NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S.

. Figueroa, RN MN Nursing Care Management of Clients with Reproductive Disorders Content Quiz 50% Exam 40% Assignments 10%

Reproductive Health Assessment Maintain privacy and confidentiality

Health History Usual CC is: Pain, discharges and secretions Biographic and Demographic Data Population growth Environmental factors o Socio-cultural, economic, political, and religious practices o Risk taking behaviours o Health seeking behaviors o Accessibility, and availability of health services, trained personnel and supplies

Past Health History a. Childhood and Infection Diseases o Hepatitis, TB, Polio, DPT, MMR b. Major Illnesses and Hospitalizations c. Medications taken d. Allergies Psychosocial History a. b. c. d. Occupation and Environment Personal habits Domestic violence Psychosocial factors

Gynecologic History a. b. c. d. Breast Menstrual cycle Contraceptive Sexual practices 169

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN e. Past obstetric problems f. Reproductive health history Diagnostic Evaluation Diagnostic Procedures Pap Smear Cervical biopsy and Colposcopy Cryotherapy and Laser Therapy Endometrial Smears and Biopsy Dilation and Curettage Hysteroscopy Ultrasonography CT Scan MRI Laparoscopy Hysterosalpingography

Cytologic Test Papanicolaou Smear 1st conducted by Dr. George Papanicolaou in the 1930s Purpose is to detect cervical CA

Patient Teachings (2-3 days before the exam) 1. Not to douche or use vaginal creams. 2. Should not be menstruating. 3. No sexual intercourse Dilatation and Curettage The cervical canal is widened with a retractor and the endometrium is scraped with a curette

Purposes 1. To secure endometrial or endocervical tissues for cytologic examination. 2. To control abnormal uterine bleeding. 3. Therapeutic measure for incomplete abortion. **IVTT Anesthesia Nubain IVS Nursing Responsibilities Explain the procedure to the patient (advantages and disadvantages) Obtain informed and signed consent. Proper draping during surgery. 170

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Proper positioning of patient. Provide emotional and psychological support. Make sure the patient is not pregnant. Monitor vital signs and monitor level of pain and consciousness. Be alert for possible complications after procedure: bleeding, uterine perforation, ascending infection.

Menstrual Disorders Any disorder related to the menstrual cycle. Heavy painful periods (Dysme) Having no period at all (Amenorrhea) Variations in menstrual patterns When periods come fewer than 21 days or more than 3 months apart, or lasts more than 10 days N is 3-5 days to 7 days Often culturally based o Hispanic American menstruating females are not allowed to walk barefoot, wash their hair, take showers or baths o Puerto Ricans believe that drinking lemon or pineapple juice will increase cramping o Some Arab women have ethno-religious prohibitions and duties during and after menstruation. They are not allowed to go out of the house because blood is considered unclean

Risk Factors Early menarche (below 11) has higher risk of severe pain Excessively overweight or underweight Smoking increases pain and alcohol prolongs the pain Physical and emotional stress Chronic pelvic pain related to underlying pathologic conditions increases the pain History of depression

1. Pre-Menstrual Syndrome - Combination of emotional and physical manifestations that occurs cyclically in the female before menstruation and regress during menstruation - Peak age is 18-40y/o - 20-60 % of women experience PMS - 21 is the most stable age for menses - Menses lasts for 30 years Clinical Manifestations o Usually appear within the last few premenstrual days and is relieved with full menstrual flow o Altered emotional states Tension Depression Irritability Hostility 171

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Insomnia Loneliness Tendency to cry easily Indecision o Behavioral Changes Depression Psychosis Suicidal tendencies o Somatic Problems Headache Breast tenderness Abdominal bloating Peripheral edema Joint paint Backache Hives Constipation 2. Dysmenorrhea - Severe uterine pain during menses - May be sharp, throbbing, dull, nauseating, burning - Affects 40% to 50% of menstruating women - Most common cause of regular absenteeism among young women - Types o Primary Dysmenorrhea Cramps occur due to increase secretion of prostaglandins that cause contractions in the uterus Usually begins 2-3 years after a woman begins to menstruate The pain typically develops when the bleeding starts and continues for 32-48h. Cramps are generally most severe during heavy bleeding o Secondary Dysmenorrhea Menstrual-related pain that accompanies another medical or physical condiction Possible causes 1. PID 2. Endometriosis 3. Uterine Prolapse 4. Uterine Myomas 5. Polyps - Pathophysiology Menstruation Synthesis of Prostaglandin Produces strong myometrial contractions or spasms Constricts blood vessels supplying the uterus Causing ischemia and pain 172

