Genitourinary Disorders

Genitourinary Disorders
Alanna Murray & Cassandra Tovey 4th Year Nursing Students St. Francis Xavier University, SON

Objectives Compare the various types of:
Female and Male Reproductive Disorders Definition Clinical Manifestations Diagnosis Nursing Intervention

Male Reproductive System

Focus Prostate disorders Erectile dysfunction
Benign Prostate Hyperplasia Prostate Cancer Prostatitis Erectile dysfunction Testicular & scrotal disorders Penile disorders

Prostate Gland A gland Location: Function:
lies just below the neck of the bladder & surrounds the urethra Function: Produces part of semen “This gland produces a secretion that is chemically and physiologically suitable to the needs of the spermatozoa in their passage from the testes” Day et al, 2010, p. 1649)

Prostate Disorders Benign prostatic hyperplasia Prostate cancer
Prostatitis

Benign Prostatic Hyperplasia
Obstruction by enlarged prostate Symptoms Dysuria Hematuria Swelling in legs Blood in semen Decreased force in stream of urine - obstruction caused by an enlarged prostate gland “The prostate is a gland about the size of a walnut that is only present in men. It is located just below the bladder and surrounds the urethra. The gland is divided into three zones: peripheral, transitional and central. In BPH, there is an overgrowth of cells in the central portion of the prostate that constricts the urethra and reduces the flow of urine. This makes it difficult for the man to empty his bladder.” (Mayo Clinic, 2012 retrieved from “BPH is very common, affecting about one third of men over 50. Although it is not prostate cancer, the symptoms of BPH are similar.” (Mayo Clinic, 2012 retrieved from Symptoms: - Trouble urinating - Decreased force in stream of urine - hematuria - Blood in semen - Swelling in legs - Discomfort in pelvic area - Bone pain (Mayo Clinic, 2012 retrieved from

Tests/Diagnosis Digital rectal exam (DRE)
Prostate specific antigen (PSA) Post-void residual volume (PVR) Uroflowmetry Cystoscopy Urodynamic pressure Ultrasound -Digital rectal exam - insert a lubricated, gloved finger into your rectum to feel the surface of the prostate and judge whether it is enlarged, tender or inflamed. -prostate specific antigen test (PSA), a blood test to screen for prostate cancer The prostate gland produces the substance PSA – it can be measured in a blood specimen, and levels increase prostate disorders -measurement of post-void residual volume (PVR), the amount of urine left in the bladder after urinating -uroflowmetry, or urine flow study, a measure of how fast urine flows when a man urinates -cystoscopy, a direct look in the urethra and/or bladder using a small flexible scope -urodynamic pressure-flow study that tests the pressures inside the bladder during urination -ultrasound of the kidney or the prostate (The Official Foundation of the American Urological Association (AUAFOUNDATION, 2012 retrieved from

Treatment/Management
Pharmaceutical Alpha-blockers 5-alpha-reductase inhibitors Surgical Transurethral resection of the prostate (TURP) Transurethral incision of the prostate (YUIP) Suprapubic resection Prostatectomy Retropubic, perineal Management: Common medical treatments are drugs and surgery. Alpha-blockers - relax muscles at the neck of the bladder and in the prostate which reduces pressure on the urethra and allows an increase to the flow of urine. 5-alpha-reductase inhibitors - inhibit the production of a hormone called DHT (Dihydrotestosterone), which contributes to prostate enlargement. (Mayo Clinic, 2012 retrieved from transurethral resection of the prostate (TURP) - a long thin instrument is used to shave off sections of the enlarged prostate. transurethral incision of the prostate (TUIP) - small cuts are made in the neck of the bladder and the prostate, reducing obstruction of the flow of urine. open prostatectomy - an incision is made in the lower abdomen in order to remove the central part of the prostate. (Mayo Clinic, 2012 retrieved from

TURP Most common type of surgical procedure for BPH
Patient receives general or spinal anesthetic A resectoscope is inserted through the urethra into the prostate and removes the blocking portions of the prostate The patient will have a CBI post surgery

CBI – Continuous Bladder Irrigation
A solution flows constantly into the bladder to reduce the chance of blood clots forming. The fluid drains out through the catheter into a collection bag. CBI is used to prevent the formation of blood clots, which could obstruct urinary output. Bladder distention resulting from output obstruction increases the risk of bleeding. Irrigating fluids are continuously infused and drained at a rate to keep urine light pink or colorless. Urine that is frankly bloody, contains many blood clots, or is decreased in amount, as well as bladder spasms, are indicators of obstruction and bleeding. Retrieved from

CBI Nursing Management
Assess drainage tubing Maintain rate of flow – fluid should be light pink or colorless Assess urinary output q1-2 hrs Assess for bladder spasms, pain and distention If there is a block, need to flush Nursing management: -assess the catheter and the drainage tubing at regular intervals. Maintain the rate of flow of irrigating fluid to keep the output light pink or colorless. Assess the urinary output every 1 to 2 hours for color, consistency, amount, and presence of blood clots assess for bladder spasms.

