Health Assessment Exam 6: Female Genitourinary System Notes

Female Genitourinary System

External Female Genital Structures

  • Components of the external genitalia (vulva or pudendum):

    • Vestibule

    • Urethral meatus: end of urethra, where urine exists body

    • Skene’s glands

    • Vaginal orifice: posterior to meatus, appears as a slit or

    • Hymen: thin cover that covers orifice may or may not be present

    • Bartholin’s glands: secretes lubricant during intercoarse

    • Mons pubis

    • Labia majora: adipose tissue extending from mons pubis

    • Labia minora: inside of labia majora

    • Frenulum (or fourchette)

    • Clitoris: small pea shaped, highly sensitive to stimulation

Details of External Genitalia

  • Mons Pubis:

    • Round, firm adipose tissue pad covering the symphysis pubis.

    • After puberty, covered with hair in an inverted triangle pattern.

  • Labia Majora:

    • Two rounded folds of adipose tissue extending from mons pubis to perineum.

    • After puberty, outer surfaces covered with hair; inner folds smooth and moist with sebaceous follicles.

  • Labia Minora:

    • Smaller, darker skin folds inside the labia majora.

    • Anteriorly, they form a hood over the clitoris (prepuce), and posteriorly they are joined by a transverse fold (frenulum or fourchette).

  • Clitoris:

    • Small, pea-shaped erectile body akin to the male penis; highly sensitive to tactile stimulation.

  • Hymen:

    • Thin, circular or crescent-shaped fold that can cover part of the vaginal orifice; may be entirely absent.

  • Bartholin’s Glands:

    • Located posterior to vaginal orifice; secrete clear lubricating mucus during intercourse; ducts are not visible but open in the groove between labia minora and hymen.

Internal Female Genital Structures

  • Components of internal genitalia:

    • Rectouterine pouch (cul-de-sac of Douglas)

    • Uterus: pear shaped, thick wall, lining shed every month during menstruation, holds baby

    • Fallopian tubes: two pliable that extend from uteren fundus to the brim of the pelvis.

    • VaginaI: tubular cannel that extends up and backwards into pelvis

    • Cervix: end of vaginal cannel, separates uterus and vagina, thins and opens when babies come out

    • Ovaries: end of fallopian tube, develop eggs(either fertilizes or uteren lining sheds) and female hormones

    • Squamocolumnar junction

    • Anterior and posterior fornix

Details of Internal Genitalia

  • Vagina:

    • Flattened, tubular canal (approx. 9 cm long) extending from the orifice into the pelvis.

    • Positioned between rectum (posteriously) and bladder and urethra (anteriorly); lined with thick transverse folds (rugae) allowing for dilation during childbirth.

  • Cervix:

    • Projects into vagina; smooth, doughnut-shaped in nulliparous women; after childbirth, os (opening) appears enlarged and irregular.

  • Uterus:

    • Pear-shaped, muscular organ, not fixed, tilting forward and superior to bladder; freely movable.

  • Fallopian Tubes:

    • Trumpet-shaped, each about 10 cm in length, extending from uterine fundus laterally.

  • Ovaries:

    • Located at the level of anterior superior iliac spine, one on each side of the uterus.

Cultural and Genetic Considerations

  • Different ethnic perceptions of Pap smear testing; notably higher cervical cancer rates in African American women despite overall declines.Paper smear test is also better at screening subtype squamous bettern than subtype adeno

  • Female circumcision (infibulation or genital mutilation):

    • Involves removal (partial/total) of the clitoris; often performed before puberty as a social custom in various cultural contexts (e.g., among some Aboriginal, Christian, or Muslim communities). Social custom

Subjective Data Gathering

  • Key Areas to Investigate:

    • Menstrual history and regularity

      • Menarche: mean age at onset at 12 to 13 years old

        • Cycle: normally every 28 days , varies from 18-45 days.

          • Amenorrhea: absent of menstruation

          • Duration: average 3 to 7 days

          • Menorrhagia: heavy menstruation. Clotting indicates heavy flow or vagina pooling

          Oligomenorrhea: infrequent menstruation, typically defined as cycles occurring at intervals longer than 35 days.

          • Dysmenorrhea: abdominal cramping and pain associated with menstruation. responds to ibuprofen because it works on uterine smooth muscle

    • Obstetric history (number of pregnancies, outcomes)

      • Gravida: number of pregnancies

      • Para: number of births

      • Abortions: interrupted pregnancies, including elective abortions and spontaneous miscarriages

    • Symptoms related to menopause

      • hot flashes, nights sweats, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, itching

    • Self-care behaviors

    • Acute pelvic pain or urinary symptoms

      • Acute pain lasts less than 6 months.

