Genitourinary History and Examination

Female and male adult genitourinary history and examination will be considered here in detail. Paediatric genitourinary history and examination are referred to and important aspects particular to developing children are outlined. The following account will both list important items as an aide-memoire and provide diagnostic tips and suggestions for history and examination.

There is likely to be an understandable reluctance to give an open and full account of some aspects of the history. The history should be conducted with sensitivity and pursued according to the importance and relevance to any presenting problems.

Menstrual history

• Age at menarche:
  • Average age in the UK is 12 years 11 months
  • There are racial variations
  • Body weight is a factor (average weight at onset 48 kg)
  • If concern about abnormal puberty (precocious puberty, delayed puberty) ask about onset of other secondary sexual characteristics and thelarche (onset of breast development)
  • Consider if relevant causes of primary amenorrhoea:
    • Conditions such as Turner's syndrome if no signs of puberty
    • Consider simple pubertal delay if other signs of puberty
  • Consider if relevant causes of secondary amenorrhoea:
    • Physiological: pregnancy, lactation
    • Psychological: anorexia nervosa, depression
    • Drugs: the contraceptive pill
    • Hormonal causes: pituitary, thyroid and adrenal disorders
    • Ovarian factors: polycystic ovaries, ovarian tumours, ovarian infection
• The pattern of the menstrual cycle. Record:
  • First day of last normal menstrual period (LNMP)
  • Days of blood loss
  • Length of cycle
  • Whether blood loss heavy: number of tampons and/or pads, whether clots present
  • What form of contraception is used.
• The normal menstrual cycle:
  • Range 21 to 35 days and average 28
  • Most healthy, fertile women have regular cycles with 1 or 2 days' variation
  • Blood loss is 50-200 mls and averages 70 mls
  • Guide to loss is use of pads and tampons
  • Passage of large clots suggests excessive bleeding
• Abnormal patterns of bleeding:
  • Polymenorrhoea: unusually frequent periods
  • Oligomenorrhoea: unusually infrequent or scanty periods (common around puberty)
  • Menorrhagia: unusually heavy periods
  • Polymenorrhagia: unusually heavy and frequent periods
  • Intermenstrual bleeding (bleeding between periods):
    • Breakthrough bleeding on the pill
    • Diseases of uterus and cervix
    • Mucosal disorders
    • Postcoital bleeding (usually local cervical or uterine disease)
  • Postmenopausal bleeding: bleeding occurring over 12 months after amenorrhoea of menopause
  • Dysfunctional uterine bleeding:
    • Abnormal bleeding that cannot be ascribed to pelvic pathology
    • Regular pattern suggests ovulation occurring
    • Irregular pattern suggests anovulatory cycles.

Urinary symptoms

• Pain:
  • During or after micturition?
  • Urethral discharge?
• Frequency of micturition:
  • At day and at night
  • Urgency with or without incontinence
  • Incontinence or urinary leakage with coughing or sneezing
• Bladder control: leakage without urgency or stress factors suggests neurological causes.
• Urine characteristics: colour, odour, whether cloudy.

Vaginal discharge

• Ask:
  • How long for?
  • Scanty or profuse?
  • Colour and consistency?
  • Odour?
  • Bloodstaining?
  • Associated symptoms (pain, fever, itching, burning)?
• Common complaint especially before the menopause.
• Physiological discharge:
  • Scanty, mucoid and odourless
  • No pruritus
  • Accentuated by cyclical changes, pregnancy and sexual arousal
• Pathological vaginal discharge is usually heavier and accompanied by pruritus:
  • How heavy?
  • Nature of discharge?
  • Consider infective and non-infective causes

Pain

Genitourinary and gynaecological disorders need to be considered in women with low abdominal pain:

• Dysmenorrhoea:
  • Occurs a day or two before and during menstruation
  • Suprapubic and cramp like (pelvic congestion, then uterine contraction)
  • If severe, consider endometriosis
• Ovulation pain:
  • Suprapubic or unilateral iliac fossa pain
  • Midcycle (mittelschmerz)
• Ovarian cysts:
  • Suprapubic or unilateral iliac fossa
  • Severe pain suggests haemorrhage into a cyst or torsion of the cyst
• Ectopic pregnancy can be a difficult diagnosis but suggested by:
  • Missed period
  • Pain often prior to any vaginal bleeding
  • Shock
• Acute pelvic infection, particularly acute salpingitis, may be accompanied by:
  • Low abdominal pain
  • Vaginal discharge
  • Fever
  • Loss of appetite

Dyspareunia

• Pain on intercourse can have psychological or organic origins.
• Vaginismus or vaginal spasm should be distinguished from pain which occurs after penetration.
• Distinguish between superficial pain suggesting vulval problems (or vaginismus) and deep dyspareunia (suggesting disease of uterus, cervix or adnexa).

