Medicine

hterventions for Clients with Gynecologic Problems

MANAGEMENT OF PATIENTS WITH FEMALE REPRODUCTIVE DISORDERS

Prepared by Assistant professor N.Petrenko, MD, PhD

Learning Objectives

1. After studying this chapter, you should be able to:

2. Compare and contrast common menstrual cycle disorders.

3. Discuss common assessment findings associated with menopause.

4. Develop a teaching plan for a client with a vaginal inflammation or infection.

5. Prioritize postoperative care for the client undergoing an anterior and/or posterior repair.

6. Analyze assessment data for clients with leiomyomas to determine nursing diagnoses and collaborative problems.

7. Formulate a plan of care for a client undergoing a hysterectomy.

8. Identify the risk factors for gynecologic cancers.

9. Discuss the psychosocial issues associated with gynecologic cancers.

Explain the purpose of radiation and chemotherapy for clients with gynecologic cancers.

10. Develop a community-based plan of care for clients with gynecologic cancers.

 

The most common reasons for seeking gynecologic care are pain, vaginal discharge, and bleeding. Nurses can play an important role in assessing gynecologic disorders by being knowledgeable about disease presentation, being sensitive to the client's complaints, and encouraging discussion about menstrual or other reproductive problems. Educating women about their bodies, helping them to recognize when profes­sional help should be sought, and teaching them how to make informed decisions about treatments are major goals for nurses working with female clients in any setting. Nurses also need to assess the effects of gynecologic problems on sexual health.


MENSTRUAL CYCLE DISORDERS

PRIMARY DYSMENORRHEA

OVERVIEW

Dysmenorrhea, or painful menstrual flow, is one of the most common gynecologic problems, occurring most often in women in their teens and early 20s. More than 50% of all women report some degree of dysmenorrhea, but only a small percentage are not able to function. Primary dysmenorrhea is not associated with pelvic pathologic changes, whereas secondary dysmenor­rhea usually begins with an underlying disease condition.

Primary dysmenorrhea usually occurs after ovulation is es­tablished. Dysmenorrhea is painful uterine cramping charac­terized by spasmodic lower abdominal pain that begins with the onset of menstrual flow, and lasts 12 to 48 hours. The pain often radiates to the lower back and thighs; nausea and vom­iting, fatigue, and nervousness may accompany the pain. Less common clinical manifestations include headache, syncope, diarrhea, bloating, and breast tenderness.

Most researchers believe that the cause of primary dysmen­orrhea is increased production and release of uterine prostaglandins. Prostaglandins are produced by the endometrium dur­ing the luteal phase of the menstrual cycle, and the levels peak at the onset of menses. Excessive prostaglandin levels stimulate the myometrium and cause severe spasms, which constrict uterine blood flow, resulting in ischemia and pain.

COLLABORATIVE MANAGEMENT

Assessment

A thorough history of the client includes the following:

  The age at menarche (onset of menstruation)

  Characteristics of menstruation

  Obstetric history

  Contraceptive history

  The type of pain

  Previous therapy

  The need for contraception

The client is asked whether she has any conditions sugges­tive of pelvic problems. To plan care, the nurse assesses emo­tional factors, such as the individual woman's response to dysmenorrhea, her attitudes about menstruation, and the ex­tent to which dysmenorrhea is perceived to disrupt her life.

Interventions

Interventions for primary dysmenorrhea include prevention, education, support, and therapeutic measures that are tailored to each woman's needs. Prostaglandin synthetase inhibitors (nonsteroidal anti-inflammatory drugs [NSAIDs]), such as ibuprofen (Motrin, Apo-Ibuprofen1^) and naproxen sodium (Anaprox, Naprosyn), are currently recommended for pain re­lief. In addition, numerous over-the-counter ibuprofen prod­ucts, such as Advil and Nuprin, provide pain relief for many clients with primary dysmenorrhea. Aspirin is a mild prostaglandin synthetase inhibitor and may relieve mild dys­menorrhea. All of these drugs can cause gastrointestinal (GI) distress and should therefore be taken with meals or milk.

Before treatment, the health care provider must assess the client's contraception needs. When contraception is not needed, prostaglandin synthetase inhibitors are the treat­ment of choice because they are required only for the dura­tion of symptoms. If contraception is a consideration, ovu-lation suppression with oral contraceptives is the treatment of choice.

Complementary and alternative therapies.

Complementary therapies that may alleviate or prevent pain include acupressure, aerobic exercise, swimming, yoga or other meditation, application of heat or cold, massage, biofeedback, and relaxation techniques. Dietary measures for the prevention of pain may include increasing the intake of vi­tamin B6, calcium, magnesium, and protein and reducing the intake of sodium to reduce fluid retention.

 


PREMENSTRUAL SYNDROME

OVERVIEW

PMS is a collection of symptoms that are cyclic in na­ture. These symptoms are followed by relief with menses and a symptom-free phase. PMS affects women of all races, socioeconomic levels, and educational levels. It seems to be more prevalent in women 30 to 40 years old. The severity increases with aging until menopause. Women are at greater risk for PMS after pregnancy, childbirth, and tubal ligation; during the perimenopausal years; and during major life stresses.

Currently, there is no agreement on a single set of diag­nostic criteria for PMS. Three elements are found in defining PMS: symptoms, severity level, and timing. Many women re­port experiencing six or more symptoms across emotional, physical, and cognitive categories.

Emotional symptoms include irritability, easily precipi­tated crying spells, low self-esteem, anxiety, and depression. Somatic or physical symptoms include breast tenderness, bloating, fluid retention, increased appetite and food cravings, insomnia, fatigue, hot flashes, headaches, and musculoskele-tal discomfort. Cognitive problems include short-term mem­ory problems, difficulty concentrating, and unclear thinking.

 

COLLABORATIVE MANAGEMENT

Assessment

There is no reported objective means of diagnosing PMS. Some researchers have attempted to differentiate premenstrual pat­terns. Determining the timing of the symptoms is as critical as noting the type of symptoms. The most effective and readily available assessment tool is a menstrual chart. The nurse in­structs the client to keep a chart for at least three consecutive cycles, showing the length of the menstrual cycle, the duration of bleeding, and the occurrence of symptoms. If the woman has PMS, the symptoms recur during the luteal phase (from ovulation to menstruation), which is followed by a symptom-free pe­riod (at least 7 days). When taking a menstrual history, the nurse also assesses to what extent the woman believes that her activities of daily living (ADLs) are disrupted by the symp­toms. Often reassurance that the symptoms are legitimate and that other women share these problems can help the client learn more about PMS. Clinical manifestations vary greatly among women and affect many body systems (Chart 1).

 

CHART 1 KEY FEATURES of Premenstrual Syndrome

Dermatologic Manifestations

Acne

Urticaria

Herpes

Respiratory Manifestations

Sinusitis

Asthma Rhinitis

Colds

Urologic Manifestations

Oliguria

Cystitis

Enuresis

Urethritis

Ophthalmologic Manifestations

Conjunctivitis

Styes

Glaucoma

Neurologic Manifestations

Headaches

Migraine

Syncope

vertigo

Numbness of hands and feet

Epilepsy (if susceptible)

Metabolic Manifestations

Edema

Breast tenderness

Behavioral Manifestations

Lowered work performance

Food cravings

Alcohol and drug overindulgence

Confusion

Sleeplessness

Lack of coordination

Suicide

Lethargy

Child abuse

Assaultive behavior

Other Manifestations

Allergies

Hypoglycemia

Joint pain

Backache

Palpitations

Water retention

Emotional or Psychologic Manifestations

Depression

Irritability

Tension

Panic attacks

Change in libido

Mood swings

Anxiety

Behavioral Manifestations

Lowered work performance

Food cravings

Alcohol and drug overindulgence

Confusion

Sleeplessness

Lack of coordination

Suicide

Lethargy

Child abuse

Assaultive behavior

Other Manifestations

Allergies

Hypoglycemia

Joint pain

Backache

Palpitations

Water retention

 

Interventions

Management of PMS focuses on eliminating the uncomfort­able symptoms. The syndrome is highly individualized; how­ever, one of the most important interventions is education.

Each woman needs information about her body, especially the menstrual cycle, so that she can begin to understand the phys­iologic basis of PMS.

Women may need to express their feelings and discuss their experiences with PMS. Self-help groups and support groups are helpful resources. These groups also encourage significant others to participate, because PMS usually affects not only the woman but also her family and friends. For ex­ample, increased family conflict, communication problems with family and friends, and decreased family cohesion occur. Other coping strategies for the woman with PMS may include spiritual support, especially participating in religious services and seeking advice from spiritual leaders.

Diet Therapy. Diet and nutrition are also important in managing PMS. If hypoglycemia (low blood glucose) occurs, the nurse instructs the woman to eat six small meals a day and to limit her intake of sugar, red meat, alcohol, coffee, tea, and chocolate.

Eliminating caffeine may help reduce irritability. Salt and sodium intake should be limited if edema occurs. Calcium, magnesium, and vitamins A, B6, and С have also been used for relief of PMS.

Drug Therapy. Drug therapy remains controversial, but some treatments have been effective. Mild potassium-sparing diuretics taken for 10 days before menstruation can provide relief for some women. Women may need to increase their intake of potassium-containing foods if they are receiv­ing this therapy.

Progesterone may relieve physical and psychologic symp­toms. Natural progesterone is preferable to synthetic proges­terone, even though the drug must be specially made by a pharmacist at the time prescribed. The daily dosage is 50 to 100 mg IM from ovulation to menstruation. Long-term side effects are unknown.

Bromocriptine mesylate (Parlodel) 2.5 mg two or three times a day with meals during the luteal phase can relieve breast symptoms. The side effects (lightheadedness and hy­potension) may not be well tolerated. Other drugs for PMS that have been used include birth control pills, gonadotropin-releasing hormone (GnRH) agonists, antidepressants, and prostaglandin inhibitors, such as nonsteroidal anti-inflamma­tory drugs (NSAIDs).


AMENORRHEA

OVERVIEW

Amenorrhea (the absence of menstrual periods) can be either primary (menstruation that has failed to occur by age 16 years) or secondary (menstruation that has started but has since stopped and has not recurred for at least 3 months). Pri­mary amenorrhea is often associated with anomalies of the re­productive tract, and the prognosis for fertility is usually poor. Secondary amenorrhea is probably due to a functional disor­der, and the prognosis for fertility is better. Amenorrhea can cause a woman much distress and concern.

Menstruation is a complex series of events that rely on the interplay of the hypothalamic, pituitary, ovarian, and en-dometrial functions. Dysfunction related to any of these four factors may cause amenorrhea (Table 1). Primary amen­orrhea is relatively uncommon. Congenital factors are responsible for about two thirds of cases, and the remaining one third of cases are caused by ovarian, pituitary, or hypo­thalamic disease. Pregnancy, lactation (breastfeeding), and menopause are the most common physiologic causes of sec­ondary amenorrhea.

TABLE 1 COMMON CAUSES OF AMENORRHEA

PRIMARY

Congenital anomalies

Hypothalamic and pituitary disorders, such as delayed puberty

Systemic disease

Thyroid and adrenal dysfunction

Diabetes mellitus

Extreme malnutrition

Ovarian disease

Malformations of the reproductive tract

SECONDARY

Pregnancy

Menopause

Lactation

Cervical stenosis

Polycystic ovary disease

Pituitary tumor or insufficiency

Psychogenic stress

Excessive physical activities

Medications

Antihypertensive agents

Birth control pills

Phenothiazines

Nutritional disorders

Obesity

Anorexia nervosa

Sudden weight loss

Ovarian disease, failure, or destruction

 

COLLABORATIVE MANAGEMENT

Assessment

The nurse assesses both the menstrual history and the ob­stetric history and asks about possible sexual activity and symptoms of pregnancy. A medical history may identify a systemic disease as a cause of amenorrhea. The nurse asks about current eating habits and any history of dieting be­cause both obesity and starvation (e.g., anorexia nervosa) can contribute to amenorrhea. Strenuous exercise associated with competitive athletics, such as long-distance running, can cause stress or a reduction in body fat, resulting in amenorrhea. The nurse assesses hormone deficiencies, such as those associated with menopause that can cause hot flashes and vaginal dryness. Women should be questioned about their ingestion of drugs (e.g., oral contraceptives, phe-nothiazines, and antihypertensives) and recent stressors. The nurse is also alert for signs of galactorrhea (watery or milky breast secretions in nonbreastfeeding or women who have not been pregnant and hirsutism (unusual hair growth in women), both of which are related to polycystic ovary disease and subsequent amenorrhea.

Interventions

The nurse's primary roles in implementing care are to explain amenorrhea in easily understandable terms and to answer questions about tests and treatments. Counseling and emotional support must be provided. Amenorrhea may be a threat to a woman's self-concept; she usually needs to ventilate her feelings about sexuality or fertility.

Interventions for specific causes of amenorrhea are based on each woman's needs. Medical and surgical management of amenorrhea is directed at the underlying causes. Treatment includes hormone replacement, ovulation stimulation, and pe­riodic progesterone withdrawal.

 


POSTMENOPAUSAL BLEEDING

OVERVIEW

Postmenopausal bleeding (vaginal bleeding occurring after a 12-month cessation of menses after the onset of menopause) is a symptom rather than a medical diagnosis. Bleeding is considered serious and should be evaluated. Gynecologic can­cer occurs in 20% to 40% of women who experience post­menopausal bleeding.

Postmenopausal bleeding can be caused by numerous be­nign and malignant conditions (Table 2). The three most common causes are atrophic vaginitis, cervical polyps, and endometrial hyperplasia.

TABLE 2 COMMON CAUSES OF POSTMENOPAUSAL BLEEDING

BENIGN

Atrophic vaginitis

Cervical polyps

Endometrial hyperplasia

Uterine fibroids

Cervical erosion

Estrogen therapy

MALIGNANT

Endometrial cancer

Cervical cancer

Ovarian cancer

Vaginal cancer

Tubal cancer

 

In a client with atrophic vaginitis, the vaginal mucosa is thin and dry and is easily traumatized by sexual intercourse and infection, causing spotting. Cervical polyps are usually soft, red, oval tissue masses that appear within the cervical canal, and they may bleed spontaneously or after intercourse.

The most serious cause of postmenopausal bleeding is en­dometrial hyperplasia (tissue overgrowth), a precursor of endometrial cancer. Bleeding is caused by declining ovarian function that leads to prolonged estrogen stimulation, produc­ing the hyperplasia that eventually breaks down and bleeds. Estrogen stimulation can also be caused by estrogen replace­ment therapy (ERT).

Because many women who report postmenopausal bleed­ing need medical or surgical interventions, assessment is the major focus. The nurse assesses the menstrual history and family history initially, including the following:

  The client's age at menopause

  The frequency and amount of bleeding

  Previous bleeding episodes. Use of medications (especially estrogen-only [unop­posed estrogen] replacement therapy [ERT])

  Gastrointestinal (GI) or genitourinary symptoms

The nurse also identifies women who are at high risk for endometrial cancer (e.g., women who are obese, hyperten­sive, or diabetic or who have never had children).

Urine and stool specimens can be collected and tested for blood to differentiate other sources of bleeding. Blood spec­imens may be drawn for hemoglobin or hematocrit determinations, because clients are often anemic as a result of ex­cessive bleeding. The nurse can prepare the woman for phys­ical and pelvic examinations, including obtaining a specimen for a Papanicolaou (Pap) test, or smear, to evaluate the cause of bleeding.

