Transcript N405 GU Presentation c Alanna`s slidesx


Compare the various types of:
› Female and Male Reproductive Disorders
 Definition
 Clinical Manifestations
 Diagnosis
 Nursing Intervention

http://www.youtube.com/watch?v=nr5W
9trSv8I
 Prostate
disorders
› Benign Prostate Hyperplasia
› Prostate Cancer
› Prostatitis
 Erectile dysfunction
 Testicular & scrotal disorders
 Penile
disorders
A gland
 Location:

› lies just below the neck of the bladder &
surrounds the urethra

Function:
› Produces part of semen
 Benign
prostatic hyperplasia
 Prostate cancer
 Prostatitis
Obstruction by enlarged prostate
 Symptoms






Dysuria
Hematuria
Swelling in legs
Blood in semen
Decreased force in stream of urine
Digital rectal exam (DRE)
 Prostate specific antigen (PSA)
 Post-void residual volume (PVR)
 Uroflowmetry
 Cystoscopy
 Urodynamic pressure
 Ultrasound


Pharmaceutical
› Alpha-blockers
› 5-alpha-reductase inhibitors

Surgical
› Transurethral resection of the prostate (TURP)
› Transurethral incision of the prostate (YUIP)
› Suprapubic resection
› Prostatectomy
 Retropubic, perineal
Assess drainage tubing
 Maintain rate of flow – fluid should be
light pink or colorless
 Assess urinary output q1-2 hrs
 Assess for bladder spasms, pain and
distention
 If there is a block, need to flush

Abdominal incision into the bladder
 Remove tissue
 Requires urethral & suprapubic catheter

› To allow for bladder repair
Low abdominal incision w/o entry into
bladder
 Choice when prostate is very
large/urethral stricture

Incision btw anus & scrotum
 Rare
 High risk of impotence
 Other risks:

› Rectourethral fistulas
› UTIs
› Epididymitis
› retention
Most common type of cancer in men
 Usually grows slowly & remains confined
to the prostate gland
 Other types can be aggressive & spread
 Types

› Locally advanced
› Biochemically recurrent
› Metastatic
› Castrate resistant
Hematuria
 Swelling in legs
 Blood in semen
 Decreased force in stream of urine
 Dysuria


Needle biopsy
› Fine needle aspiration
› Core needle/prostate biopsy
› Vacuum assisted biopsy
› Image guided biopsy
PSA test
 Intravenous pyelogram
 Active surveillance

Chemotherapy
 Radiation
 Cryotherapy
 Brachytherapy
 Hormone therapy


Obtain health history to determine
› Concerns, level of understanding, support systems


Provide education about diagnosis and
treatment plan
Provide information
› Institutional & community resources for coping
 Social services
 Support groups
 Community agencies

Assess psychological reaction to
diagnosis/prognosis
› How has he coped with past stress
Swelling & inflammation of the prostate
gland
 Caused by infectious agents carried to
the prostate from urethra

› Bacteria, fungi, mycoplasma
E. coli is the most commonly isolated
organism
 Acute or Chronic

Perineal discomfort
 Burning, urgency, frequency & pain with
or after ejaculation
 Acute bacterial – fever, chills, perineal,
rectal or low back pain, dysuria,
frequency, urgency and nocturia
 Chronic bacterial – relapsing UTIs, mild
symptoms and occasional urethral
discharge

Medical history, physical exam, DRE,
blood culture, urine & semen test,
cystoscopy, urodynamic test
 Treatment

› Antibiotics
› Alpha blockers
› Pain relievers
› Prostate massage
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Administer prescribed antibiotics
Patient education about medication
Patient education about side effects of medication
Avoid sitting for long periods
During inflammation avoid sexual arousal &
intercourse
Teaching self-care
› Antibiotics, home care, encourage fluids, avoid alcohol,
coffee, chosolate, cola and spices