Psychosexual history

This needs to be conducted sensitively. It requires experience, knowledge and good clinical judgement to recognise and define underlying psychosexual problems and differentiate them from other causes of symptoms (dyspareunia, low abdominal or pelvic pain for example). A history should include enquiry about:

• Relationship details, including issues of sexuality.
• Intercourse and sexual practices.
• Libido.
• Orgasm.
• Association of other symptoms.

Obstetric history

• Ask whether ever pregnant.
• Record completed and unsuccessful pregnancies.
• Record details of gestation at time of any miscarriages or terminations.
• Complications of pregnancy, particularly:
  • Diabetes mellitus
  • Hypertension
• Complications in labour:
  • Length of labour
  • Any methods of assisted delivery required (forceps, Caesarean section)
• Complications in the puerperium for example:
  • Haemorrhage
  • Depression or mental illness

Preparation for the examination

• Equipment should have been prepared beforehand.
• Taking the history can help establish rapport and help patients prepare for the intrusive examination which may follow.
• Most patients will be prepared for an examination if there symptoms suggest that such examination is likely to be required.
• Nevertheless time should be taken to explain any examination.
• Patients should be warned about discomfort or pain when and if this is likely.
• Ensure comfort and privacy are maintained with basic facilities for undressing.
• Offer chaperones, preferably nurses, who are qualified to assist and reassure the patient.
• Encourage patients to empty the bladder before the examination.

General examination

This should detect conditions which may either present or complicate genitourinary disease. Examples include:

• Hirsutism and/or acne reflecting possible endocrine disorders.
• Anaemia which commonly accompanies menstrual disorders.
• Conditions which are associated with menstrual symptoms:
  • Thyroid disease
  • Cushing's syndrome
  • Anorexia nervosa
  • Other chronic diseases
• Breast examination.
• Lymphadenopathy, especially inguinal nodes.
• Assessment of secondary sexual characteristics.

Abdominal examination

The uterus, vagina and adnexa lie within the pelvis but findings relevant to the genitourinary system may be visible, palpable and percussible in the abdomen. Careful abdominal examination may detect:

• Abdominal masses arising from the pelvis:
  • Large ovarian cysts can be detected by abdominal percussion revealing central dullness.
  • Pregnancy (often used to equate the size of other pelvic tumours):
    • 12 weeks - palpable above pubic bone
    • 16 weeks - palpable midway between pubic bone and umbilicus
    • 20 weeks - just below umbilicus
    • 28 weeks - just midway between umbilicus and xiphisternum
    • 34 weeks - just below xiphisternum
• Ascites: percussion reveals lateral dullness and a tympanic central abdomen.

Examining external genitalia

Prepare for examination:

• Position patient with help of chaperone on to the couch (supine, flexed hips and knees with heels together, thighs abducted).
• Cover abdomen with sheet.
• Position lighting to give clear view of external genitalia.
• Put on disposable gloves.

Examination of the vulva

• Explain the procedure to the patient.
• Systematically examine labia majora, labia minora, introitus, urethra and clitoris.
• Bartholin's glands are not normally palpable.
• Assess atrophic changes in the menopause and in pubertal development in teenagers.

Examination of the vagina

• At this point it is appropriate to assess whether further examination (both digital and speculum) is appropriate or possible. If the patient has an intact hymen and is not using tampons then further internal examination would be inappropriate.
• The practice of rectal examination to assess the genitalia indirectly (although technically possible) is rarely necessary or appropriate. It should not be performed in children. The advent of ultrasound makes such an intrusive procedure unnecessary.
• Separation of the labia and asking the patient to 'bear down' allows the examiner to visualise the vestibule and to identify:
  • Cystocoele
  • Rectocoele
  • Uterine descent or prolapse

Examination of the cervix

• Full yet concise explanation should again be offered.
• Further vaginal and cervical examination is achieved using a speculum.
• The speculum also allows access for swabs and the taking of cervical smears. If samples are to be taken, lubricant other than tepid tap water should be avoided.
• A bivalve or Cusco's speculum is usually used. The lateral position and alternative speculum may be used further to assess prolapse.
• Position of the cervix relates to uterine position (anteverted, axial or retroverted).
• Cervical os relates to whether the patient is parous or not.
• The cervix may be bluish in early pregnancy (Chadwick's sign).
• Although the squamocolumnar junction can be visualised, cytology is necessary to diagnose and exclude cervical cancer.
• Taking of cervical smears and swabs should be in accordance with local laboratory guidelines and instructions.
• The speculum should be removed carefully and without discomfort to the patient.

