A complete female genitourinary assessment addresses each of the following as indicated by the patient’s condition and orders, performed with consent, privacy, and a chaperone per policy, and compares each finding to baseline.
Vaginal bleeding or discharge — amount, character, and — critically — any bleeding after menopause, which is treated as malignancy until excluded.
Pelvic pain — its character, severity, and acuity, and any associated fever.
Post-operative gynecologic status — the surgical site or vaginal cuff after hysterectomy or other gynecologic surgery, and the signs of bleeding, infection, or dehiscence.
Pelvic-floor and prolapse status — the degree of prolapse, symptoms, and the effect on voiding and bowel function.
Pessary status where present — position, comfort, discharge, and the signs of erosion or retention.
Vulvar and perineal skin — briefly, with the detailed skin exam documented in External Genitalia.
Infection signs — local and systemic, including the perineal signs that can indicate a necrotizing infection.
Urinary and bowel symptoms as they relate to prolapse or a fistula (bladder detail in Urinary/Renal).
Vital signs where bleeding or infection is present, including for hemodynamic change with heavy bleeding.
The patient’s adherence to post-operative instructions and pessary or pelvic-floor care.
