Genitourinary Assessment: An Integral Part of a Complete Physical Examination

Article Outline

• Abstract
• Focused History
• Focused Examination
  • Preparation for the Examination
  • Inspection
  • Palpation
  • Pelvic examination
  • Suspicion of Sexual Abuse
• Case Studies
  • Case One
  • Case Two
• References
• Biography
• Copyright

Abstract 

This article provides primary care providers, including pediatric nurse practitioners, with a framework for completing a genitourinary assessment. Many primary care providers are reluctant to examine the genitalia of their patients. Routine genital examinations increase diagnostic skills, provide a baseline for future examinations, may improve parent and child compliance with the examination, and may reveal previously undiscovered anomalies or trauma. An assessment of the reproductive and urologic systems should begin with obtaining a focused history from the parent from birth to present. Techniques for performing a focused genitourinary examination will be discussed.

Physical assessment of the genitourinary system can be a challenge for the pediatric primary care provider. Many primary care providers, including pediatric nurse practitioners (PNPs), are reluctant to examine the genitalia of their patients. Hornor and McCleary (2000) found that only 67% of PNPs surveyed stated that they examine the genitalia of their prepubescent female patients at routine physical examinations more than 50% of the time. Physician studies by Ladson, Johnson, and Doty (1987) and Lentsch and Johnson (1999) indicated that 77% and 72% of physicians surveyed stated that they examined the genitalia of prepubescent females at routine physical examinations more than 50% of the time.

The value of routine genital examinations at the time of well-child physical examinations has been documented and should be performed by all primary care providers, including PNPs, at every routine physical examination. Routine genital examinations increase diagnostic skills, provide a baseline for future examinations, may improve parent and child compliance with the examination, and may reveal previously undiscovered anomalies or trauma (Johnson, 2002).

Health care providers’ ability to correctly recognize normal prepubescent female genitalia is questionable. Fewer than two thirds of physicians, chief residents, and PNPs were able to correctly identify the hymen from a photo (Dubow et al 2005, Hornor and McCleary 2000, Ladson et al 1987, Lentsch and Johnson 1999). See Table 1 for an illustration of percentage of providers who correctly identified prepubescent female genitalia.

TABLE 1. Percentage of providers who correctly identified genitalia

Data from Dubow et al 2005, Hornor and McCleary 2000, Ladson et al 1987, Lentsch and Johnson 1999.

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Focused History 

The PNP should begin an assessment of the reproductive and urologic systems by obtaining a focused history from the parent/guardian from birth to present. Parents should be questioned by the PNP regarding any genitourinary abnormalities noted at birth or any urinary difficulties in the first 24 hours of life (see Table 2). Any past genitourinary complaints also should be noted by the PNP (see Box 1).

TABLE 2. Congenital anomalies and indications for referral

Data from Gillenwater et al 2002, Potts and Mandleco 2002.

A review of the current health of the child must be completed by the PNP, including a list of current medications. The PNP should assess vital signs, noting that blood pressure often is elevated with nephritis and nephritic syndrome (Burns, Brady, Dunn, & Starr, 2004). Height, weight, and body mass index are measured, with the PNP understanding that failure to thrive can be associated with urinary tract infections in infancy and increased weight can be associated with nephritic syndrome (Burns et al.). Ear position and formation must be noted by the PNP, because low-set or abnormal ears may be an indication of renal disease (Burns et al.).

The PNP should obtain a detailed family history, including a history of congenital anomalies in a close relative. A family history of urologic or reproductive disease should be explored by the PNP.

A discussion regarding social history and habits related to the genitourinary system should occur between PNP and parent. Explore toilet training, specifically noting the age it was initiated and completed. The PNP should determine if enuresis is present and note the frequency of enuresis, time of occurrence, and methods used to control enuresis (Mercer, 2003). The presence of any unusual behaviors associated with urination, such as purposefully urinating in inappropriate places or refusing to urinate in the toilet, should be explored by the PNP.

Discussion between the PNP and patient/family should include sexuality and sexual behaviors. The issue of sexual abuse should be addressed by the PNP. Sexual abuse is defined as any sexual act, including pornography, involving a child who is unable to give consent (Adams, 1996). Explore parental concerns of sexual abuse, a family history of sexual abuse, exposure to known sexual perpetrators, previous disclosure by the child of sexual abuse, or exposure to pornography or adults engaging in sexual behavior (Hornor, 2002). Questions the PNP can ask the child to elicit information regarding sexual abuse include the following: Do you have parts of your body that no one is supposed to look at, touch, kiss, or tickle? What do you call those body parts? Has anyone ever touched, tickled, kissed, or hurt those body parts?

