Transcript Reproductive System

Reproductive System
ZOYA MINASYAN, RN,
MSN-EDU
Benign Prostate Hyperplasia
 Enlargement of prostate gland resulting from increase
in number of epithelial cells and stromal tissue
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Enlargement gradually compresses urethra.
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Partial or complete obstruction
Compression leads to clinical symptoms.
 Most common urologic problem in males
 Occurs in 50% of men over 50 and 90% of men over 80
 Approximately 25% will require treatment by age 80.
 Does not predispose to development of prostate cancer
Benign Prostate Hyperplasia
Benign prostatic hyperplasia. The enlarged prostate compresses the urethra.
Etiology and Pathophysiology
 Possible risk factors
 Family history
 Obesity
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Increased waist circumference
Physical activity level
Alcohol consumption, smoking
Diabetes
Clinical Manifestations
 Symptoms categorized into two groups
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Obstructive symptoms
Due to urinary retention
 Decrease in force of urinary stream
 Difficulty in initiating urination
 Dribbling at end of voiding
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Irritative symptoms
Associated with inflammation or infection
 Urinary frequency and urgency
 Dysuria
 Bladder pain
 Nocturia
 Incontinence
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Complications
 Related to urinary obstruction
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Acute urinary retention
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complication with sudden, painful, inability to urinate
Treatment involves catheter insertion and possible surgery
UTI and sepsis
Incomplete bladder emptying with residual urine-provides
medium for bacterial growth.
Calculi may develop in bladder because of alkalinization of
residual urine.
Renal failure: caused by hydronephrosis (swelling of kidney due
to a backup of urine)
Pyelonephritis (an ascending urinary tract infection that has
reached the pyelum (pelvis) of the kidney)
Bladder damage
Diagnostic Studies
 History and PE
 DRE ( digital rectal exam), prostate can be palpated by
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DRE.
Urinalysis with culture( presence of infection).
PSA level (Prostate-specific antigen is a protein
produced by cells of the prostate gland).
Serum creatinine (for renal insufficiency)
TRUS scan(trans rectal ultrasound) for the size of
prostate.
Uroflometry (volume of urine expelled from the
bladder per second)
Cystoscopy for internal visualiziation of the urethra
and bladder.
Diagnostic Studies
• Using DRE, the health care provider can estimate the size, symmetry, and consistency
of the prostate gland. In BPH the prostate is symmetrically enlarged, firm, and smooth.
• A urinalysis with culture is routinely done to determine the presence of infection. The
presence of bacteria, white blood cells, or microscopic hematuria is an indication of
infection or inflammation.
• Serum creatinine:
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Creatinine is a chemical waste molecule that is generated from muscle metabolism.
Creatinine is produced from creatine, a molecule of major importance for energy
production in muscles.
Creatinine is transported through the bloodstream to the kidneys. The kidneys
filter out most of the creatinine and dispose of it in the urine.
As the kidneys become impaired for any reason, the creatinine level in the blood
will rise due to poor clearance by the kidneys.
• TRUS scan allows for accurate assessment of prostate size and is helpful in
differentiating BPH from prostate cancer. Biopsies can be taken during the ultrasound
procedure.
• Uroflowmetry is helpful in determining the extent of urethral blockage and thus the type
of treatment needed.
• Cystoscopy is performed if the diagnosis is uncertain and in patients who are scheduled
for prostatectomy. Allowing internal visualization of the urethra and bladder.
Collaborative Care
 Drug therapy:
 5α-Reductase inhibitors
Example: finasteride (Proscar), dutasteride (Avodart)
 ↓ size of prostate gland
 Takes 3 to 6 months for improvement
 Side effects: decreased libido, decreased volume of
ejaculation, ED (erectile Disfx)
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α-Adrenergic receptor blockers
Examples: tamsulosin (Flomax), doxazosin (Cardura),
silodosin (Rapaflo)
 Promotes smooth muscle relaxation in prostate; facilitates
urinary flow
 Improvement in 2 to 3 weeks
 Side effects: orthostatic hypotension and dizziness,
retrograde ejaculation, nasal congestion
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Collaborative Care
 Transurethral microwave therapy (TUMT)
 Outpatient procedure: delivers microwaves directly to prostate
through a transurethral probe
 Heat causes death of tissue and relief of obstruction.
 Postop urinary retention is common.
 Patient sent home with catheter 2 to 7 days
 Antibiotics, pain medication, and bladder antispasmodic
medications given.
 Anticoagulant therapy should be stopped 10 days before
treatment.
Collaborative Care
 Transurethral needle ablation (TUNA)
 ↑ temperature of prostate tissue for localized necrosis
 Low-wave frequency used
 Only tissue in contact with needle affected
 Majority of patients show improvement in symptoms.
