Chapter 19Sensitive Pelvic Examinations

Discussing Aspects of Medical Transition with Transgender Patients: Some aspects of medical transition can affect a person’s health, make certain medical conditions more or less likely, or change which reference ranges you should refer to when interpreting lab values. If you think that medical transition could affect diagnosis, treatment, or prognosis, you will want to ask about a patient’s medical transition. It is important to ask about a person’s transition only with consent and because it pertains to the medical issue at hand. Do not ask about someone’s medical transition because of personal curiosity. Also remember that trans people may or may not ever use hormone therapy or surgical interventions as part of their transition.

• Explain Why and Ask Permission to Discuss: Trans people may have had negative healthcare encounters in the past and may wonder why you are asking about their medical transition. Try to frame your questions with an opening statement – for example: If you’ve had any hormone therapy or transition-related surgeries, it could impact what you’re experiencing now. I’d like to ask about your specific medical and/or surgical transition to ensure I’m taking care of you appropriately. Is that okay?
• Ask about Hormone Therapy: Trans people may use feminizing or masculinizing hormones as part of their transition. See Rainbow Health Ontario Protocols for Hormone Therapy for Trans Clients for more info. Important questions include:
  • Are you on any hormone therapy currently? What hormone, dose and frequency?
  • Have you been on hormone therapy in the past? Why did you stop hormone therapy?
  • Have you ever had any complications or side effects from hormone therapy?
  • If Pertinent: Any changes in your genitals since starting hormone therapy?
  • If Pertinent: Any changes in your sexual function since starting hormone therapy?
  • For patients on masculinizing hormone therapy: Are you still menstruating? When did you last have a menstrual period?
• Ask about Surgical History: Trans people may have surgery to alter primary or secondary sex characteristics as part of their transition. See Rainbow Health Ontario Transition-Related Surgeries Summary Sheets for more info. Important questions include:
  • Have you had any surgeries as part of your transition?
  • What surgeries? When? Have there been any complications?
  • What anatomical structures/organs have been removed?
• Ask about other Transition-Related Medical Care: Is there anything else you think I should know about your transition that may affect your health or medical care?
• Closing the Encounter:
  • Gratitude: Thank the patient for trusting you and being open about their social, medical and/or surgical transition with you.
  • Reflection: Reflect on what went well and what you would change the next time you are working with this patient, or with other trans patients.
  • Self-Directed Learning: Read around anything unfamiliar that came up during the encounter. Rainbow Health Ontario’s Trans Primary Care Guide is an excellent place to read around health for Transgender Patients.
  • Documentation: Document appropriately so patient does not need to repeat their story, name and pronouns every time they see you or another provider in the same clinic, etc.

(Often a Separate Heading in any Obstetrics-Gynecology Consult)

• Symptoms:
  • Pelvic Pain – See below
  • Discharge: Quantity, colour, odour, consistency, irritation, inflammation
  • Dyspareunia: insertion vs. deep penetration?
• Contraception Use: Assess patient’s satisfaction; Past methods; Condom use
• Prolapse Symptoms (Including Cystocele, Rectocele, Vaginal Vault or Uterine Prolapse):
  • General: Pelvic Pressure/Heaviness; Dependent Vaginal Bulge; Sexual Dysfunction
  • Urinary: Stress Incontinence (kink in urethra from bladder descent); Overactive Bladder
  • GI: Incomplete emptying; splinting (applying manual pressure to posterior vaginal wall to improve defecation)

For detailed Obstetrical visit notes, see Ch 20 – Obstetric Visit Notes – MF3 (Often a separate heading in any Obstetrics-Gynecology Consult)

• GTPAL: G = Gravida (gestations including current pregnancy); T = Term Births (carried to 37 wks and delivered); P = Preterm Births (carried to 20-36 wks and delivered); A = Abortions (Elective or Spontaneous <20 weeks); L = Living Children (live births)
  • Delivery Method: C-Section; Vaginal → Assisted/Instrumental (Vacuum or Forceps), Spontaneous, or Augmented (Oxytocin)
• Complications: Normal Birth Weight (BW) is 2500-4500g; Gestational diabetes characteristic BW >4500g = Macrosomia; Pre-eclampsia characteristic BW is <2500g.
• Family Planning: Is the patient interested or attempting to become pregnant?
• Infertility: Defined in terms of a couple (both female & male factors); the failure to achieve a clinical pregnancy after 12 months or more of regular, unprotected sexual intercourse

(Often incorporated into Gynecological History in an Obstetrics-Gynecology Consult)

• Last Menstrual Period (LMP); Menarche (Age at first period)
• Menses: Any recent changes?
  • Cycle length & regularity: 21-35 days; Duration: 2-7 days
  • Flow/quantity: ask # of pads in specific time period
  • Cramping: pre-menstrual, Mittelschmerz (ovulation pain), during menses
  • Premenstrual Syndrome and Premenstrual Dysphoric Disorder (PMDD – cluster of affective, behavioural and somatic symptoms)
• Menstrual abnormalities:
  • Amenorrhea: Absent menstruation (can be primary i.e. no menarche, or secondary)
  • Dysmenorrhea: painful menstruation, typically with abdominal cramps
  • Menorrhagia (Hypermenorrhea): prolonged (>7 days) or excessive (> 80 mL per cycle, soaking pads/tampons < 2 hrs duration) bleeding occurring at regular intervals
  • Oligomenorrhea: uterine bleeding occurring at infrequent, irregular intervals
  • Metrorrhagia: bleeding occurring at frequent, irregular intervals
  • Menometrorrhagia: combination of both menorrhagia & metrorrhagia (uterine bleeding that is prolonged, excessive & frequent, irregular)
  • Intermenstrual Bleeding: can be spotting in between periods
  • Post-Menopausal Bleeding: malignancy until proven otherwise
• Peri/Postmenopausal Symptoms: Hot flashes (LR+ 2.15-4.06, LR- 0.54-0.87), night sweats (LR+ 1.9, LR- 0.67-0.92), decreased sexual interest (LR+ 1.56, LR- 0.89), vaginal dryness (LR+ 1.48-3.79, LR- 0.92), abnormal bleeding, irritability (LR+ 1.23, LR- 0.83), depressed mood (LR+ 1.3-3.14, LR- 0.82-0.94), mood changes
• Important Diagnosis – Polycystic Ovary Syndrome (PCOS): ↑GnRH Pulsatility → ↑LH vs. FSH → ↑androgen production by theca cells; hyperinsulinemia → decreased Sex-Hormone Binding Globulin, ↑free testosterone → Oligo- and/or Anovulation; clinical and/or biochemical signs of hyperandrogenism (e.g. acne, hirsutism); polycystic ovaries (on US)