The PNP should discuss sexual behaviors with the parent/guardian. Sexual behaviors in prepubertal children that are considered common, normal behaviors versus of concern for sexual abuse/or psychological disorder are summarized in Table 3. The PNP must discuss consensual sexual activity with adolescents, including the age of sexual partners, number of partners, sex of partners, utilization of “safe sex” practices, and birth control.

TABLE 3. Sexual behaviors in prepubertal children

Data from Hornor, 2004.

The PNP should explore genital care practices with the parent/guardian. See Box 2 for questions to elicit information regarding genital care practices. The PNP must evaluate whether the practices are age appropriate or indicate unnecessary emphasis on genital care.

Male circumcision should be discussed by the PNP. Parents should be given accurate information regarding circumcision and be provided the opportunity to discuss potential benefits and risks (American Academy of Pediatrics, 1999). The American Academy of Pediatrics recommends the use of analgesia to decrease procedural pain associated with circumcision. Schoen, Wiswell, and Moses (2000) discussed the potential health benefits to circumcision, including prevention of penile cancer, local infection, phimosis, and urinary tract infections in the first year of life. Circumcision also decreases the risk for human immunodeficiency virus infection and other sexually transmitted diseases such as chancroid and syphilis (Alanis & Lucidi, 2004).

The PNP should obtain a menstrual history from pubescent females, including age of onset, regularity, duration, amount of flow, dysmenorrhea, and last menstrual period. Methods utilized to relieve menstrual discomfort should be addressed.

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Focused Examination 

Preparation for the Examination 

A genitourinary examination must begin with preparing the patient and family for the examination. Explain the genital examination to the patient and family. The PNP should understand that pre-adolescents and adolescents may be embarrassed and apprehensive regarding the examination (Elford & Spense, 2002). Younger children need to be reminded when it is permissible and not permissible to allow someone to touch their genital area. A calm, matter-of-fact attitude must be maintained by the PNP. Allow the parent or guardian in the examination room with younger children, and allow older children and adolescents to decide if they would like their parent present for the examination. Older children and adolescents should be allowed to choose the sex of their examiner if possible. Children and adolescents should be examined by the PNP in supine position on the examination table; young children may be examined in a semi-reclining position on their parent’s lap. Universal precautions should be utilized: wear gloves for the genital examination.

Inspection 

When examining a boy, the PNP should first note the appearance of the male genitalia (see Figure 1). The PNP must inspect the penis for bruising, swelling, erythema, lesions, rashes, or other irregularities; note if penis is circumcised. Typically, in uncircumcised infants and young children, the foreskin is normally tight and not retracted during physical examination until approximately 6 years of age. The uncircumcised foreskin or prepuce should be gently retracted if the child is older than 6 years. Never forcefully retract the foreskin; doing so may damage tissue and cause adhesions between the foreskin and the glans. The PNP also should examine the urethral meatus for location and presence of discharge; observe strength and direction of urinary stream if possible. The size and position of the scrotum and testicles should be inspected by the PNP, noting the Tanner stage of male sexual maturation (see Box 3). The amount and distribution of pubic hair, size of the penis, and development of the testicles and scrotum are inspected by the PNP when determining Tanner stage development. Typically, first testicles and scrotum begin growing, then pubic hair develops, and finally the penis enlarges.

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• FIGURE 1. 

  Male genitalia. This figure is in color online at www.jpedhc.org.

Male genital abnormalities that require referral to urology include the following: testicular torsion, that is, twisting of the testicle on its spermatic cord, causing sudden onset of acute unilateral scrotum pain (immediate referral); phimosis, that is, tightening of foreskin that prevents its retraction over the glans penis (if severe, this condition may require circumcision); and a penile/scrotal mass or nodule.