Suprapubic Resection Abdominal incision into the bladder Remove tissue
Requires urethral & suprapubic catheter To allow for bladder repair A suprapubic resection is performed to remove the enlarged central portion of the prostate (referred to as the transition zone. This is done in contrast to the “radical” prostatectomy where the entire prostate is removed abdominal incision is made into the bladder Tissue is removed by blunt dissection Will require both urethral & suprapubic catheter Allows for bladder repair if necessary (Cathy’s PP)

Retropubic Prostatectomy
Low abdominal incision w/o entry into bladder Choice when prostate is very large/urethral stricture low abdominal incision without entry into the bladder. Choice when prostrate is very large or there is urethral stricture. Retropubic is more nerve sparing so preferred to prevent erectile dysfunction. Low abd incision is made and approaches the prostrate between the pubic arch and the bladder without entering the bladder. (Cathy’s PP)

Perineal Prostatectomy
Incision btw anus & scrotum Rare High risk of impotence Other risks: Rectourethral fistulas UTIs Epididymitis retention This approach is used when all other option are not available. Wound may easily becomes infected because the incision is near the rectum Also: must be done in lithotomy position, risk of rectourethral fistulas, UTI, epididymitis, urinary retention.

Prostate Cancer Most common type of cancer in men
Usually grows slowly & remains confined to the prostate gland Other types can be aggressive & spread Types Locally advanced Biochemically recurrent Metastatic Castrate resistant Prostate cancer is cancer that occurs in a man's prostate It is the most common cancer in men Prostate cancer usually grows slowly and initially remains confined to the prostate gland, where it may not cause serious harm. However, other types can be aggressive and spread quickly. If it is found early, and remains localized to the prostate, there is a better chance of successful treatment. (Mayo Clinic, 2012 retrieved from Of the 200,000 men who will be diagnosed with prostate cancer this year 5-10% will involve advanced disease. Types of advanced prostate cancer: - Locally Advanced Prostate Cancer: Cancer that has grown to fill the prostate or grown through the prostate and may extend into the glands that help produce semen (seminal vesicles), or the bladder - Biochemically Recurrent Prostate Cancer (Rising PSA): Patients who have a rising PSA after treatment, but do not show any evidence that the disease has spread to bone or other organs. Metastatic Prostate Cancer (Hormone Sensitive): Cancer that has spread (metastasized) to the bone, lymph nodes or other parts of the body Castrate Resistant Prostate Cancer (CRPC): prostate cancer that continues to grow despite the suppression of male hormones that fuel the growth of prostate cancer cells (AUAFOUNDATION, 2012 retrieved from

Clinical Manifestations
Hematuria Swelling in legs Blood in semen Decreased force in stream of urine Dysuria Signs/Symptoms May not cause signs or symptoms in its early stages. Prostate cancer that is more advanced can cause signs and symptoms such as: - Trouble urinating - Decreased force in stream of urine - hematuria - Blood in semen - Swelling in legs - Discomfort in pelvic area - Bone pain (Mayo Clinic, 2012 retrieved from

Tests/Diagnosis Needle biopsy PSA test Intravenous pyelogram
Fine needle aspiration Core needle/prostate biopsy Vacuum assisted biopsy Image guided biopsy PSA test Intravenous pyelogram Active surveillance Tests/Diagnosis Cancer screening tests can be a good idea. They can help identify cancer early on, when treatment is most effective. A normal PSA test, combined with a digital rectal exam, can help reassure men that it's unlikely they have prostate cancer. But getting a PSA test for prostate cancer may not be necessary for some men, especially men 75 and older. Needle biopsy - common needle biopsy procedures include fine-needle aspiration and core needle biopsy. During a needle biopsy, your doctor uses a special needle to extract cells from a suspicious area. A needle biopsy is often used on tumors that your doctor can feel through your skin. (Mayo Clinic, 2012 retrived from - Fine-needle aspiration. During fine-needle aspiration, a long, thin needle is inserted into the suspicious area. A syringe is used to draw out fluid and cells for analysis. - Core needle/Prostate biopsy. A larger needle with a cutting tip is used during core needle biopsy to draw a column of tissue out of a suspicious area. - Vacuum-assisted biopsy. During vacuum-assisted biopsy, a suction device increases the amount of fluid and cells that is extracted through the needle. This can reduce the number of times the needle must be inserted to collect an adequate sample. - Image-guided biopsy. Image-guided biopsy combines an imaging procedure, such as X-ray, computerized tomography (CT), magnetic resonance imaging (MRI) or ultrasound, with a needle biopsy. Using real-time images, your doctor can make sure the needle reaches the correct spot. (Mayo Clinic, 2012 retrieved from PSA test The PSA test is used primarily to screen for prostate cancer. A PSA test measures the amount of prostate-specific antigen (PSA) in your blood. PSA is a protein produced in the prostate, a small gland that sits below a man's bladder. PSA is mostly found in semen, which also is produced in the prostate. Small amounts of PSA ordinarily circulate in the blood. The PSA test can detect high levels of PSA that may indicate the presence of prostate cancer. However, many other conditions, such as an enlarged or inflamed prostate, can also increase PSA levels. Use of the PSA test is controversial. It's important to discuss with your doctor whether you should get a PSA test and what the results may mean. (Mayo Clinic 2012 retrieved from Intravenous pyelogram Intravenous pyelogram. An intravenous pyelogram (PIE-uh-loh-gram), also called an excretory urogram, is an X-ray exam of your urinary tract. An intravenous pyelogram lets your doctor view your kidneys, your bladder and the tubes that carry urine from your kidneys to your bladder (ureters). (Mayo Clinic, 2012 retrieved from Active surveillance for prostate cancer — During active surveillance (watchful waiting) for prostate cancer, you and your doctor closely monitor your prostate cancer for any changes. No medical treatment is provided — meaning medications, radiation and surgery aren't used. Periodic tests are done to check for signs the cancer is growing. Because prostate cancer often grows slowly and may not require treatment, active surveillance can be an option for some men with prostate cancer. Active surveillance may be a good choice if your cancer is small, expected to grow very slowly, confined to one area of your prostate, and isn't causing signs or symptoms. If you are an older man or have another medical condition that limits your life expectancy and your prostate cancer isn't causing symptoms or harm, active surveillance may also be a reasonable approach. (Mayo Clinic, 2012 retrieved from

