Unit-04 Part (A) Female Reproductive Disorders Provided By Khyber Medical University Pakistan.pptx

Female reproductive disorders for Nursing student
Pathophysiology of Female Reproductive system
Menstrual Problems
Disorders related to Reproductive system

1. OBJECTIVES At the end of this unit the learners will be able to; Review the anatomy & physiology of female reproductive system. Discuss the functions of the supporting ligaments and pelvis floor muscles in maintain the position of the pelvic organs. Discuss the alteration in estrogen and progesterone level as a cause of dysfunctional menstrual cycle. Discuss the causes, pathophysiology and manifestations of the following female reproductive system. Discuss the diagnostic, medical and surgical management of the mentioned disorders. Apply nursing process including assessment, planning, implementation and evaluation of care provided to the client with implementation and evaluation of care provided to the client with disorders. Develop a teaching plan for client experiencing disorders of the reproductive system

2. Female Reproductive Disorders Reproductive tract infection Menstrual disorders Dysfunctional uterine bleeding Menopause Endometriosis Pelvic inflammatory diseases Uterine prolapse Cystocele Rectocele Fistulas Infertility Ectopic pregnancy Abortions Hydatidiform mole Ovarian cyst Ovarian tumor Uterine tumor/fibroids Breast cancer

3. Female Reproductive System The female reproductive system consists of external and internal structures. External Genitalia : The reproductive structures located outside the body are the external genitalia, or vulva. These structures include the Mons pubis, labia majora, labia minora, clitoris, and vestibule. Located superior to the symphysis pubis (where the iliac bones join at the front of the pelvis) is a mound of fatty tissue, covered with coarse hairs, This structure is the Mons pubis. Extending from the Mons pubis to the perineal floor are two large folds called the labia majora ,These protect the inner structures and contain sensory nerve endings and an have sebaceous glands and (sweat) glands.

4. Cont.. Directly under the labia majora lie the labia minora , These are smaller folds of tissue, that merge anteriorly to form clitoris. The clitoris is comparable to the male penis and is composed of erectile tissue during sexual stimulation. The space enclosing the structures located beneath the labia minora is called the vestibule. It contains the clitoris, the urinary meatus, the hymen, and the vaginal opening.

5. Accessory Glands Glands: Bilateral to the urinary meatus lie the paraurethral , or Skene's , glands , the largest glands opening into the urethra. These glands secrete mucus. Bilateral to the vaginal opening are two small, mucus-secreting glands called the greater Bartholin's glands (vestibular), which lubricate the vagina for sexual intercourse. Perineum : The perineum is diamond shaped and starts at the symphysis pubis and extends to the anus.

6. Cont.. Mammary Glands : (Breasts) The breasts are attached to the pectoral (chest) muscles. Breast tissue is identifiable in both sexes. During puberty, the female breasts change their size, shape, and ability to function. Within each lobe are many lobules that contain milk producing cells, these lobules lead directly to the lactiferous ducts that empty into the nipple. The dark pink or brown tissue surrounding the nipple is called the areola. Milk production does not start until a woman gives birth. At this time, under the influence of prolactin, the milk is formed. The hormone oxytocin allows milk to be released.

7. Internal reproductive organs The organs of the female reproductive system include the ovaries, the uterus, the fallopian tubes, and the vagina. Ovaries : The paired ovaries are the size and shape of almonds. They are located bilateral to the uterus and immediately inferior to the fallopian tubes. Each ovary contains 30,000 to 40,000 microscopic ovarian follicles. At puberty they release progesterone and the female sex hormone estrogen, and they release a mature egg during the menstrual cycle.

8. Cont.. Fallopian Tubes (Oviducts) The fallopian tubes are a pair of ducts opening at one end into the fundus and at the other end into the peritoneal cavity, over the ovary. They are approximately 4 inches (10 cm) long . The entire inner surface of the tubes is lined with cilia. Fertilization takes place in the outer third of this tube, and the fertilized ovum (zygote) is moved through the tube by a combination of muscular peristaltic movements and the sweeping action of the cilia.

9. Cont.. Uterus: The uterus is shaped like an inverted pear and measures 3 inches long by 2 inches wide in the non-pregnant uterus. It is located between the urinary bladder and the rectum and consists of three layers of tissue: the endometrium, the myometrium and the perimetrium. The uterus is divided into three major portions: The fundus (upper, rounded portion) is the insertion site of the fallopian tubes. The larger midsection is the corpus (body). The smaller, narrower lower portion of the uterus is the cervix, part of which actually descends into the vaginal. During pregnancy the uterus is capable of enlarging up to 500 times.

10. Cont.. Vagina : The vagina is a thin-walled, muscular, tube like structure of the female genitalia, approximately 3 inches (7.5 cm) long. It is located between the urinary bladder and the rectum. The vagina is lined with a mucous membrane, responsible for lubrication during sexual activity. The walls of the vagina normally lie in folds, stretches during intercourse and to allow passage of the infant during birth. The external opening of the vagina is covered by a fold of mucous membrane, skin, and fibrous tissue called the hymen.

11. Functions Of The Supporting Ligaments And Pelvis Floor Muscles To support the abdominal and pelvic viscera. To maintain the continence of urine and feces. Allows voiding, defecation, sexual activity, and childbirth.

12. Menstrual Cycle Menarche, the first menstrual cycle, usually begins at approximately 12 years of age. Each month, for the next 30 to 40 years, an ovum matures and is released about 14 days before the next menstrual flow, which occurs on average every 28 days. If fertilization occurs, menstrual cycling subsides and the body adapts to the developing fetus. The menstrual cycle is divided into three phases: (1) menstrual, (2) preovulatory, and (3) postovulatory. This discussion uses the example of a 28-day cycle. On days 1 through 5 of the cycle (the menstrual phase), the endometrium sloughs off, accompanied by 1 to 2 ounces of blood loss. The anterior pituitary gland begins to release follicle-stimulating hormone (FSH); as the level of FSH increases, the egg matures within the graafian follicle (a pocket or envelope-shaped structure where the ovaries prepare the ovum).

