Women's Health: Well-Woman Visits & Cervical Cancer Screening PDF

WEEK 11: MALE & FEMALE GU **Well-woman visit: article 1** - A comprehensive history is one of the most important aspects of a well-woman visit. - A well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health ri...

WEEK 11: MALE & FEMALE GU **Well-woman visit: article 1** - A comprehensive history is one of the most important aspects of a well-woman visit. - A well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks. - The periodic well-woman care visit should include screening, evaluation and counseling, and immunizations based on age and risk factors. - The interval for specific individual services may differ for individual patients, and the scope of services provided may vary in different ambulatory care settings. - This document will highlight resources and tools to assist obstetrician--gynecologists in the provision of comprehensive well-woman care. - the preferred and usual source of reproductive health care (including cervical cancer screening, contraception, and sexually transmitted infection services) showed that women's health care specialists (including obstetrician--gynecologists and family planning clinics) were the most used, and often the preferred, source of care compared with family medicine, internal medicine, and general medicine clinicians - A comprehensive history is one of the most important aspects of a well-woman visit. This history includes symptoms; medications; allergies; and medical, surgical, family, social, and gynecologic history, including questions on reproductive, sexual, and mental health (using screening tools as indicated) - Some specific topics that are sometimes overlooked, but that should be addressed at well-woman visits throughout the lifespan, include bone health, vulvovaginal symptoms, and sexual health - Certain risk factors and behaviors have a profound negative effect on the health of women and should be addressed during a well-woman visit.  - Smoking, poor diet, and lack of physical activity are associated with cardiovascular disease, type 2 diabetes, and multiple types of cancer, among other conditions that cause significant morbidity and are the leading causes of mortality in the United States - well-woman visit for a reproductive-aged woman is the development and discussion of her reproductive life plan to ensure that medical testing and treatments provided are aligned with her current and future plans - discussion of a reproductive life plan may include pre pregnancy counseling, infertility assessment, or the full range of contraceptive options **The Utility of and Indications for Routine Pelvic Examination: article 2** - Traditionally, a pelvic examination is performed for asymptomatic women as a screening tool for gynecologic cancer, infection, and asymptomatic pelvic inflammatory disease - It is recommended by the American College of Obstetricians and Gynecologists that pelvic examinations be performed when indicated by medical history or symptoms. - Women with current or a history of cervical dysplasia, gynecologic malignancy, or in utero diethylstilbestrol exposure should be screened and managed according to guidelines specific to those gynecologic conditions. -  the decision to perform a pelvic examination should be a shared decision between the patient and her obstetrician--gynecologist or other gynecologic care provider - Regardless of whether a pelvic examination is performed, a woman should see her obstetrician--gynecologist at least once a year for well-woman care. - A pelvic examination is not necessary before initiating or prescribing contraception, other than an intrauterine device, or to screen for sexually transmitted infections. -  pelvic examination is considered to be "routine" or a "screening" examination only when used as a screening tool to evaluate an asymptomatic woman -  only found limited evidence on its accuracy to detect four specific conditions: 1) ovarian cancer, 2) bacterial vaginosis, 3) genital herpes, and 4) trichomoniasis. The USPSTF concluded that there is insufficient evidence to make a recommendation regarding screening pelvic examinations for asymptomatic, nonpregnant women - the ACP concluded that performing pelvic examinations did not decrease ovarian cancer morbidity and mortality rates - **potential benefits of the pelvic examination include early detection of treatable gynecologic conditions before symptoms occurring** (eg, vulvar or vaginal cancer), as well as incidental findings such as **dermatologic changes and foreign bodies** - screening pelvic examinations in the context of a well-woman visit may allow gynecologists to explain a patient's anatomy, reassure her of normalcy, and answer her specific questions, - the ACP found low-quality evidence that the screening pelvic examination leads to harms such as fear, anxiety, embarrassment (reports ranged from 10% to 80% of women) or pain and discomfort  - Based on the current limited data on potential benefits and harms and expert opinion, the decision to perform a pelvic examination should be a shared decision between the patient and her obstetrician--gynecologist or other gynecologic care provider. - counseling should include a discussion about the uncertainty of the benefits and harms of the procedure and the lack of evidence for the screening pelvic examination. - It is recommended by ACOG that pelvic examinations be performed when indicated by medical history or symptoms. -  Examples of symptoms that indicate a woman should receive a pelvic examination include but are not limited to the following: abnormal bleeding, dyspareunia, pelvic pain, sexual dysfunction, vaginal dryness, vaginal bulge, urinary issues, or inability to insert a tampon. Other indications include patients undergoing a pelvic procedure (eg, endometrial biopsy or intrauterine device placement). - When an asymptomatic, nonpregnant patient presents for a well-woman visit, the obstetrician--gynecologist should explain the lack of data and potential benefits and harms of the routine pelvic examination and discuss whether the examination should be performed - the Centers for Disease Control and Prevention does not support performing a pelvic examination to screen for STIs or before initiating contraception, other than an intrauterine device, in otherwise healthy, asymptomatic individuals  - - Regardless of whether a pelvic examination is performed, a woman should see her obstetrician--gynecologist at least once a year for well-woman care  - Screening for gynecologic cancer and STIs are common reasons physicians report performing a pelvic examination in asymptomatic, nonpregnant patients. However, studies show that pelvic examinations do not decrease ovarian cancer morbidity and mortality rates - A pelvic examination is not necessary before initiating or prescribing contraception, other than an intrauterine device, or to screen for STI -  A **thorough history** should be taken from each patient to ensure that there are no indications for performing a pelvic examination. **Updated Cervical Cancer Screening Guidelines: article 3** - screening should begin at age 21 years, and screening recommendations remain unchanged for average-risk individuals aged 21--29 years and those who are older than 65 years -  - - There are now three recommended options for cervical cancer screening in individuals aged 30--65 years: primary hrHPV testing every 5 years, cervical cytology alone every 3 years, or co-testing with a combination of cytology and hrHPV testing every 5 years  - All three screening strategies are effective, and each provides a reasonable balance of benefits (disease detection) and potential harms (more frequent follow-up testing, invasive diagnostic procedures, and unnecessary treatment in patients with false-positive results) - average-risk patients aged 25--65 years, primary hrHPV testing and co-testing detect more cases of high-grade cervical intraepithelial neoplasia than cytology alone, but hrHPV-based tests are associated with an increased risk of colposcopies and false-positive results - there are two hrHPV tests approved by the FDA for primary screening in individuals aged 25 years and older -  Although cytology alone is the recommended screening method for individuals aged 21--29 years, ACOG, ASCCP, and SGO advise that primary hrHPV testing every 5 years can be considered for average-risk patients aged 25--29 years - the American Cancer Society (ACS) updated its cervical cancer screening guidelines to recommend primary hrHPV testing as the preferred screening option for average-risk individuals aged 25--65 years  - uptake of this screening method has been slow because of the limited availability of FDA-approved tests and the significant laboratory infrastructure changes required to switch to this screening platform - ACS strongly advocates phasing out cytology-based screening options in the near future  -  Until primary hrHPV testing is widely available and accessible, cytology-based screening methods should remain options in cervical cancer screening guidelines  - HPV Vaccination could prompt raising the screening initiation age to 25 years, as is recommended in the recently updated ACS guideline - Given these significant health equity concerns and the current suboptimal rates of cervical cancer screening and HPV vaccination, ACOG, ASCCP, and SGO continue to recommend initiation of cervical cancer screening at age 21 years [USPSTF