Note
Studied by 1 person
Genitourinary & GI Assessment, Cancer Screening, and Health Promotion
Urinary Elimination
Normal frequency: 5\text{–}6 voids/day (depends on fluid & caffeine intake)
Key terminology
Urgency: sudden, compelling need to void; cannot delay
Nocturia: waking at night to void; often paired with urgency in UTIs
Hesitancy: difficulty starting/maintaining stream; “kinked hose” analogy
Common in Benign Prostatic Hyperplasia (BPH)
\approx80\% of males >60\,\text{yr} have initiation issues
Urine appearance
Desired: clear, pale yellow
Cloudy → WBCs, mucus, possible UTI
Hematuria (any visible blood) → seek care; may signify infection or malignancy
“Urine color wheel” examples
Blue-green: asparagus (plus odor)
Tea-colored: bilirubin spillover; liver disease
Pink/red: blood, berries, beets, menses, UTIs, cancers
Orange: OTC UTI meds, bilirubin
Cloudy: infection
Menstrual & Reproductive History
LMP = first day of last menstrual period
Cycle length: 18\text{–}45\,\text{days} (average \approx28)
Menstrual flow: 3\text{–}7\,\text{days}
Menarche: 10\text{–}13\,\text{yr}
Terms
Amenorrhea: absence of menses
Menorrhagia: heavy/clotting flow
Dysmenorrhea: painful cramps before/during menses
COVID-19 vaccine—anecdotal reports of heavier periods (limited data)
Lack of menses: rule out pregnancy, age factors, endometrial overgrowth (↑cancer risk), hormonal methods can suppress safely (e.g., IUD)
Obstetric coding
Gravida (pregnancies), Para (live births)
Miscarriages + elective abortions grouped as “abortions” in charts
Stillbirths charted separately
Sexual history
Use gender-neutral language
Document partner number, barrier use, contraception
Smoking + estrogen pills → ↑ risk of \text{DVT}/\text{PE}
All people with cervix need HPV screening regardless of partner gender
Continence Patterns
Urge incontinence: detrusor overactivity → involuntary loss
Stress incontinence: pressure (cough, sneeze, jump) → leakage; pelvic floor weakness, postpartum trauma
Bowel Assessment
Desired stool: brown, soft, no strain
Color/consistency cues
Black, non-tarry → iron supplements
Black, tarry (melena) → upper GI bleed (digested blood)
Bright red → lower GI bleed (rectum/colon)
Constipation = <3 stools/week; types 1–2 on Bristol scale (hard “rabbit pellets” or lumpy sausage)
Diarrhea risks: dehydration (↓urine, thirst, dizziness, AMS)
Bristol Stool Form Scale
Type 4 (smooth, soft sausage/snake) = ideal
Floating stool (steatorrhea) → excess fat; seen in CF, pancreatitis, Crohn’s
Clay/gray (acholic) → biliary/liver disease
Best defecation posture: squat; use "squatty potty" to mimic
Prolonged sitting/straining → hemorrhoids, fissures
Genital & Anorectal Physical Exam
Privacy & draping essential
Positions
Lithotomy: vaginal + rectal exam
Standing bent-over: male prostate/rectal
Left lateral (Sim’s): suppositories, rectal visualization
Male Exam Highlights
Inspect penis: lesions, ulcers (syphilis chancre), vesicles (herpes), warts (HPV)
Retract foreskin if uncircumcised; MUST replace → prevent paraphimosis (ischemic constriction in <4\,\text{h})
Unable to retract at all = phimosis
Locate urethral meatus (hypospadias/epispadias if misplaced)
Palpate shaft (thumb + forefinger): smooth, semi-firm, nontender
Inspect/palpate scrotum
Left testis usually lower; temperature causes retraction
Texture: rugae; use back of hand to move penis
Testes: oval, rubbery, freely movable, mildly tender
Palpate spermatic cord upward—should be smooth, nontender
Testicular Self-Exam (TSE)
Frequency: monthly, in warm shower
Technique: support scrotum, roll each testis between thumb & fingers → report lumps, hard areas, dull ache
Testicular cancer: peak 15\text{–}35\,\text{yr}; nearly 100\% cure if early
Female Exam Highlights
