Nursing Care in Clients with General

Disturbance in Reproduction and

Sexuality
 INFERTILITY – inability to conceive or sustain
pregnancy; affects 14% of couples; if not pregnant
after at least 1 year of unprotected coitus.
  
 TYPES: 1. Primary - no previous conception
 2. Secondary - had previous viable pregnancy but
unable to conceive at present
  
 STERILITY – inability to conceive because of a known
condition such as the absence of a uterus
 SUBFERTILITY – a lessened ability to conceive
ANOVULATION-absence of ovulation such as in
Turner’s syndrome (Hypogonadism- no ova
production)

TUBAL TRANSPORT PROBLEM – caused by

chronic salpingitis (PID), ruptured appendix or
abdominal sx involving spread of infection to
the fallopian tubes
UTERINE, CERVIAL AND VAGINAL PROBLEMS:
tumors, endometriosis, vaginal infections
(producing a highly acidic vagina secretions)
MALE INFERTILITY FACTORS:
•Disturbances in spermatogenesis
•Obstruction in the seminiferous tubules, ducts or
vessels preventing movement of spermatozoa
•Qualitative or quantitative changes in the seminal
fluid
•Development of autoimmunity that immobilizes the
sperm
•Problems in ejaculation or deposition preventing
spermatozoa from being placed closed enough to the
woman’s cervix to allow ready penetration &
fertilization
INADEQUATE SPERM COUNT – counted per single ejaculation
min at 20mil per ml of seminal fluid or 50 ml per
ejaculation ; at least 50% of the sperm should be motile and
30% should be normal in shape and form;
Contributing factors:
•changes in body temp
• CRYPTORCHIDISM (undescended testis) which was not
surgically repaired before puberty may contribute to this
condition or a twisted spermatic cord after Sx;
•Varicocele – enlargement & elongation of veins
•Trauma to the testis
•Sx near the testicles that impairs the testicular circulation
•Endocrine imbalances
•Drugs or excessive alcohol use
•Excessive exposure to X-ray and radioactive substances
ASSESSMENT: Physical Assessment
History taking
Fertility testing; Semen analysis,
Ovulation monitoring
Tubal patency

MANAGEMENT: Correction of Underlying Problem

•Increasing Sperm count and motility
•Reducing infection
•Hormone therapy (Clomid, Pergonal)
•Surgery
•Artificial Insemination
•In Vitro fertilization
•Alternatives : surrogate mothers, adoption, child-free living
SEXUAL DYSFUNCTIONS
-can be lifelong or acquired and may include the following:
•Inhibited sexual desire – cause: death of a family member, divorce, or a
stressful job change; S/E of medicine or chronic disease.; obesity
•Disorders of sexual arousal – poor sexual technique; negative attitude
towards sexual relationships
•Orgasms disorders – e.g. Erectile dysfunction (ED) due to advances age;
DM; atherosclerosis
Premature Ejaculation- ejaculation before penile-vaginal
contact; can be psychological; masturbation; doubt about
muscularity; fear of impregnating a woman