13. Cont.. From days 6 through 13 (preovulatory phase), estrogen is released from the maturing graafian follicle. This estrogen causes vascularization of the uterine lining. On day 14, the anterior pituitary gland releases luteinizing hormone (LH), which causes the rupture of the graafian follicle and release of the mature ovum. The fingerlike projections of the fallopian tubes (fimbriae) sweep the ovum into the fallopian tube. Once this mature ovum has been expelled, the follicle is transformed into a glandular mass called the corpus luteum . During days 15 through 28 (postovulatory phase), the developing corpus luteum releases estrogen and progesterone. If pregnancy occurs, the corpus luteum continues to release estrogen and progesterone to maintain the uterine lining until the placenta is formed, which then takes over the job of hormonal release. If pregnancy does not occur, the corpus luteum lasts 8 days and then disintegrates. Normally the corpus luteum shrinks and is replaced by scar tissue called corpus albicans , At this point the hormone level decreases over several days and menstruation starts again.

14. Alteration In Estrogen And Progesterone Level Cause Of Dysfunctional Menstrual Cycle. Because of the relationship between the menstrual cycle and the body's mechanisms of hormonal secretion, a decrease or increase in activity of the hormonal can disturb menstruation. The most common disturbances include the following: Amenorrhea: Absence of menstrual flow. Dysmenorrhea: Painful menstruation Dysfunctional uterine bleeding (DUB): Abnormal uterine bleeding. Menorrhagia: Bleeding that is excessive in amount and duration. Metrorrhagia: Bleeding between menstrual periods.

15. 1. Reproductive Tract Infection Infections of the female reproductive tract are most commonly found in the vagina, the cervix, the fallopian tubes, and their adjacent areas. Vaginal infections may be caused by bacteria, fungi, or viruses. Infections are more likely to occur when the flora and the acidity of the vagina are disturbed by medications (e.g., birth control pills, antibiotics), stress, malnutrition, douching, aging, and disease. Organisms are often introduced from external sources by way of unclean douche nozzles, poor hygiene, inadequate hand washing, neglected nail care, soiled clothing, and intercourse. Vaginal infections can be sexually transmitted and will return unless both partners are treated.

16. List of common reproductive tract infection Simple Vaginitis: Vaginitis is an inflammation of the vagina Senile Vaginitis or Atrophic Vaginitis: Low estrogen levels cause the vulva and vagina to thin and atrophy, becoming more susceptible to bacterial invasion Cervicitis: Cervicitis is the inflammation of the cervix, it is mostly caused by sexually transmitted infections. Pelvic Inflammatory Disease: it may involve the cervix (cervicitis), uterus ( endometritis ), fallopian tubes ( salpingitis ), or ovaries ( oophoritis ) and may extend to the connective tissues. Toxic Shock Syndrome: is an acute bacterial infection caused by Staphylococcus aureus

17. Causes Of Reproductive Tract Infection R eductions in estrogen levels Bacterial invasion Poor genital hygiene Sexually transmitted diseases Irritating substance to genital Sexual abuse in girls Antibiotics Wearing tight fitting underwear's cervical caps, diaphragms, or pessary devices

18. Manifestation Of Reproductive Tract Infection Vaginitis: is yellow, white, or grayish white, curd like and generally accompanied by pruritus, burning, and edema of the surrounding tissues. skin irritations dyspareunia (painful intercourse) vaginal pain pelvic heaviness abnormal vaginal bleeding a gray, white, or yellow vaginal discharge. patient may have an elevated temperature (up to 102° F) vomiting, dizziness, headache, diarrhea, hypotension, and signs suggesting the onset of septic shock. (mostly in toxic shock syndrome)

19. Diagnostic Test For Reproductive Tract Infection D irect visual examination of the vagina C ulture of the organism Test of secretions from the endocervix, urethra, and rectum. Laparoscopic visualization of the pelvic inflammation may be necessary to confirm the extent of infection. Vaginal ultrasonic examinations Laboratory testing includes leukocyte count, estrogen level. Electrolytes in shock condition

20. Medical Management Of Reproductive Tract Infection Douching is frequently prescribed for treatment. Administer antibiotics , antifungal and analgesics orally, intravenously and local applications of vaginal suppositories, ointments, and creams. Advise the patient to use the medication at bedtime and to remain recumbent for more than 30 minutes after insertion to allow absorption and to prevent loss of any medication from the vagina. During treatment the patient should refrain from intercourse or request that her partner use a condom. M aintain proper fluid balance

21. Nursing Intervention Of Reproductive Tract Infection Instruct to wash hands before and after vaginal application of medications. Heat may be applied in the form of douches, perineal irrigations, or sitz baths. Douching too frequently can alter normal vaginal flora. direct to abstain from sexual intercourse during treatment. Instruct to male partner's use of a condom until the symptoms of infection disappear.

22. Cont.. assisting with patient's care using standard precautions. assessing pain and administering prescribed medications. monitoring vital signs. providing fluids to avoid dehydration. performing measures for comfort such as bathing, changing of perineal pads, personal hygiene, and warm douches. providing patient support with a positive, nonjudgmental attitude. positioning the patient in Fowler's position to facilitate drainage.

23. 2. Menstrual disorders The relationship between the menstrual cycle and the body's mechanisms of hormonal secretion, a decrease or increase in activity of the hormonal glands can disturb menstruation. The most common disturbances include the following: Amenorrhea: Absence of menstrual flow. Dysmenorrhea: Painful menstruation Dysfunctional uterine bleeding (DUB): Abnormal uterine bleeding. Menorrhagia: Bleeding that is excessive in amount and duration. Metrorrhagia: Bleeding between menstrual periods.

24. Pathophysiology Hypothalamus produce gonadotropin releasing hormone( GnRH ) It stimulates pituitary gland Pituitary gland secretes FSH, LH which stimulates ovaries Ovaries release estrogen and progesterone Increases or decreases of hormones causes menstrual dysfunction

25. Amenorrhea: Amenorrhea (absence of menstrual flow) is normal before puberty, after menopause, during pregnancy, and sometimes during lactation. Menstrual flow may also be absent or suppressed as a result of hormonal abnormalities. Causes include congenital defects such as an abnormal hymen blockages or narrowing of the cervix, missing uterus or vagina vaginal septum

26. Manifestation Of Amenorrhea Weight gain or loss breast discharge vaginal dryness increased hair growth changes in breast size voice changes. Diagnostic test : The pelvic examination will seek to determine the presence of structural abnormalities or the presence of growths. H ormone levels An examination of internal structure may include a computed tomography (CT) scan MRI Ultrasound H ysterosalpingogram

27. Medical management of amenorrhea Hormonal therapy Nursing intervention: Encourage patients to complete their hormonal treatment and emphasize the importance of follow-up visits. Observe menstrual flow by saving pads. Provide proper nutrition and fluids. Provide emotional support. Provide family and patient education.