• Urinary or Bowel Habit Changes: Dysuria, hesitancy, urgency, incontinence, rectal bleeding
• Lower Urinary Tract Symptoms (LUTS): Frequency, Urgency, Nocturia, Incontinence
  • Stress Incontinence (Hypermobile urethra, poor support from endopelvic fascia, incontinence with increased abdominal pressure, Detrusor not contracting, small volumes of urine at a time): Incontinence with sneezing, laughing, straining, cough
  • Urgency Incontinence (Detrusor Muscle Over-activity): Urinary urgency without full bladder
  • Overflow Incontinence (Underactive Detrusor Muscle; bladder retention and then overflow): Constant dribbling
  • Bypass Incontinence (e.g. Fistulae); Functional Incontinence (e.g. due to Dementia)
  • Note – remember to ask about Prolapse (see above) in gynecologic history if pertinent
• Can’t Miss Diagnosis – Acute Urinary Retention: sudden onset painful inability to void, suprapubic pain/discomfort palpable bladder, restlessness/distress. Etiologies include:
  • Urinary outlet obstruction (including trauma e.g. to pelvis, urethra, penis):
    • Male patients: Benign prostatic hypertrophy (BPH – see below), prostate cancer, phimosis or paraphimosis, acute bacterial prostatitis
    • Female patients: Pelvic organ prolapse such as cystocele, or pelvic masses
  • Neurogenic (important to rule out): e.g. spinal cord compression, stroke, diabetic neuropathy, Guillain-Barre syndrome –urinary retention preceding overflow incontinence
  • Medications: e.g. anticholinergics, antidepressants, anti-parkinsonian medications, antipsychotics, antihistamines, antihypertensives, muscle relaxants, opioid analgesics.

Use AUA-Symptom Score Questionnaire for BPH to screen and also to monitor response to treatment – BPH may cause can’t miss diagnosis of Acute Urinary Retention (See above)

• Incomplete Emptying: Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
• Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
• Intermittency: Over the past month, how often have you found that you stopped and started again several times when you urinated?
• Urgency: Over the past month, how often have you found it difficult to postpone urination?
• Weak Stream: Over the past month, how often have you had a weak urinary stream?
• Straining: Over the past month, how often have you had to push or strain to begin urination?
• Nocturia: Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

(Pain < 3 months duration)

• Renal causes further explored in Ch 10 – Genitourinary History and Renal Exam – MF2
• Gastrointestinal causes further explored in Ch 13 – Abdo Exam – MF3

• “Is there a chance you could be pregnant?” → impacts differential diagnosis
• Location: Unilateral vs. bilateral? Diffuse vs. focal pain? Where exactly?

• Onset: Acute vs. chronic?
  • Onset during or shortly after menses: Pelvic inflammatory disease
  • Onset with sexual intercourse or after strenuous physical exercise: Ruptured ovarian cyst
• Palliating/Provoking: Does anything make the pain better or worse?
  • Dyspareunia (pain with intercourse): Pelvic inflammatory disease, endometriosis
  • Worse with jarring movements: Pelvic inflammatory disease
  • Dysmenorrhea (painful menses): Endometriosis, adenomyosis, leiomyomas, mittelschmerz
• Quality: Is the pain sharp or dull?
• Radiation: Does the pain travel anywhere?
• Severity: How bad is it on a scale of 1-10
• Timing: Does it come and go? Or is it consistent?
• Associated Symptoms: Nausea/Vomiting
  • Constitutional symptoms: Fevers, night sweats, chills, unintentional weight loss, malaise?
  • Purulent Endocervical/Vaginal Discharge: Gonorrhea; Chlamydia; Bacterial Vaginosis; Trichomonas; Vulvovaginal; Candidiasis; Pelvic Inflammatory Disease
  • Vaginal Bleeding

Common Gynecologic Causes of Female Pelvic Pain:

• Endometriosis (Endometrial glands and stroma outside uterine cavity): Classic triad of (1) dysmenorrhea/chronic pelvic pain; (2) dyschezia (painful defecation); and (3) dyspareunia.
• Adenomyosis (Endometrial glands and stroma present in myometrium – uterine muscle): Present with dysmenorrhea and menorrhagia (heavy menses) with mobile, enlarged, soft “boggy” uterus that may be tender on bimanual pelvic exam. With fibroid degeneration, may present with acute pelvic pain, low-grade fevers, and peritoneal signs on exam.
• Uterine leiomyomas (fibroids – noncancerous tumors arising from myometrium in reproductive age females): Commonly present with pelvic pain including dysmenorrhea, menorrhagia (prolonged/heavy menses), bulk symptoms (abdominal protrusion, bowel/bladder dysfunction, early satiety), infertility or recurrent pregnancy loss
• Mittelschmerz (physiologic pain due to follicular enlargement prior to ovulation, or normal follicular bleeding at ovulation): Cyclical, mild, unilateral pain occurring midway between menses, lasting hours-days.

• Renal causes further explored in Ch 10 – Genitourinary History and Renal Exam – MF2
• Gastrointestinal causes further explored in Ch 13 – Abdo Exam – MF3

• Location: Unilateral vs. bilateral scrotal pain?
  • Focal pain (e.g. epididymitis) vs. diffuse pain (e.g. testicular torsion)?
• Onset: Acute vs. chronic?
• Palliating/Provoking: Does anything make the pain better or worse?
• Quality: Is the pain sharp or dull?
• Radiation: Does the pain travel anywhere?
• Severity: How bad is it on a scale of 1-10
• Timing: Does it come and go? Or is it consistent?
• Associated Symptoms: Nausea/vomiting; Cloudy urine (e.g. in acute bacterial prostatitis)?
  • Constitutional symptoms: Fevers, night sweats, chills, unintentional weight loss, malaise?
  • FUND Urinary Symptoms: Frequency, Urgency, Nocturia, Dysuria (pain with urination)