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Clinical Manifestations o Nausea and Vomiting o Diarrhea o Syncope o Headache o Back Pain 3. Amenorrhea - The absence of menstrual flow may be caused by one of many different conditions such as: o Extreme weight gain/loss o Congenital anomaly such as an imperforate hymen - Types and Causes o Primary Amenorrhea Exists if the first menses has not occurred by the age of 16 E.g. under developed ovary and fallopian tube; Imperforate hymen o Secondary Amenorrhea Exists when an establishing menses, of longer than 3 months, ceases Pregnancy is the most common cause of secondary amenorrhea 4. Oligomenorrhea - Light or infrequent menses, more than 35 days apart - Common in early adolescence and may extend to about 2 years - Skipping periods may indicate missed ovulation - May occur due to weight loss and eating disorders - Medical Management o Take medications 1. Progesterone preparations 2. Oral contraceptive pills 3. Anti anxiety drugs as indicated 4. NSAIDs 5. Prostaglandin Synthesis Inhibitors - Nursing Management 1. Education and supportive reassurance 2. Assess clients general health status 3. Encourage adequate nutrition 4. Encourage appropriate rest, sleep and exercise 5. Assess stress and explore methods of stress management Abnormal Uterine Bleeding May occur as infrequent episodes, excessive flow, prolonged duration or bleeding between menses Examples of AUB o Bleeding or spotting between periods o Bleeding after sexual intercourse o Bleeding heavier or for more days than N

173

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN 1. Menorrhagia - An abnormally heavy and prolonged menstrual flow at regular intervals - Causes: o Anovulatory menstrual cycles o Uterine fibrosis and adenomyosis o Spontaneous abortion o Inflammatory processes (endometritis, salphingitis) o Use of IUD (10y max) o Endometrial CA 2. Metrorrhagia - Abnormal women among premenopausal women that is not in synch with their period - Possible Causes o Ectopic pregnancy o Spotting with ovulation o Cervical polyps o Breakthrough bleeding with oral contraceptives - Alternative Remedies 1. Acupuncture and acupressure 2. Regular exercise regimen 3. Menstrual hygiene 4. Yoga and meditative technique 5. Herbs and supplements (ginger tea and aromatherapy) - Surgical Management o Endometrial Biopsy o Endometrial Ablation Removal of the endometrial lining using laser heat or Cryotherapy and treatment of the uterine lining to control bleeding o Hysterectomy (Clinical Menopause) - Nursing Responsibilities 1. Explain the procedure and secure signed consent 2. Preop and Postop care 3. Follow up instructions Return visits Reports symptoms that could indicate infections or complications 3. Pelvic Inflammatory Disease - Generalized infection of the uterine lining, fallopian tubes and ovaries which progresses to scar formation. - May be caused by pus-producing organisms like staphylococci, gonococci, streptococci, as well as viral, fungal, and parasitic infections. - Common Risk Factors o Untreated bacterial infections o STIs o Low economic status o Low educational level o Early onset of sexual activity 174

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN o Multiple sex partners o Vaginal douching o Use IUD Clinical Manifestations o Malaise o Fever o Chills o Anorexia o N and V o Acute, sharp, aching pain on both sides of the abdomen or pelvis o Abnormal vaginal discharges Diagnostic Evaluations o Specimen Cultures (Culture and Sensitivity Test) o Histologic (Examination Endometrial Biopsy Specimen) o Colposcopy (Magnified) o UTZ Medical Management o Eliminate Causative Organism Antibiotic Caution to prevent sexual activity and douching With improvement, client should return to the clinic for re-evaluation of status Hospitalization may be necessary when antibiotics are administered in maximum doses Surgical Management o Ex Lap o TAHBSO (if ovaries, fallopian tubes and uterus are severely affected) Nursing Responsibilities Promote Comfort Provided emotional and Physiological support Provide education and coping measures Establish follow up visit schedule

Nursing Care Management of Male Reproductive and Urinary Disorders Infertility The biologic inability of an individual or a couple to conceive an offspring

A couple is considered infertile if: No conception after 12 months of contraceptive free intercourse if the female is under the age of 34 No conception after 6 months of contraceptive free intercourse if the female is over the age of 35 The female is incapable if carrying a pregnancy to full term Primary Infertility When a couple have never been able to conceive 175

