Reproductive System NUR 302 Unit II Sexually Transmitted

Reproductive System NUR 302 Unit II

Sexually Transmitted Diseases n n n 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 n n Earlier maturity, increased longevity Sexual freedom, media, changes in women, marriage, religion, family Drug abuse correlates with STDs Methods of contraception

Gonorrhea n n n 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 n n n 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 n n 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 n n n n Penicillin Cipro Rocephin Cefixine Vibramycin Treat all sexual contacts of pts Abstain from alcohol & sex. intercourse

Syphilis n n n 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 n n 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 n n 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 n n n Treatment can not reverse damage IV Penicillin Doxycycline, tetracycline, erythromycin Treat maternal syphilis before week 18; treatment in 2 nd half preg-> premature labor Neurosyphilis – management also depends on neuro s/s

Chlamydial Infections: Urogenic Infections n n 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 n n 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 n n n 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 Simplex Virus (HSV) n n n n 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 n n n 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 6 wks

Clinical Manifestations: Transmission of HSV n n 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 n n 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 n n 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 n n n 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 n n n 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 n n n Risk factors for breast cancer Monthly breast self exam over age 18 Physical exam q 3 yrs age 20 – 40 & over 40 q year Mammography Follow up care

Assessment of Breast Disorders n n 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 n n n Mammography Biopsy – only definitive dx for cancer Fine needle aspiration Open surgical biopsy Stereotactic core biopsy

Benign Breast Problems n n n 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 n n n 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 n n n 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 n n n 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 n n n 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 n n Male enlargement of one or both breasts, benign Imbal of androgen & estrogen, can be s/s of other problem Pubertal gynecomastia – age 1317, disappears 4 -6 months Senescent gynecomastia

Breast Cancer

Risk Factors n n Female, age 50 or over Family history n n n n 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 n Lump n n n 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 n n n Mammography Ultrasound Biopsy n n 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 n n n 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 n n n Tumor size & differentiation Axillary node involvement DNA content analysis Genetic marker HER-2/neu (c-erb-B 2 or neu) Estrogen & progesterone receptor status Cell proliferation indices

Collaborative Care n n n 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 n n n Local – skin Regional – lymph nodes Distant metastasis n n n Skeletal Spinal cord Brain Pulmonary Liver Bone marrow

Radiation Therapy n n n 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 n n n Very responsive to chemo Combinations of drugs- effects on cell growth & division at different stages Cytoxin, 5 FU, Vincristine & Prednisone Andriamycin, 5 FU, Taxol, Taxotere S/E: GI tract, bone marrow, hair

Hormonal Therapy n n Estrogen can promote growth of breast cancer Oopherectomy, adrenalectomy, hypophysectomy Determine estrogen & progesterone receptor status of tumor Tumor regression with hormone manipulation n Tamoxifen, Toremifene, Arimidex

Nursing Care: Breast Cancer n n n 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 n n n n 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 n n 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 n n n 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 n n Health Promotion: routine screening, teach risks for cancer Psychological support - grieving Hysterectomy- vaginal or abdominal Mod amt blding 1 st 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 n n n 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 n n 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: class. II- 3 -4 mo follow up, class III> biopsy, conization; invasive- hysterectomy, radiation

Pelvic Inflam. Disease (PID) n n n 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 n n n 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 n n n 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; <8 cm or solid->laporoscopy

Problems with Pelvic Support n n n 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 2 x 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 n n n 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 n n 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 n n n 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) n n 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 n n n 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 n n n Transurethral resection of prostate (TURP) Transurethral microwave thermotherapy Transurethral needle ablation (TUNA) Transurethral electrovaporization of prostate Laser prostatectomy Urethral stents

BPH Nursing Care n n n 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 n n 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 n n n n n 3 way foley with CBI Read text p 1442 -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 n n n n S/S infection Urinary incontinence Avoid lifting Avoid constipation Fluid intake 2000 -3000 cc Address sexual questions No driving or sex til cleared by MD Follow up with MD

Prostate Cancer n n n 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 n n 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 n n n n 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 30 cc balloon, left 2 weeks and drain in incision site Complications – erectile dysfunction & incontinence Nerve sparing procedure can preserve erectile function

Conservative Treatment n n n 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 n n n 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 n n 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 n n n Age 20 -40, had undescended testes, family history, germ cell tumors Dx: palpation, sonogram, MRI, blood markers-AFP (alpha fetoprotein) &h. CG (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