Introduction

Although genitourinary symptoms are common in elderly women, these patients often do not report such symptoms to their physician. Thus, the history should specifically seek out common symptoms, such as vaginal itching and burning; pelvic pain, pressure, or protrusion; pain during intercourse; postmenopausal vaginal bleeding; hematuria; and urinary frequency, urgency, or incontinence. Patients should also be asked about their use of estrogen replacement therapy. At the same time, a sexual history is usually appropriate.

The pelvic examination is difficult in some elderly women. For example, some are embarrassed or uncomfortable. Elderly women with stiff joints and those who lack hip mobility may have difficulty assuming the usual lithotomy position and may find the left lateral position more comfortable. In the left lateral position, the patient lies on the left side with the knees flexed and the right (upward) hip flexed more than the left hip. Many clinicians are unfamiliar performing a pelvic examination with the patient in this position. Nursing homes and many hospitals lack examining rooms and equipment that facilitate such examinations in elderly patients.

The pelvic examination should be performed routinely every 1 to 2 years or whenever postmenopausal vaginal bleeding, pelvic support disorders, urethral caruncles, benign vulvar disorders, fistulas, or pelvic symptoms occur.

The pelvic examination should be performed in three steps: (1) During the external examination, the vulva and external groin area are visually inspected and palpated for ulcerations, inflammation, pigmented lesions, hypertrophic squamous changes, indurations, and nodal enlargement. (2) A speculum is inserted into the vagina and expanded to permit internal visual inspection of the vagina and cervix for atrophy, inflammation, and raised or discolored lesions. A Papanicolaou (Pap) smear is obtained at this time, and microbiology specimens (when indicated) are collected. If the speculum examination is difficult to perform because of vaginal stenosis, a smaller speculum should be used, sometimes with lubrication; once the speculum is inserted, pressure should be exerted toward the rectum. (3) The vaginal walls and cervix are palpated for paravaginal masses and cervical abnormalities; a bimanual examination is performed to assess uterine size and shape, to evaluate pelvic and adnexal structures and the lower rectum, and to detect any adnexal lesions. The deep palpation needed to assess a small uterus and ovaries sometimes causes pain; therefore, extra time, explanation, and gentleness may be required. A stool guaiac test is performed. Further diagnostic tests may be indicated and may include colposcopy, biopsy, and various imaging modalities (eg, colonoscopy).

A urologic evaluation is warranted to evaluate hematuria unaccompanied by evidence of concurrent urinary tract infection or genital atrophy; evaluation is also needed if antibiotic or estrogen treatment does not eradicate hematuria due to infection or genital atrophy.

The urologic evaluation may include intravenous urography, renal ultrasonography, urine cytology, and cystourethroscopy. Intravenous urography must be performed with care in elderly patients, who may have a decreased creatinine clearance; hydration helps reduce the risk of renal impairment, but fluid overload and heart failure can occur from overzealous hydration.