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Secondary Infertility When the couple have difficulty conceiving after already having conceived

Causes of Infertility Ovulation problems (Anovulatory menstrual cycle, premenopausal) Tubal blockage (polyps, ectopic) Male associated infertility (Hormonal, genetic, less testosterone) Age-related factors Uterine Problems (straight uterus, anterior uterus anteverted) ~ knee chest position after sex for 20 minutes Previous tubal ligation Previous tubal ligation Previous vasectomy (clinically sterile if after 20 ejaculations and 3 consecutive negative sperm count) Unexplained infertility

Subfertility (Reduced Fertility) Reduced fertility A couple that has tried unsuccessfully to have a child for a year or more May be due to hormonal, dietary, environmental and structural factors Causes Males - Smoking and alcohol consumption - Unbalanced and unhealthy diet - Excessive ejaculation - Prolonged abstinence - Workplace hazards (Hot temperature, chemical, x-rays, fumes, tight constrictive clothing) Females - Ongoing reproductive infection (cervicitis, UTI) - Anovulation - Blocked fallopian tubes - Hormonal Imbalances - Poor dietary practices - Over exposure to VDU screens

Sterility A state in which there is an absolute factor (temporary or permanent) that prevents conception Ex. Hysterectomy Bilateral Oophorectomy Tubal ligation Vasectomy Genetic

Conditions for Ovulation Ovulation on a regular basis 176

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Production of an ejaculate containing an ample number of motile spermatozoa Deposition of spermatozoa in the female reproductive tract to the fallopian tubes Arrival of the recently ovulated ovum capable of being fertilized in the fallopian tube Patency of the fallopian tube 1 tablespoon of semen = 400-500M sperm, 20M/cc

Treatment (Infertility/Subfertility) Problem based Therapeutic Reflexology (relaxes muscles, relieves stress) Behavioral therapy for sexually related problems Artificial In Vitro fertilization Surrogacy

Erectile Dysfunction Is a sexual dysfunction characterized by the inability to develop or maintain an erection sufficient for satisfying sexual performance despite arousal May be psychological or secondary to an underlying medical condition like DM, prostate and testicular problems

Possible Causes Neurogenic (brain and spinal cord injuries) Hormonal disorders (HPN and vascular diseases) Hormonal disorders (Decreased testosterone level) Psychological causes (stress, mental disorders) Aging Lifestyle (obesity, alcohol and drugs, smoking)

Treatment Oral medications sildefanil (Viagra), tadalafil (Cialis), Andros, Denegra, Enegra, Silagra, Levitra Injectables (Aprodastil) injection directly in the base of the penis before sex Vacuum therapy penis pump Penile implants/prosthesis surgical placement of a rod into the penis Counseling and behavioral therapy

Disorders of the Prostate Gland Benign Prostatic Hyperplasia (BPH) Thickening and enlargement Refers to the increase in size of the prostate in middle aged and elderly men When large nodules compress the urethral canal causing partial or complete obstruction of the urethra which interferes the normal flow of urine. 20g = normal size of the prostate

Clinical Manifestations 177

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Urinary frequency Urinary incontinence Voiding at night Weak urinary stream Intermittent and dribbling urine Straining to void Pain and dysuria

Treatment Medications A Blockers to relax smooth muscles in the prostate and bladder thus decrease urine blockage Trans-urethral Needle Ablation cause cell death in the prostate and relieve urethral obstruction Surg-TURP removal of the prostatic tissues by inserting a resectoscope through the urethra

After Surgery Patient Health Teachings Adequate Hydration Avoid straining during BM Avoid heavy lifting Eat a balanced diet Take laxatives when constipated Dont drive or operate machineries

Prevention DRE 40 y/o and above A procedure where the examiner inserts a gloved lubricated finger into the rectum to check the size, shape, and texture of the prostate Areas that are irregular, hard, or lumpy need further evaluation since they may contain cancer cells (nodules, tumors) Prostate Specific Antigen Test (PSA) NV = 4ng/mL Measures the blood level of prostate specific antigen, a protein produced by the prostate that liquefies gelatinous semen after ejaculation, allowing sperm to more easily navigate through the uterine cervix Inc PSA levels may indicate higher risk

Prostate Cancer Malignancy of the prostate gland Tends to develop in men over the age of 50 3rd leading cause of cancer death among men

