GYNECOLOGIC NURSING

ANATOMY RECALL
FEMALE REPRODUCTIVE SYSTEM:
EXTERNAL STRUCTURES ( VULVA/ PUDENDUM)
A. MONS PUBIS OR MONS VENERIS
= PAD OF FAT OVER THE SYMPHYSIS PUBIS.
HAIRLESS & SMOOTH IN CHILDHOOD, IT IS COVERED BY
DARK & CURLY HAIR CALLED ESCUTCHEON AFTER
PUBERTY. HAIR PATTERN IS TRIANGULAR WITH BASE UP.
B. LABIA MAJORA
= LENGTHWISE, TWO THICK FOLDS OF FATTY SKIN
EXTENDING FROM THE MONS TO THE PERINEUM THAT
PROTECTS THE LABIA MINORA, URINARY MEATUS AND
VAGINAL MUCOSA.
C. LABIA MINORA
= THINNER, LENGTHWISE FOLDS OF
HAIRLESS SKIN, ENCIRCLING THE CLITORIS
ANTERIORLY (PREPUCE) AND UNITE
POSTERIORLY ( FOURCHETTE) .BELOW THE
PREPUCE IS CALLED FRENULUM. HIGHLY
SENSITIVE TO MANIPULATION AND TRAUMA,
THE REASON WHY IT IS OFTEN TORN DURING
DELIVERY.
D. VESTIBULE
= TRIANGULAR SPACE LOCATED
BETWEEN THE LABIA MINORA CONTAINING
VAGINAL INTROITUS, URETHRAL MEATUS
BARTHOLIN’S & SKENE’S GLANDS
E. GLANS CLITORIS
= SMALL ERECTILE STRUCTURE;
CONTAINS NERVE ENDINGS, SENSITIVE TO
TEMPERATURE AND TOUCH. IT IS THE SEAT OF
SEXUAL AROUSAL AND EXCITEMENT IN
FEMALES. IT IS THE MOST SENSITIVE PART OF
A WOMAN’S BODY. IT IS ALSO THE
STRUCTURE THAT GUIDES THE NURSE TO THE
URINARY MEATUS.
F. URETHRAL MEATUS
= THE EXTERNAL OPENING OF THE
URETHRA. SLIGHTLY BEHIND AND TO THE SIDE
ARE THE OPENINGS OF THE SKENE’S GLANDS
(PARAURETHRAL GLANDS); THE SECRETIONS
OF WHICH HELP TO LUBRICATE THE EXTERNAL
GENITALIA. THE SHORTNESS OF THE FEMALE
URETHRA MAKES WOMEN MORE SUSCEPTIBLE
TO UTI THAN MEN.

G. HYMEN .
= A TOUGH BUT ELASTIC SEMICIRCLE OF
TISSUE THAT COVERS THE OPENING TO THE
VAGINA. THE REMNANT OF HYMEN IS CALLED
CARUNCULAE MYRTIFORMIS.
 Imperforate hymen:
 Lack of opening in the vaginal hymen
 No menstrual bleeding
 Enlarged uterus
 S/S
 Amenorrhoea
 Cryptomenorrhea -A condition where menstrual products
are prevented from exiting the body by a partial or complete
obstruction.
 Dyspareunia
 Female infertility
 Haematocolpos- An accumulation of menstrual blood in the
vagina
 Haematometra -An accumulation of blood in the uterus
 Hydrometrocolpos -accumulation of secretions in the vagina
and uterus
 TREATMENT
 Medical
therapy has no role in the
management of imperforate hymen

 SURGICAL MANAGEMENT
 Hymen incision
H. VAGINAL ORIFICE / INTROITUS
= EXTERNAL OPENING OF THE VAGINA,
COVERED BY A THIN MEMBRANE ( HYMEN) IN
VIRGINS.LOCATED LATERAL TO THE VAGINAL
OPENING ON BOTH SIDES ARE THE
BARTHOLIN’S GLANDS ( VULVOVAGINAL
GLANDS). IT LUBRICATES THE EXTERNAL
VULVA DURING COITUS AND THE ALKALINE PH
OF THEIR SECRETION HELPS TO IMPROVE
SPERM SURVIVAL IN THE VAGINA. THE
GRAFENBERG OR G-SPOT IS A VERY SENSITIVE
AREA LOCATED AT THE INNER ANTERIOR
ASPECT OF THE VAGINA.
I. FOURCHETTE
= THIN FOLD OF TISSUE FORMED BY
MERGING OF THE LABIA MAJORA AND
LABIA MINORA BELOW THE VAGINAL
ORIFICE.
J. PERINEUM
= MUSCULAR SKIN COVERED AREA
BETWEEN VAGINAL OPENING AND ANUS.
 INTERNAL STRUCTURES:
A.VAGINA
HOLLOW MEMBRANOUS & MUSCULAR CANAL,
3-4 INCHES LONG,DILATABLE, CONTAINS
RUGAE (WHICH PERMITS CONSIDERABLE
STRETCHING WITHOUT TEARING).IT IS
LOCATED IN FRONT OF THE RECTUM &
BEHIND THE BLADDER.
= PASSAGEWAY OF MENSTRUATION
= PASSAGEWAY OF FETUS
= ORGAN OF COPULATION
= SEMEN DEPOSITORY
** DODERLIEN’S BACILLUS MAINTAINS THE
NORMAL FLORA OF THE VAGINA, WHICH
MAKES THE pH OF VAGINA ACIDIC,
DETRIMENTAL TO THE GROWTH OF
PATHOLOGIC BACTERIA.
 VAGINA

 Functions:
 Organ of copulation
 Discharges
menstrual flow
 Birth canal

pH 4-5 : acidic
 RUGAE – TRANSVERSE FOLDS OF SKIN IN
THE VAGINAL WALL THAT IS ABSENT IN
CHILDHOOD, APPEAR AFTER PUBERTY &
DISAPPEARS AT MENOPAUSE.
 FORNIX-FORNICES= THE CERVIX
PROJECTS TO THE VAGINA FORMING FOUR
RECESSES OR DEPRESSION AROUND ITS
UPPER PORTION CALLED FORNICES:
ANTERIOR FORNIX, LATERAL FORNICES,
POSTERIOR FORNIX.
 VAGINITIS

 inflammation of the vagina characterized by

an increased vaginal discharge containing
numerous WBCs

Causes:
 Douches
 Antibiotics
 Hormones
 Contraceptives (oral and topical)
 Change in sexual partners
Signs and Symptoms:
 Itching
 Burning
 Pain
 Erythema
 Edema
 BARTHOLIN’S CYST
 occlusion of a duct with mucus retention resulting in a
nontender mass approx. 1-4cm in size

Causes
 if the duct becomes
blocked for any reason:
infection,
injury or chronic
inflammation
 Very rarely, caused by
cancer
 Unknown (many cases)
Causative organisms: Staphylococcus aureus
(others: S. fecalis, E. coli, N. gonorrhea, )

Symptoms:
 Bartholyn’s Cyst (asymptomatic)
 Bartholin’s Abscess - pain or tenderness, dyspareunia

Diagnosis
 clinical

Management
 incision and drainage
 marsupialization – entire abscess is incised and sewn open
 broad spectrum antibiotic
Nursing interventions
 Teach the importance of completing the course of
antibiotic
 Teach the importance of good hygiene
 Sitz bath – for both pain relief and to decrease
healing time
 CONGENITAL ABSENCE OF THE
VAGINA

 The usual lesion consists:

 absence of the middle and upper vagina,
 total absence or a rudiment in the location of the
uterus,
 an absence or one or both Fallopian tubes.

