Table 3.

Key Descriptors for Physical Examination Findings by Anatomical Site in Females with Cancer and Sexual Function Concerns

Findings and Descriptors
Anatomical Site	Inspection		Palpation		Specialized Testing
	Normal	Changes	Normal	Changes
Vulvovaginal examination
Inguinal canal		Mass	Small, mobile, non-tender lymph nodes, symmetrical	Firm, enlarged, tender lymph nodes; edema; hernia; lymphocyst
Mons pubis	Presence of pubic hair covering mons, labia majora. Adolescents: Tanner stage	Decreased, sparse or absent pubic hair due to treatment or personal alteration; radiation changes such as edema (pitting/non-pitting, location); tattoos and/or genital piercing; pigmented lesions, rash or other skin changes	No lesions, tenderness or masses	Presence of lesions, tenderness, or masses
Labia majora*	Normal size, symmetry	Note abnormal size or symmetry of structures; presence of agglutination, atrophy, edema, erosions, erythema, fissures, granulation, excoriation, laceration, fissures, inflammation, lesions, reticulated leukokeratosis, scars, ulceration, or nodules; urethral caruncle, prolapse, pallor	No lesions, tenderness or masses	Presence of lesions, tenderness, or masses; urethral or peri-urethral glandular discharge	Culture any discharge exuded from palpationof paravaginal glands, peri-urethral glands, urethra
Labia minora* Interlabial sulcus folds*
Bartholin's glands	Small, ~1–2 mm pink orifice, medial aspect inferior labia minora	Presence and size of Bartholin's gland cyst	No discharge, erythema, swelling or tenderness	Presence of discharge, erythema, swelling or tenderness
Clitoris*	Size typically 1.5–2cm long by <0.5cm wide; pink color	Agglutination or phimosis, clitoromegaly, pigmented or other lesions	Sensation to pressure	Absence of sensation; tenderness	Hormonal and radiologic testing for clitoromegaly237
Perineum	Normal size, symmetry	Note abnormal size or symmetry of structures; presence of agglutination, atrophy, edema, granulation, excoriation, laceration, fissures, inflammation, lesions, scars, ulceration, or nodules; urethral caruncle, prolapse, pallor	No lesions, tenderness or masses	Presence of lesions, tenderness, or masses; urethral or peri-urethral glandular discharge	Culture any discharge exuded from palpationof paravaginal glands, peri-urethral glands, urethra
Vestibule	Pink, glistening	Erythema, pallor, fissures, lesions	No lesions, tenderness or masses	Presence of lesions, tenderness or masses	Cotton swab test - vulvar pain mapping121,123
Vaginal opening (introitus)	Normal size, non-malodorous physiologic discharge, rugae visible	Presence of agglutination, atrophy‡, bleeding, contraction, dehiscence, discharge, dryness, erythema§,‖, pallor, scarring, stenosis or telangiectasia. Note relaxed introitus or bulge from rectocele, cystocele or vaginal vault prolapse.	Easily insert 1–2 fingers without pain	Adhesions, atrophy, dryness, fibrosis, inelasticity, scarring or stenosis	Graduated vaginal dilator examination as described in text
Urethral meatus	Normal size, symmetry	Note abnormal size or symmetry of structures; presence of agglutination, atrophy, edema, granulation, excoriation, laceration, fissures, inflammation, lesions, scars, ulceration, or nodules; urethral caruncle, prolapse, pallor	No lesions, tenderness or masses	Presence of lesions, tenderness, or masses; urethral or peri-urethral glandular discharge	Culture any discharge exuded from palpationof paravaginal glands, peri-urethral glands, urethra
Skene's glands	Small, ~1 mm pink orifice inferior and lateral to urethral meatus	Presence and size of Skene's gland cyst (rare)	No discharge, erythema, swelling or tenderness	Presence of discharge, erythema, swelling or tenderness
Urethra	Normal size, symmetry	Note abnormal size or symmetry of structures; presence of agglutination, atrophy, edema, granulation, excoriation, laceration, fissures, inflammation, lesions, scars, ulceration, or nodules; urethral caruncle, prolapse, pallor	No lesions, tenderness or masses	Presence of lesions, tenderness, or masses; urethral or peri-urethral glandular discharge	Culture any discharge exuded from palpation of paravaginal glands, peri-urethral glands, urethra
Bladder			Non-tender	Tender, cystocele, full (even after patient voids)
Vagina	Pink, rugae, physiologic discharge; non-malodorous; 6–7 cm vaginal length; if hysterectomy, cuff intact	Agglutination, ecchymoses, abnormal discharge, decreased or absent ruggae, fibrosis, granulation tissue, hematocolpos, laxity, masses, pallor, scarring, stenosis	Elastic, non-tender, lubricated, rugated	Dry, hematocolpos, inelastic, nodular, tender	Vaginal pH test; KOH and saline wet prep test for BV, yeast, trichomonas. Can also use wet prep to visualize superficial epithelial cells, which will be rare to absent inatrophic vaginitis. Pelvic Organ Prolapse Quantification (POP-Q)to assess pelvic organ prolapse131
Vaginal mucosa
Vaginal walls
Cervix*	Present or absent; ectropion size; nabothian cyst size, location	Bleeding, discharge, masses, nodules, scarring, ulceration	No cervical motion, tenderness; uniform, "cartilaginous" feel.	Cervical motion tenderness, fibrosis, firmness, tenderness, nodularity	Screening for Gonorrhea/Chlamydia. Screening Pap/HPV if indicated and in sync with primary care
