Jaundice

Transcribed from the lecture of Dr. Ngo

Section D 2011 - Mikey Silverman
Jaundice
Yellow discoloration of the skin, sclera, and mucous
membranes as a result of an elevated serum bilirubin
concentration.
Learning Objectives
To review and understand bilirubin metabolism
To learn the differential diagnosis of jaundice
To learn the subjective and objective data to be gathered
in a patient with jaundice.
Differential Diagnosis (3 types)
Isolated disorders of bilirubin metabolism
Unconjugated hyperbilirubinemia
Increased bilirubin production
Hemolysis, ineffective erythropoiesis, blood
transfusion, resorbption of hematomas
Decreased hepatocellular uptake
Drugs (rifampicin), Gliberts syndrome
Decreased conjugation
Gliberts syndrome, Crigler-Najjar syndrome
Conjugated or mixed hyperbilirubinemia
Dubin-Johnson syndrome
Rotors syndrome
Liver Disease
Hepatocellular dysfunction
Acute or subacute hepatocellular disease
Viral hepatitis, alcohol, drugs, hypotension, metabolic
disorders (Reyes syndrome), pregnancy-related
Chronic hepatocellular disease
Viral hepatitis, alcohol, autoimmune hepatitis,
metabolic (hemochromatosis, Wilson disease, NAFLD)
Hepatic Disorders with prominent cholestasis
Diffuse infiltrative disorders
Granulomatous diseases (TB, sarcoidosis, lymphoma),
amyloidosis, malignancy
Inflammation of intrahepatic bile ducts
Primary biliary cirrhosis, drugs (erythromycin, TMP-S)
Miscellaneous conditions
Drugs (estrogens), TPN, bacterial infections
Obstruction of the Bile Ducts
Choledocholithiasis a stone found at the level of the
common bile duct
Hindrance to bile flow
Manifests with jaundice, fever, pain
Cholesterol/pigment gallstones
Parasites
Ascaris, chlonorchis
Diseases of the bile ducts
Inflammation/infection (primary sclerosing cholangitis,
AIDS cholangiopathy, hepatic arterial chemotherapy,
postsurgical stricture); neoplasms (cholangiocarcinoma)
Extrinsic compression of the biliary tree
Neoplasms (pancreatic CA), pancreatitis, vascular
enlargement
History
Onset
Progression
Accompanying symptoms
Abdominal pain
Fever
Pruritis
Stool/Urine color
Weight loss
Pallor
GI bleeding
Alcohol consumption
Blood transfusion
Drug use/abuse
Sexual partner/s
Travel
Family history
Physical Examination
Jaundice
at least 51 mol for icteric sclera
Vital signs
Skin
Lymphadenopathy
Heart & lungs
Abdomen tenderness, mass, organomegaly, ascites
Extremities

Signs of Portal Hypertension

Splenomegaly obliteration of Traubs space
Ascites shifting dullness, puddle sign
Leg edema
Caput medusa
Stigmata of Liver Cirrhosis
Spider angiomata
Palmar erythema
Gynecomastia
Parotid gland enlargement
Testicular atrophy
Loss of body hair
Dupuytrens contracture
Liver Function Tests
Hepatocellular necrosis
ALT, AST
Synthetic Function
Albumin (hypoalbuminemia)
Prothrombin time (prolonged)
Cholestasis
Elevated:
Bilirubin
Alkaline Phosphatase
GGTP (together with elevated SGTP, can be sure it is a
liver dysfunction)
5 Nucleotidase
Imaging studies
Ultrasound / EUS
MRI / MRCP
CT scan
PTC
ERCP
Clinical Evaluation
Jaundice with abdominal pain & fever
Hepatocelluar carcinoma
Hepatobiliary TB
Amoebic liver abscess
Benign CBD obstruction with cholangitis (stone, stricture,
ascaris)
Malignant CBD obstruction with cholangitis (pancreatic CA)
Acute pancreatitis
Jaundice with abdominal pain, no fever
Benign CBD obstruction without cholangitis (stones,
structures, ascaris)
Malignant CBD obstruction without cholangitis (pancreatic
CA)
Hepatocellular CA
Metastatic CA to the liver
Jaundice without abdominal pain, with fever
Leptospirosis
Typhoid fever
Malaria
Sepsis
Collagen diseases
Jaundice without abdominal pain & fever
Acute hepatitis (viral, drug, alcohol)
Chronic hepatitis
Cirrhosis
Congenital hyperbilirubinemia
Malignant Obstruction of CBD