28. Dysmenorrhea Dysmenorrhea is uterine pain with menstruation, commonly called “menstrual cramps.” Primary dysmenorrhea that is not associated with pelvic disorders usually develops when ovulatory function is established and there is no underlying organic disease. Often it disappears or declines after pregnancy or by the time a woman is in her late 20s. Secondary dysmenorrhea is painful menstruation in women who have normal periods, The cause is linked to disorders of the reproductive tract. Potential causes include fibroid tumors, endometriosis, pelvic inflammatory disease (PID), sexually transmitted infections (STIs), and premenstrual syndrome (PMS).

29. Causes of dysmenorrhea N ulliparity heavy periods anxiety/depression attempts to lose weight hormonal imbalance hyper contractility of the uterus inadequate diet and exercise

30. Manifestation of dysmenorrhea A nemia , and fatigue B reast tenderness A bdominal distention N ausea and vomiting H eadache , vertigo E xcessive perspiration Pain, infrequently , dull pain in the lower pelvis that radiates toward the perineum and back. This pain may be experienced 24 to 48 hours before menses or at the onset of menses

31. Diagnostic test for dysmenorrhea complete blood count and cultures to check for the presence of STIs. A pelvic examination will be performed to assess for structural abnormalities. Ultrasonography Medical management of dysmenorrhea: Diet modification Mild analgesics are prescribed. Local applications of heat and warm showers are helpful. Supplementation with vitamin B6, calcium, and magnesium. Walking and weight loss for the overweight are helpful. Aerobic exercise is most beneficial.

32. Surgical Intervention Of Dysmenorrhea Laparoscopy: to visualize the reproductive and abdominal organs or structures. Hysterosalpingography: also known as uterosalpingography, is a radiologic procedure to investigate the shape of the uterine cavity, shape and patency of the fallopian tubes. D&C: Dilation and curettage refers to the dilation of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus. Nursing Intervention: Encourage a positive attitude and instruct women to maintain good posture, exercise, and practice good nutrition.

33. Abnormal Uterine Bleeding (Menorrhagia and Metrorrhagia) Menorrhagia is excessive bleeding at the time of regular menstrual flow. excessive bleeding can be characterized as increased in duration (more than 7 days), increased in amount (more than 80 mL), or both. Causes: Potential causes may involve uterine growths or tumors, cancer of the uterus, hormonal imbalance, pelvic inflammatory disease, medications and disorders of coagulation. In younger women it may be hormonal disturbances , but in older women it usually indicates inflammatory disturbances or uterine tumors. Uterine fibroids (also called leiomyomas ) and endometrial polyps are common causes of menorrhagia in women in their 30s and 40s. The severity of menorrhagia is usually estimated in terms of the number of pads used in excess of those used for regular menstrual flow.

34. Cont .. Metrorrhagia is the appearance of uterine bleeding between regular menstrual periods or after menopause. It requires treatment because it may indicate cancer or benign tumors of the uterus and ovaries. Endometrial cancer must be considered for postmenopausal women experiencing spotting. Diagnostic test: C omplete health history and review of the symptoms being reported. Focus should be on the past menstrual history. This should include length of periods and characteristics of the bleeding. Medication history should include the use of oral contraceptives. Review the patient's obstetrical history, sexual history should include partners, onset of regular sexual activity, and any past or present STIs.

35. Cont.. Diagnostic evaluation will include a Pap smear with speculum and pelvic examination. Laboratory testing will include blood tests and may include thyroid function assessments, hormone levels, pregnancy testing, and complete blood count studies. Endometrial biopsy and ultrasonography are also used to diagnose gynecologic causes of menorrhagia and metrorrhagia . Nursing intervention?

36. Premenstrual syndrome (PMS) Premenstrual syndrome (PMS) refers to physical and emotional symptoms that occur in the one to two weeks before a woman's period. Symptoms often vary between women and resolve around the start of bleeding. Common symptoms include acne, tender breasts, bloating, feeling tired, irritability, and mood changes. Menopause: This term refers to the normal cessation of menses, is the normal decline of ovarian function resulting from the aging process. Menopause begins in most women between 42 and 58 years of age and is characterized by eventual cessation of the menstrual flow.

37. Nursing Interventions and Patient Teaching Set up an exercise program that includes both movement and weight bearing to slow bone loss. modify coronary artery disease risk factors. Walking is an excellent weight-bearing exercise, Other exercises include bicycling, aerobic dancing three or four times per week. For patient teaching, emphasize that menopause is not the end of the patient's sex life. A nutritious diet and weight control will improve physical condition, and an exercise program will promote vitality. Interest and participation in various activities help decrease anxiety and tension. Skin creams and lotions can be used to prevent drying, pruritus, and cracking skin. Encourage the woman to perform breast self-examination (BSE) monthly and to monitor calcium intake. Women can practice Kegel exercises regularly to strengthen pelvic muscles. Emphasize that an annual physical examination is important for maintaining good health.

38. 5. Endometriosis Endometriosis is a condition in which endometrial tissue appears outside the endometrial cavity . Endometrial tissue can be found on the ovaries, the fallopian tubes, and the uterus, within the abdominal cavity and in the vagina.

39. Causes Of Endometriosis The cause of  endometriosis  is unknown. E ndometrial  tissue is deposited in unusual locations by the retrograde flow of menstrual debris through the Fallopian tubes into the pelvic and abdominal cavities. The  cause of this retrograde menstruation is not clearly understood.

40. Pathophysiology M enstrual backflow to the fallopian tubes and pelvic cavity, or through congenital displacement of the endometrial cells. The condition is believed to affect 40% to 60% of women who experience painful menstrual periods. The tissue responds to the normal monthly hormonal stimulation of the ovaries. The displaced tissue bleeds each month and forms an endometrial crust, which causes the development of an endometrial cyst. This cyst may rupture and cause further reproduction of tissue.

