ASESSMENT AND DIAGNOSIS REPRODUCTIVE SYSTEM.pptx

HEALTH ASSESSMENT AND DIAGNOSTIC EVALUATION OF REPRODUCTIVE SYSTEM DISORDERS
ANATOMIC AND PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM
FUNCTION OF THE FEMALE REPRODUCTIVE SYSTEM
1) HEALTH HISTORY AND CLINICAL MANIFESTATIONS
2) SEXUAL HISTORY
3)RISK FOR STDS
4) FEMALE GENITAL MUTILATION
5) DOMESTIC VIOLENCE
6) Incest and Childhood Sexual Abuse
7) RAPE AND SEXUAL ASSAULT
PHYSICAL ASSESSMENT
DIAGNOSTIC EVALUATION
ANATOMY AND PHYSIOLOGY OF MALE REPRODUCTIVE SYSTEM
ASSESSMENT
PHYSICAL ASSESSMENT
DIAGNOSTIC EVALUATION
RESEARCH

1. HEALTH ASSESSMENT AND DIAGNOSTIC EVALUATION OF REPRODUCTIVE SYSTEM DISORDERS Ms SUSHMA CHAWLA

2. ANATOMIC AND PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM The female reproductive system consists of external and internal structures. Other anatomic structures that affect the female reproductive system include the hypothalamus and pituitary gland of the endocrine system .

3. External Genitalia The external genitalia (the vulva) include two thick folds of tissue called the labia majora and two smaller lips of delicate tissue called the labia minora, which lie within the labia majora. The upper portions of the labia minora unite, forming a partial covering for the clitoris , a highly sensitive organ composed of erectile tissue. Between the labia minora, below and posterior to the clitoris, is the urinary meatus. This is the external opening of the female urethra and is about 3 cm (1.5 inches) long . Below this orifice is a larger opening, the vaginal orifice or introitus . On each side of the vaginal orifice is a vestibular (Bartholin’s) gland, a bean-sized that empties its mucous secretion through a small duct. The opening of the duct lies within the labia minora, external to the hymen. The area between the vagina and rectum is called the perineum

4. Internal Reproductive Structures The internal structures consist of the vagina, uterus, ovaries, and fallopian tubes. VAGINA The vagina, is 7.5 to 10 cm (3 to 4 inches) long and extends upward and backward from the vulva to the cervix. Anterior to it are the bladder and the urethra, and posterior to it lies the rectum. The anterior and posterior walls of the vagina normally touch each other. The upper part of the vagina, the fornix, surrounds the cervix (the inferior part of the uterus).

5. UTERUS The uterus, a pear-shaped muscular organ, is about 7.5 cm (3 inches) long and 5 cm (2 inches) wide at its upper part. Its walls are about 1.25 cm (0.5 inch) thick. The size of the uterus varies, depending on parity (number of viable births) and uterine abnormalities ( eg , fibroids, which are a type of tumor that may distort the uterus).

6. UTERUS The uterus lies posterior to the bladder and is held in position by several ligaments. The  broad ligament,  a fold of peritoneum, serves as a primary support for the uterus, extending laterally from both sides of the uterus and attaching it to the pelvic wall. The  round ligament,  a rope-like band of connective tissue, attaches to the uterus near the uterine tubes and extends to the labia majora . Transverse ligament  (cardinal ligament), holds the cervical part of the uterus to the lateral pelvic wall. Uterine vessels run through the cardinal ligaments. Uterosacral ligament,  stabilizes the uterus posteriorly by its connection from the cervix to the sacrum. The intact pelvic floor muscle, the   Levator ani muscles , covers the external pelvis and holds the uterus in place to prevent it from dangling into the perineal region.

7. UTERUS The uterus has two parts: The cervix, which projects into the vagina, and The fundus or body, which is covered posteriorly and partly anteriorly by peritoneum. The triangular inner portion of the fundus narrows to a small canal in the cervix that has constrictions at each end, referred to as the external os and internal os . The upper lateral parts of the uterus are called the cornua. From here, the oviducts or fallopian (or uterine) tubes extend outward, and their lumina are internally continuous with the uterine cavity

8. OVARIES The ovaries lie behind the broad ligaments, behind and below the fallopian tubes. They are oval bodies about 3 cm (1.2 inches) long. At birth, they contain thousands of tiny egg cells, or ova. The ovaries and the fallopian tubes together are referred to as the adnexa.