Approach to Patients with Hematologic

Disease
Section D 2011 - Mikey Silverman

Findings Leading to hematological Consultation

RBC Anemia, Polycythemia, Nucleated RBCs
WBC Leukopenia/Leukocytosis, Lymphocytosis,
Immature Granulocytes
Platelets Thrombocytosis/Thrombocytopenia
Lymphadenopathy/Splenomegaly
Others
Exaggerated bleeding: spontaneous/trauma related,
abnormal PT/aPTT
Leg Pain/Deep Vein Thrombosis
History
General symptoms
Performance status
Weight loss
Fever
Fatigue/malaise/lassitude

 Weakness
Specific Symptoms
By system
Performance Status
Determines the physiologic reserve of the patient
i.e. Karnofsky performance scale
Rating
Definition
100
No evidence of disease
Percent
90
Normal activity with minor signs of disease
Percent
80
Normal activity with effort; signs of disease
Percent
70
Cannot do normal activity but cares for self
Percent
60
Requires occasional assistance
Percent
50
Requires considerable assistance; frequent
Percent
medical care
40
Disabled, requires special care
Percent
30
Severely disabled; hospitalization may be
Percent
indicated
20
Very sick; hospitalization necessary for supportive
Percent
treatment
10
Moribund
Percent
0 Percent
Death
General Symptoms
Weight loss
Frequently seen in many serious diseases including
primary hematologic entities
Significant unintentional weight loss (5% body weight
over 6-12 months)
Fever
Elevation of body temperature that exceeds normal daily
variation
Increase in the
hypothalamic
set point
Mean oral
temp: 36.8 +/0.4oC
Occurs in:
Early
manifestation
of aggressive

lymphoma/acute leukemia
Accompanying immunodeficiency
Other malignancies
Fatigue/malaise/lassitude
Difficult to assess
Maybe explained by fever and muscle wasting in
patients with severe diseases
Weakness
Accompany malignant processes
Manifest as a general loss of strength/reduced capacity
for exercise
Hematologic disease
Myeloma/lymphoma: central/peripheral nervous
system invasion/compression
Specific Symptoms
Nervous system
Headache
Paresthesias
Confusion
Impairment of consciousness
Eyes
Conjunctival plethora
Diplopia
Ears
Vertigo
Tinnitus
Neck
Painless swelling
Diffuse swelling of the face
Chest/Heart
Dyspnea and palpitations
Cough
Chest pain
Nasopharynx, oropharynx, oral cavity
Epistaxis
Anosmia/olfactory hallucination
Sore tongue

Macroglossia
Gingival hyperplasia
Dryness of mouth
Dysphagia
Gastrointestinal system
Abdominal fullness/discomfort
Malabsorption
Diarrhea
Constipation
GU/Reproductive system
Impotence/bladder dysfunction
Hematuria
Priapism
Menorrhagia
Back/Extremeties
Arthritis
Hemarthroses
Bone pain
Skin
Pallor
Bronze/grayish pigmentation
Cyanosis
Jaundice
Erythromelalgia
Pruritus
Petechia/ecchymoses
Personal and Environmental History
Drug History
Sexual History
Occupational Exposure
Benzenes
Organophosphates
Herbicides
Nutrition
Dietary deficiencies
Family History
Hematologic disorders
Jaundice
History of gallstones
History of venous thromboembolism
History of hemophilia
Ethnic background
Past Medical History
Operations
Previous transfusions
Physical Examination
Pertinent body systems
Skin
Pallor/flushing
Skin color is caused by the pigment contained
therein and by the blood flowing through the
capillaries
Mucous membranes, conjunctivae, palmar creases
Cyanosis
Function of total amount of reduced hemoglobin
May be influenced by skin pigmentation
Jaundice
Observed in the skin of individuals who are not
otherwise deeply pigmented
Caused by ble pigment (direct/conjugated bile)
Petechiae
Small (1-2mm) round lesions from hemorrhages into
the skin
Present in areas of high venous pressures
No blanching on pressure
Ecchymoses
Various shapes and sizes
Blanches with pressure
Excoriations
Nails
Koilonchia
Eyes
Jaundice
Pallor
Retinal hemorrhages/exudates
Dilation of veins
Mouth
Pallor
Ulceration of oral mucosa

 Bleeding
Tongue:
macroglossia
Lymph nodes
Cervical,
supraclavicular,
axillary,
epitrochlear,
inguinal, femoral
EXTENT

1.
2.
3.

