GENITO-URINARY SYSTEM

History taking &physical examination

Dr.Abdulkadir Woliyi , MD
May,2011
Female Reproductive Anatomy
 External genitalia: includes Mons pubis, L.minora
& majora , clitoris , vulvovaginal glands , forchute
and perineum
inspected and palpated for developmental
abnormalities ,skin lesions(ulcers , plaques,
excoriations…),masses , evidence of
trauma and infection
Cont...
Bartholin’s and paraurethral glands

Bartholin gland openings are located at 4 and 8 o’clock

out side hymeneal ring, not usually visible and not palpable
when healthy
paraurethral glands (skenes glands) are adjust to distal
urethra, open in to urethra, when inflamed become enlarged and
tender , express exudates
Cont…

►Vagina :flattened tube extending from introitus

up to fornices that surround cervix
inspected using appropriately sized speculum
for vaginal discharge(color , odor , consistency..)
vaginal wall relaxation , uterine prolapse

►Uterus –has 2 parts : body and cervix joined by isthmus

►Adnexia – ovaries , tubes , supporting strs
Gynecologic and obstetric history
☻General points
►gathering of relevant information by observation ,
questioning , examination
►gentleness of manner and genuine interest needed
►adequate time should be allowed
►practice open ended question
►obtain hx in relaxed and private setting
►proceed from straight forward to more delicate
issues such as dyspareunia..
Basic History
 The basic information required by the gynecologist
consists of the following:
 Menstrual history
 Sexual history
 Obstetrical history (parity,gravidity,LNMP,labor
pain,passage of l.amini,bleeding per
vagina,screening,ANC follow up,danger sign ,medical
hx , past obstetric hx)
 Type of contraception, past and current (if appropriate)
 Papanicolaou (Pap) smear history: date and result of
last smear; diagnosis and follow-up of abnormal Pap
smears
Cont…

History of gynecologic procedures (e.g., endometrial

biopsy, laparoscopy, curettage): date; diagnosis;
treatment; and complications
 History of pelvic, vaginal, or vulvar infections:
diagnosis; frequency; and treatment
 Review of symptoms focusing on the genitourinary
areas
 History of other gynecologic problems, such as
infertility, endometriosis, or polycystic ovarian
syndrome, and their treatments
Problem Focused History

♦ Menstrual hx:
_ age of menarche,
_ frequency,interval,amount
_ menorrhagia,mertorrhagia,polymenorrhia,
dysmenorrhia,amenorrhea
♦ Vaginal discharge
Normal:mucoid endocervical secretions in
combination with desquamated vaginal wall
epithelium and normal bacteria
Cont…

Volume : varies among women and timing in menstrual cycle

Abnormal : malodorous,burning,pruritic,painful,bloody
e.g. trichomonas : greenish yellow purulent discharge
candidiasis : thick white cheese like discharge
vaginosis : fishy smelling ,gray discharge
♦Pelvic pain
- location, onset , duration , quality, and severity
r/n ship of pain to menses , physical and sexual activity
Cont…

-Response to analgesics,hormonal contraceptives, or position

-associated GI or urinary sx

♦Abnormal uterine bleeding

Bleeding is abn when it’s associated with a change in woman’s normal menstrual
period pattern or occurring after menopause

♦Dyspareunia:pain during sexual intercourse

superf : due to vulvitis
deep : endometritis,PID
Cont…

♦ Genital Ulcer
-sexual hx (gender of sexual contact ,freq, site,use
of condom , past hx of STD)
painless ulcers : syphilis,LGV , granuloma inguinale
painful ulcers : HSV,chancroid,trauma
♦ Infertility:
-a couple is infertile after 12 mothns of
unprotected sexual intercourse
-hx on frequent intercourse during the middle of
menstrual cycle
Cont…
♦Mass protruding from introitus
UVP , cystocele…
♦Urinary incontinence
- Involuntary loss of urine
- ask about hx of UTI, diuretic use , volume & timing
of fluid intake,
- stress incontinence : leakage with physical
activity(excercise , lifting ,coughing , sneezing..)
-detrusor instability:urge to void before reaching
toilet
Cont…

♦ Sexual assault and sexual function

♦ Current and previous pregnancies

▪ whether px is wanted, planned or supported
▪ parity , gravidity
▪ date of LNMP
▪ menstrual pattern before px
▪ use of contraceptives
▪ out come previous px (live birth , still birth ,
neonatal death…)
Cont…

♦ Medical back ground

diabetes ,transfusion hx , medication ,
surgery , alcohol , smoking,
♦ Family and Social hx
employment , family hx of cancer ,
congenital abn
Physical Examination
 Conditions for Pelvic Examination
→Privacy and confidentiality
→Make her relaxed
→Tell her what you are going to do
→Adequate light source
→Positioning(dorsal lithotomy,
→Empty the bladder
Cont….