•Pain disorders : Vaginismus – involuntary contraction of the muscles of

the vaginal outlet when coitus is attempted prohibiting penile
penetration
Dyspareunia-pain during coitus
Vestibulitis-inflammation of the vestibule
CANCERS –(Malignant Neoplasm)- group of cells display uncontrolled
growth through division beyond normal limits, invasion that intrudes
upon and destroys adjacent tissues, and sometimes metastasis, in
which cancer cells spread to other locations in the body via lymph or
blood.
Cancers can occur in any part of the female reproductive system—the
vulva, vagina, cervix, uterus, fallopian tubes, or ovaries. These cancers
are called gynecologic cancers.
Gynecologic cancers can directly invade nearby tissues and organs or
spread (metastasize) through the lymphatic vessels and lymph nodes
(lymphatic system) or bloodstream to distant parts of the body.
Common areas affected in female: vagina, vulva, endometrial lining,
fallopian tube, cervix, ovary , breast
Male : testicle, prostate, penis
DIAGNOSTICS: Pelvic examination UTZ
X-rays Tissue biopsy
Pap Smear CEA MRI CT Scan Bone scans
Management: chemotherapy
Surgery
Radiotherapy
Brachytherapy (Internal radiotherapy,
curietherapy; sealed source
radiotherapy-skin, cervic, breast,
prostate)
INFECTIONS
Examples of infections
HIV - Infection by the retrovirus known as human immunodeficiency virus.
Genital warts - Sexually transmitted infection caused by some sub-types of human
papillomavirus (HPV).
Herpes simplex - Sexually transmitted infection caused by a virus called herpes simplex
virus (HSV) type 2
Gonorrhea - Common sexually transmitted disease caused by the Gram-negative
bacterium Neisseria
gonorrheae
Yeast infection - Infection of the vagina by any species of the fungus genus Candida.
Pelvic inflammatory disease - Painful infection of the female uterus, fallopian tubes,
and/or ovaries with
associated scar formation and adhesions to nearby tissues and organs.
Syphilis - Sexually transmitted infection caused by the bacterium Treponema pallidum.
Pubic lice - Infection of the pubic hair by crab lice, Phthirius pubis.
Trichomoniasis - Sexually transmitted infection by the single-celled protozoan parasite
Trichomonas vaginalis.
Vulvovaginitis - inflammation of vulva and vagina
Toxic Shock Syndrome – release of toxins from bacteria which is potentially fatal
usually caused by prolong
exposure to tampons Staph. Aureus, Strep pyogenes
Trichomoniasis - Sexually transmitted infection by the
single-celled protozoan parasite Trichomonas
vaginalis.
Vulvovaginitis - inflammation of vulva and vagina
Toxic Shock Syndrome – release of toxins from
bacteria which is potentially fatal usually caused by
prolong exposure to tampons Staph. Aureus, Strep
pyogenes
ASSESSMENT: fever, pain, itching, discharges,
redness, burning sensation
MANAGEMENT: antibiotic therapy, hygiene,
monogamous sexual relationship, Immunization
DISORDERS CAUSED BY ALTERED REPRODUCTIVE DEVELOPMENT
Gender is determined by chromosomal properties during conception,
AMBIGUOUS GENITALIA-external sexual organs did not follow the
normal course of development so that birth, they are so incompletely
or abnormally formed that it is impossible to clearly determine the
gender by simple observation.
A male infant with Hypospadias ( urethral opening on the under side of
the penis and Cryptorchidism
may appear more female than male on inspection. A chromosomal
female fetus may become masculinized with exposure
to androgen in utero(clitoris appears more enlarged and looks more like
a penis, labia maybe partially fused and difficult to tell from a male
perineum; or urethra may be so far forward displaced that it is located
in the clitoris.
ASSESSMENT: Karyotyping – chromosomal pairing showing its size and
shape
Laparoscopy
IVP on sonogram
MANAGEMENT: Correct hypospadias or cryptorchidism
• Surgical removal of labial adhesions or enlarged clitoris
• Removal of non-functioning ovaries or testes to prevent
malignancy
REPRODUCTIVE DISORDERS IN MALES
•INFANT AND CHILD
PHIMOSIS- very tight foreskin that interferes with voiding
-Balanopostitis (inflammation of the glans & prepuse) caused by poor hygiene
may develop
Correction: Circumcision
CRYPTORCHIDISM-failure of one or two testes to descend from the abdominal cavity
to the scrotum (7-9 IOL or up to 6 wks after birth); associated with testicular cancer
Assessment: detection of undescended testis during birth
Management: Txt is usually delayed for 6-12 months; Sx is
Orchiopexy at 1 yr old
