During the external inspection it is useful to systematically inspect at all structures. Your queries or hypotheses based on the history-taking can direct you to carry out a closer or more extensive inspection or assessment of specific structures. Be aware that there is a lot of variation in what is considered normal.
The inspection starts with you standing beside the patient.
Describe:
- the (lower) abdominal skin.
Are there any scars or striae (pregnancy stretch marks)? - the groin
The skin in the groin is thin and slightly folded. It is an area where skin abnormalities can often occur.
During the remainder of the inspection you can sit on a stool [Figure 21] placed between the legs of the patient. Aim the lamp in such a way that the inspection area is clealy visable. At this point put on the gloves required for parting the labia.
Figure 21
- Hair pattern of the pubic region.
A normal female hair pattern is triangular shaped with the base of the triangle at the top. - Labia majora
The labia majora consist of pigmented skin with hair growth, and they are positioned around the labia minora [Figure 22]. - Labia minora
The labia minora are formed by connective tissue, covered with pink, pigmented mucous membrane and following puberty they protrude somewhat between the labia majora.
Figure 22
To conduct further inspection it is necessary to part the labia. In this way the structures positioned between the labia can be brought into view (made visible).
Part the labia by placing thumb and index finger, starting from the top, between the labia majora and the labia minora [Figure 23]. You can also use the thumb and index finger of both hands and place them between the labia majora and labia minora. Move ventrally and to the side with your fingers. If desired, you can simultaneously tighten and pull down the posterior commissure of the labia to increase the view [Figure 24].
Figure 23
Figure 24
Describe:
- The fold between labia minora and majora.
Check whether you can already see discharge or coating. - Clitoris
The clitoris lies hidden beneath the prepuce, and consists of pink, pigmented mucous membrane (see above, description of labia minora).
Then part the labia minora again, this time by placing your fingers (from the top) halfway down and parting them whilst moving ventrally.
Examine:
- Urethral orifice
The urethral orifice lies in ‘the roof of the vagina’. Often it is positioned slightly to the inside and visible as a triangular orifice in the mucous membrane. The colour is pink, just like the surrounding mucous membrane. - Paraurethral glands
The excretory ducts of the paraurethral glands, known as Skene’s glands, are located lateral to the urethral orifice (3-4 mm). Occasionally these are visible as small, dark pinpoints. - Vaginal introitus
The entrance of the vagina is covered with pink mucous membrane. In a nulliparous woman, the sides are so close together that it appears shut. In women who have previously given birth vaginally, the sides slightly deviate from each other and you will be able to see a little way into the vagina. The mucous membranes of the touching side walls and the back wall of the vagina are visible. - Hymen (residual tissue)
An intact hymen consists of a semilunar, thin mucous membrane fold that is positioned just dorsally from the vaginal introitus. If the hymen is not intact, there will almost always be residues visible in the form of thin shreds. - Excretory ducts of Bartholin’s glands.
The excretory ducts of Bartholin’s glands are, very rarely, visible as small dark pinpoints. They are located on either side of the vaginal introitus, from a dorsal viewpoint approximately one-third of the distance between the posterior commissure and the clitoris. - Posterior commissure of labia
The lower ridge of the vaginal introitus where the labia minora converge.
For inspection of the perineum and anal region it is better to use both hands. You place one hand on either side and pull the buttocks slightly down and apart [Figure 25].
Figure 25
- Perineum
The skin area between vagina and anus, consisting of slightly pigmented skin that is often wrinkled. It may be that a scar from an episiotomy or tear is visible. - Anus
Slight hair growth may be visible here. There may also be small flaps of skin present (anal skin tags / mariscae), left over from haemorrhoids.
If indicated (when suspecting a prolapse) you can ask the patient to bear down for a moment during the inspection. Attention is paid to prolapsing of the anterior and / or posterior wall and of downward movement of the vaginal portion of the cervix (it will then become visible in the introitus). Only carry this out if indicated and at the end of the inspection, since it is considered an unpleasant experience by a patient.
Palpation
If you locate a swelling during the external inspection, it must be palpated. Palpate the tissue between thumb and index finger [Figure 26] and make a rolling movement. Always do this in a crosswise manner, i.e. the right labia of the patient with your right hand.
Figure 26
The tissue of the labia majora has a loose structure.
Assess the consistency of the swelling. Note the tenderness, shape and size of the abnormality, temperature of the surrounding skin and feel whether the swelling is ‘detached’ from the underlying layer and / or the skin.