15.6 Subjective Assessment
Subjective assessment of the reproductive system involves asking questions about the health of the client and symptoms related to pathologies of the associated organs and glands. Although a full understanding of these pathologies is beyond the focus of this chapter, common issues associated with the breasts and male and female genitalia include breast cancer, fibrocystic breasts, gynecomastia, genital warts, vaginitis, benign prostatic hyperplasia, testicular cancer, fertility issues, sexual dysfunction, and body dysmorphic disorder.
Knowledge Bites
Genome sequencing for breast cancer involves analyzing the DNA of cancer cells to understand the genetic changes that drive the disease. This process can identify mutations, structural variations, and other genetic alterations that contribute to the development and progression of breast cancer. The insights gained from genome sequencing can inform personalized treatment strategies and improve patient outcomes.[1]
Common symptoms that can be related to the breasts and female and male genitalia include pain, redness, swelling, and discharge.
Many of the questions in this table align with the PQRSTU mnemonic. You should consider asking questions in order of importance, thus you do not have to follow the sequential order of PQRSTU.
You should also ask about any medications (prescribed, over the counter, or illicit) the client is taking, including the name, dose, frequency, reason for taking, and how long they have been taking it. Many types of medications can cause disruption to vaginal flora (itching, white discharge).
Always use questions focusing on health promotion during an assessment. Depending on the context, you might ask these during the subjective assessment or after an objective assessment. A “Health Promotion Considerations and Interventions” section is provided later in this chapter after the discussion of an objective assessment.
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Symptoms |
Questions |
Clinical tips |
|---|---|---|
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Genital discharge: a mix of fluid and cells from the vagina or penis which varies in color and texture and is possibly associated with an odor. Other symptoms may include itching, pain, swelling or redness. |
Do you have any genital discharge? Are you sexually active? If the client’s response is affirmative, additional probes may include: Quality/quantity: Tell me about the color and amount. Do you have any pain or itching? Region: Where do you feel it? (e.g., if male—urethra, foreskin, penis; if female—labia, urethra, vagina, perineum) Understanding: Do you know what is causing it? Do you have any related symptoms (urinary burning, redness. or lesions)? Timing: When did it begin? Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better (bathing)? Treatment: Have you treated it with anything? Do you take any medications for it? |
Abnormal genital discharge can be sign of infection or inflammation with changes in color, smell, texture, or amount. Other symptoms that may indicate abnormal discharge include: itching or irritation, pain during urination or intercourse, abdominal or pelvic pain, genital sores or blisters, and bleeding between periods or after sex. A thorough sexual history will be collected including menstrual history for females. Specimen cultures will be obtained. |
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Breast lump: a mass, growth or swelling in the breast tissue which can be benign or cancerous. Asymmetrical breast appearance, dimpling, thickening of breast skin, pain or tenderness, and nipple discharge. |
Have you noticed any lumps or changes to your breast recently? If the client’s response is affirmative, additional probes may include: Region: Where is it located? Quality/quantity: How would you describe it? Is it painful? Timing: When did you notice the change? Do you perform monthly breast self-exams? Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better? Treatment: Have you treated it with anything? Do you take any medications for it? Understand: Do you know what is causing it or what it is related to? |
The first action is to complete a family history of breast cancer. The clinical breast examination will be performed after obtaining consent using a trauma-informed approach. Possible interventions: Mammogram screening and diagnostic testing. |
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Genital lesions or ulcers are abnormal changes to the genital area skin resulting from moisture, incontinence, possible sexually transmitted infections, trauma, irritation, infections, or cancer. Other symptoms may include itching, pain, swelling, or redness. |
Have you noticed any sores on your genital area? If the client’s response is affirmative, additional probes may include: Quality/quantity: What do they look like? Are the sores open, wet, or dry? How bad is it? Is there any pain associated? Timing: When did it begin? If there is pain, is it constant or intermittent? Understanding: Do you know what is causing it or what it is related to? Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better? Other questions may include: Are you sexually active? If yes, do you use barrier methods? Does your partner have any sores? Do you have urinary incontinence? Severity: On a scale of 0-10, how would you rate the pain or discomfort? Treatment: Have you treated it with anything? Do you take any medications for it? |
Detailed sexual history will be collected. Skin care products can cause the genital skin to become irritated and develop lesions. Interventions will depend on the cause: Maintaining perineal hygiene (free incontinence care). Specimen collection or lesion biopsies. |
