Reproductive System

1. Reproductive System ZoyaMinasyan, RN, MSN-EDU

2. Benign Prostate Hyperplasia • Enlargement of prostate gland resulting from increase in number of epithelial cells and stromal tissue • Enlargement gradually compresses urethra. • Partial or complete obstruction • Compression leads to clinical symptoms. • Most common urologic problem in males • Occurs in 50% of men over 50 and 90% of men over 80 • Approximately 25% will require treatment by age 80. • Does not predispose to development of prostate cancer

3. Benign Prostate Hyperplasia Benign prostatic hyperplasia. The enlarged prostate compresses the urethra.

4. Etiology and Pathophysiology • Possible risk factors • Family history • Obesity • Increased waist circumference • Physical activity level • Alcohol consumption, smoking • Diabetes

5. Clinical Manifestations • Symptoms categorized into two groups • Obstructive symptoms • Due to urinary retention • Decrease in force of urinary stream • Difficulty in initiating urination • Dribbling at end of voiding • Irritative symptoms • Associated with inflammation or infection • Urinary frequency and urgency • Dysuria • Bladder pain • Nocturia • Incontinence

6. Complications • Related to urinary obstruction • Acute urinary retention • complication with sudden, painful, inability to urinate • Treatment involves catheter insertion and possible surgery • UTI and sepsis • Incomplete bladder emptying with residual urine-provides medium for bacterial growth. • Calculi may develop in bladder because of alkalinization of residual urine. • Renal failure: caused by hydronephrosis (swelling of kidney due to a backup of urine) • Pyelonephritis (an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney) • Bladder damage

7. Diagnostic Studies History and PE DRE ( digital rectal exam), prostate can be palpated by DRE. Urinalysis with culture( presence of infection). PSA level (Prostate-specific antigen is a protein produced by cells of the prostate gland). Serum creatinine (for renal insufficiency) TRUS scan(trans rectal ultrasound) for the size of prostate. Uroflometry (volume of urine expelled from the bladder per second) Cystoscopy for internal visualiziation of the urethra and bladder.

8. Diagnostic Studies • Using DRE, the health care provider can estimate the size, symmetry, and consistency of the prostate gland. In BPH the prostate is symmetrically enlarged, firm, and smooth. • A urinalysis with culture is routinely done to determine the presence of infection. The presence of bacteria, white blood cells, or microscopic hematuria is an indication of infection or inflammation. • Serum creatinine: • Creatinine is a chemical waste molecule that is generated from muscle metabolism. Creatinine is produced from creatine, a molecule of major importance for energy production in muscles. • Creatinine is transported through the bloodstream to the kidneys. The kidneys filter out most of the creatinine and dispose of it in the urine. • As the kidneys become impaired for any reason, the creatinine level in the blood will rise due to poor clearance by the kidneys. • TRUS scan allows for accurate assessment of prostate size and is helpful in differentiating BPH from prostate cancer. Biopsies can be taken during the ultrasound procedure. • Uroflowmetry is helpful in determining the extent of urethral blockage and thus the type of treatment needed. • Cystoscopy is performed if the diagnosis is uncertain and in patients who are scheduled for prostatectomy. Allowing internal visualization of the urethra and bladder.

9. Collaborative Care • Drug therapy: • 5α-Reductase inhibitors • Example: finasteride (Proscar), dutasteride (Avodart) • ↓ size of prostate gland • Takes 3 to 6 months for improvement • Side effects: decreased libido, decreased volume of ejaculation, ED (erectile Disfx) • α-Adrenergic receptor blockers • Examples: tamsulosin (Flomax), doxazosin (Cardura), silodosin (Rapaflo) • Promotes smooth muscle relaxation in prostate; facilitates urinary flow • Improvement in 2 to 3 weeks • Side effects: orthostatic hypotension and dizziness, retrograde ejaculation, nasal congestion

10. Collaborative Care • Transurethral microwave therapy (TUMT) • Outpatient procedure: delivers microwaves directly to prostate through a transurethral probe • Heat causes death of tissue and relief of obstruction. • Postop urinary retention is common. • Patient sent home with catheter 2 to 7 days • Antibiotics, pain medication, and bladder antispasmodic medications given. • Anticoagulant therapy should be stopped 10 days before treatment.