 

COLLABORATIVE MANAGEMENT

Nursing interventions focus on providing information and sup­port for diagnostic and treatment procedures directed at the specific causes of bleeding. An endometrial biopsy can evalu­ate the presence of malignancy. A diagnostic dilation and curettage (D&C) procedure can be used to determine malig­nancy. Atypical hyperplasia is often treated with a hysterectomy. Malignancy is usually treated with a combination of surgery, radiation therapy, and chemotherapy. The medical treatment of a woman receiving unopposed estrogen therapy may include the monthly administration of progesterone daily for the last 10 days of the estrogen therapy (days 16 to 25) or a once-per-month intramuscular (IM) prog­esterone injection. This treatment can reduce the abnormal endometrial proliferation and is suggested for the prevention of endometrial and breast cancer.

Atrophic vaginitis is managed by the administration of es­trogen via the vaginal, oral, transdermal, or subdermal route. The nurse teaches the client about ERT (Chart 2). Women who use vaginal estrogen cream need to be aware that it can cause systemic effects. Women who take estrogen may be at risk for gallbladder disease, hypertension, breast cancer, en­dometrial cancer, and coronary artery disease.

CHART 2 CLIENT EDUCATION GUIDE Estrogen Replacement Therapy

For All Types of Estrogen Replacement Therapy

  Call your health care provider if you have pain in your calves or groin, if you suddenly become short of breath, if you have abnormal vaginal bleeding, if you feel a lump in your breast, if you have a severe headache, or if you feel weak or numb in your arms or legs.

  Use sunscreen if you are in the sun for a prolonged period.

  Keep appointments for checkups.

  If your health care provider has prescribed progesterone to decrease your risk of endometrial cancer, take it as prescribed.

For Oral Therapy

  Take 1 pill a day for the first 25 days each month.

  If you feel nauseated or have intestinal upset, take your medication with food.

For Transdermal or Subdermal Administration

  Rotate the sites for the patches or injections to avoid skin irritation.

  Change the patches twice a week or according to your prescribed schedule.

For Vaginal Therapy

  Use an applicator to insert the suppository or cream daily as prescribed.

  You may need to wear a minipad to protect your clothing from soiling or staining by the drug.

 


ENDOMETRIOSIS

OVERVIEW

Endometriosis is usually a benign disease characterized by im­plantation of endometrial tissue outside the uterine cavity. The tissue typically appears on the ovaries and the cul-de-sac and less commonly on other pelvic organs and structures (Figure 1). A "chocolate" cyst is an area of endometriosis inside an ovary.

 

Figure 1 Common sites of endometriosis

 

Endometrial tissue located outside the endometrium re­sponds similarly to the endometrium to hormonal stimulation and goes through the same cyclic changes. Bleeding occurs at the site of implantation, and the blood is trapped in the tis­sues; scarring and adhesions result as the blood is reabsorbed. Endometriosis progresses slowly. It regresses during preg­nancy and at menopause. Rarely does endometriosis become a malignant disease.

The cause of endometriosis is unknown. The most accepted theories of causation are transportation and formation. There are two transportation theories: (1) implantation and (2) vascular and lymphatic dissemination. The implantation theory holds that endometrial tissue flows back through the fallopian tubes during menstruation and then implants on pelvic structures. Proponents of the vascular and lymphatic dissemination theory advocate that endometrial glands are transported through the vascular and lymphatic system to foreign locations. This latter theory may ex­plain implantation in areas outside the pelvis, such as the lungs and the kidneys. Formation theories propose that endometrial tissue develops spontaneously outside the uterus.

Endometriosis occurs most often in women in their 30s and 40s; rarely does it appear before age 20. It is most com­mon in women who have not been pregnant and in those whose mothers had endometriosis.

 

COLLABORATIVE MANAGEMENT

Assessment

The nursing assessment should be as detailed as possible and in­clude the client's menstrual history, her sexual history, and the characteristics of bleeding. Pain is the most common symptom of endometriosis. The pain usually peaks just before the menstrual flow. Pain is usually located in the lower abdomen, caus­ing many women to feel a sense of rectal pressure. The degree of pain is not related to the extent of the endometriosis but is re­lated to the site. Often women with minimal disease have more severe pain than do women with extensive disease. Other clini­cal manifestations include dyspareunia (painful sexual inter­course), painful defecation, sacral backache, hypermenorrhea (excessive, prolonged, or frequent bleeding), and infertility.

A pelvic examination may reveal pelvic tenderness, nodu­lar uterosacral ligaments, and fixed or limited movement of the uterus. Psychosocial assessment may reveal anxiety be­cause of uncertainty about the diagnosis. The woman may also have concerns about her self-concept if she is infertile and wants to become pregnant.

Diagnostic studies include blood tests (erythrocyte sedimen­tation rate [ESR] and white blood cell [WBC] count) to rule out pelvic inflammatory disease (PID). Ultrasonography is used to confirm or delineate pelvic masses that might be mistaken for endometriosis. Laparoscopy is the key diagnostic procedure for pelvic endometriosis. Examination of tissue specimens ob­tained during laparoscopy can confirm the diagnosis.

Interventions

Medical (hormonal) and surgical management may be used, depending on the symptoms, the extent of disease, and the client's desire for childbearing. Nursing management is aimed at the following:

·       Reducing pain

·       Restoring sexual function that was impaired by dyspareunia (painful sexual intercourse)

Alleviating anxiety related to the clinical manifestations of the disease and the uncertainty of the diagnosis. (Alleviating fear related to the possibility of laparoscopy or surgery)

·       Eliminating the client's knowledge deficit about the disease or its treatment

·       Preventing self-esteem disturbance related to infertility

Several organizations, including the Endometriosis Society and RESOLVE (an organization for infertile couples), offer additional information on endometriosis that may be helpful in planning care.

Nonsurgical Management. Nonsurgical manage­ment involves the use of mild analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief. The health care provider also uses hormonal therapies to relieve pain by sup­pressing ovulation. The hormonal therapies produce pseudo-pregnancy, pseudomenopause, or medical oophorectomy.

Pseudopregnancy is induced with oral contraceptives or prog­esterone. The health care provider usually prescribes a 6-month course of a low-dose estrogen oral contraceptive, followed by cyclic oral contraceptive use or therapy with progesterone alone.

The second hormonal treatment causes ovarian suppression, or pseudomenopause, by the use of danazol (Danocrine, Cy-clomen^), an antigonadotropin testosterone derivative. This therapeutic approach is the current choice of many health care providers, but it is expensive ($ 120 to $ 180 per month) and may cause undesirable side effects, including acne, hirsutism (ab­normal hair growth in unwanted areas), weight gain, decreased breast size, and hot flashes. The third hormonal treatment is the use of gonadotropin-releasing hormone (GnRH) agonists to produce a reversible medical oophorectomy. The drag can be administered by IM or subcutaneous injection or by nasal spray. Side effects in­clude hot flashes, vaginal dryness, and insomnia.

Complementary and alternative therapies.

Therapies that can relieve pain include the application of a heating pad to the abdomen or sacrum, relaxation techniques, yoga, and biofeedback. These approaches may decrease mus­cle tissue hypoxia and hypertonicity and relieve ischemia by increasing blood flow to the affected areas.

Surgical Management. Surgical management of endometriosis for a woman who wants to remain fertile is conservative and involves removal of endometrial implants and adhesions. The surgeon may use a carbon dioxide laser to treat endometriosis by vaporizing adhesions and endometrial implants. If the client does not wish to have children, the uterus and ovaries may be removed.

 


DYSFUNCTIONAL UTERINE BLEEDING

OVERVIEW

Dysfunctional uterine bleeding (DUB), a nonspecific diag­nostic term, is bleeding that is excessive or abnormal in amount or frequency without predisposing anatomic or systemic condi­tions. DUB occurs most often at either end of the span of a woman's reproductive years—when ovulation is becoming es­tablished or when it is becoming irregular at menopause.

Normally, the menstrual cycle represents a series of complex hormonal events related to balanced hypothalamic, pituitary, ovarian, and uterine functions. Menses, the sloughing of the en­dometrial lining, is an expected result. DUB occurs when there is a breakdown of these functions, causing hormonal imbalance.

The mechanism of DUB is unknown, but several theories have linked it with endometrial or myometrial dysfunction. Ex­cessive fibrinolytic activity in the endometrium and changes in prostaglandin production in the uterus may also cause DUB.

Generally, DUB occurs in the absence of ovulation when the absence is associated with ovarian dysfunction. Estrogen stimulation of the endometrium is prolonged, and the en­dometrium grows past its hormonal support, causing bleeding and desquamation (shedding of uterine lining).

Anovulatory DUB during the reproductive years is associ­ated with the following:

  Polycystic ovary disease

  Stress

  Extreme weight changes

  Long-term drag use (e.g., anticholinergics, morphine, or oral contraceptives)

Ovulatory causes of DUB are uncommon and are related to a dysfunctional corpus luteum, irregular maturation, and shedding of the endometrium.

 

COLLABORATIVE MANAGEMENT

Assessment

When interviewing a woman with DUB, the nurse takes a complete menstrual history. The client is also asked about ill­nesses, variations in weight or diet, exercise, drug ingestion, and whether she has pain.

During the physical assessment, the nurse observes for symp­toms of anemia or systemic disease, such as the following:

  Renal or hepatic disease

  Obesity

  Undernutrition

  Abnormal hair growth related to hormonal dysfunction

  Evidence of abdominal pain or masses

An examination that includes inspection of the external genitalia and a bimanual pelvic and rectal examination is es­sential to identify lesions or tenderness. A physician, a nurse practitioner, or a nurse midwife performs the internal pelvic examination.

Pelvic ultrasonography and hysteroscopy may be per­formed. In addition, the surgeon usually does an endometrial biopsy by suction aspiration or dilation and curettage (D&C). These are important procedures for women older than 40 years of age, who are at greater risk for endometrial cancer.

Interventions

Nonsurgical Management. Nonsurgical manage­ment is usually the treatment of choice, although surgery may be needed to treat DUB. Most women can be treated success­fully with hormonal manipulation. For those with anovulatory DUB, the health care provider typically prescribes medroxy-progesterone acetate (Depo-Provera) or combination oral contraceptives. If the client takes oral contraceptives, she should take 1 pill a day for 21 or 28 days, beginning on the first day of the menstrual cycle. Medroxyprogesterone is taken on days 16 to 25 of each month. Monthly withdrawal bleeding is expected with both therapies.

Women with ovulatory DUB may be treated with progestins during the luteal phase, oral contraceptives, prostaglandin in­hibitors, or danazol. The nurse explains the desired and side ef­fects of these drags and evaluates the woman's knowledge of the effects, dosage, and administration schedule.

Surgical Management. Surgical management in­cludes D&C, laser or balloon endometrial ablation, and hys­terectomy. A D&C is usually used to treat an acute episode of bleeding, but the problem often returns. Laser or balloon en­dometrial ablation is a safe alternative for women who do not re­spond to medical management or who do not need a hysterec­tomy (Barrow, 1999). A hysterectomy is usually performed only after other treatments have failed. Table 3 compares the pre-operative and postoperative care of clients undergoing a D&C or endometrial ablation. Hysterectomy is discussed later under Op­erative Procedures (Uterine Leiomyomas). If the woman has undergone a D&C or laser ablation, the nurse gives her postoperative instructions (Chart 3).

 

TABLE 3 NURSING CARE OF CLIENTS UNDERGOING SURGERY FOR DYSFUNCTIONAL UTERINE BLEEDING

 

Dilation and Curettage (D&C)

Endometrial Ablation

Usual site

Outpatient

Outpatient

Anesthesia

Local, regional, general

Regional, general

Procedure

The cervical os is dilated; the endometrium is scraped

The laser fiber is passed into the uterus through a hystero-scope; the endometrium is destroyed by laser energy, and tissues are removed by irrigating the uterine cavity with saline.

Preoperative care

Assess the client's knowledge of the procedure The client is NPO after midnight

 

 

Teach postoperative expectations

Same as for D&C

The client may be given danazol or GnRH agonist for 1 month before surgery to decrease endometrial thickness.

Counsel the client about the likelihood of sterility as a re­sult of uterine scarring.

Postoperative care

Monitor vital signs every 15 min until they are stable.

Assess the need for pain relief. Assess for vaginal bleeding. Expect discharge when the client is stable

Same as for D&C

 

Same as for D&C

Assess for spotting and vaginal drainage.

Same as for D&C

 

CHART 3 CLIENT EDUCATION GUIDE Endometrial Ablation and Dilation and Curettage

Endometrial Ablation

  Spotting and vaginal drainage are normal for several days after the procedure.

  If you have abdominal cramping, take mild analgesics, such acetaminophen (Tylenol, Atasol*1), or prostaglandin inhibitors, such as ibuprofen (Motrin).

  You can return to your normal activities within 2 or 3 days.

  You will probably be sterile because of uterine scarring.

Dilation and Curettage

  Take your temperature once a day for the next 2 days. If your oral temperature is more than 100° F (38° C), call the clinic or your doctor.

  Avoid sexual intercourse, tub bathing, and the use of tampons for 2 weeks to allow healing and prevent infection.

  Slight bleeding is normal. However, if bleeding is as heavy as during your normal menstrual period or if bleeding lasts longer than 2 weeks, call the clinic or health care provider.

  You can use a heating pad or hot water bottle to relieve abdominal cramping if it occurs.

  You can take mild analgesics, such as acetaminophen, for pain.

 


MENOPAUSE

OVERVIEW

Menopause is a normal biologic event marked for most women by the end of menstrual periods. It signifies the de­pletion of estradiol, a hormone produced by the ovaries. Al­though the meaning of menopause is the last menstrual pe­riod, the more clinically relevant perspective is to look at the months or years surrounding this event.

During the past decade there has been an explosion of in­terest among health care providers about all aspects of menopause—endocrinologic, metabolic, pathologic, socio-cultural, and psychologic. Of particular interest for clinicians is the role of hormone replacement therapy (HRT) in the man­agement of symptoms.

Much present-day interest in menopause is directed at the postmenopausal period and the medical illnesses common to postmenopausal women that may be affected by hormonal change. The most commonly discussed conditions are osteo­porosis, coronary heart disease, and breast and endometrial cancer; interest in the effects of hormones on Alzheimer's dis­ease has also emerged.

Women experience menopause as individuals, and care should be taken not to make generalizations. Women become menopausal in a variety of ways, including through surgery when the uterus and ovaries are removed and through medical treatment for cancer. Natural menopause is experienced across a wide age range, occasionally as early as the 30s or 40s or as late as the 60s. The average age at which women experience their last menstrual period is between 50 and 52 years. All women under 40 who experience an early menopause, regard­less of cause, are at higher than average risk for osteoporosis and osteoporosis-related fractures and may be at higher risk for cardiovascular disease. HRT is therefore particularly im­portant in this group.