• Mammography (Breast cancer screen): Last mammography, history of abnormal screen
• Pap Smear (Cervical cancer screen): Last pap smear, History of abnormal pap smears
  • Current Cancer Care Ontario Recommendations (e.g. Cervical Cancer)
  • Pro Comp Connection: Cancer screening is an important opportunity for patient-centred shared decision making (e.g. using patient-centred decision aid tools)
• STBBI History: Chlamydia, Gonorrhea, Syphilis, Herpes, Genital Warts, HIV
  • Previous Hepatitis B Virus (HBV) Serology: Hepatitis B Surface Antibody, Hepatitis B Surface Antigen, Hepatitis B Core Antibody → re. non-immune vs. immune vs. infected
  • Previous Hepatitis B Virus Vaccination
  • Previous Hepatitis C Virus (HCV) Serology: HCV Antibody, HCV RNA
  • Previous Human Immunodeficiency Virus (HIV) Serology: HIV Antibody, HIV Antigen, HIV RNA, Most recent CD4 count and viral load, AIDS-defining illnesses
    • Sexual partners of patients with HIV and non-negligible risk of HIV transmission: Use of PrEP (pre-exposure prophylaxis) or PEP (post-exposure prophylaxis)¹
• Breast History: Current and previous breast feeding; history of breast disease; use of Self Breast Exam, last mammogram (See Chapter 21 – Clinical Breast Examination)
• Polycystic Ovarian Syndrome: Clarifying whether patient pursuing pregnancy vs not at this time.
• Contraindications to Hormonal Contraception: 35+ years old and smoking 15+ cigarettes/day; Coronary artery disease; Cerebrovascular disease; DVT/PE; Breast Cancer; Migraine with Aura
• Contraindications to Hormone Replacement Therapy: Venous Thromboembolism; Cerebrovascular disease/Transient Ischemic Attack; Active liver disease; Unexplained vaginal bleeding (e.g. Post-Menopausal bleeding – cancer until proven otherwise); High-risk endometrial cancer

(See Ch 10 – Genitourinary History and Renal Exam – MF2)

• Benign Prostatic Hypertrophy: Previous AUA-Symptom Scores (to monitor treatment responses); Post-void residual volume on ultrasound.
• Prostate Cancer: Initial treatment based on risk-stratification into low, intermediate or high risk
  • Low Risk: Prostate-Specific Antigen (PSA) <10 ng/mL and Gleason score ≤ 6 on prostate biopsy and T1-T2a stage and asymptomatic for metastasis (e.g. bone, lymph node)
  • Intermediate Risk: PSA 10-20 or Gleason score 7 or T2b-c stage; asymptomatic for metastasis
  • High Risk: PSA >20 or Gleason score ≥ 7 on prostate biopsy or T3a or higher disease stage
  • Metastatic Disease: e.g. symptomatic metastasis to bone, lymph node
• Prostate Cancer Screening: Prostate cancer screening with Prostate-Specific Antigen (PSA) test not recommended by Canadian Task Force on Preventive Healthcare (CTFPHC)³; the Canadian Urological Association guidelines recommend offering PSA screening to men with a life-expectancy greater than 10 years using a shared decision-making model, with PSA screening follow-up frequency depending on PSA results (q4years if PSA < 1ng/mL; q2years if PSA 1-3 ng/mL; more frequent if PSA >3ng/mL)⁴
• History of Bacterial Prostatitis: Previous episodes (re. acute vs. chronic) and treatments.
• STBBI History: Chlamydia, Gonorrhea, Syphilis, Herpes, Genital Warts, HIV

• Key Idea: Differentiate fertility-preserving procedures vs. non-preserving procedures
• Urinary Incontinence: Pessary; Pelvic Floor muscle exercises; Mid-urethral sling; Urethral bulking injections; Detrusor muscle Botox injections (for urge urinary incontinence/overactive bladder)
• Total Abdominal Hysterectomy/Bilateral Salpgingo-oophrectomy (TAH-BSO): Was cervix removed? (re. cancer screen)
• Endometriosis: Endometriosis ablation/resection; Hysterectomy ± Salpgingo-oophrectomy
• Ovarian Torsion: Detorsion (if viable ovary); Unilateral salpgingo-oophrectomy (e.g. nonviable ovary)
• Ruptured Ovarian Cyst: Laparoscopic cystectomy, oophorectomy
• Adenomyosis: Hysterectomy; Uterine artery embolization
• Uterine Leiomyomas (Fibroids): Hysteroscopic resection of fibroids; Uterine artery embolization; Endometrial ablation; Myomectomy or Hysterectomy
• Cervical Cancer Diagnostic/Procedures: Colposcopy; Cone biopsy; Laser Conization; Loop Electrosurgical Excision Procedure (LEEP) – Note: Pap Smear is a screening test

(Explored further in Ch 20 – Obstetric Visit Notes – MF3)

• Caesarean-sections: Emergency vs. elective; number of C-sections; Low-transverse vs. low vertical uterine (classical) incisions, complications
  • ↑ risk of uterine rupture with Trial Of Labor After C-section (TOLAC) after short interpregnancy interval (<6 months) or previous low vertical uterine (classical) incisions – needs a repeat C-Section
• Assisted Vaginal Birth: e.g. Forceps-Assisted, Vacuum-Assisted
• Post-Partum Hemorrhage: Did patient require emergency surgery e.g. uterine artery embolization, uterine artery ligation, emergency hysterectomy (last resort)?
• Ectopic Pregnancy: Unilateral salpingectomy, unilateral salpingostomy
• Early Pregnancy Loss or Abortion: Dilation and Curettage
• Surgical Female Contraception: Tubal Ligation; Hysterectomy

• Testicular Torsion: Detorsion and fixation
• Prostate: Transurethral resection of the prostate (TURP) – e.g. for Benign Prostatic Hypertrophy or Prostate Cancer
  • Recent Transrectal Prostate Biopsy → increases risk for acute bacterial prostatitis
• Erectile Dysfunction: Penile prosthesis
• Surgical Male Contraception: Vasectomy
• Circumcision

• Cancer history: e.g. breast, ovarian, cervical, prostate, testicular
• Infertility, early menopause

(Explored further in Ch 18 – Detailed Sexual Histories – MF3)

General Sexual History (seen in Chapter 1 – General Medical History – MF1)