cervical cancer screening] - Grade A: women aged 21-65 years - screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. - For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology - Grade D - Women younger than 21 years: recommends against screening for cervical cancer  - Women who have had a hysterectomy: recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (ie, cervical intraepithelial neoplasia \[CIN\] grade 2 or 3) or cervical cancer - Women older than 65: recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer [USPSTF breast cancer screening] - The Task Force recommends all women should get screened for breast cancer every other year, starting at age 40. - More research is needed to make a recommendation for or against additional screening with breast ultrasounds or MRI for women with dense breasts and on screening women older than 75. - This draft recommendation applies to women at average risk of breast cancer - people with a family history of breast cancer  - people who have other risk factors such as having dense breasts - does not apply to people who  - have a personal history of breast cancer -  who have had a high-risk lesion on previous biopsies - who are at very high risk of breast cancer due to inheriting certain breast cancer genes -  history of high-dose radiation therapy to their chest at a young age [USPSTF prostate cancer screening ] - **Grade C** recommendations: men aged 55-69 years - the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one. -  Before deciding whether to be screened, men should have an opportunity to [discuss the potential benefits and harms of screening] with their clinician and to incorporate their values and preferences in the decision.  - **Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. ** - However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction - Grade D: men over 70 years of age - USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older **Chapter 19: female genitalia** Risk factors for cervical cancer - **HPV infection**: human papillomavirus (HPV) infection is common, and only a small percentage of those infected with untreated HPV will develop cervical cancer. The "high-risk" types include HPV 16, HPV 18, HPV 31, HPV 33, and HPV 45, as well as some others. - **HPV vaccination:** protective factor; decreases risk of cervical cancer - Pap smear history: lack of regular screening for cervical cancer; transgender men are less likely to be current on cervical cancer screening - **High parity**: patients with three or more full-term pregnancies have an increased risk of developing cervical cancer. - **Young age at parity:** patients who were younger than 17 years when they had their first full-term pregnancy are more likely to develop cervical cancer later in life than those who were not pregnant until they were 25 years or older. - **Cigarette smoking:** doubles the risk; tobacco by-products have been found in the cervical mucus of patients who smoke. - **HIV infection:** increased susceptibility to HPV infections - **Chlamydia infection:** increases risk for cervical cancer - **Diet**: diets low in fruits and vegetables may increase risk for cervical cancer; overweight patients are more likely to develop this cancer. - **DES exposure:** increased risk in patients exposed in utero to diethylstilbestrol (DES) (prescribed between 1940 and 1971 to pregnant patients at high risk of miscarriages) - **Oral contraceptives:** some evidence indicates that long-term use (more than 5 years) may slightly increase the risk of cervical cancer. - **Low socioeconomic status:** likely related to access to healthcare services, including cervical cancer screening and treatment of precancerous cervical disease Risk factors for ovarian cancer - Age: risk increases with age. Most ovarian cancers develop after menopause - Inherited genetic mutation or syndromes: increased risk with known inherited mutation of the BRCA1 or BRCA2 or PTEN gene. Increased risk hereditary non-polyposis colon cancer syndrome (HNPCC), Peutz-Jeghers syndrome, MUTYH-associated polyposis - Family history: one or more first-degree relatives (parent, sibling, child) with ovarian and/or breast cancer; strong family history of colon cancers; Ashkenazi Jewish descent; and a family history of breast and/or ovarian cancer - Obesity: patients with a body mass index of at least 30 have a higher risk of developing ovarian cancer. - Reproductive history: nulliparity or parity after age 35 years increases the risk. - Use of fertility drugs: increased risk in some studies, especially if pregnancy is not achieved - Personal history: increased risk with breast, endometrial, and/or colon cancers - Hormone replacement therapy: increased risk in postmenopausal patients. The risk seems to be higher in patients taking estrogen alone (without progesterone) for at least 5 or 10 years. - Use of oral contraceptives: protective use for 4 or more years is associated with an approximately 50% reduction in ovarian cancer risk in the general population. - Testosterone therapy: no evidence that transgender men taking testosterone have an increased risk - Diet: high-fat diet associated with higher rates of ovarian cancer in industrialized nations, but the link remains unproven Risk factors for endometrial cancer - Total number of menstrual cycles: increased risk with more menstrual cycles during a patient's lifetime (i.e., early menarche plus late menopause) - Infertility or nulliparity: during pregnancy, the hormonal balance shifts toward more progesterone. Therefore, having many pregnancies reduces endometrial cancer risk, and nulliparity increases risk - Obesity: having more fat tissue can increase a patient's estrogen levels and, therefore, increase the endometrial cancer risk. - **Tamoxifen:** an antiestrogen drug that acts like an estrogen in the uterus increases risk - **Estrogen replacement therapy (ERT):** estrogen alone (without progestins) in patients with a uterus increases risk - Testosterone therapy: no evidence that transgender men taking testosterone have an increased risk - Ovarian diseases: polycystic ovaries and some ovarian tumors such as granulosa--theca cell tumors cause an increase in estrogen relative to progestin. Some of these conditions lead to hysterectomy and oophorectomy, ending the risk for endometrial cancer. - Diet: diet high in animal fat - Diabetes: endometrial cancer more common in patients with both type 1 and type 2 diabetes - Age: risk increases with age; 95% of endometrial cancers occur in patients 40 years of age or older. - Family history: history of endometrial, breast, ovarian, or colorectal cancers - Personal history: breast or ovarian cancer, or hereditary nonpolyposis colorectal cancer syndrome; known genetic mutation in BRCA1 or BRCA2 - Prior pelvic radiation therapy: radiation used to treat some other cancers can damage the DNA of cells, sometimes increasing the risk of developing a second type of cancer such as endometrial cancer. Red Flags for Sexual Abuse - Medical Concerns and Findings - Evidence of general physical abuse or neglect - Evidence of trauma and/or scarring in genital, anal, and perianal areas - Unusual changes in skin color or pigmentation in genital or anal area - Presence of sexually transmitted infection (oral, anal, genital) - Anorectal problems such as itching, bleeding, pain, fecal incontinence, poor anal sphincter tone, bowel habit dysfunction - Genitourinary problems such as rash or sores in genital area, vaginal odor or discharge, pain (including abdominal pain), itching, bleeding, discharge, dysuria, hematuria, urinary tract infections, enuresis - Examples of Nonspecific Behavioral Manifestations - Problems with school - Dramatic weight changes or eating disturbances - Depression - Anxiety - Sleep problems or nightmares - Sudden change in personality or behavior - Increased aggression and impulsivity, sudden avoidance of certain people or places - Examples of Sexual Behaviors That Are Concerning - Use of sexually provocative mannerisms - Excessive masturbation or sexual behavior that cannot be redirected - Age-inappropriate sexual knowledge or experience - Repeated object insertion into vagina and/or anus - Child asking to be touched or kissed in genital area - Sex play between children with 4 years or more age difference - Sex play that involves the use of force, threats, or bribes Causes of Genital Bleeding in Children - Genital lesions - Vaginitis - Foreign body - Trauma - Tumors - Endocrine changes - Estrogen ingestion - Precocious puberty - Hormone-producing ovarian tumor Premenstrual Syndrome (PMS) - Etiology unclear; likely causes include hormonal factors and responses to hormonal factors - Usually begins in a patient's late 20s and increases in incidence and severity as menopause approaches - Symptoms may include breast swelling and tenderness, acne, bloating and weight gain, headache or joint pain, food cravings, irritability, difficulty concentrating, mood swings, crying spells, and depression - Symptoms occur 5--7 days before menses (luteal phase) and subside with onset of menses Endometriosis - Pelvic pain, dysmenorrhea, and heavy or prolonged menstrual flow - Objective Data - No findings - On bimanual examination, tender nodules may be palpable along the uterosacral ligaments. Lesions from sexually transmitted infections Condyloma Acuminatum (Genital Warts) - Soft, painless, wartlike lesions - History of sexual contact - Objective Data - Flesh-colored, whitish pink to reddish brown, discrete, soft growths on labia, vestibule, or perianal area (Fig. 19.47) - Lesions may occur singly or in clusters and may enlarge to form cauliflower-like masses Molluscum Contagiosum - Subjective Data - Painless lesions in genital area - Sexually active - Objective Data - White or flesh-colored, dome-shaped papules that are round or oval - Surface has a characteristic central umbilication from which a thick creamy core can be expressed - Lesions may last from several months to several years - Diagnosis usually based on the clinical appearance of the lesions - Direct microscopic examination of stained material from the core will reveal typical molluscum bodies within the epithelial cell Syphilitic Chancre - Subjective Data - Often no lesion noted, as may be internal (Fig. 19.49) - Painless genital ulcer - Sexually active - Objective Data - Solitary lesion; firm, round, small, painless ulcer - Lesion has indurated borders with a clear base - Scrapings from the ulcer, examined microscopically, show spirochetes. Condyloma Latum Lesions of secondary syphilis - Subjective Data - Healed solitary genital lesion - Sexually active - Objective Data - Flat, round, or oval papules covered by a gray exudate Genital Herpes - Subjective Data - Painful lesions in genital area - History of sexual contact - May report burning or pain with urination - Objective Data - Superficial vesicles in the genital area; internal or external (Figs. 19.51 and 19.52); may be eroded - Initial infection is often extensive, whereas recurrent infection is usually confined to a small, localized patch on the vulva, perineum, vagina, or cervix Vulva and vagina Inflammation of Bartholin Gland - Subjective Data - Pain and swelling in the groin - Objective Data - Hot, red, tender, fluctuant swelling of the Bartholin gland that may drain pus  - Chronic inflammation results in a nontender cyst on the labium. Vaginal Carcinoma Classified according to the type of tissue from which the cancer arises: squamous cell, adenocarcinoma, melanoma, and sarcoma - Subjective Data - Abnormal vaginal bleeding - Difficult or painful urination - Pain during sexual intercourse - Pain in the pelvic area, back, or legs - Edema in the legs - Risk factor: patient exposed in utero to DES - Objective Data - Vaginal discharge, lesions, and masses - Melanoma tends to affect the lower or outer portion of the vagina - Tumors vary greatly in size, color, and growth pattern. Vulvar Carcinoma Classified according to the type of tissue from which the cancer arises: squamous cell, adenocarcinoma, melanoma, and basal cell - Subjective Data - Lump or growth in or on the vulvar area or a patch of skin that is differently textured or colored - Ulcer that persists for longer than 1 month - Bleeding from vulvar area - Change in the appearance of an existing mole (specific to vulvar melanoma) - Persistent itching, pain, soreness, or burning in the vulvar area - Painful urination - Objective Data - Squamous cell carcinoma: ulcerated or raised lesion on the vulva; usually found on the labia (Fig. 19.54A) - Adenocarcinoma: ulcerated or raised lesion usually found on the sides of the vaginal opening - Melanoma: dark-colored lesion most often on the clitoris or the labia minora - Basal cell: ulcerated lesion Vaginal Infections Vaginal infections often produce a discharge  Cervix Cervical cancer Classified according to the type of tissue from which the cancer arises: squamous cell carcinoma and adenocarcinoma. There are a few other rare types of cervical cancer. - Subjective Data - Usually asymptomatic - May report unexpected vaginal bleeding or spotting - Objective Data - Often no findings on physical examination - A hard granular surface at or near the cervical os - Lesion can evolve to form an extensive irregular cauliflower growth that bleeds easily  - Early lesions are indistinguishable from ectropion. - Ulcerated area - Precancerous and early cancer changes are detected by Pap smear, not by physical examination Uterus Uterine Prolapse Descent or herniation of the uterus into or beyond the vagina - Subjective Data - Sensation of pelvic heaviness and/or uterus falling out - Tissue protruding from vagina - Urine leakage or urge incontinence, difficulty having a bowel, movement, or low back pain - Objective Data - First-degree prolapse: The cervix remains within the vagina - Second-degree prolapse: The cervix is at the introitus - Third-degree prolapse: The cervix and vagina drop outside the introitus Uterine Bleeding Abnormality in menstrual bleeding and inappropriate uterine bleeding are common gynecologic problems - Subjective Data - Shortened or lengthened interval between periods - Absence of menstruation - Normal intervals between periods with excessive flow and/or duration or decreased flow - Irregular intervals between periods with excessive flow and duration - Bleeding between periods; see Box 19.1 - Objective Data - Pelvic examination typically normal - Palpable leiomyomas - Physical findings consistent with an endocrine disorder or coagulopathy - Findings consistent with stage of pregnancy Myomas (Leiomyomas, Fibroids) Common, benign, uterine tumors - Subjective Data - Fibroid symptoms are related to the number of tumors, as well as to their size and location. Symptoms may include the following: - Heavy menses - Abdominal cramping usually felt during menstruation - Urinary frequency, urgency, and/or incontinence from pressure on the bladder - Constipation, difficult defecation, or rectal pain from pressure on the colon - Abdominal cramping from pressure on the small bowel - Generalized pelvic and/or lower abdominal discomfort - Objective Data - Firm, irregular nodules in the contour of the uterus on bimanual examination - Uterus may be enlarged. Endometrial Cancer - Subjective Data - Postmenopausal vaginal bleeding---red flag for endometrial cancer - Objective Data - None; diagnosed by endometrial biopsy Adnexa Ovarian Cysts Fluid-filled sac in an ovary - Subjective Data - Usually asymptomatic - May report lower abdominal pain: sharp, intermittent, sudden, and severe - Sudden onset of abdominal pain may suggest cyst rupture - Objective Data - Pelvic mass may be palpated - Cervical motion tenderness may be elicited. - Often an incidental finding during ultrasonography performed for other reasons Ovarian Cancer Classified by the cells from which the cancer arises: epithelial, stromal, or germ cell - Subjective Data - Often asymptomatic at first - Suspect ovarian cancer in a patient older than 40 years with persistent and unexplained vague gastrointestinal symptoms such as generalized abdominal discomfort and/or pain, gas, indigestion, pressure, swelling, bloating, cramps, or feeling of fullness even after a light meal. - Objective Data - May have no physical findings - On bimanual examination, an ovary that is enlarged in premenopausal patient or a palpable ovary in a postmenopausal patient should be considered suspicious for cancer - Further diagnostic tests are required Tubal (Ectopic) Pregnancy Ectopic pregnancy occurring outside the uterus - Subjective Data - Abnormal vaginal bleeding - Low back pain - Mild cramping on one side of the pelvis - Pain in the lower abdomen or pelvic area - If the area of the abnormal pregnancy ruptures and bleeds, symptoms may worsen. - Feeling light-headed or syncope - Pain that is felt in the shoulder area - Severe, sharp, and sudden pain in the lower abdomen - Objective Data - Marked pelvic tenderness, with tenderness and rigidity of the lower abdomen - Cervical motion tenderness; a tender, unilateral adnexal mass may indicate the site of the pregnancy (Fig. 19.62) - Tachycardia and hypotension reflect hemorrhage of a ruptured tubal pregnancy into the peritoneal cavity and impending cardiovascular collapse - A ruptured tubal pregnancy is a surgical emergency Pelvic Inflammatory Disease (PID) Infection of the uterus, fallopian tubes, and other reproductive organs; a common and serious complication of some sexually transmitted infections - Subjective Data - Symptoms may be mild or absent. - Unusual vaginal discharge that may have a foul odor - Symptoms include painful intercourse, painful urination, irregular menstrual bleeding, and pain in the upper abdomen - Objective Data - Acute PID produces very tender, bilateral adnexal areas; the patient guards and usually cannot tolerate bimanual examination - Symptoms of chronic PID are bilateral, tender, irregular, and fairly fixed adnexal areas Salpingitis Inflammation or infection of the fallopian tubes, often associated with PID; can be acute or chronic - Subjective Data - Lower quadrant pain; constant and dull or cramping; pain may be accentuated by motion or sexual activity - Coexisting purulent vaginal discharge - Abnormal vaginal bleeding - Nausea, vomiting, fever - Objective Data - Cervical motion tenderness and/or adnexal tenderness on bimanual examination - Mucopurulent cervical discharge Hydrocolpos Distention of the vagina caused by accumulation of fluid due to congenital vaginal obstruction - Subjective Data - None - Objective Data - Small midline lower abdominal mass or a small cystic mass between the labia - Condition may resolve spontaneously or may require surgical intervention - Abdominal sonography is helpful in making the correct diagnosis, showing a large midline translucent mass displacing the bladder forward Vulvovaginitis Inflammation of the vulvar and vaginal