9. FUNCTION OF THE FEMALE REPRODUCTIVE SYSTEM Ovulation At puberty (usually between ages 12 and 14), the ova begin to mature. During period known as follicular phase , an ovum enlarges as a type of cyst called a graafian follicle until it reaches the surface of the ovary, where transport occurs. The ovum (or oocyte) is discharged into the peritoneal cavity. This periodic discharge of matured ovum is referred to as ovulation . The ovum usually finds its way into the fallopian tube, where it is carried to the uterus. If it meets a spermatozoon, the male reproductive cell, a union occurs and conception takes place. After the discharge of the ovum, the cells of the graafian follicle undergo a rapid change. Gradually, they become yellow (corpus luteum) and produce progesterone, a hormone that prepares the uterus for receiving the fertilized ovum. Ovulation usually occurs 2 weeks prior to the next menstrual period.

10. The Menstrual Cycle The menstrual cycle is a complex process involving the reproductive and endocrine systems. The ovaries produce steroid hormones, predominantly estrogens and progesterone. Estrogens are responsible for developing and maintaining the female reproductive organs and the secondary sex characteristics associated with the adult female. Estrogens play an important role in breast development and in monthly cyclic changes in the uterus. Progesterone is secreted by corpus luteum . Progesterone is important hormone for conditioning the endometrium in preparation for implantation of a fertilized ovum. If pregnancy occurs, the progesterone secretion becomes largely a function of the placenta and is essential for maintaining a normal pregnancy.

11. The Menstrual Cycle (Contd.) Two gonadotropic hormones are released by the pituitary gland: FSH and LH. Follicle-stimulating hormone (FSH) is primarily responsible for stimulating the ovaries to secrete estrogen. Luteinizing hormone (LH) is primarily responsible for stimulating progesterone production . Feedback mechanisms , in part, regulate FSH and LH secretion. In addition, gonadotropin-releasing hormone (GnRH) from the hypothalamus affects the rate of FSH and LH release.

12. The Menstrual Cycle (Contd.) The secretion of ovarian hormones follows a cyclic pattern that results in changes in the uterine endometrium and in menstruation. This cycle is typically 28 days in length, but there are many normal variations (21 to 42 days). In the proliferative phase at the beginning of the cycle (just after menstruation), FSH output increases, stimulating estrogen secretion. This causes the endometrium to thicken and become more vascular. In the secretory phase near the middle portion of the cycle (day 14 in a 28-day cycle), LH output increases, stimulating ovulation. Under the combined stimulus of estrogen and progesterone, the endometrium reaches the peak of its thickening and vascularization. The luteal phase begins after ovulation and is characterized by the secretion of progesterone from the corpus luteum.

13. The Menstrual Cycle (Contd.) If the ovum is fertilized, Estrogen and progesterone levels remain high and the complex hormonal changes of pregnancy follow. If the ovum has not been fertilized, FSH and LH output diminishes, estrogen and progesterone secretion falls, the ovum disintegrates, and the endometrium, which has become thick and congested, becomes hemorrhagic. The product consisting of old blood, mucus, and endometrial tissue is discharged through the cervix and into the vagina. After the menstrual flow stops, the cycle begins again

14. Menopausal Period The menopausal period marks the end of a woman’s reproductive capacity. It usually occurs between the ages of 45 and 52 years Menopause is not a pathologic phenomenon but a normal part of aging and maturation. Menstruation ceases, and because the ovaries are no longer active, the reproductive organs become smaller. No more ova mature; therefore, no ovarian hormones are produced. An artificial menopause may occur earlier if the ovaries are surgically removed or are destroyed by radiation or chemotherapy. Besides changes in the reproductive system that reduce estrogen levels, multifaceted changes occur throughout the woman’s body.

15. Assessment The nurse who is obtaining information from the patient for the health history and performing physical assessment is in an ideal position to discuss the woman’s general health issues, health promotion, and health-related concerns.

