Chapter 54: Nursing Management: Female Reproductive Problems

INFERTILITY • Infertility is the inability to achieve a pregnancy after at least 1 year of regular intercourse without contraception. •  Diagnostic studies include ovulatory studies, tubal patency studies, and postcoital studies. Management depends on the cause and can include supplemental hormone therapy and antibiotic therapy.

ABORTION • Abortion is the loss or termination of a pregnancy before the fetus has developed to a state of viability.

Abortions are classified as spontaneous (those occurring naturally) or induced (those occurring as a result of mechanical or medical intervention). Nursing management includes the use of comfort measures to provide needed physical and mental rest. The support of the patient and her family is essential.

PREMENSTRUAL SYNDROME • Premenstrual syndrome (PMS) is a common disorder of physical and psychologic symptoms during the last few days of the menstrual cycle and before onset of menstruation. • • PMS is thought to have a biologic trigger with compounding psychosocial factors. Physical symptoms include breast discomfort, abdominal bloating, sensation of weight gain, episodes of binge eating, and headache. Anxiety, depression, irritability, and mood swings are some of the emotional symptoms. No single treatment is available to relieve symptoms. The goal is to reduce symptom severity.

DYSMENORRHEA • Dysmenorrhea is abdominal cramping pain or discomfort associated with menstrual flow. o Primary dysmenorrhea is caused by an excess of prostaglandin F2α (PGF2α) and/or an increased sensitivity to it. o Secondary dysmenorrhea is acquired after adolescence; pelvic causes include endometriosis, chronic pelvic inflammatory disease, and uterine fibroids. • • Treatment for primary dysmenorrhea includes heat, exercise, and drug therapy. For secondary dysmenorrhea, it depends on the cause. Abnormal vaginal or uterine bleeding is a common gynecologic concern and is caused by dysfunction of hypothalamic-pituitary-ovarian axis, infection, and stressful changes in lifestyle. Treatment varies depending on the cause but can include drug therapy and surgery.

ECTOPIC PREGNANCY • An ectopic pregnancy is the implantation of the fertilized ovum anywhere outside the

uterine cavity. • • Any blockage of the tube or reduction of tubal peristalsis that impedes or delays the zygote passing to the uterine cavity can result in tubal implantation. Risk factors include a history of pelvic inflammatory disease, prior ectopic pregnancy, current progestin-releasing intrauterine device (IUD), progestin-only birth control failure, and prior pelvic or tubal surgery. Eventually the tube ruptures with acute peritoneal symptoms of abdominal/ pelvic pain, missed menses, and irregular vaginal bleeding. Less acute symptoms begin 6 to 8 weeks after last normal menstrual period. Surgery is usually the treatment.

MENOPAUSE • Menopause is the physiologic cessation of menses associated with declining ovarian function. It is usually considered complete after 1 year of amenorrhea. • • • Ovarian changes start the cascade of events that result in menopause. Premenopausal symptoms include hot flashes, irregular vaginal bleeding, fat redistribution, and a tendency to gain weight. Treatment might include hormone replacement, drug therapy, and alternative therapies.

INFECTION AND INFLAMMATION OF VAGINA, CERVIX, AND VULVA • Infection and inflammation of vagina, cervix, and vulva commonly occur when natural defenses of the acid vaginal secretions (maintained by sufficient estrogen levels) and presence of Lactobacillus are disrupted. • • Abnormal vaginal discharge and reddened vulvar lesions are often noted with itching and dysuria. Treatment includes antibiotics and antifungal preparations.

PELVIC INFLAMMATORY DISEASE • Pelvic inflammatory disease (PID) is an infectious condition of pelvic cavity that may involve infection of fallopian tubes (salpingitis), ovaries (oophoritis), and pelvic peritoneum (peritonitis). • • • • PID is often the result of untreated cervicitis. The main symptom is constant lower abdominal pain. Long-term complications include ectopic pregnancy, infertility, and chronic pelvic pain. PID is usually treated with antibiotics.

ENDOMETRIOSIS • Endometriosis is the presence of normal endometrial tissue in sites outside endometrial

cavity. • • • One cause is retrograde menstrual flow through the fallopian tubes carrying viable endometrial tissues into the pelvis. Symptoms are secondary dysmenorrhea, infertility, pelvic pain, dyspareunia, and irregular bleeding. Drug therapy reduces symptoms with surgery for a potential cure.