 The vagina may be totally absent, or

represented by a rudimentary pouch of up to one
half to three quarters of an inch deep.
Vaginal agenesis
 CONGENITAL ABSENCE OF THE
VAGINA
 is a rare anomaly, 1: 5000 birth
 Known also as aplasia or dysplasia of the
Müllerian (paramesonephric) ducts.
 Referred to as ROKITANSKY-KUSTER-
HAUSER SYNDROME
 The external genitalia and vestibule, deriving
from the urogenital sinus, are normal.
 The sex chromatin pattern is female.
 endocrine system is not affected.
 Ovarian function is normal
 CONGENITAL ABSENCE OF
THE VAGINA
 Cause :
 UNKNOWN
 no known gene is linked to this condition.
 MANIFESTATION
 Primary amenorrhea and cyclic abdominal pain
 Infertility
 Inability to have intercourse
 Associated with renal malformation
 There are associated renal and vertebral anomalies (e.g.,
fused or solitary pelvic kidney, spina bifida).
 PHYSICAL FINDING
 Normal secondary female sexual characteristics are present
after puberty.
 Height is normal.
 Speculum examination of the vagina may be impossible or
difficult because of the degree of vaginal agenesis.
 The vulva, labia majora, labia minora, and clitoris are normal.
 A palpable sling of tissue may be present at the level of the
peritoneal reflection.
 Diagnostic:
 Imaging studies
 UTZ
 MRI
 Laparoscopy provides only indirect assessment
of uterine cavitation.
 Laparoscopy is the preferred procedure when
uterine remnants or endometriosis cause cyclic
pelvic pain requiring excision.
 Pyelography: Perform intravenous pyelography
to assess renal structure.
 Radiography: Perform spinal radiography to
exclude vertebral anomalies
 Management
 Treatment : Surgical
 Vaginal reconstruction
modified McIndoe vaginoplasty
 Prognosis:
 The patient may have normal sexual functioning
after surgical reconstruction.
 Surgical reconstruction does not establish the
ability to conceive through natural means.
Modified McIndoe Vaginoplasty
** DODERLIEN’S BACILLUS MAINTAINS THE
NORMAL FLORA OF THE VAGINA, WHICH
MAKES THE pH OF VAGINA ACIDIC,
DETRIMENTAL TO THE GROWTH OF
PATHOLOGIC BACTERIA.

B. UTERUS
= HOLLOW, MUSCULAR PEAR SHAPED
ORGAN LOCATED IN THE PELVIS, WEIGHING 50-
60 g IN A NON-PREGNAT WOMAN. HELD IN
PLACE BY BROAD LIGAMENTS. ABUNDANT
BLOOD SUPPLY COMES FROM UTERINE AND
OVARIAN ARTERIES.
- DURING PUBERTY, IT INCREASES IN SIZE &
REACHES ITS MAXIMUM SIZE AT 17 YRS
- FUNCTONS:
a. ORGAN OF IMPLANTATION ( NIDATION)
AND MENSTRUATION
b. RECEIVES THE OVA FROM THE
FALLOPIAN TUBE
c. FURNISHES PROTECTION FOR A
GROWING FETUS
 DIVISIONS OF THE UTERUS
1.CERVIX
= LOWER PORTION CALLED THE NECK
a. EXTERNAL CERVICAL OS = DISTAL
OPENING TO THE VAGINA
b. CERVICAL CANAL = THE CAVITY
c. INTERNAL CERVICAL OS =
OPENING TO THE UTERUS
2. FUNDUS
= UPPERMOST CONVEX PORTION AND CAN
BE PALPATED TO DETERMINE UTERINE GROWTH
DURING PREGNANCY , TO ASSESS UTERINE
CONTRACTIONS DURING LABOR,& INVOLUTION
DURING THE POSTPARTUM PERIOD
 = MOST VASCULAR PORTION
= NORMAL IMPLANTATION SITE
3. CORPUS – BODY OF THE UTERUS WHICH
MAKES UP 2/3 OF THE SAID ORGAN. HOUSES
THE FETUS DURING PREGNANCY
4.CORNUA – THE UPPER PORTION WHERE THE
FALLOPIAN TUBES ARE ATTACHED.

LAYERS:
1.PERIMETRIUM
= OUTERMOST LAYER, IT IS ATTACHED TO
THE BROAD LIGAMENTS & OFFER ADDED
SUPPORT TO THE UTERUS
 = MOST VASCULAR PORTION
= NORMAL IMPLANTATION SITE
3. CORPUS – BODY OF THE UTERUS WHICH
MAKES UP 2/3 OF THE SAID ORGAN. HOUSES
THE FETUS DURING PREGNANCY
4.CORNUA – THE UPPER PORTION WHERE THE
FALLOPIAN TUBES ARE ATTACHED.

LAYERS:
1.PERIMETRIUM
= OUTERMOST LAYER, IT IS ATTACHED TO
THE BROAD LIGAMENTS & OFFER ADDED
SUPPORT TO THE UTERUS
2. MYOMETRIUM
= MIDDLE LAYER , EXPELS FETUS DURING
BIRTH PROCESS THEN CONTRACTS AROUND
BLOOD VESSELS TO PREVENT HEMORRHAGE
(OXYTOCIN SITE)
3. ENDOMETRIUM
= INNERMOST LAYER; THIS LAYER
UNDERGO CHANGES IN RESPONSE TO THE
HORMONES AT VARIOUS PHASES OF THE
MENSTRUAL CYCLE & DURING PREGNANCY; IT
CONSISTS OF TWO LAYERS:
 Endometriosis

 Endometrial tissue outside the uterine cavity.

 when cells from the uterus, called endometrial cells,
are found outside the uterus. The cells attach to other
organs

 Pelvis most common location

 Bleeding results to inflammation, scarring of
peritoneum and adhesions
 Cause unknown
 Common in 20-45 yrs old
Common Sites 0f Endometriosis Formation
Endometriosis
 Management

 OCP-combination contraceptives to induce amenorrhea

 Analgesics
 NSAIDS
 Danazol – antiprogesterone; suppresses GnRH, low
estrogen and high androgens to suppress ovulation,
promote amenorrhea and decrease endometrial support
 GnRH agonists ie Leuprolide suppress the menstrual cycle
through estrogen antagonism
 Progestins ie Medroxyprogesterone – antiendometrial effect
 Uterine malformation Types
classification:
 Class I: Mullerian agenesis (absent uterus).

 Class II: Unicornuate uterus (a one-sided uterus).

 Class III: Uterus didelphys, (double uterus).

 Class IV: Bicornuate uterus (uterus with two horns).

 Class V: Septated uterus (uterine septum
or partition).
 Class VI: DES uterus.
 The uterine cavity has a "T-shape" as a result
of fetal exposure to diethylstilbestrol.
 unicornuate uterus
 (a womb with one 'horn') happens when
the tissue that forms the womb does not
develop properly.
 very rare condition.
 A unicornuate uterus is just half the size of
a normal UTERUS and the woman has
only one fallopian tube. However, she
usually has two ovaries
 Unicornuate uterus
 issmaller than a typical uterus and usually
has only one functioning fallopian tube.
The other side of the uterus may have
what is called a rudimentary horn.
 Unicornuate uterus

Most of the time it does not cause

any gynecologic or obstetric
problem
 DIAGNOSTIC
 Imaging studies
 Hysterosalpingography (HSG), performed
under fluoroscopy, allows evaluation of the
uterine cavity and tubal patency
 Hysteroscopy
 three-dimensional ultrasound
 laparoscopy might also be used to confirm the
diagnosis.
 RISK
 PRETERM LABOR-is thought to be because of space
restrictions; because a unicornuate uterus is smaller than a
typical uterus, the growth of the baby might trigger early
labor.