Several factors have been identified that may affect the timing of menopause. These include the following:

  Genetic influence

  Early menarche (beginning of menses)

  Hysterectomy

  Smoking

  Cancer treatment (chemotherapy or radiation)

 

 COLLABORATIVE MANAGEMENT

Assessment

Menopause transition, or perimenopause, refers to the changes in spontaneous ovarian function that precede the last menstrual period and occur gradually. Common clinical char­acteristics of the transition are a change in the woman's usual menstrual periods and the beginning of vasomotor symptoms, such as hot flashes and night sweats. These symptoms may disturb the woman's usual sleep pattern. Vaginal dryness and mood changes may also occur. The nurse asks the client about these changes and reassures her that they are normal during perimenopause.

The most common early change in the bleeding pattern is a shortening of the time between menstrual periods, which is sometimes accompanied by an increase in menstrual flow. As the transition evolves, approximately 70% of women find that their periods become lighter and farther apart until they fi­nally stop.

Some women simply stop menstruating without further change. The remaining women experience heavier bleeding, which can be either regularly timed or unpredictable. In addi­tion, abnormal bleeding in this age-group can be caused by endometrial cancer, endometrial polyps, or uterine leiomyomas (tumors).

Most women pass through the menopause transition and into the postmenopause phase with minimal symptoms and never seek treatment for menopause-related problems. Ap­proximately 20% of women, however, seek care for one or more of the symptoms discussed in this section, which are di­rectly related to menopause.

Interventions

Hormone replacement therapy (HRT), a combination of es­trogen and progestin (progesterone), is the primary medical intervention for menopause. Estrogen given alone can cause gynecologic cancers and thromboembolitic conditions, such as deep vein thrombosis.

Estrogen is available as oral, transdermal, intravaginal, and intramuscular preparations. The oral estrogens have gen­erally equivalent effects on symptoms and equivalent med­ical risk factors, so the choice of preparation for most women can be based on cost and individual side effect experience (Johnson, 1998). Transdermal estrogen offers a useful alter­native route of administration for women who prefer not to take pills, who cannot tolerate oral therapy because of gas­trointestinal (GI) side effects, or who have liver function test abnormalities, elevated triglycerides, or other conditions in which a first-pass hepatic effect is best avoided (Johnson, 1998). Side effects of estrogen occur and persist in approxi­mately 10% of women.

The most common complaints are bloating, nausea, and breast tenderness. These symptoms often resolve after a few months of estrogen use.


INFLAMMATIONS AND INFECTIONS

Vaginal discharge and itching are two of the most common complaints of female clients. Women may need information from their health care provider about the normal vaginal phys­iology, causes of symptoms, and methods of treatment. The nurse must be well informed about these topics to provide comprehensive care to clients with vaginal infections.

Vaginal infections are sometimes considered sexually transmitted diseases (STDs) because their causative organ­isms may be transmitted to sexual partners. However, infec­tions can develop without sexual contact, and sexual partners do not always become infected.

 

Simple Vaginitis

OVERVIEW

Vaginitis can develop whenever there is a disturbance of the balance of hormones and bacterial interaction in the vagina as a result of one or more of the following:

• Changes in the normal flora

Alkaline pH

Insertion of foreign bodies, such as tampons and condoms

Chemical irritations, such as from douches or sprays

Medications, especially antibiotics

Vaginitis is an inflammation of the lower genital tract. The nurse completes the assessment of vaginitis by asking ques­tions about the symptoms, assisting with a pelvic examina­tion, and obtaining vaginal smears for laboratory testing (Chart 4). The nurse is nonjudgmental and reassuring dur­ing the assessment because the client may be embarrassed or afraid to discuss her symptoms.

 

CHART 4 BEST PRACTICE Care of the Client with Simple Vaginitis

In taking a client history, ask about:

  Onset of symptoms

  Characteristics of the discharge, especially the color and odor

  Associated symptoms such as itching and dysuria

  Types of contraceptives used

  Recent use of antibiotics

  Client's sexual activity

  Any history of vaginal infection

  Client's hygiene practices: douching and using tampons

In performing a physical examination:

  Palpate the abdomen for tenderness or pain.

  Inspect the external genitalia for erythema, edema, excoriation, odor, and discharge.

  If you are qualified, perform a speculum examination to visualize the vagina and cervix, and note the source of any discharge or inflammation.

If you are qualified, perform the following laboratory tests, as ordered: a saline or potassium hydroxide wet smear and a nitrazine paper test of vaginal pH.

 

COLLABORATIVE MANAGEMENT

Interventions for vaginitis depend on the causes and the spe­cific vaginal infection (Table 4). A woman's proper health habits can be beneficial to treatment. Therefore she should get enough rest and sleep, observe good dietary habits, get regu­lar exercise, and use good personal hygiene. Popular, but not scientifically tested, hygiene practices to prevent vaginitis in­clude the following:

Perineal cleaning (wiping front to back) after urinating or defecating

Wearing cotton underwear Avoiding strong douches and feminine hygiene sprays

Avoiding tight-fitting pants

TABLE 4 COMMON VAGINAL INFECTIONS Assessment

Sexual Transmission

Physical Findings

Laboratory Findings

Drug Therapy

CANDIDA ALBICANS INFECTION

Unlikely

Odorless, white, curdlike discharge Patches on vaginal walls and cervix Inflamed vaginal walls and cervix Itching

Hyphae and spores visible on potassium hydroxide wet slide Vaginal pH 4.5 or less

 

Miconazole nitrate (Monistat), clotrimazone (Gyne-Lotrimin), or nystatin (Mycostatin) vaginal creams or suppositories for 7 days

Terconazole (Terazol) cream or suppositories for 7 days or double strength for 3 days

Tioconazole (Vagistat) single-dose vaginal application

TR1CHOMONAS VAGINADIS INFECTION

Yes

None or fishy

Itching

Strawberry spot on vaginal surface and cervix

Flagellated, pear-shaped proto­zoa on saline wet slide Vaginal pH 6-7

Oral metronidazole (Flagyl), single 2-g dose for client and sexual partners

BACTERIAL VAG1NOS1S/GARDNERELLA VAGINAUS INFECTION

Yes

Gray-white or green discharge

Fishy odor

Itching

Normal vaginal mucosa 10%-40% asymptomatic

"Clue" cells on examination of saline wet slide

Positive "whiff" test finding

Vaginal pH 5-6

Oral metronidazole 500 mg qid for 7 days, or ampicillin or tetracycline

Clindamycin 450 mg qid for 7 days

CERVICITIS

Yes

Mucopurulent discharge from endocervix

Pelvic pain, postcoital and intermenstrual bleeding

The cervix may be inflamed and bleed when touched

Need to rule out herpes, gonor­rhea, and chlamydial infection

Vaginal pH 4.5 or less

Depends on diagnosis

ATROPHIC VAGINITIS

No

Pale, thin, dry mucosa

Itching

No odor

Scant white, yellow, gray, or green discharge

Dyspareunia, postcoital bleeding

Parabasal cells Leukocyte predominance Vaginal pH 6

Topical conjugated estrogen cream V2 to 1 application at night for 7 nights, then twice weekly

 

If antibiotics are prescribed, eating yogurt or taking Lacto-bacillus culture (Lactinex) tablets may help restore the natural flora (Doderlein's bacilli) of the vagina. Education of the client focuses on preventive measures and on information about infection transmission (Chart 5).

CHART 5 CLIENT EDUCATION GUIDE Vaginal Infections

Your risk of getting vaginal infections increases if you have sex with more than one person.

When you have a vaginal infection, do not have sexual intercourse, or at least make sure that your partner wears a condom.

Sexual partners may need to be treated for infection.

The only way to identify what infection you have is to be examined by a health care provider and to get the results of laboratory tests.

Take your medicine as prescribed, not just until your symptoms go away.

 

Vulvitis

OVERVIEW

Vulvitis is an inflammatory condition of the vulva that is as­sociated with symptoms of pruritus (itching) and a burning sensation. The vulvar skin is sensitive to hormonal, metabolic, and allergic influences. Symptoms can be caused by systemic conditions, direct contact with irritants, and extension of in­fection from the vagina.

The most common skin disease affecting the vulva is con­tact dermatitis, which can be caused by an irritant, such as feminine hygiene sprays, fabric dyes, soaps and detergents, or allergens. Primary infections that affect the vulva include her­pes genitalis and condylomata acuminata (venereal warts). Secondary infections of the vulva are caused by organisms responsible for the numerous types of vaginitis, including candidiasis in diabetic women. Pediculo­sis pubis (crab lice infestation) and scabies (itch mite infesta­tion) are common parasitic infestations of the skin of the vulva. Other causes of vulvitis include the following:

  Atrophic vaginitis

  Vulvar kraurosis (postmenopausal disorder causing dryness and atrophy)

  Vulvar leukoplakia (postmenopausal atrophy and thickening of vulvar tissues)

  Cancer

  Urinary incontinence

COLLABORATIVE MANAGEMENT

Assessment of the woman usually identifies symptoms of itching and burning sensation. Erythema (redness), edema, and superficial skin ulcers also may be present. Some women may have an itch-scratch-itch cycle, in which the itching leads to scratching, which causes excoriation that then must heal. As healing takes place, itching occurs again, which leads to further scratching. If the cycle is not interrupted, the condition may become chronic, causing the vulvar skin to become white and thickened (leathery). This skin is dry and scaly and cracks easily, increasing the woman's chances of infection.

Medical treatment of clients with vulvitis depends on the cause. Nursing interventions to relieve itching include apply­ing wet compresses, sitz baths for 30 minutes several times a day, and the application of prescribed topical medications, such as hydrocortisone and fluorinated corticosteroids (be-tamethasone valerate [Valisone, Betaderm] or fluocinolone acetonide [Synalar, Fluoderm]).

The health care provider prescribes oral antibiotics if in­fection is the underlying cause. Removal of any irritant or allergen, such as by changing detergents, should be encouraged. Treatment of pediculosis and scabies is instituted if needed and includes applying lindane (1% gamma benzene hexa-chloride [Kwell, Kwellada^]) lotion, shampoo, or cream to the affected area as directed; cleaning affected clothes, bed­ding, and towels; and disinfecting the home environment (lice cannot live for more than 24 hours away from the body).

If the vulvitis is chronic or severe, laser therapy or a "skinning" vulvectomy may be performed. Preventive measures that may be helpful for vulvitis are listed in Chart 6.

 

CHART 6

BEST PRACTICE/or Prevention of Vulvitis

Wear cotton underwear.

Avoid wearing tight clothing, such as pantyhose or tight jeans, because they can cause chafing. You can also get hot and sweaty, which can cause an infection. Always wipe front to back after having a bowel move­ment or urinating.

Do not douche or use feminine hygiene sprays. If your sexual partner has an infection of his sex organs, do not have intercourse with him until he has been treated. You are more likely to get an infection if you are preg­nant, have diabetes, take oral contraceptive drugs, or are menopausal. Practice vulvar self-examination monthly.

 

Toxic Shock Syndrome

OVERVIEW

Toxic shock syndrome (TSS) was not commonly recognized by health care providers until 1980, when it was found to be related to menstruation and tampon use. Other conditions that have been associated with TSS include surgical wound infec­tion, nonsurgical focal infections, postpartum conditions, and nonmenstrual vaginal conditions. Use of the diaphragm, cer­vical cap, and vaginal contraceptive sponge has also been linked to TSS.

The pathophysiology of TSS is not clearly understood. Certain strains of Staphylococcus aureus produce a toxin that has been associated with the symptoms of TSS. Numerous theories have been reported to explain the mechanism of S. aureus absorption in TSS. The vagina may be highly suscep­tible to the toxin released by S. aureus.

In menstrually related TSS, the theories about the mecha­nisms of absorption focus on tampon use. Risk for TSS is related to the degree of absorbency of the tampon. The follow­ing are possible explanations:

* Toxins readily cross the vaginal mucosa.

* Highly absorbent tampons rub the vaginal walls and cause ulceration, which allows transport of the toxins.

* Prolonged or continued tampon use can cause chronic vaginal ulcerations through which S. aureus is absorbed.

* Plastic tampon inserters can cause ulceration through which toxins are transported.

* Toxin producing S. aureus has a growth requirement for magnesium (some tampons contain magnesium).

COLLABORATIVE MANAGEMENT

Influenza-like symptoms for the first 24 hours are common. The abrupt onset of a high temperature associated with a headache, sore throat, vomiting, diarrhea, generalized rash, and hypotension are often present. The most common clinical man­ifestations are skin changes (initially a rash resembling a severe sunburn that changes to a macular erythema similar to a drag-related rash). Because not all women experience all of these clinical manifestations, the criteria established by the U.S. Cen­ters for Disease Control and Prevention (CDC) are used in epidemiologic studies to verify cases of TSS (Chart 7).

CHART 7 KEY FEATURES of Toxic Shock Syndrome

Fever (temperature > 102° F [38.9° C]

Diffuse rash resembling sunburn

Peeling of skin—primarily the soles of the feet and the palms of the hands—1 to 2 weeks after the onset of the illness

Hypotension (systolic blood pressure <90 mm Hg or or-thostatic syncope)

Involvement of three or more of the following:

Gastrointestinal system: vomiting, diarrhea at the onset of the syndrome Musculoskeletal system: severe aching or a serum creatinine phosphatase level twice the normal level Respiratory system: acute respiratory distress syn­drome (ARDS)

Renal/urinary system: decreased urine output, pyuria

Cardiovascular system: decreased left ventrical contractil­ity; ischemic changes shown on the electrocardiogram

Liver: total bilirubin, aspartate aminotransferase (serum glutamic-oxaloacetic transaminase), and alanine aminotransferase (serum glutamic-pyruvic transami­nase) levels elevated; jaundice; disseminated in-travascular coagulation (DIC)

Hematologic system: platelet levels below normal

Central nervous system: disorientation, altered con­sciousness in the absence of fever or hypertension

Mucous membranes: hyperemia of the vaginal walls, the throat, or the conjunctiva of the eye

Negative results for the following: Rocky Mountain spot­ted fever, measles, scarlet fever, and throat, blood, and cerebrospinal fluid cultures Positive culture for Staphylococcus aureus from blood, urine, or stool

 

Management in the primary care setting focuses on client education and prevention. The nurse instructs the client on the prevention of TSS related to the use of tampons, vaginal sponges, and diaphragms (Chart 8).

 

CHART-8

CLIENT EDUCATION GUIDE Prevention of Toxic Shock Syndrome

Tampon Use

  Wash your hands before inserting a tampon.

  Do not use a tampon if it is dirty.

  Insert the tampon carefully to avoid injuring the delicate tissue in your vagina.

  Change your tampon every 3 to 6 hours.

  Do not use superabsorbent tampons.

  Use sanitary napkins at night.

  Call your health care provider if you suddenly experience a high temperature, vomiting, or diarrhea.

  Do not use tampons at all if you have had toxic shock syndrome.

  Not using tampons almost guarantees that you will not get toxic shock syndrome.

Vaginal Sponge Use

  Wash your hands before inserting a vaginal sponge.

  Use only clean water to wet the sponge.

  Do not use the sponge if it is dirty.

  Do not use the sponge for more than 30 hours at a time

  Call your health care provider if you have two or more symptoms of toxic shock syndrome.

Diaphragm Use

  Wash your hands and the diaphragm before insertion.

  Remove the diaphragm within 24 hours after intercourse.

  Do not use the diaphragm during your menstrual period.