• Normalizing Opening Statements⁵: Is it okay if I ask you a few questions about your sexual health? Some of questions are very personal. I ask everyone these questions, and I consider them to be very important. You do not have to answer any questions you don’t want to.
• Confidentiality Statement: As with all of our visits, the information we discuss will be kept confidential. I might take notes and put those in your record here, but everything will be stored securely. There are some instances where I may be required by law to break confidentiality, for example if I believe there is immediate risk of harm to yourself or others. Does this sound okay with you?
• General Sexual History⁶⁷:
  • Have you been sexually active in the past year?
  • How many partners have you had sex with in the past year?
  • What is your partner’s gender? What gender or genders are the partners you’ve had sex with in the last year?
  • Do you have any sexual concerns you would like to discuss?
  • Note: A detailed sexual history may be added to a general sexual history, depending on patient care needs. To discuss sexual health in an effective and patient-centred way, it is important to ensure a safe, private and respectful environment. The 5P’s Model of Harm Reduction⁷ (Practices; Partners; Protection from Sexually Transmitted and Blood Borne Infections = STBBIs, Past History of STBBIs; and Pregnancy) is introduced in Ch 18 – Detailed Sexual Histories – MF3

Specific Questions to ask on Genitourinary History if concerns identified:

• Any abnormal discharge from the vagina/penis? Post-coital bleeding (after intercourse)?
• Any itchiness or pain in the genital area at rest? What about during urination?
• Any pain during/after intercourse (dyspareunia)? Pain while urinating (dysuria)?
• Do you notice any new lesions/spots/marks/moles/ulcers in the genital area?
• Have you ever had a Sexually Transmitted and Blood Borne Infections (STBBI)? – previous STBBI infections increase risk for future STBBI infections

(Explored further in Ch 37 – Assessment of Substance Use Disorders – MF4)

• Smoking (important risk factor for bladder cancer)
  • Pack years = packs/day x years smoking: Use of cigarettes? E-cigarettes? Vapes?
  • Do you take oral contraceptive pills? (re: increased risk of Venous Thromboembolism while smoking)
  • Have you thought about quitting within the next 6 months? How long ago did you quit smoking?
  • The benefits of smoking cessation begin with the last cigarette.
  • 5As approach taking a smoking Hx (Explored in Chapter 38 – Motivational Interviewing – IF)
  • Pro-Comp Connection: Regarding patient’s position, do not jump to thinking in terms of “compliance” with recommendations for smoking cessation.
• Alcohol: How often do you drink alcohol (Drinks/Week)? What is size of 1 drink? What kinds of drinks?
• Recreational Drug Use: Do you now use, or have you used any of the following substances: Cannabis? Prescription drugs for non-medical purposes? Street drugs (e.g. cocaine, heroin, fentanyl, MDMA, etc.)?
  • Note: IV drug use increases risk for blood borne infection (BBI) including HIV, Hepatitis C Virus (HCV) and Hepatitis B Virus (HBV). Use of sterile injection equipment and not sharing substance use equipment are harm reduction measures that can help manage these risks.

• Chlamydia: Doxycycline or Azithromycin (safe in pregnancy)
• Gonorrhea: Ceftriaxone and Azithromycin
• Syphilis: Benzathine Penicillin G (Doxycycline if penicillin allergy)
• Genital Herpes Simplex Virus: Acyclovir, Valacyclovir or Famciclovir (PRN or prophylaxis)
• Human Papilloma Virus (HPV) Warts: Topical treatments (e.g. Imiquimod, Podofilox/ Podophyllotoxin; Trichloroacetic acid); cryotherapy; or ablative treatments (e.g. electrocautery, laser therapy)
• Human Immunodeficiency Virus (HIV): Intent may be for Pre-Exposure Prophylaxis (PrEP), Non-Occupational Post-Exposure Prophylaxis (nPEP), or Antiretroviral therapy (ART).
  • Nucleoside reverse transcriptase inhibitor (NRTI): e.g. Tenofovir, Emtricitabine, Lamivudine, Abacavir
  • Non-Nucleoside reverse transcriptase inhibitor (NNRTI): e.g. Efavirenz, Doravirine
  • Protease inhibitor (PI): e.g. Atazanavir/Ritonavir
  • Integrase strand transfer inhibitor (INSTI): e.g. Raltegravir, Dolutegravir
• Chronic Hepatitis B Virus (HBV) – Classes of Medications:
  • Interferons
  • Nucleos(t)ide analogues: Entecavir, Adefovir, Telbivudine, Tenofovir, Lamivudine
• Hepatitis C Virus (HCV) – Classes of Medications: Treatment depends on HCV viral genotype
  • Direct Acting Antivirals (DAA):
    • NS3 Inhibitors: Asunaprevir, Grazoprevir, Paritaprevir, Symeprevir
    • NS5B Inhibitors: Dasabuvir, Sofosbuvir
    • NS5A Inhibitors: Daclatasvir, Elbasvir, Lepidasvir, Ombitasvir, Velpatasvir
  • Interferons
  • Nucleoside analogues: Ribavirin

• Bacterial Vaginosis: Metronidazole PO vs. intravaginal gel; vs. Clindamycin intravaginal gel
• Trichomonas: Metronidazole
• Candida: Oral vs. topical fluconazole

• Barrier Methods (prevent STBBI): Condom (male or female), Spermicides, Diaphragm, Cervical Cap, Sponge; note – Dental Dams and Gloves do not prevent pregnancy
• Hormonal Contraception (does not prevent STBBI)
  • Long-Acting Reversible Contraception (LARC): Intrauterine Device (includes levonorgestrel IUD (e.g. Mirena, Kyleena, Jaydess) and copper IUD); Birth Control Implant (e.g. Nexplanon)
  • Short-Acting Reversible Contraception (SARC):
    • Combined Hormonal Contraception (CHC): Oral, transdermal patch, vaginal ring
      • Combined Oral Estrogen-Progestogen Contraceptives (OCP): ↑ Breast, cervical and liver cancer risk while on treatment; cessation of OCP use ↓ cancer risk in dose-dependent manner, with no excess risk by 10 years off treatment.
    • Progestin-Only Contraception: Oral contraception, Intramuscular injection (Medroxyprogesterone acetate)

• Non-Steroidal Anti-inflammatories (NSAIDs): e.g. Ibuprofen, Naproxen, Diclofenac
• SARC: Combined Hormonal Contraception; Progestin-Only Contraception
• LARC: Levonorgestrel IUD → Note: Also seen for adenomyosis and uterine fibroid symptoms
• GnRH Agonists: e.g. Nafarelin, Leuprolide, Goserelin
• GnRH Antagonists: Elagolix
  • Note: GnRH Agonists and Antagonists also seen for uterine fibroid symptoms

