Female Genitourinary System
Content
FEMALE GENITOURINARY SYSTEM
11/25/2010 11:15:00 AM
STRUCTURE AND FUNCTION y External Genitalia (vulva or pudendum) o Mons pubis- round, firm pad of adipose tissue covering the symphysis pubis o Labia major- 2 rounded folds of adipose tissue extending from the mons pubis down and around the perineum Hair covers the outer surface; infer folds are smooth and moist and contains sebaceous follicles Inside has labia minora- 2 smaller, darker folds of skin than joins anteriorly the clitoris, a small, pea-shaped erectile body, and they form a hood or prepuce o Vestibule Urethral meatus- 2.5 cm posterior to clitoris Opening of Skene¶s gland- paraurethral; duct not visible but open posterior to the urethra at the 5 and 7 o¶clock position Hymen- thin, circular or crescent-shaped fold that may cover part of the vaginal orifice Opening of the Bartholin¶s gland- secrete lubricating mucus during intercourse o Vaginal orifice- posterior to the urethrealmeatus y Internal Genitalia o Vagina- flattened, tubular canal extending from the orifice up and backward into the pelvis; 9 cm long, between rectum, bladder and urethra; has stratified squamous epithelium Wall has rugae, or folds, enabling the vagina to dilate widely during childbirth o Cervix- end of the vaginal canal, doughnut-shaped, with os; o Uterus- pear-shape, thick-walled, muscular organ; freely movable, not fixed, o Fallopian tubes- 2 pliable, trumped-shaped tubes, 10 cm, extending from the uterine fundus to the pelvis brim o Ovaries- located on one side of each uterus; 3 cm long by 2 cm wide by 1 cm thick; develops ova and female hormones y Aging Female o Female¶s hormones milieu decreases rapidly, unlike males
o Menopause- cessation of the menses (48 to 51) Includes the preceding 1 to 2 years of decline in ovarian function, shown by irregular menses, that gradually become farther apart and produce a lighter flow Ovaries stop producing progesterone and esterogen dramatic physical changes (reproductive tracts are estrogen dependent) Uterus shrink size due to dec. myometrium Ovaries atrophy to 1 to 2 cm, not palpable after menopause Ovoluntion still may occur sporadically after menopause Pelvic musculature weakens uterus drops (may protrude or prolapse into the vagina) Cervix shrinks, looks pale, with glistening epithelium Vagina becomes shorter, narrower, and less elastic w/out sexual activity, vagina atrophis to one-half of its former length and width epithelium atrophies thinner, drier, itchy fragile mucusa risk for bleeding and vaginitis y dyspareunia (pain with intercourse) vaginal pH becomes more alkaline, and a decreased glycogen content occurs from the decreased estrogen o aging women outnumber their male counterparts o sexual desire and need for full sexual expression continue Cross cultural care o When patients is a member of a traditional community; ensure modesty Have a female nurse or physician conduct pelvic examination in the presence of a family member or chaperone If woman is a virgin, avoid pelvic examination
y
Woman may also have been circumsized (infibulations or female genital mutilation) inhibit sexual pleasure
SUBJECTIVE y Menstrual history o Date of last? Age at first? How often? Frequency? Usual amount? Clotting? o Non-threatening, so it¶s a good place to start history LMP- last menstrual period Menarche- mean age at onset at 12-13; delayed onset suggests endocrine or underweight problem Cycle²normally 18 to 45 days Amenorrhea- absent menses Duration- average 3 to 7 days Menorrhagia- heavy menses Dysmenorrhea- pain during menstruation Clotting indicate heavy flow or vaginal pooling y Obstetric history o Gravida- number of pregnancies o Para- number of births o Abortions- interrupted pregnancies, including elective abortions and spontaneous miscarriages y Menopause o Sloweddown? Hormone replacement? How do you feel? o Perimenopausal period from 40 to 55 years has hormone shifts, resulting in vasomotor instability Symptoms: hot flash, numbness, tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, itching o Side effects of hormone therapy include fluid retention, breast pain or enlargement, vaginal bleeding, possibly breast cancer risk y Self-care behaviors o Frequency? Last pap smear? o Maternal ingestion of DES (diethylstilbestrol) causes cervical cancer and vaginal abnormalities in female offspring y Urinary symptoms