External: Labia majora (hair-bearing), labia minora (dark pink, moist), urethral meatus, vaginal opening
Bartholin glands (5 & 7 o’clock): palpate with gloved finger for cysts/abscesses
Perineum: thick, muscular; palpate for support
Menopause Changes (≈48\text{–}51\,\text{yr})
↓ Estrogen → sparse hair, thin dry mucosa, ↓ tone → prolapse
Symptoms: hot flashes, sweating, palpitations, mood swings, vaginal dryness (may need lubricant)
Anus & Rectum
Normal: pigmentation similar to lips, hairless, radial folds
Common lesions
Anal fissure: linear split; sharp pain, bright red blood
Hemorrhoids
• Internal (above pectinate line) – painless, mucosal, may prolapse
• External – covered by skin; can thrombose (blue, painful)Skin tags = healed hemorrhoids
Lymphatic Palpation
Inguinal nodes: non-palpable or <1\,\text{cm}, soft, mobile, non-tender; enlargement → infection, malignancy
Cancer Screening & Health Promotion
Colorectal Cancer
Average-risk adults: start screening 45\,\text{yr}
Colonoscopy q10 yr (gold standard) OR
Annual FIT (fecal immunochemical test); positive → colonoscopy
High-risk (bleeding, anemia, bowel change, ≥2 first-degree relatives): colonoscopy 20\text{–}25\,\text{yr}
Diet risk modifiers
↑ Red/processed meat, low fiber, few fruits/veggies → higher risk
Nuts & plant oils protective (expensive; “food deserts” = social determinant)
Prostate Cancer
Screening with PSA blood test (digital exam less common)
Average risk: start 50\,\text{yr}
African American or single 1° relative: 45\,\text{yr}
Multiple 1° relatives: 40\,\text{yr}
Cervical Cancer & HPV
99.9\% of cases linked to HPV
Vaccination (Gardasil‐9)
Routine: age 11\text{–}12 (can start 9)
≤14 yr: 2-dose series (0, 6\text{–}12\,\text{mo})
≥15 yr–45 yr: 3-dose series (0, 1\text{–}2, 6\,\text{mo})
Screening (if cervix present)
Pap + HPV cotest q5 yr OR Pap alone q3 yr (ages 21\text{–}65)
Stop after \ge65 with ≥3 consecutive negative Paps
Sexually Transmitted Infections (STIs)
\approx80\% of sexually active people will acquire HPV
Many STIs (chlamydia, gonorrhea, HPV, HIV) can be asymptomatic → routine testing vital
Arkansas rankings (2024)
Gonorrhea: 8th highest
Chlamydia: 8th highest
Syphilis: 8th highest; HIV cases rising
University resource: 1 free STI screening/year; schedule online; subsequent screens \$16 then \$33
Patient Education Pearls
Report hematuria, new urinary hesitancy, or change in urine color
Maintain hydration; limit caffeine
High-fiber diet + \ge2\,\text{L} water/day to prevent constipation
Use stool posture aids; avoid prolonged straining
Encourage monthly TSE; teach shower technique
Discuss PSA, colonoscopy, Pap/HPV schedule based on age & risk
Counsel on condom use, smoking cessation (↓ clot risk on OCPs), and HPV vaccination options
Urinary Elimination
Normal frequency: \approx5 ext{–}6 voids/day (highly variable, depends on fluid & caffeine intake, activity level, and certain medications)
Individual variations: Some people comfortably void more frequently, especially with high fluid intake or diuretic use. Less than 5 voids/day might indicate inadequate fluid intake or urinary retention.
Key terminology:
Urgency: A sudden, compelling, and often overwhelming need to void that is difficult to defer. It can be a symptom of conditions like overactive bladder, urinary tract infections (UTIs), or neurologic disorders.
Nocturia: Waking at night one or more times specifically to void. It's common in older adults, individuals with heart failure, uncontrolled diabetes, or UTIs. Often paired with urgency in the context of bladder irritation or infection.
Hesitancy: Difficulty, delay, or interruption in initiating or maintaining the urinary stream, often described as a “kinked hose” analogy. The effort required can be noticeable.