• Menstrual Dysfunction: Combined estrogen-progestin oral contraception; Levonorgestrel IUD; Progestin-only contraception; Biguanides (Metformin)
• Androgen Excess: Combined estrogen-progestin oral contraception; Mineralocorticoid Receptor Antagonist (Spironolactone); 5-alpha-reductase inhibitors (e.g. Finasteride); GnRH Agonists (e.g. Nafarelin, Leuprolide, Goserelin)
• Ovulation Induction (if patient currently pursuing pregnancy): Letrozole, Clomiphene

• Hormone Replacement Therapy
• Combined Estrogen-Progestogen Hormone Replacement Therapy (HRT): ↑ Breast and Ovarian cancer risk with long-term use (≥5 years); taking Estrogen without progestogen component ↑ risk of endometrial cancer.
• Vasomotor Symptoms:
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRI): Venlafaxine
  • Selective Serotonin Reuptake Inhibitors (SSRI): Paroxetine, Escitalopram, Citalopram
  • Gabapentinoids: Gabapentin
  • Alpha-2 Antagonist: Clonidine
• Atrophic Vaginitis: Moisturizers; Lubricants; Vaginal estrogen therapy (e.g. cream, tablet)

• With element of atrophic vaginitis: Vaginal estrogen therapy (e.g. cream, tablet)
• Beta-3 Adrenergic Agonists: Mirabegron, Vibegron
• Antimuscarinics: Darifenacin, Oxybutynin, Solifenacin, Fesoterodine, Tolterodine, Trospium

• Phsophodiesterase-5 (PDE5) Inhibitors: e.g. Sildenafil, Vardenafil, Tadalafil, Avanafil

• α-1 Adrenergic Receptor Antagonists: Tamsulosin, Terazosin, Doxazosin, Alfuzosin, Silodosin
• 5-alpha-reductase inhibitors: e.g. Finasteride, Dutasteride
• Note – for Overactive Bladder Symptoms secondary to benign prostatic hypertrophy, may use Beta-3 Adrenergic Agonists or Antimuscarinic Drugs as detailed above

• Room Setup: You will need a sheet; latex-free gloves; speculum and lubricant
• Draping and Patient Position: Patient draped appropriately with sheet over lower body; patient should be positioned in a Dorsal Lithotomy Position; Ask patient to lay back on examination table; Extend stirrups and ask patient to place feet in stirrups; Ask patient to slide down the examination table until their buttock is on the edge of the table; Drape patient so the sheet covers abdomen, thighs and knees and give the patient privacy to change. Don’t reach under a gown, drape or clothing to examine a patient. Enlist the patient’s help in moving the gown or drape throughout the exam, as this allows the patient to maintain some control over the degree of exposure. Only assist patients with the adjustment or removal of clothing or draping if the patient agrees or requests the physician to do so. Once examination completed, replace the gown or drape, and give the patient privacy to dress before finishing the appointment.

Say: I will inspect the external genitalia area. Are you OK if we move the drape for the examination?

Do: Observe the mons pubis (fatty deposition around symphysis pubis bone). Look at the Pubic Hair – is it age appropriate? (coordinate with the breast development re Tanner Staging, see below). Observe the labia majora, labia minora, clitoris, urethra meatus, and vaginal os. Observe any piercings. May observe the hymen. Observe Skene’s gland (paraurethral gland around vulva) and Bartholin’s glands (two small glands posterior lateral of vaginal os, for lubrication). Observe the perineum and anus. Inspect for rashes, discharge, discolouration, dermatoses, melanoma, genital warts, and STI evidence. Also observe for pelvic floor laxity (e.g. pelvic organ prolapse – is there protrusion of vaginal walls or cervix to or beyond the cervix re. uterine prolapse? Any rectal prolapse?)

Report: I can observe the mons pubis; pubic hair is appropriate for age. I note no piercings. I note no rashes, discharge, discolouration, dermatoses, melanoma, genital warts or evidence of obvious STIs.

Why Check: Genital Warts evidence of HPV; STI evidence suggestive of Herpes; Piercings ↑ infection risk; Pelvic organ prolapse is common with increasing parity, age, and menopause, which can cause a variety of pelvic (e.g. bulge or pressure symptoms), urinary (e.g. stress urinary incontinence), bowel (e.g. constipation, incomplete emptying) and sexual symptoms (e.g. impacts on sexual function).

Modification for Transmasculine Patients (FTM): Patients on masculinizing hormone therapy may have vaginal atrophy and/or clitoral enlargement. If they have had bottom surgery, you may see evidence of external genital changes (e.g. phalloplasty or metoidioplasty or clitoral release). Recent surgeries may present with evidence of healing tissue. Watch for cardinal signs of infection. In addition, the patient may not use the word vagina or vulva to describe their genitals and may use another word of their choice – if they identify their preferred terms during your assessment, use these terms where applicable when verbalizing your steps in the physical examination.

Say: I will continue to inspect the external genitalia area, inspecting the pubic hair for adolescent development.

Do: Inspect the pubic hair region according to Tanner Staging

What is Normal Pubic Hair Tanner Staging?

• Stage 1 – No pubic hair (Age 10 and younger)
• Stage 2 – Small amount of long hair with pigmentation on labia majora (Age 10-11.5)
• Stage 3 – Course and curly, begins to extend laterally (Age 11.5-13)
• Stage 4 – Adult-like hair quality, extends across pubis but not medial thighs (Age 13-15)
• Stage 5 – Final adult distribution, hair including the medial thighs (Age 15+)

Report: Based on Tanner staging of pubic hair, the patient is in Tanner Stage 4.

Why Check: Important tool for measuring development based on primary, secondary sex characteristics – for Tanner Staging of Breasts, see Chapter 21 – Clinical Breast Examination; normal progression is breast development (thelarche) → pubic hair development (pubarche) → growth spurt → menarche.

Say: I will palpate the external genital area for tenderness or other abnormalities. Please tell me if you are in discomfort.

Do: Observe for any signs of tenderness or lumps/bumps. Look at patient to assess for signs of tenderness. Look for signs of discomfort and stop the exam if signs of distress.

Report: I note no signs of tenderness or lumps or bumps on palpation.

Why Check: Important for assessing potential sources of pelvic pain

Say: I will perform a speculum exam to perform a Pap smear. Please tell me if you are in discomfort.

