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Chapter 6 – Genitourinary System CHAPTER 6 – GENITOURINARY SYSTEM First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter was revised in October 2011. Table of Contents ASSESSMENT OF THE GENITOURINARY SYSTEM ............................................6–1 PHYSICAL EXAMINATION OF THE GENITOURINARY SYSTEM ..........................6–3 Prostate Cancer Screening ................................................................................6–4 COMMON PROBLEMS OF THE GENITOURINARY SYSTEM ...............................6–4 Asymptomatic Bacteriuria ..................................................................................6–4 Cystitis................................................................................................................6–6 Pyelonephritis, Acute .........................................................................................6–9 Urethritis ...........................................................................................................6–11 Urinary Incontinence ........................................................................................6–13 Urolithiasis .......................................................................................................6–18 COMMON PROBLEMS OF THE MALE GENITOURINARY SYSTEM ..................6–20 Acute Prostatitis ...............................................................................................6–20 Balanitis ...........................................................................................................6–22 Benign Prostatic Hyperplasia ...........................................................................6–24 Epididymitis ......................................................................................................6–26 Erectile Dysfunction .........................................................................................6–28 EMERGENCIES OF THE MALE GENITOURINARY SYSTEM .............................6–31 Acute Urinary Retention ...................................................................................6–31 Testicular Torsion .............................................................................................6–33 Partial or Intermittent Testicular Torsion ...........................................................6–33 SOURCES ..............................................................................................................6–35 Clinical Practice Guidelines for Nurses in Primary Care 2011 Genitourinary System 6–1 ASSESSMENT OF THE GENITOURINARY SYSTEM1,2,3 The following characteristics of each symptom should – Polyuria be elicited and explored: – Incontinence (including urge, overflow, enuresis, – Onset (sudden or gradual) mixed, and stress) – Acuity or chronicity – Leakage of urine involuntarily – Chronology – Leakage of urine when coughing, laughing or exercising – Current situation (improving or deteriorating) – Leakage of urine when walking to the – Location and character washroom – Radiation – Use of pads or other devices to catch urine – Timing (frequency, duration, intermittent or – Inability to completely empty bladder constant) – Amount of urine lost each time – Severity and extent – Nature of urine stream (speed, strength, volume) – Precipitating and aggravating factors – Colour and odour of urine – Relieving factors – Presence of sediment, sand or stones in urine – Associated symptoms – Hematuria – Effects on daily activities – Presence of urethral or genital discharge or lesions – Previous diagnosis of similar episodes – Pain in costovertebral angle, flank or abdomen – Previous treatments – Suprapubic pain – Efficacy of previous treatments – Perineal, genital, groin or low back pain – Associated symptoms (for example, fever, chills, trauma, repetitive activity) – Painful intercourse – Libido Assess and monitor pain or discomfort using a pain – Fertility intensity instrument such as the Wong-Baker Faces Pain Scale, the Numeric Rating Scale, or the Comfort Male Genital System Scale (available at: http://painconsortium.nih.gov/ pain_scales/). Also assess presence of night pain, – Difficulty in starting or stopping urinary stream radiation or referred pain and course. – Voluntary bearing down (straining) to urinate – Hesitancy, intermittency CARDINAL SYMPTOMS – Post-void dribbling or post-void fullness In addition, the general characteristics outlined above – Circumcision should be explored for each symptom described – Discharge from penis, itching below, if applicable. – Blood in sperm – Lesions on the external genitalia Urinary System (Male and Female) – Genital, groin, suprapubic or low back pain – Frequency of urination – Testicular or scrotal pain or swelling – Amount of urine (large or small) – Erectile