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Reproductive System. Zoya Minasyan , RN, MSN-EDU. 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

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reproductive system

Reproductive System

ZoyaMinasyan, RN, MSN-EDU

benign prostate hyperplasia
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
benign prostate hyperplasia1
Benign Prostate Hyperplasia

Benign prostatic hyperplasia. The enlarged prostate compresses the urethra.

etiology and pathophysiology
Etiology and Pathophysiology
  • Possible risk factors
    • Family history
    • Obesity
      • Increased waist circumference
    • Physical activity level
    • Alcohol consumption, smoking
    • Diabetes
clinical manifestations
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
  • 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
diagnostic studies
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.

diagnostic studies1
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.
collaborative care
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
collaborative care1
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.
collaborative care2
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
collaborative care3
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


collaborative care4
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.


nursing implementation
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.

nursing implementation1
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

prostate cancer
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

  • 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.

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

sexually transmitted diseases stds
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
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)

nursing diagnoses
Nursing Diagnoses

Deficient Knowledge related to

Anxiety related to

Anticipatory grieving related to

nursing plan and interventions
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

nursing plan and interventions1
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.


Complications of STD’s

Pelvic Inflammatory Disease (PID)


Ectopic pregnancy


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

sexually transmitted diseases
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.
sexually transmitted diseases1
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.
gonorrhea etiology and pathophysiology
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.
gonorrhea clinical manifestations
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
gonococcal urethritis
Gonococcal Urethritis

Profuse, purulent drainage in a patient with gonorrhea.

gonorrhea clinical manifestations1
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.
endocervical gonorrhea
Endocervical Gonorrhea

Endocervicalgonorrhea. Cervical redness and edema with discharge.

gonorrhea clinical manifestations2
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
disseminated gonococcal infection dgi
Disseminated Gonococcal Infection (DGI)

Skin lesions with disseminated gonococcal infection. A, On the hand. B, On the fifth toe.

gonorrhea diagnostic studies
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).
gonorrhea collaborative care
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.

syphilis etiology and pathophysiology
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.
syphilis clinical manifestations
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.
chlamydial infections clinical manifestations
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
chlamydial infection
Chlamydial Infection

Chlamydialepididymitis. Red, swollen scrotum.

genital herpes etiology and pathophysiology
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

genital herpes clinical manifestations
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.
unruptured vesicles
Unruptured Vesicles

Unrupturedvesicles of herpes simplex virus type 2 (HSV-2). A,Vulvar area. B,Perianal area.

C, Penile herpes simplex, ulcerative stage.

autoinoculation of herpes simplex virus
Autoinoculation of Herpes Simplex Virus

Autoinoculation of herpes simplex virus (HSV) to the lips.

genital herpes collaborative care
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
genital warts
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
genital warts1
Genital Warts

Genital warts. A, Severe vulvular warts. B,Perineal wart. C, Multiple genital warts of the

glans penis.

genital warts collaborative care
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
nursing management
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
nursing diagnoses1
Nursing Diagnoses

Risk for infection


Ineffective health maintenance

nursing management planning
Nursing Management: Planning
  • Patient with STD will
    • Demonstrate understanding of mode of transmission and risks imposed
    • Complete treatment and follow-up
    • Notify or assist in notification of sexual contacts
    • Abstain until infection is resolved
    • Demonstrate knowledge of safer sex practices
nursing management nursing implementation
Nursing Management: Nursing Implementation

Discuss practices with all patients.

Teach to inspect partner’s genitals.

Some protection if void immediately after intercourse; wash genitalia and adjacent areas with soap and water

Proper use of condoms

Avoiding sexual contact with HIV-infected persons

Compassion and respect

Locating and examining all contacts of person with STD for testing and treatment

Counseling to verbalize feelings

Explaining side effects, need for treatment adherence, and follow-ups

Emphasize hygiene (hand washing, bathing).

Avoid douching.

Avoid synthetic materials in undergarments.

