CLINICAL SKILLS PROGRAM

of
REPRODUCTIVE SYSTEM

VENEREOLOGICAL EXAMINATION
What is the clinical skills program?
 The clinical skills program is designed to
develop and refine the clinical techniques
of medical students:
 Human interaction skills
 Physical examination behaviors

education of a sensitive and effective

physician
Goals

 To prepare students for patient contact in

community office practice programs, clinical
clerkships, residency and future personal
office practice
Objective

 After completing a practice of venereological

examination the students will be able to
perform the venereological examination
COMPREHENSIVE PATIENT MANAGEMENT
OF SEXUALLY TRANSMITTED INFECTION
(STI)

 “Correct diagnosis”
 Effective treatment
 Counseling on risk reduction
 Partner notification & treatment
 Testing for other STIs
 Clinical follow up
WHAT IS THE ESSENTIAL COMPONENTS IN
THE “DIAGNOSIS” of STI?

 History taking
 Genital/Venereological Examination
 Laboratory Examination
HOW THE STI PATIENTS FEEL ABOUT
THEIR CONDITIONS?

 Emotionally disturbed
 Embarrassed
 To show the genital
 Done a multiple sexual behaviour
 WHAT SHOULD WE DO ?

EXAMINE THE PATIENT IN :

• Privacy & chaperon
• Comfortable
• Confidentially
• Non-judgmental
• Explained : the examination & test
 SEXUALLY TRANSMITTED
INFECTIONS (STI)

INFECTIONS BY A NUMBER OF
VIRUSES, BACTERIAS, FUNGI,
PROTOZOAS OR ARTHROPODS THAT ARE
TRANSMITTED PRIMARILY THROUGH
HETERO OR HOMOSEXUAL CONTACT
STI-ASSOCIATED PRESENTING PROBLEMS

 Urethral discharge
 Vaginal discharge
 Genital ulcer
 Scrotal swelling
 Inguinal swelling
 Lower abdominal pain
 Vegetations
URETHRAL DISCHARGE
 URETHRAL DISCHARGE
GONOCOCCAL URETHRITIS NON-GONOCOCCAL
URETHRITIS
ETIOLOGY N. gonorrhoeae C. trachomatis

INCUBATION PERIOD 2-5 DAYS 1-5 WEEKS

CLINICAL FEATURES
DYSURIA SEVERE MILD

DISCHARGE QUALITY PURULENT MUCOID

DISCHARGE QUANTITY MORE (abundant) LESS (scanty)

MICROSCOPY URETHRAL SMEAR: URETHRAL SMEAR:

> 5 PMNs/hpf > 5 PMNs/hpf
GRAM NEGATIVE STAIN:
INTRA-CELLULAR DIPLOCOCCI
VAGINAL DISCHARGE
THE CAUSES OF VAGINAL DISCHARGE

1. PHYSIOLOGICAL
puberty, menstrual cycles, sexual arousal,
pregnancy

2. PATHOLOGICAL
 noninfective :
chemical, foreign body, gynecological
 infective : STI & non STI patogen
cervical infections, vaginal infections
 THE SYMPTOMS & SIGNS OF
ABNORMAL VAGINAL DISCHARGE

 EXCESSIVE
 MALODOROUS
 YELLOW OR PURULENT
 INFLAMMATION
 VAGINAL DISCHARGE : cervical infection

DIAGNOSIS GONOCOCCAL NON-GONOCOCCAL GENITAL HERPES

CERVICITIS CERVICITIS
ETIOLOGY N. gonorrhoeae C. trachomatis Herpes simplex virus

INCUBATION 2-5 days 1-5 weeks 2-10 days

PERIOD
SYMPTOMS 50% asymptomatic, 70% asymptomatic, Symptomatic
vaginal discharge, vaginal discharge (>> primary infection)
vaginal bleeding or asymptomatic
CERVIX Erythema, bleeds Erythema, bleeds Erythema, erosions,
easily, purulent easily, ectopic cervix, necrosis, purulent
discharge, may purulent discharge discharge
appear normal (37%)
 VAGINAL DISCHARGE : vaginal infection