41. Manifestations of endometriosis Dysmenorrhea is the most common complaint. Lower abdominal and pelvic pain with or without pain in the rectum, that may be unilateral or bilateral and may radiate to the lower back, legs, and groin is also reported. Symptoms are more acute during menstruation and subside after menstruation. Women higher socioeconomic classes and who postpone childbearing until the later reproductive years.

42. Diagnostic Tests for endometriosis Ultrasound Laparoscopy with a biopsy of the lesions may confirm the diagnosis. Regular pelvic examinations are recommended to monitor progression. Medical management of endometriosis : Medical treatment consists of high-dose antiovulatory medications to inhibit ovulation and suppressing menstruation. It is believed that an interruption of the menstrual cycle will slow the progress of the disorder. Some women who become pregnant are asymptomatic after pregnancy. When involvement is severe, surgery may be necessary.

43. Surgical Management Of Endometriosis A laparoscopy may be performed to remove endometrial adhesions . Sever endometriosis may require such as hysterectomy (removal of the uterus), oophorectomy (removal of the ovaries), and salpingectomy (removal of the fallopian tubes

44. Nursing intervention of endometriosis instruct the patient regarding the dosage, frequency, and side effects of prescribed medications. emphasize the importance of regular checkups and of reporting abnormal vaginal bleeding. Also encourage the patient to verbalize her concerns, and assist the patient with comfort measures. Eating a balanced diet and regular physical activity are also helpful.

45. 6. Pelvic inflammatory diseases PID is any acute, recurrent , or chronic infection that may involve the cervix (cervicitis), uterus ( endometritis ), fallopian tubes ( salpingitis ), or ovaries ( oophoritis ) and may extend to the connective tissues lying between the layers of the broad ligaments (folds of peritoneum supporting the uterus).

46. Causes of PID The most common causative organisms are Neisseria gonorrhoeae , streptococci, staphylococci, chlamydiae , and tubercle bacilli. PID can follow the insertion of a biopsy curette I rrigation catheter Abortion P elvic surgery S exual intercourse P regnancy .

47. Pathophysiology Bacterial invasion D estroy the cervical mucus, bacteria ascend into the uterine cavity. PID is serious because it may cause adhesions and sterility. Sexually active women with more than one partner are at increased risk for PID

48. Manifestation of PID T emperature elevation, chills severe abdominal pain Malaise nausea and vomiting malodorous purulent vaginal discharge Diagnostic Tests For PID sample of secretions from the endocervix, urethra, and rectum. ( Culture and sensitivity). Laparoscopic visualization of the pelvic inflammation. Vaginal ultrasonic examinations.

49. Medical Management of PID: Treatment includes antibiotics administered intravenously or intramuscularly. Intercourse must be avoided for the entire time of treatment. The patient's partner(s) must be examined and treated as well. Pain control, rest, and adequate fluid intake are essential to the care . Nursing intervention of PID: The patient is usually hospitalized to isolate the organism, use standard precautions. administer prescribed analgesics. monitoring vital signs providing fluids to avoid dehydration Provide palliative measures for comfort such as bathing, changing of perineal pads, personal hygiene, and warm douches providing patient support with a positive, nonjudgmental attitude positioning the patient in Fowler's position to facilitate drainage. Educate patient for Personal hygiene practices to reduce infection.

50. 7. Uterine prolapse A uterine prolapse is when uterus  descends toward or into the vagina. It happens when the pelvic floor muscles and ligaments become weak and are no longer able to support the  uterus. Causes of Uterine prolapse : weakened or damaged muscles and connective tissues such as ligaments allow the  uterus  to drop into the vagina. Pregnancy Childbirth hormonal changes after menopause Obesity severe coughing and straining on the toilet

51. Pathophysiology Causative agent increases intra-abdominal pressure S tretching and tearing of e ndopelvic fascia(a detachable covering) and ligaments Decreases perineum muscle tone Vagina and uterus descent Bulges on the outer vaginal area

52. Manifestation of uterine prolapse: Sensation of heaviness or pulling in your pelvis. Tissue protruding from your vagina. Urinary problems, such as urine leakage (incontinence) or urine retention. Diagnostic test for uterine prolapse: Pelvic examination Vaginal examination U ltrasound

53. Medical Management Of Uterine Prolapse Avoid heavy lifting or strenuous activities. Pessaries and surgery are two options for treatment. Surgical interventions of uterine prolapse: T he uterus is sutured back into place and repaired to strengthen and tighten the muscle bands. In postmenopausal women, the uterus may be removed (hysterectomy). For elderly women pessaries may be the treatment of choice

54. Nursing intervention of uterine prolapse During pregnancy, early visits to the health care provider permit early detection of problems. During the postpartum period, the woman can be taught to perform Kegel exercises to strengthen the muscles that support the uterus. Prescribe mild laxatives, analgesic. Instruct to avoid lifting heavy objects or standing for prolonged periods . The patient is instructed to report any pelvic pain, unusual discharge and vaginal bleeding.

55. 8. Cystocele/Rectocele A  cystocele , also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina . Causes: When the tissue, muscles, and ligaments that support the uterus and perineum have been stretched and weakened by childbearing, multiple births, or cervical tears, the organs gradually move into other positions.

56. 9. Rectocele A rectocele is a herniation (bulge) of the front wall of the rectum into the back wall of the vagina. The tissue between the rectum and the vagina is known as the rectovaginal septum and this structure can become thin and weak over time, resulting in a rectocele.

57. Manifestation of Cystocele/Rectocele Cystocele: U rinary urgency, frequency, and incontinence Fatigue and pelvic pressure. Urinary retention leads to infection Rectocele: Constipation R ectal pressure Heaviness H emorrhoids .

58. Diagnostic Test For Cystocele /Rectocele Pelvic examination Per vaginal examination Cystoscopy Sigmoidoscopy Medical management is not essential for cystocele/ rectocele.

59. S urgical Management Of Cystocele/Rectocele Cystocele and rectocele are corrected through anteroposterior colporrhaphy , a surgical repair involving repair of a defect in the vaginal wall.

60. Nursing intervention of cystocele/rectocele A liquid diet for 48 hours before surgery will help keep the bowel empty. A cleansing vaginal douche is given the evening before and the morning of surgery. Postoperative care includes checking vital signs and observing for hemorrhage. A Foley catheter is usually inserted into the bladder to keep it empty and to prevent pressure on sutures. Administer Stool softeners are often prescribed. Encourage early ambulation. Advise the patient against standing for long periods or lifting heavy objects. Coitus must be avoided until healing occurs, usually after about 6 weeks.