11. Collaborative Care • Transurethral needle ablation (TUNA) • ↑ temperature of prostate tissue for localized necrosis • Low-wave frequency used • Only tissue in contact with needle affected • Majority of patients show improvement in symptoms. • Outpatient uses local anesthesia and sedation. • Lasts 30 minutes with little pain and quick recovery • Complications include urinary retention, UTI, and irritative voiding symptoms. • Some patients require a catheter. • Hematuria up to a week

12. Collaborative Care • Laser prostatectomy • Delivers a laser beam transurethrally to cut or destroy parts of the prostate • Common procedure: visual laser ablation of the prostate (VLAP) • Takes several weeks to reach optimal results • Urinary catheter inserted • Contact laser techniques • Minimal bleeding during and after procedure • Fast recovery time • Patients may take anticoagulants. • Photovaporization of the prostate 12

13. Collaborative Care • Transurethral resection (TURP) • Removal of obstructing prostate tissue using resectoscope inserted through urethra • Outcome for 80% to 90% is excellent. • Relatively low risk • Performed under spinal or general anesthesia and requires hospital stay • Bladder irrigated for first 24 hours to prevent mucous and blood clots • Complications include bleeding, clot retention, dilutionalhyponatremia. • Patients must stop anticoagulants before surgery. 13

14. Nursing Implementation Focus: early detection and treatment Yearly physical exam and DRE for men over 50 Educate patients that alcohol, caffeine, and cold and cough meds can increase symptoms. Instruct patient with obstructive symptoms to urinate every 2 to 3 hours and when first feeling urge. Teach for adequate fluid intake. Use aseptic technique when using urinary catheter. Administer antibiotics preoperatively.

15. Nursing Implementation Postoperative care Postop bladder irrigation to remove blood clots and ensure drainage or urine Administer antispasmodics. Teach Kegel exercises. Observe patient for signs of infection. Dietary intervention Stool softeners to prevent straining

16. Prostate cancer Is a malignant tumor of the prostate gland One out of five men will develop at some point during there life Early stages are asymptomatic and later on symptoms of BPH Pain that radiate down to the hips or legs plus urinary symptoms may indicate metastasis

17. Prostatitis • Acute and chronic results from organisms reaching the prostate gland by • Ascending from the urethra • Descending from the bladder • Invasive via bloodstream or lymphatic channels • Common causative organisms are- Escherichia coli, KlebsiellsPseudominas, Enterobacter, Proteus, Chlamydia trachomatis, Neisseriagonorrhoeae, and group D streptococci. • Common manifestation: • Fever, chills, back pain, perineal pain, dysuria, frequency, urgency, and cloudy urine, prostatic swelling, tender and firm. • Dx: urinanalysis (UA) and urine culture for WBC and bacteria presence • Nursing mangement: antibiotics bactrium, cipro, floxin, vibramycin or tetracyclin. • Given 4 weeks for acute bacterial prostetitis • Oral 4-12 weeks • Imunocompromised given for lifetime.

18. Problems Hypospadias: urethral meatus is located on the ventral surface of the penis Epispadias: an opening of the urethra on the dorsal surface Phimosis: tightness or constriction of the foreskin around the head of the penis Paraphimosis: tightness of the foreskin resulting in inability to pull it forward Priapism: painfull erection lasting >6hour caused by obstruction of the venous outflow in the penis Peyronie’s disease: curved penis caused by plaque formation in one of the corpora cavernosa Epididymitis: inflammation caused by infection trauma, urinary reflux Orchitis: inflammation of testes; painful, tender and swollen Cryptochidism: un-descended testes into the scrotal sac before birth Hydrocele: fluid filled mass results from lymphatic mallfunction Spermatocele: sperm containing painless cyst of the epidiydimis Varicocele: dilation of the veins that drain the testes Testicular torsion: twisting of the spermatic cord that supplies blood to the testes and epididymis Erectile dysfunction: ED caused by DM, vascular disease, decreased hormones, trauma, stress, depression, Vasectomy: bilateral surgical ligation or resection of the vas deferens. Done in 15-30 min, local anesthesia Andropause: decline in androgen with aging, decreased level of testosterone

19. 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.

20. Nursing Assessment Syphilis ( TreponemaPallidum) Gonorrhea (NeiserriaGonorrheae) Chlamydia ( Chlamydia Trachomatis) Trichomoniasis ( TrichomonasVaginales) Candidiasis ( Candida Albicans) Herpes Type 2 (herpes Simplex Virus 2) HPV ( Human Papilloma Virus) HIV and AIDS ( Human Immunodeficiency Virus)

21. STDs

22. Nursing Diagnoses Deficient Knowledge related to Anxiety related to Anticipatory grieving related to

23. Nursing Plan and Interventions Use a non judgmental approach. Be straightforward when taking history. All information is strictly confidential. Obtain a complete sexual history. Develop teaching Plan include: Sign and symptom of STDs. Mode of transmission of STDs Reminder that sexual contact should be avoided with anyone while infected. Concise written instruction about treatment; request a return verbalization of these instructions to ensure the client has heard the instructions and understands them. Encourage client to provide information regarding all sexual contacts. Report incidents of STDs to appropriate health agencies and departments. Instruct women of childbearing age about risk to a newborn: a. Gonorrheal conjuctivitis b. Neonatal herpes c. Congenital syphilis d. Oral candidiasis Teach safer sex

24. Nursing Plan and Interventions Safer sex behavior include: a. Reduce the number of sexual contacts. b. Avoid sex with those who have multiple partners. c. Examine genital area and avoid sexual contact if anything abnormal is present. d. Wash hands and genital area before and after sexual contact. e. Use a latex condom as a barrier. f. Use water based lubricants rather than oil based lubricants. g. Avoid douching before and after sexual contact: douching increase the risk for infections because the body’s normal defenses are reduced or destroyed. h. Seek attention from health care provider immediately if symptoms occur.

