Thursday, July 22, 2010
First Well Woman Nightmare!
We saw a healthy 21 y/o G0P0 today for her first ever well-woman exam. So the game plan was I would do the H&PE, except for the pap/bimanual exam. The pt. absolutely denied any h/o sexual experimentation as she "wants to wait to get married" and also denied any h/o abuse. She'd only tried to use a tampon once and stopped because it was too uncomfortable. She also was a bit histrionic and so although I'd already done a "first" well woman exam successfully on another patient recently, I was glad the midwife was taking this on. Well, the CNM explained the procedure and also let her know that if the pt. asked her to stop, then we'd have to reschedule the appt. for another day. The midwife was able to insert one finger, w/the pt. c/o stinging, and stiffening her body up (her hymen was still partially intact). But she was unable to advance the speculum further than 1" without the pt grimacing. She once again inserted her finger, and then inserted the speculum the same distance w/the same result. The CNM then asked her, "Do you want me stop", and the pt. said yes, and so the CNM withdrew and terminated the PE. The pt. then asked "well how much more did you have to go" and indicated she preferred to get this over and done with if it there hadn't been that much more to insert. As a novice practitioner, I would have handled this differently, and I would've been wrong to do so. I would not have terminated the exam completely at the point the CNM did and kept the speculum in for a third and final try to see if I could further work w/her to "get it over and done with". It takes the sophisticated practitioner to look at the big picture here. Yeah, it would've been over and done with, but now this young lady would have been scarred with a less than ideal experience. It would have been this big traumatic event that would she would carry on through all her GYN appt's, and maybe even her sexual and OB experiences. I would have done her a disservice, esp. since it's not urgent for her to have the pap since she has a very low risk for STIs/HPV as a virgin. We told her to reschedule in 6 weeks and in the meantime, the CNM instructed her on daily use of a tampon to get her accustomed to the feel of a foreign object in her vagina (although I wonder, does one consider having her return instead in 6 months, or just wait till next year? I mean how important is it if you are not sexually active, or are we assuming that every pt. is lying?? I know it is important to make sure that anatomy is intact, but in the grand scheme of life, how soon is now?). It was a very valuable lesson for me today, that you have to keep the overall person in mind (esp. w/her being a histrionic) and think of their long term health over a "short term gain".
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I liked you self assessment and your overall analysis of the issues at hand. As I read your post, I was curious about the social history of this patient. On a well known sex-advice radio show, I once heard the topic of painful coitus discussed. The issue at the time was a woman who experienced vaginal pain every time she tried to have intercourse. The physician related that penile size (within the normal range of variation) should not cause pain in and of itself because the birth canal is capable of accomodating a full term baby. In his experience, he found that this phenomenon was often a matter of emotional comfort, and often the result of sexual or emotional trauma. With your patient, even the insertion of one finger (arguably smaller than even the smallest extremes in penile size) caused pain. It makes me wonder if there was more to her social history than meets the eye
ReplyDeleteInteresting case, not sure how I would have handled it. I think Andy has some valid point regarding the patient's history and the possibility of sexual or emotional trauma. I would probably schedule extra time for her appointments as well as premedicate her with an anti-anxiety med like valium to aid her in the examination process but I would be unlikely to promote her first vaginal experience to be the insertion of a speculum.
ReplyDeleteAll your comments are very valid. I think I've considered all of these perspectives at one time or another.
ReplyDeleteI've seen patients that NEEDED a pap smear (although there are some studies that show you don't really need a speciulum - you can get cervical cells by just inserting a brush in the vault and waiving it around), and also needed the valium. These women didn't deny their abuse history though.
I've also seen virginal women who found it VERY uncomfortable to insert a finger. One thing you could have looked for was a pediatric speculum, or a narrow Pederson (you will only find that in metal - not a plastic speculum) if you really HAVE to visualize the cervix/vault.
Intersting.