CHAPTER 27 ASSESSING FEMALE GENETALIA, ANUS, AND RECTUM

A client asks the nurse when a colonoscopy is recommended. Which advice provided by the nurse is most appropriate?

"A flexible sigmoidoscopy should be done every five years starting at age 50."

what is cystocele? what is it caused by? this results in what?

- A cystocele is a bulging in the anterior vaginal wall; caused by thickening of the pelvic musculature. - As a result, the bladder, covered by vaginal mucosa, prolapses into the vagina.

what is the first indication of cancer of the cervix? what can the lesion develop into in later stages? what is essential for this diagnosis?

- A hardened ulcer is usually the first indication of cervical cancer, but it may not be visible on the ectocervix. - In later stages, the lesion may develop into a large cauliflowerlike growth. - A Pap smear is essential for diagnosis.

where does a cervical polyp typically develop and what is a cervical polyp?

- A polyp typically develops in the endocervical canal and may protrude visibly at the cervical os. - It is soft, red, and rather fragile. Cervical polyps are benign.

what is rectocele? what is it caused by?

- A rectocele is a bulging in the posterior vaginal wall; caused by weakening of the pelvic musculature. - Part of the rectum covered by the vaginal mucosa protrudes into the vagina.

what is genital warts caused by? what characterizes them?

- Genital warts, caused by the human papillomavirus (HPV), are moist, fleshy lesions on the labia and within the vestibule. - They are painless and believed to be sexually transmitted.

What is syphilitic chancre? How are they transmitted and where do they usually develop?

- Syphilitic chancres often first appear on the perianal area as silvery-white papules that become superficial red ulcers. - Syphilitic chancres are painless. They are sexually transmitted and usually develop at the site of initial contact with the infecting organism.

what is the initial outbreak of genital herpes look like? what is genital herpes simplex?

- The initial outbreak of herpes may have many small, painful ulcers with erythematous base. Recurrent herpes lesions are usually not as extensive. - Small, painful, red-based, ulcerlike lesions of herpes simplex virus, type 2.

A 35-year-old client tells the nurse that she is concerned that she may be already starting menopause. The nurse should explain that the normal range of years for menopause to occur is which of the following?

40 to 58 years

A 25-year-old client is seen in the emergency room for abdominal pain. The nurse obtains the following information from the health history: married, nulliparas, denies prescription or over-the-counter medications or use of oral or barrier contraceptives, pain is unilateral, last menses was one (1) month ago. What is the next best action of the nurse?

Assess the client for ectopic pregnancy; Based on the health history (unilateral abdominal pain, not currently menstruating, is of childbearing age, and is not using oral or barrier methods of birth control), the client is presenting with signs and symptoms of an ectopic pregnancy. The nurse would not prepare the client for discharge because these are not normal findings and this would place the client at risk for injury if the fallopian tube ruptures. Endometriosis is a disorder in which tissue that usually lines the uterus grows outside the uterus (usually involves the ovaries and the fallopian tubes) causing a firm fixed uterus that is painful especially during menses. The nurse does not have enough information to document the presence of endometriosis. The pain associated with pelvic inflammatory disease (PID) is bilateral not unilateral.

when does atrophic vaginitis occur? discharge produces what? the vaginal mucosa is typically what? what does atrophic vaginitis cause?

Atrophic vaginitis occurs after menopause when estrogen production is low. The discharge produced may be blood-tinged and is usually minimal. The labia and vaginal mucosa appear atrophic. The vaginal mucosa is typically pale, dry, and contains areas of abrasion that bleed easily. Atrophic vaginitis causes itching, burning, dryness, and painful urination.

what are malformations from exposure to diethylstilbestrol?

DES, a drug used more than 50 years ago to prevent spontaneous abortion and premature labor, was learned to be teratogenic (capable of causing malformations in the fetus). Women who were exposed to this drug as fetuses may have cervical abnormalities that may progress to cancer. Some abnormalities associated with maternal DES use include columnar epithelium that covers most or all of the ectocervix, columnar epithelium that extends onto the vaginal wall, a circular column of tissue that separates the cervix from the vaginal wall, transverse ridge, and enlarged upper ectocervical lip.

what is ectopic pregnancy?

Ectopic pregnancy occurs when a fertilized egg attaches to the fallopian tube and begins developing instead of continuing its journey to the uterus for development. A solid, mobile, tender, and unilateral adnexal mass may be palpated if tenderness allows. The cervix and uterus will be softened, and the movement of these structures will cause pain.