o Problems with urinating? Frequency? Amount? Incontinence? Dysuria- pain when urinating Nocturia- waken during night to urinate Hematuria- blood in urine o Bile in urine or UTI urine dark, cloudy, foul smelling o Incontinence True- loss of urine without warning Urgency- sudden loss, as with acute cystitis Stress- loss of urine with physical strain fro muscle weakness Vaginal discharge o Normal discharge is small, clear or cloud, and nonirritating o White, yellow-green, gray curdlike, foul-smelling discharge vaginal infection o Dyspareunia occurs with vaginitis Factors that increase vaginitis Oral contraceptives increase glycogen content of the vaginal epithelium, providing fertile medium for some organisms Broad-spectrum antibiotics alter balance of normal flora Diabetes increases glycogen content Menses, post partum, menopause have a more alkaline vaginal pH Frequent douching alters pH Feminine hygiene spray has risk of contact dermatitis Local irritation (with nonventilating underpants) Past history o Problems? Lesions? Sores?abdominal pain? Past surgery? o Assess feelings. Some fear loss of sexual response after hysterectomy, which may cause problems in intimate relationships Sexual activity o Begin with an open-ended question to assess individual needs
y
y
y
o In a relationship? Aspects of sex satisfactory? More than one sexual partner? o Questions related to sex should be routine bec: it communicates acceptance with the individual¶s sexual activity, and believe it is important your comfort with discussion prompts person¶s interest and possibly relief that the topic has been introduced establishes a database for comparison with any future sexual activities provides opportunity to screen sexual problems ask sexual preference y Contraceptive use o Assess smoking history. Oral contraceptives, together with cigarette smoking, increase the risk of vascular problems o Infertility is considered after 1 year of engaging in unprotected sex without conceiving y Sexually transmitted disease contact y STD risk reduction o Precautions? Condoms? y Aging o Postmenopausal bleeding warrants further workup and referral o Vaginal itching, discharge, pain (associated with atrophic vaginitis) o Pressure in genital areas (occurs with pelvic musculature and uterine prolapse) OBJECTIVE y Preparation o Assemble equipment before helping the woman into position o Familiarize with vaginal speculum Grave¶s speculum- useful for most adult women, available in varying lengths and widths Pederson speculum- narrow blades, useful for young or postmenopausal women with narrowed introitus y Position o Initially, should be sitting up
y
o Equal status position is important to establish trust and rapport o For the examination; woman should be placed in lithotomyposition; supine, feet in stirrups, knees apart, buttocks at the edge of table o Decrease anxiety of the examination by: have empty bladder before examination position the exam table so that her perineum is not exposed to an inadvertent open door ask if the she would like a friend, family, or chaperone elevate her head and shoulders to semisitting position to maintain eye contact place stirrups so that legs are not abducted too far explain each step in the examination assure the woman she can stop the examination at any point if feel any discomfort use a gentle, firm touch, and gradual movement communicate throughout the examination use the techniques of the educational or mirror pelvic examination External genitalia o Inspection External genitalia Skin color; refer any suspicious pigmented lesion for biopsy Inverted triangle is the usual hair distribution Labia majora are normally symmetric, plump, and well formed If nulliparous (never gave birth)- labia are midline After a vaginal delivery- labia are gaping and slightly shriveled No lesions should be present, except for occasional sebaceous cyst (yellowish, 1 cm nodules, firm, nontender, multiple) Labia minora are dark pink and moist; usually symmetric