Chorionic gonadotropin hormone therapy
HYDROCELE – collection of fluid in the scrotum; if uncomplicated will be reabsorbed
into the body, no sx required
DIAGNOSTIC: Sonogram
HYPOSPADIAS-urethral defect in which the urethral opening is on the ventral(Lover)
aspect of the penis
EPISPADIAS – opening is on the dorsal aspect of the penis
ASSESSMENT: Routine physical examination
MANAGEMENT: No circumcision unless corrected; Testosterone cream
application
Meatotomy( urethra is extended to a normal position)
SEXUALLY TRANSMITTED DISEASES/INFECTIONS
Prevention: Abstinence or use of condom
Washing of genitals well with soap and water
Voiding immediately after coitus
Choosing partners who are at low risk for infection (non
drug users)
Education about safe sex practices and the importance of health
screening for these disorders
•Candidiasis (Yeast infection) – fungus that thrives on glycogen; during
pregnancy when high estrogen levels lead to glycogen levels that
produce favorable environment for fungal growth;
Affects about 40% of adult females who are asymptomatic
Symptoms: Vulvar reddening and pruritus
Thick, cheeselike vaginal discharge
Pain on coitus or tampon insertion
Bleeding from hairline fissures
White patches on vaginal wall
Management: Nystatin or miconazole supp or cream fro 3-7 days
Fluconazole orally
Bathing with dilute Sodium Bicarbonate solution may relieve
pruritus
Treat male partner as well
For recurrent candidiasis, test urine dro glucose
to R/O DM
•Trichomoniasis – single cell protozoan spread by coitus; incubation
period is 4-20 days; affects up to
25% of adult men and women who are asymptomatic
Symptoms: Thin irritating, frothy, gray-green discharge
Strong, putrid odor
Itching
Reddened upper vagina with pinpoint petechiae
Management: Metronidazole orally (C/I in pregnancy)
Douching with leak vinegar solution
•Bacterial Vaginosis – invasion of an organism scuh as Garnerella vaginalis; organism
thrives in the Vagina; a body area with reduced O2 level
S/S : milk to white gray vaginal discharges
Intense pruritus
Clue cells upon microscopic examination of discharges
Management:
Oral Metronidazole for 7 days
•Clamydia trichomatis – most common organism that causes STI; can cause eye
infection or pneumonia in NB
S/S: heavy grayish-white discharge
Vulvar itching
Incubation period: 1-5 weeks
Diagnosis: Culture of organism
Management: Doxocycline or tetracycline 7 days
Erythromycin if pregnant
•Genital Warts - lesions caused by the HPV rapidly growing in the vulva, vagina or
cervix; large growth can be cancerous
Management: Cautery, Cryotherapy
Children with genital warts must be investigated for sexual abuse
•Herpes Genitalis – cause by herpes virus hominis type 2 (HSV-2); NO
KNOWN CURE
•Fatal to NB or may cause systemic disease;;
Assessment: Isolation of HSV antibodies in serum
Culture of discharges from lesions
Flulike symptoms
Profuse discharge from vaginal lesions
Pain when in contact with urine/clothing
Incubation period: 3-14 days on first contact
Management: Acyclovr (Zovirax) topical ointment (use gloves when
applying) Sitz bath TID and applying cornstarch to reduce discomfort
Use of condom Topical imiquimod (Aldara) for resistant lesions
Yearly Pap smear to R/O cervical Ca
•Gonorrhea – transmitted by Neiserria gonorrhea; its symptom
appearing after 2-3 days incubation Period
S/S : urethritis in male
Urethral discharges
If untreated infection may spread to testis causing
permanent sterility
Female: slight yellowish vaginal discharges
Inflamed Bartholin’s glands wit pain
May cause PID’ arthritis or heart disease if
untreated
An infant can contract gonorrhea in the birth canal causing Gonorrheal
opthalmia. Do Culture test.
Management: Ceftriaxone SD IM plus Doxocycline for 7
days. No longer infectious after 24Hrs from start
of treatment
•Syphillis – systemic infection caused by the Spirochete treponema
pallidum
Incubation period: 10-90 days
•Appearance of lesions (CHANCRE) on penis, genitalia or labia but may
be also seen on the mouth, lips or rectal area which progresses into a
deep ulcer usually painless.
•LYMPANDENOPATHY though present but undetected by the patient.
•The vaginal lesions may last up to 6 weeks untreated then fades after
which a generalized macula-copper-colored rash appears affecting the
sole and the palms.
• latency period last from years to decades.
•Final destructive phase affects neurologic system
•Typical symptoms: blindness, paralysis, severe crippling neurologic
deformities, mental confusion, slurred speech, lack of coordination