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Testicular/Scrotal Lump. A swelling or growth in one or both testicals or scrotum which can be benign or cancerous. Associated symptoms include pain, swelling, heaviness, asymmetrical testes, or scrotal edema. |
Have you noticed any lumps or changes to your testes recently? If the client’s response is affirmative, additional probes may include: Region: Where is it located? Quality/quantity: How would you describe it? Is it painful? Timing: When did you notice the change? Do you perform monthly testicular self-exams? Severity: How would you rate it on a scale of 0-10? Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better? Treatment: Have you treated it with anything? Do you take any medications for it? Understand: Do you know what is causing it or what it is related to? |
The first action is to complete a family history of testicular cancer. The testicular external examination will be performed after obtaining consent using a trauma-informed approach. Testicular cancer (TC) is the most common cancer among 15–35-year-old males. Possible interventions: Testicular ultrasound. |
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Dyspareunia is pain during intercourse, which is more common in women than in men. It can be associated with many conditions such as UTIs, genital infections, hormonal changes, atrophy, or problems with ejaculation (males). This is an unpleasant sensation that is described subjectively in many ways, such as tenderness, achy, discomfort, burning, or sharp pain. |
Are you experiencing pain during sex? If the client’s response is affirmative, additional probes may include: Region: Where do you feel the pain/sensation? Does it radiate anywhere? Quality/quantity: Tell me about it. What does it feel like? How bad is it? Timing: When did it begin? During ejaculation? During penetration? Severity: Can you rate it on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you have had? Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better? Treatment: Have you treated it with anything? Do you take any medications for it? Understand: Do you know what is causing it or what it is related to? |
Sexual intimacies can be very embarrassing and difficult for clients to discuss/describe. Therefore, a nonjudgmental approach, open communication, and active listening are encouraged in order to develop a trusting relationship. It can have significant impact on mental health leading to depression, anxiety, and low self-esteem. Possible interventions: Open discussion of sexual practices, preferences, and history. Genital examination after obtaining consent and using a trauma-informed approach. |
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Personal and family history of breast or reproductive conditions and diseases. Common issues associated with the breasts and reproductive system include breast cancer, fibrocystic breasts, infertility, and testicular cancer. |
Do you have a family history of conditions or diseases related to the breasts or reproductive system? If the client’s response is affirmative, begin with an open-ended probe: Tell me about the condition/disease. If the client has a family history, additional probing questions might include: What are the conditions/diseases? Which family member was diagnosed? Is there any genetic testing? |
Some clients may not be familiar with the term “reproductive system.” If so, use words such as the breasts, vagina, uterus, penis, or scrotum. Some reproductive system diseases have a genetic component, and genome sequencing might be conducted for early diagnosis and treatment. |
Knowledge Bites
Gynecomastia is the enlargement of breast tissue in males. It is a benign (non-cancerous) condition that can occur at any age and is often related to hormonal imbalances. While it is usually not a serious problem, it can cause discomfort and psychological distress for those affected.
Priorities of Care
Certain symptoms associated with the breast are cues that require action:
- New onset unilateral breast enlargement or change in shape
- New onset unilateral nipple inversion, crusting, or discharge
- Orange peel skin or thickening
- Breast dimpling or retracted skin
- Palpable lymph nodes in axillary/breast region
Finding a breast lump and undergoing evaluation can be stressful and anxiety-inducing. Emotional support from family, friends, or support groups can be very helpful. Professional counseling or speaking with a breast cancer navigator or patient advocate may also provide valuable support and information.
Contextualizing Inclusivity
The U.S. Preventive Services Task Force (2024) identifies Black women as 40 percent more likely to die from breast cancer than White women, and too often get aggressive cancers at young ages. Ensuring that Black women start screening at age 40 is an important first step, but it is not enough to improve these inequities. It’s important that patients receive equitable and appropriate follow-up after screening and effective treatment of breast cancer. We are urgently calling for more evidence to better understand whether Black women could potentially be helped by different screening strategies.
References
U.S. Preventive Services Task Force. (2024, April 30). Final recommendation statement: Breast cancer screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening#bcei-recommendation-title-area
- OpenAI. (2024). ChatGPT. https://chat.openai.com/chat. Content was reviewed for accuracy by the authors. ↵