Symptomatology
PE
Laboratory abnormalities

II. Edema
Palpable swelling produced by expansion of the interstitial
fluid volume
Localized or generalized
ANASARCA gross, generalized edema
Recognized in its generalized form by puffiness of the face
and indentation of the skin following pressure (pitting
edema)

(localized/generalized)
SIZE
TEXTURE
TENDERNESS
Skeleton
Spleen
Usually non palpable
Other methods:
Traubes
Nixons
Castelo
Liver
Nervous system
Cerebral impairment,
visual impairment,
cranial nerve
dysfunciton
POEMS (polyneuropathy, organomegaly,
endocrinopathy, multiple myeloma, skin changes)
Joints
Deformities: repeated hemorrhages

2 basic steps for edema formation:

1.
Alteration in capillary hemodynamics
2.
Dietary Na and water retention by the kidneys

Edema/Urinary Complaints/Female
Genitalia
Section D 2011 - Mikey Silverman

I. Approach to patient with kidney and urinary tract

disease
II. Edema
III. Discolored Urine hematuria
IV. Abnormalities of Urine Volume
V. Renal and Ureteric Colic
VI. Symptoms related to the act of urination
VII. Symptoms of bladder outlet obstruction/prostatism
VIII. Urinary incontinence
IX. Female genital examination

I.

Approach to Patient With Kidney and Urinary Tract

disease
Primary renal disease
Secondary renal disease
Disease of the urinary tract
Anatomic localization of the Lesion
Kidneys
Glomerulus
Tubules
Interstitium
Vascular System
Lower urinary tract
Ureter
Bladder
Urethra

Cross-section of the kidney

Means of Discovery

Major causes of edema according to primary

mechanism
1.
Increased capillary hydraulic pressure
Increased plasma volume due to renal Na+ retention
Heart failure, including cor pulmonale
Primary renal sodium retention
Renal disease, including the nephrotic syndrome
Drugs: minoxidil, diazoixide, thiazoilidinediones,
calcium channel blockers, NSAIDs, fludrocortisone,
estrogens
Early hepatic cirrhosis
Pregnancy and premenstrual edema
Idiopathic edema
Venous obstruction
Cirrhosis or hepatic venous obstruction
Acute pulmonary edema
Local venous obstruction
2.
Hypoalbuminemia
Protein loss
Nephrotic syndrome
Protein-losing enteropathy
Reduced albumin synthesis
Liver disease
Malnutrition
3.
Increased capillary permeability
Idiopathic edema
Burns
Trauma
Inflammation or sepsis
Allergic reaction, including certain forms of angioedema
Adult respiratory distress syndrome
Diabetes mellitus
Interleukin-2 therapy
Malignant ascites
4.
Lymphatic obstruction or increased interstitial
oncotic pressure
Postmastectomy
Nodal enlargement due to malignancy
Hypothyroidism
Malignant ascites
5.
Uncertain mechanism
Docetaxel
Pramipexole
History

Where is the edema located?

Is the edema persistent or intermittent?
Is the edema unilateral or bilateral?
Is the edema pitting or non-pitting?
Is there a history of any disorder or drug intake that can
cause cardiac, hepatic, renal disease?
Pitting edema
Depression that does not rapidly refill and resume its
original contour
Reflects movement of excess water in response to
pressure
Non-pitting edema
Lymphedema
Pre-tibial myxedema

Principal causes of Generalized Edema

Elevated JVP, S3
gallop, occasionally
Dyspnea on exertion,
with displaced or
orthopnea, PND; edema
dyskinetic apical
Cardiac
extensive in the legs and pulse, peripheral
accentuated in the
cyanosis, cool
evening
extremities, small
pulse pressure when
severe
Ascites, JVP normal or
Dyspnea infrequent,
low, BP lower than in
except if associated with
renal or cardiac
Hepatic
significant degree of
disease, signs of
ascites, ethanol abuse
chronic liver disease
stigmata of cirrhosis
Usually chronic, may be
associated with uremia
BP may be high,
decreased appetite,
hypertensive or
metallic or fishy taste,
diabetic nephropathy,
altered sleep pattern,
periorbital edema,
Renal
difficulty concentrating,
pericardial friction
restless legs, dyspnea
rub, nitrogenous
may be present, but less
fetor, asterexis in
severe than heart failure, uremia
bubbly urine
Nephrotic syndrome
Periorbital/peripheral edema
Ascites
Bubbly urine
BP normal or elevated
CVP normal to high normal
Heavy proteinuria (>3.5 g/day)
Hypoalbuminemia
Lipiduria
Hyperlipidemia
III. Discolored Urine Hematuria
Color
Pathologic
Chyle
White
Pus
Bilirubin
Urobilin
Yellow to
orange