  After you take out the diaphragm, wash it with mild soap, rinse it, and dry it. Coating the diaphragm with a small amount of cornstarch will absorb any excess water and prevent damage to the latex rubber. Store it in a clean,

 

Primary treatment in the acute care setting includes fluid re­placement because dehydration and electrolyte imbalance re­sult from vomiting and diarrhea. The health care provider also prescribes antibiotics if the penicillin-resistant strain of S. au­reus is the cause of TSS. Other measures may include admin­istering transfusions to reverse low platelet counts, cortico­steroids to treat skin changes, and drugs to treat hypotension.


PELVIC STRUCTURE SUPPORT PROBLEMS

Uterine Prolapse

OVERVIEW

Three stages of uterine prolapse have been described ac­cording to the degree of descent of the uterus (Figure 2). Prolapse of the uterus can be caused by congenital defects, persistent high levels of intra-abdominal pressure related to the body of the uterus and the cervix protrude through the entrance to the vagina. The vagina is turned inside out. heavy physical labor or exertion, or any other event that weak­ens the pelvic supports.

 

In grade I uterine prolapse, the uterus bulges into the vagina, but the cervix does not protrude through the entrance to the vagina

In grade II uterine prolapse, the uterus bulges farther into the vagina, and the cervix protrudes through the entrance to the vagina

In grade III uterine prolapse, the body of the uterus and the cervix protruded through the entrance to the vagina. The vagina is turned inside out

Figure 2 Types of uterine prolapse.

 

CONSIDERATIONS FOR OLDER ADULTS Prolapse is often a complication of childbirth injuries and repetitive stresses occurring many years later, but it also oc­curs in older adults who have never had children. The pelvic floor that supports the uterus is weakened by aging.

 

COLLABORATIVE MANAGEMENT

Assessment findings include the client's verbalization of feel­ing as if "something is in my vagina," dyspareunia (painful sexual intercourse), backache, a feeling of heaviness or pressure in the pelvis, and bowel or bladder problems (if cystocele or rec-tocele is also present). A pelvic examination may reveal a pro­trusion of the cervix when the woman is asked to bear down.

Interventions are based on the degree of prolapse. Conser­vative treatment, such as the use of pessaries, is preferred over surgical treatment when possible. Vaginal hysterectomy with repair is the usual surgical procedure. Before surgical inter­vention, the nurse questions the woman about her desire for future childbearing (surgery may be delayed) and her desire for sexual intercourse. Surgery usually shortens and narrows the vagina, possibly causing painful intercourse.

Whenever the uterus is displaced, other structures, such as the bladder, rectum, and small intestine, are affected and can protrude through the vaginal walls.

 

Cystocele

OVERVIEW

A cystocele is a protrusion of the bladder through the vaginal wall (Figure 75-3). It is due to weakened pelvic structures. This protrusion can be caused by obesity, advanced age, childbearing, or genetic predisposition. The development of a cystocele is more noticeable in the postmenopausal years, when estrogen loss also weakens tissue supports and can cause relaxation of the supports.

COLLABORATIVE MANAGEMENT

Assessment findings may include the following:

* Difficulty in emptying the bladder

* Urinary frequency and urgency

* Urinary tract infection

* Stress urinary incontinence (loss of urine during stressful activities such as laughing, coughing, sneezing, or lifting heavy objects)

A pelvic examination reveals a significant bulge of the ante­rior vaginal wall when the woman is asked to bear down. Diag­nostic tests that may be ordered include cystography (to show the presence of bladder herniation), measurement of residual urine by catheterization, and urine culture and sensitivity testing (which may reveal infection caused by urinary retention).

If the client is asymptomatic or has mild symptoms, med­ical management is usually conservative. The health care provider may recommend a pessary to support the bladder in some clients. Estrogen therapy might be prescribed for the postmenopausal woman to prevent atrophy and weakening of vaginal walls. Kegel exercises may help strengthen perineal muscles. The nurse teaches the woman Kegel exercises, telling her to tighten and relax the perineal muscles; the woman presses the buttocks together and holds the position for at least 5 seconds. The client should repeat the exercise frequently throughout the day. An alternative exercise is to try to stop the flow of urine after urination has started and then hold the position for a few seconds before letting the urine flow again.

The health care provider may recommend surgery for severe symptoms. An anterior colporrhaphy (anterior repair) tight­ens the pelvic muscles for better bladder support. A vaginal sur­gical approach is used. Nursing care of a woman undergoing an anterior repair is similar to that for a woman undergoing a vagi­nal hysterectomy.

Postoperatively, the nurse instructs the client to limit her activities, not lift anything heavier than 5 pounds, avoid stren­uous exercises, and avoid sexual intercourse for 6 weeks. The woman should notify her health care provider if she has signs of infection, such as fever, persistent pain, or purulent, foul-smelling discharge. The client should keep her follow-up ap­pointment after surgery.

 

Rectocele

OVERVIEW

A rectocele is a protrusion of the rectum through a weakened vaginal wall (see Figure 3). This usually results from the pressure of a baby's head during a difficult delivery, a trau­matic forceps delivery, or a congenital defect of the support­ing tissues. Symptoms do not typically appear until the woman is older than 35 years of age.

 

Figure 3 In cystocele, the urinary bladder is displaced downward, causing bulging of the anterior vaginal wall. In rectocele, the rectum is displaced, causing bulging of the posterior vaginal wall.

 

COLLABORATIVE MANAGEMENT

The woman's history may reveal symptoms of constipation, hemorrhoids, fecal impaction, and feelings of rectal or vagi­nal fullness. A pelvic examination may show a bulge of the posterior vaginal wall when the woman is asked to bear down. A rectal examination reveals the presence of a rectocele. A barium enema study also confirms the presence of a rectocele. Medical management focuses on promoting bowel elimina­tion. The health care provider usually orders a high-fiber diet, stool softeners, and laxatives. The surgical procedure that strengthens pelvic supports and reduces the bulging is posterior colporrhaphy (posterior repair). If both a cystocele and a rec­tocele are present, an anterior and posterior colporrhaphy (anterior and posterior [A&P] repair) is performed

The nursing care after a posterior repair is similar to that after any rectal surgery. Postoperatively, the woman is usu­ally given a low-residue diet to prevent bowel movements and allow time for the incision to heal. The woman is told not to strain when she does have a bowel movement so that she does not put pressure on the suture line. Bowel move­ments are often painful, and the client may need pain med­ication before having a bowel movement. Sitz baths may re­lieve discomfort. Postoperative instructions for the client undergoing a posterior repair are similar to those for an an­terior repair.

Fistulas

OVERVIEW

Fistulas are abnormal openings between two adjacent organs or structures. Vaginal fistulas can occur between the vagina and the urethra (urethrovaginal), the vagina and the bladder (vesicovaginal), or the vagina and the rectum (rectovaginal). Trauma is the primary cause of fistulas, although they can re­sult from complications of surgery, vaginal delivery compli­cations, malignancy, or radiation therapy for cancer.

COLLABORATIVE MANAGEMENT

Symptoms depend on the location of the fistula. A fistula should be considered as a possible cause if a woman's history includes the following complaints:

  Leakage of urine, flatus, or feces into the vagina

  Irritation or excoriation of the vulva and vaginal tissues

  An unpleasant odor (fecal or urine) in the vagina

  A feeling of wetness or dribbling in the vagina

Women who have fistulas may be embarrassed to seek help until symptoms are severe. The client may withdraw from so­cial activities or from relationships with significant others as the symptoms become more difficult to manage.

Management depends on the fistula's location. Surgery is not recommended if infection or inflammation is present. Surgery may not be successful. Nursing care focuses on as­sisting the woman with the frequent and time-consuming per-ineal hygiene, including sitz baths; perineal cleaning with mild, unscented soap and water; and low-pressure douching with commercial deodorizing solutions or homemade solu­tions (1 teaspoon [5 mL] of nonchlorine household bleach to 1 quart [approximately 1 L] of water). The woman may need to wear sanitary napkins or disposable undergarments (such as Depends) if there is leakage of urine or feces. Other bene­ficial treatments may include the application of A and D oint­ment to excoriated tissues.

If the fistula is repaired surgically, nursing care focuses on preventing infection and avoiding stress on the repaired area (low-residue diet and administration of stool softeners for 2 weeks after rectovaginal fistula repair). Nursing care and post­operative teaching are similar to the care and teaching of the client who has a cystocele or rectocele repair.


BENIGN NEOPLASMS

Functional Ovarian Cysts

Functional ovarian cysts can occur in a woman of any age but are rare after menopause.

FOLLICULAR CYSTS

Follicular cysts usually occur in young, menstruating females. These cysts are nonneoplastic and do not grow without hor­monal influences. A cyst can develop when a mature follicle fails to rupture or an immature follicle fails to reabsorb fol­licular fluid during the second half of the menstrual cycle. The cyst is usually small (2.4 to 3.2 inches [6 to 8 cm]) and may be asymptomatic unless it ruptures. Rupture of a follicu­lar cyst or torsion (twisting) may cause acute, severe pelvic pain. The pain usually resolves after several days of bedrest and the administration of mild analgesics. If the cyst does not rupture, it usually disappears within two or three menstrual cycles without medical intervention. If the cyst does not shrink, the health care provider may prescribe oral contracep­tive pills for one or two menstrual cycles to depress ovulation. When the cyst is managed conservatively, follow-up care is necessary to confirm that it has disappeared.

If the cyst is larger than 6 to 8 cm, a neoplasm may be sus­pected, and further evaluation by ultrasonography or lap-aroscopy is necessary. Larger cysts are often associated with menstrual irregularities.

Surgery is recommended only before puberty, after menopause, or when cysts are larger than 3.2 inches (8 cm). A cystectomy (removal of the cyst) is recommended instead of an oophorectomy (removal of the ovary).

 

CORPUS LUTEUM CYSTS

Corpus luteum cysts occur after ovulation and are often asso­ciated with increased secretion of progesterone. The cysts are usually small, averaging 1.5 inches (4 cm). They are purplish red as a result of hemorrhage within the corpus luteum. Cor­pus luteum cysts are associated with a delay in the onset of menses and irregular or prolonged flow. They may be accom­panied by unilateral low abdominal or pelvic pain that is usu­ally described as dull or aching. If the cyst ruptures, in-traperitoneal hemorrhage can occur.

Corpus luteum cysts may disappear in one or two men­strual cycles or with suppression of ovulation. The treatment is the same as that for follicular cysts.

 

THECA-LUTEIN CYSTS

Theca-lutein cysts are the least common of the functional cysts. They are associated with hydatidiform mole (molar pregnancy), occurring in 50% of these complicated pregnan­cies. Theca-lutein cysts develop as a result of prolonged stim­ulation of the ovaries by excessive amounts of human chori-onic gonadotropin (hCG).

Theca-lutein cysts regress spontaneously within 3 months with the removal of the molar pregnancy or the source of ex­cessive hCG. No other treatment is usually necessary.

 

POLYCYSTIC OVARY

Polycystic ovary, or Stein-Leventhal syndrome, results when elevated levels of luteinizing hormone (LH) cause hyperstim-ulation of the ovaries, which produces multiple cysts on one or both ovaries. High levels of estrogen are produced by these cysts and are unopposed by postovulatory progesterone. Endometrial hyperplasia (tissue overgrowth) or even carcinoma may result.

A typical client is obese, is hirsute (hairy), has irregular menses, and may be infertile because of lack of ovulation. Treatment depends on which disorder is of greatest concern to the woman. The best treatment is the administration of oral contraceptives because they inhibit LH production. The health care provider may advise a woman who is older than 35 years of age and no longer desires childbearing to un­dergo a bilateral salpingo-oophorectomy (BSO) (removal of both tubes and ovaries) and hysterectomy (removal of the uterus and cervix). Women who desire fertility can be treated with drugs such as clomiphene citrate (Clomid) to stimulate ovulation.

 

Other benign ovarian cysts and tumors

DERMOID CYSTS

Dermoid cysts are the most common germ cell tumors and are benign in more than 99% of cases. These cysts are the most common ovarian tumors of childhood, although they can develop in a female of any age.

Dermoid cysts may contain hair, sebaceous material, teeth, and other calcifications. They are usually asymptomatic un­less they grow large and put pressure on other organs, such as the bladder and the bowel. The cysts develop bilaterally in some cases. They are often attached to the ovary by a pedicle (stalk).

Management of dermoid cysts is by surgical removal (cys-tectomy). If the cysts are not removed, they usually continue to grow and rupture, causing hemorrhage and infection.

OVARIAN FIBROMAS

Fibromas are the most common benign, solid ovarian neo­plasms. These pearly white tumors of connective tissue ori­gin have a low potential for becoming malignant. Fibromas can range in size from a small nodule to a mass weighing more than 50 pounds (22.7 kg). The average size is 2.4 inches (6 cm) in diameter, slightly smaller than a tennis ball. Ninety percent of fibromas are unilateral. On examination, they feel firm, have a slightly irregular contour, and are mo­bile. Fibromas greater than 6 cm in diameter may be associ­ated with ascites and may cause feelings of pelvic pressure or abdominal enlargement. Unless rupture or torsion occurs, the neoplasm is usually asymptomatic. Fibromas often occur postmenopausally.

Solid ovarian neoplasms are surgically removed. The sur­geon may perform an oophorectomy for borderline tumors (when there is a question of possible malignancy). Nursing care of a woman undergoing an oophorectomy is similar to that for a woman undergoing a tubal ligation. When both ovaries are removed, surgery-induced menopause occurs in a premenopausal women. As a result, a woman often experi­ences decreased vaginal lubrication, hot flashes, and atrophy of the vaginal epithelium. These symptoms may be treated with estrogen replacement therapy (ERT).

EPITHELIAL OVARIAN TUMORS

Epithelial ovarian tumors, serous and mucinous cystadenomas, occur in women between the ages of 30 and 50 years. Serous cystadenomas usually occur bilaterally and are more likely to become malignant than mucinous cystadenomas. Both tumors can be irregular and smooth, but mucinous cystadenomas tend to grow large, some to more than 100 pounds (45 kg).

Management of cystadenomas is usually by unilateral salpingo-oophorectomy (surgical removal of a fallopian tube and ovary), because it is often impossible to tell whether the tumor is benign or malignant. Small cystadenomas may be re­moved by cystectomy, but the larger ones are difficult to re­sect from the ovary.


UTERINE LEIOMYOMAS

OVERVIEW

Leiomyomas, also called myomas and fibroids, are the most commonly occurring pelvic tumors. They are benign, slow-growing solid tumors of the uterus.

PATHOPHYSIOLOGY

Leiomyomas initially develop from the uterine myometrium. As they grow, fibroids stay attached to the myometrium by means of a pedicle. Leiomyomas are classified according to their position in the layers of the uterus and their anatomic po­sition. The most common types of leiomyomas are intramu­ral, submucosal, and subserosal.

 

Figure 4 Classification of uterine leiomyomas

 

Intramural leiomyomas are contained in the uterine wall within the myometrium. Submucosal leiomyomas protrude into the cavity of the uterus. Subserosal leiomyomas protrude through the outer surface of the uterine wall. Subserosal leiomyomas may grow laterally and extend to the broad liga­ment.

Although most fibroids develop within the uterine wall, about 5% may appear in the cervix. Rarely, a fibroid breaks off the pedicle and attaches to other tissues (parasitic fibroid).