DIAGNOSIS NORMAL YEAST TRICHOMONAL BACTERIAL

VULVOVAGINITIS VAGINITIS VAGINOSIS
ETIOLOGY Lactobacilli Candida spp. T. vaginalis G. vaginalis,
M. hominis,
Mobiluncus sp,etc
TYPICAL none vulvar pruritus purulent discharge, vulvovaginal
SYMPTOMS and/or irritations, often profuse, malodor, slightly >
sometimes sometimes vulvar discharge
discharge >> pruritus
DISCHARGE-
- amount variable scant to moderate profuse scant to moderate
(usually scant)
- color clear or white white or yellow yellow, tan usually white
- consistency non- clumped, adherent homogeneous homogeneous, low
homogeneous, plaques viscosity,smoothly
floccular covers vaginal
mucous membrane
 VAGINAL DISCHARGE : vaginal infection

DIAGNOSIS NORMAL YEAST TRICHOMONAL BACTERIAL

VULVOVAGINITIS VAGINITIS VAGINOSIS
Inflammation None Erythema of vaginal Erythema of vaginal None
of vulvar / epithelium, introitus; vulvar epithelium;
vaginal vulvar dermatitis << petechiae of
epithelium common ectocervix
(strawberry cervix)
pH of vaginal Usually < 4.5 Usually < 4.5 Usually > 5.0 Usually > 4.7
fluid

Amine None None Present Present

(fishy odor)
with 10% KOH
Microscopy Normal Epithelial cells, PMNs >>, motile Clue cells;
epithelial cells, yeasts or Trichomonads profuse mixed
Lactobacilli >> pseudomycelia (80-90% flora with few or no
(large Gram (up to 80%), symptomatic cases) Lactobacilli
positive rods) usually few PMNs << in asymptomatic
GENITAL ULCER
DIAGNOSIS CHANCROID SYPHILIS GENITAL HERPES

ETIOLOGY H. ducreyi T. pallidum Herpes simplex virus

(type 2 >>)
INCUBATION 1-14 days (+ 3-6 days) 10-90 days (21 days) 2-10 days
PERIOD
PREDILECTION Men : Men : Men :
SITES fraenulum, prepuce, sulcus coronarius, glans penis, prepuce,
coronal sulcus, glans glans penis & penile penile shaft
penis & penile shaft shaft, perianal area Women :
Women : Women : cervix, vagina, labia,
cervix, vagina, cervix, vagina, fourchette, clitoris
fourchette, labia, fourchette, labia
perianal area
NUMBER OF 1-3 (up to 10) 1, sometimes > 1 Multiple,
LESIONS Primary infection >>
recurrent infection
 GENITAL ULCER
DIAGNOSIS CHANCROID SYPHILIS GENITAL HERPES

ULCERS :
- Initial lesions Macules, papules, Papules Vesicles
pustules

- Diameter Variable, < 2 cm 0,5 -1,5 cm 1-2 mm

- Edge Ragged undermined, Well-defined border, erythematous
irregular elevated, round or
oval.
- Depth Excavated Superficial or deep Superficial
- Base Dirty, gray/yellow Clean, red, Bright red
necrotic, bleeds with clear serum
easily,
- Induration (-) Firm (-)
- Pain Usually very tender (-)/uncommon Frequently tender
DIAGNOSIS CHANCROID SYPHILIS GENITAL HERPES

Inguinal Unilateral/bilateral, Bilateral, multiple, Bilateral, firm,

adenopathy fluctuant, painful, firm, nonfluctuant, moderatelly tender,
overlying erythema (-) Painless, overlying nonfluctuant, overlying
suppuration (+) erythema (-) erythema (-)

Constitutional Seldom Seldom (primary Often (primary inf.)

