Week 14: The Reproductive System

Options for Family Planning

-Respect patient's opinions and desires. - Know the various options available. - Match patient with best option they will use. - Patient should understand timing of ovulation in menstrual cycle. - Ensure confidential setting, especially for teenagers.

Sexually transmitted diseases and HIV infection

-United States rates highest in industrialized world. - Chlamydia trachomatis: most commonly reported Infection rates -Highest in women 15 to 19 years old -Second highest in women 20 to 24 years old -African American and American Indian/Alaska Native women with highest infection rates Most cases are undiagnosed. - Untreated: 40% develop pelvic inflammatory disease 20% become infertile - Gonorrhea: similar statistics - Syphilis: less common In the US, rates are increasing fastest in women. Transmission in women primarily heterosexual The CDC recommends HIV testing for all people 13 to 64 years of age, regardless of risk factors The U.S. Preventive Services Task Force recommends screening those at high risk. Nurses should assess risk factors for STDs and HIV infection by taking a careful sexual history, counsel patients about spread, and suggest ways to reduce high risk.

Hypospadias

A congenital displacement of the urethral meatus to the inferior surface of the penis. A groove extends from the actual urethral meatus to its normal location on the tip of the glans.

Syphilitic Chancre

A firm, painless ulcer suggests the chancre of primary syphilis. Because most chancres in women develop internally, theyoften go undetected.

Hydrocele

A nontender, fluid-filled mass within the tunica vaginalis. It transilluminates, and the examining fingers can get abovethe mass within the scrotum.

Spermatocele and Cyst of the Epididymis

A painless, movable cystic mass just above the testis suggests aspermatocele or an epididymal cyst. Both transilluminate. Theformer contains sperm, and the latter does not, but they are clinically indistinguishable.

Epidermoid Cyst

A small, firm, round cystic nodule in the labia suggests an epidermoid cyst. These are yellowish in color. Look for the dark punctum marking the blocked opening of the gland.

STD's

After establishing usual attributes of any symptoms, identify sexual preference. Sexual contacts? Concerns about HIV infection? Oral and anal sex? Past history of STDs? Safe sex?

Acute Epididymitis

An acutely inflamed epididymis is tender and swollen and maybe difficult to distinguish from the testis. The scrotum may bereddened and the vas deferens inflamed. It occurs chiefly inadults. Coexisting urinary tract infection or prostatitissupports the diagnosis.

Carcinoma of the Penis

An indurated nodule or ulcer that is usually nontender. Limitedalmost completely to men who are not circumcised, it may bemasked by the prepuce. Any persistent penile sore is suspicious.

Genital Warts (condylomata acuminata)

Appearance: Single or multiple papules or plaques of variableshapes; may be round, acuminate (or pointed), or thin andslender. May be raised, flat, or cauliflower-like (verrucous) Causative organism: Human papillomavirus (HPV),usuallyfrom subtypes 6, 11; carcinogenic subtypes rare,approximately 5-10% of all anogenital warts. Incubation:weeks to months; infected contact may have no visible warts Can arise on penis, scrotum, groin, thighs, anus; usuallyasymptomatic, occasionally cause itching and pain May disappear without treatment.

Genital Herpes Simplex

Appearance: Small scattered or grouped vesicles, 1-3 mm insize, on glans or shaft of penis. Appear as erosions ifvesicular membrane breaks Causative organism:Usually herpes simplex virus 2(90%), adouble-stranded DNA virus.Incubation:2-7 days after exposure Primary episode may be asymptomatic; recurrence usuallyless painful, of shorter duration Associated with fever, malaise, headache, arthralgias; localpain and edema, lymphadenopathy Need to distinguish from genital herpes zoster (usually inolder patients with dermatomal distribution); candidiasis

Chancroid

Appearance:Red papule or pustule initially, then forms apainfuldeep ulcer with ragged nonindurated margins;contains necrotic exudate, has a friable base Causative organism: Haemophilus ducreyi,an anaerobicbacillus. Incubation:3-7 days after exposure Painful inguinal adenopathy; suppurative buboes in 25% of patients Need to distinguish from primary syphilis; genital herpessimplex; lymphogranuloma venereum, granuloma inguinalefrom Klebsiella granulomatis(both rare in U.S.).

