Learning the female breast, gynecological, and male urogenital exams

Notice: This post contains medically-relevant graphic descriptions of pelvic exams.

We tend to have very personal and complex relationships with our sexuality, and it is perhaps because of this that the pelvic exam is one of the more salient (traumatic?) experiences associated with going to the doctor. "Turn your head and cough" is a phrase that is burned into our collective psyche. Likewise, my impression is that a woman's first gynecological exam is as much a rite of passage as menarche.

So, it's natural that I approached learning the male and female pelvic exams (a rite of passage of its own) with a little anxiety. "I would be worried if you weren't a little anxious," one of our professors said as she prepared us for the experience.

Learning how to perform the male urogenital exam and the female gynecologic exam, which I did last week, is the Foundations of Doctoring clinical correlate to the Life Cycles block. The class is divided into groups of three students per instructor. These instructors are specifically trained to teach the respective pelvic examination using their own body. Instruction for the two exams were done on separate days, and each lasted around 3 hours.

Male urogenital exam

I feel lucky that I was assigned to learn the male urogenital exam first. It's much less invasive, and there's a certain comfort level in working with someone of the same gender. It also turned out that my particular instructor was very personable, laid back, and made the experience as enjoyable as possible.

I was grouped with two other male classmates, so when the instructor opened his gown for the first time and was talking to us with his genitals exposed, the interaction almost had the feel of a locker room conversation - except that he was pointing to his genitals and expecting us to look at them. It only took a few moments for me to get over that initial shock, which I felt despite my best mental preparations. After that, the experience was wholly professional and natural.

Much of the instruction focused on the interpersonal aspects of administering this exam. Be confident, because patients can smell nervousness and inexperience. Look the patient in the eye, and watch for non-verbal signs of discomfort. Use a combination of technical and common language so the patient understands what is happening and so the examination remains professional.

Language is a very big deal. For instance, one of my classmates asked our instructor to "please spread your butt cheeks." We all busted out laughing because in that moment he couldn't think of the right way to say such a thing. We were instructed to instead say, "Please spread your buttocks."

We were also shown the different positions in which we could perform the digital rectal exam and the relative pros and cons for each position. Myself being younger than 50 years with no risk factors for prostate cancer, this was all new information to me. The preferred patient position for examining a healthy man is standing with feet shoulder-width apart, leaning over and resting the elbows on the exam table. Many of my classmates have done this before while working with their preceptor, but this was my first time performing a prostate exam.

My last comment about the male urogenital exam is that we were taught to encourage our patients to do self exams (mostly to check for testicular cancer) much like women are encouraged to monthly self breast exams. There is so much publicity about breast exams, but before this I had never heard of male self exams either from my doctor or from the media. Lance Armstrong's battle against testicular cancer did help to raise awareness with his Livestrong campaign. I believe that his organization does promote testicular self exams, but for me at least that message never got through.

Female breast exam

My experience learning the female breast and gynecological exams was quite different. First, the course coordinators broke up our all-male group, so I was with one male and one female classmate. I was grateful for this, since it might have been a little awkward having an all-male group for this particular examination. Second, our instructor was much more serious - necessarily so, again given the invasive nature of this exam.

Just like with real patients, we started with the least invasive procedure and progressed toward the more invasive ones. First on the list was the breast exam. We were instructed on both how to administer the breast exam and how to teach our patients to examine their own breasts once a month. The female breast self-exam has become so much a part of popular culture thanks to breast cancer awareness campaigns, so I was happy to learn something so practical.

Much attention was paid to patient comfort. One absolute rule was to only touch the patient with one hand at a time. This struck me as odd. Why would touching the patient with only one hand make her feel less threatened? Couldn't I do a quicker and more effective breast exam using two hands? We were told that a doctor who used two hands to do any part of the breast or gynecological exam would not be in business for very long because patients would not return to that doctor. Fair enough. But the explanation that makes more sense to me is that the patient herself will be able to use only one hand when doing the self breast exam.

Gynecological exam

After learning the breast exam, we moved on to the gynecological exam. "Who wants to go first?" In these sessions, the person who goes first gets the most detailed instruction while the other two students run through the exam as if they were administering it to a real patient. Both I and my male classmate looked over at our female classmate: "I guess it's me!" she laughed.

I have seen many pelvic exams in the emergency department, but the exam itself was never explained to me. For example, what is the doctor feeling for when he or she pushes down onto the stomach with the fingers inserted into the vagina? The point of the bimanual exam is to palpate (fancy medical terminology for feel/touch) the edges of the uterus to determine its shape and where it sits. The fingers inserted into the vagina put pressure on the cervix, while pushing down on the abdomen locates the fundus of the uterus (it's top-most border). When done correctly, we're supposed to feel pressure from the cervix pushing back onto our fingers.

It happened that my female classmate who was learning the exam first has small hands, and she was having trouble getting her fingers in deep enough to touch the cervix. Her hands started cramping. We all had a little laugh about it in this relatively relaxed setting (compared with seeing a real patient), but our instructor also took the opportunity to teach us what to do in such a situation: tilt the bed a little downward so gravity pulls everything closer toward the fingers. She was also careful to point out that having small hands should not keep someone from pursuing a career in OB/GYN.

I was surprised to learn that the gynecological exam includes a maneuver that involves insertion of a finger into the rectum. My female classmates were equally surprised, and I have yet to talk with anyone whose doctor performed this maneuver. Regardless, we were taught that no gynecological exam is complete without it. The doctor inserts the index finger in the vagina and the middle finger in the rectum simultaneously. The middle finger eventually penetrates into an open space called the pouch of Douglas. So positioned, by pushing down on the top of the uterus, the doctor can palpate the posterior (back) side of the uterus. The purpose of this is to feel for cysts or fibroids. This doesn't sound like a very comfortable procedure to experience, which probably explains why I couldn't find anyone whose gynecologist included it in the regular examination. I wonder how long it will take for this to be standard-of-care.

When it came time for me to perform the gynecological exam, the only part that gave me problems was visualizing the cervix with the speculum. We used disposable plastic speculums instead of the metal variety. To put this in perspective, my instructor went through five of these exams before me: I was her sixth and last exam of the day. Although I can't speak from personal experience, it's my understanding that these exams are uncomfortable at best. This is something of a heroic task for these instructors to lend their bodies in such a way for the purpose of educating medical students such as myself. After teaching five medical students, the tissues in her vagina and surrounding the cervix were irritated and slightly inflamed making it more difficult to use the speculum appropriately. My instructor used this as a teaching point, saying that in such a situation it may become necessary to use a slightly larger speculum. After moving from a medium to a large, I was able to find the cervix with minimal difficulty.

One last word about the gynecological exam. Just as with the male urogenital exam, using the correct language is important. Women put their feet in foot rests now instead of stirrups: "We're not riding a horse now, are we?" says our Foundations instructor. Likewise, I "remove" my finger instead of "withdraw" it, since the latter terminology may have a sexual undertone to it.

Summary

I know this was a long post, but given the potency of this experience, I feel that its length is warranted in order to communicate what I and other medical students actually experience while learning the pelvic exams for the first time. I should note that not all medical schools provide this instruction for their students. This experience makes me all the more eager to start my clerkships coming up in Phase III.