NUR314 - Health Assessment - Exam 3 Study Guide - Male and Female Genitourinary Systems (10 questions)

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What is an inguinal hernia

Indirect Inguinal Hernia
Sac herniates through internal inguinal ring; can remain in canal or pass into scrotum. Pain with straining; soft swelling that increases with increased intra-abdominal pressure; may decrease when lying down. It is the most common hernia - 60%. More common in infants <1 yo and in males 16-20 yo. Congenital or acquired.

Direct Inguinal Hernia
Directly behind and through external inguinal ring, above inguinal ligament; rarely enters scrotum. Usually painless; round swelling close to the pubis in area of internal inguinal ring, easily reduced when supine. Less common - occurs most often in men older than 40 yo and is rare in women. It is an acquired weakness; brought on my heavy lifting, muslce atrophy, obesity, chronic cough, or ascites.

Inspect and Palpate for Hernia
Inspect the inguinal region for a bulge as the person stands and as he strains down. Normally, none is present.

Bulge at external inguinal ring or at femoral canal. (A hernia may be present but easily reduced and may appear only intermittently with an increase in intra-abdominal pressure.)

Palpate the inguinal canal. For the right side, ask the male to shift his weight onto the left (unexamined) leg. Place your right index finger low on the right scrotal half. Palpate up the length of the spermatic cord, invaginating the scrotal skin as you go, to the external inguinal ring. It feels like a triangular slitlike opening, and it may or may not admit your finger. If it will admit your finger, gently insert it into the canal and ask the person to "bear down." Normally, you feel no change. Repeat the procedure on the left side. Palpable herniating mass bumps your fingertip or pushes against the side of your finger.

Aging adult and causes decreased sexual performance

The male does not experience a definite end to fertility as the female does. Around age 40 years, the production of sperm begins to decrease, although it continues into the 80s and 90s. After age 55 to 60 years, testosterone production declines very gradually so that resulting physical changes are not evident until later in life.

In the aging male, the amount of pubic hair decreases and the remaining hair turns gray. Penis size decreases. Due to decreased tone of the dartos muscle, the scrotal contents hang lower, the rugae decrease, and the scrotum looks pendulous. The testes decrease in size and are less firm to palpation. Increased connective tissue is present in the tubules, so these become thickened and produce less sperm.

In general, declining testosterone production leaves the older male with a slower and less intense sexual response, and an erection takes longer to develop and is less full or firm. Ejaculation is shorter and less forceful, and the volume of seminal fluid is less than when the man was younger. After ejaculation, rapid detumescence (return to the flaccid state) occurs, especially after 60 years of age. This occurs in a few seconds as compared with minutes or hours in the younger male. The refractory state (when the male is physiologically unable to ejaculate) lasts longer, from 12 to 24 hours as compared with 2 minutes in the younger male.

Sexual Expression in Later Life\par }{\pard \sb240 \li900 Chronologic age by itself should not mean a halt in sexual activity. The just-mentioned physical changes need not interfere with the libido and pleasure from sexual intercourse. The older male is capable of sexual function as long as he is in reasonably good health and has an interested, willing partner. Even chronic illness does not mean a complete end to sexual desire or activity.

The danger is in the male misinterpreting normal age changes as a sexual failure. Once this idea occurs, it may demoralize the man and place undue emphasis on performance rather than on pleasure. In the absence of disease, a withdrawal from sexual activity may be due to loss of spouse; depression; preoccupation with work; marital or family conflict; side effects of medications such as antihypertensives, psychotropics, antidepressants, antispasmodics, sedatives, tranquilizers or narcotics, and estrogens; heavy use of alcohol; lack of privacy (living with adult children or in a nursing home); economic or emotional stress; poor nutrition; or fatigue.

Prostatitis signs and symptoms

S: Fever, chills, malaise, urinary frequency and urgency, dysuria, urethral discharge; dull, aching pain in perineal and rectal area.

O: An exquisitely tender enlargement is acute inflammation of the prostate gland yielding a swollen, slightly asymmetric gland that is quite tender to palpation. With a chronic inflammation, the signs can vary from tender enlargement with a boggy feel to isolated firm areas due to fibrosis. Or the gland may feel normal.

Dysuria

Pain/buring with urination. Dysuria is common with acute cystitis, prostatitis and urethritis.