Primary Syphilis

Appearance:Small red papule that becomes a chancre,orpainlesserosion up to 2 cm in diameter. Base of chancre isclean, red, smooth, and glistening; borders are raised andindurated. Chancre heals within 3-8 weeks Causative organism: Treponema pallidum,a spirochete.Incubation:9-90 days after exposure May develop inguinal lymphadenopathy within 7 days;lymph nodes are rubbery, nontender, mobile Twenty to 30% of patients develop secondary syphilis whilechancre still present (suggests coinfection with HIV) Distinguish from genital herpes simplex; chancroid;granuloma inguinale from Klebsiella granulomatis(rare inU.S.; four variants, so difficult to identify).

Tumor of the testes (late)

As a testicular neoplasm grows and spreads, it may seemto replace the entire organ. The testicle characteristically feels heavier than normal.

Female External Examination

Assess the sexual maturity of an adolescent patient. -Pubic hair Examine the external genitalia. -Mons pubis, labia, perineum, labia minora, clitoris, urethral meatus, vaginal opening or introitus -Inflammation? Ulceration? Discharge? Swelling? Lacerations? Bruising? Nodules? (Herpes simplex, Behçet disease, syphilitic chancre, epidermoid cyst) Delayed puberty is often familial orrelated to chronic illness. It may also arise from abnormalities in the hypothalamus, anterior pituitary gland, or ovaries. Excoriations or itchy, small, red maculopapules suggest pediculosis pubis(lice or "crabs"). Look for nitsor lice at the bases of the pubic hairs. Enlarged clitoris in masculinizing conditions Herpes simplex, Behçet disease, syphilitic chancre, epidermoid cyst. Lacerations and/or bruising may indicate sexual abuse

Anatomy of the Groin

Because hernias are relatively common, it is important to understand the anatomy of the groin. The basic landmarks are the anterior superior iliac spine, the pubic tubercle, and the inguinal ligament that runs between them.

Bacterial Vaginosis

Cause: Bacterial overgrowth probably from anaerobic bacteria; maybe transmitted sexually Discharge: Gray or white, thin,homogeneous, malodorous; coats the vaginal walls; usually not profuse, may be minimal Other symptoms: unpleasant fishy or musty genital odor Vulva and Vaginal Mucosa: Vulva usually normal. Vaginal mucosa usually normal Laboratory evaluation: Scan saline wet mount for clue cells (epithelial cells with stippled borders); sniff for fishy odor after applying KOH ("whiff test"); vaginal secretions with pH >4.5

Candidal Vaginitis

Cause: Candida albicans, a yeast (normal overgrowth of vaginalflora); many factors predispose,including antibiotic therapy Discharge: White and curdy; may be thin but typically thick; not as profuse as in trichomonal infection; not malodorous Other Symptoms: Pruritus; vaginal soreness; pain on urination (from skin inflammation); dyspareunia Vulva and Vaginal Mucosa: The vulva and even thesurrounding skin are ofteninflamed and sometimes swollento a variable extent. Vaginalmucosa often reddened, withwhite, often tenacious patchesof discharge. The mucosa maybleed when these patches arescraped off. In mild cases, themucosa looks normal. Laboratory Evaluation: Scan potassium hydroxide(KOH) preparation forbranching hyphae of Candida

Bartholin Gland Infection

Causes of a Bartholin gland infection include trauma,gonococci anaerobes like bacteroides and peptostreptococci,and Chlamydia trachomatis.Acutely, it appears as a tense,hot, very tender abscess. Look for pus coming out of theduct or erythema around the duct opening. Chronically, anontender cyst is felt. It may be large or small

