Reproductive

Reproductive

System



NUR 302 Unit II

Sexually Transmitted Diseases

 Gonorrhea & syphilis reportable to

health dept, genital herpes & warts not

 Often STDs coexist

 30% gonorrhea - resistant strains

 25-40% cases– teenagers, young adults

 Incidence of syphilis declining

 Chlamydia trachomatis- most prevalent

Contributing Factors to STDs

 Earlier maturity, increased longevity

 Sexual freedom, media, changes in

women, marriage, religion, family

 Drug abuse correlates with STDs

 Methods of contraception

Gonorrhea

 Niesseria gonorrhoeae – in male

urethra, cervix, rectum, oropharynx

 Spread by direct physical contact

 Killed by drying, heating, washing with

antiseptic soln

 Incubation- 3-4 days

 Inflam. response->fibrous tissue,

adhesions, scarring

Clinical Manifestations

 Men: urethitis, dysuria, purulent disch.

 Women: no s/s, vaginal discharge,

dysuria, freq urination, menstr.

changes, red, swollen, purulent urethral

drainage, cervix->abscess, & spreads

 Anorectal – no s/s, proctitis, pharyngitis

Complications & Diagnosis

 Men: prostatitis, ureth strictures, sterility

 Women: PID, Bartholin abscess, ectopic preg,

infertility, DGI- skin lesions, fever, arthritis

 Opthalmia neonatorum

 Dx: culture of drainage, gram stain, history,

rectal culture, DNA probe technique &

poymerase chain reaction

Drug Therapy

 Penicillin

 Cipro

 Rocephin

 Cefixine

 Vibramycin

 Treat all sexual contacts of pts

 Abstain from alcohol & sex. intercourse

Syphilis

 Trepomema pallidium

 Destroyed by heating, drying, washing

 Enters via small breaks in skin or mucous

membrane, needle sharing, contact with

infected lesions, congenital

 Incubation: 10-90 days (3 weeks)

 Capillary dilation & swelling, proliferation of

endothelium, new blood vessels form, scar

tissue forms when healing

Clinical Manifestations

 Primary stage: chancres

 Secondary stage: systemic, spread to all

organs, rash, alopecia, adenopathy

 Latent period: no s/s, immune system

suppresses infection, + antibodies

 Late (Tertiary): gummas, ht failure,

aneurysms, paresis, psychosis, mental

deterioration, ataxia, jt damage

Complications & Diagnosis

 Gummas->bone, liver, skin damage

 Cardiovascular – ruptured aneurysms,

scarring of aortic valve

 Neurosyphilis – sudden pain anywhere

in body, mental changes, ataxia, vision

loss, prob walking

 Dx: H&P, dark field microscopy of lesion

scrapings, VDRL, RPR

Drug Therapy

 Treatment can not reverse damage

 IV Penicillin

 Doxycycline, tetracycline, erythromycin

 Treat maternal syphilis before week 18;

treatment in 2nd half preg-> premature

labor

 Neurosyphilis – management also

depends on neuro s/s

Chlamydial Infections:

Urogenic Infections

 Chlamydia trachomatis, many strains

 Urethitis & cervicitis, assoc with

gonococcal infections, incub:1-3 weeks

 S/S: urethitis, epididymitis, proctitis,

cervicitis, freq urination, barthinitis,

PID, perihepatitis

 Complic: infertility, Reiter’s disease,

PID, ectopic preg

Diagnosis & Care

 Dx: exclude gonorrhea – smear of ureth

discharge(men), first catch urine,

culture, nonculture tests

 Drugs: Vibramycin, Zithromax, Floxin

 If pregnant: Erythromycin, Amoxicillin

 Follow up care, treat partners, use

condoms, if s/s persist seek care

Lymphogramuloma

Vernereum

 Stain of C. trachomatis, chronic STD

 Africa, India, SE Asia, Caribbean, S America

 Enter skin & m membrane via abrasion,

spread via bld & enters CNS

 Penile, anal, vulvar infection, ing & fem lymph

enlargement,necrosis, abscesses, fibrosis,

lymph node dysfunction, complic – fistulas

 Rx: pt & partner, tetracycline

Genital Herpes

Herpes Simplex Virus (HSV)

 HSV-1: infection above waist

 HSV-2: genital tract & perineum

 Dormant on sensory nerve ganglion

 Recurrences: HSV moves down nerve axion

to skin or mucous membrane

 Virus enters thru mucous membrane or

breaks in skin.