Uterus*			6 wk size or smaller, mobile, well-supported	Hematometra, mass, nodule(s), uterine prolapse, uterine or adnexal tenderness, fixed or firm adnexae
Adnexa*			Small, may not be palpable; mobile
Pelvic floor examination
Perineum, Vulva	Ability to contract muscles and/or relax after contraction; able to bear down, observed as a slight bulging of the perineum	Vulva drawing in, gaping of the perineum		Presence of muscle tension or laxity at rest; inability to contract muscles and/or relax after contraction; inability to bear down
Bulbocavernous, ischiocavernosus, and transverse perineal muscles			Bilateral muscle strength, length, tone, coordination, and symmetry	Hypertonicity, tenderness (note quality of pain, e.g. burning, stinging, sharp, etc.) or tension	Modified Oxford Scaleused to assess pelvic muscle strength and endurance and assigndegree of muscle contraction around practitioner's finger159
Pelvic floor (levator) muscles			No tension, scarring, or tenderness	Identify faciitis of levator sling, prolapse, scarring, tenderness, tension, or trigger points	Modified Oxford Scaleused to assess pelvic muscle strength and endurance and assigndegree of muscle contraction around practitioner's finger159
Obturator internus muscles
Urogenital diaphragm			No tension, non-tender	Hypertonicity, tenderness (note quality of pain, e.g. burning, stinging, sharp, etc.) or tension, and/or urinary urgency triggered by palpation
Rectovaginal examination
Anus	Healthy appearing perianal skin	Patulous anus, anal fissure, anal scarring/fibrosis, external/internal hemorrhoid, excoriation, incontinent stool, perianal abscess, radiation changes to the skin such as edema (pitting/non-pitting), erythema, hypo- or hyper-pigmentation or texture (thick/thin, rough/smooth, dry)	Normal anorectal tone; anal wink reflex; grossly heme negative stool	Induration, irregularities or nodules especially along uterosacral ligaments; abnormal anorectal/resting and/or squeeze pressure, palpable lesion, anorectal stenosis, tenderness, changes to skin texture (thick/thin, rough/smooth, dry)	Anoscopy
Rectum
Rectovaginal septum			No evidence of masses, nodules, swelling, tenderness	Presence of masses, nodules, swelling, tenderness or thickness
Abdominal examination
Abdomen**		Presence of hernias, obesity, ostomies, scars or skin changes, radiation changes to the skin such as edema (pitting/non-pitting), erythema, hypo- or hyper-pigmentation or texture (thick/thin, rough/smooth, dry)	Soft, non-tender	Edema (pitting/non-pitting), changes to skin texture (thick/thin, rough/smooth, dry); hepatomegaly, splenomegaly, scars, tenderness, rebound, guarding; suprapubic tenderness or scarring
Functional breast examination
Breast††	Normal size and symmetry, no dimpling, flattening, masses, changes to the skin such as in color or thickening of the skin or pores. Adolescents: note Tanner stage	Presence of breast asymmetry‡‡, capsular contracture (around expander or implant), discoloration (of skin or donor flap), dry/moist desquamation, edema, erythema, fibrosis, hyperpigmentation, induration, lesions, masses, scarring(including hypertrophic or keloid scars), or telangiectasia	Appropriate fullness, non-tender	Disproportionate or asymmetrical fullness, fibrosis, hyperesthesia, induration, lesions, masses, seroma or tenderness
Nipples	Normal size and shape	Absence of native nipple***, presence of asymmetry, contraction, flattening or retraction in reconstructed nipple, any discharge, ulceration		Presence of discharge, loss of elasticity
Axilla	Smooth, no scarring or dimpling	Mass, scarring, cording, dimpling, radiation changes to the skin such as edema (pitting/non-pitting), erythema, hypo- or hyper-pigmentation or texture (thick/thin, rough/smooth, dry)	No palpable lymph nodes, no masses, non-tender	Palpable lymph nodes, masses, tender
Lymph nodes (axillary, supraclavicular)	No visibly enlarged lymph nodes	Visibly enlarged lymph nodes, scar from axillary lymph node dissection	Non-palpable or small, mobile, non-tender lymph nodes, symmetrical	Enlarged, tender, fixed, firm lymph node(s)
Arm	Normal size and shape	Edema	Full range of motion, non-tender	Limited or decreased range of motion, tenderness, lymphedema	Lymphedema can be quantified by measuring the circumference of arm atmidpoint, cubital fossa and midforearm

^*These structures may be surgically absent; the clitoris may be diminished in size and the glans may not be visible even with retraction of the clitoral hood in women on aromatase inhibitors.

^‡Figure 4a.

^§Figure 4b.

^‖Figure 4c.

^**Auscultation of the abdomen is also recommended to assess for normal bowel sounds.

^††Includes mastectomy, mastectomy with implant reconstruction, and mastectomy with autologous tissue reconstruction with or without a flap.

^‡‡Figure 4d.

^***Figure 4e.

Darkly shaded cells indicate where an element is not applicable or specialized testing for sexual function is not needed or available.