dysfunction – Urgency (client’s sense that he or she must void – Testicular self-examination (frequency, regularity) now, cannot wait) – History of hydrocele, epididymitis, prostatism, – Dysuria and its timing during voiding (at beginning varicocele, hernia, undescended testis, or end, throughout) spermatocele, recent vasectomy – Nocturia (new onset or increase in usual pattern) – Urinary retention or anuria Clinical Practice Guidelines for Nurses in Primary Care 2011 6–2 Genitourinary System Other Associated Symptoms FAMILY HISTORY (SPECIFIC TO GENITOURINARY SYSTEM) – Fever, chills, rigors, malaise – Nausea, vomiting – Urinary tract infections – Diarrhea, constipation – Renal disease (for example, renal cancer, – Decrease in appetite polycystic kidneys) – Weight loss – Prostate cancer – Change in sleep pattern – Diabetes mellitus – Lymphadenopathy – Kidney stones – Sexual or physical abuse MEDICAL HISTORY (SPECIFIC TO GENITOURINARY SYSTEM) PERSONAL AND SOCIAL HISTORY (SPECIFIC TO GENITOURINARY SYSTEM)4 – Cystitis, pyelonephritis – Renal disease – Personal hygiene, toileting habits – Congenital structural abnormalities in the – Fluid intake genitourinary tract – Recent injury or trauma – Renal stones – Current sexual activity; last sexual contact – Recent onset of or increase in sexual activity – Sexual orientation (male and/or female partners) – Recent genitourinary tract instrumentation (for – Contraception and condom use example, catheter, urethral dilatation, cystoscopy) – Sexual practices, including risk behaviours – Menopause (with no hormone replacement (for example, oral, anal or vaginal intercourse) therapy) – Number of sexual partners in past 2 months; – Diabetes mellitus in past year – Immunocompromised state – Satisfaction with frequency and quality of sexual – Sexually transmitted infections (including HIV experiences and hepatitis) – Symptomatic sexual partner – Sexual abuse – History of sexually transmitted infection – Mental status (can contribute to urinary – Use of contraceptive creams, foam, condoms, etc. incontinence) – Use of bubble bath, douches (by women) – Allergies – Tight-fitting underwear or other clothing – Exposure to chemical irritants – Disruption in sex life (from GU symptoms) – Medications (for example, immunosuppressants, – Smoking (associated with risk of bladder cancer) oral contraceptives, antihypertensives, – Substance use (alcohol and drugs) antipsychotics) – Sex while under the influence of drugs or alcohol – Surgical procedures – Missing work, school or social functions because – Risk behaviours (for example, unprotected sex, of genitourinary symptoms (for example, substance abuse, use of illicit injection drugs) incontinence) – Victim of abuse (for example, sexual) – Occupational exposure (for example, volatile hydrocarbons, benzene, aniline, heavy metals, ionizing radiation) – increased risk of kidney concerns 2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–3 PHYSICAL EXAMINATION OF THE GENITOURINARY SYSTEM5,6 GENERAL Percussion – Apparent state of health – Suprapubic or costovertebral angle tenderness – Appearance of comfort or distress – Bladder distention – Colour (for example, flushed, pale) Remember to also examine the following areas as part – Hydration status of your assessment: – Nutritional status (emaciated or obese) – Head, eyes, ears, nose, throat: assess for – Match between appearance and stated age pharyngitis and conjunctivitis (chlamydial VITAL SIGNS infection, gonorrhea) – Skin: assess for skin lesions, rashes, polyarthralgias – Temperature of systemic gonorrhea and hydration status – Heart rate – Respiratory rate MALE GENITAL TRACT – Blood pressure Inspection URINARY SYSTEM – Penis (including urethra, prepuce, glans, shaft, (ABDOMINAL EXAMINATION) skin): inflammation, discharge (at urethral meatus before and after instructing the client to “milk” Inspection the penis from its base), lesions (ulcers, warts), – Inguinal and femoral areas nodules, scars, swelling, asymmetry, stenosis, – Abdominal contour looking for asymmetry or ability to retract foreskin (if present), phimosis, distention (a sign of ascites), pulsations, or masses paraphimosis, hypospadias, epispadias – Peripheral vascular irregularities – Scrotum: inflammation, lesions, swelling, masses, – Previous abdominal or flank surgical scars asymmetry, rashes, warts, veins – Edema (facial, peripheral) – Pubic area: inflammation, lesions (warts, ulcers), nodules, scars, changes in hair distribution, nits – Ulcers, warts, nodules, scars, and inflammation – Inguinal and femoral areas (for hernial bulges) – Ask the client to bear down or cough while inspecting urethra for stress incontinence; repeat Palpation in females with pressure to lateral vaginal fornix –
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