This document was released in February 2022. This document will continue to be periodically updated to reflect the growing body of literature related to this topic.

Statement of Purpose

The genitourinary examination is an important part of overall health assessment in children.  Performing an efficient, accurate and respectful examination aids in the prompt diagnosis and management of pediatric genitourinary issues.  This educational module provides a comprehensive overview of the pediatric genitourinary examination, including abdomen, back, and external genital examinations.

The pediatric genitourinary examination presents special challenges.  Examination and communication techniques should be tailored to the developmental level and communication ability of the child.  Providers should ask permission to proceed to each step of the examination and should signpost what is being done.  Providers should also clearly communicate with parents/caregivers who are present for the examination.  Older children should be offered the opportunity to have a non-parental chaperone. 

The unfortunate reality of sexual abuse makes the respectful conduct of the pediatric genitourinary examination all the more important. Children may be frightened or anxious at the prospect of a genital examination, even if parents/caregivers are present.  Providers should establish rapport and trust with the child prior to efficiently performing the examination.

After completion of this online educational activity, the learner will be able to:

1. Identify key distinctions between the adult and pediatric GU exams.
2. Perform correct positioning and maneuver techniques for the pediatric GU exam.
3. Identify and utilize correct anatomical landmarks for physical exam maneuvers.
4. Begin to synthesize exam findings into clinical diagnoses and to assess level of developmental maturity.

Target Audience:

• Medical Students
• Residents
• Physician Assistants
• Nurse Practitioners

General Appearance

          Providers should familiar themselves with the physical findings associated with common congenital and acquired conditions that suggest potential underlying urologic disease. For example, asymmetric enlargement of one side of the body (hemihypertrophy) is associated with an increased risk for Wilms tumor.  Patients with shagreen patches may have tuberous sclerosus.  Note should be made of prior surgical scars.  Tanner stage should be assessed.

          In older children (Tanner stages IV and V), the Adult GU examination (add links) may be more appropriate.

          We have presented the following examination in a way that isolates each structure.  We recognize that these are artificial demarcations, and these are presented in a simplistic way to facilitate learning.  However, “normal” genitourinary anatomy exists across a broad spectrum.  Practitioners should familiarize themselves with embryologic development and may find the Prader classification system helpful in describing observed anatomy. 

Abdomen

• Inspect for skin changes, (e.g. Eagle-Barrett syndrome), asymmetry
• Palpate all four quadrants, beginning in right lower quadrant and progressing clockwise on patient’s abdomen, assessing for tenderness, rebound/guarding, masses

Flank

• Inspect for symmetry
• Palpate flanks (costovertebral angle) gently to assess for discomfort and masses

External Genitalia

          When inspecting the external genitalia, it is important to look for lesions and abrasions (which may suggest accidental or nonaccidental trauma), asymmetry, and discharge

• Phallus
  • Inspect extent of prepuce (e.g. circumferential, dorsal hooded, absent)
  • Gently retract prepuce only as far as it will go without pressure. Do not forcibly retract prepuce.  Note presence or absence of penile adhesions, epithelialized skin bridges, and/or smegma (cellular debris that may become trapped under prepuce)
  • Inspect orientation of phallus, looking for torsion (rotation), chordee (bending to one side or toward the abdomen or scrotum)
  • Inspect shape of glans
  • Evaluate location of urethral meatus (epispadiac—closer to the abdomen than the tip of the phallus, or hypospadiac—closer to the scrotum than the tip of the penis), as well as shape (meatus is normally a slit on the ventral distal surface of the glans; a smaller, circular glans may indicate meatal stenosis). When possible, the edges of the meatus should be gently retracted laterally to inspect the urethral mucosa, which should be a light pink color owing to blood vessels near the surface, and to assess for urethral discharge. In patients in whom the prepuce is not completely retractile, the meatus may be difficult to manipulate
• Scrotum
  • Inspect for symmetry and fullness
  • Inspect for rugations
  • Assess shape (e.g. bifid)
• Testicles
  • Palpate each hemiscrotum gently, in turn, assessing for the location, size, shape, consistency, and symmetry of the testes. In younger children, the epididymis can be difficult to fully palpate discretely from the testis, but the vas can be easily palpated within the spermatic cord
  • If the testis is not palpated within the ipsilateral hemiscrotum, evaluation should be performed to determine if the testis can be palpated along the expected path of descent from the abdomen. We place one hand caudal and posterior to the scrotum, and gently sweep the other down from the ipsilateral anterior superior iliac spine to the external inguinal ring, and then into the scrotum.  Application of lotion may facilitate this examination
• Hernia/hydrocele
  • In young children, it is easiest to perform this examination with the child in a supine position. If swelling is appreciated on one or both sides, the scrotal and inguinal contents should be palpated on each side to determine if the swelling is due to fluid (hydrocele) or solid components (hernia, usually fat or bowel).  If a hernia is present, reduction can be performed by gently directing the contents cranially into the internal inguinal ring.  If a hydrocele is present, very gentle pressure can be applied to determine if the fluid present will return to the abdominal cavity.  Transillumination (applying light to one side of the scrotum while inspecting from the opposite side) will show through transmission of the light in the case of hydroceles, but not hernias
  • Because hernias and hydroceles are intermittent, they may not be readily evident at the time of examination. The “silk glove sign” helps to identify a patent processus vaginalis in such situations and can be identified by rolling several fingers over the spermatic cord distal to the external inguinal ring.  The sensation of a silk glove sign is that of the finger of a glove being rolled longitudinally
• (Adult hernia and varicoceleàsee adult examination)

Clitoris

• Only the glans and hood of the clitoris should be visible, and should be discrete from the urethral meatus

Labia Majora and Minora

• Inspect for swelling, symmetry, lesions
• Hernia/hydrocele examination (above) should be performed

Female Urethral Meatus

• The urethral meatus is discrete from and located just anterior to the vagina and is circumferentially surrounded by spongy tissue. There should be no bulging
• Perineum should be inspected for discharge, which may indicate infection, glandular secretions, or ectopic ureter

Vagina

• Inspect for imperforate hymen (may not always be visible) or bulging that would suggest a collection of material proximal to the hymen
• Note should be made of the presence and characteristics of vaginal discharge

Anus

• Inspect for orthotopic location, circumferential presence of musculature

Back

• Inspect the symmetry of the back muscles
• Inspect the shape and symmetry of the buttocks
• Inspect the location of the gluteal cleft
• Look for changes in the skin along the spine (dimples, hairy patches, openings, color changes, texture changes)

Authors

2023

Kathleen Kieran, MD
Seattle, WA

Brendan Wallace, BS
New York, NY