 MISCARRIAGE-due to abnormalities in the blood supply of

the unicornuate uterus that might interfere with the
functioning of the placenta

 ECTOPIC PREGNANCY

 miscarriage in 37%
 preterm birth in 16%,
 term birth in only 45%.
 MANAGEMENT

 The resection of the obstructed hemi-

uterus can be performed laparoscopically.
 Nursing management:
 Informed consent
 Explain the procedure
 Monitor vital sign
 Emotional support
BICORNUATE UTERUS

a type of congenital uterine

malformation (müllerian duct
abnormality).
uterus is heart-shaped with two joined
cavities whereas a typical uterus has a
single cavity.
 Cause
 This can happen to women whose
mothers took a medication called DES
during pregnancy,
 it can happen for unknown reasons.
 Diagnosing Bicornuate

 hysterosalpingogram (HSG)
 hysteroscopy
 butdiagnosis should be confirmed with a
three-dimensional ultrasound or
laparoscopy.
 Double uterus
 Definition
 Ina female fetus, the uterus starts out as
two small tubes. As the fetus develops,
the tubes normally join to create one
larger, hollow organ the uterus.
Sometimes, however, the tubes don't join
completely. Instead, each one develops
into a separate cavity. This condition is
called double uterus (uterus didelphys).
 Double uterus

 Each cavity in a double uterus often leads to its own

cervix. Some women with a double uterus also have a
duplicate or divided vagina.
 Double uterus is rare — and sometimes not even
diagnosed.
 occurs in 2 %t to 4 % of women who have normal
pregnancies.
 The percentage may be higher in women with a history
of miscarriage or premature birth.
 Treatment is needed only if a double uterus causes
symptoms or complications, such as pelvic pain or
repeated miscarriages.
 Symptoms

 Some women have a double uterus and never

realize it — even during pregnancy and
childbirth.
 Possible signs and symptoms may include:
A mass in the pelvis
 Unusual pain before or during a menstrual period
 Abnormal bleeding during a period, such as blood flow
despite the use of a tampon
 Causes

 Unknown .
 The condition is associated with kidney
abnormalities, which suggests that something may
influence the development of these related tubes
before birth.
C. FALLOPIAN TUBES / OVIDUCTS /
UTERINE TUBES
= TWO SLENDER MUSCULAR TUBES
WHICH ARISES FROM EACH OF THE UPPER
CORNER OF THE UTERINE BODY AND EXTEND
OUTWARD. PROVIDES A PLACE FOR
FERTILIZATION ( CONCEPTION, FECUNDATION,
IMPREGNATION) OF OVA BY THE SPERM.
PARTS:
1.INTERSTITIAL =( 1cm) LIES WITHIN THE
UTERINE WALL. IT HAS THE SMALLEST
LUMEN.
2. ISTHMUS =( 2cm) PORTION CUT OR SEALED
DURING TUBAL LIGATION.( BTL)
3. AMPULLA =( 5cm) LONGEST PORTION,
EXACT SITE OF FERTILIZATION ( DISTAL 3RD ,
OUTER 3RD )
4. INFUNDIBULUM =MOST DISTAL PORTION;
RIM OF THE FUNNEL IS COVERED BY
FIMBRAE THAT HELPS GUIDE THE OVA INTO
THE FALLOPIAN TUBE.
 FUNCTION:
 TRANSPORT OVUM FROM OVARY TO
THE UTERUS
 SITE OF FERTILIZATION
Pelvic Inflammatory Disease: Salphingitis
 Inflammatory condition of the pelvic cavity that
may involve the ovaries, fallopian tubes,
vascular system or pelvic peritoneum. Caused
by microorganims colonizing endocervix
ascending to endometrium and fallopian tubes
 Major cause of female infertility
 Risk Factors:
 Multiplesexual partners
 Hx of PID
 Early onset of sexual activity
 IUD
 Manifestations:
 Pelvic pain ( sharp & cramping); Fever; nausea,
malaise; severe lower abdominal pain; Purulent foul
smelling vaginal discharge; Menorrhagia; tenderness
in both lower abdominal quadrants; dyspareunia
 Diagnostics & Laboratory Tests:
 Hx & PE; CBC; vaginal & endocervical culture; VDRL;
Endometrial biopsy: UTZ;
 Management:
 Antibiotics;IV fluids/ inc. oral fluid; pain meds;
Remove IUD; Evaluation of sexual partners;
application of heat to relieve pain; surgical excision of
abscess if present
Toxic Shock syndrome ( TSS)
Reproductive age, near menses or postpartum
period
D/t toxins released by S. Aureus
R/t use of tampons (Mg absorbing fibers of
tampons cause dec Mg levels contributing to
toxin production by bacteria in the lower
reproductive tract), cervical cap or
diaphragm

Manifestations: sudden high fever,

headache, vomiting, rash on trunk,
desquamation of skin, hypotension, dizziness,
diarrhea, inflamed mucous membranes
Management:
IV fluids
Antibiotics

Client education:

1.change tampons 3-6 hours

2.avoid tampons 6-8 wks after childbirth
3.do not leave diaphragms>48 hours
 BARRIER  DIAPHRAGM
-mechanically blocks sperm
METHODS from entering the cervix
-soft latex dome supported by
a metal rim
-can be inserted 2 hours
before intercourse; removed
at least 6 hours after
coitus or within 24 hours
- must be refitted if the
person gained 10 or more
lbs or has given birth
-size must fit the individual
- initially fitted by a doctor
-washable, may be used for
2-3 years
 Contraindications:
 Allergy to latex
 History of TSS
 Pelvic pain
 PID
 Tight introitus
Client Instructions:
 A woman should be fitted by an obstetrician
during the first if use & refitted after every
delivery, abortion, & weight loss of at least
10 lbs. The largest size that fits the woman
is chosen.
 Normally becomes brownish with use.
Before inserting into the vagina, it should be
inspected for tears & holes by holding it
against the light
 Spermicide gel is applied at its rim before
insertion
 Diaphragm can be inserted 2 hours before coitus
but must be left for 6 hours after intercourse.
 After use, diaphragm is washed with soap &
water, dried with a towel & can be dusted with
cornstarch. Do not use talcum powder, perfumed
substances & petrolatum jelly because they may
damage the diaphragm & irritate the vagina. It
should be stored in a plastic container in a cool
dry place.
 Can last 2-3 years
 Ifthere is difficulty in removing the diaphragm
after intercourse, bear down to bring it forward
where you can reach it with your fingers.
 Do not douche while it s inside the vagina
 Prevent TSS by:
 Washing hands before insertion or removal
 Do not leave more than 24 hours in the vagina
 Never use during menses
 Wait 12 weeks after delivery before using the
contraceptive
 Remove right away if there ssx of TSS & consult
physician
D. OVARIES
= ALMOND SHAPED ORGANS LOCATED ON
EITHER SIDE OF THE UTERUS. BEFORE
PUBERTY, THE OVARIES ARE SMOOTH, FLAT &
OVOID ORGANS. AFTER OVULATIONS, THEY
ASSUME A NODULAR & PITTED APPEARANCE.
FUNCTIONS:
= RESPONSIBLE FOR THE PRODUCTION,
MATURATION AND DISCHARGE OF OVA AND
SECRETION OF ESTROGEN AND
PROGESTERONE
= ORGAN OF OVULATION
OVARIES
 Function
 Oogenesis
 Ovulation
 Hormone
production –
estrogen &
progesteron
e
LAYERS OF THE OVARY:
1.TUNICA ALBUGINEA
- THE OUTERMOST PROTECTIVE
LAYER SURROUNDED BY A SINGLE LAYER
OF CUBOIDAL EPITHELIUM.

2. CORTEX
- THE FUNCTIONAL LAYER WHICH IS
THE SITE OF OVUM FORMATION &
MATURATION. IT CONTAINS THE
PRIMORDIAL FOLLICLES, GRAAFIAN
FOLLICLES, CORPUS LUTEUM & CORPUS
ALBICANS.
- two months intrauterine = 600,000 oogonia
- 5 months intrauterine = 6,800,000
- at birth = 2 million oocytes
- prepuberty / childhood = 300,000 to 400,000
- 36 years old = 30,000 to 40,000
- menopause = absent

3. MEDULLA - LAYER WHICH CONTAINS THE

BLOOD VESSELS, LYMPHATICS, NERVES &
MUSCLE FIBERS.
 THE MAMMARY GLANDS
THE FEMALE BREASTS ARE ACCESSORY
ORGANS OF REPRODUCTION MEANT TO
PROVIDE THE INFANT WITH THE MOST IDEAL
NOURISHMENT AFTER BIRTH.