Use of comfort measures
› analgesic agents, antispasmodic medications, bladder
sedatives, sitz baths, stool softeners
Aka Impotence
 Inability to achieve/maintain erection
 Psychogenic/organic causes

› Anxiety, fatigue, depression, pressure to
perform
› Occlusive vascular disease, endocrine
disease, cirrhosis, chronic renal failure, GU
conditions, hematologic conditions,
neurologic disorders, trauma to
pelvic/gential area, alcohol, meds, drug
abuse
Difficulty getting an erection
 Difficulty keeping an erection
 Reduced sexual desire
 Physical exam, DRE, blood tests, urine
test, ultrasound
 Overnight erection test
 Psychological exam


Medication
› Viagra, Cialis, Levitra, Staxyn
Testosterone replacement
 Penile uppository

 Alprostadil
self-injection
Penile vacuum pump
 Penile implants
 Blood vessel surgery
 Psychological counseling


Education
› Pamphlets, social supports
› Weight loss
› Exercise
› Quit smoking
› Treatment for alcohol/drug problems
› Stress reduction
Essential to prevent acquired problems
 Foreskin should retract easily
 Begin by washing tip

› Work down shaft
› Then scrotum
› Anal area last
Testicular cancer
 Testicular torsion
 Orchitis
 Epididymitis
 Hydrocele, hematocele, spermatocele
 Varicocele
 Undescended testicles

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Monthly
Best time – after bath/shower
Hold penis out of the way
Check one testicle at a time
Hold testicle btw thumb and fingers
Gently roll
Look & feel for hard lumps or smooth round
bumps
Note any change in size, shape,
consistency
Anatomy
 Diagnostic Procedures
 Disorders and Treatments

Female Anatomy

X-ray, ultrasound, MRI, PET
 PET scan usually used for pre-tx staging of selective
malignancies

Cytoscopy
 Study of cells through microscope or other equipment

Pap smear
 Speculum inserted into vagina
 Sample obtained by rotating a small spatula & cervical
brush at the os of the cervix
 Samples saved in proper medium and sent to lab for
analysis for any abnormal cell findings

Dilation and Curettage (D&C)
 Tissue is removed from the uterine cavity
 Dx or Tx of uterine conditions (bleeding,
incomplete miscarriage, etc)
 Cervix is dilated with an instrument, a curette is
inserted to remove tissue
 Anesthesia and aseptic procedure
 May experience low back pain, minimal bleeding

Endoscopic Examinations
› Laparoscopy
 OR, 2cm incision below umbilicus, CO2 pumped in,
laparoscope inserted
 View pelvic structures, dx pain, tubal sterilization,
ovarian biopsy, lysis of adhesions, myectomy
(removing fibroids)
 Complications are rare, procedure is safe and costeffective
› Hysteroscopy
 Optical instrument with light insterted through cervical
os into uterine cavity and NS or D5W infused
 Useful to evaluate endometrial pathology, adjunct to
D&C, stop bleeding through ablation, or manage a
retained IUD
 Hemorrhage, perforation and burns can occur
•
Hysterosalpingography or Uterotubography
• X-ray study of uterus and fallopian tubes
• Cannula is inserted into the cervix and contrast agent is
injected, x-rays are taken
• Can cause n/v, cramps and syncope
• Peri pad worn for several hours afterwards bc the dye can
stain clothing
• Evaluate infertility or tubal patency, or any abnormal
condition of the uterine cavity
• Can be therapeutic because it flushes the cavity

Focus
› PMS
› PID
› Endometriosis
› Cancer

Brief Overview
› Structural Disorders

PMS
› combination of Sx that occur prior to menstruation and subsides
with menstrual flow
› Dx
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Sx occur within 5 days before menstruation
Sx disappear within 4 days of onset of menstruation
Sx occur through several cycles
Premenstrual dysphoric disorder (PMDD) is Dx with severe Sx
that interfere with school, work or social life
Incidence
› Estimates vary, possibly 85% of menstruating women experience
at least 1 PMS Sx in their monthly cycle (American College of Ostetricians and
Gynecologists, 2010)
› PMS syndrome (cluster of Sx resulting in dysfunctions) affects 2-5%
of women
› Estimated 3-8% suffer PMDD (American College of Ostetricians and Gynecologists,
2010)

