CHAPTER 10 Reproductive Disorders
Section One Gynecologic Disorders
Uterine Fibroids
Overview/Pathophysiology
Uterine fibroids are the most common tumors of the female pelvis, and they occur in 35%-50% of women, with diagnosis most often between ages 35 and 50 yr. Fibroids are benign neoplasms composed of smooth muscle cells. They range in size from very small to extremely large—more than 100 lb—and are most often multiple. Fibroids are caused by the hormones estrogen and progesterone and other factors. They rarely occur before menarche and usually disappear after menopause. Fibroids are most commonly located in the uterine body, where they are described as submucosal, intramural, or subserosal, depending on their location in the myometrium, They also occur in the cervix and broad ligament. Fibroids are the most common reason for hysterectomy.
Assessment
Signs and symptoms/physical findings
The patient is asymptomatic in 60%-90% of cases. Menorrhagia, chronic dull backache, dysmenorrhea, pelvic pressure, and dyspareunia can occur. If the tumor is large, abdominal distortion can occur. Depending on location, tumors can cause urinary symptoms (frequency, urgency, incontinence, retention) or gastrointestinal (GI) symptoms (rectal pressure, constipation). Infertility, habitual abortion, or premature labor may also occur. Uterine shape is irregular, and size usually is greater than normal. Determination of size is based on equivalent gestational size for the pregnant uterus. A uterus of greater than 12-wk gestational size is considered large and usually can be palpated on abdominal examination.
Diagnostic Tests
Ultrasound
Provides information on uterine volume, number of fibroids, and their location. In addition, the adnexa and abdominal cavity are evaluated for other possible causes of symptoms, such as hydronephrosis of the kidney, ovarian neoplasms, and adenomyosis.
Collaborative Management
Most fibroids decrease by 40%-60% at menopause, which is the natural end-point to their growth.
Gonadotropin-releasing hormone (GnRH) agonists
Decrease anemia and tumor size before surgery and thus allow use of optimal surgical techniques. Maximum effect is usually seen about 12 wk after start of medication, with an approximately 50% decrease in tumor size. However, regrowth to previous size occurs within 6 mo after discontinuation of these agents. Side effects include those found in hypoestrogenic states (e.g., bone demineralization, hot flashes, mood changes, vaginal dryness).
Hysteroscopic resection
Removes submucous fibroids via a hysteroscope inserted vaginally using electrocautery and laser. Incomplete resection is common.
Endometrial ablation
Destroys submucous fibroids via hysteroscope using either laser or electrosurgical techniques or with balloon technology.
Uterine artery embolization
Uses small injected particles to block the arteries supplying the fibroids, thereby cutting off blood supply and causing the tumors to shrink.
Focused ultrasound surgery
Noninvasive, magnetic resonance imaging (MRI)-guided procedure that removes the fibroids and preserves the uterus.
Myomectomy
Removes tumor surgically via laparascope or laparotomy; preserves fertility but increases the risk of adhesions and uterine rupture during subsequent pregnancy.
Hysterectomy
Surgical removal of the uterus. It can be through a vaginal, abdominal, or laparoscopically assisted vaginal approach.
Nursing Diagnoses And Interventions
Acute pain
Desired outcomes
Within 1 hr of intervention, patient’s subjective perception of pain decreases, as documented by pain scale. Objective indicators, such as grimacing, are absent or diminished.
Nursing Interventions
Desired outcomes
Patient is normovolemic, as evidenced by BP 90/60 mm Hg or greater (or within patient’s usual range), heart rate (HR) 60-100 beats per minute (bpm), urinary output 30 mL/hr or greater, respiratory rate (RR) 20 breaths/min or less with normal depth and pattern (eupnea), skin dry and of normal color, and a soft and nondistended abdomen. Patient and significant other verbalize knowledge about signs and symptoms of excessive bleeding and are aware of the need to alert staff promptly if these findings are noted.
Nursing Interventions
Impaired urinary elimination
(oliguria or anuria) related to inadequate intake, obstruction of indwelling catheter, or ureteral ligation
Desired outcome
Within 24 hr of surgery, patient demonstrates a balanced I&O, with urinary output at least 30 mL/hr immediately following surgery.
Nursing Interventions
Grieving
related to actual or perceived loss or changes in body image, body function, or role performance secondary to lost reproductive function with hysterectomy
Desired outcomes
Before hospital discharge, patient and significant other express grief, explain meaning of the loss, and communicate concerns with each other. Patient completes self-care activities as her condition improves.
