Sexually Transmitted Diseases Reproductive System Disorders Pelvic Relaxation Disorders Anatomy of Female Reproductive System (Internal) Lateral View Sexually Transmitted Diseases (STDs) STDs are diseases that can be transmitted during intimate sexual contact. Most prevalent communicable diseases in the US. Most cases occur in adolescents and young adults. - STDs in infants and children usually indicate sexual abuse and should be reported. The nurse is legally responsible to report suspected cases of child abuse. Nursing Assessment Please see handouts, include Symptoms and Treatments. 1. Syphilis ( Treponema Pallidum) 2. Gonorrhea (Neiserria Gonorrheae) 3. Chlamydia ( Chlamydia Trachomatis) 4. Trichomoniasis ( Trichomonas Vaginales) 5. Candidiasis ( Candida Albicans) 6. Herpes Type 2 (herpes Simplex Virus 2) 7. HPV ( Human Papilloma Virus) 8. HIV and AIDS ( Human Immunodeficiency Virus) STDs Analysis ( Nursing Diagnoses) Deficient Knowledge ( specify) related to Anxiety related to Anticipatory grieving related to Nursing Plan and Interventions A. Use a non judgmental approach. Be straightforward when taking history. B. Reaasure client that all information is strictly confidential. Obtain a complete sexual history. 1. Sexual orientation 2. Sexual practices 3. Type of protection (barrier used) 4. Contraceptive practices 5. Previous history of STDs Nursing Plan and Interventions C. Develop teaching Plan include: 1. sign and symptom of STDs. 2. Mode of transmission of STDs 3. Reminder that sexual contact should be avoided with anyone while infected. 4. Concise written instruction about treatment; request a return verbalization of these instructions to ensure the client has heard the instructions and understands them. D. Encourage client to provide information regarding all sexual contacts. E. Report incidents of STDs to appropriate health agencies and departments. Nursing Plan and Interventions F. Instruct women of childbearing age about risk to a newborn: a. Gonorrheal conjuctivitis b. Neonatal herpes c. Congenital syphilis d. Oral candidiasis G. Teach safer sex Nursing Plan and Interventions Safer sex behavior include: a. b. c. d. e. Reduce the number of sexual contacts. Avoid sex with those who have multiple partners. Examine genital area and avoid sexual contact if anything abnormal is present. Wash hands and genital area before and after sexual contact. Use a latex condom as a barrier. Nursing Plan and Interventions Safer sex behavior include: cont. f. Use water based lubricants rather than oil based lubricants. g. Use a vaginal spermicidal gel. h. Avoid douching before and after sexual contact: douching increase the risk for infections because the body’s normal defenses are reduced or destroyed. i. Seek attention from health care provider immediately if symptoms occur. Complications Complications of STD’s Pelvic Inflammatory Disease (PID) Sterility Ectopic pregnancy Blindness Cancer (associated with HPV) Fetal and infant death Birth defects Mental retardation AIDS has a set of complications much broader than the other STD’s PID ( Pelvic Inflammatory Disease) It involves one or more of the pelvic structures. The infection can cause adhesions and eventually result in sterility. Manage the pain associated with PID with analgesics and warm sitz baths. Bedrest in a semi-fowler position may increase comfort and promote drainage. Antibiotic treatment is necessary to reduce inflammation and pain. Cystocele and Rectocele Objectives: At the end of this lecture, the student will be able to: Discuss relevant laboratory, diagnostic and therapeutic procedures concerning Cystocele and Rectocele Disorders. Discuss assessment findings to client with Cystocele and Rectocele. Discuss Plan of Care for client with Cystocele and/or Rectocele. Discuss client teaching regarding management of Cystocele and/or Rectocele Cystocele Definition – is a protrusion of the bladder through the vaginal wall. Commonly called “bladder drop”, a cystocele refers to the dropping or sagging of the vagina in the anterior or upper compartment. The pubocervical fascia is connective tissue that is between the bladder and anterior vaginal wall and serves as its support structure. The anterior vaginal wall is attached to the cervix at the upper portion and has attachments to the pubic bone on the lower portion. Etiology – caused by weakened pelvic muscles and/or structures. For a cystocele with mild s/s medical treatment can be tried. Surgery maybe indicated if not successful. Pathophysiology When the pubocervical fascia detaches from its upper, lower or lateral attachments a cystocele can occur. A cystocele can become large enough to result in a set of symptoms that may become bothersome. The most common symptoms associated with a cystocele are: tissue protruding from the vagina, pelvic pressure, loss of ability to empty bladder to completion, pain with intercourse, positional