The Health History

Common or concerning symptoms - Sexual preference and sexual response (nonjudgmental) - Penile discharge or lesions (color, frequency, smell) - Scrotal pain, swelling, or lesions (OLDCART) - Problems with urination (BPH or cancer, >70 +risk) Approximately 1 in 10 patients may have same-sex, bisexual, or transgender partner preferences. These patients often experience significant anxiety during clinical encounters,related to fears of clinician accep-tance, coexisting mental health conditions, sparse information about complex issues of hormonal therapy, surgical alterations, or transitions in gender identity. Lack of libido may arise from psychogenic causes such as depression, endocrine dysfunction,or side effects of medications. Erectile dysfunction may be from psychogenic causes, especially if early morning erection is preserved; also from decreased testosterone, decreased bloodflow in the hypogastric arterial system, or impaired neural innervation. Premature ejaculation is common, especially in young men. Less common is reduced or absent ejaculation affecting middle aged or oldermen. Possible causes are medications, surgery, neurologic deficits,or lack of androgen. Lack of orgasm with ejaculation is usually psychogenic. Penile discharge may accompany gonococcal (usually yellow) and nongonococcal urethritis (may beclear or white).

Pregnancy

Early symptoms of pregnancy: Amenorrhea; tenderness, tingling, or increased size of breasts; urinary frequency; nausea and vomiting; easy fatigability; feelings the baby is moving Contraception: What methods are used? Satisfied with method chosen The term abortion is used by healthcare providers to mean either aspontaneous or an induced termination of a pregnancy before thefetus is viable. Miscarriage is a layterm for the spontaneous loss of apregnancy. Be sure to clarify whether an abortion is spontaneous or therapeutic (i.e., induced). Amenorrhea followed by heavy bleeding suggests a threatened abortion or dysfunctional uterine bleeding related to lack of ovulation. Vulvovaginal Symptoms Most common: Vaginal discharge and local itching OLD CART -Amount, color, consistency, odor? -Local sores or lumps? -Painful? (Use alternative terms)

Important areas of examination

External examination -Mons pubis -Labia majora and minora -Urethral meatus, clitoris -Vaginal introitus -Perineum Demonstrate with three-dimensional models, especially for first time. Encourage patient to relax. If unable to relax, gently comment and encourage patient to share feelings. Indications for a pelvic examination during adolescence include menstrual abnormalities such as amenorrhea, excessive bleeding, or dysmenorrhea;unexplained abdominal pain; vaginal discharge; the prescription of contraceptives; bacteriologic and cytologic studies in a sexually active girl; and the patient's own desire for assessment. Rape victims - Special evaluation, special rape kit, chain of custody for evidence

Femoral Hernia

Frequency, age and sex: Least common. More common in women than in men Point of origin: Below the inguinal ligament;appears more lateral than aninguinal hernia. Can be hard todifferentiate from lymph nodes Course (examining finger): Never into the scrotum - The inguinal canal is empty.

Direct Inguinal Hernia

Frequency, age and sex: Less common. Usually in men older than 40; rare in women Point of origin: Above inguinal ligament, close tothe pubic tubercle (near theexternal inguinal ring) Course (examining finger): Rarely into the scrotum- The hernia bulges anteriorly andpushes the side of the fingerforward.

Indirect Inguinal Hernia

Frequency, age and sex: Most common, all ages, bothsexes. Often in children; may bein adults Point of origin: Above inguinal ligament, near its midpoint (the internal inguinal ring) Course (examining finger): Often into the scrotum - The hernia comes down the inguinal canal and touches thefingertip.

Female Lymphatics

From vulva and lower vagina drains into inguinal nodes Internal genitalia flows into pelvic and abdominal lymph nodes (not palpable) Three parts to a woman's reproductive history - Menstrual history - Obstetric history - Sexual history There are five phases of a woman's reproductive health: -prepuberty (pre-menstruation) -puberty (menarche) -childbearing (menstruation) -peri-menopausal -menopausal.

Health Promotion and Counseling

Important topics for health promotion and counseling -Prevention of STDs and HIV The CDC estimated 19 million new STD infections each year, with half in the15- to 24-year-old age group An estimated 25% of infected persons in the United States are unaware of their infected state. Master skills of eliciting sexual history. Counseling should be interactive. Important topics to discuss: Limiting number of partners, Using condoms, Establishing regular medical care for treatment of STDs and HIV, Encourage prompt attention for any genital lesions or penile discharge.