Treatment/Management
Chemotherapy Radiation Cryotherapy Brachytherapy Hormone therapy Treatment/Management Chemotherapy Radiation therapy Cryotherapy - freezes prostate tissue, causing cancer cells to die. Brachytherapy Hormone therapy (Mayo Clinic, 2012 retrieved from Nursing Considerations

Nursing Management Obtain health history to determine
Concerns, level of understanding, support systems Provide education about diagnosis and treatment plan Provide information Institutional & community resources for coping Social services Support groups Community agencies Assess psychological reaction to diagnosis/prognosis How has he coped with past stress Day et al, 2010, p. 1663

Prostatitis Swelling & inflammation of the prostate gland
Caused by infectious agents carried to the prostate from urethra Bacteria, fungi, mycoplasma E. coli is the most commonly isolated organism Acute or Chronic Prostatitis is swelling and inflammation of the prostate gland. It can be caused by a number of different things. If it's caused by a bacterial infection, it can usually be treated successfully. If it isn't caused by a bacteria or a cause is never identified, it can be difficult to treat. Depending on the cause, it may come on gradually or suddenly. It can get better quickly, either on its own or with treatment but some types can last for months or more or it can keep recurring (chronic prostatitis). Causes other than bacteria include: an immune system disorder, nervous system disorder, or an injury to the prostate or prostate area Risk factors for prostatitis include: - Being a young or middle-aged man - past episode of prostatitis - infection in the bladder or urethra - pelvic trauma, such as injury from bicycling or horseback riding - Not drinking enough fluids (dehydration) - having a catheter - unprotected sex HIV/AIDS

Clinical Manifestations
Perineal discomfort Burning, urgency, frequency & pain with or after ejaculation Acute bacterial – fever, chills, perineal, rectal or low back pain, dysuria, frequency, urgency and nocturia Chronic bacterial – relapsing UTIs, mild symptoms and occasional urethral discharge Signs/Symptoms Vary depending on the cause and can include: - dysuria - Difficulty urinating, such as dribbling or hesitant urination - frequent urination and nocturia - Urgent need to urinate - Pain in abdomen, groin or lower back - Pain in perineum - Pain or discomfort of the penis or testicles - Painful ejaculation - Flu-like symptoms (with bacterial prostatitis) (Mayo Clinic, 2012 retrieved from

Tests/Diagnosis & Treatment/Medical Management
Medical history, physical exam, DRE, blood culture, urine & semen test, cystoscopy, urodynamic test Treatment Antibiotics Alpha blockers Pain relievers Prostate massage Tests/Diagnosis Medical history, physical exam including DRE, blood culture, urine and semen tests, cystoscopy, bladder tests (urodynamic tests – how well you can empty your bladder). (Mayo Clinic, 2012 retrieved from Treatment/Management - Antibiotics are the most commonly prescribed treatment for prostatitis. Taken for four to six weeks, but may need to be longer if it’s chronic or recurring. If antibiotics do not help it is most likely caused by something other than a bacterial infection. - Alpha blockers which help relax the bladder neck and the muscle fibers where your prostate joins your bladder. This treatment may lessen symptoms, such as painful urination. Examples include tamsulosin (Flomax), terazosin (Hytrin), alfuzosin (Uroxatral) and doxazosin (Cardura) and come with side effects including headaches and a decrease in blood pressure. - Pain relievers for treating pain associated with prostatitis. - Prostate massage which is done by your physician using a lubricated, gloved finger — similar to a digital rectal exam. It may provide some symptom relief, but doctors disagree about how effective it is. Other treatments are being studied including heat therapy with a microwave device and drugs based on certain plant extracts. (Mayo Clinic, 2012 retrieved from

Nursing Management Administer prescribed antibiotics
Patient education about medication Patient education about side effects of medication Avoid sitting for long periods During inflammation avoid sexual arousal & intercourse Teaching self-care Antibiotics, home care, encourage fluids, avoid alcohol, coffee, chosolate, cola and spices Use of comfort measures analgesic agents, antispasmodic medications, bladder sedatives, sitz baths, stool softeners Sitz baths to relieve pain and spasm Stool softeners to prevent pain from straining Day et al, 2012, p. 1657