ETIOLOGY

The cause of leiomyomas is not precisely known. Leiomy­omas usually result from a localized proliferation of smooth muscle cells in their initial stages. The stimulus for prolifera­tion may be physical or mechanical and may operate at points of maximal stress within the myometrial layer of the uterine wall. Because there are multiple points of stress caused by the contractions of the uterine muscle, multiple fibroids develop. The growth of leiomyomas may be related to estrogen stimu­lation; fibroids often enlarge during pregnancy and diminish in size after menopause.

INCIDENCE/PREVALENCE

Leiomyomas occur in approximately 20% to 30% of women older than age 30. The rationale for why leiomyomas develop in some women and not in others is not known.

COLLABORATIVE MANAGEMENT

Assessment

history

Although most women with uterine leiomyomas are asymp­tomatic, abnormal bleeding is the most common complaint. Because African-American women and premenopausal women are at greatest risk for leiomyomas, any presence of abnormal bleeding should be discussed. There may be an in­crease in menstrual bleeding (menorrhagia), the bleeding may occur between menstrual periods (metrorrhagia), or it may be continuous

PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

Women with fibroids do not usually complain of pain, al­though acute pain may occur with torsion (twisting) of the fi­broid on the pedicle. A woman may report a feeling of pelvic pressure, constipation, or urinary frequency or retention. These symptoms result when an enlarged fibroid presses on other organs. The client may also notice that her abdomen has increased in size with or without noticeable weight gain. Dys-pareunia (painful sexual intercourse) and infertility have also been associated with leiomyomas.

Abdominal, vaginal, and rectal examinations usually es­tablish the presence of a uterine enlargement that may indi­cate a leiomyoma. However, other diagnostic procedures may be ordered to differentiate benign lesions from malignant ones.

PSYCHOSOCIAL ASSESSMENT

A woman who is symptomatic may fear that she has a malig­nancy. She may be anxious about abnormal bleeding or her failure to conceive. She may also be concerned if surgical pro­cedures are recommended. The nurse assesses the woman's feelings and concerns about her symptoms and fears of the unknown. If surgery is recommended, the significance of the loss of the uterus for the woman is explored.

LABORATORY ASSESSMENT

A complete blood count identifies iron deficiency anemia (re­lated to bleeding). A pregnancy test may be done to determine whether pregnancy is the cause of the uterine enlargement. An endometrial biopsy may be performed to determine whether the lesion is malignant.

RAOIOGRAPHIC ASSESSMENT

Computed tomography (CT) may be of some value. However, CT scans do not differentiate between benign and malignant myomas.

OTHER DIAGNOSTIC ASSESSMENT

Ultrasonography may be useful in differentiating other causes of pelvic masses, including ovarian masses and pregnancy. Culdoscopy or laparoscopy may also be of value in differen­tiating a uterine fibroid from an ovarian mass. These tests are described in Chapter 73.

Analysis

COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

The most common collaborative problem for clients with leiomyomas is Potential for Hemorrhage.

ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

In addition to the common collaborative problems, clients with leiomyomas may have one or more of the following:

  Fear and Anxiety related to an uncertain diagnosis and potential surgical treatment

  Acute Pain related to pressure from tumors

  Anticipatory Grieving or Dysfunctional Grieving related to perceived or actual loss of the uterus or reproductive function

   Sexual Dysfunction related to dyspareunia

   Ineffective Coping related to depression as a response to treatment

 

Planning and Implementation

POTENTIAL FOR HEMORRHAGE

PLANNING: EXPECTED OUTCOMES. The client with leiomyomas is expected to be free of complications such as hemorrhage and severe anemia from abnormal bleeding.

INTERVENTIONS. Observation of the leiomyomas over time, myomectomy, and hysterectomy are the methods of management. The choice depends on the size and symptoms of the fibroids and the woman's desire for future childbearing.

NONSURGICAL MANAGEMENT. If the client is asymp­tomatic or desires childbearing, the health care provider typi­cally suggests observation and examination every 4 to 6 months. If the woman is menopausal, the fibroids usually shrink, and surgical intervention may not be necessary. How­ever, a client who is receiving estrogen replacement therapy (ERT) for menopausal symptoms should know that the fibroids may continue to grow because of the estrogen stimulation.

SURGICAL MANAGEMENT. The treatment of leiomy­omas depends on whether future childbearing is desired, the age of the woman, the size of the fibroids, and the clinical manifestations. If the woman desires childbearing, the sur­geon may perform a myomectomy (the removal of leiomy­omas with preservation of the uterus) regardless of the size, number, or location of the fibroids. The surgeon may use a laser to remove the tumors. Myomectomy is usually per­formed in the proliferative phase of the menstrual cycle to minimize blood loss and to avoid the possibility of interrupt­ing an unsuspected pregnancy. A small percentage of leiomy­omas that are removed recur. Nursing care is similar to that of a woman undergoing a hysterectomy, as described later in this section under Operative Procedures.

 

CONSIDERATIONS FOR OLDER ADULTS

Baa Hysterectomy is the usual surgical management in the older woman who has multiple symptomatic leiomyomas.

 

PREOPERATIVE CARE. Preoperative teaching by the physician begins in his or her office. The physician's office nurse makes sure that the client can describe all of the op­tions for surgery, the advantages and risks of surgery, preop­erative and postoperative procedures, and recovery needs. With this information, the woman can make an informed consent to surgery.

Preoperative teaching is usually done on an individual ba­sis. The nurse should explain routine preoperative procedures, including laboratory tests for baseline data and the adminis­tration of medications such as prophylactic antibiotics.

The client will need preparation for postoperative meas­ures, including turning, coughing, deep breathing exercises (TCDB), and incentive spirometry; early ambulation; and the need for pain relief. Psychologic assessment is essential. The nurse first explores the significance of the loss of the uterus for the client. She may feel a great loss if she wishes to retain her childbearing ability, relates her uterus to her self-image and femininity, or believes that her sexual function is related to her uterus. Often a woman has misconceptions about the effects of hysterectomy (e.g., associating it with masculiniza-tion and weight gain). The nurse identifies misconceptions so that correct information can be provided and assesses the client's support system. The client may fear rejection by her husband or other sexual partner. The nurse encourages inclu­sion of the partner in all teaching sessions unless this practice is not culturally acceptable.

OPERATIVE PROCEDURES. A total abdominal hys­terectomy (TAH) is usually performed for leiomyomas larger than the gestational size of a 12-week pregnancy. The uterus and cervix are removed through a horizontal incision (tradi­tional approach) or via laparoscopic surgery, which requires a very small umbilical incision.

A uterus that has smaller fibroids may be removed via a to­tal vaginal hysterectomy (TVH). The surgeon removes the uterus and cervix through the vagina without an external sur­gical incision. In both vaginal and abdominal hysterectomies, the surgeon removes the uterus from the five supporting liga­ments, which are then attached to the vaginal cuff so that nor­mal depth of the vagina is maintained (Table 5).

 

TABLE 5 COMMON GYNECOLOGIC SURGERIES

TOTAL HYSTERECTOMY

All of the uterus, including the cervix, is removed. The proce­dure may be vaginal abdominal or laparoscopic

SUBTOTAL HYSTERECTOMY

All of the uterus, except the cervix, is removed. This proce­dure is rarely performed

BILATERAL SALPINGO-OOPHORECTOMY

Fallopian tubes and ovaries are removed.

PANHYSTERECTOMY

Total abdominal hysterectomy and bilateral salpingo-oophorectomy. The uterus, ovaries, and fallopian tubes are removed adominally.

RADICAL HYSTERECTOMY

All of the uterus is removed abdominally. The lymph nodes, the upper third of the vagina, and the surrounding tissues (parametrium) are also removed.

 

In some cases (e.g., treatment of submucous fibroids and menorrhagia), hysterectomy has been replaced by minimally invasive uterine surgery such as a transcervical endometrial resection (TCER). A hysteroscope is inserted into the uterus, and the endometrium is destroyed, usually with a diathermy resectoscope (similar to the scope used with prostate surgery). Complications specific to hysteroscopic surgery include the following:

  Fluid overload (fluid used to distend the uterine cavity can be absorbed)

  Embolism

  Hemorrhage

  Perforation of the uterus, bowel, or bladder and ureterinjury

  Persistent increased menstrual bleeding Incomplete suppression of menstruation

These complications occur less commonly when the pro­cedure is performed by an experienced surgeon. In addition, there is a small risk of subsequent pregnancy and the possi­bility of cancer developing in the scar. Hysterectomy is still the procedure of choice for women who have coexisting prob­lems, especially those with malignancy or symptomatic uterovaginal prolapse.

POSTOPERATIVE CARE. Postoperative care of the woman who has undergone a TAH is similar to that of any client who has undergone abdominal surgery. For clients who have undergone an abdominal hysterectomy, the nurse (Chart 9):

Assesses vaginal bleeding (there should be less than one saturated perineal pad in 4 hours)

Assesses abdominal bleeding at the incision site (a small amount is normal)

Checks the incision for intactness

  Maintains the urethral catheter (Foley catheter), if placed, usually for 24 hours or less for a traditional surgical approach

  Offers pain medications as ordered for the abdominal pain

CHART 9 FOCUSED ASSESSMENT of The Client After Total Abdominal Hysterectomy

Assess cardiovascular, respiratory, renal, and gastrointesti­nal status, including:

  Vital signs

  Heart, lung, and bowel sounds

  Urine output

  Temperature and color of the skin

  Red blood cell, hemoglobin, and hematocrit levels

  Activity tolerance

  Dressing and drains for color and amount of drainage

  Peripads for vaginal bleeding and clots

  Fluid intake (IVs until bowel sounds return and client is tolerating oral intake)

  Signs of thrombophlebitis

Use the following interventions to prevent postoperative complications:

  Cough and deep breathing exercises

  Incentive spirometry

  Sequential compression devices

  Ambulation

  Avoidance of heavy lifting or strenuous activity

Assess the home care teaching needs of the client related to the illness and surgery, including:

  Physiologic effects of the surgery

  Signs of symptoms to report

  Side or toxic effects of medications

  Activity limitations related to driving and use of stairs

  Follow-up care

  Postoperative restrictions related to sexual activity, use of tampons, and bathing

  Care of wound and/or drains

Assess the client's coping skills and reaction to the diagno­sis and surgical procedure.

 

Specific interventions for a vaginal hysterectomy include the following:

■ Assessment of vaginal bleeding (there should be less than one saturated pad in 4 hours) Foley catheter care Perineal care (sitz baths or ice packs) The surgeon usually removes the abdominal sutures or clips at the time of the first postoperative visit, whereas vagi­nal sutures are usually absorbed. The nurse recognizes and monitors for complications associated with hysterectomies (Table 6).

TABLE 6 COMMON POSTOPERATIVE COMPLICATIONS OF TRADITIONAL ABDOMINAL AND VAGINAL HYSTERECTOMIES

TRADITIONAL ABDOMINAL HYSTERECTOMY

  Intestinal obstruction (paralytic ileus)

  Thromboembolism

  Atelectasis

  Pneumonia

  Wound dehiscence (especially in obese clients)

  Urinary retention

VAGINAL HYSTERECTOMY

  Hemorrhage

  Urinary tract complications, especially infection or retention

  Wound infection

  Urinary retention

 

 

CRITICAL THINKING CHALLENGE

You are a nurse in the postanesthesia care unit (PACU) assigned to the care of an older adult who has undergone a total abdominal hysterectomy and bilateral salpingo-oophorectomy via a horizontal abdominal incision. On initial assessment, you note that her vital signs are within baseline, the dressing is dry and intact, and she has a scant amount of blood on her perineal pad. Immediately before she is to be transferred to the surgical unit, you find that her blood pres­sure has dropped from 124/78 to 108/60. Her pulse has in­creased from 80 to 96 within the past hour.

  Should you continue with plans to transfer the client to the surgical unit, since her vital signs are still within normal limits? Why or why not?

  What other assessments should you perform at this time?

  What might explain the change in her vital signs?

 

CONSIDERATIONS FOR OLDER ADULTS

Older women are more at risk for all complications, par­ticularly pulmonary embolism. Obese women are more at risk for thromboembolism. Psychologic complications can occur with both abdominal and vaginal procedures. Depression is the most frequent reaction reported. Other reactions are per­ceived loss of femininity and decreased libido. Loss of femi­ninity may be the problem if a woman was interested in her appearance before surgery but afterward has no interest, even when she is feeling better. Decreased sexual desire is often temporary, if it occurs, and is usually related to discomfort

 

Community-Based Care

The client with uterine leiomyomas is managed on an am­bulatory care basis unless surgical intervention is required. After hospital discharge, the client typically returns to her home.

HOME CARE MANAGEMENT

Planning for home care management begins at the time of ad­mission. The woman is usually discharged to the home setting 1 to 2 days after a traditional TAH, depending on the age and general health of the client. TVH, laparoscopic surgery, or TCER may be performed as same-day surgery in an ambula­tory setting. The client undergoing a hysterectomy should be told to avoid or limit stair climbing for 1 month. She is ad­vised to avoid tub baths (which may promote infection) and sitting for long periods (which causes pooling of blood in the pelvic vessels). The nurse also teaches the client to avoid en­gaging in strenuous activity or lifting anything weighing more than 5 pounds (2.3 kg). Some health care providers also re­strict driving for 4 to 6 weeks.

HEALTH CARE RESOURCES

Usually no special home equipment is needed for a woman who has undergone a hysterectomy. A home care nurse may be needed to assess and monitor the older client's postoperative progress if other conditions (e.g., uncontrolled diabetes) are present. Financial assistance may be needed, and referral to the hospital's department of social services or case management de­partment may be indicated if the woman has no insurance cov­erage. The nurse can provide a referral for psychologic or sexual counseling if potential problems are identified before discharge.

HEALTH TEACHING

The nurse teaches the woman who has undergone a hysterec­tomy about the following (see Chart 9):

  The physical changes to be expected

  Exercise and activities

  Diet

  Sexual activity

  Wound care (if any)

  Complications

  Follow-up care

The physical changes include cessation of menses, inabil­ity to become pregnant, weakness and fatigue during conva­lescence (may last 2 to 3 months), and absence of menopausal symptoms unless the ovaries are also removed. Moderate ex­ercise, such as walking, is encouraged, but active sports, such as jogging and aerobic exercise, should be avoided for at least 1 month.

The nurse teaches the client to consume foods that aid in healing tissues, such as foods high in protein, iron, and vita­min C. The nurse also reminds her to avoid sexual intercourse for 4 to 6 weeks. The first coital activity may cause some ten­derness or pain because the vaginal walls are tight and need to be stretched. Water-soluble lubricants can decrease discom­fort. The client should be taught the signs of complications, particularly infection. An appointment for follow-up medical care is scheduled for 1 week postoperatively.

Women who have undergone a hysterectomy need infor­mation about possible emotional reactions. Generally, women adjust well to surgery if they:

  Have completed childbearing. Work

  Have interests outside the home

  Have no misconceptions about the effects of hysterectomy

  Have support from the family, especially the husband ortheir sexual partner

Reactions may be different after vaginal and abdominal procedures, because women who have undergone a vaginal hysterectomy have no external focus (no obvious change in body image) for their feelings. Psychologic reactions can oc­cur 3 months to 3 years after surgery. Women identified as be­ing at high risk for psychologic problems may need long-term follow-up care or referral. Women may need to be counseled about signs of depression. Intermittent sadness is normal, but continued feelings of low self-esteem or loss of interest or pleasure in usual activities and pastimes is not normal and should be evaluated. The incidence of psychologic reactions often decreases after the nurse provides written materials and discusses the positive forces in the client's life with her and her family or significant others.