tissues - Subjective Data - Vaginal discharge - Discomfort, pain, or pruritus - Vulvar irritation - Burning on urination - With infants and young children, the parent may report a discharge on the diaper or panties, an abnormal vaginal odor, or redness of the vulva. - Wiping the anus from posterior to anterior, wearing tight-fitting synthetic undergarments, and using vaginal irritants such as bubble baths - Objective Data - Warm, erythematous, and swollen vulvar tissues (Fig. 19.66) - Vaginal pruritus, especially at night, suggests pinworm infection - Itching, soreness, bleeding, and vaginal discharge; bloody and foul-smelling discharge may suggest a vaginal foreign body Atrophic Vaginitis Inflammation of the vagina due to the thinning and shrinking of the tissues, as well as decreased lubrication - Subjective Data - Vaginal soreness or itching - Discomfort or bleeding with sexual intercourse - Objective Data - Vaginal mucosa is dry and pale, although it may become reddened and develop petechiae and superficial erosions - Accompanying vaginal discharge may be white, gray, yellow, green, or blood-tinged - Can be thick or watery and, although it varies in amount, rarely profuse Chapter 20: male genitalia Risk factors for cancer of male genitalia - Penile - Infection with high-risk types of HPV - Lack of circumcision with failure to maintain good hygiene - Phimosis - Age: risk increases with age - Smoking (smoking alone increases risk; smokers with HPV infection at even higher risk) - HIV infection - UV light treatment of psoriasis if genitalia exposed - Testicular - Undescended testicle (cryptorchidism): risk elevated for both testicles - Personal history of testicular cancer (the opposite testicle is at increased risk) - Family history of testicular cancer - HIV infection - Age: 20--34 years - Race: White; five times greater than that of Blacks and more than three times that of Asian Americans and Native Americans - Androgen suppression: likely decreases the risk in transgender women Hernias Hernia Protrusion of a peritoneal-lined sac through some defect in the abdominal wall. Fig. 20.16 shows the anatomy of the region and the three common types of pelvic hernias - Subjective Data - Soft swelling or bulge in inguinal area - May have pain on straining (indirect, femoral) - Objective Data - Indirect: soft swelling in area of internal ring; hernia comes down canal and touches fingertip on examination - Large hernia may be present in scrotum (Fig. 20.17) - Direct: bulge in area of Hesselbach triangle; easily reduced; hernia bulges anteriorly, pushes against side of finger on examination - Femoral: inguinal canal empty on examination - Strangulated: hernia is nonreducible; this condition requires prompt surgical intervention -  Penis Paraphimosis The inability to replace the foreskin to its usual position after it has been retracted behind the glans - Subjective Data - Retraction of the foreskin during penile examination, cleaning, urethral catheterization, or cystoscopy - Penile pain and swelling - Children may report obstructive voiding symptoms - Objective Data - Glans penis is congested and enlarged (Fig. 20.18) - Foreskin edematous - Constricting band of tissue directly behind the head of the penis - If untreated, necrosis and gangrene of the glans penis may be present (discolored, blackened, ulcerated) Chancre Skin lesion associated with primary syphilis - Subjective Data - Painless lesion on penis - History of sexual contact - Objective Data - Solitary lesion; firm, round, small, commonly located on the glans but can be located on the foreskin  - Lesion has indurated borders with a clear base - Scrapings from the ulcer, when examined microscopically, show spirochetes Genital Herpes A sexually transmitted infection caused by the herpes simplex virus (HSV) - Subjective Data - Painful lesions on penis, genital area, perineum - History of sexual contact - May report burning or pain with urination - Objective Data - Superficial vesicles on the glans, penile shaft, at the base of the penis, or around the anus  - Often associated with inguinal lymphadenopathy and systemic symptoms, including fever Condyloma Acuminata "Genital warts" caused by HPV - Subjective Data - Soft painless wartlike lesions on penis - History of sexual contact - Objective Data - Single or multiple papular lesions - May be pearly, filiform, fungating (ulcerating and necrotic) cauliflower, or plaquelike (Figs. 20.21 and 20.22) - Can be smooth, verrucous, or lobulated - May be the same color as the skin, or may be reddish or hyperpigmented - Lesions are commonly present on the prepuce, glans penis, and penile shaft, but they may be present within the urethra as well Lymphogranuloma Venereum Sexually transmitted infection of the lymphatics - Subjective Data - Painless lesion on penis - Symptoms may be systemic (fever, malaise). - History of sexual contact - Objective Data - Initial lesion is a painless erosion at or near the coronal sulcus  - Enlarged regional lymph nodes - If lymphatic drainage is blocked, penile and scrotal lymphedema may ensue - Draining sinus tract in untreated infection Molluscum Contagiosum Viral infection of the skin and mucous membranes; considered a sexually transmitted infection in adults - Subjective Data - Painless lesions on penis - Contact with an infected person - Objective Data - Lesions are pearly gray, often umbilicated, smooth, dome-shaped, and with discrete margins  - Lesions most common on the glans penis Peyronie Disease Characterized by a fibrous band in the corpus cavernosum - Subjective Data - Bending and/or indentation of the erection (Fig. 20.25) - Loss of penile length - May have pain with erection - Family history of the condition - History of Dupuytren contracture (finger joint flexion contractures; most commonly fourth and fifth fingers of the hand) - Objective Data - One or more palpable hardened areas - Reduced elasticity of the flaccid penis - Radiography or ultrasound can show plaque calcification Penile Cancer Almost all cases are squamous cell carcinoma usually originating in the glans or foreskin - Subjective Data - Painless ulceration that fails to heal - Uncircumcised - Poor penile hygiene - Objective Data - Lesion, usually on glans, may present as a reddened area - Papule or pustule - Warty growth, shallow erosion, or a deep ulceration with rolled edges (Fig. 20.26) - May have a phimosis that obscures the lesion Scrotum Spermatocele Benign cystic accumulation of sperm occurring on the epididymis - Subjective Data - Asymptomatic; incidental finding on physical examination or self-examination - Objective Data - Smooth, spherical, nontender mass at epididymis (superior and posterior to the testis)  - Usually smaller than 1 cm Varicocele Abnormal tortuosity and dilation of veins of the pampiniform plexus within the spermatic cord - Subjective Data - Usually asymptomatic (and found in course of evaluation for infertility) - May report scrotal pain or heaviness - Objective Data - Often visible only when the patient is standing; is classically described as a "bag of worms" - Graded as: - Small: palpated only during Valsalva maneuver - Moderate: easily palpated without Valsalva maneuver - Large: causing visible bulging of the scrotum Orchitis Acute inflammation of the testis secondary to infection - Subjective Data - Acute onset testicular pain and swelling - Pain ranges from mild discomfort to severe pain - Associated systemic symptoms: fatigue, malaise, myalgias, fever - Mumps orchitis follows the development of parotitis by 4--7 days. - Objective Data - Enlarged, tender testis (Fig. 20.29) - Erythematous and edematous scrotal skin - Enlarged epididymis associated with epididymo-orchitis Epididymitis Inflammation of the epididymis (a major consideration in the differential diagnosis is testicular torsion, a surgical emergency - Subjective Data - Painful scrotum - Urethral discharge - Fever - Pyuria - Recent sexual activity - Objective Data - Epididymis feels firm and lumpy; is tender (Fig. 20.30) - Vasa deferentia may be beaded - Overlying scrotum may be markedly erythematous Testicular Cancer Classified by the cells from which the cancer arises - Subjective Data - Presence of painless mass in testicle - May report scrotal enlargement or swelling - Sensation of heaviness in the scrotum - Dull ache in the lower abdomen, back, or groin - Sudden collection of fluid in the scrotum - Objective Data - Irregular, nontender mass fixed on the testis (Fig. 20.31) - Does not transilluminate - May also have hydrocele (does transilluminate) - May have associated inguinal lymphadenopathy Testicular Torsion Twisting of testis around the spermatic cord; testicular torsion is a surgical emergency - Subjective Data - Acute onset of scrotal pain, often accompanied by nausea and vomiting - Absence of systemic symptoms such as fever and myalgia - Risk factors: trauma and strenuous physical activity - Objective Data - The testicle is exquisitely tender. - Testicle is elevated ("high riding") from a twisted or shortened cord - Scrotal discoloration is often present. - Absence of cremasteric reflex on side of acute swelling Klinefelter Syndrome Congenital anomaly associated with XXY chromosomal inheritance - Subjective Data - Differences in physical, language, and social development compared with others of the same age - Concern over delayed pubertal development - Objective Data - Hypogonadism, including a small scrotum - Diminished