Erectile Dysfunction Aka Impotence
Inability to achieve/maintain erection Psychogenic/organic causes Anxiety, fatigue, depression, pressure to perform Occlusive vascular disease, endocrine disease, cirrhosis, chronic renal failure, GU conditions, hematologic conditions, neurologic disorders, trauma to pelvic/gential area, alcohol, meds, drug abuse - “also called “impotence” – the inability to achieve or maintain an erection sufficient to accomplish inter course” (Day, Paul, Williams, Smeltzer, & Bare, 2010, p. 1652) - may report decreased occurrence of erections, inability to attain solid erection or quick subsiding of his erection (Day, Paul, Williams, Smeltzer, & Bare, 2010) - incidence occurs in 25 – 50% of males over the age of 65 years (Day, Paul, Williams, Smeltzer, & Bare, 2010) - erection physiology is very complex – pelvic nerves carry parasympathetic impulses that dilate smaller blood vessels of the region and increase blood flow to the penis , expanding the corpora cavernosa – the corpora cavernosa is composed of three expandable erectile tissues along the length of the penis that fill with blood during an erection and are made of a sponge-like tissue containing irregular blood-filled spaces lined by endothelium and separated by connective tissue septa (Day, Paul, Williams, Smeltzer, & Bare, 2010) - Three events need to occur in order for an erection to happen and to last: • “First is sexual arousal • Second is the brain's communication of the sexual arousal to the nervous system which activates blood flow • Thirdly, relaxation of the blood vessels that supply blood to the penis which allows for an erection” (Peate, 2012, p. 312). If something happens to affect any of these actions or relations between them, the outcome may be erectile dysfunction (Peate, 2012). In the great majority of instances ED is not a disease but a symptom of an underlying problem. Estimates are that 15 million to 30 million American men suffer from ED. Public awareness of ED has increased significantly with the introduction of sildenafil citrate (Viagra), the first successful oral therapy for ED. Other therapies existed prior to Viagra but they were invasive or awkward to administer in sexual situations. One of the great secondary benefits wrought by the introduction of oral therapies is that they called public attention to the problem and dispelled the myth that the majority of ED was psychological. There are now three oral therapies and others in trials. (Mayo Clinic, 2012 retrieved from Causes/Risk factors: - Medical conditions, particularly diabetes or heart problems. - Using tobacco, which restricts blood flow to veins and arteries. Over time tobacco use can cause chronic health problems that lead to erectile dysfunction. - Being overweight, especially if you're very overweight (obese). - Certain medical treatments, such as prostate surgery or radiation treatment for cancer. - Injuries, particularly if they damage the nerves that control erections. - Medications, including antidepressants, antihistamines and medications to treat high blood pressure, pain or prostate cancer. - Psychological conditions, such as stress, anxiety or depression. (The brain plays a key role in triggering the series of physical events that cause an erection, starting with feelings of sexual excitement. A number of things can interfere with sexual feelings and cause or worsen erectile dysfunction) - Drug and alcohol use, especially if you're a long-term drug user or heavy drinker. - Prolonged bicycling, which may compress nerves and affect blood flow to the penis, can lead to temporary erectile dysfunction. (Mayo Clinic, 2012 retrieved from

Clinical Manifestations & Tests/Diagnosis
Difficulty getting an erection Difficulty keeping an erection Reduced sexual desire Physical exam, DRE, blood tests, urine test, ultrasound Overnight erection test Psychological exam Erectile dysfunction symptoms may include persistent: - Trouble getting an erection - difficulty keeping an erection - Reduced sexual desire ( Mayo Clinic, 2012 retrieved from - “diagnosis requires a sexual and medical history, investigation of symptoms, a physical and neurologic examination, an evaluation of medication, alcohol, and drug use, and numerous laboratory studies” (Day, Paul, Williams, Smeltzer, & Bare, 2010, p. 1652) Tests/Diagnosis - Physical exam. This may include careful examination of the penis and testicles and checking nerves for feeling. - Digital rectal exam. - Blood tests. A sample of your blood may be sent to a lab to check for signs of heart disease, diabetes, low testosterone levels and other health problems. - Urine tests (urinalysis). Like blood tests, urine tests are used to look for signs of diabetes and other underlying health conditions. - Ultrasound. This test can check blood flow to your penis. It involves using a wand-like device (transducer) held over the blood vessels that supply the penis. It creates a video image to let your doctor see if you have blood flow problems. This test is sometimes done in combination with an injection of medications into the penis to determine if blood flow increases normally. - Overnight erection test. Most men have erections during sleep without remembering them. This simple test involves wrapping special tape around your penis before you go to bed. If the tape is separated in the morning, your penis was erect at some time during the night. This indicates the cause of your erectile dysfunction is most likely psychological and not physical. - Psychological exam. Your doctor may ask you questions to screen for depression and other possible psychological causes of erectile dysfunction. (Mayo Clinic, 2012 retrieved from

Treatment/Medical Management
Medication Viagra, Cialis, Levitra, Staxyn Testosterone replacement Penile uppository Alprostadil self-injection Penile vacuum pump Penile implants Blood vessel surgery Psychological counseling Management Oral medications  Oral medications are a successful erectile dysfunction treatment for many men. - Sildenafil (Viagra) - Tadalafil (Cialis) - Vardenafil (Levitra, Staxyn) Other treatments: Testosterone replacement, Testosterone replacement, Alprostadil self-injection (smooth muscle relaxant causing blood to flow into penis)., Penile vacuum pump (induction of erection with a vacuum; maintained with constriction band around the base of penis), penile implants, blood vessel surgery, psychological counseling, penile suppository is a smooth muscle relaxant causing blood to flow into penis – inserted into the urethra Mayo Clinic, 2012 retrieved from