Cause is unknown
› Serotonin regulation considered to play a role
› Diet, exercise, stress considered to play a role
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Clinical Manifestations
› Physical:
 Headache
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Fatigue
Low back pain
Fluid retention: bloating, breast tenderness
Abd fullness
› Behavioral & emotional:
 General irritability
 Mood swings, binge eating, crying
 Depression, anxiety

Medical
› There is little evidence or
research that nonpharmacological
therapies are effective
› Suggestions:
 Exercise is
encouraged
 Avoid caffeine, highfat foods, refined
sugars
 Chart Sx to anticipate
and cope with them

Pharmacological
 SSRI’s (Prozac, Sarafem)
 GnRH agonists (stops prod’n of
oestrogen, usually stops
menstruation after ~2 months
of Tx)
 Prostaglandin inhibitors
(ibuprofen, naproxen)
 Antianxiety agents
 Calcium supplement
 Vitamins B, E, magnesium, oil of
evening primrose have been
used but there is no research to
evaluate their effectiveness
• Nsg Management
– Help the client chart onset of Sx
– Record a nutritional Hx to determine if the diet is low in
essential nutrients
– Facilitate positive coping measures: illicit family support
during PMS, plan work to accommodate PMS days which
may be less productive
– Encourage exercise, meditation, imagery
– Encourage adherence to medication regime and explain
expected effects of meds
– Encourage client to enroll in a PMS help group to gain an
understanding of others’ experiences
– Assess for suicidal, incontrollable or violent behavior
– Implement reporting protocols if assessment findings
indicate a safety risk to client or family

Primary dysmenorrhea
› Painful menstruation with no identifiable pelvic pathology
› Occurs at menarche or shortly after
› Thought to be caused by excessive prostaglandin
production which causes contraction of the uterus and
arteriolar vasospasm

Secondary dysmenorrhea
› As for primary, except pelvic pathology contributes to the Sx
(endometriosis, tumor, etc)
› Pain may occur before menses, with ovulation and with
intercourse

Symptoms
› Crampy pain just before or after menstruation
starts and continues for 48-72 hrs
› In secondary dysmenorrhea, pain may occur
before menses, with ovulation and with
intercourse

Diagnosis
› Pelvic exam is used to rule out endometriosis,
PID, fibroid uterus, adenomyosis (thickening of
uterine wall)

Nsg Management
 Reduce anxiety by explaining the reason for the
discomfort
 Low heat locally applied to abd – may counteract
some of the hormonal activity and vasodilate the
vessels
 Increase physical exercise if possible
 Secondary dysmenorrhea is managed by treating the
underlying pelvic pathology

Pharmacological
 Provide analgesia prophylactically before onset
 Prostaglandin inhibitors – q4h, aspirin, ibuprofen,
naproxen, mefenamic acid – determine which one
works best for the client
 Low dose oral contraceptives provide Sx relief in >90% of
clients

What is it?
Inflammation of the pelvic cavity

How does it manifest?
 May begin with cervicitis and may involve inflammation of the
uterus, fallopian tubes, ovaries, pelvic peritoneum or pelvic
vascular system
 Infection may be acute, subacute, recurrent or chronic
 Infection may be local or widespread - WBC in vaginal fluid
 Causes narrowing and scarring of fallopian tubes which inc risk
for ectopic pregnancy, infertility, recurrent pelvic pain due to
adhesions, tubo-ovarian abscess, recurrent disease

Causes:
›
Usually bacterial but may be viral, fungal or parasitic
 Gonorrheal or chlamydial organisms most common causes