Urethral opening appears stellate or slitlike and is midline Vaginal opening, or introitus, may appear as a narrow vertical slit or as a larget opening Perineum is smooth. A well healed episiotomy scar, midline or mediolateral, may be present after a vaginal birth Anus has a coarse skin of increased pigmentation o Palpation Assess urethra and Skene¶s glands dip gloved finger in warm water to lubricate gently milk urethra, and check if any discharge assess for pelvic musculature palpate perineum ask woman to squeeze vaginal opening around your fingers y decreased tone may diminish sexual satisfaction separate vaginal orifice and ask woman to strain down y bulging of the vaginal wall indicates cystocele, rectocele, or uterine prolapse Internal genitalia o Speculum examination Proper size Warm and lubricate under warm running water; avoid gel lubricant bec. it is bacteriostatic; distort cytology Dedicate one hand to the patient and the other hand to picking up equipment in the room Apply pressure downward to avoid pressure on sensitive urethra Ease insertion by asking woman to bear down o Inspect the cervix and its Os Color- normally pink and even; if pregnant it looks blue (Chadwick¶s sign), and pale after menopause
y
Position- midline, either anterior or posterior; projects 1 to 3 cm into the vagina Lateral position may be due to adhesion or tumor; projection of more than 3 cm may be a prolapse Size- diameter is 2.5 cm Hypertrophy of more than 4 cm occurs with inflammation or tumor Os- small and round in nulliparous woman; if parous, it is horizontal irregular slit and also may show healed lacerations Surface- normally smooth, but cervical eversion, or ectropion, may occur normally after vaginal deliveries Difficult to distinguish; biopsy may be needed y Refer any suspicious red, white, or pigmented lesion for biopsy Nabothian cysts- benign growths that commonly appear after childbirth; smooth yellow, nodules that may be sinle or multiple Cervical polyp- bright red growth protruding from the os Note cervical secretion- secretions may be clear and thing, or thick, opaque and stringy; always they are odorless and nonirritating o Obtain cervical smears and cultures Screens for cervical cancer Do not obtain during woman¶s menses or if a havey infectious disease is present Do not douche, have intercourse, or put anything into the vagina within 24 hours before collecting specimens Vaginal pool- use Ayre spatula over the vaginal wall and lateral to the cervix; if mucusa is dry, normosaline may be used Cervical scrape- insert the bifid end of the Ayre spatula into the vagina; with the more pointed bump into the cervical os; rotate 360 to 720 degrees; use single stroke
Endocervical specimen- insert cytobrush into the os; safe during pregnancy; rotate 70 degrees in one direction; avoid leaving a thick specimen that would be hard to read under the microscope o Inspect the vaginal wall Normally, the wall looks pink, deeply rugated, moist and smooth, and is free of inflammation or lesions; normal discharge is thin and clear, or opaque and stringy, but always odorless Candidiasis- thick, white, and curdlike Trichomoniasis- profuse, watery, gray-green, and frothy o Bimanual examination- use both hands to palpate the internal genitalia to assess location, size, and mobility, to screen for mass and tenderness One hand is in the abdomen while other inserts 2 fingers into the vagina Palpate Cervix- feels smooth and firm (like tip of nose) but softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell¶s sign); evenly rounded; mobility from side to side should produce no pain y Hard, nodular, irregular, and immobilize with malignancy Uterus y Position: anteverted, midposition, aneflexed, retroverted, retroflexed y Normally feels firm, smooth, with rounded fundus; should be freely movable and nontender Adnexa- push the abdominal hand while your intravaginal fingers in the lateral fornix y Try to capture ovary- normally feels smooth, firm, almond shaped, highly movable; slightly sensitive bu not painfaul y Fallopian tube is not palpable normally
y
o Pulsation or palpable fallopian tube suggests ectopic pregnancy o Rectovaginal examination Rectovaginal septum should feel smooth, thin, firm, and pliable Rectovaginal pouch, or cul-de-sac, it a potential space and usually not palpated Uterine wall and fundus feel firm and smooth Rotate intrarectal finger to check rectall wall and anal spincter tone Aging adult o Natural lubrication is decreased so more lube is needed during examination o Menopause pubic hair decrease, skin is thinner and fat deposits decrease leaving the mons and pubis smaller and the labia flatter o Instead of 2 fingers in examination, use 1 finger due to possible stenosis
11/25/2010 11:15:00 AM