ASSESSMENT: recognition of symptoms ART (Automated
Reagin Test
VDRL(Venereal Disease Research Lab Test RPR(Rapid
Plasma Reagin Test)
FTA-ABS (Flourescent treponemal antibody
absorption test)
•Adult Women TABLE 10-1
•Fibrocystic breast disease – most common benign breast condition affecting women
ages 20 – 45. S/S : round,fluid0filled cyst in the connective tissues, movable,
well-delineated lump, palpable, visible from the surface, most often at the upper
outer quadrant; Changes with ovulation, pregnancy ( firm & hard to soft) and
disappears at menopause; Can be painful, tender and stretched
Management: Avoid cola beverages (m, chocolates, aspirinethylxanthine in
caffeine, theophylline & theobromine increases its forrmation)
Discontinue smoking
Mild diuretic to reduce Na retention during or before
menses
If ineffective, aspirate cyst under LA to reduce size and
for biopsy
Oral contraceptives (synthetic androgen to suppress
estrogen)
 estrogen)
•Fibroadenomas – tumors consisting of fibrotic and glandular components
occurring in response to estrogen stimulation
•Increases in size during adolescence, lactation or pregnancy or during estrogen
therapy oral contraceptive S/S : round, well-delineated, firmer, more rubbery
than fluid-filled cyst; Calcifies occasionally; painless, movable
Mangament: Excision
•Breast hypertrophy - abnormal breast enlargement (progesterone is
responsible for normal breast growth and halts at puberty as it
rises to mature strength but if it is slowed down it takes years
Drawback: feeling of self-conscoius, back pain, difficulty to maintain
posture, slouching, rounded shoulder; low self-concept
Mngmnt: Surgical reduction (if large glandular tissues are removed
lactation is no longer possible)
•Breast hypoplasia – less than average breast size due to reduced amount of fatty
tissue
Drawback : low self esteem
Mngmnt: breast augmentation (implant – saline
•Breast cancer -refers to cancers originating from breast tissue, most commonly from
the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers
originating from ducts are known as ductal carcinomas; those originating from lobules
are known as lobular carcinomas. There are many different types of breast cancer,
with different stages (spread), aggressiveness, and genetic makeup; survival varies
greatly depending on those factors.
10
•10% of all cancer cases, 2nd most common of all non-skin Ca
subjective sign, of breast cancer is typically a lump that
feels different from the rest of the breast tissue.
More than 80% of breast cancer cases are discovered when the woman
feels a lump.] The first medical sign, or objective indication of breast
cancer as detected by a physician, is discovered by lumps found in
lymph nodes located in the armpits[ can also indicate breast cancer.;
redness, mild flaking of nipple skin
primary risk factors : sex age, childbearing, hormones, a high-fat
diet,] alcohol intake obesity,] and environmental factors such as tobacco
use, radiation[, endocrine disruptors and shiftwork.
Diagnosis: Physical exam., mammography, FNAB
Mangmnet: mastectomy , drug therapy , chemo,
radiotherapy
•Uterine cancer/Endometrial Ca
Affects the uterine body and it linings
Signs and symptoms
Vaginal bleeding and/or spotting in postmenopausal
women
Abnormal uterine bleeding, abnormal menstrual periods
Bleeding between normal periods in premenopausal
women in women older than 40: extremely long, heavy,
or frequent episodes of bleeding (may indicate
premalignant changes)
Anemia, caused by chronic loss of blood. (This may occur
if the woman has ignored symptoms of prolonged or
frequent abnormal menstrual bleeding.)
Lower abdominal pain or pelvic cramping
Thin white or clear vaginal discharge in postmenopausal
women.
Risk factors
high levels of estrogen , endometrial hyperplasia, obesity,
hypertension ,polycystic ovary syndrome
nulliparity (never having carried a pregnancy), infertility (inability
to become pregnant),early menarche
late menopause, endometrial polyps or other benign growths of
the uterine lining, diabetes
high intake of animal fat; pelvic radiation therapy; breast cancer;
ovarian cancer ;heavy daily alcohol consumption
•Mastitis - inflammation of breast tissue. S. aureus is the most common
etiological organism responsible, but S.epidermidis and streptococci are
occasionally isolated as well.
Types: puerperial - due to blocked milk ducts
Non-puerperal –
S/S: Breast tenderness or warmth to the touch
General malaise or feeling ill
Swelling of the breast