 Outpatient uses local anesthesia and sedation.
 Lasts 30 minutes with little pain and quick recovery
 Complications include urinary retention, UTI, and irritative
voiding symptoms.
 Some patients require a catheter.
 Hematuria up to a week
Collaborative Care
 Laser prostatectomy
 Delivers a laser beam transurethrally to cut or destroy parts of
the prostate
 Common procedure: visual laser ablation of the prostate
(VLAP)
Takes several weeks to reach optimal results
 Urinary catheter inserted
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Contact laser techniques
Minimal bleeding during and after procedure
 Fast recovery time
 Patients may take anticoagulants.
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Photovaporization of the prostate
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Collaborative Care
 Transurethral resection (TURP)
 Removal of obstructing prostate tissue using resectoscope
inserted through urethra
 Outcome for 80% to 90% is excellent.
 Relatively low risk
 Performed under spinal or general anesthesia and requires
hospital stay
 Bladder irrigated for first 24 hours to prevent mucous and
blood clots
 Complications include bleeding, clot retention, dilutional
hyponatremia.
 Patients must stop anticoagulants before surgery.
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Nursing Implementation
 Focus: early detection and treatment
 Yearly physical exam and DRE for men over 50
 Educate patients that alcohol, caffeine, and cold and
cough meds can increase symptoms.
 Instruct patient with obstructive symptoms to
urinate every 2 to 3 hours and when first feeling
urge.
 Teach for adequate fluid intake. Use aseptic
technique when using urinary catheter.
 Administer antibiotics preoperatively.
Nursing Implementation
Postoperative care
 Postop bladder irrigation to remove blood clots and
ensure drainage or urine
 Administer antispasmodics.
 Teach Kegel exercises.
 Observe patient for signs of infection.
 Dietary intervention
 Stool softeners to prevent straining
Prostate cancer
 Is a malignant tumor of the prostate gland
 One out of five men will develop at some point
during there life
 Early stages are asymptomatic and later on
symptoms of BPH
 Pain that radiate down to the hips or legs plus
urinary symptoms may indicate metastasis
Prostatitis
 Acute and chronic results from organisms reaching the
prostate gland by
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Ascending from the urethra
Descending from the bladder
Invasive via bloodstream or lymphatic channels
Common causative organisms are- Escherichia coli, Klebsiells
Pseudominas, Enterobacter, Proteus, Chlamydia trachomatis,
Neisseria gonorrhoeae, and group D streptococci.
 Common manifestation:
 Fever, chills, back pain, perineal pain, dysuria, frequency, urgency,
and cloudy urine, prostatic swelling, tender and firm.
 Dx: urinanalysis (UA) and urine culture for WBC and
bacteria presence
 Nursing mangement: antibiotics bactrium, cipro, floxin,
vibramycin or tetracyclin.
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Given 4 weeks for acute bacterial prostetitis
Oral 4-12 weeks
Imunocompromised given for lifetime.
Problems
Hypospadias: urethral meatus is located on the ventral surface of the penis
Epispadias: an opening of the urethra on the dorsal surface
Phimosis: tightness or constriction of the foreskin around the head of the penis
Paraphimosis: tightness of the foreskin resulting in inability to pull it forward
Priapism: painfull erection lasting >6hour caused by obstruction of the venous outflow
in the penis
Peyronie’s disease: curved penis caused by plaque formation in one of the corpora
cavernosa
Epididymitis: inflammation caused by infection trauma, urinary reflux
Orchitis: inflammation of testes; painful, tender and swollen
Cryptochidism: un-descended testes into the scrotal sac before birth
Hydrocele: fluid filled mass results from lymphatic mallfunction
Spermatocele: sperm containing painless cyst of the epidiydimis
Varicocele: dilation of the veins that drain the testes
Testicular torsion: twisting of the spermatic cord that supplies blood to the testes and
epididymis
Erectile dysfunction: ED caused by DM, vascular disease, decreased hormones,
trauma, stress, depression,
Vasectomy: bilateral surgical ligation or resection of the vas deferens. Done in 15-30
min, local anesthesia
Andropause: decline in androgen with aging, decreased level of testosterone
Sexually Transmitted Diseases (STDs)
 STDs are diseases that can be transmitted during
intimate sexual contact.
 Most prevalent communicable diseases in the US.
 Most cases occur in adolescents and young adults.
- STDs in infants and children usually
indicate sexual abuse and should be
reported. The nurse is legally responsible
to report suspected cases of child abuse.