Abstinence during treatment period, condoms afterward

Avoid oral-genital contact.

nursing management evaluation
Nursing Management:Evaluation
  • Patient with STD will
    • Demonstrate modes of transmission
    • Use appropriate hygienic measures
    • Experience no reinfection
    • Demonstrate compliance with follow-up protocol


When caring for a patient with a sexually transmitted disease, it is important that the nurse teach the patient to:

1. Advise all sexual partners of the need for treatment.

2. Use a condom for sexual intercourse during treatment.

3. Engage in monogamous relationships to prevent reinfection.

4. Wash the genitalia before sexual intercourse to prevent disease transmission.



The nurse teaches the patient with genital herpes about the use of:

1. Acyclovir ointment.

2. Oral acyclovir (Zovirax).

3. Human papillomavirus vaccine.

4. Podofilox (Condylox) topical gel.

pid pelvic inflammatory disease
PID ( Pelvic Inflammatory Disease)
  • It involves one or more of the pelvic structures.
    • Fallopian tubes (salpingitis)
    • Ovaries (oophoritis)
    • Pelvic peritonitis (peritonitis)
  • PID is often the result of untreated cervicitis: infection ascends to cervix-uterus-fallopian tubes-ovaries-peritoneal cavity.
    • Chlamydia trachomatis and Neisseriagonorrhoeas are the most common organisms of PID.
pelvic inflammatory disease
Pelvic Inflammatory Disease

Pelvic inflammatory disease. Acute infection of the fallopian tubes and ovaries. The tubes and

ovaries have become an inflamed mass attached to the uterus. A tubo-ovarian abscess is also present.

pid pelvic inflammatory disease1
PID ( Pelvic Inflammatory Disease)
  • Clinical manifestation:
    • Lower abdominal pain
    • Walking can increase the pain
    • Spotting after intercourse-purulent discharge from cervix or vagina
    • Cramping pain with menses, irregular bleeding
    • Lower abdominal tenderness
    • Tubo-ovarian abscess may leak or rupture resulting in pelvic or generalized peritonitis
    • Embolisms may occur as the result of thrombophlebitis of the pelvic veins
    • Septic shock and Fritz-Hugh-Curtis syndrome
      • When PID spreads to liver and causes acute perihepatitis
  • Collabotative care:
    • 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
      • Doxycycline (Vibromycin)
      • Cefoxitin (Mefoxin)

Extreme cases-hysterectomy

  • Definition:
    • is a protrusion of the bladder through the vaginal wall.
    • Commonly called “bladder drop”,
    • refers to the dropping or sagging of the vagina in the anterior or upper compartment.

Etiology :

    • Caused by weakened pelvic muscles or structures.
    • When the pubocervical fascia detaches from its upper, lower or lateral attachments a can occur.
    • 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.
  • Common symptoms:
    • tissue protruding from the vagina,
    • pelvic pressure,
    • loss of ability to empty bladder to completion,
    • pain with intercourse,
    • positional bladder voiding, and
    • vaginal pain.
  • For mild s/s medical treatment can be tried.
  • Surgery maybe indicated if not successful.
  • Definition:
    • It is a protrusion of the anterior rectal wall through the posterior vaginal wall.
  • Etiology:
    • Caused by a defect of the pelvic structures or a difficult delivery or forceps delivery.

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.

A rectocele occurs when a break in the septum allows the rectum to push into the vaginal area.

  • Symptoms
    • Tissue protrusion from the vagina,
    • pelvic pressure,
    • inability to empty bowels,
    • pain with intercourse, and
    • discomfort with physical activities.
  • Mild s/s can also be medical treatment can also be tried.
  • If not successful, surgery maybe indicated.
risk factors for cystocele and rectocele
Risk Factors for Cystocele and 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 and rectocele
Diagnostic Procedures: Cystocele and Rectocele
  • Cystocele:
    • Pelvic Examination – reveals a bulging of the anterior wall when the client is instructed to bear down.
    • Voiding cystourethrography
      • to identify the degree of bladder protrusion and
      • amount of urine residual.
  • 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 cystocele and rectocele
Nursing Interventions: Cystocele and Rectocele
  • 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 cystocele and rectocele1
Nursing Interventions: Cystocele and Rectocele

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 atrophic vaginitisand 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 post-menopausal stage. However this condition can sometimes be caused by other circumstances. .

3. To loose weight if obese.

4. To eat high-fiber diet and drink adequate fluids to prevent constipation.

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Nursing Interventions: Cystocele and Rectocele

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.