Small Testis

In adults, testicular length is usually <3.5 cm. Small, firm testes in Klinefelter syndrome,usually <2 cm. Small, soft testes suggesting atrophyare seen in cirrhosis, myotonicdystrophy, use of estrogens, andhypopituitarism; may also followorchitis.

Hernias

Inspection Inguinal and femoral areas Valsalva maneuver If bulge is present, refer patient to physician or advanced practitioner for follow-up. Absence of bulge does not guarantee absence of a hernia, difficult to assess in obese patient. If suspicious, refer to physician.

Early Prenatal Care

Lowers perimortality infant rate Gynecology exams before pregnancy help identify potential problems Preparation for pregnancy: • Stopping alcohol and tobacco use • Weight loss • Taking folic acid and calcium

Menstrual History Definitions

Menarche, menstruation, menopause - When did you start? - When did your last period start? - How often do you have periods? - How long do they last? - How heavy is the flow? (The dates of previous periods cansignal possible pregnancy or men-strual irregularities) Dysmenorrhea? Primary dysmenorrhea results from increased prostaglandin production during the luteal phase of themenstrual cycle, when estrogen and progesterone levels decline. Causes of secondary dysmenorrhea include endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease, and endometrial polyps. - Premenstrual syndrome? Emotional and behavioral symptoms: depression, angry outbursts, poor concentration, irritability, anxiety, confusion, crying spells, sleep disturbance. - Amenorrhea? Other causes of secondary amenorrhea include low body weight fromany cause, including malnutrition,anorexia nervosa, stress, chronicillness, or hypothalamic-pituitary-ovarian dysfunction (primary amenorrhea= failure of periods to initiate)

Menopause

Menopause -Usually occurs between 48 and 55 years - following fluctuation of FSH and LH and ovarian function Perimenopausal -Onset of variable cycle length, hot flashes, flushing, sweating After menopause -Vaginal dryness, dyspareunia, mild hirsutism, hair loss Women may ask about many alternative compounds and botanicalsfor relief of menopause-related symptoms. Most have not been well studied or proved to be beneficial. Estrogen replacement relieves symptoms but increases risk of thrombosis Postmenopausal bleeding in endometrial cancer, hormone replacement therapy, uterine and cervical polyps

Testicular self-examination

Most common cancer between ages of 15 and 34 If detected early, the prognosis is excellent Risk factors: Cryptorchidism, History of carcinoma in contralateral testicle, Mumps orchitis, Inguinal hernia, Hydrocele in childhood Encourage monthly self-examinations Seek physician evaluation for: Painless lump, swelling, or enlargement in either testicle, Pain or discomfort in a testicle or scrotum, Feeling of heaviness or sudden fluid collection in scrotum, Dull ache lower abdomen or groin - Screening for prostate cancer Second leading cause of death in men Primary risk factors: Age: increases after 50 years, Ethnicity: higher in African Americans, Family History: 15% of men diagnosed with affected first- degree relative, Diet: possibly intake of dietary fat, especially saturated fats and fats from animal sources, but evidence remains inconclusive Men with symptoms of prostate disorders should be referred to urologist. - Incomplete emptying of the bladder - Urinary frequency or urgency - Weak or intermittent stream or straining to initiate flow - Hematuria - Nocturia - Bony pain in pelvis

Sexual preference and sexual response

Neutral and nonjudgmental questions Relationship status Sexual dysfunction is classified by the phase of sexual response. A woman may lack desire, she may fail to become aroused and attain adequate vaginal lubrication, or despite adequate arousal, she maybe unable to reach orgasm. Causes may include lack of estrogen, medical illness, or psychiatric conditions. Superficial pain suggests local inflammation, atrophic vaginitis, or inadequate lubrication; deeper pain may be from pelvic disorders or pressure on a normal ovary. The cause of vaginismus may be physical or psychological. More commonly, however, a sexual problem is related to situational or psychosocial factors.

Lymphatics

Penile and scrotal surfaces drain into inguinal nodes. When an inflammatory or possibly malignant lesionis found on these surfaces, assess the inguinal nodes for enlargement or tenderness. Testes drain into abdomen where enlarged nodes are clinically undetectable.