Read to
brown to
purple

Blue to
green

Porphobilin
Porphobilinogen
Uroporphyrin
Glomerular Diseases
Extraglomerular
diseases
Hemoglobinuria
Myoglobinuria
Biliverdin
Pseudomonas
infection

Non-pathologic
Phosphates
Concentrated urine
Rifampicin
Food color
Carrots
Nitrofurantoin
Natural food
pigments (beets)
Artificial food coloring
Phenothiazines
Phenazopyridines
Laxatives
(phenolpthalein,
senna)
Vitamin B complex
Phenyl salicylates
Thymol
Triamterene
Amvtriptyline

Hematuria
Macroscopic (grossly visible) red or brown urine
Microscopic (urinalysis) - >/- 2 RBCs/hpf
Origin
Kidney glomerulus dysmorphic RBC
Ureter
Bladder
Prostate
Urethra
Clotting mechanism defect
Etiology

History
Color
Transient or persistent
Partial or total
Partial
Initial anterior urethral lesion (urethritis, stricture,
meatal stenosis)
Terminal posterior urethra, bladder neck, prostate
Total (throughout urination)
Above the level of the bladder (stones, tumor, TB,
nephritis)
Associated symptoms
Frequency, dysuria, urgency, suprapubic pain
Flank or CVA pain
Passage of wormlike clots
Painful or painless
Painless hematuria
Bladder or kidney tumor
Polycystic kidneys
Acute GN
Sickle cell disease
Tuberculosis
Post-traumatic
Post-exercise
Painful hematuria
Stones
Urinary tract infection
Renal infarction
Ingestion of foods containing red vegetable dyes (beets)
Medications: aspirin, anticoagulants, laxatives
History of recent upper respiratory tract infection
Positive family history of renal disease polycystic
kidney disease, sickle cell, blood dyscrasia
Recent vigorous exercise or trauma
Travel or residence in areas endemic for Schistosoma
haematobium, or tuberculosis
Cyclic hematuria passage of hematuria during or after
menstruation
PE
Pallor
Petechiae, echymoses, lymphadenopathy, splenomegaly
blood dyscrasia
CVA tenderness and fever renal infarction
Suprapubic tenderness bladder
Bilaterally enlarged kidneys PKD
AF/valvular heart disease renal embolism/infarction
IV. Abnormalities of Urine Volume
Oliguria/Anuria
Normal load of metabolic waste product cannot be
excreted
Oliguria 24-h urine output of < 400-500 mL/day
Anuria complete absence of urine < 50 mL/day
Azotemia retention of nitrogenous waste products
(asymptomatic)
Uremia signs and symptoms brought about by azotemia
(elevated BUN and creatinine) dialysis
Etiology
Acute renal failure
Pre-renal
Renal
Post-renal
Chronic renal failure (> 3 months; irreversible)
Note: non-oliguric renal failure urine output of >500
mL/day with acute or chronic azotemia
Location of the Cause?

Clinical assessment of ARF

Search for reversible factors that may be exacerbating ARF,
e.g., hypervolemia, ongoing administration of nephrotoxic
medications
Examine for clinical evidence of uremia (e.g., asterixis,
confusion, hiccups, nausea, vomiting, pericarditis)
Clinical assessment of intravascular volume
Review most recent laboratory results for metabolic
complications: hyperkalemia, acidosis, hyperphosphatemia
Review drug prescription: discontinue all non-essential drugs
and adjust dose or dose interval of drugs eliminated by
kidney
Review nutritional status: consider protein, salt, potassium
and phosphate restriction: consider need for enteral
nutrition or hyperalimentation
Polyuria
More than 3L urine/day
Etiology
Excretion of non-absorbable solutes (osmolar loads)
glucose, mannitol
Excretion of water defect in ADH production or renal
responsiveness (diabetes insipidus)
History
Symptoms of uncontrolled DM
Intake of medications
PE state of hydration
V. Renal and Ureteric Colic
Renal Colic
Dull, aching, steady pain in the CVA just lateral to the
sacrospinalis muscle and just below the 12th rib
Often unilateral
Severe crescendo/decrescendo type of pain
Radiates from CVA to hypochondrium (umbilicus)
Due to sudden distention of the renal capsule
Acute pyelonephritis
Acute ureteral obstruction
Ureteral colic
Similar characteristic as renal colic
Severe colicky back pain that radiates from CVA towards
inguinal ligament into the scrotum or labia majora
Acute obstruction passage of a stone or blood clots
Ureteral stone
Proximal ureteral stone lateral flank to abdominal
region; pain radiates to the testicle (T11-12)
Mid portion of the ureter, R side pain radiates to the
McBurneys point
Midportion of the ureter, L LLQ
Distal ureteral stone pelvis to inguinal canal/inner
thigh/groin/genitalia
Ureterovesical junction bladder irritability (frequency,
urgency)