16. 1) HEALTH HISTORY AND CLINICAL MANIFESTATIONS Obtain a general health history Past illnesses and experiences that are specific to women’s health. Menstrual history (including menarche, length of cycles, length and amount of flow, presence of cramps or pain, bleeding between periods or after intercourse, bleeding after menopause) History of pregnancies (number of pregnancies, outcomes of pregnancies) • History of exposure to medications (diethylstilbestrol [DES], immunosuppressive agents, others) Pain with menses (dysmenorrhea), pain with intercourse (dyspareunia), pelvic pain

17. HEALTH HISTORY AND CLINICAL MANIFESTATIONS ( contd ) History of vaginal discharge and odor or itching History of problems with urinary function ( ie , frequency or urgency); may be related to STDs or pregnancy History of problems with bowel or bladder control Sexual history History of sexual abuse or physical abuse History of surgery or other procedures on reproductive tract structures (including female genital mutilation or female circumcision) History of chronic illness or disability that may affect health status, reproductive health, need for health screening, or access to health care History of genetic disorder

18. 2) SEXUAL HISTORY A sexual assessment Includes both subjective and objective data. Health and sexual histories, Physical examination findings, and Laboratory results are all part of the database.

19. PURPOSE OF A SEXUAL HISTORY The purpose of a sexual history is To obtain information that provides a picture of the woman’s sexuality and sexual practices and promotes sexual health. The sexual history may enable the patient to discuss sexual matters openly The nurse can move from areas of lesser sensitivity to areas of greater sensitivity after establishing initial rapport. In obtaining a sexual history, the nurse must not assume the patient’s sexual preference until clarified. When asking about sexual health, the nurse also cannot assume that the patient is married or unmarried.

20. Sexual History (contd.) The PLISSIT model of sexual assessment and intervention may be used PERMISSION :- The assessment begins by introducing the topic and asking the woman for permission to discuss issues of sexual functioning. History taking continues by inquiring about present sexual activity, sexual orientation and sexual dysfunction and causes of current problem. LIMITED INFORMATION :- Limited information about sexual function may be provided to the patient. SPECIFIC SUGGESTIONS :-As the discussion progresses, the nurse may offer specific suggestions for interventions. INTENSIVE THERAPY:- For some women, a professional who specializes in sex therapy may provide more intensive therapy as needed. provides a safe environment for discussing these sensitive topics

21. 3)RISK FOR STDS Risk for STDs can be assessed by asking about number of partners in the past year or in the patient’s lifetime. Young women may be apprehensive about irregular periods, may be concerned about STDs, or may need contraception . They may want information on using tampons, emergency contraception, or issues related to pregnancy. Perimenopausal women may have concerns about irregular menses ; Menopausal women may be concerned about vaginal dryness and burning with intercourse. Women of any age may have concerns about sexual satisfaction, orgasm or anorgasmia (lack of orgasm ).

22. 4) FEMALE GENITAL MUTILATION Female genital mutilation (FGM) refers to the partial or total removal of the external female genitalia or other injury to female organs. Individuals from some cultures believe that FGM promote hygiene, protects virginity and family honor, prevents promiscuity, improves female attractiveness and male sexual pleasure, and enhances fertility. It is viewed in some cultures as a rite of passage to womanhood. Many organizations ( eg , WHO, Amnesty International) are working to end this practice.

23. Female Genital Mutilation Four types of FGM are known: Type I – Clitoridectomy i.e Excision of the clitoral prepuce; Type II – Excision i.e Total excision of the clitoral prepuce and glans with partial or total excision of the labia minora ; Type III – Infibulation Excision of part or all of the external genitalia and stitching or narrowing of the vaginal opening

24. Types of FGM Type IV – Other/ Unclassified which includes pricking, piercing, or incision of the clitoris, the labia, or both, stretching of the clitoris or surrounding tissues, and introduction of corrosive substances into the vagina. FGM is usually performed between 4 and 10 years of age; hemorrhage and infection may be consequences.

25. 5) DOMESTIC VIOLENCE Domestic violence is a broad term that includes CHILD ABUSE, ELDER ABUSE, AND ABUSE OF WOMEN AND MEN. Abuse can be emotional, physical, sexual, or economic . Battering involves repeated physical or sexual assault in a context of coercive control and, more broadly, emotional degradation, threats, and intimidation.

26. Domestic Violence (contd.) This is an important point to emphasize when a woman states that her partner has hurt her but has promised to change. Batterers can change their behavior, but not without extensive counseling and motivation. Asking each woman about violence in her life in a safe environment is part of a comprehensive assessment and universal screening and it should be included in the health history of all women

27. 6) Incest and Childhood Sexual Abuse One in five women has experienced incest or childhood sexual abuse. Victims of childhood sexual abuse experience more chronic depression, PTSD, morbid obesity, marital instability, GI problems, and headaches , as well as greater use of health care services. Chronic pelvic pain in women is often associated with physical violence , emotional neglect, and sexual abuse in childhood. Women who have experienced rape or sexual abuse may have difficulty with pelvic examinations. Nurses should be prepared to offer support and referral to psychologists, community resou rces and self help groups.