Clinical Manifestations Asymptomatic in early development Urinary dysfunction (frequency, pain, difficulty) Hematuria Sexual dysfunction (impotency/painful ejaculation) 178

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Cause Specific cause is unknown Risk factors include: genetics, age, diet, lifestyle, and environmental factors, hormonal influence

Prevention Foods, vitamins, and medication Soy beans, green tea, cauliflower, broccoli Ejaculation frequency Frequent masturbation at ages 20-30 increases risk Prostate Screening Annual DRE PSA blood test

Prostatitis Painful inflammation of the tissues of the prostate gland

Types Acute Bacterial Prostatitis May result from ascending bladder infection May be sexually transmitted Manifests through fever, chills, and shakes and urinary difficulties Chronic Bacterial Prostatitis Due to ongoing bacterial infection in the prostate Generally asymptomatic

Disorders of the Testacles Testicular Cancer Usually non-malignant and non-metastizing Easiest to cure among all types of cancer when detected early Affects men 15-40 years old Major risk factors are Cryptorchidism (Undescended testes), inguinal hernia and mumps

Clinical Manifestations A lump or hardening of one of the testicles Abnormal sensitivity (either numbness or pain) Loss of sexual activity or interest A dull ache in the lower abdomen or groin (sometimes described as a heavy sensation) Lumbago lower back pain A sudden increase or decrease of one or both testes as much as 3 times the original size Blood in the semen General body malaise

179

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Treatment Radiation Chemotherapy Orchiectomy (surgical removal of the testes)

Prevention Regular Self-testicular examination

Hydrocele The buildup of liquid in a fold of the mucous membrane of the scrotum Common in young boys and usually disappears as they grow older May be a result of hernia, CA or orchitis

Varicocele A swelling in the scrotum that occurs when the veins at the top of the scrotum enlarges

Disorders of the Penis Urethritis An inflammation of the urethra Viral and bacterial causes may include E. Coli, Herpes simplex, trichomonas

Signs and Symptoms include: Milky or pus-like discharges Stinging or burning pain upon urination Itching, burning, tingling or irritation inside the walls of the penis

Preventions Proper perineal care Abstinence from sex until cured Hydration Avoid spicy foods Isolate personal belongings to prevent spread Encourage use of condoms Health teachings on responsible sexuality

Urethral Stricture Abnormal urethral narrowing

180

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Causes Inflammation or scar tissue from surgery, disease, or injury Increased risk for whose with history of STI Recurring Urethritis BPH

Phimosis and Balantinis Phimosis A condition where the foreskin cannot be fully retracted from the head of the penis May be caused by Balantinis a skin condition of unknown origin that causes a whitish ring of tissue to form the tip of the prepuce May also occur due to repeated catheterization or forceful retraction of the foreskin

Priapism When the erected penis does not return to its flaccid state despite the absence of both physical and psychological stimulation within 4 hours Cause is unknown but associated with neurological and vascular factors May be secondary to use of medications like anti-HPN, antipsychotics, and medications for erectile dysfunction

Peyronies Disease Connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis causing an abnormal curvature when erect It makes sex painful and difficult Cause is unknown but related to traumatic injury to the penis

Penile Cancer Is a malignant carcinoma found of the foreskin or on the tissues surrounding the penis Symptoms include redness, irritation, a sore lump on the penis Risk factors include smoking, phimosis, history of STI (HPV)

Nursing Care Management of Clients with STIs STIs Infections that are spread from person to person through penetrative, unprotected sex Are dangerous because they are easily spreads and often asymptomatic during the early stages of infection 1 in 4 active teens have STIs 181

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Clinical Manifestations Sores or blisters near the genitals, anus or mouth Burning sensation or pain during urination Pruritus, foul odor, or unusual discharges from your genitals or anus Pain in the lower abdomen Vaginal bleeding between menstrual periods

Common STIs Gonorrhea CA: Neisseria Gonorrhoeae Incubation period: 2-30 days Symptoms occur 4-6 days after infection May be transmitted to newborn during childbirth. (Ophthalmia neonatorum)

Chlamydial Infections Syphilis CA: Treponema pallidum The Great Imitator because it has numerous symptoms similar to other diseases May be transmitted to newborn during childbirth (Congenital Syphilis) If untreated, it may damage the heart, bones, brains, aorta and eyes CA: Chlamydia trachomatis Usually asymptomatic during development stage May cause severe uterine bleeding to women Chlamydia conjunctivitis may progress to blindness