Caliceal stone
Asymptomatic
Small, non-obstructing

Gross hematuria
Renal pelvis stone
Asymptomatic
Flank/CVA pain (ureteropelvic junction)
Stones history
Age of onset
Family history of stone
Fractures/immobilization hypercalcemia
Previous UTI or manipulation
Renal or ureteric colic
Associated symptoms nausea, vomiting
Fever and chills (UTI)
Gross hematuria stone passage
Dietary habits/fluid intake
Stones PE
Flank tenderness
Tophi
VI. Symptoms related to the act of urination
Dysuria
Painful urination
Tingling or burning sensation in the perineum during or
just after voiding
Caused by one of the 2 conditions
Inflammation involving the urethra and bladder trigone
Inflammation involving the vaginal labia
Etiology
Etiology
Location
Lower UTI (bacterial) bladder and urethra
Acute pyelonephritis upper urinary tract
Chlamydial urethritis urethra
Gonococcal urethritis urethra
Other urethritis
urethra
No recognized pathogen
urethra
Vaginitis
vagina
History
Onset of symptoms
Nature of symptoms
Pain intensity
Timing
Initial/during urination
Urethritis
Urethral obstruction
Meatal ulcer
Terminal
Cystitis (with dull and steady suprapubic pain)
Bladder calculi
Prostatitis/seminal vasculitis
Localization
Associated Symptoms
Frequency
Nocturia
Incontinence
Hematuria
Pelvic/back pain
Fever/chills
Vaginal discharge
Last menstrual period
Sexual activity, type of contraception, symptoms in
partner
History of prior urinary or gynecologic symptoms and
infections
Conditions which might predispose to treatment failure
(diabetes, pregnancy, recent antibiotic treatment,
hospitalization, urological instrumentation, urological
anatomic anomaly)
Allergy to medications
PE
Abdominal examination
CVA tenderness acute pyelonephritis
Suprapubic tenderness cystitis
Genital exam
Prostate exam
Frequency
Frequent voiding without increased urine flow
Decreased voiding interval (<2 hours)
Pollakuria abnormal increased frequency of urination
The normal capacity of the bladder is 400 mL
Etiology
Residual urine reduces the functional capacity of the
organ
Bladder inflammation infection, stones, tumor
Bladder fibrosis TB, radiation cystitis, interstitial
cystitis, schistosomiasis
Urgency

 Sudden and compelling desire to pass urine that is difficult

to defer
Nocturia
Waking at night from sleep to void (>/= 2x)
May be a symptom of renal disease due to a decrease in
the function of renal parenchyma with loss of
concentrating power
Can occur in the absence of disease
History
On average, how many times do you wake up at night to
void?
Fluid intake (24 hour, bedtime, diuretic fluids)
Medications (diuretics, xanthines, beta-blockers,
cholinesterase inhibitors)
Co-morbid conditions
Associated symptoms
Obstructive hesitancy, weak urinary stream,
incomplete emptying, intermittency)
Irritative frequency, urgency, urinary incontinence
PE
Comprehensive PE
Enuresis
Nocturnal urinary incontinence
Nighttime bed wetting
Physiologic during the first 2-3 years of life
May be functional or due to delayed neuromuscular
maturation of the urethrovesical component
May also be a symptom of organic disease (UTI, distal
urethral stenosis in girls, posterior urethral valves in boys,
neurogenic bladder)

VII.