Nursing Management Education Pamphlets, social supports Weight loss
Exercise Quit smoking Treatment for alcohol/drug problems Stress reduction Nursing Implications Educate: - Provide educational opportunities such as pamphlets or consultation with appropriate persons regarding effects of drug on sexual functioning. - Assess drinking and drug history of pregnant client. Provide information about effects of substance abuse on the reproductive system and fetus including increased risk of premature birth, brain damage, and fetal malformation. - Discuss prognosis for sexual dysfunction, such as impotence or low sexual desire. - quit smoking. If you have tr Encourage and accept individual expressions of concern.ouble quitting, get help. Try nicotine replacement (such as gum or lozenges), available over-the-counter, or ask your doctor about prescription medication that can help you quit. - Lose weight. Being overweight can cause — or worsen — erectile dysfunction. - Get regular exercise. This can help with underlying problems that play a part in erectile dysfunction in a number of ways, including reducing stress, helping you lose weight and increasing blood flow. - Get treatment for alcohol or drug problems. Drinking too much or taking certain illegal drugs can worsen erectile dysfunction directly or by causing long-term health problems. Work through relationship issues. Improve communication with your partner and consider couples or marriage counseling if you're having trouble working through problems on your own. Mayo Clinic, 2012 retrieved from

Genital Hygiene Essential to prevent acquired problems
Foreskin should retract easily Begin by washing tip Work down shaft Then scrotum Anal area last Effective genital hygiene is essential to prevent acquired penile problems Foreskin should retract easily Begin by washing tip, work down shaft, then scrotum, anal area last (Cathy’s PP)

Testicular & Scrotal Disorders
Testicular cancer Testicular torsion Orchitis Epididymitis Hydrocele, hematocele, spermatocele Varicocele Undescended testicles Testicular cancer – most common cancer in men 15 to 35 yrs of age, but can occur in males of any age Testicular torsion -Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum. The reduced blood flow causes sudden and often severe pain and swelling. Often occurs in males aged Orchitis – inflammation of the testes caused by pyogenic, viral, spirochetal, parasitic, traumatic, chemical, or unknown factors – mumps is one such factor Epidiymitis –infectiono f the epididymis that usually descends from an infected prostate or urinary tract – may also develop as a complication of gonorrhea and chlamydia Hydrocele, hematocele, spermatocele – hydrocele is collection of fluid generally in the tunica vagtinalis of the testes. Spermatocele is an abnormal sac (cyst) that develops in the epididymis, and a hematocele is a collection of blood in the scrotum. Varicocele – an abnormal dilation of the veings of the pampiniform venous plexus in the scrotum Undescended testicles - Undescended testicle (cryptorchidism) is a testicle that hasn't moved into its proper position in the bag of skin hanging behind the penis (scrotum) prior to the birth of a baby boy. Day et al, 2010 & Mayo Clinic, 2012

Cathy’s PP

Testicular Exam Monthly Best time – after bath/shower
Hold penis out of the way Check one testicle at a time Hold testicle btw thumb and fingers Gently roll Look & feel for hard lumps or smooth round bumps Note any change in size, shape, consistency The best time to do the self-exam is during or after a bath or shower, when the skin of the scrotum is relaxed. To do a testicular self-exam: Hold your penis out of the way and check one testicle at a time. Hold the testicle between your thumbs and fingers of both hands and roll it gently between your fingers. Look and feel for any hard lumps or smooth rounded bumps or any change in the size, shape, or consistency of the testes. If anything abnormal is found see a doctor Retrieved from

Cathy’s PP

Female Reproductive System and Disorders

Overview Anatomy Diagnostic Procedures Disorders and Treatments

Female Anatomy

Diagnostic Procedures
X-ray, ultrasound, MRI, PET PET scan usually used for pre-tx staging of selective malignancies Cytoscopy Study of cells through microscope or other equipment Pap smear Speculum inserted into vagina Sample obtained by rotating a small spatula & cervical brush at the os of the cervix Samples saved in proper medium and sent to lab for analysis for any abnormal cell findings (Day et al., 2010, p1535)

Dilation and Curettage (D&C) Tissue is removed from the uterine cavity Dx or Tx of uterine conditions (bleeding, incomplete miscarriage, etc) Cervix is dilated with an instrument, a curette is inserted to remove tissue Anesthesia and aseptic procedure May experience low back pain, minimal bleeding

Endoscopic Examinations Laparoscopy OR, 2cm incision below umbilicus, CO2 pumped in, laparoscope inserted View pelvic structures, dx pain, tubal sterilization, ovarian biopsy, lysis of adhesions, myectomy (removing fibroids) Complications are rare, procedure is safe and cost-effective Hysteroscopy Optical instrument with light insterted through cervical os into uterine cavity and NS or D5W infused Useful to evaluate endometrial pathology, adjunct to D&C, stop bleeding through ablation, or manage a retained IUD Hemorrhage, perforation and burns can occur

Hysterosalpingography or Uterotubography X-ray study of uterus and fallopian tubes Cannula is inserted into the cervix and contrast agent is injected, x-rays are taken Can cause n/v, cramps and syncope Peri pad worn for several hours afterwards bc the dye can stain clothing Evaluate infertility or tubal patency, or any abnormal condition of the uterine cavity Can be therapeutic because it flushes the cavity

Disorders of the Female Reproductive System
Focus PMS PID Endometriosis Cancer Brief Overview Structural Disorders

