Transcript Gynecological Considerations in Treating Women with Physical

GYNECOLOGICAL
CONSIDERATIONS
IN TREATING
WOMEN WITH
PHYSICAL DISABILITIES
Developed by the Center for Research On Women with Disabilities, Baylor College of Medicine
OBJECTIVES
• Identify effects of physical disabilities on masking symptoms
and creating special concerns in reproductive health.
• Describe factors that interfere with diagnosing STD’s in
women with physical disabilities.
• Select special techniques for conducting pelvic
examinations.
• List the requirements of the Americans with Disabilities Act
(ADA) for medical facilities.
• Recognize the symptoms of physical and sexual abuse, and
refer women appropriately.
22%
Percentage of Women
with Disabilities
Compared to
Overall
Population
U.S. Census, 1994.
FINDINGS
National Study of Women with
Physical Disabilities
• 94% sexually active
• Equal rates of STDs
• 31% denied services
• Significantly less likely to receive exams
• Barriers significantly discouraging
• 62% abused
CASE STUDY
Day 1
HISTORY: 24-year-old; Complete T2 SCI;
Intermittent catheterization;
Previous UTIs & Yeast infections
EXAM: Discharge; Frequent leg spasms.
TREATMENT: OTC miconazole
CASE STUDY
Day 11
COMPLAINTS: Fever; Headache; Sweating
EXAM: 160/95; 70 bpm; Bruises; Firm,
tender abdomen; Elevated WBC;
Few bacteria
DIAGNOSIS: Urinary Tract Infection
TREATMENT: Oral cotrimoxazole
CASE STUDY
Day 15-ICU
COMPLAINTS: Fever; Headache; Sweating;
Nausea; Flushing; Cold feet
EXAM: 210/105; Bowel sounds absent;
Firm abdomen; WBC 21K w/97%
segs; Staphylococcus epi, E. Coli
Klebsiella; BP elevates w/bimanual
exam (EXAM STOPPED)
DIAGNOSIS: Urosepsis
TREATMENT: Nitroprusside drip; ceftazidime
CASE STUDY
Day 16-18
TREATMENT: Ampicillin; Clindamycin;
Exploratory laparotomy drainage
DIAGNOSIS: Acute salpingitis and tuboovarian abscess; Cultures grow
chlamydia
NOTE: Day 18 fever resolves, BP returns
to 100/70 mmHg
STDs in women w/SCI
Factors Interfering with Diagnosis:
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•
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Common symptoms absent or undetected
Findings attributed to more common causes
Nonspecific signs and symptoms unrecognized
Delay in seeking medical attention
AUTONOMIC DYSREFLEXIA
Lesion
Stimulus
AUTONOMIC DYSREFLEXIA
Symptoms
•
•
•
•
Severe hypertension
Pallor
Piloerection
Sweating
AUTONOMIC DYSREFLEXIA
Management
• Education / Prevention
• Gentle use of speculum
• Local anesthetic
AUTONOMIC DYSREFLEXIA
Treatment
•
•
•
•
•
•
•
•
Remove stimulus
Gentle use of speculum
Local anesthetic
Stop exam
Reposition patient
Loosen clothing
Check bladder / rectum
Administer short acting antihypertensive
THE GYNECOLOGICAL EXAM
• History—menstrual and sexual
• Examination
 Breast—inspection and palpation
 Pelvic—speculum, bimanual
 Rectal
• Screening tests as appropriate
 Mammogram
 Pap Test
 Vaginitis & STD’s
 Fecal occult blood
 Bone density
• Contraceptive counseling
PATIENT TRANSFERS
EXAM POSITIONS
EXAM POSITIONS
CONTRACEPTION
• General
 Data scarce
 Effects of hormones on
disabilities
• Oral contraceptives
 Thrombotic predisposition
 Effect on coagulation markers
 Benefits
CONTRACEPTION
•
Depo-provera and
norplant
 Irregular bleeding
 Decreased bone mass
• Barrier methods
 Inconvenient
 UTI
• IUDs
 Pelvic inflammatory
disease
MENSTRUAL MANAGEMENT
• Manual dexterity
• Transfer techniques
• Pharmaceutical
intervention
DISABILITY & MENOPAUSE
• Premature
osteoporosis
OTHER ISSUES
• Decreased tissue turgot & strength
• Loss of skin elasticity
• Reduced blood supply to skin & soft tissue
• Vasomotor instability
ABUSE
• High prevalence among women with disabilities
• Longer periods of time
• More difficulty resolving abusive situations
• More likely abuse in medical settings
• Excuses for signs of abuse
ABUSE
Clues from Medical History
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Inconsistent description
Time delay
Accident-prone history
Suicide attempts or depression
Repeated psychosomatic complaints
(Adapted from Salber PR, Taliaferro, E, 1995)
ABUSE
Clues from Medical History (cont.)
• Alcoholism and/or drug abuse
• Injuries during pregnancy
• Poor nutrition
• Other pregnancy-related problems
• Post-traumatic stress syndrome
• Disability-related abuse
HOW TO HELP
What To Do For Abused Patient
• Talk about abuse
• Assess degree of danger
• Help develop safety plan
• Document the incident
• Plan for follow-up
• Provide resource information
ADA - Examples of Disabilities
• Orthopedic, visual, speech
and hearing impairments
• Cerebral palsy
• Epilepsy
• Muscular dystrophy
• Multiple sclerosis
• Cancer
• Heart disease
•
•
•
•
•
•
Diabetes
Mental retardation
Psychiatric disability
Specific learning disabilities
Tuberculosis
Past history of drug
addiction and/or
alcoholism
ADA REQUIREMENTS
• Guaranteed services
• Equal services
• Integrated setting
• Facility evaluation
• Accessibility modifications
• Administrative or eligibility criteria
• Practices, policies, and procedures
• Providers’ costs
IDEAL PHYSICIAN’S OFFICE
• Hallways and exam room able to
accommodate wheelchair
• Adjustable-height, extra-wide padded
exam table
• Platform scale
• Staff trained to assist with dressing and to
be sensitive to disability issues
GOOD EXAMPLES
EXAM TABLE
ADJUSTABLE
HEIGHT
PLATFORM SCALE
HOPES & DREAMS
This CME Presentation was developed by the
Center for Research on Women with Disabilities
Margaret A. Nosek, PhD, Executive Director
Department of Physical Medicine and Rehabilitation
Baylor College of Medicine
Houston, Texas
www.bcm.tmc.edu/crowd/
With funding from the
Paralyzed Veterans Association, Education and Training Foundation
and the
National Institute on Disability and Rehabilitation Research