Pain or a burning sensation continuously or while breast-feeding
Skin redness, often in a wedge-shaped pattern
Fever of 101 F (38.3 C) or greater
Txt: antibiotic therapy 1 week
May recur, causes milk stasis or abscess
•Ovarian Cyst
n ovarian cyst is any collection of fluid, surrounded by a very thin wall,
within an ovary. Any ovarian follicle that is larger than about two
centimeters is termed an ovarian cyst. An ovarian cyst can be as small as
a pea, or larger than an orange.
Most ovarian cysts are functional in nature, and harmless (benign).[1] In
the US, ovarian cysts are found in nearly all premenopausal women, and
in up to 14.8% of postmenopausal women.
Ovarian cysts affect women of all ages. They occur most often, however,
during a woman's childbearing years.
cysts larger than 5 centimeters in diameter
Classification
[Functional cysts
Some, called functional cysts, or simple cysts, are part of the normal
process of menstruation. They have nothing to do with disease, and can
be treated. There are 3 types, Graafian, Luteal, and Hemorrhagic. These
types of cysts occur during ovulation. If the egg is not released, the
ovary can fill up with fluid. Usually these types of cysts will go away after
a few period cycles.
] Graafian follicle cyst
Main article: Follicular cyst of ovary
One type of simple cyst, which is the most common type of ovarian cyst,
is the graafian follicle cyst, or follicular cyst.
] Corpus luteum cyst
Main article: Corpus luteum cyst
Another is a corpus luteum cyst (which may rupture about the time of
menstruation, and take up to three months to disappear entirely).
Hemorrhagic cyst
A third type of functional cyst, which is common, is a Hemorrhagic cyst,
which is also called a blood cyst, hematocele, and hematocyst. It occurs
when a very small blood vessel in the wall of the cyst breaks, and the
blood enters the cyst. Abdominal pain on one side of the body, often the
right side, may be present. The bleeding may occur quickly, and rapidly
stretch the covering of the ovary, causing pain. As the blood collects
within the ovary, clots form which can be seen on a n UTZ. Occasionally
hemorrhagic cysts can rupture, with blood entering the abdominal
cavity. No blood is seen out of the vagina. If a cyst ruptures, it is usually
very painful. Hemorrhagic cysts that rupture are less common. Most
hemorrhagic cysts are self-limiting; some need surgical intervention.
Even if a hemorrhagic cyst ruptures, in many cases it resolves without
surgery. Patients who don't require surgery will experience pain for 4 -
10 days after, and may require several days rest. Studies have found that
women on tetracycline antibiotics recover 25% earlier than the majority
of patients, a surprising correlation found in 2004. Sometimes surgery is
necessary, such as a laparoscopy ("belly-button surgery" that uses small
Dermoid cyst
] Endometrioid cyst
Main article: Chocolate cyst of ovary
An endometrioma, endometrioid cyst, endometrial cyst, or chocolate cyst is caused by
endometriosis, and formed when a tiny patch of endometrial tissue (the mucous membrane
that makes up the inner layer of the uterine wall) bleeds, sloughs off, becomes transplanted, and
grows and enlarges inside the ovaries.
Pathological cysts
The incidence of ovarian carcinoma (malignant cancer) is approximately 15 cases per 100,000
women per year.[8]
Other cysts are pathological, such as those found in polycystic ovary syndrome, or those
associated with tumors.
A polycystic-appearing ovary is diagnosed based on its enlarged size — usually twice normal —
with small cysts present around the outside of the ovary. It can be found in "normal" women,
and in women with endocrine disorders. An ultrasound is used to view the ovary in diagnosing
the condition. Polycystic-appearing ovary is different from the polycystic ovarian syndrome,
which includes other symptoms in addition to the presence of ovarian cysts, and involves
metabolic and cardiovascular risks linked to insulin resistance. These risks include increased
glucose intolerance, type 2 diabetes, and high blood pressure. Polycystic ovarian syndrome is
associated with infertility, abnormal bleeding, increased incidences of pregnancy loss, and
pregnancy-related complications. Polycystic ovarian syndrome is extremely common, is thought
to occur in 4-7% of women of reproductive age, and is associated with an increased risk for
endometrial cancer. More tests than an ultrasound alone are required to diagnose polycystic
ovarian syndrome.
Signs and symptoms