Common in Benign Prostatic Hyperplasia (BPH)- Typically observed in men as the prostate enlarges with age, compressing the urethra. Approximately 80\% of males older than 60 years experience significant initiation issues due to BPH. Other causes include strictures or neurologic conditions.
Urine appearance:
Desired: Clear, pale yellow, and transparent. This indicates adequate hydration and proper kidney function.
Cloudy $\rightarrow$ Suggests the presence of white blood cells (pyuria), mucus, bacteria, phosphates, or protein. Often a sign of a possible UTI or dehydration.
Hematuria (any visible blood) $\rightarrow$ Requires immediate medical attention. It can signify infection (e.g., cystitis), kidney stones, trauma, or more seriously, malignancy (e.g., bladder or kidney cancer). Even small amounts should be investigated.
“Urine color wheel” examples (non-exhaustive, always consider recent intake/meds):
Blue-green: Can be due to certain medications (e.g., methylene blue, cimetidine, propofol), dyes in food, or even asparagus (which also imparts a distinct odor).
Tea-colored/dark brown: Often indicates bilirubin spillover, suggesting impaired liver function (e.g., hepatitis, cirrhosis) or biliary obstruction. Could also be from certain laxatives or muscle relaxants.
Pink/red: Most commonly due to blood (hematuria), but can also be influenced by consumption of red berries (e.g., blueberries, blackberries), beets, or rhubarb. Female menses can also give a reddish hue. UTIs, kidney stones, and various cancers are serious causes.
Orange: Can be caused by certain over-the-counter UTI medications (e.g., phenazopyridine), vitamin B supplements, or again, bilirubin excretion.
Cloudy: As mentioned, often indicative of infection due to the presence of pus, bacteria, and epithelial cells.
Menstrual & Reproductive History
LMP = First day of the Last Menstrual Period. Crucial for calculating gestational age in pregnancy or tracking cycle regularity.
Cycle length: Typically ranges from 21\text{–}45 days for adolescents and 21\text{–}35 days for adults (average \approx28 days). Regularity is key.
Menstrual flow: Duration typically ranges from 3\text{–}7 days.
Menarche: The age of first menstruation, typically between 10\text{–}13 years. Early or late menarche can have implications for future health.
Terms:
Amenorrhea: The complete absence of menstrual periods. Can be primary (never started by age 15) or secondary (cessation for 3 or more cycles or 6 months after previously regular periods). Causes include pregnancy, hormonal imbalances, excessive exercise, extreme weight loss, or certain medical conditions.
Menorrhagia: Abnormally heavy or prolonged menstrual bleeding, often with large clots or requiring frequent pad/tampon changes. Can lead to anemia.
Dysmenorrhea: Painful menstrual cramps experienced before or during menses. Can be primary (no underlying pathology) or secondary (due to conditions like endometriosis, fibroids, or adenomyosis).
COVID-19 vaccine—Anecdotal reports of temporary changes in menstrual cycles, including heavier periods or altered timing, have been noted, though comprehensive long-term data are still being gathered, and effects are generally mild and temporary.
Lack of menses: Always rule out pregnancy first. Other significant factors include age (e.g., menopause, perimenopause), significant weight changes, excessive stress, hormonal imbalances (e.g., Polycystic Ovary Syndrome - PCOS), or medications. Endometrial overgrowth (endometrial hyperplasia) due to unopposed estrogen is a concern as it can increase cancer risk. Hormonal methods like IUDs or birth control pills can safely suppress menses.
Obstetric coding (often documented using the GTPAL system):
G (Gravida): Total number of confirmed pregnancies a woman has had, regardless of outcome (includes current pregnancy, miscarriages, abortions).
T (Term): Number of pregnancies carried to term ( 37 weeks or more).
P (Preterm): Number of pregnancies delivered preterm (between 20 and 36 weeks and 6 days).
A (Abortions): Number of pregnancies lost before 20 weeks, including spontaneous miscarriages and elective abortions. (Note: Stillbirths, defined as fetal death after 20 weeks, are often charted separately or can be included in P, depending on the system).
L (Living): Number of living children.
Sexual history:
Utilize gender-neutral and inclusive language when inquiring about sexual partners and practices (e.g., “Do you have sex with men, women, or both?”).