Kegel exercises are said to be good for treating vaginal prolapse and preventing uterine prolapsein women and for treating prostate pain and swelling resulting from benign prostatic hyperplasia(BPH) and prostatitis in men.

nursing interventions cystocele and rectocele3
Nursing Interventions: Cystocele and Rectocele

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


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
Vaginal Pessary

A vaginal pessary is a removable device placed into the vagina. It is designed to support areas of pelvic organ prolapsed.

post operative care cystocele and rectocele
Post – Operative Care: Cystocele and Rectocele
  • 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 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 (surgically planned incision on the perineum and the posterior vaginal wall during the labor). 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.
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Post-Operative Care: Cystocele and Rectocele

5. Provide a liquid diet followed by low – residue diet until normal bowel function returns.

6. Instruct client how to care for indwelling catheter at home.

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 stitches.

9. Teach the client how to perform client intermittent self-catheterization techniques in the event that client is unable to void.

post operative care cystocele and rectocele2
Post-operative Care: Cystocele and Rectocele

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 cystocele and rectocele
Complications :Cystocele and Rectocele

Residual urine in the bladder at risk for recurrent bladder infection and possibly kidney infections.


Dyspareunia (painful sexual intercourse) is a possible surgical complication due to surgical alteration of the orifice.

needs of older adults cystocele and rectocele
Needs of Older Adults: Cystocele and Rectocele

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-operataive complications.

Performing Kegel exercises and manipulating pessary maybe more difficult for older adults.

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.

uterine prolapse1
Uterine Prolapse

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.

Repeated straining over the years which can weaken pelvic floor and lead to uterine prolapse.

Pregnancy and trauma incurred during childbirth, particularly with large babies or after a difficult labor and delivery.

Loss of muscle tone associated with aging

In rare circumstances, may be caused by a tumor in the pelvic cavity.

Genetics : Women of Northern European descent have a higher incidence of uterine prolapse than do women of Asian and African descent.

uterine prolapse risk factors
Uterine Prolapse: 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.

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Uterine Prolapse

Sign and Symptoms:

Mild uterine prolapse client may experience no signs or symptoms.

Moderate to severe uterine prolapse

- 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

- Symptoms that are less in the morning and worsen as the day goes on.

test and diagnostic procedures
Test and Diagnostic Procedures

Pelvic exam.

A complete pelvic exam

-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.

-Ultrasound or magnetic resonance imaging (MRI)

uterine prolapse treatment
Uterine Prolapse - Treatment

For mild uterine prolapse, treatment usually is not needed.

Options include using a supportive device (pessary) inserted into the vagina or having surgery to repair the prolapse.

Loosing weight, stopping smoking

Lifestyle changes

Achieve and maintain a healthy weight, to

Perform Kegel exercises, to strengthen pelvic floor muscles.

Avoid heavy lifting and straining, to reduce abdominal pressure on supportive pelvic structures.

surgical procedure
Surgical Procedure

Vaginally –

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— 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
  • Possible complications of uterine prolapse include:
    • Ulcers-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); 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.
abnormal vaginal bleeding
Abnormal Vaginal Bleeding

Balloon thermotherapy for treatment of menorrhagia. A, Balloon-tipped catheter is inserted into the

uterus through the vagina and cervix. B, The balloon is inflated with a sterile fluid that expands to fit the size

and shape of the uterus. The fluid is heated to 188° F (87° C) and maintained for 8 minutes while the uterine

lining is treated. C, Fluid is withdrawn from the balloon and the catheter is removed.

abnormal vaginal bleeding1
Abnormal Vaginal Bleeding

Menorragia-excessive or prolonged bleeding

Oligomenorrhia-long intervals between meses-more than 35 days

Metrorrhagia- irregular bleeding or bleeding between menses

ectopic pregnancy
Ectopic Pregnancy

Ectopic pregnancy occurring in the fallopian tube.

nursing and collaborative management ectopic pregnancy
Nursing and Collaborative Management:Ectopic Pregnancy

Laparoscopic treatment of ectopic pregnancy in the right fallopian tube.

ectopic pregnancy1
Ectopic Pregnancy

Implantation of the fertilized ovum anywhere outside the uterine cavity

Can cause abdominal pain, vaginal bleeding, breast tenderness, GI disturbance

breast disorders
Breast disorders

Mastalgia- breast pain

Mastitis- inflammatory condition

Fibroadenoma-benign breast lumps

Fibrocystic changes-benign condition caused by development of excess fibrous tissue and cyst formation

breast cancer
Breast cancer
  • Risk factor
    • Female
    • Age of >50
    • Family history
    • Early menarche (before age 12)
    • Pregnancy after 30
    • Weight gain
    • Physical inactivity
    • Alcohol consumption
    • Exposure to ionizing radiation