pubic, axillary, and facial hair - Enlarged breast tissue - Tall stature, long legs, short trunk  - In mild cases, no abnormalities will be present; however, the individual will be infertile **Chapter 21: anus, rectum, and prostate** Stool Characteristics in Disease Changes in the shape, content, or consistency of stool suggest that some Disease process is present. Stool characteristics can sometimes point to the type of disorder present; therefore, you should be familiar with the following characteristics and associated disorders: - Intermittent, pencil-like stools suggest a spasmodic contraction in the rectal area. - Persistent, pencil-like stools indicate permanent stenosis from scarring or from pressure of a malignancy. - Decreased caliber (pencil-thin stools) indicate lower rectal stricture. - A large amount of mucus in the fecal matter is characteristic of intestinal inflammation and mucous colitis. - Small flecks of bloodstained mucus in liquid feces are indicative of amebiasis. - Fatty stools are seen in patients with pancreatic disorders and malabsorption syndromes, such as cystic fibrosis. - Stools the color of aluminum (caused by a mixture of melena and fat) occur in tropical sprue, carcinoma of the hepatopancreatic ampulla, and children treated with sulfonamides for diarrhea Risk factors Prostate cancer - Age: Older than 50 years - Race/ethnicity: more common in African Americans and in Caribbean patients of African ancestry; less common in Asian American and Hispanic/Latinos than in non-Hispanic whites - Geography: common in North America and northwestern Europe, Australia, and on Caribbean islands; less common in Asia, Africa, Central America, and South America - Family history of prostate cancer: twice the risk with one first-degree relative; risk increases with more than one first-degree relative. The risk is higher for those who have a brother with prostate cancer than for those who have a father with it. - Inherited cancer syndromes: BRCA1, BRCA2 mutations; hereditary nonpolyposis colorectal cancer (Lynch syndrome) - Gonadectomy in transgender women may reduce but does not eliminate the risk of prostate cancer Anal cancer - Infection with high-risk type HPV - HPV-related conditions: anal warts, cervical cancer - Multiple sexual partners - Receptive anal intercourse - Cigarette smoking - Immunosuppression: HIV infection - Gender/ethnicity: more common in white females and black males Common Causes of Rectal Bleeding  STIs STIs that affect the anus include the following: HSV infection of the skin and mucosa causing recurring sores and pain Gonorrheal infection of the mucosa, producing an infectious discharge HPV, causing anal warts Parasites that affect the entire gastrointestinal tract Syphilis, early infection causing a painless lesion Hepatitis and HIV are two STIs whose symptoms do not appear on the anus but can be transmitted through anal sex practices. It is possible to acquire an STI without penetration. Oral--anal contact, whether from kissing or from oral contact with fingers that have been touching the anus, can spread bacteria and cause infection. The use of sex toys may also transmit certain infections. [Abnormalities] [Anus, Rectum, And Surrounding Skin] Pilonidal Cyst Cyst or sinus near the cleft of the buttocks - Subjective Data - Usually asymptomatic - May have pain with sitting and inflammation from secondary infection - Objective Data - Cyst or sinus seen as a dimple with a sinus tract opening - Located in the midline, superficial to the coccyx and lower sacrum (Fig. 21.7) - Opening may contain a tuft of hair and be surrounded by erythema - A cyst may be palpable Anal Warts (Condyloma Acuminata) Growths in or around the anus and genital area - Subjective Data - Patients may be unaware that the warts are present - Objective Data - Single or multiple papular lesions in or around the anus and genital area - May be pearly, filiform, fungating (ulcerating and necrotic) cauliflower, or plaquelike Perianal and Perirectal Abscesses Infection of the anal tissue or glands - Subjective Data - Painful and tender anal area - Fever - Pain on defecation or with sitting or walking - Risk factors: - Crohn Disease - Immunosuppression - Objective Data - Perianal abscess: tender swollen fluctuant mass in the superficial subcutaneous tissue just adjacent to the anus - Perirectal abscess: tender mass that may be indurated, fluctuant, or draining Anorectal Fissure Tear in the anal mucosa - Subjective Data - History of hard stools - Bleeding seen in toilet or on toilet paper - Rectal pain, itching, or bleeding - Objective Data - Examination is painful and may require local anesthesia. - Fissure most often in the posterior midline, although it can also occur in the anterior midline - Sentinel skin tag may be seen at the lower edge of the fissure -  May be ulceration through which muscles of the internal sphincter are seen - Internal sphincter is spastic Anal Fistula Inflammatory tract that runs from the anus or rectum and opens onto the surface of the perianal skin or other tissue - Subjective Data - May report chills, fever, nausea, vomiting, and malaise - Objective Data - External opening of a fistula appears as a pink or red, elevated, granular tissue on the skin near the anus - Palpable indurated tract may be present on digital rectal examination - Serosanguineous or purulent drainage may appear with compression of the area Pruritus Ani Itching of the anal area - Subjective Data - Anal burning or itching that may interfere with sleep - Objective Data - Excoriation, thickening, and pigmentation of anal and perianal tissue Hemorrhoids Swollen veins in the lower portion of the rectum or anus - Subjective Data - External: May cause itching, bleeding, and discomfort - Internal: no discomfort unless they are thrombosed, prolapsed, or infected - Bleeding may occur with or without defecation - Objective Data - Usually not visible at rest, they can protrude on standing and on straining at stool - Thrombosed hemorrhoids appear as blue, shiny masses at the anus - Internal: soft swellings that are not palpable on rectal examination and are not visible unless they prolapse through the anus; proctoscopy usually required for diagnosis - Hemorrhoidal skin tags, which can appear at the site of resolved hemorrhoids, are fibrotic or flaccid and painless Polyps Abnormal growth of tissue projecting from the mucous membrane - Subjective Data - Asymptomatic - Rectal bleeding - Objective Data - Rectal polyp may protrude through rectum (Fig. 21.12) - Rectal polyps are sometimes palpable on rectal examination as soft nodules and can be either pedunculated (on a stalk) or sessile (closely adhering to the mucosal wall) - Colonoscopy or proctoscopy is usually required for diagnosis, and biopsy is necessary to distinguish benign from malignant Anal Cancer Cancer of the anal skin, mucosa, or glands - Subjective Data - May be asymptomatic - May report: - Bleeding from the anus or rectum - Pain or pressure in the area around the anus - Itching or discharge from the anus - A lump near the anus - A change in bowel habits such as constipation, diarrhea, and the thinning of the stools - Objective Data - Raised erythematous mucosa - White scaling mucosa - Pigmented mucosa - Mucosal ulceration - Verrucous lesion Colorectal Cancer Cancer of the large intestine or rectum - Subjective Data - Bleeding is most common symptom - Often asymptomatic - May report: - Change in bowel habits or stool characteristics - Abdominal pain or tenderness - Personal or family history of colon polyps - Family history of colon cancer - Objective Data - Rectal cancer may be felt as a sessile polypoid mass with nodular raised edges and areas of ulceration; the consistency is often stony, and the contour is irregular - Carcinoma higher in the colon not palpable - Polyps or lesions visualized on colonoscopy or flexible sigmoidoscopy\\ Prostate Prostatitis Inflammation and infection of the prostate gland - Subjective Data - Acute - Pain - Urination problems - Sexual dysfunction - Fever, chills, shakes - Chronic - Asymptomatic - Frequent bladder infections - Frequent urination - Persistent pain in the lower abdomen or back - objective Data - Acute - Gentle examination imperative; massage of the prostate can cause bacteremia. - Prostate enlarged, acutely tender, and often asymmetric - Abscess may develop, felt as a fluctuant mass in the prostate. - Seminal vesicles are often involved and may be dilated and tender on palpation; however, the prostate may feel boggy, enlarged, and tender or have palpable areas of fibrosis that simulate neoplasm. - Bacteria in the urine - Chronic - Prostate may be normal in size and consistency. - May be enlarged and boggy - Prostate massage required for specimen collection Benign Prostatic Hypertrophy (BPH) Nonmalignant enlargement of the prostate - Subjective Data - Symptoms of urinary obstruction: hesitancy, decreased force and caliber of stream, dribbling, incomplete emptying of the bladder, frequency, urgency, nocturia, and dysuria - Objective Data - Prostate feels smooth, rubbery, symmetric, and enlarged - Median sulcus may or may not be obliterated Prostate cancer - Subjective Data - Early carcinoma asymptomatic - As the malignancy advances, symptoms of urinary obstruction occur (see symptoms listed for BPH) - Objective Data - A hard, irregular nodule may be palpable on prostate examination - Prostate feels asymmetric, and the median sulcus may be