ABNORMAL FINDINGS; VAGINITIS

In assessing female genitalia, the nurse may suspect vaginal infection from signs such as redness or lack of color, unusual discharge and secretions, reported itching, and other typical symptoms of the kinds of vaginitis discussed here.

what is endometriosis?

In endometriosis, the uterus is fixed and tender. Growths of endometrial tissue are usually present throughout the pelvic area and may be felt as firm, nodular masses. Pelvic pain and irregular bleeding are common.

what is ovarian cancer?

Masses that are cancerous are usually solid, irregular, nontender, and fixed.

what is an ovarian cyst?

Ovarian cysts are benign masses on the ovary. They are usually smooth, mobile, round, compressible, and nontender.

What is pelvic inflammatory disease?

Pelvic inflammatory disease (PID) is typically caused by infection of the fallopian tubes (salpingitis) or fallopian tubes and ovaries (salpingo-oophoritis) with an STI (i.e., gonorrhea, Chlamydia). It causes extremely tender and painful bilateral adnexal masses (positive chandelier sign).

what is bacterial vaginosis?

The cause of bacterial vaginosis is unknown (possibly anaerobic bacteria), but it is thought to be sexually transmitted. The discharge is thin and gray-white, has a positive amine (fishy smell), and coats the vaginal walls and ectocervix. The labia and vaginal walls usually appear normal, and pH is greater than 4.5 (5.5-6.0).

What is cyanosis of the cervix?

The cervix normally appears bluish in the client who is in her first trimester of pregnancy. However, if the client is not pregnant, a bluish color to the cervix indicates venous congestion or a diminished oxygen supply to the tissues.

What is normal enlargement?

The only uterine enlargement that is normal results from pregnancy and fetal growth. In such cases, the isthmus feels soft (Hegar sign) on palpation, and the fundus and isthmus are compressible between 10 and 12 weeks of pregnancy.

what is uterine cancer (cancer of the endometrium)?

The uterus may be enlarged with a malignant mass. Irregular bleeding, bleeding between periods, or postmenopausal bleeding may be the first sign of a problem.

how does a cervical erosion differ from cervical eversion? how does it appear? where does it usually occur?

This condition differs from cervical eversion in that normal tissue around the external os is inflamed and eroded, appearing reddened and rough. Erosion usually occurs with mucopurulent cervical discharge.

What is mucopurulent cervicitis? what does it indicate?

This condition produces a mucopurulent yellowish discharge from the external os. It usually indicates infection with Chlamydia or gonorrhea. However, these STIs may also occur with no visible signs, although the discharge may change the cervical pH (3.8-4.2).

A female client with HIV has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.

what is candidal vaginitis (moniliasis) caused by? what does this infection cause?

This infection is caused by the overgrowth of yeast in the vagina. It causes a thick, white, cheesy discharge. The labia may be inflamed and swollen. The vaginal mucosa may be reddened and typically contains patches of the discharge. This infection causes intense itching and discomfort.

What is trichomonas vaginitis (trichomoniasis) caused by and how is it usually transmitted? how is the discharge? the labia may appear what? what does this infection cause?

This type of vaginal infection is caused by a protozoan organism and is usually sexually transmitted. The discharge is typically yellow-green, frothy, and foul smelling. The labia may appear swollen and red, and the vaginal walls may be red, rough, and covered with small red spots (or petechiae). This infection causes itching and urinary frequency in the client. Upon testing, the pH of vaginal secretion will be greater than 4.5 (usually 7.0 or more). If a sample of vaginal secretions is stirred into a potassium hydroxide solution (KOH prep), a foul odor (typically known as a "+" amine) may be noted.

what is uterine fibroids (myomas)?

Uterine fibroid tumors are common and benign. They are irregular, firm nodules that are continuous with the uterine surface. They may occur as one or many and may grow quite large. The uterus will be irregularly enlarged, firm, and mobile.

when does uterine prolapse occur? how is it graded?