STRUCTURES:
• LOBES =EACH BREAST CONSISTS OF 15-20
LOBES FOUND IN EACH BREAST WHICH ARE
SUBDIVIDED INTO LOBULES
• LOBULES – COMPOSED OF CLUSTERS OF
ACINAR CELLS ( RESPONSIBLE FOR MILK
PRODUCTION)
3.ACINAR CELLS – MILK SECRETING CELLS THAT
IS STIMULATED BY PROLACTIN
4.LACTIFEROUS DUCTS = MILK RESERVOIR –
WHICH OPEN TO THE NIPPLE.
5.AREOLA = DARK PIGMENTED PART AROUND THE
NIPPLE
6. MONTGOMERY TUBERCLE = SECRETES FATTY
SUBSTANCE TO LUBRICATE NIPPLES
7. NIPPLE = ELEVATED PART OF THE BREASTS
CONTAINING 15-20 OPENINGS FROM THE
LACTIFEROUS DUCTS
8. COOPER’S LIGAMENT = PROVIDES SUPPORT TO
THE MAMMARY GLAND
 PHYSIOLOGY OF MILK PRODUCTION
** THE PRODUCTION OF BREAST MILK IS NOT
ACHIEVED DURING PREGNACY BECAUSE OF
THE PREDOMINANCE OF ESTROGEN &
PROGESTERONE.
** IMMEDIATELY AFTER THE DELIVERY OF THE
PLACENTA, THERE IS MARKED DECREASE OF
BOTH ESTROGEN & PROGESTERONE W/C
SERVES AS A STIMULUS FOR THE APG TO
PRODUCE PROLACTIN.
** PROLACTIN ACTS ON THE ACINI CELLS TO
STIMULATE PRODUCTION OF MILK & ARE
THEN STORED IN THE LACTIFEROUS DUCTS.
** AS THE INFANT SUCKS, THE PPG IS
STIMULATED TO RELEASE THE HORMONE
OXYTOCIN CAUSING THE COLLECTING
SINUSES OF THE MAMMARY GLANDS TO
CONTRACT, FORCING MILK FORWARD
THROUGH THE NIPPLES CALLED “LET DOWN
REFLEX” OR “MILK EJECTION REFLEX”.
 BREAST DISORDERS
Breast CA
Benign Breast CA
 Fibrocystic breast disease
 Most common benign condition of the breast
 20-50 yo
 D/t imbalance between hormones
 Rare in postmenopausal women not taking HRT
 Not risk for Ca except if px has (+) family hx and w/
atypical cellular changes on biopsy
S/sx: bilateral cyclic pain, tenderness, nipple discharge

Dx: mammography, sonography, FNA

Mgmt: restrict Na, mild diuretic, Danazol (hormone inhibitor),

Bromocriptine and Tamoxifen to decrease symptoms
 Fibroadenoma
 2nd most common
 Teens, early 30’s
 Not associated w/ breast Ca

S/sx: freely movable, solid, well defined, sharply delineated,

rounded w/ a rubbery texture

Dx: USG, FNA

Mgmt: surgery of enlarged

 BREAST CANCER
** PRESENCE OF MALIGNANT TUMORS
USUALLY IN THE UPPER OUTER
QUADRANT OF THE BREAST. IT IS
ASSOCIATED WITH NULLIPARITY OR
HAVING THE FIRST CHILD AFTER AGE
35.
1.MOST COMMON NEOPLASM IN WOMEN
2. LEADING CAUSE OF DEATH IN WOMEN
AGE 40 above
MEDICAL MANAGEMENT:
1.USUALLY SURGICAL EXCISION;
OPTIONS ARE SIMPLE LUMPECTOMY,
SIMPLE MASTECTOMY, MODIFIED
RADICAL MASTECTOMY AND RADICAL
MASTECTOMY
2.TREATMENT WITH CHEMOTHERAPY,
RADIATION AND HORMONE THERAPY
** PARTIAL MASTECTOMY =
(LUMPECTOMY) REMOVAL OF LUMP &
SURROUNDING BREAST TISSUE
 **SIMPLE MASTECTOMY = REMOVAL OF
THE BREAST
** RADICAL MASTECTOMY = REMOVAL
OF THE BREAST, PECTORAL MUSCLES,
PECTORAL FASCIA & NODES (PECTORAL,
SUBCLAVICULAR, APICAL AND AXILLARY)
** MODIFIED RADICAL MASTECTOMY =
RADICAL MASTECTOMY BUT PECTORAL
MUSCLES ARE NOT REMOVED
MOST COMMON SITE OF METASTASIS:
** BONE, BONE MARROW, SOFT TISSUE,
LUNGS, LIVER AND BRAIN.
C. ASSESSMENT FINDINGS:
1.PALPATION OF LUMP (UPPER OUTER
QUADRANT MOST FREQUENT SITE)
USUALLY FIRST SYMPTOM
2. SKIN OF BREAST DIMPLED
3. NIPPLE DISCHARGE
4. ASSYMETRY OF BREAST
5. SURGICAL BIOPSY PROVIDES DEFINITE
DIAGNOSIS
**BREAST BIOPSY**
1. EXCISION =REMOVAL OF MASS FOR
CYTOLOGIC STUDIES
2. INCISION= REMOVAL OF TISSUE FROM
MASS OF CYTOLOGIC STUDIES
3. NEEDLE= (ASPIRATION) = REMOVAL
OF TISSUE OR FLUID FROM MASS
THROUGH A NEEDLE FOR CYTOLOGIC
STUDY
LABORATORY DATA:
- MAMMOGRAPHY REVEALS THE
PRESENCE OF NON-PALPABLE LESION.
- BASELINE MAMMOGRAPHY SHOULD BE
MADE BETWEEN AGES 35-40.
NURSING INTERVENTIONS:
1.PROVIDE ROUTINE PRE-OP & POST-OP
CARE.
2. ELEVATE CLIENT’S ARM ON OPERATIVE
SIDE ON PILLOWS TO MINIMIZE EDEMA.
3. DO NOT USE ARM ON AFFECTED SIDE FOR
BLOOD PRESSURE MEASUREMENTS, IV’S
OR INJECTIONS
4. TURN ONLY TO BACK & UNAFFECTED SIDE
5. MONITOR CLIENT FOR BLEEDING ( CHECK
UNDER AFFECTED ARM)
Risk Factors:
Age, female, family hx, HRT > 5 yrs, overweight after
menopause, alcohol, no history of pregnancy or 1st
pregnancy after age 30, never breastfeeding, early
menarche, late menopause, radiation, upper
socioeconomic areas, geographic location

Dx: mammography, FNA, USG, MRI

 May be managed by surgery, radiation therapy,
and/or chemotherapy
Tamoxifen (anti-estrogen)
Emotional responses
Nursing care in addition to routine postop care:
 Inspect dressing and incision for bleeding
 To prevent lymphedema (pooling of lymph
circulation in involved arm), elevate it on a pillow,
turn patient to back and unaffected side; avoid
constricting clothing and using the arm for blood
pressure measurement, IVs, injections
 To prevent muscle contractures, encourage an
exercise program with gradual progression from
those that do not stress the incision to adduction
and external rotation
 Promote acceptance of new body image by
providing emotional support
 What is Dyspareunia?
 Vaginal pain after sexual intercourse.
 Painful sexual intercourse.
 CAUSES Dyspareunia
 Poor vaginal lubrication
 Reduced libido
 Reduced estrogen
 Vaginal dryness
 Inadequate foreplay
 Menopause
 Perimenopause
 Lactation - causes vaginal dryness
 Dyspareunia

 Post-childbirth
 Episiotomy - if performed for childbirth
 Vaginal infection
 Cystitis
 Urethritis
 Vaginal infection
 Vulva infection
 Atrophic vaginitis
 Vaginal changes from childbirth
 CAUSES Dyspareunia