11/25/2010 11:15:00 AM
11/25/2010 11:15:00 AM
STRUCTURE AND FUNCTION y External Genitalia (vulva or pudendum) o Mons pubis- round, firm pad of adipose tissue covering the symphysis pubis o Labia major- 2 rounded folds of adipose tissue extending from the mons pubis down and around the perineum Hair covers the outer surface; infer folds are smooth and moist and contains sebaceous follicles Inside has labia minora- 2 smaller, darker folds of skin than joins anteriorly the clitoris, a small, pea-shaped erectile body, and they form a hood or prepuce o Vestibule Urethral meatus- 2.5 cm posterior to clitoris Opening of Skene¶s gland- paraurethral; duct not visible but open posterior to the urethra at the 5 and 7 o¶clock position Hymen- thin, circular or crescent-shaped fold that may cover part of the vaginal orifice Opening of the Bartholin¶s gland- secrete lubricating mucus during intercourse o Vaginal orifice- posterior to the urethrealmeatus y Internal Genitalia o Vagina- flattened, tubular canal extending from the orifice up and backward into the pelvis; 9 cm long, between rectum, bladder and urethra; has stratified squamous epithelium Wall has rugae, or folds, enabling the vagina to dilate widely during childbirth o Cervix- end of the vaginal canal, doughnut-shaped, with os; o Uterus- pear-shape, thick-walled, muscular organ; freely movable, not fixed, o Fallopian tubes- 2 pliable, trumped-shaped tubes, 10 cm, extending from the uterine fundus to the pelvis brim o Ovaries- located on one side of each uterus; 3 cm long by 2 cm wide by 1 cm thick; develops ova and female hormones y Aging Female o Female¶s hormones milieu decreases rapidly, unlike males
o Menopause- cessation of the menses (48 to 51) Includes the preceding 1 to 2 years of decline in ovarian function, shown by irregular menses, that gradually become farther apart and produce a lighter flow Ovaries stop producing progesterone and esterogen dramatic physical changes (reproductive tracts are estrogen dependent) Uterus shrink size due to dec. myometrium Ovaries atrophy to 1 to 2 cm, not palpable after menopause Ovoluntion still may occur sporadically after menopause Pelvic musculature weakens uterus drops (may protrude or prolapse into the vagina) Cervix shrinks, looks pale, with glistening epithelium Vagina becomes shorter, narrower, and less elastic w/out sexual activity, vagina atrophis to one-half of its former length and width epithelium atrophies thinner, drier, itchy fragile mucusa risk for bleeding and vaginitis y dyspareunia (pain with intercourse) vaginal pH becomes more alkaline, and a decreased glycogen content occurs from the decreased estrogen o aging women outnumber their male counterparts o sexual desire and need for full sexual expression continue Cross cultural care o When patients is a member of a traditional community; ensure modesty Have a female nurse or physician conduct pelvic examination in the presence of a family member or chaperone If woman is a virgin, avoid pelvic examination
y
Woman may also have been circumsized (infibulations or female genital mutilation) inhibit sexual pleasure
SUBJECTIVE y Menstrual history o Date of last? Age at first? How often? Frequency? Usual amount? Clotting? o Non-threatening, so it¶s a good place to start history LMP- last menstrual period Menarche- mean age at onset at 12-13; delayed onset suggests endocrine or underweight problem Cycle²normally 18 to 45 days Amenorrhea- absent menses Duration- average 3 to 7 days Menorrhagia- heavy menses Dysmenorrhea- pain during menstruation Clotting indicate heavy flow or vaginal pooling y Obstetric history o Gravida- number of pregnancies o Para- number of births o Abortions- interrupted pregnancies, including elective abortions and spontaneous miscarriages y Menopause o Sloweddown? Hormone replacement? How do you feel? o Perimenopausal period from 40 to 55 years has hormone shifts, resulting in vasomotor instability Symptoms: hot flash, numbness, tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, itching o Side effects of hormone therapy include fluid retention, breast pain or enlargement, vaginal bleeding, possibly breast cancer risk y Self-care behaviors o Frequency? Last pap smear? o Maternal ingestion of DES (diethylstilbestrol) causes cervical cancer and vaginal abnormalities in female offspring y Urinary symptoms