Therapeutic communication and sexual history with an adolescent male

Ask questions that seem appropriate for boy's age but be aware that norms vary widely. When you are in doubt, it is better to ask too many questions than to omit something. Children obtain information, often misinformation, from the media, Internet, and peers at surprisingly early ages. You may be sure your information will be more thoughtful and accurate. Ask direct, matter-of-fact questions. Avoid sounding judgmental.

Start with a permission statement. "Often boys your age experience...." This conveys that it is normal and all right to think or feel a certain way.

Try the ubiquity approach. "When did you...?" rather than "Do you...?" This method is less threatening because it implies that the topic is normal and unexceptional.

Do not be concerned if a boy will not discuss sexuality with you or respond to offers for information. He may not wish to let on that he needs or wants more information. You do well to "open the door." The adolescent may come back at a future time.

Around age 12 to 13 years, but sometimes earlier, boys start to change and grow around the penis and scrotum. What changes have you noticed? Have you ever seen charts and pictures of normal growth patterns for boys? Let us go over these now.

Who can you talk to about your body changes and about sex information? How do these talks go? Do you think you get enough information? What about sex education classes at school? How about your parents? Is there a favorite teacher, nurse, doctor, minister, or counselor to whom you can talk?

Boys around age 12 to 13 years (SMR3) have a normal experience of fluid coming out of the penis at night, called nocturnal emissions, or "wet dreams." Have you had this? An occasional boy confuses this with a sign of STI or feels guilty.

Teenage boys have other normal experiences and wonder if they are the only ones who ever had them, like having an erection at embarrassing times, having sexual fantasies, or masturbating. Also, a boy might have a thought about touching another boy's genitals and wonder if this means he might be homosexual. Would you like to talk about any of these things? A boy may feel guilty about experiencing these things if not informed that they are normal.

Often boys your age have questions about sexual activity. What questions do you have? How about things like birth control or STIs such as gonorrhea or herpes? Any questions about these? Assess level of knowledge. Many boys will not admit they need more knowledge.

Are you dating? Someone steady? Have you had intercourse? Are you using birth control? What kind Avoid the term "having sex." It is ambiguous, and teens can take it to mean anything from foreplay to intercourse. Use behavior-specific words. What kind of birth control did you use the last time you had intercourse? This particular question often reveals that the teen is not using any method of birth control.

Has a nurse or doctor ever taught you how to examine your own testicles to make sure they are healthy? Assess knowledge of testicular self-examination.

Has anyone ever touched your genitals and you did not want them to? Another boy, or an adult, even a relative? Sometimes that happens to teenagers. They should remember it is not their fault. They should tell another adult about it.

Side effects and Erectile dysfunction medications

Penile erection is managed by two different mechanisms. The first one is the reflex erection, which is achieved by directly touching the penile shaft. The second is the psychogenic erection, which is achieved by erotic or emotional stimuli. The former uses the peripheral nerves and the lower parts of the spinal cord, whereas the latter uses the limbic system of the brain. In both conditions, an intact neural system is required for a successful and complete erection. Stimulation of penile shaft by the nervous system leads to the secretion of nitric oxide (NO), which causes the relaxation of smooth muscles of corpora cavernosa (the main erectile tissue of penis), and subsequently penile erection. Additionally, adequate levels of testosterone (produced by the testes) and an intact pituitary gland are required for the development of a healthy erectile system. As can be understood from the mechanisms of a normal erection, impotence may develop due to hormonal deficiency, disorders of the neural system, lack of adequate penile blood supply or psychological problems. Restriction of blood flow can arise from impaired endothelial function due to the usual causes associated with coronary artery disease, but can also be caused by prolonged exposure to bright light.

Erectile dysfunction is characterized by the regular or repeated inability to obtain or maintain an erection. There are several ways that erectile dysfunction is analyzed:
- Obtaining full erections at some times, such as when asleep (when the mind and psychological issues, if any, are less present), tends to suggest the physical structures are functionally working.
- Other factors leading to erectile dysfunction are diabetes mellitus (causing neuropathy).