 Narrow vaginal
 Hymen
 Psychological disorders
 Anxiety
 Vaginismus
 Endometriosis
 Hemorrhoids
 CAUSES Dyspareunia
 Pelvic infection
 Pelvic inflammatory disease
 Genital tract tumor
 Vaginal tumors
 Vaginal surgery
 Pelvic disorders
 Sexual organ disorders
 Some causes of deep penetration intercourse pain in women
include:
 Pelvic inflammatory disease
 Pelvic tumor
 MANAGEMENT Dyspareunia
 History and physical examination with pelvic and rectal
exams
–Timing: Onset (e.g., upon entry, after intercourse),
duration, persistence after intercourse, prior
occurrence(s)
–Associations: Symptoms may occur with all vaginal or
vulvar contact, with intercourse only, with exams only,
with masturbation, or with memories or recollections of
prior occurrences or traumatic experiences
–Alleviating and aggregating factors during intercourse
–Qualifiers: Burning, sharp, dull, aching, throbbing,
stabbing
–Include complete psychiatric history and exam
 Vaginismus:
 Vaginal entrance muscle spasms triggered
by sex
 Involuntary contraction of muscle at the
outlet of the vagina when coitus is
attempted prohibiting penile penetration or
during sexual intercourse.
 CAUSES

Fear of sex
Unpleasant sexual experience
Negative attitude to sex
TREATMENT

PSYCHOLOGICAL
COUNSELLING
Prognosis of Vaginismus

Most women recover to normal

sex life and motherhood with
treatment.
 FRIGIDITY

Loss of libido
Sexual aversion disorder
 Signs / symptoms
 Loss of female libido
 Lack of enjoyment of intercourse
 Painful intercourse
 Vaginal dryness
CAUSES

1. Organic
2.Functional
 Organic
 Malformation
 Imperforate hymen
 Vaginal stenosis
 Hermaphroditism
 Retroverted uterus
 Turner syndrome-the normal XX sex
chromosomes for a female, only one X
chromosome is present(45X0) . female sexual
characteristics are present but generally
underdeveloped.
 Organic
 Inflammation
 PID
 Cystitis
 Anal fissure
 Vaginitis
 Salphangitis
 endometeritis
 Organic
 Trauma
 Enlargemale organ
 Masturbation
 Sexual molestation/raped
 Functional Cause
 Psychological cause
 Fear or hostility regarding intercourse
 Anxiety : previous rape
 Marital difficulties
 Diagnostics
 Pelvic
& rectal exam
 Chromosomal analysis if indicated
 Hormonal analysis
 FSH
 Estradiol

 UTZ/vaginal smear & culture

 Gynecologic exam
 Treatment
 Treatthe cause
 Estrogen therapy as prescribed
 Psychiatrist
 Emotional support
MALE REPRODUCTIVE SYSTEM: ANDROLOGY

B. Penis: the male organ of copulation; a cylindrical

shaft consisting of:
a. corpora cavernosa -two lateral columns of
erectile tissue
b. corpus spongiosum - encases the urethra
Parts: 1.The glans penis, a cone-shaped expansion of
the corpus spongiosum that is highly sensitive in
males.
2. Shaft or body
3. Prepuce or Foreskin – retractable skin
covering the glans & removed during circumcision.
Unretractable or tight foreskin is called
PHIMOSIS.
-Erection is stimulated by parasympathetic nerve
C. Scrotum: a pouch hanging below the penis
that contains the testes.
INTERNAL STRUCTURES:
A.TESTES
= TWO OVOID SHAPED BODY THAT LIE
INSIDE THE SCROTUM
= ENCASED BY A PROTECTIVE WHITE
FIBROUS CAPSULE AND COMPRISES A
NUMBER OF LOBULES
= EACH LOBULE CONTAINS INTERSTITIAL
CELLS ( LEYDIG’S CELLS) AND SEMINIFEROUS
TUBULES
= SEMINIFEROUS TUBULES PRODUCE
SPERMATOZOA
= LEYDIG’S CELLS PRODUCE THE HORMONE
TESTOSTERONE
FUNCTIONS OF THE TESTES:
1. SPERMATOGENESIS
= PROCESS BY WHICH THE
SPERMATOCYTES ARE DEVELOPED INTO
MATURE SPERMATOZOA
2. HORMONE PRODUCTION
a. TESTOSTERONE = AN ANDROGEN OR
MUSCULINIZING HORMONE RESPONSIBLE
FOR
** GROWTH & DEVELOPMENT OF
SECONDARY SEX CHARACTERISTICS
b. FSH = FOLLICLE STIMULATING HORMONE
= CAUSES RAPID SPERM PRODUCTION BY
THE TUBULE
c. ICSH – INTERSTITIAL CELL STIMULATING
HORMONE
= STIMULATES LEYDIG’S CELLS TO
INCREASE TESTOSTERONE PRODUCTION
 Spermatogenesis
Testes

Contain Leydig cells produces testosterone

Testosterone ALERT: it takes 64

days for sperm to
reach maturity
Stimulates
APG secrete FSH & LH
stimulates seminiferous tubules to produce
spermatozoa
 Sperm Pathway
 Testes ---produces sperms

 Epididymis conducts sperm to Vas deferens

 Seminal vesicles ( secretion of fructose & protein)

 Ejaculatory duct

 Urethra ( 8 inches) ( cowper’s gland secretes

alkaline fluid)

 OUT
Male
MALE REPRODUCTIVE SYSTEM:
B. Internal Structures

1. Epididymis: serves as reservoir for sperm storage and

maturation. Approximately 20 ft. it takes 12-20 days for
the sperm to travel the length of Epididymis.

A total of 64 days before they reach maturity.

(“Treatment= 2 months”).
Aspermia - (absence of sperm)
Oligospermia- if < 20 million sperm/ ml

2. Vas deferens: a duct extending from epididymis to the

ejaculatory duct and seminal vesicle, providing a
passageway for sperm.
Varicocele- varicosity of internal spermatic cord
Vasectomy (male birth control)

3. Seminal vesicle: are two convoluted pouches that lie along

the lower portion of the bladder and empty into the urethra
by the way of ejaculatory ducts
MALE REPRODUCTIVE SYSTEM:

4. Ejaculatory duct: the canal formed by the union of

the vas deferens and the excretory duct of the
seminal vesicle, which enters the urethra at the
prostate gland.

5. Prostate Gland: located just below the urinary

bladder. Secretes alkaline and most of the seminal
fluid.

6. Bulbourethral glands or Cowper’s Gland: adds

alkaline fluid to the semen. Counterpart of the
Bartholin’s glands in females.

7. Urethra: the passageway for both urine and semen,

extending from the bladder to the urethral meatus.
(8 inches in long)
SEMINAL FLUID / SEMEN:
= A GRAYISH WHITISH SUBSTANCE
CONTAINING SPERMATOZOA AND FRUCTOSE
RICH SUBSTANCES.
= AT THE TIME OF EJACULATION,
APPROXIMATELY 3-5 ML OF SEMEN IS
SECRETED WITH ABOUT 100 MILLION
SPERMATOZOA PER ML, OR ABOUT 250-500
MILLION SPERMATOZOA AT EACH
EJACULATION. IF THE SPERM COUNT DROPS
TO LESS THAN 20 MILLION PER ML OF
SEMEN, THE RATE IS CONSIDERED
INFERTILE.
SEXUAL DYSFUNCTION
IN MALE
Erectile dysfunction
Impotence
 Erectile dysfunction
(Impotence)
 Inability of the man to produce or maintain
erection , long enough for vaginal penetration
or partner satisfaction.
 Formerly called impotence
 Causes
 Physical cause
 Common causes of erectile dysfunction
include:
 Heart disease
 Clogged blood vessels (atherosclerosis)
 High blood pressure
 Diabetes
 Obesity
 Metabolic syndrome
 Causes
 Other causes of erectile dysfunction include:
 Certain prescription medications -antidepressants,
antihistamines and medications to treat high blood
pressure, pain and prostate cancer
 Tobacco use
 Alcoholism and other forms of drug abuse
 Treatments for prostate cancer
 Parkinson's disease
 Multiple sclerosis
 Hormonal disorders such as low testosterone
(hypogonadism)
 Surgeries or injuries that affect the pelvic area or spinal
cord
 Psychological causes of erectile dysfunction
The brain plays a key role in triggering the series of
physical events that cause an erection, beginning with
feelings of sexual excitement. A number of things can
interfere with sexual feelings and lead to — or worsen
— erectile dysfunction. These can include:
 Depression
 Anxiety
 Stress
 Fatigue
 Poor communication or conflict with your partner
 Ultrasound. This test can check blood flow to your penis.
 Neurological evaluation.
 Dynamic infusion cavernosometry and cavernosography (DICC).
 This procedure involves injecting a dye into penile blood vessels to
permit view any possible abnormalities in blood pressure and flow into
and out of your penis. It's generally done with local anesthesia by a
urologist who specializes in erectile dysfunction.
 Nocturnal tumescence test.
 A simple test that involves wrapping a special perforated tape around
the penis before going to sleep can confirm whether you have
erections while you're sleeping. If the tape is separated in the
morning, your penis was erect at some time during the night. Tests of
this type confirm that there is not a physical abnormality causing
erectile dysfunction, and that the cause is likely psychological.
 Oralmedications
Oral medications available to treat ED include:
 Sildenafil (Viagra)
 Tadalafil (Cialis)
 Vardenafil (Levitra)