61. 10. Vaginal Fistulas A fistula is defined as an abnormal opening between two organs. Vaginal fistulas are the organs involved For example: A Urethrovaginal Fistula is an opening between the urethra and the vagina. A Vesicovaginal Fistula is an opening between the bladder and the vagina. A Vesicouterine fistula is an opening between the urinary bladder and uterus. A Rectovaginal Fistula is an opening between the rectum and the vagina .

62. Causes of fistulas ulcerating process radiation weakening of tissue by pregnancies surgical interventions Manifestation of fistulas: odor of urine or feces a bladder infection constant trickling of urine into the vagina allows feces and flatus into the vagina.

63. Diagnostic test for vaginal fistulas methylene blue instillation in the bladder Pyelogram cystoscopy Pelvic examination Medical management of vaginal fistulas: Smaller fistulas may be managed conservatively. The vesicovaginal fistula may be managed with application of a fibrin glue sealant, which is applied on the fistula . Larger fistulas may require surgical intervention accompanied by urinary or bowel diversion. A diet high in protein, to promote healing. Dietary fiber is beneficial to prevent constipation and straining. Antibiotics are included in the plan of treatment.

64. Surgical Management Of Vaginal Fistulas Repair of vaginal fistula Nursing Intervention of vaginal fistula: Provide hygiene care for leakage of urine or stool into the vagina is disturbing for the patient. Sitz baths, deodorizing douches, perineal pads, and protective undergarments are necessary. If the fistula is repaired surgically, a Foley catheter is inserted postoperatively to prevent strain on the suture. Provide high protein and high fiber diet. Instruct to avoid heavy lifting and straining.

65. 11. Infertility Infertility is defined as the inability to conceive after 1 year of sexual intercourse without birth control measures. Primary infertility refers to couples who have never conceived. Secondary infertility refers to couples who have conceived but are now unable to do so. An estimated 10 to 15% of couples are infertile . Women are most fertile between 20 and 29 years of age. After age 35 fertility begins to decline. A man's fertility does not dramatically decrease with aging.

66. Female related causes of infertility Female-related causes of infertility include ovulatory issues, hormonal imbalances, and structural abnormalities. Women who do not experience ovulatory menstrual cycles will not conceive. Hormonal imbalances can be linked to problematic levels of estrogen, progesterone, and follicle-stimulating hormone (FSH). These hormones are responsible for the maturation and release of the ovum from the ovaries as well as preparation of the uterus for implantation of the fertilized egg. Structural abnormalities may include scarring from sexually transmitted infections or endometriosis, abnormalities in the shape and size of the uterus, the presence of uterine fibroid tumors, and blockages in the fallopian tubes. Lifestyle factors that may play a part in a woman's fertility include increasing age, smoking, excessive alcohol use, athletic training, obesity, or being underweight

67. Male related causes of infertility The inability to conceive may be attributed to the woman or the man. Ninety percent of male-related infertility is caused by abnormalities in the sperm. The sperm count may be diminished or absent. Structural abnormalities and low motility may account for infertility. Abnormally shaped sperm cannot penetrate and fertilize the ovum. Additional male related causes include hormonal imbalances, anatomical abnormalities, and genetic defects . The use of alcohol and drugs, smoking, exposure to environmental toxins, and some medications may result in reduced or absent fertility. Illness such as cancer and the related treatments may render a man infertile

68. Diagnostic test for infertility Male testing: Genetic defects and disorders of the testes are explored. Male infertility testing includes semen analysis, which measures the quantity and quality of semen, volume of sperm cells, sperm motility. endocrine imbalance testing. Female testing: assessment of ovulatory functioning. endometrial biopsy Hysterosalpingography and hysterography to assess the position and alignment of the reproductive organs . Male and female interaction studies include ( Huhner's test) which examines the cervical mucus for motile sperm cells after intercourse. testing both the man and woman for normalcy of their sex chromosomes

69. Medical management of infertility The management of infertility problems depends on the cause. If infertility is secondary to an alteration in ovarian function, supplemental hormone therapy may be attempted to restore and maintain ovulation. Structural abnormalities may be investigated for surgical correction. Fibroid, tumors and scar tissue may be candidates for surgery. administration of estrogens can improve the quantity and quality of the cervical mucus. Eliminating or reducing psychological stress can improve the emotional climate, making it more conducive to achieving a pregnancy. Education of the couple regarding the probable time of ovulation and appropriate coital technique may also be indicated. Timing of sexual intercourse to the days preceding and at ovulation is best.

70. Cont.. When a couple has not succeeded in conceiving even with infertility management, another option is intrauterine insemination with the partner's or a donor's sperm. If this technique does not succeed, in vitro fertilization (IVF) may be used. IVF is the removal of mature oocytes from the woman's ovarian follicles via laparoscopy, followed by fertilization of the ova with the partner's sperm in a Petri dish. When fertilization occurred , some of the resulting embryos are transferred into the woman's uterus. The procedure requires 2 or 3 days to complete and is used in cases of fallopian tube obstruction, decreased sperm count, and unexplained infertility. IVF is costly and emotionally stressful, but it has become an accepted therapy for infertile couples.

71. Surgical management of infertility surgery is required include: For female the removal of uterine fibroids, polyps and endometriosis tissue. For men, surgical treatments include vasectomy reversal and varicocele repair, a procedure treating varicose veins in the scrotum.

72. Nursing Intervention Of Infertility The nurse has a major responsibility for teaching and providing emotional support throughout the infertility testing and treatment period. Provide support when Feelings of anger, frustration, sadness, and helplessness between partners and between the couple. Infertility can generate great tension in a marriage as the couple. Shame and guilt may arise when other people become involved in such an intimate area procedure. Encourage couples to participate in a support group for infertile couples and in individual therapy. Give couples ample opportunity to plan what is financially realistic.

73. 12. Ectopic Pregnancy It occurs when a fertilized ovum becomes implanted on any tissue other than the uterine lining ( eg , the fallopian tube, ovary, abdomen, or cervix). The most common site of ectopic pregnancy is the fallopian tube.

74. Risk factors of ectopic pregnancy History of pelvic inflammatory disease Tubal Structural Defects Endometriosis Past history of reproductive organs surgery Smoking Assistive Reproductive Techniques Low Progesterone Levels.