Genital Herpes CA: Herpes Simplex Virus Typical manifestations show clusters of sores with inflamed papules and vesicles on the outer surface of the genitals Herpetic proctitis Inflammation of the anus and the rectum Common in individuals engaging in anal intercourse

Genital Warts Highly contagious STI caused by HPV Transmission is through direct skin to skin contact during vaginal, oral, and anal intercourse Latency period may occur for months to yeas with no signs and symptoms Clusters of warts may grow all throughout the genital area

Trichomoniasis CA: Trichomonas vaginalis Primarily a urogenital tract infection and commonly infects the urethra and vagina Symptoms include vaginitis, cervicitis, urethritis, and pruritus, frothy, foul smelling discharges 182

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Pubic Lice Otherwise known as crab lice, Pediculosis pubis are parasitic insects notorious for infesting the human genitals They feed exclusively on blood Only known hosts are humans and gorillas Transmission is through sexual intercourse but may also be transferred through shared towels, clothing or beds Treatment includes rinsing agents as well as plucking, cutting and shaving infected pubic hair

Hepatitis B CA: Hepatitis B Virus Primarily affects liver causing inflammation (Acute Viral Hepatitis) The only sexually transmitted Hepatitis 2-30 days incubation

Transmission Exposure to infected blood and body fluids Unprotected sex Re-use of contaminated needles During childbirth NOT transmitted through saliva and sweat

Symptoms Jaundice Vomiting Loss of appetite Body aches General ill health May eventually develop into liver cirrhosis and liver CA

Treatment is geared towards strengthening the immunity and prevention by vaccination HIV/AIDS Modes of Transmission BT (99%) Infected needles (99%) Mother to child transmission (transplacental) Pregnancy (15%) Delivery (20%) Breastfeeding (30%) Sexual intercourse (1%)

Pathology Expsosure to HIV Window period (6 months) 183

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Asymptomatic period Full blown AIDS Death Prevention and Control A Abstinence B Be mutually faithful to uninfected partner C Careful sex (Condom use) D Drug free (Dont use drugs) E Education and early detection and treatment

STI Prevention Avoid exposure to infected bodily fluids (breast milk, blood, semen, and vaginal secretions) Avoid unprotected sexual intercourse Always wear undergarments when trying on bathing suits Get vaccinated for Hepatitis B Get annual pap test (women)

Nursing Care Management of Clients with Breast Disorders Breast CA Malignant tumor that develop from the cells of t the breast Usually begins in the milk ducts and lobules invading the nearby healthy cells towards the axillary region

Symptoms Lump in the breast Changes in size and shape Unusual discharges from the nipples Orange peel appearance of the skin on thebreast

Risk Factors Increased age Genetics Early onset of menarche Use of Hormone Replacement Therapy (HRT) Obesity Long term use of oral contraceptives Drinking alcohol 184

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Late pregnancy (after 35 years old)

Prevention Regular BSE Mammogram Healthy lifestyle

Treatment Chemotherapy Radiation therapy Lumpectomy or mastectomy Hormone therapy

Mammography Radioactive examination of the human breast Used as a diagnostic and screening tool for the early detection of breast CA Shows calcifications that would indicate degenerative changes in breast tissue Detection of masses for further screening

Galactography An x-ray examinations that uses mammography and contrast material to obtain pictures called galactograms Can locate small cancerous masses hat cannot be determined in any other way through the breastmilk ducts Indicated for women with bloody or clear discharges but with a N mammogram

Gynecomastia Development of abnormally large mammary glands in males resulting to breast enlargement May affect 1 or both breast Milk production may or may not be present Not physically harmful but may have psychological effects Cause is unknown but may be attributed to imbalanced sex hormones or medications

Uterine Disorders I. Endometriosis A condition where endometrial-like cells and tissues appear and flourish outside of the uterine cavity due to overproduction of estrogen Lesions may be found in the ovaries, fallopian tubes, pelvic walls and other areas of the pelvis May also appear in the vagina, bladder, intestines, rectum and other nearby organs Common among women in their reproductive years Cause is unknown but there are some theories: Retrograde Menstruation - Menstrual tissues flow backwards towards the fallopian tubes and deposits on the pelvic organs where it seeds and grows