      • Urgent conditions= pelvic inflammatory disease, appendicitis, ruptured ovarian cyst, ovarian torsion

    • Vaginal discharge characteristics

    • Past medical and surgical history

    • Patient-centered care

      • Pap Smear recommendations: no test for women under 21 years old. Every 3 years for 21-30 years old. HPV and Pap every 5 years for 30-65 years old. Should begin at 21 years old no matter what sexual history

    • Sexual activity, contraceptive methods, and STI contacts

History Questions for Data Collection

  • Menstrual History:

    • Age at first period, last menstrual period, frequency, duration, flow, clotting, associated pain, and symptoms. How do you treat cramps, do they interfere with activities, is there bloating, breast tenderness, or moodiness too?

  • Menopause History: has to be 12 months straight w/ no menstruation. Perimenopausal period from age 40-55

    • Changes in menstruation, associated symptoms (e.g., hot flashes, mood swings), and treatment. Using hormone replacement, how much, how is it working, do you have side effects. How do you feel about going through menopause.

  • Urinary Symptom History:

    • Problems with urination (frequency, burning, blood in urine). Do you awaken because of urination, what color is urine, Hx of UTI’s

  • Vaginal Discharge History:

    • Character of discharge (color, smell), associated symptoms, treatment history. Meds taken, family Hx of diabetes, part of cycle in now, do you use vaginal douche, do you use feminine hygiene spray, how often, do you wear nonventilating underwear. Have you treated the discharge with anything

  • Past History:

    • Any genital problems, surgeries. Do you have lesions, sores and how were those were treated? abdominal pain.

  • Sexual Activity:

    • Status of sexual relationships, satisfaction, and preferences. Satisfied, more than one partner

  • Contraceptive Use:

    • Current methods used, their satisfaction, past methods, discussions on future pregnancies.Discussion with partner about children

  • STI History:

    • Contact with partners having STIs, precautions taken (e.g., condom usage). When, how was this treated, were there complications. Do you use condoms, do you know why

Objective Data: Positioning for Examination

  • Initial Position:

    • Patient should begin sitting up to establish rapport; for examination, transition to lithotomy position with legs in stirrups.

      • body supine, feet in stirrups, knees apart, and butt at the edge of exam table

      • ask to lift hips up and talk about prefer of socks or not.

      • educate about whats going to happen

      • Place arms at sides or across chest

      • Give drape to cover stomach and legs exposing only vulva to view

      • Push down drape between legs and elevate head so face is seen during exam

        • This is very uncomfortable for women so be aware of privacy and comfortability of patient

        • empty bladder before exam, position away from door, ask if friend/family/nurse in room, elevate head

        • explain each step before done

        • assure you can stop at anytime

        • use gentle, firm touch, and gradual movements

        • communicate through entire exam and maintain a dialog to share information

        • use techniques of educational or mirror pelvic exam

  • Draping:

    • Drape the patient fully, exposing only the vulva while ensuring comfort.

  • Conducting the Exam:

    • Explain each step to the patient; assure them they can stop at any point.

    • Use gentle touches and maintain communication throughout.

  • Summary Checklist

    • Inspect external genitalia

    • Palpate labia, skene and bartholin glands

    • using vaginal speculum, inspect cervix and vagina

    • obtain specimen for cytologic study

    • perform bimanual exam

    • perform rectovaginal exam

    • test stool

Pelvic Examination Considerations

  • Many women feel anxious or vulnerable; help them feel comfortable by ensuring privacy and providing explanations.

    • anxious about findings, painful due to pathology, feels exposed, muscle tension, full bladder, don’t know what to expect, cultural differences

Educational Pelvic Examination

  • Reinforces active patient participation; consider a mirror for the patient to view anatomy and foster engagement.

    • can learn about their body and watch the examination done by Dr. Women are more willing to comply with treatment when she shares decisions

Speculum Examination

  • Proper speculum selection is vital; warm and lubricate it before use to enhance comfort. Internal genitalia assessment of cervix, vagina, and

    • Normally cervical mucosa is pink, even, midline, either posterior or anterior, 2.5 cm in diameter

      • Before childbirth the OS will be small, pink, moist, and circular

      • After childbirth the OS will be slanted (horizontally) but still pink and moist

Health Recommendations

  • HPV Vaccine:

    • Protects against most cervical cancer; recommended for pre-sexually active individuals; involves three injections over six months. (11-12 years old)

      • Still need pap tests and pelvic exams

    • It is a significant advance in women's health, reducing future cervical cancer cases.

Abnormalities in Female Genitalia

  • External Genitalia:

    • Conditions such as pediculosis pubis, syphilitic chancres, herpes simplex, HPV warts, urethritis, and abscess of Bartholin’s glands, urethral caruncle, red rash, contact dermatitis

  • Cervical Abnormalities:

    • Bluish cervix, erosion, HPV-related lesions, polyps, carcinomas, cyanosis

  • Pelvic Musculature Issues:

    • Conditions include cystocele, rectocele, and uterine prolapse.

  • Vulvovaginal Inflammations:

    • Conditions such as atrophic vaginitis, candidiasis, trichomoniasis, bacterial vaginosis, chlamydia, and gonorrhea.