75. Pathophysiology Once the fertilized ovum implants, it begins to grow and develop. It becomes too large to be contained. This results in pain. If the pregnancy is not aborted, it ultimately results in rupture of the tube and bleeding into the abdominal cavity. Ectopic pregnancy is a significant cause of maternal morbidity and mortality, even in developed countries.

76. Manifestation Of Ectopic Pregnancy The woman often presents with lower abdominal pain. The pain may be diffuse or one sided. Vaginal bleeding may be present. If the fallopian tube has ruptured, she may have vaginal bleeding, referred shoulder pain, and abdominal rigidity. Nausea and vomiting with pain. Sharp abdominal cramps Diagnostic Test For Ectopic Pregnancy: Vaginal ultrasound Pregnancy test Abdominal ultrasound

77. Medical Management of ectopic pregnancy : A vaginal examination also is performed by doctor, to treat surgically and pharmacologically. Provide hydration. i f the fallopian tube is ruptured and significant bleeding occurs, blood transfusions may be necessary. Pharmacologic therapy Single or multiple doses of methotrexate may be prescribed for treatment of the unruptured ectopic pregnancy, It destroys the rapidly by dividing cells.

78. Surgical management of ectopic pregnancy A laparotomy , requires removal of the pregnancy and related damaged tissue. R emoval of the fallopian tube (salpingectomy) or repair of the damaged tube (salpingostomy). Abdominal  salpingectomy  patients usually require about 3-6 weeks  recovery  time, while laparoscopic patients will typically heal within 2-4 weeks. Both patients should be able to walk after about three days. Get plenty of rest during your  recovery , but make an effort to get regular light exercise as well.

79. Nursing intervention of ectopic pregnancy Provide support to woman and her family that may include anger, grief, guilt, and self-blame. Provide education to woman she also may be anxious about her ability to become pregnant. use therapeutic communication techniques that help the woman deal with her anxiety and grief. Observe vaginal bleeding, lower abdominal pain, signs of sepsis. Provide nutrition balance and hydration. Advice to postpone pregnancy for 3months atleast .

80. 13. Abortion Abortion is the termination of pregnancy before the age of viability or 20 weeks of gestation. The two types of abortion are: S pontaneous abortion : which results from natural causes. Spontaneous abortion is generally referred to by the lay public as a miscarriage. Most spontaneous abortions occur during the first trimester of pregnancy.

81. Cont.. Therapeutic abortion: (including elective abortion), which is the interruption of the pregnancy for medical or personal reasons. medical   abortion  (the " abortion  pill") – taking medication to end the pregnancy. surgical  abortion a minor procedure to remove the pregnancy.

82. Spontaneous abortion classified Threatened abortion: Unexplained bleeding and cramping occur. The fetus may or may not be alive. Membranes remain intact, and the cervix remains closed. Inevitable abortion: Bleeding increases, and the cervical os begins to dilate. Membranes may rupture. Complete abortion: All products of conception are expelled from the uterus . Incomplete : Some, but not all, of the products of conception are expelled.

83. Cont .. Missed abortion: The fetus dies and growth ceases, but the fetus remains in utero. Amenorrhea continues, but no uterine growth is measurable. In fact, the uterus may decrease in size. Septic abortion: Malodorous bleeding, elevated temperature, and cramping may be present, cervix is opened and abdominal tenderness is typical. Habitual abortion: This is often referred to as recurrent spontaneous abortion, when the woman has spontaneously aborted in three or more consecutive pregnancies, emotional trauma is increased, especially.

84. Causes of abortion Maternal Age Parity Chronic Infections Chronic Diseases Poor Nutrition Recreational Drug use (chemical substances are usually started to provide pleasure)like morphine, alcohol etc. Common manifestation of abortion: The main presenting symptom is bleeding, which may or may not be accompanied by cramps or backache.

85. Medical Management Of Abortion A dminister intravenous (IV) fluids and replace blood loss with transfusions, as ordered. If blood loss occurred, iron supplementation may be ordered. Rh-negative women need the administration of RhoGAM . ( RhoGAM  is a prescription medicine that is used to prevent Rh immunization, a condition in which an individual with Rh-negative blood develops antibodies after exposure to Rh-positive blood.  RhoGAM  is administered by intramuscular (IM) injection.  RhoGAM  is purified from human plasma containing anti-Rh)

86. C ont.. Threatened abortion: Decreased activity, sedation, and avoidance of stress. Inevitable , incomplete abortion : Prompt termination of pregnancy is accomplished, usually by dilation and evacuation (D&E). Complete abortion: No further intervention may be needed if uterine contractions are adequate to prevent hemorrhage and if there is no infection. Missed abortion: If spontaneous evacuation of the uterus does not occur, pregnancy is terminated with method appropriate either medically or surgically.

87. Cont.. Septic abortion: Pregnancy is immediately terminated with appropriate method, Cervical culture and sensitivity studies are done, and broad-spectrum antibiotic therapy (e.g., ampicillin) is started. Treatment for septic shock is initiated if necessary. If signs of uterine infection are seen, such as an elevated temperature, vaginal discharge with a foul odor, or abdominal pain .

88. Surgical management of abortion D&C: Dilation and curettage refers to the dilation of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus. D&E: Dilation and evacuation is the dilation of the cervix and surgical evacuation of the contents in the uterus. Laparotomy: to drain the abscess in sever condition.

89. Nursing intervention of abortion Instruct patient to avoid sexual intercourse until bleeding has stopped. Acknowledge that patient has experienced a loss and that time is needed for recovery. Instruct family that She may experience mood swings and depression. Instruct patient to take antibiotics as prescribed. Advise patient to postpone attempts at pregnancy for at least 2 months to allow her body to recover. Advice to take balance diet, food reach in iron. Encourage to take fluid intake. Advise patient to report any heavy, bright red bleeding to physician.

90. 14. Hydatidiform Mole (Molar Pregnancy) Hydatidiform mole (molar pregnancy) is a gestational trophoblastic disease (the abnormal growth of trophoblasts , the cells that normally develop into the placenta . ) (the placental tissue is abnormal and swollen and appears to form fluid-filled cysts.) Hydatidiform moles come in two distinct types: complete (or classic) mole. partial mole.