bladder voiding, and vaginal pain. Cystocele Cystocele Rectocele Definition: It is a protrusion of the anterior rectal wall through the posterior vaginal wall. Etiology – It is caused by a defect of the pelvic structures or a difficult delivery or forceps delivery. Mild s/s can also be medical treatment can also be tried. If not successful, surgery maybe indicated. Rectocele The rectovaginal septum is the connective tissue that separates the rectum (bowel) from the vagina. Defects in the rectovaginal septum can result in a rectocele. The rectovaginal septum is attached at its upper portion to the cervix and the lower portion to the perineum. The perineum is the space between the vaginal opening and the anus. Rectocele A rectocele occurs when a break in the septum allows the rectum to push into the vaginal area. Symptoms most commonly associated with a rectocele are: Tissue protrusion from the vagina, pelvic pressure, inability to empty bowels, pain with intercourse, and discomfort with physical activities. Rectocele Risk Factors for Cystocele Obesity Advanged age (loss of estrogen) Chronic constipation Family History Childbearing Risk Factors for Rectocele Pelvic structure defects Difficult childbirth Forceps Delivery Previous hysterectomy Diagnostic Procedures Cystocele: Pelvic Examination – reveals a bulging of the anterior wall when the client is instructed to bear down. Voiding cystourethrography is performed to identify the degree of bladder protrusion and amount of urine residual. Diagnostic Procedures Rectocele: Pelvic examination reveals a bulging of the posterior wall when the client is instructed to bear down Rectal examination and /or barium enema reveals presence of rectocele. Surgeries: Cystocele : Anterior colporrhaphy – This uses a vaginal approach, the pelvic muscles are tightened. Rectocele: Posterior colporrhapy – Using a vaginal perineal approach, the pelvic muscles are tightened. Anterior Posterior Repair if surgery for both Cystocele and Rectocele is indicated. Nursing Interventions Assessments: - Monitor for signs and symptoms of a Cystocele: Urinary frequency Urinary urgency Stress incontinence Urinary tract infection Sense of vaginal fullness - Monitor for signs and symptoms of a Rectocele: Constipation Hemorrhoids Sensation of mass in the vagina Pelvic pressure pain Difficulty with intercourse. Nursing Interventions - Preventions 1. Avoid traumatic vaginal childbirth – early and adequate episiotomy. An episiotomy is a surgical incision made in the area between the vagina and anus (perineum). This is done during the last stages of labor and delivery to expand the opening of the vagina to prevent tearing during the delivery of the baby. 2. Inform the client about measures to prevent atropic vaginitis and of the advantage of prevention. Atrophic vaginitis (also known as vaginal atrophy or urogenital atrophy) is an inflammation of the vagina (and the outer urinary tract) due to the thinning and shrinking of the tissues, as well as decreased lubrication. This is all due to a lack of the reproductive hormone estrogen. The most common cause of vaginal atrophy is the decrease in estrogen which happens naturally during perimenopausal, and increasingly so in postmenopausal stage. However this condition can sometimes be caused by other circumstances. Prevention 3. Advise client at risk to lose weight if obese. 4. Instruct client to eat high-fiber diet and drink adequate fluids to prevent constipation. Interventions: 1. Kegel exercises – tightened pelvic muscles for a count of 10, relax slowly for a count of 10 repeat in sequences of 15 in lying down, sitting, and standing position. The aim of Kegel exercises is to improve muscle tone by strengthening the pubococcygeus muscles of the pelvic floor. Kegel is a popular prescribed exercise for pregnant women to prepare the pelvic floor for physiological stresses of the later stages of pregnancy and vaginal childbirth. Kegel exercises are said to be good for treating vaginal prolapse and preventing uterine prolapse in women and for treating prostate pain and swelling resulting from benign prostatic hyperplasia(BPH) and prostatitis in men. Kegel exercises may be beneficial in treating urinary incontinence in both men and women. Kegel exercises may also increase sexual gratification. Nursing Interventions 2. Estrogen Therapy – to prevent uterine atrophy and atrophic vaginitis. Inform client of client’s risk from complication of hormone therapy. E.g. cardiovascular or embolic history. Monitor for s/e of estrogen therapy e.g. water retention, headaches. 3. Weight loss and changes in diet. 4. Vaginal Pessary – removable rubber, plastic or silicon device inserted into the vagina to provide support and block protrusion into vagina. Teach client how to insert, remove, and clean the device. Monitor for possible bleeding or fistula formation. Vaginal Pessary A vaginal pessary is a removable device placed into the vagina. It is designed to support areas of pelvic organ prolapse. Post – Operative Care 1. 