25. 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

26. Sexually Transmitted Diseases • Infectious diseases most commonly transmitted through sexual contact • Can also be transmitted by • Blood • Blood products • Autoinoculation • Can be bacterial or viral • Usually start as lesions on genitals or mucous membranes and can spread to other areas • All cases of gonorrhea and syphilis (and in most states chlamydia) must be reported to state or local public health authorities. Still underreported.

27. Sexually Transmitted Diseases • Changes in methods of contraception • Condom is best protection against STDs but still is not used frequently in general population. • Oral contraceptive effects on acidity of vaginal/cervical secretions promote growth of certain organisms, causing STDs.

28. Gonorrhea: Etiology and Pathophysiology • Caused by Neisseriagonorrheae • Gram-negative bacteria • Direct physical contact with infected host • Mucosa with columnar epithelium is susceptible. • Present in genitalia, rectum, and oropharynx • Easily killed by drying, heating, or washing with antiseptic • Incubation period: 3 to 8 days • Provides no immunity to subsequent reinfection • Elicits inflammatory process that can lead to fibrous tissue and adhesions • Tubal pregnancy • Chronic pelvic pain • Infertility in women • Neonates can develop a gonococcal infection from an infected mother during delivery.

29. GonorrheaClinical Manifestations • Men • Initial site infection is urethra. • Symptoms • Develop 2 to 5 days after infection • Dysuria • Profuse, purulent urethral discharge • Unusual to be asymptomatic

30. Gonococcal Urethritis Profuse, purulent drainage in a patient with gonorrhea.

31. Gonorrhea : Clinical Manifestations • Women • Mostly asymptomatic or have minor symptoms • Vaginal discharge • Dysuria • Frequency of urination • After incubation • Redness and swelling occur at site of contact. • Greenish, yellow purulent exudates often develops. • May develop abscess • Disease may remain local or may spread by tissue extension to uterus, fallopian tubes, and ovaries.

32. Endocervical Gonorrhea Endocervicalgonorrhea. Cervical redness and edema with discharge.

33. Gonorrhea: Clinical Manifestations • Eye infections in newborns • Instillations of prophylactic erythromycin (0.5%) ophthalmic ointment or silver nitrate (0.1%) aqueous solution • Untreated infants develop permanent blindness. • Orogenital: Gonococcalpharyngitis can develop. • Anorectal gonorrhea: Usually from anal intercourse • Symptoms include soreness, itching, and discharge of anus. • Complications • Women • Include pelvic inflammatory disease (PID), Bartholin’s abscess (the buildup of pus that forms a lump (swelling) in one of the Bartholin's glands, which are located on each side of the vaginal opening), ectopic pregnancy, and infertility • Usually asymptomatic, so seldom seek treatment • Small percentage develop disseminated gonococcal infection (DGI). • Skin lesions, fever, arthralgia, arthritis, or endocarditis • Men • Include prostatitis, urethral strictures, and sterility • Often seek treatment early, so less likely to develop complications

34. Disseminated Gonococcal Infection (DGI) Skin lesions with disseminated gonococcal infection. A, On the hand. B, On the fifth toe.

35. Gonorrhea: Diagnostic Studies • Women • Smears and discharge do not establish diagnosis. • Female GU tract harbors organisms resembling N. gonorrhea. • Must have culture to confirm diagnosis • Drug therapy • Treatment in early stage is curative. • Most common • Oral dose of cefixime (Suprax) • IM dose of ceftriaxone (Rocephin) Fluoroquinolones are no longer used. • Patients with coexisting syphilis are likely to be treated with azithromycin (Zithromax) or doxycycline (Vibramycin).

36. Gonorrhea: Collaborative Care All sexual contacts of patients must be evaluated and treated. Patient should be counseled to abstain from sexual intercourse and alcohol during treatment. Reexamine if symptoms persist after treatment.