Early Sx
› Vaginal discharge:
›
›
›
›
abnormal,
mucopurulent
Dyspareunia
Lower abd/pelvic
pain
Tenderness after
menstruation
Pain that increases
while voiding or
defecating

Additional Sx
›
›
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›
›
›
›
Fever
General malaise
Anorexia
N/V
Headache
Constipation
Menstrual difficulties
Intense tenderness on
palpation of uterus or
movement of cervix

Medical Management
› Broad spectrum antibiotics
 IV Regimen A: Cefotan or Cefotoxitin IV PLUS Doxycycline PO or IV
(CDC, 2011)
 IV Regimen B: Clindamycin IV PLUS Gentamicin IV
 IM/PO: Ceftriaxone PLUS Doxycycline +/- Metronidazole
(CDC, 2011)
 IM/PO: Cefoxitin PLUS Probenecid +/- Metronidazole
(CDC, 2011)
› Hospitalization if infection is moderate-severe
 Bed rest, IV fluids, IV antibiotics
 NG suction for abd distention or ileus (intestinal obstruction)
 Treat sexual partners – necessary to prevent re-infection

Nursing management
› Bed rest, semi-Fowler’s position to facilitate dependent
›
›
›
›
›

drainage
Monitor VS
Monitor vaginal discharge
Administer analgesics for pain
Heat to abd for pain relief
**Follow infection precautions when handling peri pads:
 Wear gloves
 Dispose of pads in biohazardous waste
 Meticulous hand washing
Health Promotion/Education
 Condoms/safe sex
 Proper peri-care (front to back)
 Discourage using a douche – introduces bacteria and
reduces normal flora
 Annual gynecological exam

Cells similar to those that line the uterus, grow outside the
uterus and form lesions

Chronic disease

Affects 5-15% of women of reproductive age and 25-35% of
infertile women

Major cause of chronic pelvic pain and infertility

Risk factors:
› Having fewer children or children late in life
› Familial: common where close female relatives have it
› Shorter menstrual cycle, less than 27 days, flow longer than
7 days, outflow obstruction
› Younger age at menarche

Transplantation Theory – most accepted
theory:
› backflow of menses (retrograde menstruation)
transports endometrial tissue to ectopic sites (outside
the uterus) through the fallopian tubes
› During menstruation, the ectopic endometrial tissue
responds to hormonal stimulation, just as it would in
the uterus
› The ectopic tissue bleeds but has no outlet, and
causes pain and adhesions
Endometriosis: presence of
endometrial glands and stroma outside of the normal location
Ovarian endometrioma
Peritoneal endometrioma
Ovarian endometriosis histology Ovarian chocolate cyst
Adenomyosis
Lung endometriosis
(BMJ, 2003; Med. Inform., 2006; BMJ, 2001; Respirology, 2006)

Manifestations
›
›
›
›
›
›
›
›

Dysmenorrhea
Dyspareunia
Pelvic discomfort/pain
Dyschezia (pain with bowl movement)
Depression
loss of work
Relationship difficulties
Infertility due to fibrosis, adhesions, or substances
produced by the implants (ex: prostaglandins)
Dx
› Bimanual pelvic exam: fixed tender nodules
palpated, limited uterine mobility due to
adhesions
› Laparoscopy confirms dx and helps stage the
disease based on severity of adhesions

Pharmacologic Therapy
› Analgesics & prostaglandin inhibitors for pain
› Hormone therapy for suppressing endometriosis and
menstrual pain
 oral contraceptives
 Cyclomen – hormone causing atrophy of the
endometrium & amenorrhea
 GnRH agonists – dec estrogen and cause amenorrhea

Surgical management
 Laparoscopy and lasering of endometrial tissue &
adhesions
 Other such as: hysterectomy, oophorectomy, bilateral
salpingo-oophorectomy, appendectomy