28. 7) RAPE AND SEXUAL ASSAULT Men, women, and children may be victims. Sexual assault nurse examiners, emergency department staff, and gynecologists perform the collection of forensic evidence that is needed for criminal prosecution. Oral, anal, and genital tissue is examined for evidence of trauma, semen, or infection. Saliva, hair, and fingernail evidence is also collected. Cultures are obtained for STDs, and prophylactic antibiotics are prescribed. HIV testing is offered and is repeated in 3 to 6 months.

29. Rape and Sexual Assault HIV prophylaxis is not universally recommended but is considered when mucosal exposure to contamination has occurred. Prophylaxis against chlamydia and gonorrhea are provided. Emergency contraception is provided if requested. Emotional counseling is provided, and follow-up treatment visits are arranged. Rape trauma syndrome is emotional reaction to sexual assault and may consist of shock, sleep disturbances, nightmares, flashbacks, anxiety, anger, mood swings, and depression. It is important for survivors to discuss & obtain professional counseling. Screening for abuse, rape, and violence should be part of routine assessment

30. PHYSICAL ASSESSMENT Periodic examinations and routine cancer screening are important for all women. An annual breast and pelvic examination is important for all women age 18 or older and for those who are sexually active, regardless of age. Alleviate anxiety by explaining the procedure and teaching. Before the examination begins, the patient is asked to empty her bladder and to provide a urine specimen if urine tests are part of the total assessment.

31. POSITIONING Supine lithotomy position is used most commonly, although the upright lithotomy position (in which the woman assumes a semisitting posture) may also be used. If the patient is too ill, disabled, or neurologically, the Sims’ position may be used

32. ARTICLES REQUIRED:- The following equipment is obtained and readily available: A good light source; Vaginal speculum; Clean examination gloves; Lubricant, spatula, cytobrush , glass slides, fixative solution or spray; and diagnostic testing supplies for screening for occult rectal blood if the woman is older than 40. Latex-free gloves should be available if the patient or clinician is allergic to latex.

33. INSPECTION Inspection Inspects the labia majora and minora , noting the epidermal tissue of the labia majora ; Lesions of any type ( eg , venereal warts, pigmented lesions [melanoma]) are evaluated. In the nulliparous woman, the labia minora come together at the opening of the vagina. In women who have delivered children vaginally, the labia minora may gape and vaginal tissue may protrude.

34. INSPECTION Trauma to the anterior vaginal wall during childbirth may result in cystocele ( bladder protruding into submucosa of the anterior vaginal wall) . Childbirth trauma may also have affected the posterior vaginal wall, producing a bulge caused by rectal cavity protrusion (rectocele) . The cervix may descend under pressure through the vaginal canal and be seen at the introitus (uterine prolapse) . To identify such protrusions, the examiner asks the patient to “bear down.”

35. INSPECTION Inspect introitus for superficial mucosal lesions. The labia minora is separated by the fingers of the gloved hand and the lower part of the vagina palpated. In virgins , a HYMEN may be felt circumferentially within 1 or 2 cm of the vaginal opening. The hymenal ring usually permits the insertion of one finger. Rarely, the hymen totally occludes the vaginal entrance (imperforate hymen). In women who are not virgins, a rim of scar tissue representing the remnants of the hymenal ring may be felt. The Bartholin’s glands lie between the labia minora and the remnants of the hymenal ring. An abscess of the Bartholin’s gland requires incision and drainage

36. SPECULUM EXAMINATION The speculum is grasped in the dominant hand. The speculum is gently inserted into the posterior portion of the introitus and slowly advanced to the top of the vagina; The speculum is then slowly opened CERVIX The cervix is inspected. In nulliparous women, the cervix usually is 2 to 3 cm wide and smooth. Women who have borne children may have a laceration, usually transverse, giving the cervical os a “ fishmouth ” appearance .

37. SPECULUM EXAMINATION ABNORMAL GROWTH- Malignant changes may not be obviously differentiated from the rest of the cervical mucosa. Small, benign cysts may appear on the cervical surface. These are usually bluish or white and are called nabothian cysts. A polyp of endocervical mucosa may protrude through the os and usually is dark red . Polyps can cause irregular bleeding; they are rarely malignant and usually are removed easily in an office or clinic setting. A carcinoma may appear as a cauliflower-like growth that bleeds easily when touched. Bluish coloration of the cervix is a sign of early pregnancy (Chadwick’s sign).