PMS – Premenstrual Syndrome
combination of Sx that occur prior to menstruation and subsides with menstrual flow Dx Sx occur within 5 days before menstruation Sx disappear within 4 days of onset of menstruation Sx occur through several cycles Premenstrual dysphoric disorder (PMDD) is Dx with severe Sx that interfere with school, work or social life Incidence Estimates vary, possibly 85% of menstruating women experience at least 1 PMS Sx in their monthly cycle (American College of Ostetricians and Gynecologists, 2010) PMS syndrome (cluster of Sx resulting in dysfunctions) affects 2-5% of women Estimated 3-8% suffer PMDD (American College of Ostetricians and Gynecologists, 2010) Day et al, 2010, p1547

PMS Cause is unknown Clinical Manifestations
Serotonin regulation considered to play a role Diet, exercise, stress considered to play a role Clinical Manifestations Physical: Headache Fatigue Low back pain Fluid retention: bloating, breast tenderness Abd fullness Behavioral & emotional: General irritability Mood swings, binge eating, crying Depression, anxiety

PMS: No Known Cure Medical Pharmacological Suggestions:
There is little evidence or research that non-pharmacological therapies are effective Suggestions: Exercise is encouraged Avoid caffeine, high-fat foods, refined sugars Chart Sx to anticipate and cope with them Pharmacological SSRI’s (Prozac, Sarafem) GnRH agonists (stops prod’n of oestrogen, usually stops menstruation after ~2 months of Tx) Prostaglandin inhibitors (ibuprofen, naproxen) Antianxiety agents Calcium supplement Vitamins B, E, magnesium, oil of evening primrose have been used but there is no research to evaluate their effectiveness Day et al, 2010, 1547

PMS Nsg Management Help the client chart onset of Sx
Record a nutritional Hx to determine if the diet is low in essential nutrients Facilitate positive coping measures: illicit family support during PMS, plan work to accommodate PMS days which may be less productive Encourage exercise, meditation, imagery Encourage adherence to medication regime and explain expected effects of meds Encourage client to enroll in a PMS help group to gain an understanding of others’ experiences Assess for suicidal, incontrollable or violent behavior Implement reporting protocols if assessment findings indicate a safety risk to client or family

Dysmenorrhea Primary dysmenorrhea Secondary dysmenorrhea
Painful menstruation with no identifiable pelvic pathology Occurs at menarche or shortly after Thought to be caused by excessive prostaglandin production which causes contraction of the uterus and arteriolar vasospasm Secondary dysmenorrhea As for primary, except pelvic pathology contributes to the Sx (endometriosis, tumor, etc) Pain may occur before menses, with ovulation and with intercourse

Dysmenorrhea Symptoms Diagnosis
Crampy pain just before or after menstruation starts and continues for hrs In secondary dysmenorrhea, pain may occur before menses, with ovulation and with intercourse Diagnosis Pelvic exam is used to rule out endometriosis, PID, fibroid uterus, adenomyosis (thickening of uterine wall) Day et al, 2010, p.1548

Dysmenorrhea Nsg Management Pharmacological
Reduce anxiety by explaining the reason for the discomfort Low heat locally applied to abd – may counteract some of the hormonal activity and vasodilate the vessels Increase physical exercise if possible Secondary dysmenorrhea is managed by treating the underlying pelvic pathology Pharmacological Provide analgesia prophylactically before onset Prostaglandin inhibitors – q4h, aspirin, ibuprofen, naproxen, mefenamic acid – determine which one works best for the client Low dose oral contraceptives provide Sx relief in >90% of clients

Pelvic Inflammatory Disease
PID

PID http://video.about.com/std/PID.htm

PID What is it? How does it manifest? Causes:
Inflammation of the pelvic cavity How does it manifest? May begin with cervicitis and may involve inflammation of the uterus, fallopian tubes, ovaries, pelvic peritoneum or pelvic vascular system Infection may be acute, subacute, recurrent or chronic Infection may be local or widespread - WBC in vaginal fluid Causes narrowing and scarring of fallopian tubes which inc risk for ectopic pregnancy, infertility, recurrent pelvic pain due to adhesions, tubo-ovarian abscess, recurrent disease Causes: Usually bacterial but may be viral, fungal or parasitic Gonorrheal or chlamydial organisms most common causes Day et al, 2010, p WBC in vaginal fluid: CDC, 2011,

PID Early Sx Additional Sx Fever
Vaginal discharge: abnormal, mucopurulent Dyspareunia Lower abd/pelvic pain Tenderness after menstruation Pain that increases while voiding or defecating Additional Sx Fever General malaise Anorexia N/V Headache Constipation Menstrual difficulties Intense tenderness on palpation of uterus or movement of cervix Day et al, 2010, p1580

PID Medical Management Broad spectrum antibiotics
IV Regimen A: Cefotan or Cefotoxitin IV PLUS Doxycycline PO or IV (CDC, 2011) IV Regimen B: Clindamycin IV PLUS Gentamicin IV IM/PO: Ceftriaxone PLUS Doxycycline +/- Metronidazole (CDC, 2011) IM/PO: Cefoxitin PLUS Probenecid +/- Metronidazole (CDC, 2011) Hospitalization if infection is moderate-severe Bed rest, IV fluids, IV antibiotics NG suction for abd distention or ileus (intestinal obstruction) Treat sexual partners – necessary to prevent re-infection Day et al, 2010, p1580 Recommended Parenteral Regimen A Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours Recommended Parenteral Regimen B Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted. Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days ORCefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days CDC, 2011,