 

Evaluation: Outcomes

The nurse evaluates the care of the client who has under­gone surgery for leiomyomas on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes include that the client will:

  Be free of hemorrhage

  State the role of the reproductive system and the changes hat occur after a hysterectomy (without misconceptions)

  Recover from surgery without complications

  Demonstrate a positive psychologic adjustment to surgery as evidenced by the absence of depression and the resence of a positive self-concept

  Resume sexual activities at her previous level of satisfaction


BARTHOLIN'S CYSTS

OVERVIEW

Bartholin's cysts are one of the most common disorders of the vulva. The cysts result from obstruction of a duct. The se­cretory function of the gland continues, and the fluid fills up the obstructed duct. The cause of the obstruction may be in­fection, congenital stenosis or atresia, thickened mucus near the ductal opening, or mechanical trauma, such as lacerations or episiotomy.

COLLABORATIVE MANAGEMENT

Assessment

The client may be asymptomatic if the cyst is small, but a his­tory may reveal complaints of dyspareunia, inadequate geni­tal lubrication, or a mass in the perineal area. A large cyst usu­ally causes constant localized pain and may cause difficulty walking or sitting. Physical examination of the vulva reveals a swelling immediately beneath the skin in the posterior por­tion of the vulva. The cyst may appear brown or sanguineous, depending on its contents. Usually the cyst is unilateral and ranges from 3/8 to 4 inches (1 to 10 cm) in size.

If the cyst is draining, the health care provider usually re­quests that the fluid be sent to the laboratory for culture (for gonorrhea and aerobic and anaerobic organisms) and sensitiv­ity testing. If the woman is older than 40 years of age, a spec­imen of the cyst should be sent for pathologic examination to determine whether the lesion is benign or malignant.

Interventions

If the woman is asymptomatic, no interventions are necessary. If the cysts are symptomatic, simple incision and drainage (I&D) may provide temporary relief; however, cysts tend to re­cur as the opening of the duct becomes obstructed again. Usu­ally the health care provider establishes a permanent opening for drainage. Marsupialization (formation of a pouch that is a new duct opening) is accomplished using local, regional, or general anesthesia. Any postoperative discomfort may be re­lieved by the administration of analgesics and sitz baths. The health care provider may prescribe prophylactic antibiotics.

Bartholin's cysts may become infected. Abscesses are formed when bacteria, such as Escherichia coli or Staphylococ-cus aureus, enter the duct, resulting in infection that closes the duct. An abscess usually ruptures spontaneously within 72 hours of formation. Interventions for the woman with an abscess in­clude the administration of analgesics and application of moist heat (sitz baths or hot wet packs) to the vulva. The health care provider usually orders broad-spectrum antibiotics to treat the infection. I&D of the abscess may provide temporary relief.

The health care provider may totally excise the Bartholin's glands in women older than 40 years of age when cancer is suspected or if repeated infections with abscess formation oc­cur. Postoperative interventions include the following:

  Application of ice packs or sitz baths several times a day for comfort and promotion of healing

  Administration of analgesics for pain, if needed

  Prophylactic administration of antibiotics

  Assessment of the incision for signs of healing or infection

 

CERVICAL POLYPS

Cervical polyps are pedunculated (on stalks) tumors arising from the mucosa and extending to the opening of the cervical os. The cause is unknown, although polyps result from a hy-perplastic condition of the endocervical epithelium. They may also be due to inflammation. Polyps are the most common be­nign neoplastic growth of the cervix. Cervical polyps are most common in multiparous women older than 40 years of age.

A woman may be asymptomatic, or a history may reveal complaints of premenstrual or postmenstrual bleeding or bleeding after coitus. A speculum examination may reveal small (3/8 to l!/2-inch [1- to 4-cm]) single or multiple polyps. They are bright red; have a soft, fragile consistency; and may bleed when touched.

Polyp removal is easily accomplished as an office proce­dure. The base of the polyp can be grasped with a clamp, and the polyp can be twisted off and sent to the pathology labora­tory for evaluation. Electrocautery or chemical cautery usu­ally stops any bleeding at the site of removal. After the pro­cedure, the nurse may instruct the client to avoid tampon use, douches, and sexual intercourse for a week or until healing has taken place.


MALIGNANT NEOPLASMS

Endometrial Cancer

OVERVIEW

Endometrial cancer (cancer of the uterus) is one of the most commonly occurring reproductive cancers (American Cancer Society, 2000). This type of cancer is asymptomatic in its early development and has a good prognosis in 80% to 90% of cases.

 

CONSIDERATIONS FOR OLDER ADULTS

Endometrial cancer is a slow-growing tumor primarily oc­curring in postmenopausal women. The average age at onset is 61 years. The incidence declines after the age of 70 years (DeStefano & Bertin-Matson, 1996).

 

PATHOPHYSIOLOGY

Adenocarcinoma of the endometrium accounts for 75% to 80% of all endometrial cancers. It arises from the glandular component of the endometrial mucosa and may be preceded by endometrial hyperplasia (tissue overgrowth). The initial growth of the cancer is within the uterine cavity, followed by extension into the myometrium and the cervix. Spread outside the uterus occurs as follows:

  Through lymphatic spread to the ovaries and parametrial, pelvic, inguinal, and para-aortic lymph nodes

  By hematogenous metastasis (spread by blood) to the lungs, liver, or bone

  By transtubal or intra-abdominal spread to the peritoneal cavity

 

ETIOLOGY

Risk factors associated with endometrial cancer include obe­sity, diabetes mellitus, hypertension, a history of uterine polyps, a history of infertility, nulliparity and polycystic ovary disease. Estrogen stimulation, including unopposed meno-pausal estrogen replacement therapy (ERT), late menopause (after age 52 years), postmenopausal bleeding, and a family history of uterine cancer also predispose a woman to endome­trial cancer. Table 7 compares the risk factors for endome­trial cancer with those for other female reproductive cancers.

 

TABLE 7 RISK FACTORS FOR CANCERS OF THE REPRODUCTIVE SYSTEM

Risk Factor

Endometrial Cancer

Cervical Cancer

Ovarian Cancer

Vulvar Cancer

Vaginal Cancer

Fallopian Tube Cancer

Gestational Trophoblastic Disease

Age

50-65 yr of age

CIS: 30-40 yr of age

Invasive: 40-60 yr of age

Infrequent before 35 yr of age; range usually is 40-65 yr of age

After 40 yr of age; peak is 60-70 yr of age

Most after 50 yr of age; adenocarcinoma: 14-30 yr of age

DES exposure in utero

After 50 yr of age; range is 18-80 yr of age

After 40 yr of age; before 20 yr of age

Family history

Increased risk

Increased risk

 

Vulvar or cervical cancer

_

Personal history

Diabetes, hypertension

Breast, bowel, or endometrial cancer

Cervical cancer, diabetes, vulvar disease

Ovarian or uterine cancer, infertility

Previous molar pregnancy (3%-5%)

Race

Caucasians

African Americans, Native Americans

Caucasians

Asian-Americans; Mexican-Americans

Mother's age at birth

<18yr

>30yr

Body size

Obesity

Possibly obesity

Parity

Nulliparity

Multiparity

Nulliparity

Multiparity

Nulliparity

Estrogen use

Prolonged use; >3 yr menopausally

Possibly long-term birth control pill use

Smoking

Possibly increased risk

Possibly double the risk

Infection (STD)

Possibly STD (herpes simplex virus type 2 or papillomavirus infection)

Possibly STD (papillomavirus infection)

STD (herpes simplex virus type 2 or papillomavirus infection)

PID, chronic salpingitis

Exposure to infectious agents

CIS, Carcinoma in situ; DES, diethylstilbestrol; PID, pelvic inflammatory disease; STD, sexually transmitted disease.

INCIDENCE/PREVALENCE

The National Cancer Institute (NCI) estimates that more than 35,000 new cases of endometrial cancer occur annually in the United States (American Cancer Society, 2000). Thus about 1 of every 100 women in the United States has endometrial cancer.

 

CULTURAL CONSIDERATIONS

Endometrial cancer occurs more often in Caucasian women than in African-American women and typically in post­menopausal women ages 50 to 65 years. Survival rates differ between Caucasian and African-American women with en­dometrial cancer; Caucasian women have higher survival rates (American Cancer Society, 2000). The difference in sur­vival rates appears to be related to the occurrence of higher-grade lesions and more aggressive cell types in African-American women.

 

COLLABORATIVE MANAGEMENT

Assessment

The primary symptom of endometrial cancer is post­menopausal bleeding. In addition, the woman may complain of a watery, serosanguineous vaginal discharge, low back or abdominal pain, and low pelvic pain (caused by pressure of the enlarged uterus). A pelvic examination may reveal the presence of a palpable uterine mass or uterine polyp. The uterus is enlarged if the cancer is in an advanced stage.

Before a diagnosis is made, the client may deny that the symptoms are related to cancer. During the diagnostic phase, the woman may express fears and concerns about having a ma­lignancy. After the diagnosis is confirmed, she may express dis­belief, anger, depression, anxiety, or withdrawal behaviors.

The health care provider orders basic diagnostic tests to determine the client's overall status. The results of the tests may also indicate the presence of metastasis. These tests in­clude the following:

  Chest x-ray examination to detect metastasis

  Intravenous pyelography (IVP), or excretory urography, to assess renal function and to assess for renal metastasis

  Barium enema study to assess for intestinal metastasis

   Computed tomography (CT) of the pelvis to identify the origin and spread of the tumor

  Lymphangiography to assess for lymph node metastasis

  Liver and bone scans to assess for distant metastasis Fractional dilation and curettage (D&C [scraping individual sections of the uterus]) and endometrial biopsy are the definitive diagnostic procedures for endometrial cancer. Other tests that may be useful for some clients include proctosigmoidoscopy, ultrasonography, and hysteroscopy (examination of the uterus via an endoscope).

 

Interventions

Nonsurgical interventions (radiation therapy and chemother­apy) and surgery may be used alone or in combination, de­pending on the stage of the cancer.

NONSURGICAL MANAGEMENT. Radiation therapy and chemotherapy are the two major nonsurgical methods used to treat endometrial cancer.

RADIATION THERAPY. The health care provider orders radiation therapy (external and internal) if the stage of cancer is hard to determine and if surgery is planned for stage II and III cancers. Clients usually receive radiation therapy for 6 weeks preoperatively to destroy cancer cells in the pericervi-cal lymphatics and to inhibit recurrence.

Intracavitary Radiation. If intracavitary radiation ther­apy (IRT [brachytherapy]) is selected, the radiologist places an applicator within the woman's uterus through the vagina while she is anesthetized. After the correct position of the ap­plicator is confirmed by x-ray examination, the client is taken to the hospital room and a radiologist places a radioactive iso­tope in the applicator, which remains for 1 to 3 days. Before the procedure, the nurse instructs the client on postprocedure activities, such as deep breathing and leg exercises. While the radioactive implant is in place, the woman is strictly isolated, usually in a private room. The nurse informs the client that she is restricted to bedrest on her back with the head of the bed flat or slightly elevated (20 degrees or less). Movement in bed is restricted to prevent dislodgment of the radioactive source.

A Foley catheter is inserted into the bladder to prevent dis­lodgment of the implant, which can be caused by a full blad­der or attempts to void. The nurse carefully assesses the skin for breakdown over bony pressure points during the activity restriction period. The client is usually placed on a low-residue diet (to prevent bowel movements that might dislodge the implant), and fluid intake is encouraged (to prevent stasis of urine and possible infection). The health care provider usu­ally prescribes the following:

  Antiemetics

  Broad-spectrum antibiotics (to prevent bladder infections)

  Tranquilizers (to help the client relax)

  Analgesics

  Heparin or Lovenox (to prevent thromboembolism)

  Antidiarrheal medications (to prevent bowel movements)

Radiation precautions are practiced while the implant is in place. The nurse organizes care so that minimal time is spent at the bedside. Care is given as far away from the radioactive source as possible and behind lead shields when possible. Nurses who are pregnant or attempting to become pregnant should not be assigned to these clients. Visitors are restricted to brief visits, and pregnant women and children younger than 18 years should not be allowed to visit.

External Radiation. External radiation therapy may be used to treat all stages of endometrial cancer. It is usually used in combination with surgery, preoperatively or postopera-tively. Depending on the extent of the tumor, external radia­tion is given on an ambulatory care basis for 4 to 6 weeks. The lateral extensions of the tumor in the parametrium and pelvic wall nodes are irradiated. Specific in­structions for the woman undergoing external radiation for endometrial cancer include monitoring for signs of skin breakdown, especially in the perineal area, no sunbathing, and no bathing over the markings outlining the treatment site. The nurse informs the client that cystitis and diarrhea are common complications, as are nutritional problems that result from anorexia.

CHEMOTHERAPY. Chemotherapy is used as a palliative treatment in advanced and recurrent disease. Chemotherapeu-tic agents used for palliative treatment of endometrial cancer include doxorubicin (Adriamycin), cisplatin, and cyclophosphamide (Cytoxan, Procytox). These agents are used as sin­gle agents or in combination, and the length of treatment and dosage are determined by the woman's response to treatment. Chapter 25 discusses nursing interventions for clients receiv­ing chemotherapy.

OTHER DRUG THERAPY. The health care provider may choose progestational therapy for stage I and II cancers that are estrogen dependent and for palliative treatment of stage IV can­cer. The hormones commonly prescribed are medroxyprogesterone acetate (Depo-Provera) and megestrol acetate (Megace). Tamoxifen citrate (Nolvadex, Tamofen), an antiestrogen, is also used. The progestational agents do not cause acute side ef­fects, but nausea and vomiting and hot flashes are associated with tamoxifen.

SURGICAL MANAGEMENT. The surgeon typically per­forms a total abdominal hysterectomy (removal of the uterus and cervix) and bilateral salpingo-oophorectomy (removal of both tubes and ovaries) for stage I tumors without cervical in­volvement. A radical hysterectomy (see Table 75-5) with bi­lateral pelvic lymph node dissection is performed for stage II cancer. Nursing care for a radical hysterectomy is essentially the same as that for a total abdominal hysterectomy except that the woman's hospitalization is usually longer and her convalescence may be extended.

PSYCHOSOCIAL SUPPORT. Women need to discuss their concerns about the presence of cancer and the potential for recurrence. The nurse provides emotional support and tries to create an atmosphere that encourages the woman to ask questions or express her fears and concerns. Family mem­bers or significant others are included in discussions when possible.

Reactions to radiation therapy vary. Some women may feel radioactive or "unclean" after treatments and may exhibit withdrawal behaviors. The nurse needs to correct such mis­conceptions.

Women who have chemotherapy may be upset if alopecia (hair loss) occurs. The nurse warns the client of this possibil­ity before treatment starts. Wigs, scarves, or turbans can be worn until regrowth occurs.

 

Community-Based Care

The client with endometrial cancer is managed at home unless surgery is indicated. After surgery, the client is usually dis­charged to her home.