37. Syphilis: Etiology and Pathophysiology • Caused by Treponemapallidum; Spirochete bacterium • Enters the body through breaks in skin or mucous membranes • Facilitated by abrasions that occur during sexual intercourse • Causes production of antibodies that react with normal tissues • Destroyed by drying, heating, or washing • May also be spread through • Contact with infectious lesions • Sharing of needles among IV drug users • Spread in utero after 10th week of pregnancy • Infected mother has a greater risk of stillbirth or of having a baby who dies shortly after birth. • Association with HIV • Syphilitic lesions on the genitals enhance HIV transmission.

38. Syphilis: Clinical Manifestations • Variety of signs/symptoms can mimic another disease. • Neurosyphilis causes degeneration of brain with mental deterioration. • Sudden attacks of pain • Loss of vision and sense of position • Primary stage • Chancres appear. • Painless indurated lesions • Occur 10 to 90 days after inoculation • Lasting 3 to 6 weeks • See Table 53-3 for more information.

39. Chlamydial Infections: Clinical Manifestations • Men • Urethritis • Dysuria • Urethral discharge • Proctitis • Rectal discharge • Pain during defecation • Urethritis • Dysuria • Urethral discharge • Proctitis • Rectal discharge • Pain during defecation • Women • Cervicitis • Mucopurulent discharge • Hypertrophic ectopy • Urethritis • Dysuria • Frequent urination • Pyuria • Bartholinitis • Purulent exudate • Perihepatitis • Fever, nausea, vomiting, right upper quadrant pain • PID • Abdominal pain, nausea, vomiting, fever, malaise, abnormal vaginal bleeding, menstrual abnormalities • Can lead to chronic pain and infertility

40. Chlamydial Infection Chlamydialepididymitis. Red, swollen scrotum.

41. Genital Herpes: Etiology and Pathophysiology Caused by herpes simplex virus (HSV) Enters through mucous membranes or breaks in the skin during contact with infected persons HSV reproduces inside cell and spreads to surrounding cells. Virus enters peripheral or autonomic nerve endings. Ascends to sensory or autonomic nerve ganglion, where it is dormant Recurrence when virus descends to initial site of infection Persists for life

42. Genital Herpes: Clinical Manifestations • Primary (initial) episode • Burning or tingling at site • Small vesicular lesion appear on penis, scrotum, vulva, perineum, perianal areas, vagina, or cervix. • Vesicles contain large quantities of infectious virus particles. • Complications • Autoinoculation to extragenital sites • Lips, breasts, and fingers • High risk of transmission in pregnancy with episode near delivery • Active lesion is indication for cesarean section.

43. Unruptured Vesicles Unrupturedvesicles of herpes simplex virus type 2 (HSV-2). A,Vulvar area. B,Perianal area. C, Penile herpes simplex, ulcerative stage.

44. Autoinoculation of Herpes Simplex Virus Autoinoculation of herpes simplex virus (HSV) to the lips.

45. Genital Herpes: Collaborative Care • Drug therapy • Inhibit viral replication • Suppress frequent recurrences • Acyclovir (Zovirax) • Valacyclovir (Valtrex) • Famciclovir (Famvir) • Not a cure, but shorten duration and healing time and reduce outbreaks • Symptomatic care • Genital hygiene • Loose-fitting cotton underwear • Lesions clean and dry • Sitz baths • Barrier methods during sexual activity

46. Genital Warts • Estimated 20 million Americans are currently infected. • Most common STD in the United States • Caused by human-papilloma-virus (HPV) • Usually types 6 and 11 • Highly contagious • Frequently seen in young, sexually active adults • Incubation period: 3 to 4 months • Discrete single or multiple growths • White to gray and pink-fleshed colored • May form large cauliflower-like masses

47. Genital Warts Genital warts. A, Severe vulvular warts. B,Perineal wart. C, Multiple genital warts of the glans penis.

48. Genital Warts: Collaborative Care • Treatments • Chemical • Trichloroacetic acid (TCA) • Bichloroacetic acid (BCA) • Podophyllin resin • For small external genital warts • Patient managed • Podofilox (Condylox/Condylox gel) • Imiquimod (Aldara) • Immune response modifier • If warts do not regress with previously mentioned therapies • Cryotherapy with liquid nitrogen (freezing a wart using a very cold substance). • Electrocautery (to cut through soft tissue to access a surgical site) • Laser therapy • Use of α-interferon (to trigger the protective defenses of the immune system) • Surgical removal

49. Nursing management • Subjective data • Past medical history, including sexual history • Medication use • IV drug use • Nausea/vomiting • Dysuria • Urethral discharge • Burning lesions • Vaginal discharge • Presence of genital or perianal lesions • Objective data • Fever • Visual assessment of lesions, warts, rash • Purulent rectal discharge • Proctitis • Urethral and cervical discharge • Laboratory findings

50. Nursing Diagnoses Risk for infection Anxiety Ineffective health maintenance