Setup: Explain what speculum is and why the test is being performed. Select an appropriately sized speculum (you can ask about patient’s history of speculum exams and if a smaller one was needed). Can demonstrate temperature of speculum on patient’s thigh (avoid if sterile speculum e.g. obstetrics). Lubricate the speculum.

Insertion: Hold with 2 fingers over top of speculum with thumb in between speculum screw (speculum closed). Let patient know you will begin, and speculum may feel cold. Gently spread labia. DON’T TOUCH CLITORIS (painful). Ask patient to breathe in; as patient breathes out, insert speculum transversely. Apply a gentle downward pressure against the posterior vaginal wall to advance the speculum. Angle the tip of the speculum towards the sacral hollow. Open speculum to visualize the cervix – If cervix is not visible, close speculum and re-adjust (often need to either advance further or withdraw a little with gentle downward pressure). Tighten screw to keep in place. Inspect cervix for colour, position, size, shape of os, discharge, bleeding, abnormal smells, foreign bodies, polyps and growths. Rotate speculum to completely visualize the vagina.

Sample Collection:

(1) Pap Smear (Cervical Cancer Screen) – Using combined brush, insert longest middle brush through cervical os, rotate 2 turns and remove, place sample cap in sample bottle for analysis – done BEFORE Cervical Swab.

(2) Cervical Swabs (Gonorrhea & Chlamydia) - Media for each STI available, allow swab to sit in os for 2-3 seconds; performed if raised clinical suspicion for STBBI.

Removal: Unscrew the speculum, remove carefully.

Report: I have collected a pap smear sample for routine screening, as well as cervical swabs for STI testing.

Why Check: Pap smears are an important cervical cancer screening tool; cervical swabs can help diagnose STIs, in particular chlamydia and gonorrhea. Pap smear done before cervical swab to not disturb Pap smear process. If vaginitis is suspected, discharge present on non-dependent areas of vagina – note that secretions pooling on the speculum are usually physiologic.

Modification for Transmasculine Patients (FTM): Patients who are transmasculine may have had hysterectomy or bilateral salpgingo-oophrectomy (BSO). If this is the case – clarify if they have had their cervix removed, as this would be important with respect to Paps for Cervical Cancer Screening.

Note: For a helpful “how-to” video on providing trans competent cervical cancer screening (specifically for transmasculine patients), please visit: https://hamiltontranshealth.ca/trans-pap-101/

Say: I will perform a bimanual exam to assess uterine size, position and mobility, and to palpate adnexa (e.g. fallopian tubes). We assess this for every patient. Please tell me if you are in discomfort.

Do: Lubricate one hand. Ask patient to breathe in; as patient breathes out, insert 2 fingers (index and middle). Place one hand on abdomen, other palpating under cervix. Assess if uterus ANTEVERTED (Uterus felt between two hands, palpate when breathes out; cervix should feel like your nose) or RETROVERTED (Can only feel with hand in vagina). Assess uterus size and mobility. Slide vaginal fingers to one side then another, palpating for adnexa and adnexal tenderness. Look for signs of discomfort and stop the exam if signs of distress.

Report: Uterus is anteverted/retroverted, with normal size and mobility. The adnexa are normal.

Why Check: Important part of routine gynecological exam re palpation for the internal structures from anterior approach, orientation of uterus, etc. The likelihood of suspected ectopic pregnancy is increased with positive cervical motion tenderness (LR+ 4.9, LR- 0.62) and with an adnexal mass (LR+ 2.4). The absence of adnexal tenderness decreases the likelihood of suspected ectopic pregnancy (LR- 0.57).

Modification for Transmasculine Patients (FTM): Patients who are transmasculine may have had hysterectomy or bilateral salpingo-oophorectomy (BSO). If this is the case – clarify if they have had their cervix removed, as this would be important with respect to Paps for Cervical Cancer Screening.

Say: I will perform a rectovaginal exam to assess rectal tone and for any abnormalities, which we assess for every patient. Please tell me if you are in discomfort.

Setup: Gloves on, lubricate finger (if stock bottle, DROP from nozzle – avoid stock contamination). Ask patient to bare down and insert index finger into vaginal canal and middle finger into anal canal simultaneously.

Do: Ask patient to squeeze around your fingers; note anal sphincter tone. Place 1 hand on abdomen to simultaneously palpate posterior aspect of uterus and rectal walls. Note any tenderness, masses, polyps, or nodules on uterosacral ligaments. Note any fluid in pouch of Douglas. Palpate for rectocele or enterocele. Look for signs of discomfort and stop the exam if signs of distress.

Report: Normal anal sphincter tone on palpation. No tenderness, masses, polyps, fluid accumulation in Pouch of Douglas, or nodules on uterosacral ligaments were palpable. No rectocele or enterocele palpated.

Why Check: Important part of routine gynecological exam re palpation for the internal structures from posterior approach, fluid accumulation in Pouch of Douglas, etc.

Modification for Transmasculine Patients (FTM): Patients who are transmasculine may have had hysterectomy or bilateral salpingo-oophorectomy (BSO). If this is the case – clarify if they have had their cervix removed, as this would be important with respect to Paps for Cervical Cancer Screening.

Note: Important to include palpation of lymph nodes in the inguinal and subinguinal lymph node regions. For details on how to conduct a Lymph Node exam, see Chapter 11 – Lymph Node Exam – MF2.

Why Check: Localized pelvic lymphadenopathy can be important sign in lower extremity infection, in sexually transmitted and blood-borne infections (STBBI) and in malignancy.

Say: I will use a Cotton Swab (Q-Tip) to examine the external genitalia area for tenderness. Please tell me if you are in discomfort.

Set-Up: Patient is positioned in dorsal lithotomy position; you will need a gauze-pad and a cotton swab, along with gloves.

Do: Using a gauze-pad, gently retract the labia minora to expose the vestibule (bounded by Hart’s line midway inner labia minora, extending to hymenal remnant tissue). Conceptually, this forms a clock-face with Urethral meatus at 12:00, 6:00 is posterior fourchette. Palpate at multiple sites in a randomized fashion to control for sensitization, recording the patient’s pain ratings with the position palpated according to a clock-face. Specific areas to palpate include vulva, vestibule, hymenal ring, Bartholin and Skene Glands.

Report: At [5:00] the patient had a pain reading of [5/10]; no other sites elicited tenderness to palpation.

Why Check: Highly sensitive test specifically to look for Vulvodynia (Sensitivity 100%, Specificity 83.53%) – Vulvodynia is persistent pain of the external female genital area that lasts >3 months, not caused by infection, skin disorder, or other medical condition.