Nursing Assessment
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Syphilis ( Treponema Pallidum)
Gonorrhea (Neiserria Gonorrheae)
Chlamydia ( Chlamydia Trachomatis)
Trichomoniasis ( Trichomonas Vaginales)
Candidiasis ( Candida Albicans)
Herpes Type 2 (herpes Simplex Virus 2)
HPV ( Human Papilloma Virus)
HIV and AIDS ( Human Immunodeficiency
Virus)
STDs
Nursing Diagnoses
 Deficient Knowledge related to
 Anxiety related to
 Anticipatory grieving related to
Nursing Plan and Interventions
Use a non judgmental approach. Be straightforward when taking history.
All information is strictly confidential. Obtain a complete sexual history.
Develop teaching Plan include:
Sign and symptom of STDs.
Mode of transmission of STDs
Reminder that sexual contact should be avoided with anyone while infected.
Concise written instruction about treatment; request a return verbalization of these
instructions to ensure the client has heard the instructions and understands them.
Encourage client to provide information regarding all sexual contacts.
Report incidents of STDs to appropriate health agencies and departments.
Instruct women of childbearing age about risk to a newborn:
a. Gonorrheal conjuctivitis
b. Neonatal herpes
c. Congenital syphilis
d. Oral candidiasis
Teach safer sex
Nursing Plan and Interventions
 Safer sex behavior include:
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Reduce the number of sexual contacts.
Avoid sex with those who have multiple partners.
Examine genital area and avoid sexual contact if
anything abnormal is present.
Wash hands and genital area before and after
sexual contact.
Use a latex condom as a barrier.
Use water based lubricants rather than oil based lubricants.
Avoid douching before and after sexual contact: douching
increase the risk for infections because the body’s normal
defenses are reduced or destroyed.
Seek attention from health care provider immediately if
symptoms occur.
Complications
 Complications of STD’s
 Pelvic Inflammatory Disease (PID)
 Sterility
 Ectopic pregnancy
 Blindness
 Cancer (associated with HPV)
 Fetal and infant death
 Birth defects
 Mental retardation
 AIDS has a set of complications much broader than the
other STD’s
Sexually Transmitted Diseases
 Infectious diseases most commonly transmitted
through sexual contact
 Can also be transmitted by
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Blood
Blood products
Autoinoculation
 Can be bacterial or viral
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Usually start as lesions on genitals or mucous membranes and can
spread to other areas
 All cases of gonorrhea and syphilis (and in
most states chlamydia) must be reported to
state or local public health authorities. Still
underreported.
Sexually Transmitted Diseases
 Changes in methods of contraception
 Condom is best protection against STDs but still is not
used frequently in general population.
 Oral contraceptive effects on acidity of vaginal/cervical
secretions promote growth of certain organisms, causing
STDs.
Gonorrhea: Etiology and Pathophysiology
 Caused by Neisseria gonorrheae
 Gram-negative bacteria
 Direct physical contact with infected host
 Mucosa with columnar epithelium is susceptible.
 Present in genitalia, rectum, and oropharynx
 Easily killed by drying, heating, or washing with antiseptic
 Incubation period: 3 to 8 days
 Provides no immunity to subsequent reinfection
 Elicits inflammatory process that can lead to fibrous tissue and
adhesions
 Tubal pregnancy
 Chronic pelvic pain
 Infertility in women
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Neonates can develop a gonococcal infection from an infected mother during
delivery.
Gonorrhea
Clinical Manifestations
 Men
 Initial site infection is urethra.
 Symptoms
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Develop 2 to 5 days after infection
 Dysuria
 Profuse, purulent urethral discharge
Unusual to be asymptomatic
Gonococcal Urethritis
Profuse, purulent drainage in a patient with gonorrhea.
Gonorrhea : Clinical Manifestations
 Women
 Mostly asymptomatic or have minor symptoms
Vaginal discharge
 Dysuria
 Frequency of urination
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After incubation
Redness and swelling occur at site of contact.
 Greenish, yellow purulent exudates often develops.
 May develop abscess
 Disease may remain local or may spread by tissue extension to
uterus, fallopian tubes, and ovaries.
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Endocervical Gonorrhea
Endocervical gonorrhea. Cervical redness and edema with discharge.
Gonorrhea: Clinical Manifestations
 Eye infections in newborns
 Instillations of prophylactic erythromycin (0.5%) ophthalmic ointment or
silver nitrate (0.1%) aqueous solution
 Untreated infants develop permanent blindness.
 Orogenital: Gonococcal pharyngitis can develop.
 Anorectal gonorrhea: Usually from anal intercourse
 Symptoms include soreness, itching, and discharge of anus.