Document partner number, types of sexual activity, consistent barrier use (e.g., condoms), and current contraception methods employed. This information is vital for STI risk assessment and appropriate counseling.
Smoking + estrogen-containing oral contraceptive pills (OCPs) $\rightarrow$ Significantly increases the risk of venous thromboembolism (DVT/PE - deep vein thrombosis/pulmonary embolism) due to combined pro-thrombotic effects. This is a critical counseling point.
All individuals with a cervix require regular HPV screening (Pap tests and/or HPV co-testing) regardless of their sexual orientation or partner's gender, as HPV transmission can occur through various intimate skin-to-skin contacts.
Continence Patterns
Urge incontinence: Characterized by involuntary urine loss associated with an urgent, sudden need to void. This is typically caused by detrusor (bladder muscle) overactivity, leading to involuntary bladder contractions. Often described as not being able to 'make it to the bathroom in time'.
Stress incontinence: Involuntary leakage of urine that occurs with increases in intra-abdominal pressure (e.g., during coughing, sneezing, laughing, lifting, or jumping). It is primarily due to weakness of the pelvic floor muscles or insufficiency of the urethral sphincter, common after childbirth or with aging.
Bowel Assessment
Desired stool: Typically described as brown, soft, formed, and passed without straining or pain. Consistency and color can vary slightly based on diet and hydration.
Color/consistency cues:
Black, non-tarry $\rightarrow$ Often indicates the use of iron supplements or consumption of certain foods like black licorice, spinach, or blueberries. The stool does not have the sticky, foul-smelling quality of melena.
Black, tarry (melena) $\rightarrow$ This is a distinctive, sticky, black, and very malodorous stool, indicative of an upper gastrointestinal (GI) bleed, where blood has been digested by stomach acids. Common causes include peptic ulcers, gastritis, or esophageal varices.
Bright red $\rightarrow$ Suggests a lower GI bleed (e.g., from the rectum, anus, or distal colon). Causes include hemorrhoids, anal fissures, diverticulitis, inflammatory bowel disease, or colorectal cancer.
Constipation = Passing fewer than 3 stools per week, or having difficulty passing stools (e.g., straining, feeling of incomplete evacuation, hard stools). Types 1\text{–}2 on the Bristol Stool Form Scale (hard “rabbit pellets” or lumpy sausage) are typical. Chronic constipation can lead to hemorrhoids, anal fissures, or fecal impaction.
Diarrhea risks: Significant risk of dehydration due to excessive fluid loss. Signs include decreased urine output, increased thirst, lightheadedness or dizziness upon standing (orthostatic hypotension), and altered mental status (AMS) in severe cases. Electrolyte imbalances are also a major concern.
Bristol Stool Form Scale (a useful tool for patient education):
Type 1: Separate hard lumps, like nuts (hard to pass).
Type 2: Sausage-shaped but lumpy.
Type 3: Like a sausage but with cracks on its surface.
Type 4: Like a sausage or snake, smooth and soft = ideal and easy to pass.
Type 5: Soft blobs with clear-cut edges (passed easily).
Type 6: Fluffy pieces with ragged edges, a mushy stool.
Type 7: Entirely liquid, watery, no solid pieces.
Floating stool (steatorrhea) $\rightarrow$ Stool that is greasy, foul-smelling, and floats, indicating excess fat in the stool. This results from malabsorption of fats and is seen in conditions like cystic fibrosis (CF), chronic pancreatitis, Crohn’s disease, or celiac disease.
Clay/gray (acholic) $\rightarrow$ Stool that lacks normal brown pigmentation, appearing pale or clay-colored. This suggests a lack of bile entering the intestines, often due to biliary obstruction (e.g., gallstones in the bile duct, pancreatic head tumors) or severe liver disease affecting bile production.
Best defecation posture: Squatting, as it straightens the anorectal angle and relaxes the puborectalis muscle, facilitating easier and more complete bowel evacuation. Using a "squatty potty" or similar stool can help mimic this natural posture.
Prolonged sitting/straining $\rightarrow$ Increases intra-abdominal pressure and venous pressure in the anal region, significantly contributing to the development or worsening of hemorrhoids and anal fissures.