91. Causes of Hydatidiform mole Hydatidiform mole etiology is unknown. although an ovular defect may occur. Women are at higher risk for hydatidiform mole formation if they have undergone ovulation early teens, or are older than 40 years of age. Pathophysiology: The mole results from fertilization of an egg. Placental cell starts to grow abnormally in large amount. The developing cells resemble a cluster of grapes. The fluid-filled vesicles grow rapidly, causing the uterus to be larger than expected for the duration of the pregnancy.

92. Manifestation Of Hydatidiform Mole Hydatidiform mole in the early stage cannot be distinguished from those of normal pregnancy. vaginal bleeding occurs in almost 95% of cases. vaginal discharge may be dark brown or bright red Uterus larger than expected Anemia from blood loss excessive nausea and vomiting abdominal cramps caused by uterine distention There is no fetal movement, FHR, or palpable fetal parts.

93. Diagnostic test for Hydatidiform mole Diagnosis can be made with ultrasound scan. amniography (radiographic visualization of the outlines of the uterine cavity, placenta, and fetus after injection of a radiopaque substance into the amnion .) measurement of pregnancy level in the blood . Medical Management of Hydatidiform moles: The molar pregnancy is traditionally managed with a suction curettage. monitor patient repeated on a monthly basis. After surgical removal if hydatidiform return to positive findings may signal the presence of carcinoma. Women who have experienced a molar pregnancy must avoid becoming pregnant for a year. Even with removal of the products of conception, cells may remain behind and develop into a malignancy.

94. Nursing Intervention Of Hydatidiform Moles The woman and her family need information about the disease process, the necessity for a long course of follow-up, and the possible consequences of the disease. Help the woman understand and cope with pregnancy loss. Encourage the woman and her family to express their feelings, provide counseling resources if needed. Explain the need to postpone a subsequent pregnancy the next year, and provide contraception counseling. Provide proper nutrition and fluid intake to replace the blood loss.

95. 15. Ovarian cyst Ovarian cysts are benign tumors that arise from dermoid cells of the ovary. Ovarian cysts  are fluid-filled sacs or pockets in an ovary or on its surface . Causes Of Ovarian Cyst: Hormonal problems Endometriosis Pregnancy Severe pelvic infection Pathophysiology Of Ovarian Cyst: When the follicle fails to rupture and continues to grow, a follicular  cyst  occurs. When the corpus luteum fails to involute and continues to grow, a corpus luteum  cyst  occurs

96. Manifestation of ovarian cyst Ovarian cysts enlarge and are palpable on physical examination. They may cause no symptoms, or they may result in a disturbance of menstruation. a feeling of heaviness slight vaginal bleeding. sharp abdominal pain Diagnostic test for ovarian cyst: Ultrasound (pelvic, abdomen) Hormonal level test Physical examination

97. Medical management of ovarian cyst The cysts may be removed by ovarian cystectomy. Often ovarian cysts are not removed if the patient is not experiencing any symptoms . Administer hormonal therapy. Surgical management of ovarian cyst: small incision using laparoscopy or through a larger abdominal incision (laparotomy ). During   surgery , cyst removed (cystectomy), leaving the  ovary  intact.

98. Nursing intervention of ovarian cyst Provide proper nutrition, diet high in protein and iron. Encourage fluid intake. Observe for vaginal bleeding and abdominal pain. Observe for signs of sepsis, check vital signs. Provide emotional support to the patient and family. Instruct patient to observe menstrual cycle regularity, blood flow.

99. 16. Ovarian Tumor/ cancer Ovarian cancer, the fifth most common cause of cancer death in women, is the leading cause of gynecologic death. Ovarian cancer is a abnormal growth of cells inside the ovaries. Causes And Pathophysiology Of Ovarian Cancer: Women at increased risk are those who are infertile, an- ovulatory, nulliparous, and habitual aborters. Because they reduce the number of ovulatory cycles, thus reducing exposure to estrogen, the following practices can reduce the risk of ovarian cancer. oral contraceptive use (greater than 5 years), multiple pregnancies, breastfeeding, and early age of first birth.

100. Manifestation Of Ovarian Cancer abdominal discomfort Flatulence mild gastric disturbances and pressure Bloating Cramps sense of pelvic heaviness feeling of fullness change in bowel habits Pain is not an early symptom, As the tumor progresses, abdominal girth enlarges from ascites (accumulation of fluid in the peritoneal cavity), and there is flatulence with distention. Other symptoms may include urinary frequency, nausea, vomiting, constipation, menstrual irregularities, and weight loss. difficulty eating feeling full quickly, and urinary urgency or frequency

101. Diagnostic Test For Ovarian Tumor P elvic examination may help to identify pelvic masses Post menopause palpable ovary syndrome (a palpable ovary in a woman 3 to 5 years after menopause) may indicate an early tumor. CT scan of the pelvis and abdomen T umor biopsy (laparotomy) Needle aspiration of ascetic fluid can also detection of cancer cells in the fluid. A blood test to determine CA-125 is used to identify women with ovarian cancer. Vaginal ultrasonography

102. Medical Management Of Ovarian Tumor Treatment often involves surgery alone or with radiation or chemotherapy. Treatment depends on the stage of ovarian cancer. Surgical Management Of Ovarian Tumor: O mentectomy (excision of portions of the peritoneal folds). Oophorectomy (ovary is removed) intraperitoneal chemotherapy, administered through a surgically implanted catheter, in addition to the standard IV chemotherapy. Nursing Intervention?

103. 17. Uterine Tumor/Fibroids Leiomyomas (fibroids, myomas) are the most common benign tumors of the female genital tract. Fibroids are benign tumors arising from the muscle tissue of the uterus, abnormal growth of cells. Causes Of Uterine Tumor: Estrogen and progesterone Growth hormones Major stresses

104. Manifestation Of Uterine Tumor Some women with fibroid tumors are asymptomatic. Increasing pressure of tumors on the uterus and pelvic organs may cause discomfort. Pain dysmenorrhea abnormal uterine bleeding Menorrhagia, If the fibroid tumor becomes large enough to cause pressure on other structures, the patient may have backache, constipation, and urinary symptoms. Diagnostic Test For Uterine Tumor: pelvic examination pelvic ultrasonography MRI x-rays CT scan. Hysterosalpingogram (Surgical intervention such as a laparoscopy or hysteroscopy may be used to visualize fibroid tumors .)

