus and symphysis; push down slowly.

Brace elbow of your pelvic arm against your hip, and keep it horizontal; woman must be relaxed.

Bimanual Examination: Uterus

Assess with intravaginal fingers in anterior fornix.

Determine position, or version, of uterus.

In many women, uterus is anteverted; you palpate it at level of pubis with cervix pointing posteriorly.

Two other positions occur normally: midposition and retroverted.

Palpate uterine wall with your fingers in fornices.

Bounce uterus gently between your abdominal and intravaginal hands.

Normally it feels firm and smooth, with contour of fundus rounded; it softens during pregnancy; it should be freely movable and nontender.

Bimanual Examination: Adnexa

Move both hands to right to explore adnexa.

Place abdominal hand on lower quadrant inside anterior iliac spine and place intravaginal fingers in lateral fornix.

Push abdominal hand in and try to capture ovary.

Often you cannot feel ovary; normally feels smooth, firm, almond shaped, and movable, sliding through fingers.

Fallopian tube is not palpable normally; no other mass or pulsation should be felt.

Move to left to palpate other side.

Then, withdraw your hand and check secretions on fingers before discarding the glove.

Normal secretions are clear or cloudy and odorless.

Rectovaginal Examination (1 of 2)

Use this technique to assess rectovaginal septum, posterior uterine wall, cul-de-sac, and rectum.

Change gloves to avoid spreading any possible infection; lubricate first two fingers.

Instruct woman this may feel uncomfortable and will mimic feeling of moving her bowels.

Ask her to bear down as you insert your index finger into vagina and your middle finger gently into rectum.

Rectovaginal Examination (2 of 2)

While pushing with abdominal hand, repeat steps of bimanual examination.

Keep intravaginal finger on cervix so intrarectal finger does not mistake cervix for a mass.

Rectovaginal septum should feel smooth, thin, firm, and pliable.

Uterine wall and fundus feel firm and smooth.

Rotate intrarectal finger to check rectal wall and anal sphincter tone.

Check your gloved finger as you withdraw; test any adherent stool for occult blood.

Give woman tissues to wipe area; help her to sit up

Developmental Competence: Infants and Children

Preparation

Infant: place on examination table

Toddler/preschooler: place on parent’s lap

Frog-leg position: hips flexed, soles of feet together and up to bottom

Preschool child may want to separate her own labia.

No drapes: young girl wants to see what you are doing

School-age child: place on examination table, frog-leg position, no drapes

During childhood routine screening limited to inspection of external genitalia to determine that (1) structures are intact, (2) vagina is present, and (3) hymen is patent.

Developmental Competence: Newborn

Genitalia somewhat engorged but resolves

Labia majora swollen, labia minora prominent and protrude beyond labia majora; clitoris looks relatively large, and hymen appears thick

Because of transient engorgement, vaginal opening more difficult to see now than it will be later

A sanguineous vaginal discharge or leukorrhea (mucoid discharge) normal during first few weeks due to maternal estrogen effect; may also cause transient breast engorgement and secretion.

Normally no irritation or foul-smelling discharge is present.

Developmental Competence: School-Age Girl

Around 7 to 10 years of age, the mons pubis thickens, labia majora thicken, and labia minora become slightly rounded.

Pubic hair appears beginning around age 11, although sparse pubic hair may occur as early as age 8.

Normally hymen is perforate.

Almost always in these age groups, an external examination will suffice.

If needed, an internal pelvic examination is best performed by a pediatric gynecologist using specialized instruments.

Developmental Competence: Adolescent (1 of 2)

Girl has special needs during genitalia examination.

Examine her alone, without mother present.

Assure privacy and confidentiality.

Allow plenty of time for health education and discussion of pubertal progress.

Assess her growth velocity and menstrual history, and use SMR charts to teach breast and pubic hair development.

Provide education about normal findings such as physiologic leukorrhea (increased vaginal fluid) due to estrogen effect.

Developmental Competence: Adolescent (2 of 2)

Perform pelvic examination when history suggests indication.

Start periodic Pap smears when intercourse begins.

Although techniques of examination are listed in adult section, you will need to provide additional time and psychological support for adolescent having her first pelvic examination.

First pelvic examination experience determines how adolescent will approach future care.

Developmental Competence: Pregnant Woman

Depending on week of gestation of pregnancy, inspection shows enlarging abdomen.

Height of fundus ascends gradually as fetus grows.

External genitalia show hyperemia of perineum and vulva because of increased vascularity.

During bimanual examination, the isthmus of uterus feels softer and is more easily compressed between your two hands (Hegar’s sign).

Developmental Competence: Aging Woman

To avoid painful examination, take care to lubricate instruments and examining hand adequately.

Use Pedersen speculum, rather than Graves, because its narrower, flatter blades are more comfortable in women with vaginal stenosis or dryness.

Internally, rugae of vaginal walls decrease, and walls look pale pink because of thinned epithelium.

Cervix shrinks and looks pale and glistening.

With bimanual examination, you may need to insert only one gloved finger if vaginal stenosis exists.

Uterus feels smaller and firmer, and ovaries are not palpable normally.

Older women may have special needs and will appreciate following plans of care.

Health Promotion Teaching: Adolescent

Talking points:

Recommendations for HPV vaccination with complete series

Preparation for possible sexual activity

Providing information to prevent STIs

Gender identity and sexual identity

Use of alcohol and drugs

Physical safety in family and sexual relationships

Cyberbullying and bullying behaviors

External Genitalia Abnormalities

Pediculosis pubis (crab lice)

Herpes simplex virus—type 2 (herpes genitalis)

Syphilitic chancre

Red rash—contact dermatitis

HPV warts

Urethritis

Abscess of Bartholin gland

Urethritis and UTI

Urethral caruncle

Abnormalities (1 of 2)

Pelvic musculature

Cystocele

Rectocele

Uterine prolapse

Cervix

Bluish cervix—cyanosis

Erosion

HPV (condylomata)

Polyp

Diethylstilbestrol (DES) syndrome

Cervical cancer

Abnormalities (2 of 2)

Vulvovaginal inflammations

Atrophic vaginitis

Candidiasis (moniliasis)

Trichomoniasis

Bacterial vaginosis

Chlamydia

Gonorrhea

Pediatric genitalia

Ambiguous genitalia

Vulvovaginitis in child

Enlargement

Adnexal enlargement

Fallopian tube mass—acute salpingitis, pelvic inflammatory disease (PID)

Fallopian tube mass—ectopic pregnancy

Fluctuant ovarian mass —ovarian cyst

Solid ovarian mass—ovarian cancer

Polycystic ovary syndrome—PCOS

Uterine enlargement

Pregnancy

Myomas (leiomyomas, uterine fibroids)

Carcinoma of the endometrium

Endometriosis

Summary Checklist: Female Genitourinary System

Inspect external genitalia.

Palpate labia, Skene’s and Bartholin’s glands.

Using vaginal speculum, inspect cervix and vagina.

Obtain specimens for cytologic study.

Perform bimanual examination: cervix, uterus and adnexa.

Perform rectovaginal examination.

Test stool for occult blood.

Neurological & Genitalia

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