o Problems with urinating? Frequency? Amount? Incontinence? Dysuria- pain when urinating Nocturia- waken during night to urinate Hematuria- blood in urine o Bile in urine or UTI urine dark, cloudy, foul smelling o Incontinence True- loss of urine without warning Urgency- sudden loss, as with acute cystitis Stress- loss of urine with physical strain fro muscle weakness Vaginal discharge o Normal discharge is small, clear or cloud, and nonirritating o White, yellow-green, gray curdlike, foul-smelling discharge vaginal infection o Dyspareunia occurs with vaginitis Factors that increase vaginitis Oral contraceptives increase glycogen content of the vaginal epithelium, providing fertile medium for some organisms Broad-spectrum antibiotics alter balance of normal flora Diabetes increases glycogen content Menses, post partum, menopause have a more alkaline vaginal pH Frequent douching alters pH Feminine hygiene spray has risk of contact dermatitis Local irritation (with nonventilating underpants) Past history o Problems? Lesions? Sores?abdominal pain? Past surgery? o Assess feelings. Some fear loss of sexual response after hysterectomy, which may cause problems in intimate relationships Sexual activity o Begin with an open-ended question to assess individual needs
y
y
y
o In a relationship? Aspects of sex satisfactory? More than one sexual partner? o Questions related to sex should be routine bec: it communicates acceptance with the individual¶s sexual activity, and believe it is important your comfort with discussion prompts person¶s interest and possibly relief that the topic has been introduced establishes a database for comparison with any future sexual activities provides opportunity to screen sexual problems ask sexual preference y Contraceptive use o Assess smoking history. Oral contraceptives, together with cigarette smoking, increase the risk of vascular problems o Infertility is considered after 1 year of engaging in unprotected sex without conceiving y Sexually transmitted disease contact y STD risk reduction o Precautions? Condoms? y Aging o Postmenopausal bleeding warrants further workup and referral o Vaginal itching, discharge, pain (associated with atrophic vaginitis) o Pressure in genital areas (occurs with pelvic musculature and uterine prolapse) OBJECTIVE y Preparation o Assemble equipment before helping the woman into position o Familiarize with vaginal speculum Grave¶s speculum- useful for most adult women, available in varying lengths and widths Pederson speculum- narrow blades, useful for young or postmenopausal women with narrowed introitus y Position o Initially, should be sitting up
y
o Equal status position is important to establish trust and rapport o For the examination; woman should be placed in lithotomyposition; supine, feet in stirrups, knees apart, buttocks at the edge of table o Decrease anxiety of the examination by: have empty bladder before examination position the exam table so that her perineum is not exposed to an inadvertent open door ask if the she would like a friend, family, or chaperone elevate her head and shoulders to semisitting position to maintain eye contact place stirrups so that legs are not abducted too far explain each step in the examination assure the woman she can stop the examination at any point if feel any discomfort use a gentle, firm touch, and gradual movement communicate throughout the examination use the techniques of the educational or mirror pelvic examination External genitalia o Inspection External genitalia Skin color; refer any suspicious pigmented lesion for biopsy Inverted triangle is the usual hair distribution Labia majora are normally symmetric, plump, and well formed If nulliparous (never gave birth)- labia are midline After a vaginal delivery- labia are gaping and slightly shriveled No lesions should be present, except for occasional sebaceous cyst (yellowish, 1 cm nodules, firm, nontender, multiple) Labia minora are dark pink and moist; usually symmetric