105. Medical Management Of Uterine Tumor Administer medication for Pain management Women who experience heavy menstrual bleeding may require iron supplementation. Dysmenorrhea may be managed with low-dose oral contraceptives . Prior to surgical intervention medications may be prescribed to shrink the tumors. A gonadotropin-releasing hormone agonist ( GnRHa ) may be administered by injection or nasal spray, or implanted. Surgical Management Of Uterine Tumor: Myomectomy (removal of uterine myomas )is the procedure of choice for women hoping to maintain fertility. If during the surgery there is severe bleeding or an obstruction is found, a hysterectomy may still be necessary. A hysterectomy is performed if the fibroids cause excessive vaginal bleeding or if the woman has no desire to maintain fertility.

106. Cont.. Uterine Artery Embolization : This procedure consists of injecting embolic material (small plastic or gelatin beads) into the uterine artery, which carries the material to the fibroid branches and thus occludes the arteries supplying blood to the tumor. Deprived of oxygen and nutrients, the tumor shrinks over time and symptoms diminish.

107. Nursing intervention of uterine tumor Provide explanation of treatment plan, either a total hysterectomy or pelvic examination at regular intervals to monitor the status of the fibroid tumor. instruct the patient about the dosage, frequency, and possible side effects of prescribed medications. Provide diet, high in iron due to blood loss. encourage the patient to express her feelings and assist her with coping mechanisms. Provide physical and emotional support to patient.

108. 18. Breast Cancer/Tumor Breast cancer is the second most common malignancy (after lung cancer) affecting women. Breast cancer is typically abnormal and extra growth of cells. The cause of breast cancer is unknown. Breast cancer is usually an adenocarcinoma, arising from the epithelium and developing in the lactiferous ducts, it infiltrates the parenchyma (the functioning tissue of an organ).

109. Causes of breast cancer Being female Increasing age history of breast  disease family history of breast cancer Radiation exposure Obesity Parity (total number of pregnancies) Risk is decreased for women who gave birth. women who are not sexually active infertile women women who became pregnant for the first time after 30 years of age Menopause after 55 years of age Risk is increased for women diagnosed with some other form of cancer, such as endometrial, ovarian, or colon cancer. if cancer has appeared in one breast, it is more likely to occur in the other breast.

110. Pathophysiology of breast cancer Breast cancer is usually an adenocarcinoma, arising from the epithelium and developing in the lactiferous ducts; it infiltrates the parenchyma (the functioning tissue of an organ other than the supporting or connective tissue). The cancer occurs most often in women who have not given birth or breastfed a child. It occurs most often in the upper outer quadrant of the breast because this is the location of most of the glandular tissue. A slow-growing breast cancer may take up to 10 or more years to become palpable, or to reach the size of a small pea. In breast cancer, metastasis occurs via the lymphatic system and bloodstream, The most common sites for metastasis are, in order, the bones, lungs, pleura, other breast sites, central nervous system, and liver

111. Manifestation of breast cancer Breast cancer is detected as a lump Breast tumors are usually small, solitary, irregularly shaped , non-tender , and non-mobile . There may be a change in skin color feelings of tenderness puckering or dimpling of tissue (skin with the appearance and texture of an orange peel) nipple discharge retraction of the nipple axillary tenderness More than 90% of breast cancers are detected by the patient. Women should perform BSEs monthly, preferably 1 week after menses. Postmenopausal women should perform a BSE on the same day each month.

112. Diagnostic test for breast cance r R egular performance of BSE Regular clinical breast examination (CBE), and routine mammography. P hysical examinations Personal and family history Mammography Breast tissues Biopsy Fine needle aspiration : is a type of biopsy procedure, a thin needle is inserted into an area of abnormal-appearing tissue or body fluid, the sample collected, can help make a diagnosis or rule out conditions such as cancer. U ltrasound

113. Stages Of Breast Cancer Stage 0 : Refers to carcinoma in situ, in which the tumor is confined to the milk duct or the lobule, no lymph nodes have been affected, and no metastasis has occurred. Stage I: The tumor is 2 cm or smaller, Lymph nodes are negative. There is no distant cancer spread. Stage IIA: The tumor is 5 cm or smaller, It may have spread to one, two, or three axillary nodes. There is no distant cancer spread. Stage IIB: The tumor can be larger than 5 cm, Up to three lymph nodes may be involved, but there is no metastasis to other organs. Stage IIIA: The tumor may be more than 5 cm and has spread to more than 3 but fewer than 10 lymph nodes. No distant organs are involved. Stage IIIB: The tumor, regardless of size, has spread to the chest wall or the skin. There is lymph node involvement but no distant metastasis. Stage IIIC: Refers to any size tumor, including one that has spread to the chest wall or the skin. There is involvement of 10 or more lymph nodes, but no distant metastasis. Stage IV: The tumor can be any size. There is nodal involvement

114. Medical management of breast cancer The intervention for treatment of breast cancer depends on the tumor stage, the patient's age and health, the hormonal status, and the presence of estrogen receptors in the tumor. Radiation , chemotherapy Staging : After breast surgery and axillary dissection, it completes the process. Axillary lymph node dissection or sentinel lymph node mapping is usually performed regardless of the treatment option selected.

115. Surgical Intervention Of Breast Cancer Surgery plays a vital role in the management of breast cancer. Lumpectomy: removed along with the tumor, This surgery is usually done when the tumor is small and located on the peripheral area of the breast. A simple mastectomy involves removal of the entire breast. The skin flap is retained to cover the incised area. Both pectoralis major and pectoralis minor muscles are left intact. The patient has the option of breast reconstruction.

116. Cont... A modified radical mastectomy may be performed if the tumor is 4 cm or larger, In this operation all breast tissue, overlying skin, nipple, and pectoralis minor muscles are removed, as are samples of axillary lymph nodes, The pectoralis major muscle remains intact. The patient has the option of breast reconstruction.

117. Nursing Intervention Of Breast Cancer P lay an active role as listener, reinforce information provided by the health care provider, and encourage the patient to verbalize her concerns and recognize her feelings about the surgery. Provide wound care. Perform aseptic techniques. Provide emotional support to patient. Administer medication as ordered by doctor.

118. References Brunner, L. S., & Suddarth , D. S. (2005). Text Book of Medical- Surgical Nursing (10th Edition). Philadelphia: Lippincott .