Pelvic Examination: Pevlic Examination in older women

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Special Considerations with the Geriatric Patient The pelvic examination proceeds similarly to that of most women. Special considerations in examining the elderly patient include age-related co-morbidities that may make postioning difficult or the examination uncomfortable. Some of the following recommendations may also apply to younger women with disabilities. The knee-chest position. From Seidel. Most elderly women can be examined in the dorsal lithotomy position. For some, conditions that limit hip or knee movement, such as arthritis, make the left lateral decubitus position more comfortable. With practice, thorough bimanual and speculum examinations can be done with the patient in this position. For bed-bound women, placing an inverted bedpan under the sacrum to elevate the pelvis will facilitate the examination. Click here for more information about positioning in older women. The effects of estrogen withdrawal make examination of the vulva particularly important. After menopause the skin of the vulva loses elasticity and there is degeneration of underlying fat and connective tissues. Inflammation caused by irritants, Candida infection, and vulvar dystrophies are common and treatable and are easily identified on pelvic examination. Any lesion that is pigmented or does not respond to topical therapy should undergo biopsy. Atrophic vaginitis is also common and is indicated by the presence of a urethral caruncle or by inflamed vulvar and vaginal tissue. In women who are not receiving estrogen replacement therapy, vaginal stenosis and atrophy are very common. Small speculums should be used to examine these women. Lubricant may be necessary for the speculum examination but should be avoided if a Papanicolaou smear is to be obtained. Cystocele, a hernial protrusion of the urinary bladder through the anterior wall of the vagina. From Seidel. Rectocele, a hernial protrusion of part of the rectum through the posterior wall of the vagina. From Seidel. The speculum can be taken apart and the lower half used to hold down the floor and roof of the vagina to look for cystocele and rectocele, respectively, while the patient coughs or performs the Valsalva maneuver. Urinary leakage with cough or straining may also be observed, indicating stress incontinence. Bimanual examination is important to detect pelvic masses or tenderness. Any palpable ovarian tissue in a postmenopausal woman warrants further investigation, as does any uterine mass. Pelvic floor muscle strength and control can be assessed for incontinent patients by having them contract the muscles during digital examination. This technique can also be used to teach Kegel exercises more effectively. The authors are indebted to Dr. Wendy Adams for her assistance and expertise on geriatric issues in the pelvic examination.

Note: women's health