The examination of a female begins with the PNP noting the appearance of the female external genitalia (see Figure 2). The PNP should inspect the mons pubis and labia for color, size, symmetry, bruises, lesions, and rashes. Next, the PNP should separate the labia and using traction pull toward the examiner to reveal the clitoris, labia minor, posterior fourchette, urethral meatus, hymen, and vaginal orifice (see Box 4). A pen light or otoscope light can be used to provide illumination. The PNP must note any bruises, lesions, rashes, discharge, swelling, or other irregularities and document any inability to visualize structures within the vestibule due to labial adhesions. It is vital for the PNP to inspect the posterior rim of the hymen from 3 to 9 o’clock with an understanding of normal anatomic variations of the prepubertal hymen: crescentic (hymenal tissue absent for 11 to 1 o’clock); annular (hymenal tissue present from 12 to 12 o’clock); and redundant or fimbriated (hymenal tissue that folds onto self, opening may be difficult to visualize) (Heger et al, 2002). The hymen may be smooth and delicate or have shallow notches and/or bumps, which are variations of normal. The prepubescent hymen is sensitive to touch; the slightest touch is very uncomfortable for the patient. The hymen changes during puberty because of the release of estrogen, becoming thickened, redundant, moist, and dull or pale in color (see Figure 3 and compare with Figure 2 to contrast a pubertal and prepubertal hymen). Also, the pubescent hymen is no longer sensitive to touch and can be palpated with a cotton applicator during inspection without causing the patient discomfort.

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• FIGURE 2. 

  Prepubertal female genitalia including hymen. This figure is in color online at www.jpedhc.org.

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• FIGURE 3. 

  Estrogenized (pubertal) hymen. This figure is in color online at www.jpedhc.org.

Hymenal variations that require referral to gynecology include microperforate (abnormally small opening), cribiform (multiple small openings), septate (band of tissue present in opening creating two hymenal openings), and imperforate (no visible opening). An imperforate hymen requires a simple hymenotomy at the time of diagnosis. Hymenotomy may be required for microperforate, cribiform, and septate hymen prior to tampon usage or sexual intercourse. Characteristics of any vaginal/urethral discharge or bleeding should be noted by the PNP. The Tanner stage of female sexual development should be observed (see Box 3). Initially no pubic hair is present; then, as puberty is beginning, soft downy hair, straight hair, or slightly curly hair develops along the labia majora. As sexual maturity progresses, pubic hair becomes more coarse, darker, and curly and spreads to the mons pubis and then to the thighs.

The PNP should inspect the urethra of both males and females for the presence of prolapse, the protrusion of the urethral mucosa beyond the meatus (Shurtleff & Barone, 2002). Refer the patient to urology if the prolapse persists. The PNP should visualize the inguinal area and note any change in contour and symmetry. A small bulging over the femoral canal may indicate a femoral hernia in a female. A bulging in the inguinal area may indicate an inguinal hernia in a male.

Palpation 

The PNP should palpate the inguinal area in boys and girls for lymph nodes and other masses. A localized infection could result in tenderness, heat, or inflammation in palpated nodes.

Palpation of the kidney is difficult because of its deep position within the abdominal cavity. The tip of the right kidney is normally palpable on inspiration. The bladder may be palpated slightly above the pubic symphysis in infants and young children. Palpation of the male genitalia includes palpating the penile shaft for nodules or masses, palpation of the scrotum for the presence of testicles (see Box 5), and palpation of the spermatic cord for tenderness, masses, or swelling (Ball & Bindler, 2003). Female genitalia typically are not palpated on examination.

Pelvic examination 

Pelvic examinations typically are performed only on pubescent females. Indications include irregular vaginal bleeding, complaints of unexplained abdominal or pelvic pain, severe dysmenorrhea, amenorrhea, consensual sexual activity with a vaginal discharge, and sexual assault/abuse with unexplained vaginal bleeding. A concern of possible sexually transmitted infection also is an indication for a pelvic examination, and testing should include cervical cultures for chlamydia and gonorrhea (GC) as well as a wet prep for trichomonas, bacterial vaginosis, and candida.

Nonsexually active adolescents should begin routine pelvic examinations at age 21 years (American Cancer Society, 2002). Sexually active adolescents should have a pelvic examination, including a Papanicolaou smear and testing for sexually transmitted diseases, within 3 years following the onset of sexual activity and then yearly. More frequent indications for pelvic examination include changes in sexual partners, vaginal symptoms, exposure to or a history of a sexually transmitted disease, or engaging in high-risk sexual behaviors.