Medication
Phosphodiesterase type 5 inhibitors
The cyclic nucleotide phosphodiesterases constitute a group of enzymes that catalyze the hydrolysis of the cyclic nucleotides cyclic AMP and cyclic GMP. They exist in different molecular forms and are unevenly distributed throughout the body.
One of the forms of phosphodiesterase is termed PDE5. The prescription PDE5 inhibitors sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) are prescription drugs which are taken orally. They work by blocking the action of PDE5, which causes cGMP to degrade.

Alprostadil
Alprostadil in combination with the permeation enhancer DDAIP has been approved in Canada under the brand name Vitaros as a topical cream first line treatment for erectile dysfunction.

Another treatment regimen is injection therapy. One of the following drugs is injected into the penis: papaverine, phentolamine, and prostaglandin E1.

Contraindications
PDE5 inhibitors are contraindicated in those taking nitrate medication. They are also contraindicated in men for whom sexual intercourse is inadvisable due to cardiovascular risk factors.

Adverse reactions
The occurrence of adverse drug reactions (ADRs) with PDE5 inhibitors appears to be dose related. Headache is a very common ADR, occurring in >10% of patients. Other common ADRs include: dizziness, flushing, dyspepsia, nasal congestion or rhinitis. On October 18, 2007, the U.S. Food and Drug Administration (FDA) announced that a warning about possible sudden hearing loss would be added to drug labels of PDE5 inhibitors. Since 2007 there is evidence that 5-phosphodiesterase inhibitors can cause an anterior optic neuropathy. Other ADRs and their incidence vary with the agent and are listed in their individual pages.

Drug interactions
PDE5 inhibitors are primarily metabolised by the cytochrome P450 enzyme CYP3A4. The potential exists for adverse drug interactions with other drugs which inhibit or induce CYP3A4, including HIV protease inhibitors, ketoconazole, itraconazole, and other anti-hypertensive drugs such as Nitro-spray (due to its capacity to diminish blood pressure).

HPV vaccinations

In June 2006, the Advisory Committee on Immunization Practices (ACIP) voted to recommend the first vaccine developed to prevent cervical cancer. The ACIP is a national group of experts that advises the Centers for Disease Control and Prevention (CDC) on vaccine issues. This represents one of the most important advances in women's health in recent years.

The vaccine targets human papilloma virus (HPV), the virus responsible for most cases of cervical cancer. HPV is the most common sexually transmitted infection (STI). Most people who have become infected with HPV do not even know they had it because the virus usually does not cause any symptoms and in 90% of the cases, the body's immune system can fight it off. However, sometimes the virus lingers in a woman's cervix and can cause changes that may eventually lead to cervical cancer.

The HPV vaccine is recommended for girls ages 11 to 12 but can be started as early as 9 years of age. Catch-up vaccination is recommended for 13- to 26-year-old females who did not receive the vaccine series. Ideally, the HPV vaccine is recommended before they become sexually active because it is not effective if the individual is already infected with HPV. However, sexually active females may still benefit, since few women are infected by all four HPV types (6, 11, 16, 18) targeted by the vaccines. It is contraindicated during pregnancy and lactation. The HPV vaccine is given in three separate injections over a 6-month period. The second and third doses are 2 and 6 months after the first dose. The vaccine can be administered at the same visit as other age-appropriate vaccines, such as the Tdap, Td, and hepatitis B vaccines.

It is important to remind women that obtaining the vaccine does not mean that they can forget about routine pelvic examinations and Papanicolaou (Pap) tests. The vaccine will protect against major types of HPV that cause cervical cancer, but not all types. Pap tests can detect cell changes in the cervix {\i before} they turn into cancer, at an early, curable stage. Other than the vaccine, the only way to prevent HPV is to abstain from all sexual activity. Using protection, such as a condom, may not be enough because areas not covered by a condom can be exposed to the virus.

Human Papillomavirus (HPV) Genital Warts
S: Painless warty growths, may be unnoticed by woman.
O: Pink or flesh-colored, soft, pointed, moist, warty papules. Single or multiple in a cauliflower-like patch. Occur around vulva, introitus, anus, vagina, cervix.

HPV infection is common among sexually active women, especially adolescents, regardless of ethnicity or socioeconomic status. Risk factors include early age at menarche and multiple sexual partners. The long incubation period (6 weeks to 8 months) makes it difficult to establish history of exposure.