Some or all of the following symptoms[may be present, though it is possible not to

experience any symptoms:
Dull aching, or severe, sudden, and sharp pain or discomfort in the lower abdomen
(one or both sides), pelvis, vagina, lower back, or thighs; pain may be constant or
intermittent -- this is the most common symptom
Fullness, heaviness, pressure, swelling, or bloating in the abdomen
Breast tenderness
Pain during or shortly after beginning or end of menstrual period.
Irregular periods, or abnormal uterine bleeding or spotting
Change in frequency or ease of urination (such as inability to fully empty the bladder),
or difficulty with bowel movements due to pressure on adjacent pelvic anatomy
Weight gain
Nausea or vomiting
Fatigue
Infertility
Increased level of hair growth
Increased facial hair or body hair
Headaches
A coronal CT demonstrating a large hemorrhagic ovarian cyst. The cyst is
Strange pains in ribs, which feel muscular
delineated
Bloating
bybruises
Strange nodules that feel like theunderyellow
the layer of skin bars with blood seen anteriorly.
[edit] Diagnosis

Ovarian cysts are usually diagnosed by either ultrasound or CT scan.

[Treatment
About 95% of ovarian cysts are benign, meaning they are not cancerous.
[14]

Treatment for cysts depends on the size of the cyst and symptoms. For
small, asymptomatic cysts, the wait and see approach with regular
check-ups will most likely be recommended.
Treatment
About 95% of ovarian cysts are benign, meaning they are not cancerous.
[
Treatment for cysts depends on the size of the cyst and symptoms. For
small, asymptomatic cysts, the wait and see approach with regular
check-ups will most likely be recommended.
Pain caused by ovarian cysts may be treated with:pain relievers,
including acetaminophen (Tylenol), nonsteroidal
anti-inflammatory drugs such as ibuprofen (Motrin, Advil), or narcotic
pain medicine (by prescription) may help reduce pelvic pain.[15] NSAIDs
usually work best when taken at the first signs of the pain.a warm bath,
or heating pad, or hot water bottle applied to the lower abdomen near
the ovaries can relax tense muscles and relieve cramping, lessen
discomfort, and stimulate circulation and healing in the ovaries.[Bags of
ice covered with towels can be used alternately as cold treatments to
increase local circulation.[combined methods of
hormonal contraception such as the
combined oral contraceptive pill -- the hormones in the pills may
regulate the menstrual cycle, prevent the formation of follicles that
can turn into cysts, and possibly shrink an existing cyst
Also, limiting strenuous activity may reduce the risk of cyst rupture or
torsion.
Cysts that persist beyond two or three menstrual cycles, or occur in
post-menopausal women, may indicate more serious disease and should
be investigated through ultrasonography and laparoscopy, especially in
cases where family members have had ovarian cancer. Such cysts may
require surgical biopsy. Additionally, a blood test may be taken before
surgery to check for elevated CA-125, a tumor marker, which is often
found in increased levels in ovarian cancer, although it can also be
elevated by other conditions resulting in a large number of false
positives.[18]
For more serious cases where cysts are large and persisting,
doctors may suggest surgery. Some surgeries can be performed
to successfully remove the cyst(s) without hurting the ovaries,
while others may require removal of one or both ovaries