obliterated - Biopsy required for diagnosis Enterobiasis (Roundworm, Pinworm) Infection caused by a small, thin, white roundworm, Enterobius vermicularis - Subjective Data - Intense itching of the perianal area - Parents often describe unexplained irritability in the infant or child, especially at night - Objective Data - Perianal irritation often results from scratching - Can be diagnosed using Scotch tape test: press the sticky side of cellulose tape against the perianal folds, and then press the tape on a glass slide; nematodes can be seen on microscopic examination **Slides for genitourinary** The five "P"s stand for:  - Partners (don't assume gender) - Practices (oral, vaginal, rectal) - Protection from STDs  - Past history of STDs  - PID - Risk for cancer - Recurring STI chance  - Prevention of pregnancy  Reproductive health - "addresses the reproductive processes, functions and system at all stages of life. Reproductive health, therefore, implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so." Sexual healthExternal  -  "is a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence." Female (xx chromosome) - Stage 2 begins with breast buds -- 8-13 years old (median age=9-10 yrs) - Peak height velocity about 1 year later - Menarche \~2-2.5 years later (m=12.5 yrs.) - Adult appearance at stage 5 after 4-5 years Males (xy chromosome) - Stage 2 begins with testicular enlargement to \> 2.5cm and changes in scrotal skin (9-14 years old) - Pubic and axillary hair develops - Penis begins to grow in width and length, Tanner 3 - Peak height velocity in Tanner 4 stage - Adult appearance at stage 5 The menstrual cycle - Ovarian cycle, follicular phase, ovulatory phase, luteal phase, endometrial cycle, menstrual phase, proliferative phase, secretory phase - Menstrual cycle may be irregular at the beginning during puberty and end during perimenopause. - It is important to understand the menstrual cycle with regards to fertility and contraception. - Complete year without a period- menopause  Female anatomy - Urethral opening - Vagina opening - Anus  closely aligned - Females more at risk for UTI (ecoli) - Reproductive organs -- more internal & protected than male - Hormonal variations with menses Male reproductive system - Male reproductive system: Sperm production occurs in the testicles. Upon reaching puberty, a man will produce millions of sperm cells every day. Note the urethra serves both for the passage of urine and semen. Also note the distance from the anus. - \- Dysuria -- uncommon unless STI or obstruction due to enlarged prostate, kidney stone etc. - Anytime a man has dysuria, its complicated, men should not get a simple UTI Gender identity:  - Individual person's internal sense of self and his or her own understanding of his or her gender within a cultural context - Can alter cultural labels applied to a relationship Sexual orientation: LGBTQ+ - Minority group that experiences higher rate of health disparities and has unique health care needs - Label assigned by culture referring to a person's romantic/intimate preferences The sexual history - The single most important rule is: - To be non-judgmental and part of our health GU & GYN History Questions -Ask About: - The 5 Ps  - Detailed pregnancy history:  GTPAL and complications - Gravida = ( \# pregnancies) T = (\# of full-term births) P = (\# of preterm births) A = (\# abortions- includes miscarriages ) L = \# living children - Detailed menstrual history. LMP (if late -- do pregnancy test) -  Contraception and family planning - Ask if Breastfeeding - Sexual pleasure and libido (desire) - Urinary hx: UTIs, incontinence etc. - Intimate Partner Violence or past hx of abuse - A wellness exam for a woman presents an opportunity to counsel about healthy lifestyle and to minimize health risks. A thorough woman's health history includes the following elements: a menstrual history, a gynecological history, a sexual history, and an obstetric history. - Menstrual history: Include the age of menarche, the length and frequency of the cycle, the type and amount of menstrual flow, and any associated symptoms, including dysmenorrhea, cramping, mood swings, headaches/migraines, bloating, premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), bleeding between periods or after intercourse, or odor. Note the first day of the last menstrual period (FDLMP). A thorough menstrual history also includes a history of perimenopause or menopause if this is applicable to the patient. Review the patient's current bleeding pattern, if any. If she is no longer bleeding, find out when her last menstrual period was. Discuss if she is experiencing any vasomotor symptoms, including night sweats, hot flashes/flushes, vulvovaginal atrophy or dryness, and/or mood changes. Has she ever been on or does she currently use any form of hormone replacement therapy? - Gynecological history: Discuss past cervical and vaginal cytology, including the date of her last Pap smear and her results, any history of abnormal Pap smears, any additional treatments or procedures such as a colposcopy, and any follow-up measures. Ask about any medical history of fibroids, abnormal bleeding, gynecological surgeries or procedures, and address any concerns such as abnormal vaginal discharge, odor, dyspareunia, vaginal pruritus, vaginal dryness, and any lesions in the vaginal or inguinal area. - Sexual history: Ask about current and past sexual activity. Discuss the number of lifetime partners, the current number of partners, and whether she is sexually active with men, women, or both. Does she have any history of sexual abuse, or any history of sexual assault, and does she currently feel safe in her current relationship(s)? Review any history of sexually transmitted infections (STIs) and/or pelvic inflammatory disease. Include dates, treatment of infections, and whether partners also received treatment. Has she had the human papillomavirus vaccine? Discuss current practices to prevent pregnancy and STIs. Discuss her current contraception method, any previous contraception method(s), and the reason(s) for discontinuing other methods. Ask about her ability to achieve orgasm, sexual motivation, and sex drive. - Obstetric history: When discussing the obstetric history, GPA and TPAL are two commonly used mnemonics to ensure all information is obtained (Table 2.2). In addition to this information, ask about any complications during pregnancy, labor, or postpartum. Did labor happen spontaneously, was it induced, or was it a cesarean delivery? If applicable, what was the reason for the cesarean delivery? Ask about ability to conceive and if any infertility methods or procedures were used. - Common Mnemonics for Obstetric History - G (Gravida) - Number of total pregnancies - P (Para) - Number of viable births - A or Ab (Abortus) - Number of abortions -  Preconception planning - History questions - Ask about previous pregnancies - Immunizations- cannot get HPV or live vaccines - Regularity of menstrual cycle - Do they take folic acid - How long have you been trying - How old are you  - What medications are you taking - Consider chronic diseases such as hypertension, diabetes - Do they want to lose weight before becoming pregnant  - Do they smoke or drink  - Screenings - STI - Health Promotion Teaching -- Primary Prevention - Preconception counseling (use of folic acid prior to pregnancy) - Vaccines CDC - schedules - Healthy weight, diet and exercise - Use of condoms & STD prevention - Contraceptive use - Stress reduction and limited alcohol use - HPV Infection and Cervical Cancer - Human papillomavirus (HPV): primary cause of cervical cancer (99.7% worldwide) - HPV Vaccine -- 11 to 26 years old -- Male & Female - - 2021 USPSTF - Age 21-24: Pap test every 3 years, HPV test every 5 years, or HPV/Pap cotest every 5 years - Age 25-29: HPV test every 5 years (preferred)\ HPV/Pap cotest every 5 years (acceptable)\ Pap test every 3 years (acceptable) - Age 30-65:  pap test every 3 years, HPV test every 5 years, or HPV/Pap cotest every\ 5 years - Age 65 and older: No screening if a series of prior tests were normal and not at high risk for cervical cancer Health Promotion Teaching -- Secondary Prevention & Screenings USPSTF A & B  - BRCA 1/2 , Breast, Cervical Cancer and CRC Screening - Preconception counseling; vaccinations UTD? Alcohol/Drug Misuse, Tobacco - Smoking/Vaping - Healthful Diet and Physical Activity, Behavioral interventions  for weight loss to prevent obesity morbidity & mortality - STDs: Chlamydia, GC, HIV, Hep B, Hep C, Syphilis - Depression & including Post-partum  - High Blood Pressure - Intimate Partner Violence Cancer Screening: Cervical 21-65 and Colorectal Cancer 45 -75 y.o.  - Cervical cancer deaths in the United States have decreased since the implementation of widespread cervical cancer screening and most cases occur in women who have not been adequately screened. - USPSTF Recommendation: Periodic screening based on age and method (see below). - Ages and Frequency 21 to 29 years: cervical cytology alone every 3 years - 30 to 65 years: screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (co-testing). - Colorectal Cancer Screening: Colorectal cancer is most common among adults over age 45years and early detection with screening can reduce mortality. - USPSTF Recommendation: Screen for colorectal cancer starting at age 45 years and continuing until age 75 years. - Ages and Frequency 45 to 75 years: frequency varies by method - Clinical Practice Screening methods include gFOBT (guaiac-based fecal occult blood test), FIT (fecal immunochemical test), or FIT-DNA (multitargeted stool DNA test) every 1-2 years; flexible sigmoidoscopy or computed tomography (CT) colonography every 5 years; and colonoscopy every 10 years. BRCA 1/2 Gene & Breast Cancer Screening - Risk Assessment for BRCA1/2 Testing - Rationale: Inherited mutations of the BRCA1/2 gene increase risks for breast, ovarian, fallopian tube, and peritoneal cancer. These mutations occur in an estimated 1 in 300 to 500 women (0.2% to 0.3%) in the general population, but are more common within families with previously diagnosed cancer. - USPSTF Recommendation: Assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. Women without positive family histories do not require genetic counseling or BRCA testing. - Mammography for Breast Cancer Screening - Rationale: Breast cancer is the second-leading cause of cancer death among women in the United States. - WPSI Recommendation: Initiate mammography screening no earlier than age 40 and no later than age 50 for women at average risk for breast cancer. Screening should continue through at least age 74 and age alone should not be the basis to discontinue screening. A common Chief Concern:Dysuria- pain with urination  - ¼ of all adult women experience an episode of acute dysuria each year (men much less) - Second only to respiratory illness for office visits - Causes: Infection (most common cause), some common pathogens: -   UTI (80-90% e-coli) -    vaginitis (monilia/yeast, BV, trichomonas) , urethritis (chlamydia, GC, HSV, trich, candida) - Noninfectious causes (consider irritants, trauma, estrogen deficiency etc after r/o infection) Urinary Tract Infections: Epidemiology  - One of the most common problems in primary care - The most common bacterial infection affecting humans - Of nosocomial infections UTI accounts for 40% - related to indwelling Foley catheters - Up to 50% of all women will experience at least one episode of UTI in their lives - UTIs in females outnumber males 25 to 1 - 20 to 50 times more likely in reproductive years  - After age 50, incidence similar UTIs - Sources of Bacteria: Bowel, Perineum, Vagina - Organisms:  E coli -- 80% of UTI's Klebsiella;Enterobacter Proteus, Pseudomonas, Staphylococcus saprophyticus (5 --15%) Enterococcus Candida , Adenovirus type 11 Risk Factors for UTI - Host Factors - Female - Male \>60 years - Menopause/Estrogen deficiency (vaginal and urethral atrophy) - Immunologic suppression - Structural/organic:  - BPH - Diaphragm use - Constipation - Kidney stones - Cystocele - Rectocele - Tumor - Stenosis - Neuropathy - Behavioral Factors:  - Sexual intercourse - Diaphragm/spermicide use - Not voiding after coitus? - Incontinence - Structural, functional  - Medications - Instrumentation:  - Catheters - Diagnostic Procedures - Surgery  - Other Factors:  - Pregnancy - Dehydration - Diabetes Classification - Uncomplicated - Usually occur in otherwise healthy females - Isolated UTI - Not pregnant - UTI not secondary to a structural, functional or neurologic problem - Complicated  - Lower or upper  - Related to a structural, functional or neurologic problem - Occur more than twice in one year - Woman is pregnant - From antibiotic-resistant organisms - Any UTI in a male, should send it off for culture  Pathogenesis- UTI - Uncomplicated - 95%  of infections ascend via the urethra with fecal microorganims (gram-negative aerobes) - Escherichia coli  80-90% - Staphylococcus saprophyticus  10-15% - Klebsiella species  2-5% - Enterobacter species  2% - Other routes are: - Hematogeneous spread...from distant focus of infection - Direct extension...fistulas secondary to diverticulitis or Crohn's disease - Complicated  - Anatomic or Functional - ​​Outlet obstruction (cystocele, rectocele, BPH, fecal impaction, diaphragm use) - Congenital abnormalities - Vesicoureteral reflux - Ureteral or urethral strictures - Pregnancy - Infections or Stones - Prostatic calculi, prostatitis - Kidney stones - Focal kidney infection - Chronic pyelo - Immunosuppression - Diabetes - Tumors - Pregnancy - Chemotherapy or other immunosuppressive medications - HIV/AIDS - Aging process - Neurologic dysfunction - Diabetic neuropathy   - Multiple sclerosis - Stroke   - spinal cord injury or stenosis - Escherichia coli  32% - Enterococci  15% - Pseudomonas aeruginosa  12.5% - Klebsiella species  7.5% - Proteus species 7.5% \*Key History Questions: Complicated or Uncomplicated  UTI? - Do you have back pain? - Have you had fever and chills in the past few days? - How many urinary tract infections have you had in the past 12 months? (3 or less could be uncomplicated)  - Have you ever had testing for problems in the urinary tract or seen a urologist for any reason? - Do you have diabetes? - Are you pregnant? UTI in the Older Adult - Increased incidence - Immobility & neuropathy - BPH & stones - Atrophic changes - Increased residual urine - Fluid restriction - Fecal incontinence - Decreased bactericidal activity of urine & prostatic secretions - Instrumentation - Infections are often atypical - Incontinence may be an early symptom - Typical irritative symptoms may or may not be present - May present with change in behavior/mental status: - Lethargy - Agitation - Flu-like symptoms - Delirium  UTI Caveats - Any UTI in a male is considered to be complicated - The possibility of an STI should be high on the list of differential diagnoses - Develop gradually over days to weeks - Uti develops over a couple of days - Uncomplicated lower tract UTIs may present with symptoms of complicated upper tract infections and vice versa \*Differentiating UTIs from STIs - In general... - STIs develop over several days to weeks as opposed to 1-3 days in acute UTI - An STI usually presents only with dysuria; the symptom of urgency is not present - Sexual history is important!  Often, the patient has a new partner and/or has not used condoms Chief Concern Urinary Incontinence: Age & Risk Factors - Common problem especially in older adults - Categorized according to underlying anatomical or physiological impairment - [Stress incontinence] -- leaking of urine during activities (coughing, laughing etc -- pelvic floor weakness - [Urge incontinence] (overactive bladder) - [Overflow incontinenc]e (over distension to bladder) Reversible Factors that Can Cause Urinary Incontinence - D Delirium, dementia, dehydration, diet - I Infection (UTI) - A Atrophic vaginitis/urethritis - P Pharmaceuticals - E Endocrine/excess urine production - R Restricted mobility, retention - S Stool impaction  Common Diagnostic Tests - Urinalysis: clean catch - Routine - Microscopic: most sensitive indicator of infection = more than 5 WBCs/high powered field in the urine - Microscopic is more sensitive than dipstick for hematuria and bacteriuria and is the only way to detect casts. - Urine Culture: needed for reoccurring UTI, upper UTI, during pregnancy or other medical complications (complex) - "Wet Prep" NS & KOH microscopy done (PPM) primary care: Look for clue cells (BV) & yeast along with trichomonas Provider Performed Microscopy - Quality and Safety is important. - Must be trained to accurately diagnosis. - Examples includes "wet preps", urine microscopy, gram stains for GC, etc. Common Screening or Diagnostic Tests - Also check for STI to include HIV and Syphilis  as indicated. - STIs and screening - Gonorrhea, chlamydia, trichomonas (NAAT test by vaginal secretions or urine - HIV & Syphilis -- usually blood tests - genital warts, genital herpes (lesions & hx often easy way to dx) - Cervical Cancer Screening: PAP & HPV testing from Cervical Os - Prostate PSA, Testosterone levels as indicated - Renal disease - CBC as indicated, Sed rate as indicated, Metabolic panel/blood sugar Common Diagnostic Tests - [Renal Function] - **BUN** - Increases by 10-20 mg/dl/day if Renal Function absent  - Serum Creatinine is a better measure of Renal Function  - BUN is Protein dependent  - High protein diet  - Catabolism - **Creatinine (serum)** - Reflects renal filtration...is an excellent marker of renal damage and progressive renal failure - Formed as an end-product of creatinine phosphate metabolism in muscle - Formed at a constant rate and little influenced by diet - Normal = 0.6-1.0 mg/dL in women;  0.8-1.3 mg/dL in men (due to diff. in muscle mass) - Increases by 1.0-1.5 mg/dl/day if no Renal Function  - Often unchanged until 25-50% of Renal Function lost  - Doubled Serum Creatinine implies 50% Renal Function - Measurement of urine proteins - 24-hour urine collection - Microalbuminuria [Imaging Studies] - IVP - CT & US now preferred tools Screening: Asymptomatic Bacteriuria - Screening for asymptomatic bacteriuria and UTI - Recommended only in selected high-risk populations (pregnant women-12 to 16 Weeks\' Gestation)  - May consider in certain procedures (prostate, patients with recent catheterization, patients with know hx of renal calculi or structural abnormalities, before having procedures).  Best to not over treat with antibiotics. Men's Sexual Health History  - Questions about the genitalia flow naturally when assessing the GU system. - Ask about prostate symptoms (see handout -- nocturia, difficulty starting/stopping flow of urine etc.  - Past hx of STDs: Remember 5 Ps as STI can involve any body opening. - Any condom use or other forms for protection. - History of present illness: Normal functioning of male genitourinary and reproductive systems, health maintenance, and health-promotion needs - Presenting symptoms: Penile discharge/lesions; scrotal pain, swelling, or lesions; inguinal/groin swelling, pubic area rash/itching, reproductive health, sexual health concerns  (ED) - Ask about Prostate Sx:  Medical Emergency -- Severe Inguinal Pain Clinical Presentations: Testicular Torsion - History - Acute, intense pain - May be associated with nausea & vomiting - May have h/o onset during physical activity...but not always - PE - Firm, exquisitely tender testicular mass - Scrotal discoloration (blue dot), erythema. - No cremasteric reflex on affected side - Prehn sign + pain relieved with lifting of testicle (may point to epididymitis). No relief with testicular torsion - Note that this is a surgical emergency! - 6 hours of less = 90% of testicular viability - \> 12 hours = 50% - \> 24 hours = 10% BPH - Lower Urinary Tract Symptoms (LUTS) - Obstructive - Weak stream - Intermittency - Straining - Incomplete emptying - Irritative - Frequency - Urgency - Nocturia USPSTF Screening for Prostate Cancer (PSA Testing) - Recommendation Summary. Grade C -  For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)--based screening for prostate cancer should be an individual one.. - Grade D: - The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older. Men's Sexual Health History  - Sexual problems in men include: an inability to acquire or maintain an erection satisfactory for sexual intercourse (impotence or erectile dysfunction (ED); lack of interest in sex (diminished libido); premature ejaculation; and delayed or inhibited ejaculation.  - Direct questions will help you assess each phase of the sexual response (libido, ED) - ED - Erectile dysfunction is the most common sexual disorder for men. Multifactorial etiology with physical and psychological factors: - Physical causes include: Urological, Vascular, Neural, Endocrine and Pelvic disorders, Smoking and Medications. - Increased age (testosterone, hormonal, prostate changes) - Diabetes, Cardiovascular Disease and Hypertension - Psychological causes include, but are not limited to: -  fatigue, stress, performance anxiety, poor self image or lack of communication with sexual partner/s, depression, and other psychological factors. - Erectile Dysfunction & Cardiometabolic Risk - ED is a primary vascular disorder in men \> 30 yrs old therefore potent predictor of cardiovascular disease (CVD). - ED is associated with HBP, hyperlipidemia, DM, & depression. - ED is independent predictor of CV morbidity & mortality in DM patients with silent CAD. - ED precedes CVD by 2 to 5 years. - ED predicts CVD in non-DM middle aged men. Erectile Dysfunction & Coronary Artery Disease - May be different manifestations of the same underlying blunted endothelial dependent vasodilation response. - Therefore, impaired vasodilation of the penile artery may be the first vascular "stress test" of a more diffuse vascular disease process. - Framingham risk score (FRS) suggests ED is a potent predictor of all-cause death and the composite of CVD, myocardial infarction, stroke & heart disease.\* - Patients with ED should be evaluated for CVD risk factors and aggressively treated for hypertension, hyperlipidemia, diabetes & obesity. Who is at Risk for STD/HIV - Any sexually active individual but special focus on: - Females less than 25 years old - Pregnant Females - Men who have sex with men - Substances use (alcohol, drugs) - Past Hx of STD - New partner and/or \> 1 partner a year - Pay/Paid for Sex: Not necessarily for money, could be for housing/food/drug purposes  - Individuals  just out of correctional facilities - Military, college students, truck drivers \* Don't assume, take a good sexual history and screen/test as needed. USPSTF Recommends HIV Screening  (April 2013)= A - Adolescents and Adults 15-65 Years Old - The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. - Pregnant Women - The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. - Other Relevant USPSTF Recommendations: The USPSTF has made recommendations on behavioral counseling to prevent sexually transmitted infections - PrEP -- Primary Prevention for HIV STD/HIV Inter-relationships - Behavioral - Both are sexually transmitted - Epidemiological - Populations with high rates of STDs show disproportionally high rates of sexually-transmitted HIV - Immunological - STDs result in changes in immune cells of  the mucous membranes ("Pink Parts"), which can facilitate sexual HIV acquisition & transmission STI Overview "Sores" (ulcers) - Syphilis - Genital herpes (HSV-2, HSV-1) - Others uncommon in the U.S. - Lymphogranuloma venereum - Chancroid - Granuloma inguinale "Drips" (discharges) - Gonorrhea - Chlamydia - Nongonococcal urethritis / mucopurulent cervicitis - Trichomonas vaginitis / urethritis - Candidiasis (vulvovaginal, less problems in men) Other major concerns Genital HPV (especially type 16, 18) and Cervical Cancer Abnormal Findings  - Syphilis - STI caused by Treponema pallidum - Spread by direct contact with a chancre - Genital warts - Most commonly caused by HPV types 6 and 11 - Genital herpes - Viral STI caused by herpes simplex virus type 1 or 2 - Drips (discharges) - Gonorrhea - STI caused by the bacterium Neisseria gonorrhoeae, which commonly infects the cervix, uterus, fallopian tubes, and urethra - Chlamydia - Most commonly reported bacterial STI, caused by Chlamydia trachomatis - Trichomonas - STI caused by infection with a protozoal parasite, Trichomonas vaginalis Progression of Untreated Syphilis - Primary -- local invasion; painless ulcer (chancre) - Secondary -- systemic disease; blood-borne spread to all major organ systems - Latent -- silent infection; transmission still possible - Tertiary -- noninfectious; significant morbidity & mortality -  Laboratory Test for Gonorrhea  - Gram stain - Gram negative intracellular or extracellular diplococci  - Culture - on Thayer-Martin agar,  use to be the \"gold standard\" for diagnosis - NAAT (Nucleic Acid Amplification Testing) - Superior to culture - Vaginal or urine specimens  - Best test for females  Think STI/HIV... - We need to do our due diligence to get to a right diagnosis. - Ask questions in history r/t sexual behavior and IVDU (sex  and/or needles) - Acute HIV infection -- may present with flu like sx, sore throat, swollen lymph nodes & rash - Erythematous non-specific rash - Lymphadenopathy - Mucocutaneous ulcerations (oral/vaginal/esophageal) - Pharyngitis - Neurologic abnormalities (including encephalitis) - Oral manifestations - Presentation may be similar to mono - Acute HIV infection can resemble infectious mononucleosis, flu, or other viral syndromes. Typical symptoms include fever, headache, fatigue, and swollen lymph nodes. People may also experience aching muscles and a rash that occurs anywhere on the body and may change locations. These symptoms may last from a few days to 4 weeks, and then subside. - After an infection with HIV, antibodies to the virus can be detected in the blood. This is called HIV seroconversion (converting from HIV negative to HIV positive), and usually occurs within 3 months of exposure, but on rare occasions may occur up to a year after exposure. - Following the acute infection, there may be no further evidence of illness for the next decade. - - -  Screening Tests for HIV - Laboratory Screening Tests: should be FDA approved antigen/antibody combination immunoassay that detects HIV 1 and HIV 2 antibodies and HIV 1 p24 antigen. - FDA --approved tests for detection and confirmation of HIV infection include combination tests (for p24 antigen and HIV 1/2 antibodies) if indeterminate do RNA nucleic acid test (NAT)  - If it is a dx test (clinical sx) with qualitative HIV-1 RNA  to look for acute HIV infections Acute HIV Diagnostic Test  - An [HIV ELISA/Western blot](http://www.nlm.nih.gov/medlineplus/ency/article/003538.htm) is usually negative or indeterminate during the acute infection and will become positive over the next 3 months.  - An HIV RNA viral load is positive in patients with acute HIV infection. A lower-than-normal CD4 count may indicate suppression of the immune system. The CD4 count usually improves 1-2 months following acute infection.  - A [blood differential](http://www.nlm.nih.gov/medlineplus/ency/article/003657.htm) may show abnormalities.  - P24 antigen blood test is often positive Documentation for Male Pelvic  and Rectal Exam - Inguinal: Nontender, no nodal enlargement. Femoral pulses 2+/2+ without thrills or bruits. No herniations noted. - External genitalia: Normal appearance and pubic hair distributions. No lesions or infestation noted. No urethra discharge. Penis is/is not circumcised. Testicles are descended and do not appear atrophied. There are no masses or tenderness on palpation. No thickening or tenderness of epididymis. Bilateral inguinal hernia exam in negative. - Recto/prostate Exam: perianal area intact without lesions, fissures or hemorrhoids. Rectal exam reveals good sphincter tone present with no pain or tenderness on insertion of finger. No masses palpable and hemoccult was negative. Prostate without nodules or masses palpable. Male Genitalia; Rectal Exam - Demonstrates the assessment of male or female genitalia and rectal exam on lab model - And be prepared to discuss and demonstrate -- cervical cancer screening, STI screening, POC tests for vaginal discharge, dysuria, late menstrual period, BPH symptoms.