Male and Female Genitourinary and Breast Assessment Guide

Clinical Assessment Techniques

When collecting subjective data, utilize the "5 P's" to ensure a comprehensive sexual history: Partners, Practices, Protection, Prevention of pregnancy, and Past history of STIs. Additionally, screen for urinary symptoms such as dysuria, frequency, urgency, nocturia, hesitancy, and straining.

During the physical exam, inspect the penis for color, lesions, and discharge. In uncircumcised patients, the foreskin should be retracted to check for smegma (which should be wiped away and documented). When inspecting the glans, compress it to check for urethral discharge.

For the scrotum, slight asymmetry of the testes is considered normal. If a mass is palpated, perform transillumination to help differentiate whether the mass is cystic (transilluminates) or solid.

Exam Tip: Lymph Node Palpation Always palpate the inguinal lymph nodes (both vertical and horizontal chains). Abnormal findings include nodes that are enlarged, hard, matted, or fixed.

Health Promotion: Testicular Self-Examination (TSE)

While not strictly mandated by all guidelines, many patients utilize Testicular Self-Examination (TSE) to identify changes. Use the TSE mnemonic for patient education:

• T — Timing: Perform once a month.
• S — Shower: Use warm water to relax the scrotum.
• E — Examine: Check for lumps or changes and report them immediately.

Female Genitourinary Assessment

Anatomy and Developmental Considerations

The female GU system involves complex hormonal influences that change throughout the lifespan.

• Infancy: Maternal estrogen can cause engorged genitalia and breast tissue in newborns. It is also common to see pseudomenses, which is a normal blood-tinged vaginal discharge in infants.

• Adolescence: Pubic hair development typically begins around ages 8–10, followed by axillary hair and menarche (the start of menses). Irregularity in menstrual cycles is common during this stage. Tanner staging is again used to monitor sexual maturity.

• Pregnancy: The growing uterus displaces other organs. Increased cervical and vaginal secretions are common, which can increase the risk of candidiasis (yeast infection).

• Ambiguous Genitalia: Clinicians should be aware of intersex variations, which occur in approximately 1–2% of the population.

Clinical Assessment Techniques

For a female GU exam, the patient should be placed in the lithotomy position. Ensure the patient has emptied their bladder and emphasize privacy and consent.

1. Inspection: Assess the external genitalia for color, symmetry, hair distribution, and any lesions or discharge.
2. Palpation: Palpate the posterior labia majora at the 5:00 and 7:00 positions to assess the Bartholin glands; they should be soft and nontender.
3. Speculum Exam: Used to inspect the cervix and vagina. The cervix should appear pink, smooth, and nontender.
4. Bimanual Exam: This involves inserting two fingers into the vagina to press up on the cervix while palpating the abdomen with the other hand. The cervix should be round and firm, and the uterus should be smooth, firm, and midline.

Rectal Assessment

While the provided materials focus heavily on the GU systems, the learning objectives emphasize that a comprehensive assessment includes the rectum. In clinical practice, this involves inspecting the perianal area for symmetry, skin integrity, and any lesions or hemorrhoids, followed by palpation to assess sphincter tone and the rectal mucosa.

Breast and Axillae Assessment

Though often categorized separately, breast assessment is frequently integrated into female GU exams due to shared hormonal and anatomical considerations.

Developmental and Aging Changes

• Adolescence: Estrogen stimulates thelarche (breast development) around age 9–10. Temporary asymmetry and tenderness are normal. In males, gynecomastia (benign breast enlargement) may occur temporarily during puberty.
• Pregnancy: Breasts enlarge, become more nodular, and nipples may darken. Colostrum may be present mid-pregnancy.
• Menopause: Decreased hormones lead to breast tissue atrophy (causing a drooping appearance) and increased tissue density (calcification).

Clinical Inspection and Palpation

When inspecting the breasts, observe the patient in various positions (sitting, hands on hips, leaning forward) to check for symmetry and ensure the breasts move without fixation to the chest wall. Watch for abnormal skin changes like dimpling or peau d'orange (an orange-peel texture).

During palpation, use the pads of the fingers in a circular motion (light, medium, and deep) using either the overlapping strip method or the pinwheel method. Always palpate the axillary, supraclavicular, and infraclavicular lymph node chains.

Documentation Tip: Describing a Mass When documenting a breast mass, always include:

1. Location: Use the clock method and distance from the nipple.
2. Size and Shape: Approximate dimensions.
3. Consistency and Mobility: Is it soft, firm, or hard? Is it movable or fixed?.
4. Pain: Note if it is tender or nontender.
5. Associated Changes: Note any skin dimpling or lymphadenopathy.