38. PAP SMEAR A Pap smear is obtained by rotating a small spatula at the os , followed by a cervical brush rotated in the os . The tissue obtained is spread on a glass slide and sprayed or fixed immediately A small broom-like device can also be used to obtain specimens for the Pap smear. A specimen of any purulent material appearing at the cervical os is obtained for culture and placed in an appropriate medium for transfer to a laboratory. In patients at high risk for infection , routine cultures for gonococcal and chlamydial organisms are recommended to prevent pelvic infection, fallopian tube damage, and subsequent infertility

39. BIMANUAL PALPATION The examination is performed with the forefinger and middle finger of gloved and lubricated hand. These fingers are placed in the vaginal orifice, advanced vertically along the vaginal canal, and the vaginal wall is palpated . Any firm part of the vaginal wall may represent old scar tissue CERVICAL PALPATION The cervix is palpated and assessed for its consistency, mobility, size, and position. The normal cervix is uniformly firm not hard. Softening of the cervix is a finding in early pregnancy. Hardness and immobility of cervix may reflect invasion by a neoplasm. Pain on gentle movement of cervix is called a positive chandelier sign & indicates a pelvic infection.

40. BIMANUAL PALPATION (contd.) UTERINE PALPATION To palpate the uterus, the examiner places the opposite hand on the abdominal wall halfway between the umbilicus and the pubis and presses firmly toward the vagina . Movement of the abdominal wall causes the body of the uterus to descend, and the pear-shaped organ becomes freely movable between the abdominal examining hand and the fingers of the pelvic examining hand. Uterine size, mobility, and contour can be estimated through palpation. Fixation of the uterus in the pelvis may be a sign of endometriosis or malignancy. The body of the uterus is curving anteriorly toward the abdominal wall. Some women have a retroverted or retroflexed uterus, whereas others have a uterus that midline.

41. BIMANUAL PALPATION (contd.) ADNEXAL PALPATION Right and left adnexal areas are palpated to evaluate the fallopian tubes and ovaries. The fingers of the hand examining the pelvis are moved first to one side, then to the other. The adnexa (ovaries and fallopian tubes) are trapped between the two hands and palpated for an obvious mass, tenderness, and mobility. Commonly, the ovaries are slightly tender, and the patient is informed that slight discomfort on palpation is normal

42. BIMANUAL PALPATION (contd.) VAGINAL AND RECTAL PALPATION Bimanual palpation of the vagina and rectum is accomplished by placing the index finger in the vagina and the middle finger in the rectum. A gentle movement of these fingers toward each other compresses the posterior vaginal wall and the anterior rectal wall and assists the examiner in identifying the integrity of these structures.

43. DIAGNOSTIC EVALUATION CYTOLOGIC TEST FOR CANCER (PAP SMEAR) Cervical secretions are gently removed from the cervical os , transferred to a glass slide, and fixed immediately by spraying with a fixative. A Thin-prep Pap specimen is immersed in a solution rather than being placed on a slide. This method allows for human papillomavirus (HPV) testing if the Pap smear result is abnormal The Bethesda Classification system has been developed to promote consistency in reporting Pap smear results and to assist in standardizing management guidelines Terminology includes the following categories: Low-grade squamous intraepithelial lesion (LSIL), which is equivalent to cervical intraepithelial neoplasia (CIN 1) and to mild changes related to exposure to HPV High-grade squamous intraepithelial lesions (HSIL), which equates to moderate and severe dysplasia, carcinoma in situ (CIS), and CIN 2 and CIN 3

44. Diagnostic Evaluation (contd.) COLPOSCOPY AND CERVICAL BIOPSY All suspicious Pap smears should be evaluated by colposcopy. The colposcope is a portable microscope that allows the examiner to visualize the cervix and obtain a sample of abnormal tissue for analysis. After inserting a speculum and visualizing the cervix and vaginal walls, the examiner applies acetic acid to the cervix. Subsequent abnormal findings that indicate the need for biopsy include Leukoplakia (white plaque visible before applying acetic acid), Acetowhite tissue (white epithelium after applying acetic acid), Punctation (dilated capillaries occurring in a dotted or stippled pattern), Mosaicism (a tile-like pattern), and atypical vascular patterns.