Genital & Anorectal Physical Exam
Privacy & draping are essential throughout the exam to ensure patient comfort, dignity, and trust. Always explain each step.
Positions:
Lithotomy: Patient lies on their back with hips and knees flexed, feet in stirrups. This position is standard for vaginal, cervical, and rectal exams in females, and can also be used for some male genital exams or rectal exams.
Standing bent-over: Patient stands and bends forward at the waist, resting elbows on a table or wall. Used primarily for male prostate and rectal exams, especially for palpation.
Left lateral (Sim’s): Patient lies on their left side with the right knee and thigh drawn up toward the chest. This position is useful for administering suppositories, performing sigmoidoscopies, or visualizing the rectal area.
Male Exam Highlights
Inspect penis: Observe for any skin lesions, ulcers (e.g., painless, firm chancre of syphilis; painful, vesicular lesions of herpes simplex virus), vesicles, or warts (associated with Human Papillomavirus - HPV). Note any discharge from the urethral meatus.
Retract foreskin if uncircumcised: In uncircumcised males, gently retract the foreskin to inspect the glans and urethral meatus for lesions, discharge, or inflammation. It is CRUCIAL to replace the foreskin immediately after inspection to prevent paraphimosis (a painful and potentially ischemic constriction of the glans by the retracted foreskin, which requires urgent reduction, ideally within <4 hours to prevent necrosis).
Phimosis: A condition where the foreskin cannot be retracted at all over the glans penis, either due to scarring or congenital tightness.
Locate urethral meatus: Identify its position on the glans. Note any misplacement, such as hypospadias (urethral opening on the ventral/inferior aspect of the penis) or epispadias (urethral opening on the dorsal/superior aspect).
Palpate shaft: Gently palpate the entire shaft of the penis between the thumb and forefinger. It should feel smooth, semi-firm when flaccid, and nontender. Note any induration, plaques (e.g., Peyronie's disease), or tenderness.
Inspect/palpate scrotum:
Scrotal positioning: The left testis usually hangs slightly lower than the right due to the longer spermatic cord. Scrotal temperature regulation mechanisms cause the testes to retract closer to the body (e.g., cold conditions) or relax further away (e.g., warmth).
Texture: The scrotal skin is typically rugated (folded). Use the back of the hand to gently move the penis away to allow for clear inspection and palpation of the scrotum.
Testes: Each testis should be palpated separately. They should feel oval, rubbery, smooth, freely movable within the scrotum, and mildly tender to palpation. Note any masses, significant tenderness, or changes in consistency.
Epididymis: Located on the posterior-superior aspect of each testis, it should feel soft, nodular, and non-tender.
Spermatic cord: Gently palpate the spermatic cord (containing the vas deferens, blood vessels, and nerves) upward from the epididymis. It should feel smooth, non-tender, and distinct. Note any masses or thickening.
Testicular Self-Exam (TSE)
Frequency: Monthly, preferably during or immediately after a warm shower/bath when the scrotal skin is relaxed.
Technique: Encourage supporting the scrotum with one hand, then gently rolling each testis individually between the thumb and fingers of the other hand. Report any new lumps (even if painless), hard areas, changes in size or shape, or a dull ache in the groin or scrotum. Knowledge is power: most testicular cancers are highly curable if detected early.
Testicular cancer: Most common solid tumor in men aged 15\text{–}35 years. With early detection and treatment, the cure rate is nearly 100\%.
Female Exam Highlights
External Female Genitalia (Vulva):
Labia majora: The outer, hair-bearing folds of skin.
Labia minora: The inner, thinner, hairless folds, typically dark pink and moist.
Urethral meatus: The external opening of the urethra, located between the clitoris and vaginal opening.
Vaginal opening (introitus): The entrance to the vagina.
Bartholin glands: Located on either side of the vaginal opening at approximately 5 and 7 o’clock positions. Palpate with a gloved finger to assess for tenderness, swelling, cysts, or painful abscesses, which can occur if the ducts become blocked.
Perineum: The thick, muscular area between the vaginal opening and the anus. Assess its integrity, and palpate for support and tenderness. Note any scarring from episiotomy or tears during childbirth.
