Reproductive System Disorders

reproductive system for both males & females 1. provide sexual pleasure 2. produce children gynecology- branch of medicine dealing with female reproductive disorders

Female Reproductive
Anatomy
External- vulva
1.

1. mons pubis-fatty pad with hair 2. external genitalia 1. labia majora 2. labia minora 3. clitoris 4. Bartholin & Skenes glands around vaginal opening 1. produce & secrete lubricating fluids 3. urinary meatus 4. vagina 5. rectum 6. perineum-area between external genitalia & rectum

Breasts
1. 2 on anterior chest 1. nourish baby

Internal diagram
1. consists of 2 ovaries, 2 tubes, 1 uterus, 1 vagina 2. vagina 1. organ of sexual pleasure 2. outlet for menstruation 3. birth canal 4. about 3-4 inches long 3. uterus 1. pear shaped 2. cervix or neck

3. fundus or body 4. 3 layers (endometrium, myometrium, perimetrium) 4. tubes 1. fallopian, uterine, oviducts 2. attached to uterus 3. fimbriae at ends 4. about size of IV tubing 5. ovaries 1. gonads 2. almond shaped 3. each contains 30,000-40,000 ova to be matured 1. designated ovum matures as graafian follicle 2. matures & ejected toward tube (ovulation) 3. if unites with sperm- conception 4. if no conception- expelled with blood (50-60 cc) as menstruation 1. 28 day cycle 2. 4-5 days duration 6. female sex hormones 1. estrogen 1. develop & maintain 2nd sex characteristics 2. prepare for growth of fetus 2. progesterone 1. develop of breast & endometrium 3. androgen 1. normal hair growth @ puberty

Menstruation
1. 2. 3. 4. 5. 6. 7. 8. p. 938 generally 28 days influenced by FSH & LH from pituitary 1-5 menstrual flow 6-13 ovum maturing with estrogen production 14 ovulation 15-28 progesterone produced to prepare uterine lining for possible conception "period" not "sick or curse"

Terms
1. 2. 3. 4. menstruation ovulation menarche- first period menopause 1. climacteric, change of life

2. cessation of menstrual flow 3. generally between 45-52 years

Premenstrual Syndrome (PMS), Ovarian Cycle Syndrome

1/3-1/2 women between 20-50 9-12 Million

At Risk
1. 1. 2. 3. 4. 5. 6. 7. 8. over 30 major life stressors ?nutrition problems with birth control pills (BCP) marital status history pre-eclampsia multiparity depression

Factor
1. 2. 3. 4. in absenteeism decreased productivity difficult interpersonal relationships lifestyle disruptions

Cause
1. 1. 2. 3. 4. 5. unknown ? hormonal imbalance ? vitamin deficiency ? excessive prostaglandins ? abnormal Mg metabolism

S&S
1. 1. weight gain 2. bloating 3. general irritability (mood swings, fear of losing control, binge eating, crying spells)

4. headache 5. inability to concentrate 6. food cravings 7. acne 8. fatigue 9. low back pain 10. engorged or painful breasts 11. feeling of abdominal fullness onset 7-10 days before period & ends with period

Rx.
1. mild analgesics 2. routine exercise 3. diet- worse if sugar, salt, caffeine, or chocolate

Menstrual Disorders
1. dysmenorrhea 1. painful menstruation 2. primary if no physical 3. secondary if disease 4. up to 75% menstruating females 5. S&S- painful cramps (onset to 12-24 hours after) 6. Rx.- usual activities, analgesics prn, heat, birth control pills 2. amenorrhea 1. absence of menses 2. delayed if over 16 without menses 3. several causes (stress, emotional upset, nutritional disturbances, pregnancy) 3. menopause 1. climateric 2. cessation of menses associated with ovarian failing lasts over 1 year 3. 45-55 years 4. S&S 1. no menses 2. hot or warm flashes 3. night sweats 4. dizziness 5. chills 6. chest pain 7. inability to concentrate 5. Rx 1. estrogen

1. benefits 1. less bone loss 2. less risk of osteoporosis & pathologic fractures 3. less risk colon cancer 2. increased risk 1. breast cancer 2. blood clot formation 3. coronary heart disease 4. gallbladder disease