HOME CARE MANAGEMENT

Home care after surgery for endometrial cancer is the same as that after a hysterectomy (see Operative Procedures [Uterine Leiomyomas]). Women who are receiving chemother­apy or external radiation therapy are usually treated on an am­bulatory care basis, which may mean that the woman and her family have to plan daily activities around trips to the clinic or the health care provider's office. If the tumor recurs and cure is not likely, the client and her family need to think about hos­pice care and whether the woman can be cared for in the home.

HEALTH TEACHING

For the woman who has undergone a hysterectomy for en­dometrial cancer, the teaching plan is the same as that for the woman who has undergone a hysterectomy for uterine leiomyomas (see Postoperative Care). Side effects to report to the health care provider include vaginal or rectal bleeding, foul-smelling discharge, abdominal pain or distention, and hematuria.

The high dose of radiation causes sterility, and vaginal shrinkage can occur. Vaginal dilators can be used with water-soluble lubricants for 10 min/day until sexual activity resumes (in 10 days to 6 weeks). The woman is not radioactive, and her partner will not "catch" cancer from engaging in sexual intercourse. A normal diet may be resumed.

All prescribed medications are reviewed, including the dosage and schedule of administration, therapeutic effects, and side effects. The nurse also emphasizes the importance of keeping appointments for follow-up care.

Often women experience emotional crises because of the physical effects of cancer treatments. Radical hysterectomy may be seen as mutilating, and chemotherapy may affect the woman's body image if hair loss occurs. A woman may ex­hibit a grief reaction to this perceived change in body image.

The feelings of loss depend on the visibility of the loss, the function of the loss, and the amount of emotional investment. The nurse may need to help the woman adapt to the body changes. One way to do this is to encourage self-care as soon as the woman's condition is stable. A calm, accepting attitude may also be helpful.

Death can occur with or without treatment. Women and their families or significant others have concerns about recur­rence. All want to pass the 5-year survival mark without a re­currence. If there is a recurrence, the woman may be hostile and may exhibit characteristics of a grief reaction. The nurse encourages clients to ventilate their feelings. Response to loss and grieving are discussed in Chapter 9.

HEALTH CARE RESOURCES

In the United States, local American Cancer Society chapters provide written materials about endometrial cancer, as well as information about local support groups. If the client is in the terminal stages of cancer, hospice care may be appropriate. If nursing care is needed at home, the hospital nurse or case manager refers the client and her family to a commu­nity health or home care agency. A referral to a social services agency may be needed if the woman is unable to meet the fi­nancial demands of treatment and long-term follow-up.


CERVICAL CANCER

OVERVIEW

Cervical cancer is one of the most common reproductive can­cers among women in the United States. Cervical cancer is also the third most common cause of death related to repro­ductive cancers (American Cancer Society, 2000). Death rates for cervical cancer have dropped 50% in the past two decades, primarily because of the availability of Pap tests for screening of premalignant cervical changes. However, among some eth­nic/racial groups, Pap smears are not common as a screening test for cervical cancer. For example, in a study by Kim et al. (1999), only 34% of Korean-American women in the sample reported having a Pap smear (see the Evidence-Based Practice for Nursing box).

PATHOPHYSIOLOGY

Cervical cancer may be described as preinvasive or invasive. Preinvasive cancer is limited to the cervix; invasive cancer is in the cervix and other pelvic structures. Preinvasive lesions usu­ally originate in the area called the transformation zone (Figure 5). This area includes the squamocolumnar junction, which is located near the external cervical os, where changes in the squamous and columnar (glandular) epithelium normally oc­cur. Abnormal squamous epithelium can also be found in this zone. These cells can develop into invasive carcinoma.

 

 PREMENARCHAL   MENARCHAL  MENSTRUATING   MENOPAUSAL POSTMENOPAUSAL

Figure 5 The location of the transformation zone at various stages of adult development.

 

These premalignant changes can be described on a contin­uum from dysplasia—the earliest premalignant change—to carcinoma in situ (CIS), the most advanced premalignant change. Preinvasive cancers can also be designated by the term cervical intraepithelial neoplasia (CIN) and classified according to severity:

  CIN I: mild

  CIN II: moderate

  CIN III: severe to carcinoma in situ

 

Squamous cell cancers spread by direct extension to the vaginal mucosa, lower uterine segment, parametrium, pelvic wall, bladder, and bowel. Metastasis is usually confined to the pelvis, but distant metastases can occur through lymphatic spread and, rarely, via the circulatory system to the liver, lungs, or bones. Table 8 shows the clinical stages of can­cer of the cervix.

 

TABLE 8 CLINICAL STAGES OF CANCER OF THE CERVIX

Stage

Characteristics

I

Carcinoma is strictly confined to cervix (extension to corpus should be disregarded)

    I a

Preclinical carcinoma

       I a 1

Minimal microscopically evident stromal invasion

       I a 2

Microscopic lesions no more than 5-mm depth measured from base of epithelium surface or glandular surface from which it originates, and horizontal spread not to exceed 7 mm

    I b

All other cases of stage I; occult cancer should be marked "occ"

II

Carcinoma extends beyond cervix but has not extended to pelvic wall; it involves vagina, but not as far as lower third

     II a

No obvious parametrial involvement

     II b

Obvious parametrial involvement

III

Carcinoma has extended to pelvic wall; on rectal examination, there is no cancer-free space be­tween tumor and pelvic wall; tumor involves lower third of vagina; all cases with hydronephrosis or nonfunctioning kidney should be included unless they are known to be due to another cause

      III a

No extension to pelvic wall, but involvement of lower third of vagina

      III b

Extension to pelvic wall, or hydronephrosis or nonfunctioning kidney due to tumor

IV

Carcinoma has extended beyond true pelvis or has clinically involved mucosa of bladder or rectum

      IV a

Spread of growth to adjacent pelvic organs

      IV b

Spread to distant organs

 

ETIOLOGY

The exact cause of squamous cell cervical cancer is unknown, but numerous factors may be involved. An association has been identified with early and frequent sexual contact and with viral infections of the cervix, such as herpes simplex virus type 2, cytomegalovirus, and papillomavirus.

Risk factors associated with cervical cancer include low socioeconomic status, early age at first sexual contact or first pregnancy, multiple sexual partners, and intrauterine exposure to diethylstilbestrol (DES). Other possible risk factors include sexual intercourse with men whose previous sexual partners had cervical cancer, use of oral contraceptives, cigarette smok­ing, and vitamin A and С deficiencies. Nulliparity and diabetes mellitus are also associated with adenocarcinoma of the cervix.

 

Do Korean-American women have Pap smears for screening of cervical cancer?

Kim, K., et al. (1999). Cervical cancer screening knowledge and practices among Korean-American women. Cancer Nursing, 22(4), 297-302.

The nursing researchers in this study surveyed 159 Korean-American women between 40 and 69 years of age to deter­mine if they knew what a Pap smear was and if they had ever had one. The 1987 Cancer Control Supplement questionnaire was translated into Korean and used to collect the data. Twenty-six respondents had never heard of the Pap smear, and only 34% reported ever having one. The most commonly cited reason for not having a Pap test was the absence of dis­ease symptoms.

Critique. The researchers undertook a study to examine possible differences among a group of non-Caucasian women. Although this was a descriptive study, it paves the way for further study of other non-Caucasian health practices.

Implications for Nursing. The findings of this study have implications for nurses who work with this population and other culturally diverse groups. Health education about Pap smears is crucial if cervical cancer is to be found in its earliest stage to ensure a positive outcome. Some subjects thought that the Pap smear was appropriate as a treatment rather than a health promotion/illness prevention Intervention.

 

CULTURAL CONSIDERATIONS

The rate of cervical cancer is twice as high for African-American women as for Caucasian women. The mortality rate is more than twice as high for African-American women as for Caucasian women (American Cancer Society, 2000).

 

INCIDENCE/PREVALENCE

The National Cancer Institute (NCI) estimates that there are more than 14,000 new cases of cervical cancer (excluding CIS) and more than 4400 deaths in the United States annually. Al­though the rate of invasive cervical cancer has decreased over the last several decades, it has increased in recent years in women younger than 50 years of age (American Cancer Society, 2000). CIN occurs mainly in young women; the peak incidence of dysplasia occurs in clients in their mid-20s. CIS occurs in women about 30 years old, and invasive cancer occurs most commonly in the late 40s.

 

COLLABORATIVE MANAGEMENT

Assessment

The woman who has preinvasive cancer is often asympto­matic. The classic symptom of invasive cancer is painless vaginal bleeding. The bleeding may start as spotting between menstrual periods or after coitus or douching. As the malig­nancy grows, the bleeding increases in frequency, duration, and amount. It may become continuous.

The woman may also complain of a watery, blood-tinged vaginal discharge that may become dark and foul smelling as the disease progresses. Leg pain (along the sciatic nerve) or unilateral swelling of a leg may be a late symptom or may in­dicate recurrent disease. Other signs of recurrence or metas­tasis (spread) may include unexplained weight loss, pelvic pain (caused by pressure of the tumor on the bladder or the bowel), dysuria (painful urination), hematuria (bloody urine), rectal bleeding, chest pain, and coughing. A physical exami­nation may not reveal any abnormalities in early preinvasive cervical cancer; the internal pelvic examination may identify late-stage disease.

Laboratory assessment of the woman begins with a Pap smear. If the results are abnormal, the smear is repeated be­fore further studies are done. If abnormal tissue is detected on a subsequent Pap test, further testing is done. If invasive cer­vical cancer is diagnosed, laboratory tests such as those de­scribed earlier for the investigation of endometrial cancer are performed.

The health care provider may perform a colposcopic exami­nation to view the transformation zone, where dysplasia, cervi­cal intraepithelial neoplasia (CIN), and carcinoma in situ (CIS) usually originate. If abnormal tissue is recognized, multiple biopsies of the cervical tissue are performed.

The health care provider usually performs an endocervical curettage (scraping of the endocervix from the internal to the external os) as well. Because this procedure is uncomfortable, the nurse may need to encourage the woman to use relaxation or breathing exercises to cope with the cramping and pain. A small amount of bleeding is expected and may occur for up to 2 weeks after the biopsies.

 

Interventions

Nursing care of the client with cervical cancer is similar to that for endometrial cancer. The only interventions discussed here are those that differ from those for the client with en­dometrial cancer.

NONSURGICAL MANAGEMENT. Nonsurgical interven­tions for cervical cancer depend on the stage of disease and may include laser therapy, cryosurgery, radiation therapy, chemotherapy, or hysterectomy.

LASER THERAPY. Laser therapy is an ambulatory care procedure that is used whenever all of the boundaries of the lesion are visible under colposcopic examination and the en­docervical curettage findings are normal. In laser therapy, the invisible beam is directed to the abnormal tissues, where energy from the beam is absorbed by the fluid in the tissues, causing them to vaporize. There is usually a small amount of bleeding associated with the procedure. The woman may have a slight vaginal discharge, and healing occurs in 6 to 12 weeks.

CRYOSURGERY. Cryosurgery is another common treat­ment for CIN. A probe is placed against the cervix to cause freezing of the tissues and subsequent necrosis. Although this treatment can also be considered a type of surgery, no anes­thesia is required. After the procedure, the client may experi­ence slight cramping. The woman has a heavy watery dis­charge for several weeks after the procedure; she should avoid sexual intercourse and the use of tampons while discharge is present because the cervix is friable and these precautions will decrease the risk of infection.

RADIATION THERAPY. Most women with invasive cervi­cal cancer are treated with radiation. For cancer that has ex­tended beyond the cervix but not to the pelvic wall, radiation therapy is as effective as a radical hysterectomy. Intracavitary and external radiation therapies are used in combination, de­pending on the extent and location of the lesion. Intracavitary implants (brachytherapy) are usually used for lesions that have extended beyond the pelvic wall. External therapy is of­ten given first to shrink the tumor and increase the effective­ness of the implant. Nursing care related to radiation therapy is presented in the earlier discussion of endometrial cancer.

CHEMOTHERAPY. Chemotherapeutic agents have gen­erally performed poorly in the treatment of cervical cancer. These agents are usually reserved for unresectable recurrent tumors or disseminated metastatic disease (DeStefano & Bertin-Matson, 1996). Two drugs that have shown some re­sponse are cisplatin and 5-fluorouracil (5-FU).

SURGICAL MANAGEMENT. The surgical procedure for cervical cancer depends on the extent of the disease and whether the client wants to have children.

CONIZATION. Conization is the definitive treatment for clients with microinvasive cervical cancer. This procedure is done when the lesion cannot be visualized by colposcopic ex­amination. A cone-shaped area of cervix is removed surgi­cally and sent to the laboratory to determine the extent of the malignancy. Potential complications associated with coniza­tion include hemorrhage, uterine perforation, incompetent cervix, cervical stenosis (hardening), and preterm labor for future pregnancies.

Conization may be used therapeutically for women with CIN who desire further childbearing or less extensive surgical treatment. Long-term follow-up care is needed because new lesions can develop.

HYSTERECTOMY. A hysterectomy may be performed as treatment of microinvasive cancer if the client does not desire childbearing. A vaginal approach is commonly used. A radi­cal hysterectomy and bilateral pelvic lymph node dissection is as effective as radiation for treating clients with cancer that has extended beyond the cervix but not to the pelvic wall. Information about hysterectomy is found under Operative Pro­cedures (Uterine Leiomyomas).

PELVIC EXENTERATION. One of the most radical surgi­cal procedures is pelvic exenteration. It is performed for re­current cancers if there is no evidence of tumor outside the pelvis and no lymph node involvement.

Preoperative Care. Nursing care of the woman sched­uled for exenteration includes assessment of preoperative anxiety, concerns about the impact on sexual function, and the ability to adjust to her altered body image. The nurse involves family members or significant others in discussions about postoperative expectations. Physical preparation includes se­lection of stoma sites, extensive bowel preparation, and ex­tensive radiographic and laboratory tests to assess for spread of cancer outside the pelvis. The nurse teaches the client about the following:

  Postoperative recovery in a critical care unit

  Pain management

  Presence of numerous intravenous (IV) and arterial catheters

  Nasogastric suction

  Colostomy and/or urinary diversion (e.g., ileal conduit, Kock ileal urinary pouch)

Operative Procedures. There are three types of exen­teration: anterior, posterior, and total (Figure 6). Anterior exenteration is the removal of the uterus, cervix, ovaries, fal­lopian tubes, vagina, bladder, urethra, and pelvic lymph nodes. Posterior exenteration is the removal of the uterus, cervix, ovaries, fallopian tubes, descending colon, rectum, and anal canal. Total exenteration is a combination of anterior and posterior procedures. When the bladder is removed, urine is diverted through a urinary diversion (e.g., ileal conduit or Kock ileal urinary pouch). When the colon, rectum, and anal canal are removed, a colostomy is created for passage of feces. The stomas are located on the abdomen—the colostomy on the left and the ileal conduit on the right.

 

 

Anterior exenteration is removal of all pelvic organs except the descending colon, rectum, and anal canal. Urine can be diverted into an ileal conduit or urinary Kock pouch.

Posterior exenteration is removal of all pelvic organs except the bladder. A colostomy is created for the passage of feces.

Total exenteration is removal of all pelvic organs with creation of an ileal conduit or urinary Kock pouch and a colostomy.

Figure 6 Pelvic exenteration.