When contemplating the necessity of pelvic examination, always remember to perform the least invasive examination to answer the clinical question. Speculum examinations for a nonsexually active adolescent can be very uncomfortable and should be performed only when absolutely necessary. A nonsexually active adolescent with a vaginal discharge should have cultures obtained by touching the vagina with a cotton-tipped applicator without the use of a speculum.

It is important to remember that some parents and adolescents fear that the speculum will alter virginity. The PNP should reassure parents and patients that a properly performed speculum examination will not alter the hymen.

Prior to performing the pelvic examination, the PNP should explain the procedure to the patient, utilizing a diagram and showing the patient the speculum. A Huffman speculum (1/2 × 4½ inches) is utilized if hymenal opening is small (Heger et al, 2002). For a sexually active adolescent a Pederson speculum (7/8 × 4 ½ inches) or occasionally a Graves speculum (1 3/8 × 3 ¾ inches) is appropriate (Heger et al., 2002). A plastic speculum with an attached light source may be used.

Next, the PNP should place the patient in the lithotomy position with her feet in stirrups. The buttocks must be at the end of the table, with knees flexed and relaxed to each side.

The PNP must inspect the external genitalia, noting any rashes, lesions, or discharge. Sexually active adolescents may have a hymen without any obvious changes, a narrow hymenal rim, or myrtiform caruncles, that is, small bumps of residual hymen along the lower edge.

Next, the PNP should warm the speculum with water, which will also serve as a lubricant. The PNP will place one gloved finger on the hymenal rim at 6 o’clock and instruct the adolescent to relax in this area. The speculum is inserted posteriorly with a downward direction and then opened to reveal the cervix. The PNP should note cervical size, shape, color, and mobility. The cervix is usually dull pink in color; however, many adolescents may have an erythematous area surrounding the os. The presence and characteristics of any discharge should be noted. Small pinpoint hemorrhagic spots on the cervix, that is, strawberry cervix, may be due to trichomonas. The PNP should obtain samples for a Papanicolaou smear, cultures, and wet prep with the speculum in place. Collapse and remove the speculum after visualization of the vagina and cervix.

The PNP should carefully palpate the uterus and adnexa; one or two gloved fingers with lubricant gel are inserted into the vagina with the other hand on the abdomen. Normal ovaries are less than 3 cm long and are rubbery (Heger et al., 2002). A urine or serum human chorionic gonadotropin test should be completed if indicated.

Suspicion of Sexual Abuse 

If the genitourinary assessment raises a concern of possible sexual abuse, the concern must be explored. Box 6 defines criteria for the PNP to use in determining when to report concerns of suspected sexual abuse. It is essential for the PNP to remember that a normal anogenital examination does not negate the possibility of sexual abuse. Up to 95% of children who give history of sexual abuse, including penile penetration of the vagina and/or anus, will have a normal anogenital examination (Adams 1996, Heger et al 2002, Johnson 2002).

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Case Studies 

The following case studies will help illustrate the importance of including a genital-urinary assessment when completing a physical examination. Note the essential information gleaned from gathering a detailed behavioral and medical history.

Case One 

Ryan, a 6-year-old boy, is being seen by his PNP for his annual physical examination accompanied by his mother. The PNP obtains a current health history. Ryan has no current medical complaints and is taking no medications. Vital signs are within normal limits, and height and weight are at the 50% percentile when assessed today in the office. Ryan’s mother reports no family history of birth defects, urologic disease, or reproductive disease.

Ryan’s PNP reviews his toilet training history and discovers that Ryan was toilet trained at 3 years; however, in the past 6 months, he has begun having occasional daytime and nocturnal enuresis. Mother states that the enuresis started 2 to 3 months after beginning kindergarten. Genital care practices are discussed with mother and appear to be age appropriate.

The PNP then discusses sexual behaviors with Ryan’s mother. Ryan’s mother was reluctant to discuss these behaviors but eventually shared that Ryan has gotten in trouble at school three or four times for attempting to touch the genitals of classmates. His mother clearly is embarrassed by this disclosure and states, “I just don’t know what to do; he never did anything like this in preschool.” The mother states that she does not know how to talk to Ryan about this behavior, tells him to stop the behavior, and punishes him with a time out. Ryan also is reluctant to go to school.

