History of Present Illness
. History-taking Skills: Students should be able to obtain, document, and
present a medical history that contributes to the accurate diagnosis of
tract infection and urosepsis, including:
History of presenting illness:
The presence and pattern of dysuria
Decreased urinary output
o confusion (in the elderly)
• Past medical history that might point to a risk for UTI and urosepsis:
o Prior UTI
o Structural kidney disease, including renal calculi
o Indwelling urinary catheter
o Prostatic hypertrophy
o Diabetes mellitus
o Recent (within the last 3 months) antimicrobial use
• Family history that might point to familial and genetic conditions that
may be associated with UTI:
o Structural kidney disease, including renal calculi
• Social and personal factors that might represent a risk for UTI:
o Sexual activities (relation of symptoms to intercourse)
ASSESSMENT OF Male GENITOURINARY SYSTEM
MALE GENITOURINARY EXAMINATION
INSPECTION: Inspect the abdomen and flank. If the renal size is large enough, a visible
mass may be seen. This is usually only seen in a child or thin adult.
PALPATION: Palpate the kidney with the patient in the supine position. Push the
kidney forward with the one hand in the back, and palpate the kidney with
the other hand pressing the abdomen. Ask the patient to take a deep
breath while trying to keep the abdomen soft. Palpate the lower pole of
The kidney is usually not palpable in a normal adult but is in children and
Causes of visible and/or palpable kidneys:
large simple cyst
Because of the position of the ureter deep within the retroperitoneal space, the ureter is not
visible or palpable except for massive hydronephrosis in an infant or small child.
INSPECTION: A midline mass in the suprapubic area may be an enlarged bladder.
PALPATION: Gently palpate the suprapubic area. With palpation of a midline mass,
suspect a distended bladder if the patient has the urge to void with gentle
pressure on the mass.
A distended bladder may be difficult to palpate if the patient is obese or is
unable to relax during the exam.
PERCUSSION: Percussion of a distended bladder caused a dull sound. Percussion of a distended loop of
bowel will be tympanitic.
Causes of distended bladder:
o urethral valves (child)
o Prostatic hypertrophy or carcinoma
o urethral stricture
Decreased bladder tone:
o neurogenic bladder (spinal cord injury)
o myogenic (overstretched bladder)
Senility or bed rest:
INSPECTION: Look at the penis. Are there any lesions present?
Ulcer: syphilis, herpes simplex or chancroid
Bumps: condylomata acuminata, molluscum contagiosum
Retract the foreskin. You may find:
INSPECTION: Open the meatus. You may find condylomata acuminata or a discharge.
A discharge may be normal seminal emission, gonococcal, trichomonal,
nonspecific urethritis (NSU), condylomata or foreign body.
Is the meatus on the glans penis or is it proximal (hypospadias). If a
hypospadias is present, the foreskin is typically not complete and is
missing in the ventral surface.
PALPATION: Palpate the shaft of the penis:
Dorsal: This may reveal a plaque (Peyronie’s Disease), thrombosed
dorsal penile vein, or carcinoma.
Ventral: (Urethra) may reveal induration due to carcinoma, stricture or
Note: Small non-tender nodes are palpable in normal individuals.
INSPECTION: Inspect the scrotal wall. Any dermatological lesion may affect the
Edema may be due to systemic causes as hepatic, renal or cardiac failure.
Fluid overload (often seen with burn therapy).
Enlargement may be due to intrascrotal pathology (see below).
Note: The right testicle usually lies in a higher position than the left.
INSPECTION: The scrotal contents should be examined in a systematical manner, i.e.
Testis: The testis is slightly oblong or egg shaped with a smooth surface.
It measures approximately 3 x 5 cm. in size and the size may vary greatly
from individual to individual. Both testicles are usually the same size in
the same individual unless there is a pathology present in one or both
Epididymis: The epididymis is a structure typically found on the
posterior surface of the testis like a crescent. It is tender when squeezed.
It is soft and uniform in character with the globus major (head) slightly
larger and usually cephalad in position than the globus minor (tail).
Cord: The cord contains the blood vessels, vas deferens, fat and nerves.
The vas is palpable as a distinct cord like structure usually present on the
posterior portion of the cord.
Transillumination is aided by a dark room and a bright light. This is done
by placing the light source (flashlight) usually on the posterior portion of
the scrotum and noting transillumination of light through the scrotum.
ASSESSMENT OF FEMALE GENITOURINARY
External Genital Examination
1. Put on exam gloves.
2. Start in a sitting position.
3. Inform patient, both verbally and by touch, the examination is to begin.
4. Inspect and identify to patient the following external structures:
a. mons pubis
b. labia majora
c. labia minora
e. urethral meatus
C. Speculum Examination and Routine Procedures
1. Check speculum prior to insertion. (Mechanically and temperature-use warm water to heat
2. Inform patient, both verbally and by touch, that speculum exam is to begin.
3. Hold speculum at 45° angle
4. Insert speculum properly
a. Using one finger at the introitus to help patient relax perineal muscles:
Place one finger at the introitus and proceed with pubococcygeal relaxation techniques, introducing second
pressing down on the perineal body.
Insert speculum partially over fingers depressing perineal body without causing discomfort to the patient by
speculum toward the posterior vaginal wall, away from the urethra.
When the speculum is inserted about 1-1 .“, remove your fingers. Maintain gentle downward pressure toward
b. Using closed speculum place downward pressure to relax perineal muscles
5. Rotate speculum while inserting at a slight downward angle following the natural path of the vagina. With
hand, gently move labia out of path of the speculum to avoid pinching and discomfort. Speculum is horizontal
6. Open speculum blades slowly to 1” to 2”
7. Locate and identify cervix
8. Secure speculum in open position
9. Inspect the cervix
10. Inspect vaginal walls while removing speculum
11. Allow speculum to close completely prior to withdrawal from the introitus.
12. Dispose of speculum appropriately or place into designated container for cleaning.
D. Abdominal-Vaginal Bimanual Pelvic Examination
1. Examiner should be standing.
2. Apply lubricant to index and middle fingers of dominant gloved hand.
3. Inform patient, both verbally and by touch, that bimanual examination is about to begin.
4. Encourage patient’s participation in relaxation technique of the pubococcygeal muscle of the vagina to
5. Introduce index and middle fingers of gloved hand into the vagina, and turn hand to a palm up position.
is hyper-extended, 4th and 5th fingers are flexed on palm. Avoid contact with the clitoral area with your thumb.
Palpation of the uterus
1. Locate/identify cervix.
2. Palpate the body and apex of the uterus between vaginal hand and abdominal hand.
3. Note size, shape, and position of the uterus moving hands together laterally.
Palpation of the adnexa and ovaries (repeat steps on both sides)
1. Move intravaginal fingers into vaginal lateral fornix.
2. Push down with fingers of abdominal hand as if to meet intravaginal fingers just above the mid-point of the
3. Bend the intravaginal fingers up towards the abdominal hand, keeping them relaxed.
4. Maintaining depth, move both sets of fingers simultaneously toward mons pubis to locate ovary with the
5. Characterize ovary between both sets of fingers.
6. If ovary is not located with initial attempt, re-position hands and repeat procedure.