 Viral shedding in absence of lesion

 Incubation: 1-45 days, (ave. 6)

Clinical Manifestations

 Initial burning tingling

 Vesicular lesion on penis, scrotum, vulva,

perineum, perianal, vagina, cervix

 Rupture, ulcer, crust, epithelialization

 Pain, fever, headache, malaise, myalgia,

lymphadenopathy

 Dysuria, retention, vag discharge

 Lesions last 17-20 days, new dev 6wks

Clinical Manifestations:

Transmission of HSV

 Transmission with or without lesion & if

asymptomatic

 Barrier contraception decreases

transmission

 Avoid sex when lesion present

 Antiviral agents reduce but not prevent

viral shedding

Complications & Diagnosis

 CNS- aseptic meningitis, lower neuron

damage

 Virus spread to fingers, lips, breast

 HSV & pregnancy – hi risk transmission

to infant, C- Section

 Dx: s/s, history, culture

Care & Drug Therapy

 Wear loose cotton underwear, keep

lesions dry, hairdryer, good hygiene,

sitz bath, pour water when urinating

 Health promotion: use condoms,

abstain from sex if have lesions

 Pain: lidocaine, codeine, ASA

 Zovirax, Valtrex, Famvir

Condylomata Acuminata:

Genital Warts

 Human papilloma virus (HPV), highly

contagious, incubation 1-6 mo

 Single, multiple growths, grow rapidly

during preg, may transmit to baby

 Link with cervical & vulvar cancer & in

men anorectal & penile cancer

 Dx: by appearance of lesion, Virapap

 Tx: remove symptomatic warts

Nursing Management of STDs

 Assessment

 Health promotion: “safe sex”, teaching

pt with STD, screening cervical cancer

& STDs, case finding, community educ

 Acute care: psychol support, explain tx

& s/e, follow up rx, teach hygiene,

abstinence from sex

Breast Disorders:

Health Promotion Practices

 Risk factors for breast cancer

 Monthly breast self exam over age 18

 Physical exam q3yrs age 20 – 40 & over

40 q year

 Mammography

 Follow up care

Assessment of Breast

Disorders

 Males: 1% breast cancer, gynacomastia

 Breast cancer mostly post menopause

 Family history significant

 Assess: pain, nipple discharge, lump

size, location, rate of growth,

correlation with menstrual cycle,

consistency, mobility, shape, single or

multiple ducts, one or both breasts

Diagnostic Studies

 Mammography

 Biopsy – only definitive dx for cancer

 Fine needle aspiration

 Open surgical biopsy

 Stereotactic core biopsy

Benign Breast Problems

 Mastalgia – Pain, coincides with menstrual

cycle

 Mastitis – inflammation, lactating women,

staph via cracked nipple, fever, red, warm,

tender, continue breast feeding , use shield

or express milk

 Lactational breast abscess – no response to

antibiotics, I&D, C&S, express & discard milk

Fibrocystic Changes

 Benign, excess fibrous tissue, cyst, pinches

nerve endings->pain

 No risk for cancer, nodules in bilateral upper

outer quadrant

 Common age 35 – 50, response to estrogen

& progesterone

 Lump well rounded, delineated, movable,

enlarge with menstrual cycle

 DX: mammogram, ultrasound

Fibrocystic Changes

 Aspirate or biopsy esp if hi risk for

breast cancer

 Teach breast self exam, follow up

exams thu life, report new lumps or

changes

 Wear good bra, lo salt diet, decrease

chocolate & caffeine, diuretic,

hormones, vit E, Danazol, decr stress

Fibroadenoma

 Benign, cause of breast tumor in

women under 25, African Americans

 Increased estrogen sensitivity

 Small, painless, round, movable, soft or

rubbery, slow growth, no relation to

cycle but increase if pregnant

 Dx: biopsy, tx- excision

 Teach self breast exam, follow up

Benign Breast Problems

 Nipple discharge – milky,serous, bloody,

green, brown

 Intraductal papilloma – warts in

mammary ducts

 Ductal ectasia– peri & postmenopausal,

sticky, multicolored discharge, burning,

itchy, bloody discharge, nipple

retraction, abscess

Gynecomastia

 Male enlargement of one or both

breasts, benign

 Imbal of androgen & estrogen, can be

s/s of other problem

 Pubertal gynecomastia – age 13-

17,disappears 4-6 months

 Senescent gynecomastia

Breast Cancer

Risk Factors

 Female, age 50 or over

 Family history

 BRCA-1, BRCA-2 gene mutations

 H/O breast, colon, endometrial, ovarian cancer

 Early menarche

 Full term pregnancy after age 30, nulliparity

 Benign breast disease with atypical epithelial

hyperplasia

 Obesity after menopause

 Exposure to ionizing radiation

Clinical Manifestations

 Lump

 commonly found in upper outer quadrant

 hard, irreg shape, not delineated

 fixed, nontender

 Dimpling of skin

 Nipple discharge, retracted nipple

 Orange peel skin

Diagnostic Studies

 Mammography

 Ultrasound

 Biopsy

 Fine needle biopsy

 Stereotactic core biopsy

 Axillary lymph node status – 4 or more +

nodes ->greatest risk of recurrence

 Lymphatic mapping & sentinel lymph node

dissection

Types of Breast Cancer

 Ductal cancer

 Lobular cancer

 Insitu vs invasive

 Paget’s disease – malignant persistent

lesion of areola & nipple

 Inflammatory breast cancer – rare,

most malignant, red, warm, orange peel

or hives look

Prognosis Variables

 Tumor size & differentiation

 Axillary node involvement

 DNA content analysis

 Genetic marker HER-2/neu (c-erb-B2 or

neu)