PID Nursing management Health Promotion/Education
Bed rest, semi-Fowler’s position to facilitate dependent drainage Monitor VS Monitor vaginal discharge Administer analgesics for pain Heat to abd for pain relief **Follow infection precautions when handling peri pads: Wear gloves Dispose of pads in biohazardous waste Meticulous hand washing Health Promotion/Education Condoms/safe sex Proper peri-care (front to back) Discourage using a douche – introduces bacteria and reduces normal flora Annual gynecological exam Day et al, 2010, p1580

Endometriosis

Endometriosis Cells similar to those that line the uterus, grow outside the uterus and form lesions Chronic disease Affects 5-15% of women of reproductive age and 25-35% of infertile women Major cause of chronic pelvic pain and infertility Risk factors: Having fewer children or children late in life Familial: common where close female relatives have it Shorter menstrual cycle, less than 27 days, flow longer than 7 days, outflow obstruction Younger age at menarche

Endometriosis: Pathophysiology
Transplantation Theory – most accepted theory: backflow of menses (retrograde menstruation) transports endometrial tissue to ectopic sites (outside the uterus) through the fallopian tubes During menstruation, the ectopic endometrial tissue responds to hormonal stimulation, just as it would in the uterus The ectopic tissue bleeds but has no outlet, and causes pain and adhesions .

Endometriosis: presence of
endometrial glands and stroma outside of the normal location Ovarian endometrioma Ovarian endometriosis histology Ovarian chocolate cyst Peritoneal endometrioma Adenomyosis Lung endometriosis Chocolate cyst – endometrial tissue in an ovarian cyst Adenomyosis – thickening of uterine wall due to endometrial tissue moving into its muscular walls Lung endometriosis – endometrium migrates to lung, causes SOB, pneumothorax Day et al, 2010, p.1589 (BMJ, 2003; Med. Inform., 2006; BMJ, 2001; Respirology, 2006)

Endometriosis Manifestations Dx Dysmenorrhea Dyspareunia
Pelvic discomfort/pain Dyschezia (pain with bowl movement) Depression loss of work Relationship difficulties Infertility due to fibrosis, adhesions, or substances produced by the implants (ex: prostaglandins) Dx Bimanual pelvic exam: fixed tender nodules palpated, limited uterine mobility due to adhesions Laparoscopy confirms dx and helps stage the disease based on severity of adhesions Day et al, 2010, p.1589

Endometriosis Pharmacologic Therapy Surgical management
Analgesics & prostaglandin inhibitors for pain Hormone therapy for suppressing endometriosis and menstrual pain oral contraceptives Cyclomen – hormone causing atrophy of the endometrium & amenorrhea GnRH agonists – dec estrogen and cause amenorrhea Surgical management Laparoscopy and lasering of endometrial tissue & adhesions Other such as: hysterectomy, oophorectomy, bilateral salpingo-oophorectomy, appendectomy Fulgarate – cut with high frequency current

Endometriosis Nsg Management
Health Hx to determine specific Sx, time of onset, medications that are effective, etc Alleviate anxiety by explaining the various diagnostic procedures Address the possibility of infertility and explore options Dispel myths Encourage client to report dysmenorrhea or dyspareunia Provide client contact to the Endometriosis Association for info and support for the physical pain and emotional distress

Gynecological Cancers

Cancers Cervical Ovarian Uterine Vulvar Vaginal Fallopian Tubes

Cervical Cancer Nsg management: Often due to HPV infection
Spreads to regional pelvic lymph nodes if not treated S/S rare in early stages S/S late stage: discharge, irregular bleeding, bleeding after sexual intercourse Preventable and treatable Pap screening can identify pre-invasive lesions and prevent cancer Nsg management: Preventive counselling regarding: Delay 1st intercourse, avoid HPV infection, reproductive health, safer sex, smoking cessation, HPV immunization for females aged 9-26 yrs Facilitate access and utilization of gynecological care Day et al, 2010, p. 1593

Ovarian Cancer Nsg management:
Tumors of the cells that produce eggs, produce hormones or of the epithelial cells on the ovary surface (most common) Causes more deaths than any other cancer of the female reproductive system Ovarian tumours are often difficult to detect b/c they are deep in the pelvis No early screening mechanism exists, tumour markers are being explored (ex: CA-125 antigen testing) Risk factors: Age, Industrialized countries, Breast cancer **article S/S are nonspecific: inc abd girth, pelvic pressure, bloating, back pain, constipation , abdominal pain, urinary urgency, indigestion, flatulence, leg pain, pelvic pain Nsg management: Support and information regarding therapies (chemo, radiation, palliation, thoracentesis) IV therapy to manage fluid and electrolyte imbalances, parenteral nutrition, pain control, small frequent meals, decreasing fluid intake, diuretics, rest, Day et al, 2010,

Uterine Cancer Cancer of the uterine endometrium Risk factors:
Age over 55 Postmenopausal bleeding Obesity causing inc estrone levels Estrogen therapy without progesterone S/S: irregular bleeding Tx: total hysterectomy and bilat salpingo-oophorectomy adjuvant radiation Day et al, 2010, p. 1593