Nsg Management
› Health Hx to determine specific Sx, time of onset,
medications that are effective, etc
› Alleviate anxiety by explaining the various diagnostic
procedures
› Address the possibility of infertility and explore options
› Dispel myths
› Encourage client to report dysmenorrhea or
dyspareunia
› Provide client contact to the Endometriosis
Association for info and support for the physical pain
and emotional distress
Cervical
 Ovarian
 Uterine
 Vulvar
 Vaginal
 Fallopian Tubes

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



Often due to HPV infection
Spreads to regional pelvic lymph nodes if not treated
S/S rare in early stages
S/S late stage: discharge, irregular bleeding, bleeding after
sexual intercourse
Preventable and treatable
› Pap screening can identify pre-invasive lesions and
prevent cancer
Nsg management:
 Preventive counselling regarding: Delay 1st intercourse, avoid
HPV infection, reproductive health, safer sex, smoking
cessation, HPV immunization for females aged 9-26 yrs
 Facilitate access and utilization of gynecological care


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




Tumors of the cells that produce eggs, produce hormones or
of the epithelial cells on the ovary surface (most common)
Causes more deaths than any other cancer of the female
reproductive system
Ovarian tumours are often difficult to detect b/c they are
deep in the pelvis
No early screening mechanism exists, tumour markers are
being explored (ex: CA-125 antigen testing)
Risk factors: Age, Industrialized countries, Breast cancer
**article
S/S are nonspecific: inc abd girth, pelvic pressure, bloating,
back pain, constipation , abdominal pain, urinary urgency,
indigestion, flatulence, leg pain, pelvic pain
Nsg management:
 Support and information regarding therapies (chemo,
radiation, palliation, thoracentesis)
 IV therapy to manage fluid and electrolyte imbalances,
parenteral nutrition, pain control, small frequent meals,
decreasing fluid intake, diuretics, rest,




Cancer of the uterine endometrium
Risk factors:
› Age over 55
› Postmenopausal bleeding
› Obesity causing inc estrone levels
› Estrogen therapy without progesterone
S/S: irregular bleeding
Tx:
› total hysterectomy and bilat salpingooophorectomy
› adjuvant radiation
Primarily squamous cell carcinoma
 Little is known about the causes


S/S: long-standing pruritis & soreness, bleeding, foulsmelling discharge, pain, visible lesions, mass that
becomes hard, ulcerated and cauliflower-like

Tx: excision, laser ablation, chemotherapy creams,
cryosurgery

Nsg management
› Education on delaying 1st intercourse, avoiding
exposure to HPV, avoiding smoking, regular pelvic
and pap exams
› Encourage self-exams regularly


Primary cancer is squamous in origin
50% caused by HPV

S/S: pt often does not have Sx, but may report
slight bleeding after intercourse, spontaneous
bleeding, vaginal discharge, pain, an urinary or
rectal Sx

Dx: often by pap smear

Tx: excision, laser therapy, topical chemotherapy,
radiation, surgery


Rare
Least common genital cancer

S/S: profuse watery discharge, colicky lower abd
pain or abnormal vaginal bleeding, enlarged
fallopian tube

Tx: surgery & radiation
• Total hyst – removal of uterus and cervix
• Subtotal – removal of uterus, spare cervix
• Total abd hyst with bilateral salpingo-oophorectomy –
removal of uterus, cervix, fallopian tubes and ovaries
(for malignancies)
• Radical hyst – uterus and surrounding tissue removed,
including upper third of vagina and pelvic lymph nodes

Hysterectomy can be a treatment option for
women experiencing
›
›
›
›
›

Fibroids
Endometriosis
Prolapse
Cancer
Abnormal Uterine Bleeding
Surgical Approaches
› Open or “traditional” procedures (abd incision)
› Minimally invasive procedures (MIP) – through
vagina or abd laproscopy
Total Hysterectomy
Vaginal Hysterectomy
•“traditional” or “open”
procedure
•Large incision or
“bikini cut” (4–6 inches)
Laparascopic Hysterectomies

