A look at reproductive disorders
Because of the misinformation and cultural taboos surrounding the reproductive system, reproductive disorders present a special nursing challenge. Problems such as erectile dysfunction, abnormal uterine bleeding, and infertility strike at a patient’s deepest sense of self. Besides needing expert health care, each patient requires sensitive counseling and straightforward teaching.
Anatomy and physiology
To meet the patient’s needs, you’ll need a clear understanding of the female and male reproductive systems.
Female reproductive system
Major female external genitalia include the vulva, which contains the mons pubis, clitoris, labia majora, labia minora, and adjacent structures (Bartholin’s glands, Skene’s glands, and the urethral meatus). Major internal genitalia include the vagina, uterus, ovaries, and fallopian tubes.
Love those hormones!
Hormonal influences determine the development and function of external and internal female genitalia and affect fertility, childbearing, and the ability to experience sexual pleasure.
Hormones and the menstrual cycle
The hypothalamus, ovaries, and pituitary gland secrete hormones that affect the buildup and shedding of the uterine lining during the menstrual cycle. Ovulation occurs through a network of positive and negative feedback loops that run from the hypothalamus, to the pituitary, to the ovaries, and back to the hypothalamus and pituitary.
The menstrual cycle consists of three phases: menstrual (preovulatory), proliferative (follicular), and luteal (secretory). These phases correspond to the phases of ovarian function. (See Understanding the menstrual cycle, page 639.)
Cessation of menses usually occurs between ages 40 and 55. Although the pituitary gland still releases follicle-stimulating hormone (FSH) and luteinizing hormone (LH), the body has exhausted the supply of ovarian follicles that respond to these hormones, so menstruation no longer occurs. A woman is considered to have reached menopause after menses are absent for 1 year.
Male reproductive system
The two major organs of the male reproductive system are the penis and testes. This system supplies male sex cells through sperm formation or spermatogenesis and is involved in male sex hormone secretion.
Sperm formation begins when a male reaches puberty and usually continues throughout life. Stimulated by male sex hormones, mature sperm cells are formed continuously within the seminiferous tubules.
Sperm on the move
Newly mature sperm pass from the seminiferous tubules through the vasa recta into the epididymis. Only a small number of sperm can be stored in the epididymis; most of them move into the vas deferens, where they’re stored until sexual stimulation triggers emission. Sperm cells retain their potency in storage for many weeks. After ejaculation, sperm survive for 24 to 72 hours at body temperature.
Hormones and sexual development
Male sex hormones (androgens) are produced in the testes and the adrenal glands. Leydig’s cells are located in the testes between the seminiferous tubules. These cells secrete testosterone, the most significant male sex hormone. They proliferate during puberty and remain abundant throughout life. Testosterone is responsible for the development and maintenance of male sex organs and secondary sex characteristics. It’s also required for spermatogenesis.
Male sexuality is also affected by other hormones. Two of these — LH, also known as interstitial cell-stimulating hormone, and FSH — directly affect testosterone secretion.
Although a reproductive system assessment may be embarrassing for your patient, it’s an essential part of an examination. If performed with sensitivity and tact, your assessment may uncover concerns that the patient was previously unwilling to share.[\sociallocker]
First, establish a good rapport to help the patient relax and confide in you. Then begin your assessment by obtaining a detailed reproductive health history. Ask your questions in a comfortable environment that protects the patient’s privacy. Leave time for the patient to ask questions about his reproductive organs or sexual activity.
Ask the patient about her chief complaint, reproductive history, family history, and social history.
Using the PQRST method, help the patient describe her chief complaint, along with any other concerns. Also ask about the patient’s menstrual history. How old was she when she began to menstruate? How long does her period usually last? How often does it occur? Does she have cramps or an unusually heavy or light flow? When was her last period? Metrorrhagia (bleeding between regular menstrual periods) may be normal in patients taking low-dose oral contraceptives or progesterone; otherwise, it may indicate pathology.