Subjective information and vaginal discharge

- Any unusual vaginal discharge? Increased amount? Normal discharge is small, clear or cloudy, and always nonirritating.
- Character or color: white, yellow-green, gray, curdlike, foul smelling? Suggests vaginal infection; character of discharge often suggests causative organism
- When did this begin? Acute versus chronic problem.
Is the discharge associated with vaginal itching, rash, pain with intercourse? Rash is result of irritation from discharge. Dyspareunia occurs with vaginitis of any cause.
- Taking any medications? Factors that increase risk for vaginitis include: Oral contraceptives increase glycogen content of vaginal epithelium, providing fertile medium for some organisms; Broad-spectrum antibiotics alter balance of normal flora.
- Family history of diabetes? Diabetes increases glycogen content.
- What part of your menstrual cycle are you in now? Menses, postpartum, menopause have a more alkaline vaginal pH.
- Use a vaginal douche? How often? Frequent douching alters pH.
- Use feminine hygiene spray? Spray has risk for contact dermatitis.
- Wear nonventilating underpants, pantyhose? Treated the discharge with anything? Result? Can cause local irritation.

Therapeutic communication and sexual relationship questions with a female patient

- Often women have a question about their sexual relationship and how it affects their health. Do you? Are you in a relationship involving sex now? Begin with open-ended question to assess individual needs. Include appropriate questions as a routine.
- Are aspects of sex satisfactory to you and your partner? Communicates that you accept individual's sexual activity and believe it is important.
- Satisfied with the way you and partner communicate about sex? Your comfort with discussion prompts person's interest and possibly relief that the topic has been introduced.
- Satisfied with your ability to respond sexually? Establishes a database for comparison with any future sexual activities.
- Do you have more than one sexual partner? Provides opportunity to screen sexual problems.
- What is your sexual preference: relationship with a man, with a woman, both? The practice environment must be welcoming and respectful of lesbians and bisexual women to discuss their health concerns.
- Currently planning a pregnancy, or avoiding pregnancy?
- Do you and your partner use a contraceptive? Which method? Is this satisfactory? Do you have any questions about method? Which methods have you used in the past? Assess smoking history. Oral contraceptives, together with cigarette smoking, increase the risk for vascular problems.
- Have you and partner discussed having children?
- Have you ever had any problems becoming pregnant? Infertility is considered after 1 year of engaging in unprotected sexual intercourse without conceiving.

Therapeutic communication and sexually transmitted infections

- Any sexual contact with partner having an STI, such as gonorrhea, herpes, HIV/AIDS, chlamydial infection, venereal warts, syphilis? When? How was this treated? Were there any complications? An STI includes all conditions that can be transmitted during intimate sexual contact with an infected partner.
- Any precautions to reduce risk for STIs? Use condoms at each episode of sexual intercourse?

Papanicolaou (Pap) Smear and patient education prior to exam

The Papanicolaou, or Pap, test screens for cervical cancer and not for endometrial or ovarian cancer. Do not obtain during the woman's menses or if a heavy infectious discharge is present. Instruct the woman to not douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens. Obtain the Pap smear before other specimens so you will not disrupt or remove cells. Most U.S. clinics have changed from conventional cytology collection using glass slides to liquid-based cytology vials. Using liquid-based cytology, the cervical specimens are dipped into a vial with preservative rather than being smeared on a slide. Conventional glass slides can come back from the laboratory as unsatisfactory because of obscuring by blood or inflammation or clumped distribution of cells. Thus evidence shows that just stirring off the cells into the liquid vial results in fewer unsatisfactory tests and is more sensitive in detecting cervical neoplasia. Using liquid-based cytology, microscopic evaluation is made clearer by the uniform spread of epithelial cells in a thin layer. Also, after cytology examination, pathologists can perform further studies on the liquid remnant such as testing for high-risk HPV types. Whichever collection method you are using, collect the cellular specimens from the following three locations.

The increased use of the Papanicolaou (Pap) test in the United States has resulted in a 74% decline in the cervical cancer death rate between 1955 and 1992.

Select the proper-size speculum. Warm and lubricate the speculum under warm running water. Regarding Pap test cytology, evidence shows applying a small amount (dime size) of water-soluble gel lubricant on the outer inferior blade increases patient comfort and yields no more unsatisfactory slides than does water-only lubricant.

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