What is a sexual physical examination?

It is often helpful to the clinician to examine your body in the sexual healthcare setting. Some of the anatomic structures that your clinician might examine during a sexual physical examination include the following:

Vulva: The external female genitalia not including the breasts. The vulva includes the labia majora and labia minora.

Perineum: The skin between the vagina opening and the anus. The perineum has nerve endings, which, when stimulated, can produce enjoyable sensations during intercourse. The perineum can be injured or traumatized during vaginal childbirth. Delivery with a vacuum or forceps and undergoing an episiotomy (laceration or cutting) can affect the perineum and cause a neuroma, or bundle of sensitive nerve endings, to form and can cause pain during penetration.

Vagina: The vagina is the internal structure that leads to the cervix and uterus. The opening is external and is between 5 and 7 inches long but can expand if needed (childbirth). The walls of the vagina have folds, which also can expand, and the folds have nerve endings, which may be sensitive to touch. The back one-third is more sensitive to pressure. During arousal, there is increased blood flow to the vagina and more natural lubrication is created.

Mons pubis: The mons pubis is a mound of soft flesh that sits directly on the pubic bone. It may be covered by pubic hair[1] or groomed according to the woman's interest or desires.

Labia (lips): Labia majora are on the outside, and the labia minora (smaller) are on the inside. In different women, the labia are a variety of shapes, color, and sizes, and no two women are the same. The labia have an abundant nerve supply, and some women experience pleasure when they are touched or caressed. Clitoris: The clitoris is the female sexual organ that is located where the inner lips meet. The clitoris consists of a rounded area or head (glans[2]) and a longer part (shaft) that contains muscular tissue. The tissue of the inner lips covers the shaft of the clitoris (hood). The size and shape is variable among women. There is a high concentration of nerve endings in this area and it is sensitive to direct and indirect touch or pressure. The clitoris is designed for sexual pleasure and this is the organ's only known function. When a woman becomes aroused, the clitoris fills with blood and increases in size. After orgasm, the clitoris returns to its normal size in about 10 minutes. The clitoris can be stimulated through direct or indirect contact. Direct contact with the clitoris by touching, rubbing, finger, vibrator, or tongue can cause intense excitement and sexual pleasure for many women.

Cervix, uterus, Fallopian tubes, and ovaries: These internal female organs are usually assessed with bimanual vaginal examination[3]. The cervix is the area that joins the uterus to the vagina; Pap smears assess cells of the cervix. The uterus is a hollow, pear-shaped organ also known as the womb; a fertilized embryo grows in the uterus until delivery. There are two Fallopian tubes, and they are approximately 4 inches long and connect the ovaries to the uterus; eggs and sperm often join and become fertilized in the Fallopian tubes. The two ovaries produce many female hormones, release an egg monthly, and are located on either side of the uterus.

Dr Laura Bermans recent publication in the Current Sexual Health Reports on genital self-image brings forth some interesting results. Women have some misconceptions about their genitals, and some are worried about the shape size or even odor of their genitals. The genital self-image study reiterated that women who have a negative perception of their genitals may have decreased sexual response and sexual satisfaction. The study also found that women with positive genital self-esteem had more sexual desire, less sexual distress, and lowered rates of depression.

Detailed genitopelvic examinations to evaluate and discern urogenital atrophy are paramount and often necessary to rule out underlying pathology or atrophic changes. Atrophy is a chronic progressive medical condition that is associated with tissue and organ deterioration and dryness. Urogenital atrophy contributes to atrophic vaginitis[4] (inflammation of the vagina) and may lead to sexual complaints in many women. A pelvic examination with careful inspection can reveal a pale, smooth, thinned epithelium (the outermost lining of the vaginal canal) that is extremely friable (fragile). It may even bleed on light touch. The vagina may be dry without lubrication, pale, and may contain petechiae. The vaginal mucosa [5] (tissue lining the vaginal canal) might appear flat and blanched instead of the lush pinkish color with associated rugae (ridges and folds) of a healthy vagina. The vaginal tissue will have decreased pliability, elasticity, and stretchability. External genitalia with loss of or sparse pubic hair, introital stenosis ( the opening of the vagina becomes tight and narrow, making penetration or sexual intercourse painful), and labial fusion of the labia minora or majora or obliteration may also help pinpoint a differential diagnosis. Evaluation of the vaginal depth as well as the rectal surfaces can be helpful. Palpation of the vagina walls can identify points of deep and superficial muscular or pelvic pain, which may require specific physical therapy or trigger point evaluation. The clitoris, clitoral hood, and surrounding structures warrant a comprehensive evaluation. Shrinkage of the clitoral anatomy and introital stenosis are always concerning to the female patient and may signal a decreased estrogen state.

Clinical examination of the tissues for signs of atrophy should include a simple acid/base test with pH paper to assess the vaginal environment. The vaginal pH is typically elevated in those who suffer from vaginitis. Vaginal cytology (cells) can also be used as an adjunct for diagnostic purposes. It is prudent for the clinician to exclude other causes of vaginal complaints such as candidiasis, bacterial vaginitis, and trichomoniasis as well as other sexually transmitted diseases that can interfere with normal vaginal flora. A quick and simple office-based wet mount and whiff test can be performed to exclude any underlying or compounding infectious etiology.

A complete physical examination can also be completed to assess your general health and rule out possible chronic diseases that may affect your sexual response cycle. Thyroid, heart, and lung assessment can also be helpful in the complete physical assessment for sexual complaints.

What laboratory test or other radiological evaluations can I expect?

Occasionally, after a complete history and physical examination are done, your healthcare provider may decide that further testing is needed to help confirm the diagnosis. Comprehensive analysis of hormonal profiles (estrogen, testosterone, prolactin, progesterone) is warranted, and the sexual healthcare professional may include a blood work panel as part of the dynamic workup. Some lab tests that may be done include complete blood count; thyroid stimulating hormone; prolactin; adrenal gland precursors such as DHEA and DHEAS; sex steroids such as an estrone, estradiol, progesterone, and testosterone panel including free testosterone; and sex hormone binding globulin. Cholesterol panel and liver function tests may also be included.

Some of the testing must be done after you have fasted briefly, whereas others must be done during specific times of your menstrual cycle to avoid cycle and diurnal variation. Some doctors do measure hormones regularly to monitor progress, whereas others do not measure hormones and do not place much credence in lab tests. This varies from provider to provider.

The importance of many laboratory tests has come into question because there is some concern regarding reliability and normative values for women across the life cycle. Sometimes a pelvic or transvaginal sonogram may be warranted to assess pelvic anatomy and rule out underlying structural pathology. Some other advanced sexual health assessments tools that the sexual medicine specialist may utilize include vulvos-copy (examination of the vulva and surrounding structures with a microscope to rule out underlying vulvar pathology), vaginal photoplethysmography (objective measurement of genital blood flow with a special probe), functional magnetic resonance imaging (used primarily in research settings, where the brain is evaluated), biothesiometry (assessment of pelvic neurologic status), and perineometry (assessment of pelvic floor musculature).

  • [1] Hair that appears on portions of the external genitalia in both sexes at puberty.
  • [2] The terminal knob of the penis or clitoris.
  • [3] Examination of the vagina, cervix, and uterus as well as the other internal pelvic organs with the use of gloved fingers that are inserted into the vagina while the other hand presses on the abdomen.
  • [4] Inflammation of the vagina.
  • [5] A surface layer of cells or epithelium that is lubricated by the secretions of mucosal glands.
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