Internal examination of the uterus

Offer explanation of the bimanual examination required to examine the uterus, Fallopian tubes and ovaries internally.
• Expose introitus holding apart labia with gloved hand.
• Introduce lubricated right index and middle fingers.
• Palpate using abdominal and right hand.
• Identify cervix, uterus. Right and left adnexa are not normally palpable.
• Assess size, consistency and mobility of organs felt. Identify tenderness.
• In pregnancy the cervix softens (Hegar's sign).
• Cervical excitation may occur with infection or inflammation of either uterus or adnexa.
• Discuss findings in more detail when the patient is dressed and prepared to take in information.

Care should again be taken to ensure privacy and comfort for both history and examination. Establish confidence and rapport. Allow the patient to describe their complaint or problem. It may again be appropriate and necessary to ask details about sexual and psychosexual history. Specific questions may be appropriate. Significant symptoms are described below.

Urethral discharge

A relatively common presenting symptom. Ask about:

• Dysuria.
• Possible exposure to sexually transmitted diseases:
  • When was contact?
  • Has partner had symptoms?
  • Any other symptoms (for example with Reiter's syndrome):
    • Joint pains
    • Eye inflammation, pain or grittiness
    • Gastrointestinal symptoms

Testicular pain

This can be an intense pain. Enquiry should be made about:

• Trauma.
• Speed of onset.
• Association with other conditions (for example mumps).
• Other urinary symptoms, such as dysuria or urethral discharge.
• Possible causes include trauma, infection, torsion and epididymitis.

Genital ulcers

Sexually transmitted disease is likely. Enquiry should be made with this in mind.

Impotence

Impotence covers a number of different conditions and causes. Consider:

• Emotional and psychological factors.
• Drugs and alcohol.
• Any association with other relevant diseases (diabetes mellitus, neurological disease, cardiovascular disease).
• Whether there is:
  • Loss of libido
  • Erectile failure

Infertility

This may be primary (no conception) or secondary (past conception). History should cover:

• Conception history.
• Length of infertility.
• Sexual history:
  • Timing and frequency of intercourse
  • Impotence and ejaculation
• Medication history.
• Medical history:
  • Conditions affecting erectile function
  • Any chemotherapy or cancer treatment
• History of sexual development.

Urinary symptoms

The history should cover the following questions (it is possible to use scoring systems to assess these symptoms):

• Dysuria?
• Frequency of micturition?
• Any terminal dribbling of micturition?
• Hesitancy of micturition?
• How full is the urinary stream?
• Have symptoms developed gradually or suddenly?

The genitourinary examination should incorporate a general examination and an abdominal examination. Such brief examination should assess:

• General sexual development and secondary sexual characteristics.
• Gynaecomastia.
• Evidence of liver disease, thyroid disease.
• Hernias and hernial orifices.

The male genitalia are more accessible for examination.

Penis

The size and shape variation of the normal penis is quite wide. Examination should involve inspection and palpation of:

• Prepuce.
• Glans.
• Skin (looking for ulcers, rashes).
• Shaft of penis (for plaques of Peyronie's Disease).
• Urethral discharge.

Scrotum

• Inspect scrotal skin.
• Palpate testes.
• Identify scrotal swellings:
  • Is it possible to get above the swelling?
  • Is the swelling solid or cystic?
  • Is there a hydrocele, varicocele or epididymal cyst?
• Examine groin and lymphatics

Prostate

This is examined by rectal examination to assess:

• Size.
• Consistency.
• Any swelling.
• Presence of the medial sulcus.
• Any tenderness.

This should involve parents and be done sensitively and carefully. Genitourinary disease in children is more varied and complex (for example ambiguous genitalia) than in adults. In general medical practice the history will usually focus on presenting complaints but, in babies particularly, will involve screening for disease as well. Some of the history overlaps with that for adults but an understanding of normal growth and development, particularly of normal pubertal development, is essential in paediatric practice. Child abuse may present with genitourinary symptoms. The issue of Gillick competence may be relevant when examinations are undertaken without parental consent.

Again this will be conducted with a good understanding of normal growth and pubertal development. Sensitive handling is essential and, broadly speaking, intrusive and intimate examinations are rarely appropriate. Ultrasound and other investigative techniques can now be used to assess internal organs. Inspection is often all that is required.