Ryan’s PNP is concerned about this new behavior in Ryan and realizes that she needs to explore it further. The PNP asks Ryan basic questions about his body. She has him identify body parts. She then wants to know if he understands the concept of private parts, so she asks him if he has parts of his body that no one is supposed to look at, touch, kiss, or tickle. Ryan appropriately identifies his penis and anus as private parts. The PNP then asks if anyone has ever touched, tickled, or hurt his private parts. Ryan replies, “Ben and Sam.” The PNP asks, “What did Ben and Sam do?” Ryan replied, “Sucked my pee pee (penis).” The PNP asks, “Where were you when this happened?” Ryan replied, “In the bathroom at school.” Ryan’s PNP asks, “Who are Ben and Sam?” Ryan’s answer is, “Boys in my class.” The PNP knows that although the boys are age mates, the sexual play that occurred between Ryan, Ben, and Sam is concerning sexual behavior and that she will need to report this information to Child Protective Services. The PNP realizes that a forensic interview will be conducted at the child advocacy center; therefore, she terminates her interview of Ryan.

The PNP then completes a physical examination of Ryan. Ryan’s physical examination, including his anogenital examination, is normal. Ryan’s penis is circumcised, no discharge is noted from the urethral meatus, and the testes are palpable bilaterally. The PNP discusses testing for sexually transmitted diseases with the mother and determines that testing for sexually transmitted diseases is not necessary based on the age of the perpetrators, the act that was completed, and the absence of any penile discharge.

Ryan’s PNP and mother discuss that the oral-genital contact described by Ryan is a concerning sexual behavior and will need to be reported to Child Protective Services. They discuss the need for appropriate sexual abuse–specific counseling for Ryan, especially because he has started acting out on other children. Appropriate counseling resources are given, as well as the number for the local child advocacy center.

Case Two 

Megan, a 9-year-old girl accompanied by her mother, is being seen for the first time by her PNP for her annual physical examination. The PNP obtains a current health history. The mother reports that Megan is fine but had a cold last week. Megan is taking no medications. Her vital signs are within normal limits, and her height and weight are at the 50th percentile when assessed in the office.

Megan’s medical history is reviewed with Megan and her mother, and it is unremarkable. No birth defects, reproductive problems, or urologic problems in the family are noted. Toilet training and genital care practices are reviewed with the mother and appear to be age appropriate. The PNP reviews Megan’s sexual behaviors and general behaviors with the mother, and all appear to be age appropriate.

The PNP then completes a physical assessment of Megan. Prior to examining the genital area, Megan’s PNP asks her simple questions regarding her body. Megan is able to identify her breasts, vagina, and anus as parts of her body that are private that no one should touch, look at, or hurt. Upon explaining the genital examination to Megan, her mother requests that the genital examination be deferred, stating “this (the examination) makes Megan uncomfortable and Dr Smith understands and never looks there.” Megan’s PNP realizes that a genital examination is an essential part of a complete physical examination; therefore, she takes the time to explain that Megan is growing and developing and that it is important that her entire body be examined. She allows Megan and her mother to ask questions. Megan and her mother state that they are comfortable with the PNP proceeding with the examination.

The PNP notes thin fine pubic hair along Megan’s labia and breast bud development; therefore, she determines that Megan’s sexual development is Tanner II. Labial traction is applied by the PNP, with Megan lying in a supine frog-leg position. The PNP is able to separate the labia and can visualize the urethral meatus, clitoris, labia minora, and posterior fourchette; however, the hymenal opening cannot be visualized. The PNP then uses various techniques to provide visualization of the hymenal opening, including releasing labial traction and then reapplying, floating the hymen by flushing with normal saline solution or water, and placing Megan in the knee-chest position. After using a variety of techniques, the PNP is unable to visualize Megan’s hymenal opening.

The PNP realizes that Megan may have an imperforate hymen, which requires a hymenotomy to correct. The PNP discusses with Megan and her mother her inability to visualize Megan’s hymenal (vaginal) opening and the need to refer her to a gynecologist for further evaluation. Megan’s PNP stresses to the mother the importance of following through with seeing the gynecologist because Megan is beginning to physically mature and with the onset of menses, the absence of a hymenal opening becomes significant. The PNP reassures Megan and her mother that the gynecologist will examine Megan and determine the need for any further treatment.

Physical assessment of the genital and urinary system is an essential piece of a complete physical examination. These case scenarios illustrate the importance of including the genito-urinary history and physical assessment when examining children. Following essential points can facilitate the assessment for both patient and provider.

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