Menopause Changes (\approx48\text{–}51 years)
This marks the cessation of menstrual periods, typically occurring around age 50. It is primarily due to a significant decrease in estrogen production by the ovaries.
Physiological changes: Leads to thinning and sparse pubic hair, thinning and drying of the vaginal and urethral mucosa (vaginal atrophy), and decreased pelvic muscle tone, increasing the risk of uterine or bladder prolapse.
Symptoms: Common symptoms include hot flashes (sudden sensations of heat, often with sweating), night sweats, palpitations, mood swings (irritability, anxiety, depression), sleep disturbances, and vaginal dryness, which can lead to dyspareunia (painful intercourse) and increased susceptibility to urinary tract infections. Lubricants or vaginal estrogen therapy may be needed for dryness.
Anus & Rectum
Normal: The perianal skin typically has pigmentation similar to the lips, is generally hairless, and characterized by radial folds that extend outward from the anus. The anal opening should be closed and smooth.
Common lesions:
Anal fissure: A linear split or tear in the anal canal lining, often due to trauma from passing hard stools. Characterized by sharp, searing pain during and after defecation, and bright red blood on the stool or toilet paper.
Hemorrhoids: Swollen, inflamed veins in the rectum and anus, categorized by their location:
Internal hemorrhoids: Originate above the pectinate (dentate) line within the anal canal. They are typically painless because the mucosa above this line has visceral innervation. They may bleed bright red blood during defecation, and can prolapse (protrude) outside the anus, sometimes requiring manual reduction.
External hemorrhoids: Located below the pectinate line, covered by skin that has somatic innervation, making them very sensitive and often painful. They can thrombose (form a blood clot within the vein), appearing as a blue, tense, and exquisitely painful lump at the anal margin.
Skin tags: Small, soft growths of skin around the anus, often residual from a healed external hemorrhoid after its thrombus has resolved. They are typically asymptomatic but can interfere with hygiene.
Lymphatic Palpation
Inguinal nodes: These lymph nodes are located in the groin area. Normally, they are non-palpable or may be felt as small (less than 1 cm), soft, mobile, and non-tender nodules. Enlargement, tenderness, firmness, or fixation of these nodes (e.g., greater than 1-2 cm, hard, non-mobile) suggests an underlying issue such as infection (e.g., from an STI, lower extremity infection) or malignancy (e.g., lymphoma, metastatic cancer from pelvic or lower extremity sites).
Cancer Screening & Health Promotion
Colorectal Cancer
Average-risk adults: Screening typically begins at age 45 years. Key screening options include:
Colonoscopy: The gold standard. A procedure to visualize the entire colon. Recommended every 10 years if results are normal. It allows for direct visualization, biopsy of suspicious lesions, and removal of polyps.
Annual FIT (fecal immunochemical test): A non-invasive test that detects occult blood in stool. If positive, a colonoscopy is required for follow-up to identify the source of bleeding. Other stool-based tests like gFOBT (guaiac-based Fecal Occult Blood Test) detect blood but are less specific.
Other less common options include CT colonography (virtual colonoscopy) and flexible sigmoidoscopy.
High-risk individuals: Screening starts earlier due to increased risk factors, such as personal history of inflammatory bowel disease, certain polyps, or a strong family history. Examples:
Personal history of inflammatory bowel disease (Crohn's, Ulcerative Colitis) or certain polyp types: More frequent colonoscopies.
Family history: If there's a first-degree relative (parent, sibling, child) diagnosed with colorectal cancer before age 60, screening should begin at age 40 or 10 years before the youngest affected relative's diagnosis, whichever is earlier. For multiple first-degree relatives, even earlier or intensified screening may be recommended.
Dietary risk modifiers:
Increased risk: High consumption of red and processed meats, low fiber intake, and diets lacking in fruits and vegetables are associated with a higher risk.
Protective factors: Diets rich in fruits, vegetables, and whole grains, adequate vitamin D, and possibly nuts and plant oils (e.g., olive oil) are associated with a reduced risk. However, access to these healthy dietary components can be limited in "food deserts" or for individuals with low socioeconomic status, highlighting social determinants of health.