Dx. Tests p. 950-952

1. pelvic examination 1. p. 952 2. annually after 18 or while sexually active 3. supine lithotomy best 4. drape for privacy 5. void before exam 6. note-cystocele, rectocele, prolapse, hymen 7. speculum exam (warm but not lubricated, note any discharge) 8. Pap smear 1. cytologic exam to detect cervical cancer 2. no douching before 3. no vaginal meds 4. no bath 48 hours before 5. not if menstruating or infection 6. wooden spatula, glass slide, fixative prn 7. class (1- normal, 2- atypical but not malignant- usually inflammation, 3-5 indicates degree of malignancy) 9. bimanual- change gloves between vaginal & rectal exam 10. endometrial biopsy- similar to Pap but specifically from uterus 2. mammogram 1. baseline generally between 35-40 then every 1-2 years until 50 then yearly 2. earlier if history 3. no underarm deodorant 3. biopsy 1. frozen section 2. aspiration, incisional (just piece), excisional (entire lesion removed) 4. dilatation & curettage (D&C) 1. dilatation & evacuation 2. done under anesthesia 3. secure tissue for cytology 4. control abnormal bleeding 5. incomplete abortion

5. laparoscopy 1. direct visualization 2. minor surgical procedures 3. insufflation (inject CO2 into abdomen)

Female History p. 953

menarche normal cycle & flow pregnancies sexual activity & contraceptive use indulge in damaging health practices (smoking, ETOH)

Danger Signals
spotting, irregular or excessive bleeding bleeding after menopause

Pelvic Relaxation Syndrome

1. prolapse 1. pix p. 861 2. uterus falls into vagina 3. pessary- mechanical support 4. surgery- suspension 2. cystocele 1. pouching of bladder into vagina 2. surgery- anterior colporrhaphy 3. rectocele 1. pouching of rectum into vagina 2. surgery-posterior colporrhaphy 3. if both- A&P repair 4. fistulas 1. abnormal opening between vagina & bladder or rectum

Leiomyomas (Fibroids, Myomas, Fibromyomas)

benign nulliparous Afro-American 3-9x white 20% white 40-50% Afro-American over 30 years

S&S
1. 1. 2. 3. 4. 5. some have none menorrhagia- excessive bleeding during menses pain, backache constipation metrorrhagia- bleeding between periods or after menopause

Rx
hysterectomy or myomectomy

Nursing
count pads/ hour

Endometriosis
cells similar to those lining uterus found outside of uterus 5-15% childbearing 30-45% infertility

At Risk

1. 1. 30 years 2. familial (history in mother, sisters, first degree females) 3. early menarche 4. short regular periods with heavy flow 5. overachievers 6. perfectionists 7. high IQ 8. generally Caucasians 9. nulliparity 10. higher socioeconomic 3-5 Million affected career female disorder 1. 1. marry later 2. children later 3. fewer children

S&S
deep-seated aching lower abdomen 1-2 days before period for 2-3 days

Rx
1. 1. hormone (estrogen- progesterone) 2. surgery 1. laparoscopy 2. laser 3. D&C 4. bilateral salpingectomy (BSO) 5. total abdominal hysterectomy (TAH)

Vaginal Infections
1. candidiasis- monilia 1. fungal or yeast 2. result of prolonged antibiotic therapy 3. frequently in pregnancy 4. diabetes 5. steroids

6. oral contraceptives 7. S&S 1. vaginal discharge (thick white cheesy, curd-like, little odor) 2. itching 3. more severe before period 8. dx. by culture 9. Rx.- antifungals 10. patient education 1. cotton underwear 2. no damp swimsuits in warm weather for long periods 3. eating 8 oz. yogurt/ day while taking antibiotics 2. trichomoniasis 1. protozoa 2. S&S 1. vaginal discharge (copious frothy green-yellow, malodorous, irritating) 2. burning, 3. itching 3. dx. by slide 4. Rx 1. flagyl for both partners 2. avoid intercourse 3. chlamydial infections 1. most common STD 2. leading cause of pelvic inflammatory disease (PID) 3. occurs 10x more than reported 4. increasing among sexually active teens 5. often asymptomatic 6. most prevalent & damaging 7. linked to ectopic pregnancy & infertility 8. Rx.- antibiotics

Pelvic Inflammatory Disease (PID)

cause of 180,000 hospitalizations/ year 1 Million reported q year 1 of 7 childbearing pathogenic

At Risk
1.