Urethral opening appears stellate or slitlike and is midline Vaginal opening, or introitus, may appear as a narrow vertical slit or as a larget opening Perineum is smooth. A well healed episiotomy scar, midline or mediolateral, may be present after a vaginal birth Anus has a coarse skin of increased pigmentation o Palpation Assess urethra and Skene¶s glands dip gloved finger in warm water to lubricate gently milk urethra, and check if any discharge assess for pelvic musculature palpate perineum ask woman to squeeze vaginal opening around your fingers y decreased tone may diminish sexual satisfaction separate vaginal orifice and ask woman to strain down y bulging of the vaginal wall indicates cystocele, rectocele, or uterine prolapse Internal genitalia o Speculum examination Proper size Warm and lubricate under warm running water; avoid gel lubricant bec. it is bacteriostatic; distort cytology Dedicate one hand to the patient and the other hand to picking up equipment in the room Apply pressure downward to avoid pressure on sensitive urethra Ease insertion by asking woman to bear down o Inspect the cervix and its Os Color- normally pink and even; if pregnant it looks blue (Chadwick¶s sign), and pale after menopause
y
Position- midline, either anterior or posterior; projects 1 to 3 cm into the vagina Lateral position may be due to adhesion or tumor; projection of more than 3 cm may be a prolapse Size- diameter is 2.5 cm Hypertrophy of more than 4 cm occurs with inflammation or tumor Os- small and round in nulliparous woman; if parous, it is horizontal irregular slit and also may show healed lacerations Surface- normally smooth, but cervical eversion, or ectropion, may occur normally after vaginal deliveries Difficult to distinguish; biopsy may be needed y Refer any suspicious red, white, or pigmented lesion for biopsy Nabothian cysts- benign growths that commonly appear after childbirth; smooth yellow, nodules that may be sinle or multiple Cervical polyp- bright red growth protruding from the os Note cervical secretion- secretions may be clear and thing, or thick, opaque and stringy; always they are odorless and nonirritating o Obtain cervical smears and cultures Screens for cervical cancer Do not obtain during woman¶s menses or if a havey infectious disease is present Do not douche, have intercourse, or put anything into the vagina within 24 hours before collecting specimens Vaginal pool- use Ayre spatula over the vaginal wall and lateral to the cervix; if mucusa is dry, normosaline may be used Cervical scrape- insert the bifid end of the Ayre spatula into the vagina; with the more pointed bump into the cervical os; rotate 360 to 720 degrees; use single stroke
Endocervical specimen- insert cytobrush into the os; safe during pregnancy; rotate 70 degrees in one direction; avoid leaving a thick specimen that would be hard to read under the microscope o Inspect the vaginal wall Normally, the wall looks pink, deeply rugated, moist and smooth, and is free of inflammation or lesions; normal discharge is thin and clear, or opaque and stringy, but always odorless Candidiasis- thick, white, and curdlike Trichomoniasis- profuse, watery, gray-green, and frothy o Bimanual examination- use both hands to palpate the internal genitalia to assess location, size, and mobility, to screen for mass and tenderness One hand is in the abdomen while other inserts 2 fingers into the vagina Palpate Cervix- feels smooth and firm (like tip of nose) but softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell¶s sign); evenly rounded; mobility from side to side should produce no pain y Hard, nodular, irregular, and immobilize with malignancy Uterus y Position: anteverted, midposition, aneflexed, retroverted, retroflexed y Normally feels firm, smooth, with rounded fundus; should be freely movable and nontender Adnexa- push the abdominal hand while your intravaginal fingers in the lateral fornix y Try to capture ovary- normally feels smooth, firm, almond shaped, highly movable; slightly sensitive bu not painfaul y Fallopian tube is not palpable normally
y
o Pulsation or palpable fallopian tube suggests ectopic pregnancy o Rectovaginal examination Rectovaginal septum should feel smooth, thin, firm, and pliable Rectovaginal pouch, or cul-de-sac, it a potential space and usually not palpated Uterine wall and fundus feel firm and smooth Rotate intrarectal finger to check rectall wall and anal spincter tone Aging adult o Natural lubrication is decreased so more lube is needed during examination o Menopause pubic hair decrease, skin is thinner and fat deposits decrease leaving the mons and pubis smaller and the labia flatter o Instead of 2 fingers in examination, use 1 finger due to possible stenosis
11/25/2010 11:15:00 AM
11/25/2010 11:15:00 AM