 ACTION :
 Chemically known as phosphodiesterase inhibitors, these
drugs enhance the effects of nitric oxide, a chemical that
relaxes muscles in the penis. This increases the amount of
blood flow and allows a natural sequence to occur — an
erection in response to sexual stimulation.
 Hormone replacement therapy
For the small number of men who have testosterone deficiency,
testosterone replacement therapy may be an option.
 Penis pumps
 This treatment involves the use of a hollow tube with a hand-
powered or battery-powered pump. The tube is placed over the
penis, pump is used to suck out the air. This creates a vacuum
that pulls blood into the penis.
 Once you achieve an adequate erection, slip a tension ring
around the base of the penis to maintain the erection. then remove
the vacuum device. The erection typically lasts long enough for a
couple to have sex. remove the tension ring after intercourse.
 Vascular surgery
This treatment is usually reserved for men whose blood flow has been
blocked by an injury to the penis or pelvic area.
 The goal of this treatment is to correct a blockage of blood flow to
the penis so that erections can occur naturally. But the long-term
success of this surgery is unclear.
 Penile implants
The inflatable device allows to control when and how long
you have an erection, These implants consist of either an
inflatable device or semirigid rods made from silicone or
polyurethane. This treatment is often expensive and is
usually not recommended until other methods have been
considered or tried first. As with any surgery, there is a
small risk of complications such as infection.
 Psychological counseling and sex therapy

 Stress, anxiety or depression is the cause of erectile

dysfunction
 Counseling can help, especially when your partner
participates.
 Nursing care
 Patient education
 Limitor avoid the use of alcohol.
 Avoid illegal drugs such as marijuana.
 Stop smoking.
 Exercise regularly.
 Reduce stress.
 Get enough sleep.
 Get help for anxiety or depression.
 advised regular checkups and medical screening tests.

 Communicate with patient and partner openly

MENOPAUSE = PERMANENT
CESSATION OF MENSTRUAL CYCLES
THAT OCCURS BETWEEN 45 & 55 Y/O;
ave: 50y/o

= THE POINT AT WHICH NO

FUNCTIONING OOCYTES REMAIN IN
THE OVARIES
S/SX OF MENOPAUSE:
1.HOT FLASHES – SENSATION OF HEAT THAT
BEGINS IN THE FACE TO THE CHEST &
PROFUSE PERSPIRATION.
2. LOSS OF BREAST MASS & FIRMNESS,
ATROPHY OF REPRODUCTIVE ORGANS.
3. DYSPAREUNIA ( PAINFUL INTERCOURSE)
DUE TO DECREASED VAGINAL LUBRICATION.
4. OSTEOPOROSIS - ESTROGEN PROMOTES
CALCIUM DEPOSITION IN THE BODY. A FALL
IN ESTROGEN LEVELS WILL LIBERATE
CALCIUM FROM THE BONES MAKING THEM
BRITTLE
MX:
1.ESTROGEN REPLACEMENT THERAPY ( HRT;
ERT)
2. CALCIUM ( 1g/DAY AT HS) & VIT. D
SUPPLEMENTATION
3. LIBERAL FLUID INTAKE TO DILUTE URINE AS
MORE CALCIUM IS LIBERATED FROM THE
BONES & COULD CAUSE RENAL CALCULI.
4. WEIGHT BEARING EXERCISES
MX OF HOT FLASHES:
1.DRESS IN LAYERED LOOK, REMOVE OUTER
CLOTHING DURING ATTACKS.
3. AVOID EMOTIONAL STRESS
4. AVOID FOODS THAT COULD TRIGGER HOT
FLUSHES: SPICY FOODS, COFFEE, TEA,
ALCOHOL
5.USE COOLING TECHNIQUES: FANS,
SHOWERS, ICE CUBES
NURSING CARE:
1.ENCOURAGE WOMAN TO ENGAGE IN
REGULAR EXERCISE PROGRAM TO MAINTAIN
MUSCLE TONE
2. EMPHASIZE ADEQUATE INTAKE OF CALCIUM
3. VIT D FOR BETTER CALCIUM ABSORPTION.
VAGINAL LUBRICANT FOR PAINFUL
INTERCOURSE.
5. INSTRUCT TO AVOID SMOKING & ALCOHOL
6. REGULAR PHYSICAL EXAMINATION.
 SEXUALLY TRANSMITTED DISEASES

 Trichomoniasis
 Chlamydia
 Gonorrhea
 Syphilis
 Herpes simplex
 Condylomata acuminatum
 Human Immunodefiency Virus (HIV) and AIDS
 TRICHOMONIASIS
 protozoan infection: Trichomona vaginalis

Signs and Symptoms

 Frothy yellow-green malodorous vaginal discharge
 “strawberry” cervix
 Vaginal irritation & inflammation
 Dyspareunia
 Dysuria
 Vulvar itching

Among males: usually asymptomatic

Diagnosis
 microscopic exam of vaginal discharge

-positive motile flagellated protozoa in a saline wet mount

 elevated vaginal pH 5.5+ (alkaline)

Management
 Sexual partner should receive oral treatment.
 Metronidazole (Flagyl) 500 mg BID for 7 days or a single 2
g dose (contraindicated during pregnancy)
Home Remedy
 Acidic vaginal douche : 1 tablespoon vinegar with 1 liter water to
counteract the alkaline environment of the vagina that favors the
growth of Trichomonas vaginalis

Nursing interventions
 Include sexual partner in treatment.
 Advise use of condom during intercourse
 Nursing alerts:
- Concurrent alcohol ingestion with Metronidazole causes severe
GI symptoms (Antabuse-like reaction)
- Metronidazole is associated with preterm labor, premature rupture
of membranes and postcesarean infection
 CHLAMYDIA

 most common cause of mucopurulent cervicitis

 most common bacterial STD in women
 caused by gram (-) bacterium Chlamydia trachomatis
 Vertical transmission to newborns may result in
conjunctivitis and otitis media
 Tends to coincide with gonorrhea infection

IP: 2-10 days

Risk Factors
 Sexual activity < 20 years
 Multiple sexual partners
 Lower socioeconomic status
 (+) others STDs
Signs and symptoms
 May be asymptomatic
 Gray white/ yellowish vaginal discharge
 Burning and itchiness
 Bleeding between periods
 Mucopurulent cervicitis
 Painful and frequent urination

Diagnosis
 (+) culture/ antigen detection test on cervical smear
 Polymerase chain reaction (PCR)
Management
 Doxycycline 100 mg PO BID for 7 days
(causes fetal long bone deformity if used in pregnancy)
 Azithromycin (Zithromax) 1 g PO in a single dose
 Erythromycin 500 mg QID for pregnant patient
 Patient may also be treated for gonorrhea with a single
IM shot of Ceftriaxone 250 mg
 Infant treated with Erythromycin ophthalmic ointment

Nursing interventions
Client teaching:
 Teach the importance of completing the course of
antibiotic
 Use condom during sex
 Sexual partner should receive treatment
Complications
 Pelvic inflammatory disease (PID)
 Ectopic pregnancy
 Fetus transmittal (vaginal birth); may cause conjunctivitis

(also associated with premature rupture of membranes,

preterm labor and endometriosis, low birth weight and
perinatal mortality due to placental transmission)
 GONORRHEA
 Morning drop, Clap, Jack
 Sexually transmitted disease caused by gram (-)
Neisseria gonorrhea, which causes inflammation of
the mucus membrane of the genito urinary tract

