Despite the increasingly widespread use of imaging of the urinary tract, a thorough history and examination is essential in the assessment of all patients presenting with genitourinary symptoms.

The presentation must be assessed in the context of the age, gender, and the past medical, gynaecological and surgical history of the patient. Urinary symptoms may not be indicative of urological abnormality but may have other causes such as neurological disease, diabetes or even anxiety.

The following account will both list important items as an aide-mémoire and provide diagnostic tips and suggestions for history and examination.The separate partner article Genitourinary History and Examination (Male) covers detail specific to male patients. Paediatric genitourinary history and examination are referred to and important aspects particular to developing children are outlined.

Female genitourinary history

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 there is concern about abnormal puberty (precocious puberty, delayed puberty) ask about onset of other secondary sexual characteristics and thelarche (onset of breast development)
  • Consider if there are 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 there are 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 was heavy: number of tampons and/or pads, whether clots were present
  • What form of contraception is used.
• The normal menstrual cycle:
  • Range is 21 to 35 days and average is 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 the 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?
  • Blood staining?
  • 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 noninfective 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
  • Mid-cycle (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 is suggested by:
  • Missed menstrual 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 the 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

Other symptoms

• Loin pain; urinary calculi can cause ureteric obstruction and lead to severe loin pain which radiates to the symphysis pubis or testis. The sudden onset of pain in renal colic or acute urinary retention contrasts with the gradual build-up of pain from a renal tumour or the slow development of urinary symptoms from outflow obstruction. Ask about associated features such as pain, haematuria or incontinence.
• Urinary incontinence; may be stress incontinence, detrusor instability, detrusor underactivity or urethral obstruction.
• Urethral discharge may occur as a result of a sexually transmitted disease.
• Systemic symptoms of acute renal failure or chronic renal failure, e.g. anorexia, vomiting, fatigue, pruritus and peripheral oedema.
• Some patients have no symptoms but abnormalities are discovered on measuring blood pressure or abnormalities on routine urinalysis, renal function or serum biochemistry.

Occupational history

• Exposure to chemical carcinogens such as 2-naphthylamine or benzidine in the chemical or rubber industries may induce bladder cancer many years later.

Foreign travel

• Travel to Egypt or Africa may result in exposure to schistosomiasis.
• Dehydration during a holiday in a hot climate may lead to the development of renal stones.

Family history

• A family history of renal failure or polycystic kidney disease may be relevant to the underlying problem.

Past medical history

• Neurological diseases may cause abnormal bladder function, e.g. Parkinson's disease, multiple sclerosis or cerebrovascular disease.
• Any history of renal disease, hypertension, diabetes, gout or past back injury may also be relevant. Abdominal or pelvic surgery can cause denervation injury to the bladder.
• Previous surgery, e.g. for urinary incontinence.
• Ureteric injury may occur in abdominal or gynaecological operations.

Medication history

• A full current and past medication history is important.
• Past history of analgesic abuse may be a cause of renal failure.
• Dosages of some drugs may need to be adjusted or stopped in renal failure.

Obstetric history

• Stretching of the pelvic muscles during pregnancy can cause stress incontinence.
• Problems with vaginal delivery or a forceps delivery may damage the perineum causing urinary symptoms.

Female genitourinary examination

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

Examining external genitalia

Prepare for examination:

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

Examination of the vulva

• Explain the procedure to the patient.
• Systematically examine the 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:
  • Cystocele
  • Rectocele
  • 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 the labia apart with a gloved hand.
• Introduce lubricated right index and middle fingers.
• Palpate uterus between abdominal (left) hand and internal (right) hand.
• Identify the cervix and uterus. The 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 the uterus or adnexa.
• Discuss findings in more detail when the patient is dressed and prepared to take in information.

The genitourinary history and examination in children

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. Developmental aspects may be important in both the history and examination. Aspects of this are covered in other separate articles - for example, Puberty - Normal and Abnormal, Paediatric History and Paediatric Examination.

History

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.

Examination

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 - more detailed examination is best done by paediatricians - and it may be better left to them so the child is only examined once.

Internet and further reading

• Manufacturer's PIL, Ocufen Eye Drops®, Allergan Ltd, electronic Medicines Compendium. Dated July 2008.
• Standards for the management of sexually transmitted infections, British Association for Sexual Health and HIV (2010)