Scrotal Edema

Pitting edema may make the scrotal skin taut; seen in congestive heart failure or nephrotic syndrome

Abnormal Uterine Bleeding

Polymenorrhea- intervals of fewer than 21 days between menses Oligomenorrhea- infrequent bleeding Menorrhagia- excessive flow Metrorrhagia- intermenstrual bleeding Postcoital bleeding-bleeding/spotting during intercourse Causes vary by age group and include pregnancy, cervical or vaginal infection, cancer, cervical or endometrial polyps or hyperplasia, fibroids, bleeding disorders, hormonal contraception or replacement therapy. Postcoital bleeding suggests cervical polyps or cancer, or in an older woman, atrophic vaginitis

HPV Vaccine

Recommended: 11 to 26 years old Only prevents HPV 16- and 18-related cervical intraepithelial neoplasia grade 2 or 3 adenocarcinoma in situ in women with no prior exposure to these types Less effective in women already exposed to one of the four HPV types Does not treat existing HPV cervical infections, genital wards, precancers, or cancers

Record Your Findings

Recording the pelvic examination: female genitalia -Structures? - Color? - Inflammation? - Discharge? - Size? - Tenderness?

Important topics for health promotion and counseling (female)

Reproductive system education - Accurate understanding of function and appearance - Enable woman to take control of her reproductive health - Seek appropriate care in a timely fashion Changes in menopause - Psychological and physiologic changes - Mood shifts, hot flashes, accelerated bone loss, vulvovaginal atrophy Cervical cancer screening: the Pap smear and HPV infection - Risk factors for cervical cancer: Viral and behavioral, High-risk strains of HPV - Other risk factors: Early sexual activity, Multiple sex partners, History of STDs

Genital Herpes

Shallow, small, painful ulcers on red bases suggest a herpes infection. Initial infection may be extensive, as shown.Recurrent infections usually are confined to a small local patch.

Recording the physical examination: male genitalia and hernias

Skin Lesions Masses Discharges Swellings Pain

The scrotum and its contents

Skin, Lift scrotum to inspect posterior surface -Rashes, epidermoid cysts, rarely skin cancer Scrotal contours -A poorly developed scrotum on one or both sides suggests cryptorchidism (an undescended testicle). Common scrotal swellings include indirect inguinal hernias, hydroceles, and scrotal edema - Epidermoid cysts: common, benign

The Penis

Skin: check for excoriations or inflammation. Look for nits or lice at the bases of the pubic hairs. -Pubic or genital excoriations sug-gest the possibility of lice (crabs) orsometimes scabies. Prepuce (foreskin) - Retract to inspect glans if prepuce in place -Phimosisis a tight prepuce that cannot be retracted over the glans.Paraphimosisis a tight prepuce that, once retracted, cannot bereturned. Edema ensues. Glans -Balanitis (inflammation of theglans); balanoposthitis (inflammation of the glans and prepuce) Location of the Urethral Meatus -Hypospadiasis a congenital, ventral displacement of the meatus on the penis Discharge: usually there is none -Profuse yellow discharge in gonococcal urethritis; scanty white or clear discharge in nongonococcalurethritis. Definitive diagnosis requires Gram stain and culture.

Male Anatomy and Physiology

The shaft of the penisis formed by three columns of vascular erectile tissue: the corpus spongiosum, containing the urethra, and two corpora cavernosa. Thecorpus spongiosum forms the bulb of the penis, ending in the cone-shapedglanswith its expanded base, orcorona. In uncircumcised men, the glans iscovered by a loose, hood-like fold of skin called the prepuceor foreskin where smegma,or secretions of the glans, may collect. The urethra is locatedventrally in the shaft of the penis; urethral abnormalities may sometimes befelt there. The urethra opens into the vertical, slit-like urethral meatus,located somewhat ventrally at the tip of the glans. The testesare ovoid, rubbery structures approximately 4.5 cm long, rang-ing in size from 3.5 cm to 5.5 cm. The left testis usually lies lower than the right

Acute Orchitis

The testis is acutely inflamed,painful, tender, and swollen. It maybe difficult to distinguish from theepididymis. The scrotum may bereddened. Seen in mumps and otherviral infections; usually unilateral.