Uterine prolapse occurs when the uterus protrudes into the vagina. It is graded according to how far it protrudes into the vagina. In first-degree prolapse, the cervix is seen at the vaginal opening; in second-degree prolapse, the uterus bulges outside of the vaginal opening; in third-degree prolapse, the uterus bulges completely out of the vagina.

what is a rectole?

a bulging of the rectum into the vagina

A nurse begins the speculum examination and finds the vaginal orifice tight. What is the appropriate action by the nurse to facilitate the insertion of the speculum?

ask to bear down and relax the muscles of the perineum

A 30-year-old paralegal analyst comes to the clinic reporting a bad-smelling vaginal discharge with some mild itching, present for about 3 weeks. Douching did not help. She has had no pain with urination or with sexual intercourse. She has noticed that the smell increases after intercourse and during her period last week. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Past medical history consists of one spontaneous vaginal birth. She is married with one child. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure, and her father died from heart disease. On examination she appears healthy and has unremarkable vital signs. On examination of the perineum no lesions are noted. On palpation of the inguinal nodes there is no lymphadenopathy. On speculum examination a thin gray-white discharge is seen in the vault. The pH of the discharge is over 4.5, and there is a fishy odor when potassium hydroxide KOH is applied to the vaginal secretions on the slide. Wet prep shows epithelial cells with stippled borders (clue cells). What type of vaginitis best describes her findings?

bacterial vaginosis Bacterial vaginosis generally has a homogenous, grayish-white, thin discharge. The pH will be over 4.5, and the KOH wet prep releases a strong fishy odor, known as a "positive whiff test." Any basic pH fluid (semen or blood) will cause the fish-like odor, often after intercourse, as with this client. The wet prep will show clue cells, which are epithelial cells with borders stippled by bacteria.

A 28-year-old married clothing sales clerk comes to the clinic for her annual examination. She requests a refill on her birth control pills. Her only complaint is painless bleeding after intercourse. She denies any other symptoms. Her past medical history consists of two spontaneous vaginal births. Her past six Pap smears have all been normal. She is married with two children. Her mother is in good health, and her father has high blood pressure. Examination shows a young woman appearing healthy and relaxed. Her vital signs are unremarkable, and her head, eyes, ears, throat, neck, cardiac, lung, and abdominal examinations are normal. Visualization of the perineum shows no lesions or masses. Speculum examination shows a red mass at the os. On taking a Pap smear the mass bleeds easily. Bimanual examination shows no cervical motion tenderness. Both ovaries are palpated and nontender. What is the most likely diagnosis related to the abnormality of her cervix?

cervical polyp

Which of the following is a downward displacement of the bladder toward the vaginal orifice?

cystole

A young adult woman presents at the clinic stating, "I think I have a yeast infection." The nurse notes this is the third time in the past 90 days that this client has been to the clinic for yeast infections. What should the nurse consider as a comorbidity to be discussed with this client?

diabetes rationale; A client with recurring yeast infections should be evaluated for diabetes and HIV. None of the other options are associated with recurrent yeast infections.

The nurse is advising a client who is diagnosed with pelvic inflammatory disease (PID) about the side effects of PID. What serious condition may occur as a result of this disease?

ectopic pregnancy

A nurse observes a thick, white, cheesy discharge at the vaginal opening, with irritation and swelling of the labia. The nurse recognizes this finding as most likely indicating what type vaginal infection?

moniliasis

The outermost layer of the vaginal wall is composed of

pink squamous epithelium and connective tissue

When inserting the vaginal speculum, the nurse angles the blades obliquely and presses along the posterior vaginal wall to:

prevent pressure on the urethra

Which position occurs when the uterus turns posteriorly as a whole unit?

retroversion

While inspecting a client's vagina, the nurse notes transverse folds in the outer layer of pink squamous epithelium. These folds are known as which of the following?

rugae

An older adult client visits the clinic for a gynecologic examination. The client tells the nurse that she has been told that she has uterine prolapse. The nurse should further assess the client for

stress incontinence

When palpating the internal female genitalia, the nurse separates the client's labia and asks her to strain down to assess which of the following?

support of vaginal walls

During a physical examination of a female client's reproductive system, the nurse detects a thick white discharge from the labia. The client's vulva appears inflamed. How should the nurse document this finding?

symptoms of candidal vaginitis

A 57-year-old woman calls the clinic reporting painful intercourse followed by spotting. She tells the nurse that she hasn't had a period in 2 years. What should the nurse tell her?

these findings are common in postmenopausal women

During the examination of the external genitalia, the nurse notices drainage from the urethra. The nurse should prepare to assess this client for which condition?

urethritis rationale; Drainage from the urethra indicates possible urethritis, which may have many causes. Lice infestation causes irritation and a whitish dandruff appearance on the pubic hairs but does not cause vaginal discharge or swelling. Abscess of Bartholin's gland with the presence of vaginal discharge can be sign of infection with Neisseria gonorrhoeae (gonorrhea). Trichomoniasis causes a greenish discharge with a fishy odor.

In the female client, the tube of muscular tissue that extends from the vaginal introitus to the uterus is called what?

vagina

The skin folds of the labia majora and the labia minora form a boat-shaped area termed the

vestibule