 Complications
 Women
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Include pelvic inflammatory disease (PID), Bartholin’s abscess (the buildup of
pus that forms a lump (swelling) in one of the Bartholin's glands, which are
located on each side of the vaginal opening), ectopic pregnancy, and infertility
Usually asymptomatic, so seldom seek treatment
Small percentage develop disseminated gonococcal infection (DGI).
 Skin lesions, fever, arthralgia, arthritis, or endocarditis
Men
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Include prostatitis, urethral strictures, and sterility
Often seek treatment early, so less likely to develop complications
Disseminated Gonococcal Infection (DGI)
Skin lesions with disseminated gonococcal infection. A, On the hand. B, On the fifth toe.
Gonorrhea: Diagnostic Studies
 Women
 Smears and discharge do not establish diagnosis.
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Female GU tract harbors organisms resembling N. gonorrhea.
Must have culture to confirm diagnosis
 Drug therapy
 Treatment in early stage is curative.
 Most common
Oral dose of cefixime (Suprax)
 IM dose of ceftriaxone (Rocephin) Fluoroquinolones are no
longer used.
 Patients with coexisting syphilis are likely to be treated with
azithromycin (Zithromax) or doxycycline (Vibramycin).
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Gonorrhea: Collaborative Care
 All sexual contacts of patients must be evaluated and
treated.
 Patient should be counseled to abstain from sexual
intercourse and alcohol during treatment.
 Reexamine if symptoms persist after treatment.
Syphilis: Etiology and Pathophysiology
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Caused by Treponema pallidum; Spirochete bacterium
Enters the body through breaks in skin or mucous
membranes
Facilitated by abrasions that occur during sexual intercourse
 Causes production of antibodies that react with normal tissues
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Destroyed by drying, heating, or washing
May also be spread through
 Contact with infectious lesions
 Sharing of needles among IV drug users
 Spread in utero after 10th week of pregnancy
 Infected mother has a greater risk of stillbirth or of having a
baby who dies shortly after birth.
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Association with HIV
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Syphilitic lesions on the genitals enhance HIV transmission.
Syphilis: Clinical Manifestations
 Variety of signs/symptoms can mimic another
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disease.
Neurosyphilis causes degeneration of brain with
mental deterioration.
Sudden attacks of pain
Loss of vision and sense of position
Primary stage
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Chancres appear.
Painless indurated lesions
 Occur 10 to 90 days after inoculation
 Lasting 3 to 6 weeks
 See Table 53-3 for more information.
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Chlamydial Infections: Clinical Manifestations
 Men
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Urethritis
 Dysuria
 Urethral discharge
Proctitis
 Rectal discharge
Pain during defecation
Urethritis
 Dysuria
 Urethral discharge
Proctitis
 Rectal discharge
 Pain during defecation
 Women
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Cervicitis
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Urethritis
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Purulent exudate
Perihepatitis
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Dysuria
Frequent urination
Pyuria
Bartholinitis
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Mucopurulent discharge
Hypertrophic ectopy
Fever, nausea, vomiting, right
upper quadrant pain
PID
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Abdominal pain, nausea,
vomiting, fever, malaise,
abnormal vaginal bleeding,
menstrual abnormalities
Can lead to chronic pain and
infertility
Chlamydial Infection
Chlamydial epididymitis. Red, swollen scrotum.
Genital Herpes: Etiology and Pathophysiology
 Caused by herpes simplex virus (HSV)
 Enters through mucous membranes or breaks in the skin
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during contact with infected persons
HSV reproduces inside cell and spreads to surrounding
cells.
Virus enters peripheral or autonomic nerve endings.
Ascends to sensory or autonomic nerve ganglion, where
it is dormant
Recurrence when virus descends to initial site of
infection
Persists for life
Genital Herpes: Clinical Manifestations
 Primary (initial) episode
 Burning or tingling at site
 Small vesicular lesion appear on penis, scrotum, vulva,
perineum, perianal areas, vagina, or cervix.
 Vesicles contain large quantities of infectious virus particles.
 Complications
 Autoinoculation to extragenital sites
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Lips, breasts, and fingers
High risk of transmission in pregnancy with episode near
delivery
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Active lesion is indication for cesarean section.
Unruptured Vesicles
Unruptured vesicles of herpes simplex virus type 2 (HSV-2). A, Vulvar area. B, Perianal area.
C, Penile herpes simplex, ulcerative stage.
Autoinoculation of Herpes Simplex Virus
Autoinoculation of herpes simplex virus (HSV) to the lips.
Genital Herpes: Collaborative Care
 Drug therapy
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Inhibit viral replication
Suppress frequent recurrences
Acyclovir (Zovirax)
 Valacyclovir (Valtrex)
 Famciclovir (Famvir)
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Not a cure, but shorten duration and healing time and reduce
outbreaks
 Symptomatic care
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Genital hygiene
Loose-fitting cotton underwear
Lesions clean and dry
Sitz baths
Barrier methods during sexual activity
Genital Warts
 Estimated 20 million Americans are currently infected.