symptoms syphilis) Seldom (recurrent inf.)
Microscopy Gram : Dark field micr : Giemsa :
Gram (-), parallel- Treponemal Multinucleated giant
arrays (‘rail-track’ or movement cells
‘school of fish’)
VENEREOLOGICAL
EXAMINATION
IN FEMALE
 Greet client
 Explain the patient
 Wash your hand
 Voiding prior examination
 • Venereological examination :
The patient should be examined in
privacy, preferably by chaperon with
the same gender
• CASE
Mrs. Vadis 22 years old, single, working
in massage parlor with many sexual
partners, visiting STI Clinic with the
chief complain of increased vaginal
discharge for 1 week. The last sexual
intercourse was 2 weeks ago without
condom.
EXPLAIN THE PURPOSE OF
EXAMINATION

• Mrs. Vadis, after I asked you all about your

signs and symptoms, now allow me to
examine your genital.
• The purpose of this procedure is to find the
causes of your problem.
• During examination, I will take the specimen
collection from the cervix and vagina, its
often painful, but don’t worry, I will try to
perform it gently.
• Verbal consent : do you mind ?
• Dr : have you urinate Mrs. vadis?
• Mrs. Vadis : Not yet doc!
• Dr : oke, for succesfull examination
please urinate.
Lithotomy Position
Put the Glove
Inguinal Region  Inspect
Inguinal Region  Palpate

Lymphadenopathy ? : size, consistency, mobility

& tenderness
Skin & Pubic Hair

Lesion, lice, nits ?

Papule  Molluscum Contagiosum
 Nits

Pediculosis pubis
INSPECT LABIA MAJORA & MINORA

Erythema, oedema, fissuring & lesions :

erosion, ulcer or papules ?
Erythema & Edema  Candidosis Vulvovaginitis
Erosion  Genital Herpes
Ulcers  Syphilis
Ulcers  Chancroid
Papule  Condylomata (syphilis 2)
Papules  Warts
 Labia minora  separated

Any discharge ?  amount, colour, consistency

 INSPECT
URETHRA & PERIURETHRAL

Erythema, oedema, any lesions or discharge ?

Discharge : amount, colour, consistency
 Milking urethra by gentle presure
by forefinger from above downword
 Palpate the Bartholin’s gland

Infected  tender & pus (+) at inflamed duct orifice

Insert a speculum
 vagina, at an angle
 hollow the sacrum
 opened to reveal
the cervix
 INSPECT VAGINAL WALL

Erythema, erosions, ulcers, papules or discharge ?

White clumped discharge  Candidosis
Yellow, homogen, frothy discharge 
Trichomoniasis
 INSPECT CERVIX

Erythema, oedema, any lesions or discharge ? 

amount, colour, consistency
External os cervix is wiped clean
with cotton wool  inspect

Any lesions ?
Erosions, ulcers
or papules ?
Cervicitis gonorrhoea
Petechiae “Strawberry cervix” 
Trichomoniasis
Erythema, erosions  Genital Herpes
 N. gonorrhoeae

Insert a cotton-tipped swab about 1-2 cm into

endocervix  firmly rotating 10 sec
Spread the smear thinly on slide
 Gram staining
Second swab  put in to the
transport medium
 C. trachomatis

Rubbed cotton tip swab against the mucous membrane

of endoccervix  placed into transport medium
 Trichomonas vaginalis

A drop of saline sol.(trichomonas) is added to the slide

Mixed with vaginal secretion from vaginal wall
Placed the cover slip on it, sealed the edge with vaseline to
prevent drying.
 Candida

• A drop of 10% KOH is added to the slide

• Mixed with vaginal secretion from vaginal wall
• Placed the cover slip on it, sealed the edge with vaseline to
prevent drying.
pH Determination of vaginal fluid

Held the pH paper with forcep 

Appled to the vaginal wall near the lateral fornix
 Whiff Test or Amine Test

A drop of 10% KOH is added to vaginal fluid pooling

in the speculum.
The test (+)  “fishy odor”
 Insert the first two fingers into the
vagina  cervix is palpated and moved

Normally : NO painful
 Buttocks  separated

Inspection for any lesions

Papule  Condyloma Accuminata
Papule  Condyloma Accuminata
• Dr. : Okay Mrs. Vadis, the examination
is finished, please get dressed, and
while I recording the result of your
genital examination and performed the
laboratory examination, please wait in
the waiting room, thank you!