Symptoms of Bladder Outlet Obstruction/Prostatism

Obstructive symptoms
Hesitancy
Loss of force and decrease caliber of urinary stream (weak
stream)
Dribbling
Abdominal straining
Intermittency
Acute urinary retention
Chronic urinary retention
Sense of residual urine
Cystitis
Prostatism
Syndrome which occurs with progressive vesicle
obstruction
Stages:
1.
Early stage (irritability)
Bladder musculature begins to hypertrophy
Contraction of hypertrophied detrusor muscle is so
strong, causing spasm
Urgency and frequency
2.
Stage of compensation
Obstruction increases, further hypertrophy of bladder
musculature
Bladder develops contractions strong enough to
overcome resistance at the bladder neck
Exhaustion of the detrusor muscle as it nears end of
the contraction phase
Urgency and frequency plus hesitancy, loss in force
and size of urinary
3.
Stage of decompensation
Bladder tone becomes impaired
Urethral resistance exceeds detrusor power
Inability of the bladder to contract and expel the
contents of the bladder
Marked hesitancy, need for straining to initiate
urination, very weak and small stream, acute urinary
retention, residual urine, overflow incontinence
Differential diagnosis
Obstructive
BPH/prostate CA
Vesical neck obstruction
Urethral stricture
Functional
Detrusor neuromuscular dysfunction
Detrusor instability
Psychogenic voiding dysfunction
Infectious and Neoplastic
Cystitis
Bladder CA
Prostatitis
Prostatic abscess
PE
Enlarged kidneys CVA mass

CVA tenderness infection

Palpable bladder distended bladder
Palpation of the urethra induration (stricture)
DRE (Digital rectal examination)
Atony of anal sphincter
Enlarged prostate
Tender prostate (prostatitis)

Palpation of the
posterior surface of the
prostate gland. Feel for
the lateral lobes and
median sulcus

Enlarged Prostate

VIII. Urinary Incontinence

Involuntary leakage of urine
Urgency sudden and compelling desire to pass urine that
is difficult to defer
Urge Incontinence
Inability to hold urine once the urge to void occurs
Secondary to involuntary bladder contractions
Causes: cystitis
CNS disorder upper motor neuron lesion
Can be seen in tense, anxious women in the absence of
infection
Stress Incontinence
Leakage of urine due to increased intraabdominal
pressure
Involuntary leakage with coughing, sneezing, laughing,
running
Causes: weakness of bladder neck supports (pelvic floor
relaxation); urethral sphincter damage
Unusual in nulliparous women
Overflow incontinence
Paradoxical incontinence
Loss of urine due to chronic urinary retention or
secondary to a flaccid bladder
Mechanical dysfunction resulting from an overdistended
bladder
Causes
Anatomic obstruction by prostatic hypertrophy and
strictures
Neurologic abnormalities that impair detrusor
contractility (multiple sclerosis); spinal lesions
Symptoms
Weak urinary stream
Dribbling
Hesitancy
Frequency
Nocturia
Functional Incontinence
Intact urinary tract but factors like cognitive abilities,
immobility, or musculoskeletal impairments lead to
incontinence
Organic dementia, psychiatric patients
Patients may have more than one type of
incontinence at any given time
History
Onset and course of incontinence
Associated lower urinary tract symptoms
Leakage frequency, timing, volume
Precipitants (medications, caffeinated beverages,
coughing, laughing, physical activity)
Bowel and sexual function
Status of other medical conditions and symptoms, along
with their temporal relationship to urinary incontinence
onset or worsening
Any prior incontinence treatment surgery
Have you leaked urine in the past 3 months?
Which precipitants led to leakage?
Which precipitant caused leakage most often?
PE
Comprehensive PE
Abdominal examination to look for masses and
tenderness, distended bladder

 Rectal examination to check for masses and impaction,

prostate consistency and symmetry
Genital examination in women to assess adequacy of
pelvic support; to assess presence of rectocoele,
cystocoele
IX.
Female Genital Examination
External Examination
Inspection and Palpation
Labia Majora
Labia Minora
Clitoris
Urethral orifice
Vaginal introitus
Skene and bartholin glands
Muscle Tone
Draped patient in dorsal
lithotomy position

Separation of the Labia

Examination of internal genitalia with speculum

Palpation of Skene
Glands

Palpation of Bartholin
Glands

Bimanual palpation of the uterus

Palpating the Perineum

Bimanual palpation of adnexa, sweep abdominal

fingers downward to capture ovary

Cystocele

Internal Examination
Use a speculum cervix
Bimanual Examination
Cervix
Uterus
Adnexa and ovaries
Rectovaginal examination
Anal sphincter
Rectal walls and rectovaginal septum

Rectocele

Rectovaginal Examination
Anal sphincter
Rectal walls and rectovaginal septum
Uterus
Adnexa
Stool

Rectovaginal examination