45. Diagnostic Evaluation (contd.) An endocervical curettage may be performed during colposcopy if a problem is suspected based on Pap smear findings. This analysis of tissue from the cervical canal is used to determine whether abnormal changes have occurred in the cervical canal. If these biopsy specimens show premalignant cells or CIN, the patient usually needs cryotherapy, laser therapy, or a cone biopsy (excision of an inverted tissue cone from the cervix)

46. Diagnostic Evaluation (contd.) An endocervical curettage may be performed during colposcopy if a problem is suspected based on Pap smear findings. This analysis of tissue from the cervical canal is used to determine whether abnormal changes have occurred in the cervical canal. If these biopsy specimens show premalignant cells or CIN, the patient usually needs cryotherapy, laser therapy, or a cone biopsy (excision of an inverted tissue cone from the cervix)

47. Diagnostic Evaluation (contd.) CRYOTHERAPY AND LASER THERAPY Cryotherapy (freezing cervical tissue with nitrous oxide) and Laser treatment are used in the outpatient setting. Cryotherapy may result in cramping and occasional feelings of faintness (vasovagal response). A watery discharge is normal for a few weeks after the procedure as the cervix heals.

48. Diagnostic Evaluation (contd.) CONE BIOPSY AND LEEP If the endocervical curettage findings indicate abnormal changes or if the lesion extends into the canal, the patient may undergo a cone biopsy. This can be performed surgically or with a procedure called LEEP (loop electrosurgical excision procedure), which uses a laser beam. Usually performed in the outpatient setting, LEEP is associated with a high success rate & has a low incidence of complications. The gynecologist excises a small amount of cervical tissue, and the pathologist examines the borders of the specimen to determine if they are free of disease. A patient anesthetized for a surgical cone biopsy is advised to rest for 24 hours after the procedure and to leave any vaginal packing in place until the physician removes it (usually the next day). The patient is instructed to report any excessive bleeding.

49. Diagnostic Evaluation (contd.) ENDOMETRIAL (ASPIRATION) BIOPSY A tissue sample obtained through biopsy permits diagnosis of cellular changes in the endometrium. Endometrial biopsy, a method of obtaining endometrial tissue, is performed during the pelvic ex amination Usually, the procedure can be performed without anesthesia; however, a paracervical block or a small injection of lidocaine into the uterus is effective if required. The examiner may apply a tenaculum (a clamp-like instrument that stabilizes the uterus) after the pelvic examination and then inserts a thin, hollow, flexible suction tube ( pipelle or sampler) through the cervix into the uterus. Endometrial biopsy is usually indicated in cases of irregular bleeding, postmenopausal bleeding, and infertility

50. Diagnostic Evaluation (contd.)

51. Diagnostic Evaluation (contd.) DILATION AND CURETTAGE A dilation and curettage (D & C) may be diagnostic (identifies the cause of irregular bleeding) or therapeutic (often temporarily stops irregular bleeding). The cervical canal is widened with a dilator and the uterine endometrium is scraped with a curette. The purpose of the procedure is to secure endometrial or endocervical tissue for cytologic examination, to control abnormal uterine bleeding, and as a therapeutic measure for incomplete abortion.

52. Diagnostic Evaluation (contd.) ENDOSCOPIC EXAMINATIONS Laparoscopy (Pelvic Peritoneoscopy ) A laparoscopy involves inserting a laparoscope (a tube about 10 mm wide into the peritoneal cavity through a 2-cm (0.75-inch) incision below the umbilicus to allow visualization of the pelvic structures.L Laparoscopy may be used for diagnostic purposes ( eg , in cases of pelvic pain when no cause can be found) or treatment. Laparoscopy also facilitates many surgical procedures, such as tubal sterilization, ovarian biopsy, myomectomy, and lysis of adhesions (scar tissue that can cause pelvic discomfort).

53. Diagnostic Evaluation (contd.) Hysteroscopy ( transcervical intrauterine endoscopy) allows direct visualization of all parts of the uterine cavity by means of a lighted optical instrument. The procedure is best performed about 5 days after menstruation stops, in the estrogenic phase of the menstrual cycle. The vagina and vulva are cleansed, and a paracervical anesthetic block is performed or lidocaine spray is used. The instrument used for the procedure, a hysteroscope , is passed into the cervical canal and advanced 1 or 2 cm under direct vision. Uterine-distending fluid (normal saline solution or 5% dextrose in water) is infused through the instrument to dilate the uterine cavity and enhance visibility.