Vulvar Cancer Primarily squamous cell carcinoma
Little is known about the causes S/S: long-standing pruritis & soreness, bleeding, foul-smelling discharge, pain, visible lesions, mass that becomes hard, ulcerated and cauliflower-like Tx: excision, laser ablation, chemotherapy creams, cryosurgery Nsg management Education on delaying 1st intercourse, avoiding exposure to HPV, avoiding smoking, regular pelvic and pap exams Encourage self-exams regularly Day et al, 2010, p. 1594

Vaginal Cancer Primary cancer is squamous in origin 50% caused by HPV
S/S: pt often does not have Sx, but may report slight bleeding after intercourse, spontaneous bleeding, vaginal discharge, pain, an urinary or rectal Sx Dx: often by pap smear Tx: excision, laser therapy, topical chemotherapy, radiation, surgery Day et al, 2010, p. 1598

Fallopian Tube Cancer Rare Least common genital cancer
S/S: profuse watery discharge, colicky lower abd pain or abnormal vaginal bleeding, enlarged fallopian tube Tx: surgery & radiation Day et al, 2010, p. 1598

Hysterectomy Surgical removal of the uterus
22% of women in Canada over age 35 yrs have had a hyst; this doubles the rate in England and European nations Types Total hyst – removal of uterus and cervix Subtotal – removal of uterus, spare cervix Total abd hyst with bilateral salpingo-oophorectomy – removal of uterus, cervix, fallopian tubes and ovaries (for malignancies) Radical hyst – uterus and surrounding tissue removed, including upper third of vagina and pelvic lymph nodes Day et al, 2010, p.1600

Hysterectomy Facts Surgical Approaches
Hysterectomy can be a treatment option for women experiencing Fibroids Endometriosis Prolapse Cancer Abnormal Uterine Bleeding Surgical Approaches Open or “traditional” procedures (abd incision) Minimally invasive procedures (MIP) – through vagina or abd laproscopy

Laparascopic Hysterectomies
Total Hysterectomy Vaginal Hysterectomy “traditional” or “open” procedure Large incision or “bikini cut” (4–6 inches) Laparascopic Hysterectomies

Hysterectomy Nsg pre-op management:
Shave lower abd and pubic and perineal region, clean with soap & water Ensure NPO the night before to empty the intestinal tract Bladder must be empty Enema & antiseptic douche may be ordered the night before Administer pre-op meds as prescribed for relaxation Day et al, 2010

Hysterectomy Nsg post-op management:
Care for circulation to prevent thrombophlebitis, DVT, PE, hemorrhage Infection prevention Monitor voiding to ensure bladder problems have not occurred; Indwelling catheter may be needed Monitor bowel function to ensure paralytic ileus has not occurred Provide pain control Assess emotional status regarding loss of femininity, relaitonship issues, family issues…offer support and resources to help them address their situation Day et al, 2010

Female Structural Disorders
Fistulas of the Vagina Pelvic Organ Prolapse: Cystocele, Rectocele, Enterocele

Vaginal Fistulas An abnormal opening between 2 internal hollow organs or between an internal hollow organ and the exterior of the body May be congenital Usually due to trauma from surgery, vaginal delivery, radiation therapy, carcinoma Goal: Tx infection and eliminate fistula Rest, diet, antibiotics Surgery in some cases Day et al, 2010, p.1582

Rectovaginal Vesicovaginal Sx: Fecal incontinence,
Flatus Discharged through vagina Sx: Continuous leakage of urine into the vagina

Pelvic Organ Prolapse Prolapse: Risk Factors: Types Age
weakening of the vaginal walls allowing the pelvic organs to descend and protrude into the vaginal canal Risk Factors: Age Parity & large baby delivery (causing tears in musculature) Types Cystocele – bladder descends into vagina Rectocele – rectum pushes up on the posterior wall of the vagina Enterocele – intestinal wall protrudes into vagina Complete prolapse – uterus drops and may protrude from the vagina resulting in pressure and urinary problems Day et al, 2010, p.1582

Management: Kegel exercises
Enterocele Rectocele Cystocele Management: Kegel exercises Pessary: Doughnut or ring-shaped device positioned in the vagina to keep the organs properly aligned surgery

Management: Kegel Exercises

References American Cancer Society. (2012). Retrieved from
ularCancer/do-i-have-testicular-cancer-self-exam Centers for Disease Control and Prevention. (2012). Sexually Transmitted Diseases: Pelvic Inflammatory Disease. Retrieved from Cesario, S. (2010). Advances in the early detection of ovarian cancer: How to hear the whispers early. Nursing for Women’s Health, 14(3), Day, R., Paul, P., Williams, B., Smeltzer, S. & Bare, B. (2010). Canadian Textbook of Medical Surgical Nursing (2nd Canadian Ed.). Philadelphia: Lippincott Williams & Wilkins. Mayo Foundation for Medical Education and Research. (2012). Erectile Dysfunction. Retrieved from Mayo Foundation for Medical Education and Research. (2012). Prostatic Hyperplasia. Retrieved from Mayo Foundation for Medical Education and Research. (2012). Prostatitis. Retrieved from Mayo Foundation for Medical Education and Research. (2012). Prostate Cancer. Retrieved from Peate, I. (2012). Breaking the silence: helping men with erectile dysfunction. British Journal Of Community Nursing, 17(7), The Official Foundation of the American Urological Association. (2012). Urology. Retrieved from The Official Foundation of the American Urological Association. (2012). Urology fact sheet.

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