Urogenital: Examination (F)

Systemic Examination

1. Environment, general appearance
2. Hands, arms, face, neck, chest
3. Abdomen, back, legs
4. Urine

Genitalia Examination

1. External genitalia
2. Speculum, Pap smear
3. Internal genitalia

Systemic Examination

Environment

• Dialysis tubes in flesh [urine].
• Dialysis bags [urine].
• Catheter [urine].
• Table: baby congratulation cards.

General appearance

• Weight: anorexic (amenorrhoea) or obese (polycystic ovary).
• Hydration level: under (ARF) [urine].
• Skin pigmentation (kidney excretion problems) [urine].
• Hyperventilation (acidosis) [urine].
• Hiccupping (uremia) [urine].
• Twitching, spasms (hypocalcemia, N2 retention) [urine]. 

Hands

• Nails: leuconychia [white transverse bands], Muehrcke's nails [white paired lines near fingernail tip] (nephrotic syndrome's hypoalbuminemia) [urine].
• Nails: others (do later) [urine].
• Palmar creases: pallor (anemia) [urine].
• Wrists: shunts from prior dialysis [urine].

Arms

• Scratch marks (2° hyperparathyroid).
• Uremic frost [white powder on skin] (chronic renal failure) [urine].
• Peripheral neuropathy (chronic renal failure 2° to diabetes) [urine].
• Bone tenderness (low vit D).
• Blood pressure (HTN 2° to chronic renal failure) [urine].
• Postural hypotension if applicable (ARF) [urine].

Face, neck

• Eyes: jaundice, anemia.
• Eyes: fundi (diabetes). See Fundi Examination [urine].
• Mouth: fetor.
• Mouth: ulcers, infections.
• Face: rash (SLE, systemic sclerosis) [urine].

Chest

• Heart: CHF.
• Heart: hypertension.
• Heart pericarditis.
• Lung: pulmonary edema.

Abdomen

• Scars: nephrectomy [may need to roll pt. on side], kidney transplant.
• Distension (APKD/ Wilm's tumor [young], nephrotic syndrome, ascities, dialysis).
• Palpate kidneys.
• Palpate enlarged bladder.
• Palpate hepatomegaly, splenomegaly (APKD).
• Palpate AAA, so can DDx from renal stenosis on auscultation.
• Assess ascites. See Ascites.
• Percuss enlarged bladder.
• Auscultate renal bruit: above umbilicus 2cm lateral to midline, then in flanks (renal artery stenosis).
• Urinary catheter.

Back

• Ask if tenderness in back.
• Sacral edema (CHF, nephrotic syndrome).
• Gently strike base of spine with fist for tenderness (renal osteomalacia, 2° hyperparathyroidism) [urine.
• Gently do Murphy's kidney punch in renal angle for tenderness (kidney infection).

Legs

• Edema [urine].
• Peripheral vascular dz (chronic renal failure 2° to diabetes) [urine].
• Injured toes from diabetes (chronic renal failure 2° to diabetes) [urine].
• Purpura.
• Toes: tophi (gout) [urine].

Urine

• See Urinalysis Reference.

Genitalia Examination

• Woman with emptied bladder.
• In lithotomy position [on back, legs apart, knees bent], or L lateral position if cannot.
• Gloves on.

External genitalia

• Rashes, ulcerations, swellings, lesions.
• Separate labia with forefinger and thumb, examine clitoris.
• Look for discharge:
  • Bloody.
  • Purulent.
• Tell pt. to bear down: look for prolapse (cystocele, rectocele).
• Tell pt. to cough (stess incontinence).
• Palpate Bartholin's glands [posterior of labia major] (palpable = Bartholin cyst/ abcess).
• If exam normal so far, tell pt.

Speculum

• Do speculum, pap smear before manual examination to avoid contamination
• Lubricate, warm bivalve speculum.
• Screw speculum until won't rattle. Grip like a gun.
• One hand separates labia, other hand inserts speculum in upwards direction with blades closed.
• Open blades, inspect vagina and cervix.
• If exam normal so far, tell pt.

Pap smear

• With speculum distended.
• Insert spatula against cervical os, rotate it 360°.
• Optionally, insert a brush to obtain some endocervical cells.
• Use other end of spatula on vaginal wall for homonal assessment.
• Smear samples on slides.
• If Trichomonas or thrush, smear on wet slides. If gonorrhea, obtain culture.
• Close speculum as it is withdrawn, so prevent trapping cervix.

Internal genitalia

• Lubricate index, middle finger if necessary.
• Left hand separates labia with index finger, thumb.
• Insert index then middle finger into vagina, locate cervix: size, shape, position, tenderness, mobility.
• Palpate fornices.
• Palpate ovaries (palpable = mass).
• Bimanual: fingers up, and push other hand down back on pubic symphysis.
• With bimanual, palpate uterus: ante- or retroverted, as well as properties.
  • Large nodular (fibroids).
  • Smooth enlargement (pregnant, submucous fibroids, adenomyosis).