54. Diagnostic Evaluation (contd.) Hysterosalpingography or Uterotubography Hysterosalpingography is an x-ray study of the uterus and the fallopian tubes after injection of a contrast agent. The diagnostic procedure is performed to evaluate infertility or tubal patency and to detect any abnormal condition in the uterine cavity. Sometimes the procedure is therapeutic because the flowing contrast agent flushes debris or loosens adhesions. Some patients experience nausea, vomiting, cramps, and faintness. After the test, the patient is advised to wear a perinealpad for several hours because the radiopaque agent may stain clothing.

55. Diagnostic Evaluation (contd.) CT Scan MRI Ultrasonography

56. MALE REPRODUCTIVE SYSTEM

57. ANATOMY AND PHYSIOLOGY OF MALE REPRODUCTIVE SYSTEM The structures in the male reproductive system are the Testes Vas deferens ( ductus deferens) Seminal vesicles Penis Accessory glands Prostate gland and Cowper’s gland (bulbourethral gland)

58. TESTICULAR DEVELOPMENT The testes are formed in the embryo within the abdominal cavity near the kidney. During the last month of fetal life, they descend posterior to the peritoneum and pierce the abdominal wall in the groin . Later, they progress along the inguinal canal into the scrotum. In this descent, they are accompanied by blood vessels, lymphatics , nerves, and ducts, which support the tissue and make up the spermatic cord.

59. TESTICULAR DEVELOPMENT This cord extends from the internal inguinal ring through the abdominal wall and the inguinal canal to the scrotum. As the testes descend into the scrotum, a tubular extension of peritoneum accompanies them. Normally, this tissue is obliterated during fetal development. When this peritoneal process is not obliterated but remains open into the abdominal cavity, a potential sac remains into which abdominal contents may enter to form an indirect inguinal hernia. The testes are encased in the scrotum, which keeps them at slightly lower temperature than the rest of the body to facilitate spermatogenesis(production of sperm). The testes consist of numerous seminiferous tubules in which the spermatozoa form. Collecting tubules transmit the spermatozoa into the epididymis

60. GLANDULAR FUNCTION The testes have a dual function: The formation of spermatozoa from the germinal cells of the seminiferous tubules and the secretion of the male sex hormone testosterone , which induces and preserves the male sex characteristics. The prostate gland lies just below the neck of the bladder. It surrounds the urethra and is traversed by the ejaculatory duct, a continuation of the vas deferens. This gland produces a secretion that is chemically and physiologically suitable to the needs of the spermatozoa in their passage from the testes. Cowper’s gland lies below the prostate. This gland empties its secretions into the urethra during ejaculation, providing lubrication.

61. GLANDULAR FUNCTION The penis has a dual function- copulation and urination. Anatomically, it consists of the glans penis, body, and root. The glans penis is the soft, rounded portion at the distal end of penis. The urethra, opens at the tip of the glans. The glans is naturally covered or protected by elongated penile skin—the foreskin—which may be retracted to expose the glans.

62. ASSESSMENT HEALTH HISTORY AND CLINICAL MANIFESTATIONS Assessment of male reproductive function begins with an evaluation of urinary function and symptoms. This assessment also includes a focus on sexual function as well as manifestations of sexual dysfunction. The patient is asked about his usual state of health and any recent change in general physical and sexual activity. Any symptoms or changes in function These symptoms may include those associated with an obstruction caused by an enlarged prostate gland: increased urinary frequency, decreased force of urine stream, “double” or “triple” voiding (the patient needs to urinate two or three times over a period of several minutes to completely empty his bladder). The patient is also assessed for dysuria, hematuria, and hematospermia .

63. ASSESSMENT Assessment of sexual function and dysfunction is an essential part of every health history. The extent of the history will depend on the patient’s presenting symptoms and the presence of factors that may affect sexual function: Chronic illnesses ( eg , diabetes, multiple sclerosis, stroke, cardiac disease), Use of medications that affect sexual function ( eg , many antihypertensive and anti cholesterolemic medications, psychotropic agents), stress, and alcohol use.

64. ASSESSMENT Discussing sexuality with patients with an illness or disability can be uncomfortable for nurses and other health care providers. Health care professionals may unconsciously have stereotypes related to sexuality about people who are ill or disabled ( eg , ill or disabled persons are asexual or should remain sexually inactive). In addition, patients are often embarrassed to initiate a discussion about these issues with their health care providers The PLISSIT (permission, limited information, specific suggestions, intensive therapy) model of sexual assessment and intervention may be used to provide a framework for nursing interventions.