 Most common STD in the United States
 Caused by human-papilloma-virus (HPV)
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Usually types 6 and 11
 Highly contagious
 Frequently seen in young, sexually active adults
 Incubation period: 3 to 4 months
 Discrete single or multiple growths
 White to gray and pink-fleshed colored
 May form large cauliflower-like masses
Genital Warts
Genital warts. A, Severe vulvular warts. B, Perineal wart. C, Multiple genital warts of the
glans penis.
Genital Warts: Collaborative Care
 Treatments
 Chemical
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Patient managed
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Trichloroacetic acid (TCA)
Bichloroacetic acid (BCA)
Podophyllin resin
For small external genital warts
Podofilox (Condylox/Condylox gel)
Imiquimod (Aldara)
Immune response modifier
If warts do not regress with previously mentioned therapies
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Cryotherapy with liquid nitrogen (freezing a wart using a very cold
substance).
Electrocautery (to cut through soft tissue to access a surgical site)
Laser therapy
Use of α-interferon (to trigger the protective defenses of the immune
system)
Surgical removal
Nursing management
 Subjective data
 Past medical history,
including sexual history
 Medication use
 IV drug use
 Nausea/vomiting
 Dysuria
 Urethral discharge
 Burning lesions
 Vaginal discharge
 Presence of genital or
perianal lesions
 Objective data
 Fever
 Visual assessment of
lesions, warts, rash
 Purulent rectal discharge
 Proctitis
 Urethral and cervical
discharge
 Laboratory findings
Nursing Diagnoses
 Risk for infection
 Anxiety
 Ineffective health maintenance
Nursing Management: Planning
 Patient with STD will
 Demonstrate understanding of mode of transmission and risks
imposed
 Complete treatment and follow-up
 Notify or assist in notification of sexual contacts
 Abstain until infection is resolved
 Demonstrate knowledge of safer sex practices
Nursing Management: Nursing Implementation
 Discuss practices with all patients.
 Teach to inspect partner’s genitals.
 Some protection if void immediately after intercourse; wash genitalia
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and adjacent areas with soap and water
Proper use of condoms
Avoiding sexual contact with HIV-infected persons
Compassion and respect
Locating and examining all contacts of person with STD for testing and
treatment
Counseling to verbalize feelings
Explaining side effects, need for treatment adherence, and
follow-ups
Emphasize hygiene (hand washing, bathing).
Avoid douching.
Avoid synthetic materials in undergarments.
Abstinence during treatment period, condoms afterward
Avoid oral-genital contact.
Nursing Management:Evaluation
 Patient with STD will
 Demonstrate modes of transmission
 Use appropriate hygienic measures
 Experience no reinfection
 Demonstrate compliance with
follow-up protocol
Question
When caring for a patient with a sexually transmitted disease,
it is important that the nurse teach the patient to:
1. Advise all sexual partners of the need for treatment.
2. Use a condom for sexual intercourse during treatment.
3. Engage in monogamous relationships to prevent
reinfection.
4. Wash the genitalia before sexual intercourse to prevent
disease transmission.
Question
The nurse teaches the patient with genital
herpes about the use of:
1. Acyclovir ointment.
2. Oral acyclovir (Zovirax).
3. Human papillomavirus vaccine.
4. Podofilox (Condylox) topical gel.
PID ( Pelvic Inflammatory Disease)
 It involves one or more of the pelvic structures.
 Fallopian tubes (salpingitis)
 Ovaries (oophoritis)
 Pelvic peritonitis (peritonitis)
 PID is often the result of untreated cervicitis:
infection ascends to cervix-uterus-fallopian tubesovaries-peritoneal cavity.
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Chlamydia trachomatis and Neisseria gonorrhoeas are the
most common organisms of PID.
Pelvic Inflammatory Disease
Pelvic inflammatory disease. Acute infection of the fallopian tubes and ovaries. The tubes and
ovaries have become an inflamed mass attached to the uterus. A tubo-ovarian abscess is also present.
PID ( Pelvic Inflammatory Disease)
 Clinical manifestation:
 Lower abdominal pain
 Walking can increase the pain
 Spotting after intercourse-purulent discharge from cervix or vagina
 Cramping pain with menses, irregular bleeding
 Lower abdominal tenderness
 Tubo-ovarian abscess may leak or rupture resulting in pelvic or generalized
peritonitis
 Embolisms may occur as the result of thrombophlebitis of the pelvic veins
 Septic shock and Fritz-Hugh-Curtis syndrome
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When PID spreads to liver and causes acute perihepatitis
 Collabotative care:
 Manage the pain associated with PID with analgesics and warm sitz baths.