Nursing Interventions
Patient-Family Teaching and Discharge Planning
Provide verbal and written information about the following areas of self-care to patients who have had a hysterectomy:
Pelvic Organ Prolapse
Overview/Pathophysiology
A pelvic organ prolapse is a downward displacement of the vaginal walls and/or the uterus as a result of weakness of the supporting muscles and ligaments. In severe cases, tissues may protrude from the vaginal opening. In the past, types of prolapse were described by naming the adjacent organ and included such terms as the following: cystocele, bulging of the posterior bladder wall into the vagina; uterine prolapse, bulging of the uterus through the pelvic floor into the vagina; rectocele, protrusion of the rectum into the posterior vagina; and enterocele, herniation of the small bowel into the vagina. Now anatomic descriptions of nine specific sites in the vagina with the hymen as the reference point are used to describe prolapse.
The primary cause of pelvic organ prolapse is a vaginal delivery in which pelvic connective tissue is stretched and torn. Other causes include connective tissue disorders, neuromuscular dysfunction, and surgical procedures, as well as conditions that cause repetitive increased abdominal pressure to the pelvic floor such as chronic cough or a long history of straining with constipation.
Assessment
Symptoms usually do not appear until menopause or later and are not usually consistent with the degree of prolapse.
Signs and symptoms/physical findings
Vary with the involved organs; can include a sensation of vaginal fullness, heaviness, or of bearing down in the pelvis; low backache (more severe by day’s end); inability to empty bladder with voiding; urinary frequency, dysuria, stress incontinence, incontinence resulting from urgency, and recurrent cystitis; dyspareunia or lack of sensation with intercourse; bulging at the introitus; continuous urge to have a bowel movement, constipation, difficulty generating pressure to pass stool (intravaginal digital pressure may be needed to facilitate defecation), incontinence of flatus or feces, and presence of hemorrhoids or fecal impaction. Manual pelvic examination reveals a soft mass that bulges into the vagina. The mass increases in size with coughing or straining and can be more apparent when a divided speculum is used. The pelvic examination provides more information when performed with patient standing. As patient bears down, a firm mass can be palpated in the lower vagina. Diagnosis may be aided with insertion of a pessary (i.e., reduced symptoms after insertion increase likelihood that symptoms are related to pelvic organ prolapse).
Diagnostic Tests
Urodynamic evaluation
Involves study of the flow of urine from the bladder through the urethra to differentiate stress incontinence from urgency incontinence. A combination of tests is used, including voiding flow rate, urethral pressure profile, urethroscopy, and cystometrogram.
Collaborative Management
Urinary catheterization
Empties a distended bladder. This is an emergency measure rather than a permanent correction.
Estrogen therapy
For urogenital symptoms in the postmenopausal woman. It is provided intravaginally in small daily doses as cream, suppository, or ring and used in combination with a progesterone if the uterus is present. For example, a vaginal ring that delivers a small dose of estradiol may be inserted for 90 days.
Pessary
A rubber, plastic, or silicone device inserted into the vagina to support pelvic structures. It may be used if there is prolapse of the uterus or if surgery is contraindicated or unwanted by patient.
Hysterectomy
Corrects uterine prolapse. It may be performed abdominally or vaginally, although the latter approach is used if other vaginal surgery is also being performed.
Anterior colporrhaphy
Surgical procedure via vaginal approach to suspend the bladder. It involves separating the anterior vaginal wall from the bladder and urethra, excising the redundant thinned vaginal wall, urethropexy (urethral suspension), plicating the bladder neck, and suturing the remaining vagina to provide support for the bladder.
Posterior colporrhaphy
Surgical procedure via vaginal approach to separate the posterior vaginal wall from the rectum, excise redundant vaginal tissue, and rejoin the rectovaginal septum with sutures to reduce the rectal herniation.
Surgical techniques for stress incontinence
Procedures include those that correct anatomic hypermobility, such as retropubic bladder neck suspension operations, needle suspension procedure, tension-free vaginal tape procedures, and some sling procedures. Procedures that correct intrinsic sphincteric weakness or dysfunction include sling operations and periurethral injections. Salvage operations include implantation of an artificial urinary sphincter and urinary diversion.
Nursing Diagnoses and Interventions
Constipation
related to restriction against straining, low-residue diet, or pain with defecation secondary to surgical procedure
Desired outcomes
After the early postoperative period, patient reports bowel movements within her normal pattern and with minimal discomfort. Patient verbalizes need to alert staff before and after bowel movements and to avoid straining during defecation.
Nursing Interventions
Patient-Family Teaching and Discharge Planning
Provide verbal and written information about the following areas of self-care to patients who have had surgery for a pelvic prolapse:
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