2. 3. 4. Administer analgesics, antimicrobials, and stool softeners/laxatives as prescibed. Provide perineal care at least twice daily following surgery and after urination or bowel movement. Apply an ice pack to the perineal area to relieve pain and swelling. Suggest that the client take frequent warm sitz baths to soothe the perineal area. A sitz bath is a plastic tub that fits over the toilet and can be filled with water. Sitting in the warm water for 15 to 20 minutes can provide relief from the discomfort from hemorrhoids, fistulas, anal fissures, or an episiotomy. This can be done by sitting in a bathtub filled with a few inches of water, but using a plastic sitz bath that fits over the toilet is often more convenient. Post-operative care 5. Provide a liquid diet immediately following surgery followed by low – residue diet until normal bowel function returns. 6. Intruct client how to care for indwelling catheter at home following surgery. 7. Recommend to client to drink at least 2,000 ml of fluid daily, unless contraindicated. 8. Following removal of the catheter, instruct the client to void every 2-3 hour to prevent a full bladder and stress on sticthes. 9. Teach the client how to perform client intermittent selfcatheterization techniques in the event that client is unable to void. Post-operative Care 10. Caution the client to avoid straining at defecation, sneezing, coughing, lifting, and prolonged sitting, walking, or standing following surgery. 11. Instruct the client to tighten and support pelvic muscles when coughing or sneezing. 12. Post-operative restrictions include avoidance of strenuous activity, weight lifting greater than 5 lbs. and sexual intercourse. Client may stay in the hospital from 1 to 2 days. Will probably be able to return to normal activities in about 6 weeks. Avoid strenuous activity for the first 6 weeks, and increase activity level gradually. Most women are able to resume sexual intercourse in about 6 weeks. Complications and Nursing Implications Residual urine in the bladder at risk for recurrent bladder infection and possibly kidney infections. Constipation. Dyspareunia (painful sexual intercourse) is a possible surgical complication due to surgical alteration of the orifice. Needs of Older Adults Cystocele and rectocele develop in older female clients usually following menopause. Older clients tend to overuse laxatives and enemas for the relief of constipation. Older adults are more susceptible to post-operataives complications. Performing Kegel exercises and manipulating pessary maybe more difficult for older adults. NCLEX type of Questions The nurse caring for a client who is wearing a pessary for conservative management of a cystocele knows that client understood instructions well if the client will state: a. “Discomfort from the pessary is expected and should not be of concern”. b. “I will report to my physician any change in color, amount, odor, or consistency of vaginal discharge”. c. I need to return to my physician for check up following insertion after 8 weeks”. d. “I will just re-insert the pessary in the event it falls out”. Question #2 What instruction should the nurse provide to the client concerning clean intermittent selfcatheterization that will limit occurrence of possible infection? a. Attempt to void prior to catheterization. b. Wash the perineal area from back to front using gentle motion. c. Allow urine to flow until flow stops. d. Wash hands thoroughly. Uterine Prolapse Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal. Causes Uterine prolapse often affects postmenopausal women who've had one or more vaginal deliveries. Damage to supportive tissues during pregnancy and childbirth. Effects of gravity. Loss of estrogen and: Repeated straining over the years which can weaken pelvic floor and lead to uterine prolapse. Causes Pregnancy and trauma incurred during childbirth, particularly with large babies or after a difficult labor and delivery. Loss of muscle tone associated with aging and reduced amounts of circulating estrogen after menopause. In rare circumstances, uterine prolapse may be caused by a tumor in the pelvic cavity. Genetics also may play a role in strength of supporting tissues. Women of Northern European descent have a higher incidence of uterine prolapse than do women of Asian and African descent. Risk Factors One or more pregnancies and vaginal births Giving birth to a large baby Increasing age Frequent heavy lifting Chronic coughing Frequent straining during bowel movements Genetic predisposition to weakness in connective tissue Some conditions, such as obesity, chronic constipation and chronic obstructive pulmonary disorder (COPD), can place a strain on the muscles and connective tissue in the pelvis and may play a