1. 2. 3. 4. 5. 6.

sexually transmitted disease (STD) multiple partners previous PID after childbirth or abortion intrauterine device (IUD) 15-24 years

S&S
1. 1. vaginal discharge 2. low abdominal pain 3. pelvic pain & tenderness following menses

Rx
antibiotics (take all) can lead to sterility

Patient Education
1. 1. 2. 3. 4. change sanitary pads q3-4h cotton crotch clean front to back safe sex with barrier protection

Toxic Shock Syndrome (TSS)

late 1970's risk- women under 30 menstruating using tampons 6-7 per 100,000 menstruating women can occur in males associated with 1. 1. cellulitis 2. surgical wound infection

3. subc. abscess 4. nasal packing

S&S
1. 1. 2. 3. 4. 5. 6. 7. sudden fever (102) Nausea, vomiting, diarrhea myalgia low B/P septic shock sore throat headache 8. red & macular rash on torso, palms, & feet followed by peeling in 1-2 weeks dx. by culture

Rx
1. 1. bedrest 2. antibiotics 3. symptomatic Patient Education 1. 1. no superabsorbent tampons 2. change q4h 3. alternate with pads at night

Cancer
excluding breast ca- 26,400 deaths/ year 1. cervical 1. risk 1. 2. 3. 4. 5. 6. 7. human papillomavirus (HPV) multiple partners venereal warts virus 15% have genital herpes chronic infections exposure to viruses lower socioeconomic

8. HIV 9. unprotected sex 10. Afro-American 11. diethylstilbesterol (DES) 12. first intercourse @ early age (under 20) 13. smoking 14. poor diet 15. 35-55 years 16. generally asymptomatic 2. dx. by Pap 3. staging 4. Rx 1. conization 2. laser 3. cryo 4. cauterization 5. hysterectomy 6. radiation 5. S&S 1. may complain of postcoital bleeding 2. spotting between periods 3. bleeding after menopause 2. uterine/ endometrial cancer 1. most frequently dx 2. q year.- 33,000 dx. with 5700 deaths 3. risk 1. early menarche 2. late menopause 3. taking estrogen especially after menopause 4. no children 5. Caucasian, middle class 6. no sexual relations 7. Jewish 8. 50-70 years 4. 5 yr. survival- over 90% 5. Rx 1. surgery 1. hysterectomy (TAH) 1. can also be done for cancer, endometriosis, prolapse, injury 2. may feel no longer a woman 3. no longer menstruates 4. hormones if ovaries also removed [BSO] 5. total- uterus & cervix 6. subtotal- uterus only 7. radical/ panhysterectomy (ovaries, cervix, uterus, tubes, pelvic lymph nodes, part of vagina)

8. vaginal or abdominal 2. drugs- hormones (Megace, Depo-Provera) 3. chemotherapy 4. radiation 2. frequently postmenopausal bleeding 3. dx by endometrial biopsy 3. ovary cancer 1. most lethal 2. silent killer 3. 14,500 deaths in 1998 4. 45-65 years [in industrialized areas except Japan] 5. #1 gyn death, #3 reproductive cancer 6. risk 1. sister/mother with BRCA1 or BRCA2 gene (associated with breast ca) 2. nulliparity 3. European American females 4. smoking, ETOH 5. infertility 6. high fat diet 7. using products containing talc 7. ?prevent 1. pregnancy 2. breast feeding 3. tubal ligation 4. ?birth control pills 8. dx.- ?CA-125 test 9. low survival rate (under 40%) 10. 75% mets by dx. 11. Rx.- radiation, surgery, chemotherapy

Breast Significance
associated with femininity in Western culture if disease suspected 1. 1. fear of disfigurement 2. fear of loss of sexual attraction 3. fear of death

Fibrocystic Breast Disease

chronic cystic mastitis lumpy breast syndrome 30-50 years breast ca 3-4x more likely familial link with caffeine dx. 1. 1. routine mammogram 2. breast self exam (BSE) q month (pix. p. 949) 3. surgery- bx. ?vitamin E daily diet- eliminate caffeine (teas, colas, coffee, chocolate)

Breast Cancer
worldwide- strikes q3minutes, kills q12minutes US- 1 of every 10 females/ year #1- lung cancer (22%), breast cancer (19%) 5 yr. survival rate- 97% if localized, 76% if spread regionally, 21% if distant metastasis anytime after menarche but 2/3 after 50 years 96% know BSE but only 33% perform it regularly

Cause
1. 1. unknown

2. 3. 4. 5.

genetic white more over 65 2x younger under 1% males

At Risk
1. 1. history of breast cancer on either side 2. over 50 3. family history especially female (sister or mother) 4. no children 5. first child after 30 6. no breast feeding 7. early menarche before age 12 8. obesity 9. increased dietary fat (weak support now) & ETOH consumption 10. smoking 11. natural menopause after 50 12. oral contraceptives 13. hormone replacement 14. exposure to carcinogens 15. other cancer 16. silicone implants most tumors in upper outer quadrant 2007- 178,480 women, 2030 men