Prostate Cancer
Screening involves a discussion between patient and provider about the benefits and risks of the PSA (Prostate-Specific Antigen) blood test (a protein produced by prostate cells) and the digital rectal exam (DRE).
Screening recommendations:
Average risk: Discussion about screening typically begins at age 50 years.
**African American men or those with a single first-degree relative (father, brother, son) diagnosed before age 65$): Discussion should begin earlier, around age 45 years, due to increased risk.
**Multiple first-degree relatives diagnosed before age 65$): Discussion for screening may begin as early as age 40 years.
Note on DRE: While historically a cornerstone of screening, the DRE is less commonly used for routine prostate cancer screening alone now due to its lower sensitivity and specificity compared to PSA. It remains valuable for specific clinical indications, such as evaluating symptomatic prostate issues.
Cervical Cancer & HPV
99.9\% of cervical cancer cases are strongly linked to high-risk Human Papillomavirus (HPV) infection.
HPV Vaccination (Gardasil-9, protects against 9 HPV types):
Routine vaccination: Recommended for adolescents aged 11\text{–}12 years, as this age group typically has the best immune response. Vaccination can start as early as age 9 years.
Dosing schedule:
For individuals initiating vaccination before their 15th birthday: A 2-dose series (0, followed by 6\text{–}12 months later).
For individuals aged 15 through 45 years at initiation: A 3-dose series (0, 1\text{–}2 months later, followed by 6 months after the first dose).
**Cervical Cancer Screening (if cervix present):
Ages 21\text{–}29: Pap test alone every 3 years.
Ages 30\text{–}65: Preferred method is Pap + HPV co-testing every 5 years. Alternatively, a Pap test alone every 3 years is acceptable.
Discontinuation: Screening can typically stop after age 65 years if there is a history of at least 3 consecutive negative Pap tests or 2 consecutive negative co-tests within the last 10 years, and no history of high-grade precancerous lesions or cervical cancer.
Sexually Transmitted Infections (STIs)
Approximately 80\% of sexually active people will acquire HPV at some point in their lifetime, making vaccination crucial.
Many STIs (e.g., chlamydia, gonorrhea, HPV, HIV, herpes) can be asymptomatic, meaning individuals may carry and transmit infections without knowing it. This makes routine and targeted testing vital, especially for at-risk populations.
**Arkansas rankings (as of 2024, context for local prevalence):
Gonorrhea: 8th highest state incidence.
Chlamydia: 8th highest state incidence.
Syphilis: 8th highest state incidence. HIV cases are also noted to be rising.
University resource: Many universities offer health services that include sexual health. For example, some may provide 1 free STI screening per year (e.g., covering common bacterial STIs). Subsequent screens might be available at a reduced fee (e.g., \$16 for the second, then \$33 for subsequent), encouraging regular testing where needed.
Patient Education Pearls
Encourage patients to report any new or unusual changes in urinary patterns, such as hematuria (blood in urine), new onset of urinary hesitancy or urgency, significant changes in urine color (beyond dietary influences), or persistent discomfort.
Maintain adequate hydration by drinking sufficient fluids throughout the day. Remind patients to limit excessive caffeine and alcohol intake, which can act as bladder irritants or diuretics.
Advise a high-fiber diet (e.g., fruits, vegetables, whole grains) combined with a fluid intake of at least \ge2 liters of water per day to prevent constipation and promote regular, soft bowel movements.
Educate on and encourage the use of stool posture aids like a "squatty potty" or footstool to optimize defecation mechanics; emphasize avoiding prolonged straining or sitting on the toilet, which can contribute to hemorrhoids.
For male patients, strongly encourage and teach the technique for monthly Testicular Self-Exams (TSE), emphasizing that it should be done in a warm shower and reported lumps or changes should prompt immediate medical evaluation.
Discuss age- and risk-appropriate cancer screening guidelines for colorectal cancer (colonoscopy, FIT), prostate cancer (PSA, shared decision-making), and cervical cancer (Pap/HPV schedule), explaining the 'why' behind each recommendation.
Provide comprehensive sexual health counseling on condom use for STI prevention, smoking cessation (especially for those on oral contraceptive pills to reduce DVT/PE risk), and the benefits and availability of HPV vaccination for all eligible individuals.