• Draping and Patient Positioning: Sitting at side of exam table, with legs over the side of exam table, gown on; or standing; or lying down. Don’t reach under a gown, drape or clothing to examine a patient. Enlist the patient’s help in moving the gown or drape throughout the exam, as this allows the patient to maintain some control over the degree of exposure. Only assist patients with the adjustment or removal of clothing or draping if the patient agrees or requests the physician to do so. Once examination completed, replace the gown or drape, and give the patient privacy to dress before finishing the appointment.
• Typical Scenarios for Male Genital Exam:
  • New patient to your practice as a family physician → if patient doesn’t want it done, it’s not done, but advise patient to give it some thought for the next annual physical as an important part of general exam to detect abnormalities.
  • Patient comes in with symptomatic presentation → pain, swelling, discharge.
  • Newborn screening (external genitalia, undescended testes, etc.)
• Idiosyncratic Chief Complaints: Pearly papules are normal (little bumps), but patients sometimes will present to clinic about it because they’re worried about it, considering them abnormal.

Say: I will inspect the external genitalia area. Are you OK if we move the drape for the examination?

Do: Inspect for abdominal masses, scars, and suprapubic distension. Inspect the skin for rashes, ulcers, warts, nodules, scars (scratching) and piercings. Note whether pubic hair pattern is age appropriate. (Look at skin beneath pubic hair) – I note no pediculosis (lice) in pubic hair. Inspect inguinal region for bulges or masses.

Report: I note the pubic hair is appropriate for age. I note no piercings. I note no rashes or skin abnormalities, bulges or masses.

Why Check: Suprapubic distension raises concern for urinary retention. Hair pattern could be indicative of liver dysfunction. Important to inspect for knits as well.

Modification for Transfeminine Patients (MTF): Patients on feminizing hormone therapy may have decreased testicular volume. If they had had bottom surgery, you may see evidence of external genital changes (e.g. orchiectomy or vaginoplasty). Recent surgeries may present with evidence of healing tissue. Watch for signs of infection. In addition, the patient may not use the word penis or scrotum to describe their genitals and may use another word of their choice – if they identify their preferred terms during your assessment, use these terms where applicable when verbalizing your steps in the physical examination.

Say: I will inspect the penis, which we inspect for every patient. It is normal for patients to experience a partial erection. If this happens, we can take a couple of minutes’ break and then continue with the exam. Please tell me if you are in discomfort.

Do: Note whether the patient is circumcised/uncircumcised. Look for Symmetry, Erythema, Atrophy, Deformities or Scars (SEADS) on dorsal surface.

Say: Can you move the penis superiorly so I can inspect the bottom?

Do: Repeat SEADS inspection on ventral surface. Assess for normal pearly papule bumps.

Say (If patient uncircumcised): Can you retract the foreskin so I can inspect the area?

Do: Once patient retracts foreskin (prepuce), inspect glans penis – look for lesions, normal clear discharge (if present), and balanoposthitis (inflammation of glans and foreskin). Then inspect urethral meatus - look for hypospadias (urethral meatus located on inferior surface of glans) and blood at meatus (e.g. in trauma scenario). Foreskin should retract easily and not cause pain – look for phimosis (unable to fully retract foreskin) and paraphimosis (foreskin unable to return to normal position).

Report: The patient is circumcised/uncircumcised. I note normal SEADS on both dorsal and ventral surface. I note normal pearly papule bumps. On the glans penis, I note no lesions, and a normal clear discharge.

Why Check: Circumcision relevant for Phimosis risk re: fluid accumulates → foreskin unable to fully retract; a urologic emergency is paraphimosis, where the prepuce cannot be returned to normal position.

• Blood at the meatus: Classic sign of urethral trauma in male with pelvic fracture – do NOT insert a Foley Catheter in this patient.

Modification for Transfeminine Patients (MTF): Patients on feminizing hormone therapy may have decreased testicular volume. If they had had bottom surgery, you may see evidence of external genital changes (e.g. orchiectomy or vaginoplasty). Recent surgeries may present with evidence of healing tissue. Watch for signs of infection. In addition, the patient may not use the word penis or scrotum to describe their genitals and may use another word of their choice – if they identify their preferred terms during your assessment, use these terms where applicable when verbalizing your steps in the physical examination.

Say: I will inspect the scrotum, which we inspect for every patient. Please tell me if you are in discomfort.

Do: Inspect for edema in the scrotum. Ask the patient to lift the testes, then inspect for edema on underside of scrotum. Inspect scrotum for swelling, size, bumps, veins, scars, or excoriation (scratching). Inspect for normal axial orientation, colour slightly hyperpigmented vs. rest of skin, and Rugae present.

What is Normal? It is normal for one testicle to be lower than other (usually left side lower)

Do: I note no swelling of the scrotum, with no rashes or skin abnormalities.

Why Check: If edema present, can be a clue to cardiogenic dependent edema. Swelling in the testes can be due to hydrocele, hernia or varicocele. Scratching raises concern for Pediculosis Pubis = Lice, or Scabies = Parasite. Normal for one testicle to be lower vs. other (usually left side lower).

Modification for Transfeminine Patients (MTF): Patients on feminizing hormone therapy may have decreased testicular volume. If they had had bottom surgery, you may see evidence of external genital changes (e.g. orchiectomy or vaginoplasty). Recent surgeries may present with evidence of healing tissue. Watch for signs of infection. In addition, the patient may not use the word penis or scrotum to describe their genitals and may use another word of their choice – if they identify their preferred terms during your assessment, use these terms where applicable when verbalizing your steps in the physical examination.

Say: I will continue to inspect the external genitalia area, inspecting the pubic hair for adolescent development.

Do: Inspect the pubic hair region according to Tanner Staging.

What is Normal Genital Tanner Staging?

• Stage 1 – Testicular volume < 1.5mL; Penis 3cm or less (Prepubertal) (Age 9 and younger)
• Stage 2 – Testicular volume 1.6-6mL; scrotum thins, reddens, and enlarges; penis unchanged (Age 9-11)
• Stage 3 – Testicular 6-12mL; scrotum enlarges; penis lengthens to about 6cm (Age 11-12.5)
• Stage 4 – Testicular volume 12-20mL; scrotum enlarges and darkens; penis lengthens to 10cm, circumference increases (Age 12.5-14)
• Stage 5 – Testicular volume >20mL; scrotum is adult, penis 15cm in length (Age 14+)

Do: Inspect the pubic hair region per Tanner Staging

What is Normal Pubic Hair Tanner Staging?