65. PHYSICAL ASSESSMENT In addition to the physical examination, two essential components address disorders of the male genital or reproductive system: The digital rectal examination and The testicular examination

66. Digital Rectal Examination The digital rectal examination (DRE) is recommended as part of the regular health checkup for every man older than 40 years of age; it is invaluable in screening for cancer of the prostate gland. The DRE enables the examiner to assess the size, shape, and consistency of the prostate gland . Tenderness of the prostate gland on palpation and the presence and consistency of any nodules are noted.

67. Testicular Examination The male genitalia are inspected for abnormalities and palpated for masses. The scrotum is palpated carefully for nodules, masses, or inflammation. Examining the scrotum can reveal such disorders as hydrocele, hernia, or tumor of the testis. The penis is inspected and palpated for ulcerations, nodules, inflammation, and discharge. The testicular self-examination is important in early detection of testicular cancer. This self examination should begin during adolescence.

68. Diagnostic Evaluation

69. PROSTATE-SPECIFIC ANTIGEN TEST The prostate gland produces prostate specific antigen (PSA), measured in a blood specimen Many factors can increase PSA levels, including BPH, prostate cancer, and infections of the prostate and urinary tract. The PSA test and DRE are used to detect prostate cancer. The normal value is 0.2 to 4.0 ng/ mL. Values over 4.0 are considered elevated. An elevated PSA level is not a specific indicator of prostate cancer. A PSA test, along with DRE, is recommended by the American Cancer Society annually for men at high risk.

70. ULTRASONOGRAPHY Transrectal ultrasound (TRUS) studies may be performed in patients with abnormalities detected by DRE or elevated PSA levels . After DRE, a lubricated, condom-covered, rectal probe transducer is inserted into the rectum along the anterior wall. TRUS may be used in detecting nonpalpable prostate cancers and in staging localized prostate cancer. Needle biopsies of the prostate are commonly guided by TRUS.

71. PROSTATE FLUID OR TISSUE ANALYSIS Specimens of prostate fluid or tissue may be obtained for culture when disease or inflammation of the prostate gland is suspected. A biopsy of the prostate gland may be necessary for histologic examination. This may be performed at the time of prostatectomy or by means of a perineal or transrectal needle biopsy.

72. TESTS OF MALE SEXUAL FUNCTION If the patient cannot engage in sexual intercourse to his satisfaction, a detailed history is obtained. Nocturnal penile tumescence tests may be conducted in a sleep laboratory to monitor changes in penile circumference during sleep (using a mercury strain gauge placed around the penis); The results help to identify the cause of erectile dysfunction. Arterial blood flow to the penis is measured with the Doppler probe. Nerve conduction tests and psychological evaluations are also part of the diagnostic workup.

73. Research Sexual Violence against Adolescents in the State of Espírito Santo, Brazil: An Analysis of Reported Cases Objective:  We describe the prevalence of the reported cases of sexual violence against adolescents and analyze their associated factors. Methods:  A cross-sectional analytical study ( n  = 561) was conducted with reported data on sexual violence against adolescents in the state of Espírito Santo registered in SINAN between 2011 and 2018 to understand the prevalence and predictors of sexual violence against adolescent victims, as well as to describe the perpetrators and the nature of the aggression Results:  The prevalence of sexual violence was 32.6%, and 93% of the victims were female. In both males and females, the reported sexual violence was associated with a younger age (10-12 years old), living at home, being related to the perpetrator, and a history of sexual violence. 

74. RESEARCH Testicular self-examination: attitudes and practices among young men in Europe Background:  Testicular self examination (TSE) is recommended for the early detection of testicular cancer. Evidence from North America suggests there is only limited public awareness of its importance among the young male population Method:  Attitudes to TSE were evaluated by questionnaire in a sample of 16,486 students. Frequency of TSE practice was reported by the 7,304 men in the sample. The data were collected as part of the European Health Behavior Survey Conclusion:  Both the low levels of TSE and the low ratings of the importance of TSE suggest that young men in Europe are unaware of the value of this comparatively simple method of early detection of cancer. If a highly educated population group in the "at risk" age category is not carrying out the recommendations, it is unlikely that there are higher levels of compliance in other groups. 

75. Thank you