Age 15, period
In girls, menses generally starts about 2 years after breast budding or by age 15. If it hasn’t and if no secondary sex characteristics have developed, the patient should be evaluated by a practitioner.
Ask the patient if she has ever been pregnant. If so, how many times? How many times did she give birth? If she gave birth, did she have a vaginal or cesarean delivery? If indicated, ask the patient about her birth control use.
Because some reproductive problems tend to be familial, ask about family history. Ask the patient if she or anyone in her family ever had reproductive problems, hypertension, diabetes mellitus (including gestational diabetes mellitus), obesity, heart disease, or gynecologic surgery.
Ask the patient about her libido and if she’s sexually active. If so, ask her when she had sexual relations last and if she has more than one partner. Ask if her sexual partner or partners have any signs or symptoms of infection, such as genital sores, warts, dysuria, or penile or vaginal discharge. If indicated, discuss safe sex practices and prevention of sexually transmitted diseases (STDs).
The most common complaints about the male reproductive system are penile discharge, erectile dysfunction, infertility, and scrotal or inguinal masses, pain, and tenderness.
Analyze the patient’s chief complaint. Also ask him if he’s circumcised. If he isn’t, can he retract and replace the prepuce easily? Inquire whether he has any pain or has noticed lumps or ulcers on his penis. These can signal an STD. Does he have scrotal swelling? This can indicate an inguinal hernia, a hematocele, epididymitis, or a testicular tumor. Ask whether he has penile discharge or bleeding.
If the patient had reproductive system problems in the past or had problems in other body systems, this may affect his current reproductive function. Be sure to ask these questions:
• Have you fathered any children? If so, how many and how old are they? Have you ever had a problem with infertility? If so, is it a current concern?
• Have you ever been diagnosed with an STD or other infection in the genitourinary tract? If so, what was the specific problem and were there any complications? How long did the problem last? What treatment was provided?
• Do you have a history of undescended testes or an endocrine disorder? Have you ever had mumps? If so, did the disease affect your testes?
Questions about family health history can provide clues to disorders with known familial tendencies. Ask the patient if anyone in his family has had infertility problems, a hernia, or cancer of the reproductive tract.
Obtain information about the patient’s lifestyle and relationships with others. Ask the patient about his libido, if he’s sexually active, and if he has more than one partner. If indicated, ask what precautions he takes to prevent contacting an STD and/or what steps he and his partner take to prevent pregnancy. If he’s experiencing sexual difficulty, is it affecting his emotional and social relationships?
Physical assessment of the female patient involves inspection and palpation. You may examine only the external genitalia or perform a complete gynecologic examination, which includes examination of both the external and internal genitalia. For the male patient, physical assessment involves inspecting and palpating the groin, penis, and scrotum. If the patient is age 50 or over or has a high likelihood of prostate problems, you may also palpate the prostate gland.
Examining the female patient
You may assist a practitioner with a gynecologic assessment or perform the assessment yourself. Before the examination, ask the patient to void to prevent discomfort and inaccurate findings during palpation. Have her disrobe and put on an examination gown. Then perform hand hygiene and put on gloves. Have the patient lie in the supine position, and drape all areas not being examined. Make sure you explain the procedure to her. Begin by examining the external genitalia; then move to the internal genitalia.
Inspecting the external genitalia
If the patient complains of sores or itching, you may only need to inspect her external genitalia to determine the origin of the problem. In any case, uncover the pubic area, and inspect pubic hair for amount and pattern. In younger adult women, it’s usually thick and appears on the mons pubis as well as the inner aspects of the upper thighs. Perimenopausal and postmenopausal women typically have thinner pubic hair.
Using your index finger and thumb, gently spread the labia majora and look for the labia minora. Both labia should be pink and moist with no lesions.