 Bedrest in a semi-fowler position may increase comfort and promote drainage.
 Antibiotic treatment is necessary to reduce inflammation and pain
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Doxycycline (Vibromycin)
Cefoxitin (Mefoxin)
Extreme cases-hysterectomy
Cystocele
 Definition:
is a protrusion of the bladder through the vaginal wall.
 Commonly called “bladder drop”,
 refers to the dropping or sagging of the vagina in the anterior or
upper compartment.
Etiology :
 Caused by weakened pelvic muscles or structures.
 When the pubocervical fascia detaches from its upper, lower or
lateral attachments a can occur.
 The pubocervical fascia is connective tissue that is between the
bladder and anterior vaginal wall and serves as its support
structure.
 The anterior vaginal wall is attached to the cervix at the upper
portion and has attachments to the pubic bone on the lower
portion.
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Cystocele
 Common symptoms:
 tissue protruding from the vagina,
 pelvic pressure,
 loss of ability to empty bladder to completion,
 pain with intercourse,
 positional bladder voiding, and
 vaginal pain.
 For mild s/s medical treatment can be tried.
 Surgery maybe indicated if not successful.
Cystocele
Rectocele
 Definition:
 It is a protrusion of the anterior rectal wall through the
posterior vaginal wall.
 Etiology:
 Caused by a defect of the pelvic structures or a difficult
delivery or forceps delivery.
Rectocele
 The rectovaginal septum is the connective tissue that
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separates the rectum (bowel) from the vagina.
Defects in the rectovaginal septum can result in a
rectocele.
The rectovaginal septum is attached at its upper
portion to the cervix and the lower portion to the
perineum.
The perineum is the space between the vaginal
opening and the anus.
A rectocele occurs when a break in the septum
allows the rectum to push into the vaginal area.
Rectocele
 Symptoms
 Tissue protrusion from the vagina,
 pelvic pressure,
 inability to empty bowels,
 pain with intercourse, and
 discomfort with physical activities.
 Mild s/s can also be medical treatment can also be
tried.
 If not successful, surgery maybe indicated.
Rectocele
Risk Factors for Cystocele and Rectocele
Risk Factors for Cystocele
 Obesity
 Advanged age (loss of estrogen)
 Chronic constipation
 Family History
 Childbearing
Risk Factors for Rectocele
 Pelvic structure defects
 Difficult childbirth
 Forceps Delivery
 Previous hysterectomy
Diagnostic Procedures: Cystocele and Rectocele
 Cystocele:
 Pelvic Examination – reveals a bulging of the anterior wall when the client
is instructed to bear down.
 Voiding cystourethrography
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to identify the degree of bladder protrusion and
amount of urine residual.
 Rectocele:
 Pelvic examination reveals a bulging of the posterior wall when the client is
instructed to bear down
 Rectal examination and /or barium enema reveals presence of rectocele.
 Surgeries:
Cystocele : Anterior colporrhaphy – This uses a vaginal approach,
the pelvic muscles are tightened.
Rectocele: Posterior colporrhapy – Using a vaginal perineal
approach, the pelvic muscles are tightened.
Anterior Posterior Repair if surgery for both Cystocele and
Rectocele is indicated.
Nursing Interventions: Cystocele and Rectocele
 Assessments:
 Monitor for signs and symptoms of a Cystocele:
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Urinary frequency
Urinary urgency
Stress incontinence
Urinary tract infection
Sense of vaginal fullness
 Monitor for signs and symptoms of a Rectocele:
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Constipation
Hemorrhoids
Sensation of mass in the vagina
Pelvic pressure pain
Difficulty with intercourse.
Nursing Interventions: Cystocele and Rectocele
1. Avoid traumatic vaginal childbirth – early and adequate episiotomy.
An episiotomy is a surgical incision made in the area
between the vagina and anus (perineum). This is done during the last
stages of labor and delivery to expand the opening of the vagina to prevent
tearing during the delivery of the baby.
2. Inform the client about measures to prevent atrophic vaginitis and of the
advantage of prevention.
Atrophic vaginitis (also known as vaginal atrophy or
urogenital atrophy) is an inflammation of the vagina (and the outer
urinary tract) due to the thinning and shrinking of the tissues, as well as
decreased lubrication. This is all due to a lack of the reproductive hormone
estrogen.
The most common cause of vaginal atrophy is the decrease
in estrogen which happens naturally during perimenopausal, and
increasingly so in post-menopausal stage. However this condition can
sometimes be caused by other circumstances. .