• Tanner Stage 1 – No pubic hair (Age 10 and younger)
• Stage 2 – Small amount of long hair with pigmentation on labia majora (Age 10-11.5)
• Stage 3 – Course and curly, begins to extend laterally (Age 11.5-13)
• Stage 4 – Adult-like hair quality, extends across pubis but not medial thighs (Age 13-15)
• Stage 5 – Final adult distribution, hair including the medial thighs (Age 15+)

Report: Tanner staging of testes shows patient in Tanner Stage X; on tanner staging of pubic hair, Stage Y.

Why Check: Important tool for measuring development based on primary and secondary sex characteristics

Say: I will palpate the penis for discharge or urethral strictures, which we assess for every patient. It is normal for patients to experience a partial erection. If this happens, we can take a couple of minutes’ break and then continue with the exam. Please tell me if you are in discomfort.

Do: Palpate for discharge by squeezing with two fingers the glans at top and bottom, have a swab ready to collect discharge. Palpate urethra on ventral side of penis with two fingers on the dorsal side, thumb on the ventral side of the penis. Palpate shaft for tenderness, abnormalities, fibrotic plaques or ridges.

Report: I note no urinary strictures and have collected discharge for lab analysis.

Why Check: In patients with penis fractures, important to check for swelling both on inspection and on palpation. Also important to palpate if concern for a lesion or evidence of scarring (Peyronie’s disease), or concern about discharge or urinary strictures.

Modification for Transfeminine Patients (MTF): Patients on feminizing hormone therapy may have decreased testicular volume. If they had had bottom surgery, you may see evidence of external genital changes (e.g. orchiectomy or vaginoplasty). Recent surgeries may present with evidence of healing tissue. Watch for signs of infection. In addition, the patient may not use the word penis or scrotum to describe their genitals and may use another word of their choice – if they identify their preferred terms during your assessment, use these terms where applicable when verbalizing your steps in the physical examination.

Say: I will palpate the testes, which we assess for every patient. It is normal to feel uncomfortable, but it should not feel painful. Please tell me if you are in pain.

Do: Place thumb and finger on opposite sides to assess contour of testes individually. Assess size, swelling, masses and tenderness. A normal testis is firm and rubbery. Palpate for spermatic cord. Palpate for a “bag of worms” suggestive of a varicocele. Palpate for the epididymis, palpable as a ridge on the posterolateral side of the testes. To differentiate between a hernia and hydrocele (collection of fluid in either tunica vaginalis or persistent processus vaginalis), can perform 3 tests:

• Transillumination – shine a light through the scrotum – transillumination (soft red) suggests hydrocele, no transillumination suggests hernia.
• Reducibility – ask patient to lie down for about 1 minute– hernia mass will disappear vs. hydrocele won’t.
• Palpation Above Mass – If able to palpate above the mass, suggests a hydrocele; if unable to palpate above the mass, suggests a hernia (as the hernia is continuous all the way to the superficial inguinal ring)

Report: Normal adult size, contour and symmetry between the testes. I note no masses or lumps and varicosities or evidence of hydrocele.

Why Check: More common to palpate in male genital exam, as initial part of palpating for inguinal canal

Modification for Transfeminine Patients (MTF): Patients on feminizing hormone therapy may have decreased testicular volume. If they had had bottom surgery, you may see evidence of external genital changes (e.g. orchiectomy or vaginoplasty). Recent surgeries may present with evidence of healing tissue. Watch for signs of infection. In addition, the patient may not use the word penis or scrotum to describe their genitals and may use another word of their choice – if they identify their preferred terms during your assessment, use these terms where applicable when verbalizing your steps in the physical examination.

Say: I will palpate the groin and for any hernias, which we assess for every patient. Please tell me if you are in discomfort.

Do: Find the spermatic cord and follow it up to the external (superficial) inguinal ring; can use pubic tubercle as landmark for identifying the external (superficial) inguinal ring; or invaginate upper part of scrotum upward to find superficial inguinal ring and pubic tubercle. Apply pressure along the superficial inguinal ring. Ask patient to cough forcefully re Valsalva and turn their head so you don’t get coughed on. If you feel a lump pressing against the applied pressure, that is a hernia.

Then, remove your finger, and ask the patient to cough or bear down and see if the lump extends and descends into the inguinal canal, upper part of the scrotum or lower part of the scrotum.

Note: The External Ring re Inguinal Hernia is normally Triangular in Shape, NOT circular as shown on typical models. Need to palpate inguinal hernias in standing position, if possible, re dependent hernia.

Report: I note no hernias on palpation of the inguinal canal.

Why Check: Assessing for hernias – note that while hernias can be Indirect (travel down the inguinal canal, loosening ring integrity due to patency of processus vaginalis) or Direct (abdominal wall defect, poor abdominal muscle tone), it is hard to differentiate these by physical exam.

Say: I will palpate the prostate to assess for any lumps, masses or tenderness with a rectal exam. Please let me know if you feel any pain. It is normal to feel an urge to pass urine when palpating the prostate.

Setup: Gloves on, lubricate finger (if stock, DROP from nozzle – avoid contamination of stock). The patient lies on their left side, both knees and hips flexed towards the chest. Spread the buttocks.

Do: Soft rounded pad of your finger should go through; stop for a moment at the anal verge then continue; rotate hand to feel all sides of walls (should not be a sensation for patient, except the urge to pass urine once feeling the prostate). Check for any lumps and masses on the prostate, and for tenderness (e.g. for prostatitis)

Report: No evidence of benign prostatic hypertrophy or boggy. No evidence of hemorrhoids.

Why Check: A routine part of male genital exam; an edematous and exquisitely tender prostate on palpation is an important sign e.g. in acute bacterial prostatitis. The presence of asymmetry, lumps or nodules raises concern for malignancy. The prostate exam is distinct from DRE of Abdominal Exam (Chapter 13)

Note: Important to include palpation of lymph nodes in the inguinal and subinguinal lymph node regions. For details on how to conduct a Lymph Node exam, see Chapter 11 – Lymph Node Exam – MF2

Why Check: Localized pelvic lymphadenopathy can be important sign in lower extremity infection, in sexually transmitted and blood-borne infections (STBBI) and in malignancy.