185

II. -

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Genetic Predisposition - Women with 1st degree relatives with the disease are more vulnerable - Gets worst in the next generation\ Lymphatic or Vascular Distribution - Endometrial fragments may travel through the blood stream or lymphatic system and end up in distant sites like lungs, brain, skin and/or eyes Environmental Factors - Toxins, chemical, and hazards in the environment Symptoms Pelvic pain that may not/may correlate with menstruation - Before, during or after menses - When voiding - During ovulation - During or after sex - Felt in the lower back region Diarrhea or constipation during menses Abdominal bloating Heavy or irregular bleeding Fatigue May cause infertility or subfertility Treatment (Symptomatic) Pain killers - Simple analgesics/mild narcotics - NSAIDs - Caution against prolonged/overuse as it may cause addiction Hormone Therapy to regulate estrogen production and relieve symptoms - Combine oral contraceptive pills - Caution against S/E Laparoscopic surgery - Removal of all endometrial lesions, cysts and adhesions Hysterectomy Nutritional Therapy to Relieve pain - Vitamin E stops cell damage and repairs weakened cells - Vitamin A is a natural antihistamine - B-Complex Benign Uterine Tumors Aka uterine fibroids or myomas Composed of solid fibrous tissues and localized in the Myometrium Affects women between ages 30-40 Develops once the body starts producing estrogen and grows more quickly during pregnancy Usually shrinks and disappears after menopause Diagnosis Standard Gynecological Exam UTZ (transvaginal) Symptoms Abnormal Uterine Bleeding (Extended menstruation) Pain during menstruation Abdominal swelling and incontinence when the fibroids have grown bigger

186

III. -

IV. -

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Treatment Surgery a. Myomectomy - Only removes individualized tumors without damage to the uterus b. Hysterectomy may be indicated when - Sever abnormal bleeding - Excessively large fibroids - Disrupts functions of other organs like the bowels and the bladder Endometrial CA A malignancy of the endometrium which usually occurs within or after the menopausal stage 3rd leading cause of gynecological cancer death Symptoms Vaginal bleeding or spotting after menopause Abnormally heavy or prolonged uterine bleeding for pre-menopausal women Lower abdominal pain or pelvic cramping Thin, white or clear vaginal discharges Anemia Risk Factors Increased levels of estrogen Nulliparity Infertility Obesity HPN Early menarche and late menopause Uterine polyps or abnormal growths in the endometrium Diagnosis Pap Smear shows abnormal cellular changes Hysteroscopy direct visualization of the uterus to detect tumors and lesions Endometrial Curettage and Biopsy Transvaginal UTZ to evaluate endometrial thickness CT Scan imaging studies to evaluate extent of the disease Cervical CA Malignant neoplasm of the cervical CA Annual incidence of 16 per 100000 women Peak incidence is 45-55 years age group but occurs slightly earlier among those from lower sub-economic groups At present, 60% of women who develop cervical CA have never been screened Risk Factors Human Papilloma Virus neither partner may have visible warts Multiple sex partners Young age of first pregnancy High parity Low social status With multiple sex partners HIV Early age of first coitus Symptoms May be asymptomatic during early stages Diagnosis established after routine cervical smear Post coital, post menopausal, or intra menstrual bleeding occurs in 80-90% of patients 187

V. -

VI. -

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Blood stained vaginal discharges Treatment Restrict progress of infection Relief of pain For younger women, surgical management is restricted to removing endometrial tissues but preserving the ovaries For older women, hysterectomy may be recommended Preventive Measures Awareness Regular Screening Vaccination a. Works only before infection occurs b. Usually given to girls age 9-26 or before the first coitus Protected sex Avoid smoking Good nutrition to boost immune system Uterine Prolapse The displacement of the uterus from the pelvic cavity down to the vaginal canal due to the weakening of the connective tissues and ligaments supporting it Possible Causes Too many vaginal coughs Obesity and chronic cough Constant constipation Signs and Symptoms A feeling of as if sitting on a small ball Difficult or painful sexual intercourse Low backache Protrusion of cervix from vaginal opening Sensation of heaviness or pulling in the pelvis Vaginal bleeding Treatment Vaginal Pessary a. A device inserted into the vagina to hold the uterus in place Lifestyle Changes a. Weight loss for obese women b. Avoid straining and heavy lifting c. Prevent or treat cough Surgery ~ hysterectomy Uterine Retroversion The uterus tips backwards and sags downwards Usually a result of uterine malpositioning during pregnancy Common among multiparas Signs and Symptoms Abdominal pain or pelvic pressure Uterine contractions or cramping Bowel and bladder dysfunctions Treatment Bladder decompression a. Use of intermittent or indwelling catheter 188