IP: 3-7 days

Signs and Symptoms

 Females: may be asymptomatic; may have purulent
vaginal discharge, pelvic pain and fever; dyspareunia
Males: Painful urination; purulent yellow penile
discharge; urethritis
(decreased sperm count)
 Newborn: yellow discharge, both eyes
Diagnosis
 gram stain and culture of
cervical secretions on
Thayer Martin medium

Complications
 PID
 ectopic pregnancy
 infertility
 Chorioamnionitis
 ophthalmia neonatorum in
newborns (associated with
severe eye infection and
blindness)
 preterm delivery
 sterility & pelvic
inflammatory disease
Management (single dose only)
 Ceftriaxone (Rocephin) 125 mg IM (drug of choice for
pregnant women)
 Ofloxacin (Floxin) 400 mg orally
 Treat concurrently with Doxycycline or Azithromycin for
50% infected w/ Chlamydia
 Ophthalmic ointment is routinely given as Crede’s
prophylaxis to prevent opthalmia neonatorum
(0.5% Erythromycin or 1% Tetracycline ointment for
newborn babies)
Nursing interventions
Health Teachings:
 Avoid sexual intercourse until cured of the infection or
use condom to prevent transmitting the infection.
 Examination and treatment of sexual partner to
prevent reinfection is necessary.
 Return to clinic for check-up in 4 to 7 days after
completion of treatment.
 Monitor treatment
 SYPHILIS
 caused by motile anaerobic spirochete Treponema
pallidum
 “ beautiful” fast moving but delicate spiral thread
 can cross the placental barrier

IP: 10 - 90 days

 can cause 100% fetal infection if primary and

secondary infection is untreated, and 6-14% fetal
infection in latent syphilis
• 2nd trimester infections cause spontaneous abortion,
preterm labor, stillbirth and congenital anomalies
• 3rd trimester infection causes enlarged liver,spleen,
skin rash and jaundice in a newborn
Signs and Symptoms

 Primary Stage - painless chancre on genitalia, anus or

mouth; most infectious stage

 Secondary Stage - about 2 months after primary

syphilis resolves; generalized maculopapular skin rash
including palms and soles
- painlesscondylomata lata on vulva
- hepato/ splenomegaly
- headache; anorexia; fever

 Latent syphilis – asymptomatic

 Tertiary Stage –most destructive stage;

neurosyphilis/permanent damage (insanity); gumma
(necrotic granulomatous lesions), aortic aneurysm
Primary – painless chancre Secondary – generalized
rash

Tertiary - gumma
Diagnosis
 VDRL (venereal disease research laboratory test)
or RPR (rapid plasmin reagin) – nonspecific tests
- for screening and to follow treatment course
(decrease fourfold in 3-6 months)
 Fluorescent Treponemal Antibody AbsorptionTest
(FTA-ABS) or Microhemagglutination Assay for
Antibodies to TP (MHA-TP)– specific tests for
syphilis
 Dark-field microscopic examination of lesion- 1st
and 2nd stage
Management
 Primary and secondary and early latent disease - Pen G
(Benzathine Penicillin G 2.4 M U IM)
- Alternatives: Tetracycline 500 mg orally QID or
Doxycycline 100 mg orally BID
 Tertiary - IV Pen G
 Erythromycin & Cefriaxone are the drugs of choice for
pregnant women

Complications
 Congenital syphilis in newborn if untreated in late
pregnancy
 Late abortion
 Stillbirth
Health Teachings :
 Educate women to recognize signs of syphilis.
 Educate women to seek immediate treatment if known
exposure occurs.
 Encourage women to wear cotton underwear.
 Use condom during intercourse.
 Sexual partners must also be treated to prevent
re-infection.
 No sexual intercourse until lesions disappear
 After completion of treatment, the woman is
treated monthly & the sexual partner at 3 months,
6 mos & 12 mos.

 Fetus will not be affected if the mother is treated

before the 5th month. Emphasize the importance of
screening for syphilis during the first prenatal visit
for early detection & treatment.

 Inform patients treated with penicillin about Jarish

Herxheimer reaction, a reaction to penicillin
characterized by: fever, chills, malaise, headache,
nausea, & tachycardia. This is a normal reaction
that subsides within 24 hours.
 HERPES GENITALIS
 Sexually transmitted disease caused by the Herpes
Simplex Virus 2 (HSV 2)

Signs and Symptoms

 Flulike symptoms (malaise, myalgia, nausea, fever)
 Vulvar burning and pruritus
 Painful vesicles (cervix, vagina, perineum, glans penis) 2
- 20 days after exposure
 Painful genital ulcer
 Recurrent episodes 1-6x a year (during stress, fever,
menstruation)
 Dyspareunia

Diagnosis
 Viral culture
 Pap smear (shows cellular changes)
 Tzanck smear (scraping of ulcer for staining) –
multinucleated giant cells
Management
 Antiviral agents – Acyclovir
200 mg PO q 4 hrs for 5 days
 Sitz bath
 Analgesics
Complications: Health teachings
 Meningitis • NO sexual activity in the
presence of lesions and 10-14
 Neonatal infection days after lesions subsided
(vaginal birth) • Keep vulva clean and dry in the
 Trigeminal herpes zoster presence of lesions (wearing of
cotton underwear)
(facial muscle paralysis) • Sitz bath
• use foley catheter if retention
persists
• Povidone- iodine douche and
acyclovir NOT used during
pregnancy
 CONDYLOMA ACUMINATUM
 Genital warts
 Genital or venereal warts caused by
Human Papilloma Virus (HPV)
 May be a precursor to cervical cancer

 HPV types 6 & 11 – condyloma acuminatum

 HPV types 16, 18 and 31 – cervical cancer

Signs and Symptoms: Single or multiple dry soft,

fleshy painless (wartlike) growths on the vulva,
vagina, cervix, urethra, or anal area; penis
 Can evolve into larger cauliflower-like growths
 Vaginal bleeding, discharge, odor and dyspareunia
 Diagnosis
 Clinical
 Pap smear-shows cellular
changes (koilocytosis)
Acetic acid swabbing (will
whiten lesion)

Management
 Small lesions – treated
topically with podophyllin
or trichloroacetic acid
 Larger lesions – ablated
with cryotherapy, laser
Complications
vaporization or surgical
•Neoplasia excision.
•Neonatal laryngeal  Recurrence rate : 20%
papillomatosis
(vaginal birth)
Health Teachings
 Inform the patient that infection with the virus
increases the incidence of CERVICAL CANCER
 Therefore: Annual PAP smear is indicated
HUMAN IMMUNODEFICIENCY VIRUS
(HIV and AIDS)
 causative agent of acquired
immunodefiency syndrome
(AIDS)
 characterized by progressive
immune system impairment
 destroys T cells and cell-
mediated response
 makes the patient more
susceptible to infections and
unusual cancers
 HIV and AIDS
 Immunity declines and
opportunistic microbes
set in
 Retrovirus (HIV1 & HIV2)
 HIV is an RNA-based
retrovirus that requires a
 No known cure
human host to replicate

 Average time between HIV

infection and development
of AIDS: 8 -10 years

 HIV attacks and kills CD4+

cells (T helper cells) that
regulate immune response
Mechanisms of Transmission
 Sexual intercourse
 Contact with contaminated blood,

semen, breast milk and other

body fluids
 Blood Transfusion
 IV drug use
 Transplacental /

during birth
 Needlestick injuries
HIGH RISK GROUPs
 Homosexual or bisexual
 Intravenous drug users
 BT recipients before 1985
 Sexual contact with HIV+
 Babies of mothers who
are HIV+
 THE INFECTED MOTHER
CAN PASS THE VIRUS
TO THE FETUS DURING
PREGNANCY &
CHILDBIRTH OR VIA THE
BREAST MILK
Signs and Symptoms
1. Acute viral illness (1 month after initial exposure) :
fever, malaise, lymphadenopathy