S&S
1. 1. 2. 3. 4. 5. 6. 7. insidious in situ does not have localized tumor nontender movable lump (95%, discovered by self or partner) orange peel or dimpling asymmetry affected elevated pain late

Dx
1. 1. biopsy 2. staging 3. breast exam

1. professional exam 1. done by doctor 2. at least every 3 years between ages 20-40 years & then annually 3. should check axilla also 2. mammogram 1. baseline generally between 40-49 then annually after 50 2. earlier if history 3. no underarm deodorant 3. self breast exam (SBE) 1. p. 949 2. monthly generally between days 5-10 when first day of menses as day 1 3. if menopause- first day of month 4. most tumors discovered by BSE, tumor 2.5 cm, 50% already in lymph nodes 4. biopsy 1. frozen section 2. aspiration 3. incisional (just piece) 4. excisional (entire lesion removed)

Rx
1. 1. surgical with radiation (radioactive implants), hormonal, or chemotherapy 1. simple excision (lumpectomy) 2. mastectomy (simple, modified, radical depending upon amount tissue removed) 3. sometimes breast reconstruction can be done but must start preparing at time of mastectomy

Nursing
1. 1. emotional support (Reach for Recovery) 2. post-op 1. arm elevated 2. pain relief 3. ambulate 4. exercises p. 968

Patient Education
1.
1. NO holding cigarette, blood drawing, injections, B/P, jewelry including watch,

heavy bags or purse

2. wear gloves in kitchen or when gardening 3. avoid heavy lifting with affected arm

Male Reproductive
Anatomy Diagram p. 973
1. 2 testes 1. produce sperm & testosterone 2. located in scrotum 2. 2 epididymis 1. coiled tube to mature sperm (about 20 feet if uncoiled) 3. 2 vas deferens, ductus deferens 1. site of vasectomy 4. 2 seminal vesicles to provide fluid for lubrication 5. 1 prostate 1. walnut sized encircling urethra below neck of bladder 2. secretes fluid 6. 1 urethra- provides exit of urine & sperm from body 7. 1 penis 1. glans penis 2. end (prepuce or foreskin) 3. principle organ for sexual pleasure 8. male sex hormones 1. androgens, primarily testosterone 2. essential for development & maintenance of 2nd sex characteristics 3. promote metabolism, growth of bones & muscle & libido

Aging
prostate enlarges decreased sperm production (still fertile) longer to obtain erection more time between erections

Male History
urinary problems sexual problems lifestyle & social history (ETOH, smoking, drugs, frequency of sex, protected?, history trauma)

Erectile Dysfunction (Impotence)

inability to achieve or maintain erection sufficient to accomplish satisfactory intercourse multiple causes 1. 1. psychogenic (10-20%) 2. physiologic 3. drugs

Rx
1. 1. pharmacology (Viagra, cialis, hormone therapy) 2. mechanical- vacuum constriction device 3. penile implants prn p. 976

Miscellaneous Conditions diagram p. 980

1. hydrocele 1. fluid accumulation 2. surgery- hydrocelectomy 2. hypospadius 1. congenital abnormality 2. opening of urethra 3. no circumcision 4. surgery over stages 3. spermatocele 1. painless 2. generally reabsorbed 4. varicocele 1. dilated veins

2. frequently requires surgery

Testicular Torsion
twisting of testes & spermatic cord S&S- sudden onset acute scrotal pain potential medical emergency Rx. generally surgery

Phimosis
foreskin cannot be retracted over glans Rx.- circumcision (removal of foreskin, watch for bleeding)

Priapism
uncontrolled persistent erection causing penis to become very large, hard, & often painful urologic emergency Rx.- BR, sedation, ice, surgery prn

Benign Prostatic Hypertrophy (BPH)

50% over 50 90% over 70 increased in Afro-Americans cause uncertain

Risk Factors
1. 1. 2. 3. 4. 5. age family history race, ethnicity hormones diagram 981

S&S
1. 1. 2. 3. 4. 5. 6. 7. 8. hesitancy in starting stream decrease in size & force of stream increased frequency & urgency nocturia interruption of stream terminal dribbling (after urination) sensation of incomplete emptying of bladder acute urinary retention

Rx
depends upon size, severity, age, condition, associated diseases meds to shrink prostate (Proscar, Flomax) transurethral resection (TUR) 1. 1. diagram p. 983 2. most common 3. NO incision 4. ideal for poor risk 5. shorter hospital stay 6. post-op 1. continuous bladder irrigation [CBI] 1. p. 983 2. 3 way catheter 3. prevent clot formation which could obstruct catheter 4. accurate I&O 5. run at rate to keep urine clear 2. pain relief (bladder spasms- B&O suppository) 7. complications (hemorrhage, infection, thrombosis)