Cryptorchidism

The testis is atrophied and may lie inthe inguinal canal or the abdomen,resulting in an unfilled scrotum. Asabove, there is no palpable left testisor epididymis. Cryptorchid is markedly raises the risk for testicular cancer.

Epispadias

The urethral meatus is located on the top of the glans (dorsalside). This condition is a congenital defect and occurs rarely.

Female Reproductive Anatomy and Physiology

The urethral meatus opens into the vestibule between the clitoris and the vagina. Just posterior to it on either side lie the openings of theparaurethral(Skene)glands. The openings of Bartholin glandsare located posteriorly on either side ofthe vaginal opening but are not usually visible. Bartholin glands themselvesare situated more deeply. Both the Skene glands and the Bartholin glandsprovide lubrication during sexual intercourse. The vaginais a musculomembranous tube extending upward and posteri-orly between the urethra and the rectum. The vaginal mucosa lies in transverse folds, or rugae.

Female Reproductive Anatomy and Physiology II

The vagina lies almost at a right angle to the uterus,a flattened fibromuscular structure shaped like an inverted pear. The uterus has two parts: the body, or corpus,and the cervix, both joined at the isthmus. The convex upper surface of the body is termed the uterine fundus. The distal cervix protrudes into the vagina, dividing the upper vagina into three recesses, the anterior, posterior, and lateral fornices. The vaginal surface of the cervix, the ectocervix, is seen easily with the help of a speculum. At its center is a round, oval, or slit-like depression, the external os of the cervix, which marks the opening into the endocervical canal. The ectocervix is covered by the plushy, red columnar epithelium surrounding the os, which resembles the lining of the endocervical canal,and a shiny pink squamous epitheliumcontinuous with the vaginal lining. Thesquamocolumnar junction forms the boundary between these two types of epithelium. The squamocolumnar junction migrates toward theos, creating the transformation zone. This is the area at risk for later dysplasia and cancer, which is sampled by the Papanicolaou, or Pap smear

Torsion of the Spermatic Cord

Torsion, or twisting, of the testicle on its spermatic cordproduces an acutely painful, tender, and swollen organ that is retracted upward in the scrotum. The scrotum becomes redand edematous. There is no associated urinary infection.Torsion, most common in adolescents, is a surgicalemergency because of obstructed circulation.

Trichomonal Vaginitis

Trichomonas vaginalis,a protozoan; is often but not always acquired sexually Discharge: Yellowish green or gray, possibly frothy; often profuse and pooled in the vaginal fornix; may be malodorous Other Symptoms: Pruritus (though not usually assevere as with Candidainfection); pain on urination (from skin inflammation orpossibly urethritis); dyspareunia Vulva and Vaginal Mucosa: Vestibule and labia minora maybe reddened. Vaginal mucosamay be diffusively reddened,with small red granular spots orpetechiae in the posteriorfornix. In mild cases, themucosa looks normal Lab Evaluation: Scan saline wet mount fortrichomonads

Scrotal Hernia

Usually an indirect inguinal hernia that comes through the external inguinal ring, so the examining fingers cannot get above it within the scrotum.

Tumor of the testes (early)

Usually appears as a painless nodule. Any nodule within the testis warrants investigation for malignancy

Uterine Prolapse

Uterine prolapse occurs when the uterus protrudes into the vagina.

Varicocele of the Spermatic Cord

Varicocele refers to varicose veins of the spermatic cord,usually found on the left. It feels like a soft "bag of worms"separate from the testis, and slowly collapses when the scrotumis elevated in the supine patient. Infertility may be associated.

Female Internal Examination

Visual examination of vagina and cervix Equipment: Light, speculum Vaginal muscle tone? Color? ulcerations/? Inflammation? Discharge? Masses in vagina or on cervix? Obtain specimen for Papanicolaou smear. Manual palpation of internal organs (cervix, uterus) • Position, size, mobility, shape, regularity, masses, tenderness

Venereal Wart (Condyloma Acuminatum)

Warty lesions on the labia and within the vestibule suggest condyloma acuminatum. They result from infection with human papillomavirus.