 Estrogen & progesterone receptor

status

 Cell proliferation indices

Collaborative Care

 TNM Classification: size of tumor, nodal

involvement, metastasis -> staging 0-IV

 Breast conservation surg (lumpectomy) with

radiation

 Modified radical mastectomy with/out

reconstruction

 Axillary node dissection

 Follow up care rest of life- reoccurrence at

surg site or opposite breast

Recurrence & Metastasis

 Local – skin

 Regional – lymph nodes

 Distant metastasis

 Skeletal

 Spinal cord

 Brain

 Pulmonary

 Liver

 Bone marrow

Radiation Therapy

 Primary radiation therapy – after tumor

removed, external beam, s/e

esophagitis, tracheitis, fatigue, skin,

breast edema

 Radiation as adjunct to therapy- pre-op

 Palliative – rx of metastasis to bone,

brain, chest, soft tissue, relieves pain,

decrease reoccurrences

Chemotherapy

 Very responsive to chemo

 Combinations of drugs- effects on cell

growth & division at different stages

 Cytoxin, 5FU, Vincristine & Prednisone

 Andriamycin, 5FU, Taxol, Taxotere

 S/E: GI tract, bone marrow, hair

Hormonal Therapy

 Estrogen can promote growth of breast

cancer

 Oopherectomy, adrenalectomy,

hypophysectomy

 Determine estrogen & progesterone receptor

status of tumor

 Tumor regression with hormone manipulation

 Tamoxifen, Toremifene, Arimidex

Nursing Care: Breast Cancer

 Psychol support during dx & tx

 Provide info on tx choices, diag tests

 Pre-op teaching

 Help restore arm function on affected

side- elevate, finger/arm exercises

 Lymphedema- arm never dependent,

no BP, bld work, or injections

 Pain, fear, body image disturbance

Nursing Care: Breast Cancer

 Reach to Recovery Program

 Accurate answers to questions

 Teach follow up care

 Report fever, inflammation, redness, swelling,

weakness, new pain, SOB

 Prosthesis, breast reconstruction

 Implications on sexual identity

 Depression

Mammoplasty

 Surgical change in breast size or shape

 Breast augmentation – saline implants

 Breast reduction

 Post-op – drains, observe s/s

hemorrhage or infection, wear good

supporting continuously for 2-3 weeks,

no strenuous exercise

Ovarian Cancer

 Risk factors: family history, hi fat diet, age,

BRCA-1 gene mutation

 Protective: mult preg, breast feeding, preg at

early age

 Asymptomatic early, pain, increase in

abdomen, ascites, bowel & bladder prob

 Dx: CA-125, yrly exam, ultrasound

 Rx: total hysterectomy, chemo, radiation

Nursing Implementation

 Health Promotion: routine screening, teach

risks for cancer

 Psychological support - grieving

 Hysterectomy- vaginal or abdominal

 Mod amt blding 1st 8 hrs, urinary retention,

abd distention, menopause, thrombophlebitis

 Discharge: no lifting, brisk walking, dancing,

can swim, no menses, 4-6 wks no sex

Endometrial Cancer

 Risk factor- unopposed estrogen, incr age,

obesity, hi BP, DM

 Adenocarcinoma common, grows slow, mets

late, early dx & tx-> + prognosis

 Mets to liver, lung, bone,brain

 S/S: abnormal uterine bleeding

 Dx: endometrial biopsy; tx total

hysterectomy, radiation, progesterone,

chemo

Cervical Cancer

 Slow progression, repeated cervical injury;

HPV with smoking

 No s/s early, leukorrhea, intermenstral blding,

anemia, wt loss, cachexia

 Dx: Pap test, Schiller iodine test, biopsy,

colposcopy

 Rx: classII- 3-4mo follow up, class III>

biopsy, conization; invasive- hysterectomy,

radiation

Pelvic Inflam. Disease (PID)

 Untreated cervicitis ascends; may involve

fallopian tubes, ovaries, pelvic peritoneum

 S/S: lower abdom pain, spotting, vag

discharge, fever

 Dx: s/s, pelvic exam

 Complications: septic shock, Fitz-Hugh Curtis

symdrome, abscess, peritonitis, emboli

 Long term: ectopic preg, infertility, chr pain

PID: Collaborative & Nsg Care

 Antibiotics, no sex 3 wks, BR- Semi Fowler’s

position, fluids, exam partners, repeat exam

48-72 hrs, analgesics

 Prevention- teach risk factors, early recog &

tx cervicitis

 Monitor pain, heating pad lower abd, sitz

bath, teaching prevention- barrier methods,

reason for BR, VS, monitor vaginal discharge

Benign Tumors

 Leiomyomas (fibroids, myomas)

 S/S: none, heavy blding,abd pressure

 Rx: observe over time, surgery

 Cervical polyps:cherry red, soft, seen on

pelvic exam. Rx: excise

 Benign ovarian tumors: cystic &

neoplasms; laporoscopy

Problems with Pelvic Support

 Uterine prolapse-uterus into vagin.canal

 Cystocele- weak bet bladder & uterus

 Rectocele- weak bet uterus & rectum

 Rx: Kiegal exercises, pessary, surgery

 Post-op care: perineal care 2x day & after

urination, ice pack, later heat

 Discharge: laxatives, douches, no lifting, long

sitting, standing, no sex til MD oks

Male Reproductive Problems



Benign Prostatic

Hypertrophy(BPH)

BPH etiology &

pathophysiology

 Increase in epithelial cells in prostate,

does not predispose to prostate cancer

 Age related endocrine changes

 Dihydroxytestosterone, estrogen

 Inner part of prostate enlarges->

compresses urethra->obstruction

 Risk factors – family history, diet with

zinc, butter margarine

BPH Symptoms

 S/S: gradual, decr in force of urinary

stream, hesitancy starting, end dribble,

feeling of retention, nocturia, urgency

 Irritation due to infection – frequency,

nocturia, dysuria, incontinence

BPH Diagnosis

 Digital rectal exam – symmetrical, enlarged,

smooth

 U/A with C/S

 PSA(Prostate Specific Antigen) r/o prostate

cancer

 Creatinine

 Transrectal ultrasound with biopsies –r/o

cancer

 Cystoscopy, uroflow

Treatment – Conservative

(based on s/s)

 Watch & wait, diet decrease caffeine, artificial

sweeteners, avoid cold meds &

anticholinergics, restrict fluids at nite

 Meds – Proscar blocks enzyme to convert

dihydroxytestosterone to testosterone

 Alpha adrenergic recteptor blocker->relax

smooth muscle –Cardura, Hytrin, Flomax

 Herba – saw palmetta

BPH Treatment

 Nonsurgical: intermittent cath, foley,

coils, stents, balloon dilatation, TUMA

 Surgery: laser ablation, TURP, TUIP,

suprapubic resection, retropubic

resection, perineal resection

 Complications: hemorrhage, infection,

bladder spasm, urinary incontinence,

erectile problems

Treatment - Invasive

 Transurethral resection of prostate

(TURP)