Nsg pre-op management:
› Shave lower abd and pubic and perineal
›
›
›
›
region, clean with soap & water
Ensure NPO the night before to empty the
intestinal tract
Bladder must be empty
Enema & antiseptic douche may be ordered
the night before
Administer pre-op meds as prescribed for
relaxation

Nsg post-op management:
› Care for circulation to prevent thrombophlebitis, DVT, PE,
hemorrhage
› Infection prevention
› Monitor voiding to ensure bladder problems have not
occurred; Indwelling catheter may be needed
› Monitor bowel function to ensure paralytic ileus has not
occurred
› Provide pain control
› Assess emotional status regarding loss of femininity,
relaitonship issues, family issues…offer support and
resources to help them address their situation
•Cystocele, Rectocele, Enterocele
•An abnormal opening
between 2 internal hollow
organs or between an internal
hollow organ and the exterior
of the body
•May be congenital
•Usually due to trauma from
surgery, vaginal delivery,
radiation therapy, carcinoma
•Goal: Tx infection and
eliminate fistula
•Rest, diet, antibiotics
•Surgery in some cases
Rectovaginal
Sx: Continuous leakage of urine
into the vagina
Sx: Fecal incontinence,
Flatus Discharged through vagina
• weakening of the vaginal walls allowing the pelvic organs to
descend and protrude into the vaginal canal
• Age
• Parity & large baby delivery (causing tears in musculature)
• Cystocele – bladder descends into vagina
• Rectocele – rectum pushes up on the posterior wall of the
vagina
• Enterocele – intestinal wall protrudes into vagina
• Complete prolapse – uterus drops and may protrude from the
vagina resulting in pressure and urinary problems
Enterocele
Cystocele
Rectocele
•Management:
•Kegel exercises
•Pessary: Doughnut or ring-
shaped device positioned in
the vagina to keep the organs
properly aligned
•surgery
American Cancer Society. (2012). Retrieved from
http://www.cancer.org/Cancer/TesticularCancer/MoreInformation/DoIHaveTestic
ularCancer/do-i-have-testicular-cancer-self-exam
Centers for Disease Control and Prevention. (2012). Sexually Transmitted Diseases: Pelvic Inflammatory
Disease. Retrieved from http://www.cdc.gov/std/treatment/2010/pid.htm
Cesario, S. (2010). Advances in the early detection of ovarian cancer: How to hear the whispers early.
Nursing for Women’s Health, 14(3), 222-234.
Day, R., Paul, P., Williams, B., Smeltzer, S. & Bare, B. (2010). Canadian Textbook of
Medical Surgical
Nursing (2nd Canadian Ed.). Philadelphia: Lippincott Williams
&
Wilkins.
Mayo Foundation for Medical Education and Research. (2012). Erectile Dysfunction. Retrieved from
http://mayoresearch.mayo.edu/mayo/research/urology/erectile_dysfunction.cfm
Mayo Foundation for Medical Education and Research. (2012). Prostatic Hyperplasia. Retrieved from
http://mayoresearch.mayo.edu/mayo/research/urology/prostatic_hyperplasia.cfm
Mayo Foundation for Medical Education and Research. (2012). Prostatitis. Retrieved from
http://www.mayoclinic.com/health/prostatitis/DS00341
Mayo Foundation for Medical Education and Research. (2012). Prostate Cancer. Retrieved
from
http://www.mayoclinic.com/health/prostate-cancer/DS00043
Peate, I. (2012). Breaking the silence: helping men with erectile dysfunction. British
Journal Of
Community Nursing, 17(7), 310-317.
The Official Foundation of the American Urological Association. (2012). Urology. Retrieved
from
http://www.urologyhealth.org/urology/index.cfm?article=59
The Official Foundation of the American Urological Association. (2012). Urology fact sheet.
http://www.urologyhealth.org/urology/articles/_notes/AdvPCFactSheet.pdf