VII. -

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Patient positioning a. Sleeping in prone position b. Intermittent knee chest or in all fours c. Manual uterine replacement Cervical Polyps Growths on the surface of the cervical canal where it opens into the vagina Usually asymptomatic and benign but may cause irregular menstrual bleeding Cause is unknown but associated with cervical inflammation and erosion Patient show red or purple projections around the cervical canal Signs and Symptoms Foul smelling discharges Bleeding between periods Heavier bleeding during periods Post coital bleeding Treatment Polypectomy Biopsy NSAIDs

Ovarian Cancer Risk Factors Age older than 40 Family history of ovarian or breast cancer Nulliparity History of infertility History of dysmenorrhea Use of hormone stimulating hormones

Clinical Manifestations Bloody vaginal discharges Urinary frequency and urgency Malnutrition with weight loss Abdominal pressure, fullness, swelling, bloating Lower abdominal pain/discomfort General severe pain

Preventive Measures Full term pregnancy Oral contraceptive use Breast feeding Bilateral Oophorectomy Routine pelvic exam (with Pap test) Transvaginal UTZ

189

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Vaginal Disorders Vaginitis An infection or irritation of the vagina

3 Categories of Infection Yeast Infection: Candidiasis caused by Candida albicans (pruritic) Bacterial: Sexually transmitted Parasitic: Trichomoniasis case by Trichomonas vaginalis

Symptoms Irritation and itching of genital area Inflammation of the labia majora, labia minora or perineal area Vaginal discharge (purulent, curdled milk appearance) Foul vaginal odor Discomfort or burning when urinating Pain or irritation during sex

Diagnosis and Management Culture and Sensitivity Test Oral and topical antibiotics Antifungals an antibacterials Proper perineal hygiene

Vaginal Fistula Abnormal winding or opening between two internal or hallow organs

Types 1. Vesicovaginal vagina to bladder 2. Rectovaginal vagina to rectum 3. Urethrovaginal vagina to urethra Causes Congenital or as a result of injury or surgery Spread of malignant lesions Result of inflammatory diseases After prolonged, difficult labor and traumatic delivery

Clinical Manifestations Foul vaginal discharge Painless vaginal bleeding Pruritus Pain Presence of vaginal lesions or masses Urinary frequency Urine, flatus and feces leak into the vagina 190

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN Irritated vaginal and vulval tissues

Vulvar Disorders Vulvitis Inflammation of the vulva Risk Factors Skin disorders Inflammatory problems Allergies Post menopausal atrophy and dryness Uncontrolled diabetes Scabies CA Incontinence Poor perineal hygiene Treatment Hydrocortisone cream Hydroxyzine HCl (Atarax) Measures to relive itching Apply cold compress Wear light, non restrictive clothes, cotton underpants Avoid feminine hygiene sprays Keep vulva dry and clean

Vulvar Cancer Vulvar CA is rare, accounting only for less than 2% of all genital tract CA in women Clinical Manifestation Long standing pruritus Post coital bleeding Foul smelling discharges Dysuria Vulvar edema A sore or swelling in the vagina (does not heal) Medical Management Systemic or topical antibiotics Steroid creams Hormone creams Chemotherapy if metastatic Nursing Management Treat itchiness with antipruritic cream Psychosocial support Health teachings on proper hygiene Surgical Management Vulvectomy a. Simple Vulvectomy - Removal of labia majora, labia minora, sometimes glans clitoris b. Radical Vulvectomy

191

NCM202B_A Care of Clients with Reproductive Disorders Miss Mary Anne S. Figueroa, RN MN - Excision of tissue from the anus to a few cm below the symphysis pubis (skin, labia majora, labia minora, glans clitoris) Bartholinitis Inflammation of one or both Bartholins glands Causes Obstruction of the ducts due to bacterial and viral strains of Streptococcus, Staphylococcus, Gonococcus, E. Coli Signs and Symptoms Swelling of one or both glands Abscess in infected gland Treatment Incision and drainage of the purulent material Excision of the entire gland and its duct Nursing Intervention Local heat application Provide comfort and support Health teaching on proper perineal hygiene

192