3. To loose weight if obese.
4. To eat high-fiber diet and drink adequate fluids to prevent constipation.
Nursing Interventions: Cystocele and Rectocele
1. Kegel exercises – tightened pelvic muscles for
a count of 10, relax slowly for a count of 10 repeat
in sequences of 15 in lying down, sitting, and
standing position.
Kegel exercises are said to be good for treating
vaginal prolapse and preventing uterine prolapse
in women and for treating prostate pain and
swelling resulting from benign prostatic
hyperplasia(BPH) and prostatitis in men.
Nursing Interventions: Cystocele and Rectocele
2. Estrogen Therapy – to prevent uterine atrophy and
atrophic vaginitis.
 Inform client of client’s risk from complication of
hormone therapy. E.g. cardiovascular or embolic
history.
 Monitor for s/e of estrogen therapy e.g. water
retention, headaches.
3. Weight loss and changes in diet.
4. Vaginal Pessary – removable rubber, plastic or
silicon device inserted into the vagina to provide
support and block protrusion into vagina.

Teach client how to insert, remove, and clean the
device.
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Monitor for possible bleeding or fistula formation.
Vaginal Pessary
 A vaginal pessary is a removable device placed into
the vagina. It is designed to support areas of pelvic
organ prolapsed.
Post – Operative Care: Cystocele and Rectocele
1.
Administer analgesics, antimicrobials, and stool
softeners/laxatives as prescibed.
1.
Provide perineal care at least twice daily following surgery and
after urination or bowel movement.
2.
Apply an ice pack to relieve pain and swelling.
3.
Suggest that the client take frequent warm sitz baths to soothe
the perineal area.
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A sitz bath is a plastic tub that fits over the toilet and can be filled with
water. Sitting in the warm water for 15 to 20 minutes can provide relief
from the discomfort from hemorrhoids, fistulas, anal fissures, or an
episiotomy (surgically planned incision on the perineum and the
posterior vaginal wall during the labor). This can be done by sitting in a
bathtub filled with a few inches of water, but using a plastic sitz bath that
fits over the toilet is often more convenient.
Post-Operative Care: Cystocele and Rectocele
5. Provide a liquid diet followed by low – residue diet
until normal bowel function returns.
6. Instruct client how to care for indwelling catheter at
home.
7. Recommend to client to drink at least 2,000 ml of fluid
daily, unless contraindicated.
8. Following removal of the catheter, instruct the client
to void every 2-3 hour to prevent a full bladder and
stress on stitches.
9. Teach the client how to perform client intermittent
self-catheterization techniques in the event that client
is unable to void.
Post-operative Care: Cystocele and Rectocele
10. Caution the client to avoid straining at defecation,
sneezing, coughing, lifting, and prolonged sitting,
walking, or standing following surgery.
11. Instruct the client to tighten and support pelvic
muscles when coughing or sneezing.
12. Post-operative restrictions include avoidance of
strenuous activity, weight lifting greater than 5 lbs. and
sexual intercourse.
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Client may stay in the hospital from 1 to 2 days. Will probably be
able to return to normal activities in about 6 weeks. Avoid
strenuous activity for the first 6 weeks, and increase activity level
gradually.
Most women are able to resume sexual intercourse in about 6
weeks.
Complications :Cystocele and Rectocele
 Residual urine in the bladder at risk for recurrent
bladder infection and possibly kidney
infections.
 Constipation.
 Dyspareunia (painful sexual intercourse) is a
possible surgical complication due to surgical
alteration of the orifice.
Needs of Older Adults: Cystocele and Rectocele
 Cystocele and rectocele develop in older female
clients usually following menopause.
 Older clients tend to overuse laxatives and enemas
for the relief of constipation.
 Older adults are more susceptible to post-
operataive complications.
 Performing Kegel exercises and manipulating
pessary maybe more difficult for older adults.
Uterine Prolapse
 Occurs when pelvic floor muscles and
ligaments stretch and weaken, providing
inadequate support for the uterus.
 The uterus then descends into the vaginal canal.
Uterine Prolapse
 affects postmenopausal women who've had one or more vaginal
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deliveries.
Damage to supportive tissues during pregnancy and childbirth.
Effects of gravity.
Loss of estrogen.
Repeated straining over the years which can weaken pelvic floor
and lead to uterine prolapse.
Pregnancy and trauma incurred during childbirth, particularly
with large babies or after a difficult labor and delivery.
Loss of muscle tone associated with aging
In rare circumstances, may be caused by a tumor in the pelvic
cavity.
Genetics : Women of Northern European descent have a higher
incidence of uterine prolapse than do women of Asian and
African descent.