LEIOMYOMAS • Leiomyomas (uterine fibroids) are benign smooth-muscle tumors that occur within the uterus. • • Symptoms may include abnormal uterine bleeding, and pain. Treatment depends on size of tumor and may include surgery.

CERVICAL CANCER • There is a strong relationship between sexual exposure of papillomavirus (HPV) and dysplasia. • • • • Later signs are leukorrhea, intermenstrual bleeding, and pain. The finding of an abnormal Pap test indicates need for follow-up. Invasive disease is treated with surgery, radiation, and chemotherapy. A new vaccine can protect against most types of cervical cancer.

ENDOMETRIAL CANCER • The major risk factor of endometrial cancer is unopposed estrogen. • • • It has low mortality rate, as most cases are diagnosed early. The first sign of endometrial cancer is abnormal uterine bleeding. Treatment is total hysterectomy and bilateral salpingo-oophorectomy with lymph node biopsies. Radiation and chemotherapy may also be given.

OVARIAN CANCER • The etiology of ovarian cancer is generally not known. • •

Most women with ovarian cancer have advanced disease at diagnosis. The greatest risk factor is family history. In the early stages, manifestations are vague and may consist of abdominal discomfort (gas, indigestion, pressure, bloating, cramps) and change in bowel habits. Yearly bimanual pelvic examinations should be performed to identify an ovarian mass.

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Treatment includes surgery, chemotherapy, and radiation. Nurses can teach women importance of routine screening for cancers of the reproductive system.

UTERINE PROLAPSE • Uterine prolapse is the downward displacement of uterus into the vaginal canal.

Symptoms are dyspareunia, dragging or heavy pelvic feeling, backache, and bowel or bladder problems if cystocele or rectocele is also present. Therapy depends on degree of prolapse and can include strengthening exercises, and a pessary.

SEXUAL ASSAULT • Sexual assault is the forcible perpetration of a sexual act on a person without his or her consent. It can include sodomy, forced vaginal or anal intercourse, oral copulation, and assault with a foreign object. • • • • Physical injuries may include bruising and lacerations to perineum, hymen, vulva, vagina, cervix, and anus. Feelings of humiliation, degradation, embarrassment, anger, self-blame, and fear of another assault are commonly expressed. Ensuring the woman’s emotional and physical safety is the highest priority. Follow-up physical and psychologic care is essential.

****Chapter 55: Nursing Management: Male Reproductive Problems
BENIGN PROSTATIC HYPERPLASIA (BPH) • Benign prostatic hyperplasia (BPH) is prostate gland enlargement due to increased epithelial cells and stromal tissue. • • • • BPH results from endocrine changes associated with the aging process. The compression of the urethra leads to clinical symptoms including decrease in caliber and force of the urinary stream, difficulty in initiating voiding, intermittency and dribbling. Conservative and initial treatment is “watchful waiting” when there are no symptoms or only mild ones. Drug therapy may also be used. Invasive treatment of symptomatic BPH involves prostate resection or ablation.

PROSTATE CANCER • Prostate cancer is the most common cancer among men, excluding skin cancer. • Risk factors include family history, age, and ethnicity.

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Symptoms of prostate cancer are similar to those for BPH, including dysuria, hesitancy, dribbling, frequency, and urgency. Elevated levels of prostate-specific antigen (PSA) indicate prostatic pathology, although not necessarily prostate cancer. The conservative approach to management is “watchful waiting.” Invasive therapies include radical prostatectomy and cryosurgery. Treatment may also include drugs, hormones, chemotherapy, and radiation. The nursing role is to encourage patients, in consultation with health care providers, to have annual prostate screening (PSA and digital rectal examination) starting at age 50 or younger if risk factors present.

PROSTATITIS • The term prostatitis describes a group of inflammatory and noninflammatory conditions affecting the prostate gland. • • It includes acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis. Antibiotics are used for acute and chronic bacterial prostatitis.

EPIDIDYMITIS • Epididymitis is an acute, painful inflammatory process of the epididymis secondary to an infectious process, trauma, or urinary reflux down the vas deferens. • • Antibiotic use is important for both partners if transmission was through sexual contact. Conservative treatment consists of bed rest with elevation of scrotum, use of ice packs, and analgesics.