role in the development of uterine prolapse. Uterine Prolapse Sign and Symptoms Uterine prolapse varies in severity. Mild uterine prolapse client may experience no signs or symptoms. Moderate to severe uterine prolapse. Client will experience the following sign and symptomes: - Sensation of heaviness or pulling in pelvis - Tissue protruding from your vagina - Urinary difficulties, such as urine leakage or urine retention - Trouble having a bowel movement - Low back pain - Feeling as if sitting on a small ball or as if something is falling out of vagina - Sexual concerns, such as sensing looseness in the tone of vaginal tissue - Symptoms that are less bothersome in the morning and worsen as the day goes on. Test and Diagnostic Procedures Pelvic exam. A complete pelvic exam to check for signs of uterine prolapse. – -Client will be examined while lying down and while standing up. Your physician may ask client to bear down as if having a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic muscles, client may also be instructed to contract them, as if you are stopping the stream of urine. Imaging tests. - Imaging tests aren't generally needed for uterine prolapse, but they're sometimes helpful in assessing the degree of prolapse. Physician may recommend an ultrasound or magnetic resonance imaging (MRI) to further evaluate your condition. Uterine Prolapse - Treatment For mild uterine prolapse, treatment usually is not needed. But if uterine prolapse makes client uncomfortable or disrupts normal life, client might benefit from treatment. Options include using a supportive device (pessary) inserted into the vagina or having surgery to repair the prolapse. Treatments Losing weight, stopping smoking and getting proper treatment for contributing medical problems, such as lung disease with coughing, may slow the progression of uterine prolapse. If client have very mild uterine prolapse, either without symptoms or with symptoms that aren't terribly bothersome, no treatment is necessary. However, pelvic floor may continue to lose tone, making the uterine prolapse more severe. Treatments Lifestyle changes Lifestyle changes may be the first step to ease symptoms of uterine prolapse: Achieve and maintain a healthy weight, to minimize the effects of being overweight on supportive pelvic structures. Perform Kegel exercises, to strengthen pelvic floor muscles. Avoid heavy lifting and straining, to reduce abdominal pressure on supportive pelvic structures. Treatments Vaginal pessary A vaginal pessary fits inside the vagina and is designed to hold the uterus in place. The pessary can be a temporary or permanent form of treatment. Surgery to repair uterine prolapse If lifestyle changes fail to provide relief from symptoms of uterine prolapse, or if client prefer not to use a pessary, surgical repair is an option. Surgical repair of uterine prolapse usually requires vaginal hysterectomy to remove uterus and excess vaginal tissue. In some cases, surgical repair may be possible through a graft of client own tissue, donor tissue or some synthetic material onto weakened pelvic floor structures to support your pelvic organs. Surgical Procedure Vaginally - generally preferred because vaginal procedures are associated with less pain after surgery, faster healing and a better cosmetic result. However, vaginal surgery may not provide as lasting a fix as abdominal surgery. If the uterus is not removed during surgery, prolapse can recur. Laparoscopic techniques — using smaller abdominal incisions, a lighted camera-type device (laparoscope) to guide the surgeon and specialized surgical instruments — offer a minimally invasive approach to abdominal surgery. Client might not be a good candidate for surgery to repair uterine prolapse if still plan to have more children. Pregnancy and delivery of a baby put strain on the supportive tissues of the uterus and can undo the benefits of surgical repair Women with major medical problems, anesthesia for surgery might pose too great a risk. Pessary use may be your best treatment choice for bothersome symptoms in these instances. Complications Possible complications of uterine prolapse include: Ulcers. In severe cases of uterine prolapse, part of the vaginal lining may be displaced by the fallen uterus and protrude outside the body, rubbing on underwear. The friction may lead to vaginal sores (ulcers). In rare cases, the sores could become infected. Prolapse of other pelvic organs. If client experienced uterine prolapse, client may also have prolapse of other pelvic organs, including your bladder and rectum. A prolapsed bladder (cystocele) bulges into the front part of client’s vagina, which can lead to difficulty in urinating and increased risk of urinary tract infections. Weakness of connective tissue overlying the rectum may result in a prolapsed rectum (rectocele), which may lead to difficulty having bowel movements.