Uterine Prolapse: Risk Factors
 One or more pregnancies and vaginal births
 Giving birth to a large baby
 Increasing age
 Frequent heavy lifting
 Chronic coughing
 Frequent straining during bowel movements
 Genetic predisposition to weakness in connective tissue
 Some conditions, such as obesity, chronic constipation
and chronic obstructive pulmonary disorder (COPD),
can place a strain on the muscles and connective tissue
in the pelvis and may play a role in the development of
uterine prolapse.
Uterine Prolapse
Uterine Prolapse
Sign and Symptoms:
 Mild uterine prolapse client may experience no signs or
symptoms.
 Moderate to severe uterine prolapse
- Sensation of heaviness or pulling in pelvis
- Tissue protruding from your vagina
- Urinary difficulties, such as urine leakage or urine retention
- Trouble having a bowel movement
- Low back pain
- Feeling as if sitting on a small ball or as if something is falling
out of vagina
- Sexual concerns
- Symptoms that are less in the morning and worsen as the day
goes on.
Test and Diagnostic Procedures
 Pelvic exam.
A complete pelvic exam
-Client will be examined while lying down and
while standing up. Your physician may ask client to
bear down as if having a bowel movement to see
how much that affects the degree of prolapse.
To check the strength of your pelvic muscles, client
may also be instructed to contract them, as if you
are stopping the stream of urine.
 Imaging tests.
-Ultrasound or magnetic resonance imaging (MRI)
Uterine Prolapse - Treatment
 For mild uterine prolapse, treatment usually is not
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needed.
Options include using a supportive device (pessary)
inserted into the vagina or having surgery to repair the
prolapse.
Loosing weight, stopping smoking
Lifestyle changes
Achieve and maintain a healthy weight, to
Perform Kegel exercises, to strengthen pelvic floor
muscles.
Avoid heavy lifting and straining, to reduce
abdominal pressure on supportive pelvic structures.
Surgical Procedure
Vaginally –
less pain after surgery, faster healing and a better cosmetic result.

However, vaginal surgery may not provide as lasting a fix as abdominal
surgery. If the uterus is not removed during surgery, prolapse can recur.
Laparoscopic techniques — using smaller abdominal incisions,
a lighted camera-type device (laparoscope) to guide the surgeon—
offer a minimally invasive approach to abdominal surgery.
 Client might not be a good candidate for surgery to repair uterine
prolapse if still plan to have more children.
 Pregnancy and delivery of a baby put strain on the supportive
tissues of the uterus and can undo the benefits of surgical repair
Complications
 Possible complications of uterine prolapse include:

Ulcers-part of the vaginal lining may be displaced by the fallen
uterus and protrude outside the body, rubbing on underwear. The
friction may lead to vaginal sores (ulcers); the sores could become
infected.
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Prolapse of other pelvic organs. If client experienced uterine
prolapse, client may also have prolapse of other pelvic organs,
including your bladder and rectum.
A prolapsed bladder (cystocele) bulges into the front part of
client’s vagina, which can lead to difficulty in urinating and
increased risk of urinary tract infections.
Weakness of connective tissue overlying the rectum may result in a
prolapsed rectum (rectocele), which may lead to difficulty having
bowel movements.
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Abnormal Vaginal Bleeding
Balloon thermotherapy for treatment of menorrhagia. A, Balloon-tipped catheter is inserted into the
uterus through the vagina and cervix. B, The balloon is inflated with a sterile fluid that expands to fit the size
and shape of the uterus. The fluid is heated to 188° F (87° C) and maintained for 8 minutes while the uterine
lining is treated. C, Fluid is withdrawn from the balloon and the catheter is removed.
Abnormal Vaginal Bleeding
 Menorragia-excessive or prolonged bleeding
 Oligomenorrhia-long intervals between meses-more
than 35 days
 Metrorrhagia- irregular bleeding or bleeding
between menses
Ectopic Pregnancy
Ectopic pregnancy occurring in the fallopian tube.
Nursing and Collaborative Management:
Ectopic Pregnancy
Laparoscopic treatment of ectopic pregnancy in the right fallopian tube.
Ectopic Pregnancy
 Implantation of the fertilized ovum anywhere
outside the uterine cavity
 Can cause abdominal pain, vaginal bleeding, breast
tenderness, GI disturbance
Breast disorders
 Mastalgia- breast pain
 Mastitis- inflammatory condition
 Fibroadenoma-benign breast lumps
 Fibrocystic changes-benign condition caused by
development of excess fibrous tissue and cyst
formation
Breast cancer
 Risk factor
 Female
 Age of >50
 Family history
 Early menarche (before age 12)
 Pregnancy after 30
 Weight gain
 Physical inactivity
 Alcohol consumption
 Exposure to ionizing radiation