 Transurethral microwave thermotherapy

 Transurethral needle ablation (TUNA)

 Transurethral electrovaporization of

prostate

 Laser prostatectomy

 Urethral stents

BPH Nursing Care

 Health promotion: age 40 yrly medical

history, >50 & s/s diagnostic screening

 Avoid sudafed, phenylephrine, caffeine,

alcohol

 Void every 2 hrs, maintain fluid Intake

Pre-op Care

 Relieve obstruction – c oude (curved) cath,

fillifrom (rigid) cath, lidocaine as lubricant

 Antibiotics if infection

 Restore drainage with foley, hi fluid intake

 Address sexual concerns – all procedures

result in retrograde ejaculation so ejaculation

diminished, semen eliminated when pt voids

Post-op Care BPH

 3 way foley with CBI

 Read text p1442-1443 !!

 Maintain patency of foley, aeseptic technique

 Blood clots are expected 24-36 hrs BUT bright red

blood not-> hemmorrhage

 Bladder spasms

 Sphincter control poor>dribbling, incontinence

 Check for s/s

 Infection

 Stool softeners

BPH Home Care

Discharge Teaching

 S/S infection

 Urinary incontinence

 Avoid lifting

 Avoid constipation

 Fluid intake 2000-3000cc

 Address sexual questions

 No driving or sex til cleared by MD

 Follow up with MD

Prostate Cancer

 Most common cancer among men excluding

skin cancer

 Risk factors – age, family history, African

American, hi fat diet, exposure to chemical

cadium

 Incidence increases at age 50, 80% mostly

65 & older

 Androgen dependent cancer

 Outer aspect prostate gland

 Spreads direct extension, by lymph or blood

Prostrate Cancer

 Slow growing, spreads via lymph, blood,

direct extension to lungs, liver, head of

femur, pelvic bones, lower spine

 Pain – problem after metastisis

 S/S: none early, BPH s/s, pain down legs +

urinary s/s->metastasis

 Dx: screening with PSA, rectal exam->

asymmetrical, large, nodules, biopsy, CT

scans for metastasis

Radical Prostatectomy

 Remove all prostate, seminal vesicles, neck of

bladder

 Long term survival, use for men under 70, good

health, no metastasis

 Retropubic approach or perineal resection

 Post-op – foley in urethra with 30cc balloon, left 2

weeks and drain in incision site

 Complications – erectile dysfunction & incontinence

 Nerve sparing procedure can preserve erectile

function



Conservative Treatment

 Slow growing, may defer tx, watch and

wait

 Life expectancy Less 10 yrs

 Comorbid disease

 Low grade, low stage tumor

 Followed with PSA, rectal exams

Collaborative Care

 TURP or total prostatectomy

 Radiation: external beam radiation,

seed implants (brachytherapy)

 Drug therapy: antiandrogen therapy –

Lupron, Zoladex, Casadex, Proscar

 Orchidectomy or estrogen therapy

(diethylstilbestrol)

 Prostatic cryotherapy

Prostatitis

 Bacterial, chr. bacterial, nonbacterial,

prostatodynia

 S/S bacterial: fever, chills, dysuria,

urethral disch, low rectal, back, pelvic

pain, post ejaculation pain, prostrate

swollen, tender, warm, firm

 Dx: s/s, WBC, u/a

 Tx: antibiotic, Cipro, analgesics

Testicular Cancer

 Age 20-40, had undescended testes, family history,

germ cell tumors

 Dx: palpation, sonogram, MRI, blood markers-AFP

(alpha fetoprotein) &hCG (human chorionic

gonadatropin),orchidectomy & staging of tissue

 S/S: lump, feeling of heaviness, swelling

 Teach self exam, radical orchidectomy

 Discuss sperm banking, potential to interfere with

erections & fertility

 Metastasis – back pain, cough, dysphagia, seizures,

alterations vision