1. Clinical latency - 8 yrs w/ no symptoms; towards

end, bacterial and skin infections and constitutional
symptoms - AIDS related complex;
lymphadenopathy, night sweats, malaise, diarrhea,
weight loss and unusual recurrent infections such as
oral candidiasis, varicella zoster or herpes simplex
 CD4 counts 400-200

3. AIDS (full blown) - 2 yrs; CD4 T lymphocytes

< 200 w/ (+) ELISA or Western Blot and opportunistic
infections
Exhibits one or more of the ff
 Extreme fatigue
 Intermittent fever
 Night sweats
 Chills
 Lymphadenopathy
 Enlarged spleen
 Anorexia
 Weight loss
 Severe diarrhea
 Apathy and depression
 PTB
 Kaposi’s sarcoma
 Pneumocystis carinii
 AIDS dementia
 Opportunistic Infections
 Candidiasis infection of
esophagus, trachea, bronchi or
lungs
 Cryptococcus meningitis
 Cytomegalovirus (CMV) retinitis
>>> blindness
 Herpes simplex outbreaks
lasting longer than 30 days
 HIV wasting syndrome
 Invasive cervical cancer
 Kaposi’s sarcoma in clients
over age 60
 Lymphoma
 Mycobacterium tuberculosis
(TB)
 PCP (Pneumocystis carinii
pneumonia)
 Toxoplasmic encephalitis
 Toxoplasmosis
 Varicella Zoster (Shingles)
HIV Infection Effects on the Infant
• Transmission through the  Microencephaly
placenta (greatest near  CNS lymphomas
term)  CVA’s
• delivery due to exposure in  Respiratory failure
birth canal secretions and
blood(60%)
 Lymphadenopathy
• breast milk
 Developmental anomalies
• Focus of care: treat the infection; reduce the risk of perinatal
transmission through maintenance or reduction of viral load

• Tx: oral Zidovudine initiated at 14-34 weeks AOG and

continued throughout pregnancy, IV dose during labor and
delivery and neonatal dose 8-12 hours after delivery

• Suggested mode of delivery depends on viral load: >1000

copies/ml, C/S might reduce transmission

• Bathe the newborn as soon as possible after delivery; all

needle procedures made after the bath
 Laboratory Tests
 ELISA – Enzyme Linked Immunosorbent Assay
(first test conducted)

 Western Blot – confirmatory test

 Rapid HIV test

 Suds hiv-1
 Results are obtained in less than 10 minutes
 Color indicator similar to pregnancy test
 Positive result needs a confirmatory test
 Laboratory Tests
 Immunofluorescence assay (IFA): also confirmatory
 p24 antigen: detects HIV antigen in children
<18 months; can be useful at any age; diagnostic if
2 or more (+) results
 Polymerase chain reaction
 Virus culture

 CD4+ : used to assess immune status, risk for

disease progression, and the need for PCP
prophylaxis after 1 year of age
 A (+) ELISA that fails to be confirmed by Western
blot or IFA should not be considered (-) and repeat
testing should take place in 3 - 6 months.
 CD4+ T cell counts
 monitors the progression of HIV
 As the disease progresses, usually the
number of CD4 T cell counts decreases,
with a resultant decrease in immunity.

 Normal CD4 T cell count: 500 – 1600

cells/μL
 HIV CLASSIFICATION
CATEGORY 1 – CD4+ 500 OR MORE
 CD4 T cell count >500 cells/μL:
Immune system is healthy

CATEGORY 2 – CD4+ 200-499

 CD4 T cell count between 200 – 499 cells/ μL:
Immune system problems

CATEGORY 3 – CD4+ LESS THAN 200

 CD4 T cell count <200 cells/μL:
Severe immune system problems
 CD4 count below 200:
considered to have AIDS

 If a person has 2 or more

opportunistic infections, she
is considered to have AIDS,
regardless of HIV testing or
CD4 count.
 CD4 to CD8 ratio

 monitors the progression of the disease

 Normal ratio- 2:1
 In HIV and AIDS, because of the low number of
CD4, this ratio is low.
 How to Diagnose

 HIV+
2 consecutive positive ELISA and
1 positive Western Blot Test

 AIDS+
HIV+
CD4+ count below 500/ml
Exhibits one or more of the signs and symptoms
stated above

 Full blown AIDS

CD4 is less than 200/ml
 Goals of therapy
 slow the growth of the virus/ decrease the viral load
 prevent and treat opportunistic infections
 provide nutritional support and symptomatic treatment

PREVENTION
A - ABSTINENCE
B - BE FAITHFUL
C - CONDOMS
D - DON’T USE DRUGS
DRUGS

 NO cure
 NO vaccination
 Antiretrovirals are usually
started when the CD4
count falls to 500 or
below.
 DRUGS
 Prophylaxiswith Co-trimoxazole (Bactrim)
against Pneumocystis carinii pneumonia (PCP)
when CD4 count falls below 200 cells/μL.

 Prophylaxiswith Rifabutin (Mycobutin) against

MAC (Mycobacterium avium complex) when
CD4 count falls below 100 cells/μL.
 DRUGS
Anti-retroviral Therapy (ART)
1. Nucleoside Reverse Transcriptase Inhibitors NRTI’s
INTERFERES WITH DNA CHAIN

Zidovudine (AZT) / (Azidothymidine)

Deoxyadenosine (DDI)
Dideoxycytidine (DDC)
S/E – NEUROPATHY AND RASH

Side Effects of Zidovudine

 Anemia
 Granulocytopenia
 Headache
 Nausea
 DRUGS

2. Non-nucleoside Reverse Transcriptase

Inhibitors NNRTI’s
- BINDS TO REVERSE TRANSCRIPTASE AND
BLOCKS RNA AND DNA REPLICATION
 Ritonavir (Norvir)
 S/E – RASH, HEPATOTOXICITY, BONE
MARROW DEPRESSION
 DRUGS
3. Protease Inhibitors PI
 BLOCK VIRUS ABILITY TO BREAK DOWN
LARGER PROTEIN MOLECULES
 Indinavir (Crixivan)
 S/E – HEPATOTOXICITY, NV, ABDOMINAL PAIN,
RENAL CALCULI
 Nursing Interventions
1. Provide respiratory support.
2. Administer respiratory treatment as prescribed.
3. Administer oxygen as prescribed.
4. Maintain fluid and electrolyte balance.
5. Monitor for signs of infection.
6. Prevent the spread of infection.
7. Initiate standard and other precautions as necessary.
8. Provide comfort as necessary.
9. Provide meticulous skin care.
10. Provide adequate nutritional support as prescribed.
 Strict adherence to client confidentiality is important.

 Universal precautions, including personal protective

gear, should be used consistently and correctly with
every client every time there is a chance of coming
into contact with blood or body fluids.

4 Components of Personal Protective Gear

a. Gloves
b. Gown
c. Mask
d. Face shield
 Health teachings

For infected persons:

1. Avoid infections
2. Use latex condom to protect partner during sexual
intercourse
3. Do not donate blood, sperm, organs or other body
tissues
4. Do not share items with other persons that may be
contaminated with blood & other body fluids
5. Do not breastfeed infant
For non-infected persons:
1. Stick to one partner, practice monogamous
relationship
2. Use condoms
3. Avoid anal & oral sex
4. Practice good personal hygiene
5. Practice healthful living: exercise, adequate rest,
nutritional diet, safe sex
6. Be aware of the signs & symptoms of infections:
Weight loss of greater than 10% of body weight
Chronic diarrhea, more than one month
Prolonged fever, lasting more than one month
AIDS cannot be transmitted by sharing foods, eating
utensils, toilet, swimming pools, water
Precautionary measures for health workers:
 Handle all sharp instruments with care, use
disposable needles & do not reuse as much as
possible
 Protect yourself, increase resistance to infection by
proper diet, exercise, rest & sleep
 Avoid body fluids – label blood & other specimens
of a person known or suspected with AIDS properly,
clean blood spills with disinfectant
 Practice strict aseptic technique –
handwashing,wear gloves, clean, disinfect &
sterilize
 Wear, protective clothing when necessary – gloves,
masks, goggles
ALWAYS KNOW YOUR DATE
ARE YOU ALWAYS
COMPLAINING?
ThAnK YoU Po!!!!
END