Check for cervical discharge. Normal discharge varies in color and consistency. It’s clear and stretchy before ovulation, white and opaque after ovulation, and usually odorless and nonirritating to the mucosa. No other discharge should be present.
Palpating the external genitalia
Next, spread the labia with one hand and palpate with the other. The labia should feel soft. Note swelling, hardness, or tenderness. If you detect a mass or lesion, palpate it to determine its size, shape, and consistency.
If you find swelling or tenderness, see if you can palpate Bartholin’s glands, which usually aren’t palpable. To do this, insert your index finger carefully into the patient’s posterior introitus, and place your thumb along the lateral edge of the swollen or tender labium. Gently squeeze the labium. If discharge from the gland results, culture it.
Examining the internal genitalia
As part of a complete gynecologic assessment, obtain a Papanicolaou (Pap) smear after inspecting the cervix. (Obtain the smear before touching the cervix in any manner.) Also obtain other specimens if an abnormal cervical or vaginal discharge indicates infection.
Examining the male patient
Before examining the reproductive system of a male patient, perform hand hygiene and put on gloves. Make the patient as comfortable as possible, and explain what you’re doing every step of the way. This helps the patient feel less embarrassed.
Inspect the penis, scrotum, and testicles as well as the inguinal and femoral areas.
First, evaluate the color and integrity of the penile skin. It should be loose and wrinkled over the shaft and taut and smooth over the glans penis. The skin should be pink to light brown in whites, light to dark brown in blacks, and free from scars, lesions, ulcers, or breaks of any kind.
Retract and replace
Ask an uncircumcised patient to retract his prepuce, or foreskin, to expose the glans penis. Inspect the glans for ulcers or lesions. Then ask the patient to replace the foreskin over the glans. He should be able to retract and replace the foreskin easily. Ask him about his cleaning routine. The urethral meatus, a slitlike opening, is normally located at the tip of the glans. There should be no discharge from it.
First, evaluate the amount, distribution, color, and texture of pubic hair. Hair should cover the symphysis pubis and scrotum.
Scrutinizing scrotal skin
Next, inspect the scrotal skin for lesions, ulcerations, induration (hardness), or reddened areas, and evaluate the scrotal sac for symmetry and size. The scrotal skin should be coarse and more deeply pigmented than the body skin. The left testis usually hangs slightly lower than the right.
Check the inguinal area for obvious bulges — a sign of hernias. Then ask the patient to bear down as you inspect again. This maneuver increases intra-abdominal pressure, which pushes a herniation downward and makes it more easily visible. Also check for enlarged lymph nodes, a sign of infection.
After inspection, palpate the penis and scrotum for structural abnormalities; then palpate the inguinal area for hernias.
To palpate the penis, gently grasp the shaft between the thumb and first two fingers and palpate along its entire length, noting any indurated, tender, or lumpy areas. The flaccid penis should feel soft and have no nodules.
Like the penis, the scrotum can be palpated using the thumb and first two fingers. Begin by feeling the scrotal skin for nodules, lesions, or ulcers.
Into the sack
Next, palpate the scrotal sac. Typically, the right and left halves of the sac have identical contents and feel the same. You should feel the testes as separate, freely movable oval masses low in the scrotal sac. Their surface should feel smooth and even in contour. Slight compression of the testes should elicit a dull, aching sensation that radiates to the patient’s lower abdomen. This pressure-pain sensation shouldn’t occur when the other structures are compressed. No other pain or tenderness should be present.
Gently palpate the epididymis on the posterolateral surface by grasping each testis between your thumb and forefinger and feeling from the epididymis to the spermatic cord or vas deferens up to the inguinal ring. The epididymis should feel like a ridge of tissue lying vertically on the testicular surface. The vas deferens should feel like a smooth cord and be freely movable. The arteries, veins, lymph vessels, and nerves, which are located next to the vas deferens, may feel like indefinite threads.
Palpate the inguinal area for hernias. A hernia will feel like a small bulge or mass.