→Female assistant(chaperone)
→Instrument (speculum…
→Should be in non threatening process and
sequential(hands-arms –eyes-head-
chest- breast- abdomen-legs-pelvic exam.)
Cont…
 Pelvic Examination

Four components
1.Examination of external genitalia
2.Speculum exam.
3.Digital vaginal exam.
4.Bimanual pelvic exam.
Cont…

Indications for a pelvic examination during

adolescence include
 Menstrual abnormalities such as amenorrhea,
excessive bleeding, or dysmenorrhea,
 unexplained abdominal pain, vaginal discharge,
the prescription of contraceptives,
 bacteriologic and cytologic studies in a sexually
active girl, and
 the patient’s own desire for assessment.
Cont…

Examination of External Genitalia

Inspection and palpation
•Pubic hair pattern
masculine- diamond, feminine- inverted triangle
infected hair follicle
•skin of vulva
mon’s pubis , perineal area for dermatitis , discoloration,
ulcers , swelling e.g, tumors
•L.majora & minora
ulcers , swelling e.g. condylomata accuminata
 Cont…
•Urethral orifice
same color as surrounding skin
milk for any discharge
•bartholins gland area
swelling , tenderness (cyst , abscess, ca)

•Hymen
rupture before birth , imperforate ( pathological )
septate, microperforate , cribriform , annular
•Check for perineal support
open the labia with two fingers, ask the pt to strain
cont…

Speculum exam
Types : pederson (bivalve)speculum,
Sims speculum
others Ferguson's speculum
The following should be documented
vagina _ color , cong. Anomalies , rugae , fornices,
discharge scars lacerations…
cervix: _ color , os , erosions, scars ,
mass , discharge ,bleeding
obtain specimen for cervical cytology
speculum
Digital Vaginal Exam
 The pt should be on supine with knees drawn up and separated
 Labia are gently parted with index finger and thumb of left hand
 insert index finger of rt hand in to vagina
 insert middle finger of the same hand

Important for exam. of

▪ vaginal masses , tenderness or stenosis
▪ fornices
▪ cervix_ consistency : normal like tip of nose
malignancy : firm to hard
motion tenderness,position,regularity,
Bimanual Pelvic Exam.
 Index and middle finger of dominant hand are used
to examine the vagina & uterus , elevating them
 Abdominal hand used to sweep the pelvic organs
down wards
 To delinate the uterus &adnexea
 Factors such as obesity , other pelvic abns ,
examiner's experience affect exam. Of ovaries and
adexea
 cervix : nose tip consistency , close external os ,
smooth surface,2-4 cm moved in all direction
Cont…
 Uterus : L=9cm ,w=7cm,d=2cm,wt=70-90gm(non pregnant)
 anteverted & anteflexed ,
retroverted & retroflexed(20%)
non tender , mobile in all direc , smooth surface,
firm consistency

 Ovaries : palpable in reproductive age , not palpable in obse

and post menopausal
 Adnexae : for masses , tenderness
Cont…

Assess strength of pelvic muscles

ask the pt to squeeze against your fingers on lateral walls
of vagina , as hard & as long she can,>3sec=full strength
impaired strength: age , vaginal deliveries, neurologic
deficits
associated with urinary stress incontinence
Rectovaginal Examination
 Reintroduce your index finger into the vagina &middle finger
in to the rectum
 Cul-de-sac , uterosacral lig,to asses retro displaced uterus &
adnexea in virgins ,rectal tumors ,hemorrhoids , ocult blood
Abdominal Examination in pregnancy

 Inspection(straie
gravidaruml.nigra,scars,fetal mov’t)
 Palpation(fundal height,fetal
poles&lie,presentation,)
 Auscultation(FHB)
Male genitalia history

 Common or concerning symptoms

▪penile discharge or lesions
▪scrotal pain , swelling, or lesions
▪sexual function and,
response:arousal,organsm
ejaculation
Male Genitalia Examination

 Inspection & palpation

Penis- skin , prepuce , glans (size,scratch,ulcer,),
urethral meatus , position(hypospadia,epispadia),
phimosis , paraphimosis
compress glans for discharge
chronic urethral discharge
scrotum: scratch,ulcers,swelling
painful: epididimorchitis , torsion,strangulated hernia
painless: testicular tumor , hydrocele
Cont…

Testis: shape,consistency,tenderness,swelling
hydocele,tumor,filariasis,hernia,varicocele
spermatid cord
varicocele,thickened vasdeference
Hernias
inpect inguinal,femoral ,scrotal areas for bulges
ask the pt to stain down
palpate
direct,indirect,femoral hermnias
THANK YOU