Nursing

1. 1. NO rectal temps, tubes, or enemas 2. no vigorous exercise, heavy lifting, or sexual relations for 2-6 weeks

Cryptorchidism
undescended testicle (1 or both) Rx.- hormones, surgery (orchiopexy) by age 5-7 10-30x testicular cancer

Epididymitis
infection under 35 occupations involving not urinating when urge occurs result of UTI/ STD

S&S
1. 1. unilateral pain & soreness 2. swelling in scrotum & groin 3. elevated temp

Rx
1. 1. 2. 3. 4. 5. bedrest scrotum elevated antibiotics ice later 1. ambulate 2. scrotal support (Bellvue bridge) 3. sitz baths 6. analgesics

Patient Education
1. 1. no straining or lifting 2. avoid sexual excitement 3. takes up to 4 weeks or more to return to normal

Orchitis
inflammation of testes generally result of blood-borne infection from epididymitis, gonorrhea (GC), trauma, surgery, TB, mumps S&S similar to epididymitis Rx.- bedrest, scrotal support, ice

Prostatitis
infection of prostate generally after chlymadia or GC S&S- perineal pain, fever, urethral discharge Rx.- elevate scrotum, force fluids, Sitz baths, antibiotics

Penile Cancer
rare associated with poor hygiene, delayed or no circumcision, history of STD S&S- painless nodular growth on foreskin Rx.- surgery with chemotherapy & radiation

Cancer Testes
most common cancer in 15-40 years leading cause ca deaths 25-35 years cure over 90% if detected early & responds to Rx cause unknown at risk 1. 1. 2. 3. 4. 5. age 15-40 cryptorchidism (48x) exposure to DES or oral contraceptive pills (OCP) first two fetal months family history men from US, UK or Scandinavia

S&S
1. 1. testes enlarged without pain 2. ?gynecomastia screen after age 15- self exam q month after warm bath or shower Rx.- surgery, radiation, chemotherapy sperm bank

Cancer of Prostate
2nd most common cancer deaths in males 2007- 218,890, 80% in over 65 1 of 11 men

Risk Factors
1. 1. age (over 40)

2. 3. 4. 5. 6.

race (Afro-American) family history occupational exposure to certain chemicals high animal fat diet increased testosterone

S&S similar to BPH screening 1. 1. over 50- yearly digital rectal exam 2. PSA yearly after 50 3. start @ 45 if @ risk

Rx.
1. 1. surgery p. 983 1. suprapubic prostatectomy (removed through abdominal incision) 2. perineal prostatectomy (removed through perineal incision) 3. retropubic prostatectomy (low abdominal incision) 4. post-op 1. catheter must drain well 2. radiation 3. hormone & chemotherapy

Nursing
1. 1. 2. 3. 4. 5. prevent infection keep stools soft perineal exercises dressing held in place by split T binder or padded athletic support post-op similar to BPH

Gynecomastia
overdeveloped breast tissue in male maybe unilateral or bilateral generally benign

biopsy if unilateral surgery

Sexually Transmitted Diseases (STD)

acquired through sexual contact old term- venereal disease most common infections in U.S.; 1 of 20 infected q year 1 of 6 has had over 15 Million/year 2/3 under 25 years increase due to ETOH or drug use

At High Risk
1. 1. 2. 3. 4. 5. 6. 7. sexual partner infected multiple sex partners unprotected nonbarrier sexual relations history STD adolescent oral contraceptives pregnancy

women at risk since S&S not as obvious

primary prevention most important!!

reportable to health department

Chlamydia
already covered

Gonorrhea
can be resistant to penicillin 800,000/year highest rates in 20-24 year olds with rapid rise in teens under 15 highest rate females 15-19 & males 20-24 Afro-American 25x Euro-American males (discharge from penis, burning) Rx with cefixime, cipro or vibramycin

Syphilis
Afro-American 50x Euro-American Hispanics 3x Euro-American each infected individual has an average of 3 different sexual contacts at risk can be congenital chancre (primary sore, p. 999) three stages can affect any organ Rx.- penicillin

Herpes Genitalia
viral lesions when contagious

45 Million 1/2 Million new per year no cure S&S- itching, pain, lesions (p. 996) for about 2 weeks Rx.- treat S&S, antiviral nursing- relieve pain, control infection

AIDS
already covered

Trichomoniasis
already covered

main Rx for all STD- prevention

must get sexual history with names of contacts confidential private gloves while examining genitalia

NPN 151 Medical Surgical Nursing I Russlyn A. St. John