 

Postoperative Care. After surgery, the client often is admitted to a critical care unit for the first 1 to 2 days because of the high risk for complications resulting from the massive tissue resection. The nurse assesses for the following:

  Cardiovascular complications such as hemorrhage and shock

  Pulmonary complications such as atelectasis and pneumonia

  Fluid and electrolyte imbalances such as metabolic acidosis or alkalosis and dehydration

  Renal or urinary complications

  Pain

The nurse or assistive nursing personnel also assists with deep breathing and coughing hourly, monitors urine output and specific gravity, monitors parenteral nutrition, and pro­vides colostomy and urinary diversion care.

Once the client's condition is stable, she returns to the reg­ular postoperative unit. The nurse continues postoperative in­terventions. During the recovery period, the nurse assesses for the following:

  Late cardiovascular complications such as deep vein thrombosis and pulmonary emboli

  Gastrointestinal (GI) complications such as paralytic ileus

  Wound infections

  Wound dehiscence or evisceration

  Pain

The nurse administers prophylactic heparin or low-molecular weight heparin (enoxaparin [Lovenox]) and main­tains the use of antiembolism stockings or sequential com­pression devices (SCDs) for the prevention of thrombosis, as ordered. The nurse also auscultates the lungs frequently, as­sesses for the presence of bowel sounds and wound infection, administers antibiotics as prescribed, and manages pain with a gradual withdrawal of opioid analgesics.

After the surgeon removes the operative dressings, per-ineal irrigations may be implemented. Irrigation is usually done with normal saline solution applied with an Asepto sy­ringe. This is followed by drying of the perineum with a heat lamp (25 W at a distance of 18 inches [45 cm]) or a hair dryer (using warm air). Care must be taken to avoid burning the client. Sitz baths may be ordered as tolerated. (Postoperative care of clients with colostomies and urinary diversions is dis­cussed elsewhere in this text).

 

Community-Based Care

If the client has undergone a hysterectomy, the discharge planning is similar to that described for endometrial cancer. For the client who has undergone a pelvic exenteration, the discharge planning is more involved.

HOME CARE MANAGEMENT

The client who has undergone a pelvic exenteration is usually in the hospital for at least 1 week postoperatively. She may be discharged to a skilled nursing facility or subacute unit for continued recovery and care or may be discharged directly to home. When the client returns home, she needs assistance. She is not able to engage in strenuous activities associated with most household work for up to 6 months. The family may need to consider outside help if there is no one in the family who can assume household responsibilities.

No special equipment is needed in the home, although a convoluted foam mattress or other special pressure-relieving device may be placed on the bed to prevent skin breakdown and to increase comfort. Colostomy and ureterostomy pouches and equipment for changing the pouches can be purchased in local pharmacies.

HEALTH TEACHING

The nurse teaches the woman who has undergone a pelvic ex­enteration how to manage new functions with equipment (colostomy and urinary diversion) and to perform activities of daily living (ADLs) and self-care. The perineal opening may drain mucus for several months to a year. The client can wear sanitary napkins (minipads or maxipads) if they are beltless (so as not to interfere with the stomas). The woman may need help in adjusting her diet to maintain high nutritional require­ments for healing while selecting foods that are tolerated. The woman should be able to state the effects, dosages, and side effects of all medications prescribed.

Sexual function is different after exenteration (even if an artificial vagina is constructed), and the couple may need counseling about alternatives to intercourse. Even with vagi­nal reconstruction, the use of vaginal dilators is necessary to achieve desired sexual function.

Physical activities may be limited during convalescence. If walking is not permitted, the nurse encourages range-of-motion exercises. Follow-up care is important. The nurse counsels the client about keeping all follow-up appointments. Information about late complications (e.g., infection and bowel obstruction) is needed so that the woman can seek medical care promptly.

Usually by 3 to 5 days after surgery, the woman begins ex­pressing grief about her body changes. At first she may deny changes by refusing to look at the wound or stoma sites. Later she may become depressed or withdrawn or even angry or hostile. She may then move to reality testing by asking ques­tions about her care, watching the nurses do wound care, and becoming actively involved in self-care.

The woman may have mood swings, and the nurse is alert when the woman becomes depressed so that interventions can be implemented. The woman needs intense emotional support if she is to adapt to her altered body image and functions.

Unless the woman has vaginal reconstruction after anterior or total pelvic exenteration, she is not able to have vaginal in­tercourse. The nurse must assess the need for sexual counsel­ing by listening for cues about altered perceptions of body im­age and anxiety about her sexual partner's response. Further sexual counseling may be needed to provide information on alternative methods of sexual gratification.

HEALTH CARE RESOURCES

Resources for the woman who has cervical cancer are similar to those for the woman with endometrial cancer.


OVARIAN CANCER

OVERVIEW

Ovarian cancer is the leading cause of death from female re­productive malignancies. Death rates have risen during the past four decades, and it is projected that 1 of every 70 women will develop ovarian cancer sometime in her life (American Cancer Society, 2000). Survival rates continue to be low be­cause ovarian cancer is poorly detected in its early stages.

Of all ovarian cancers, 85% are epithelial tumors; the most common type is serous adenocarcinoma. These tumors grow rapidly, spread quickly, and are often bilateral. Of all epithe­lial tumors, ovarian tumors are associated with the worst prognosis.

The cancer spreads by several mechanisms:

  Direct spread to other organs in the pelvis that are in close proximity to the ovary (e.g., uterus, bladder, and colon)

  Distal spread through lymphatic drainage (via paraaortic and iliac lymph nodes to the rest of the pelvis, abdomen or liver, lung, or bones)

  Peritoneal seeding (malignant spread of free-floating cells, usually after the development of ascites)

The cause of ovarian cancer is not precisely known. Sug­gested etiologic theories include a familial association; an en­vironmental association related to products of industry in countries such as the United States and those of western Eu­rope; and a hormonal association, as evidenced by increased incidence with menopause, nulliparity, and breast cancer and decreased incidence with oral contraceptive use.

Therefore risk factors include a family history of ovarian cancer; a history of breast, bowel, or endometrial cancer; nul­liparity; infertility; and a history of dysmenorrhea or heavy bleeding. Diets high in animal fat have also been linked to ovarian cancer. Ovarian cancer ranks second to endometrial cancer in incidence. The incidence increases in women older than 40 years of age and peaks at 50 to 55 years of age.

 

COLLABORATIVE MANAGEMENT

Assessment

Women with ovarian cancer may complain of abdominal pain or swelling or have vague symptoms of abdominal discom­fort, such as dyspepsia, indigestion, gas and distention, and other mild gastrointestinal (GI) disturbances. The woman may have a history of ovarian imbalance, such as evidenced by premenstrual tension, heavy menstrual flow, or dysfunc­tional bleeding.

The only sign may be an abdominal mass, which may be noticed only after it reaches a size of 6 inches (15 cm). Most pelvic examinations do not identify abnormalities. However, an enlarged ovary found postmenopausally should be evalu­ated as though it were malignant.

The woman with ovarian cancer has concerns similar to those described for the woman with endometrial cancer. Be­cause the malignancy is usually diagnosed in an advanced stage, fears of death and dying are common and may be more of a concern than the proposed treatments.

Cytologic examination has limited application because a Pap smear is abnormal in only 20% to 30% of women with ovarian cancer, even in advanced cases. Diagnosis depends on surgical exploration. Usually a complete laboratory workup is done before exploratory surgery, including a complete blood count, urinalysis, and liver studies if ascites occurs.

The level of ovarian antibody designated as CA-125 may be elevated if ovarian cancer is present. This test may be use­ful to monitor a woman's progress after treatment but may not be as useful for diagnostic purposes.

Ultrasonography, intravenous pyelography (IVP), com­puted tomography (CT), and radiography are used in detect­ing ovarian tumors. In addition, a barium enema study and an upper GI radiographic series can be performed to rule out tu­mor in the adjacent structures.

Exploratory laparotomy is performed to diagnose and stage ovarian tumors. Ovarian cancer is the only neoplasm that is staged when it is removed (Table 9).

TABLE 9 STAGING CLASSIFICATION OF OVARIAN CANCER

Stage

Characteristics

I

Growth limited to ovaries

   I a

Growth limited to one ovary; no ascites; no tumor on external surface; capsule intact

   I b

Growth limited to both ovaries; no ascites; no tumor on external surfaces; capsules intact

   I c

Tumor either stage la or Ib, but with tumor on sur­face of one or both ovaries, or with capsule rup­tured, or with ascites present containing malig­nant cells, or with positive peritoneal washings

II

Growth involving one or both ovaries with pelvic extension

     II a

Extension and/or metastases to uterus and/or tubes

     II b

Extension to other pelvic tissues

     II c

Tumor either stage Ha or lib, but with tumor on sur­face of one or both ovaries, or with capsule(s) ruptured, or with ascites present containing ma­lignant cells or with positive peritoneal washings

III

Tumor involving one or both ovaries with peritoneal implants outside pelvis and/or positive retroperi-toneal or inguinal nodes; superficial liver metasta­sis but with histologically proven malignant ex­tension to small bowel or omentum

     III a

Tumor grossly limited to true pelvis with negative nodes but with histologically confirmed micro­scopic seeding of abdominal peritoneal surfaces

     III b

Tumor of one or both ovaries with histologically confirmed implants of abdominal peritoneal sur­faces, none exceeding 2 cm in diameter; nodes are negative

     III c

Abdominal implants greater than 2 cm in diameter and/or positive retroperitoneal inguinal nodes

IV

Growth involving one or both ovaries with distant

 

Interventions

Nursing care of the woman with ovarian cancer is similar to that of the woman with endometrial or cervical cancer. The options for treatment depend on the extent of the cancer and include chemotherapy (systemic or intraperitoneal), im-munotherapy, radiation therapy (external or intraperitoneal), and surgery.

NONSURGICAL MANAGEMENT. Chemotherapy and radiation therapy are the two most common nonsurgical op­tions for ovarian cancer.

CHEMOTHERAPY. The health care provider usually pre­scribes chemotherapeutic agents postoperatively for all stages of ovarian cancer, although their purpose is usually palliative for stage IV tumors. Cisplatin, carboplatin, paclitaxel (Taxol), isofamide, doxorubicin (Adriamycin), hexamethylmelamine, methotrexate, and 5-fluorouracil (5-FU) have been used as single agents for treating ovarian cancer (DeStefano & Bertin-Matson, 1996). Combinations of agents seem to obtain higher response rates, especially if cisplatin is one of the drugs used.

Chemotherapy is usually administered every 3 to 4 weeks for 1 week and can be administered on an inpatient or an am­bulatory basis. Intraperitoneal chemotherapy is the instillation of chemotherapeutic agents into the abdominal cavity. With the use of this method, it is believed that the cytotoxic effects of the drugs on the tumor are increased. Immunotherapy is also used to treat ovarian cancer. It alters the immunologic re­sponse of the ovary and promotes tumor resistance.

RADIATION THERAPY. External radiation therapy is used postoperatively if tumors have invaded other organs. It metastases; if pleural effusion is present, there must be positive cytologic findings to allot a case to stage IV; Parenchymal liver metastasis equals stage IV may be given with chemotherapy or alone. Radioactive colloids have also been injected into the abdomen to increase survival rates. A primary beta-emitter, 32P, is in­jected through a catheter placed during surgery. After instilla­tion, the woman is asked to turn frequently for 1 to 2 hours to facilitate the distribution of the radioactive colloids throughout the peritoneal cavity (e.g., turning to the right, to the left, head down, feet down, prone, and supine).

SURGICAL MANAGEMENT. Total abdominal hysterec­tomy and bilateral salpingo-oophorectomy is the surgical pro­cedure for all stages of ovarian cancer. In clients with stage III or IV cancer, the goal is to remove as much of the cancer as possible because it has spread to adjacent organs. Nursing care of the woman is similar to that of the woman undergoing a hysterectomy for uterine leiomyomas.

A second-look procedure (laparoscopy or laparotomy) is performed, usually after 1 year of chemotherapy, to confirm the absence or presence of tumor and to remove any new or residual tumor if it was too large to be removed at the first op­eration. Nursing care is similar to that of the client after any major abdominal surgery.

The woman who is faced with the diagnosis of advanced ovarian cancer may be concerned about dying. She needs to be encouraged to ventilate her feelings about her diagnosis. Realistic assurance, as well as accurate information about treatments, can be provided. Often providing the woman with information about ovarian cancer and its treatment decreases her fears. Providing continuity of care, with at least one regu­lar caregiver, may be helpful. The nurse encourages the client to use her support system, including family members, friends, and a spiritual leader, such as a rabbi or other clergy member. A visit from another woman who has survived a similar dis­ease may decrease fears.

If there is recurrence, the woman may deny symptoms at first or express feelings of anger and grief. The family is of­ten fearful of the outcome. The nurse needs to provide en­couragement and support during this difficult time and help the woman and her family or significant others work through their grief and prepare for death.


VULVAR CANCER

OVERVIEW

Vulvar cancer represents only 4% of all gynecologic malig­nancies, even though it ranks fourth in occurrence. Vulvar cancer is slow growing, stays localized for a long time, and metastasizes late. Vulvar cancer occurs most commonly in women 50 to 70 years of age. More than 50% of the cases of vulvar cancer occur in women older than 60 years of age. Of all vulvar cancers, 90% are squamous cell carcinomas. The other 10% consist of adenocarcinomas, sarcomas, and Paget's disease. Most vulvar cancers develop in the absence of pre-malignant changes in the epithelium, but occasionally they develop and spread similarly to cancer of the cervix.

The first change is usually vulvar atypia or mild dysplasia (vulvar intraepithelial neoplasia [VIN] I), followed by moder­ate dysplasia (VIN II) and then severe dysplasia or carcinoma in situ (VIN III) until the lesion becomes invasive. Vulvar can­cer can spread directly to the urethra, the vagina, or the anus and through the lymphatic system to the inguinal, femoral, and deep iliac pelvic nodes.

The cause of vulvar cancer is unknown. There is no proven relationship with sexually transmitted diseases (STDs), al­though a history of condylomata acuminata (venereal warts) may be present. A strong relationship exists between vulvar cancer and herpes simplex type II, human papillomavirus, and capsid antigen. Obesity, hypertension, diabetes, smoking, and granulomatous disease of the vulva have been suggested as pos­sible causes, but no scientific data support these suggestions.

Vulvar cancer seldom occurs before age 40 years, although studies have found premalignant changes in women in their 20s and 30s. This increase may be linked to the increase in sexually transmitted infections.

The prognosis for vulvar cancer is related to the stage of the cancer and whether cancer is present in the lymph nodes. Guidelines for the early detection and prevention of vulvar cancer include performing monthly vulvar self-examination, having an annual pelvic examination, and practicing "safe sex."

 

COLLABORATIVE MANAGEMENT

Assessment

Women with vulvar lesions are likely to report irritation or itching in their perineal area. Sometimes they describe a "sore that will not heal." Bleeding is a late symptom. Women usually try to treat themselves before seeking medical help. Of­ten a lesion has been present for months. Embarrassment has been suggested as the reason why older women delay seeking medical attention.

Pelvic examinations usually reveal multifocal lesions, the majority of which develop on the labia. The lesions may be whitish or reddish, and the vulvar skin may be excoriated as a result of irritation.

The woman may be anxious or fearful about the diagnosis of cancer. She may have fears that her partner will reject her because of the diagnosis, or she may worry about disfigure­ment related to surgery. The nurse needs to assess the woman's past experiences in coping with stressful situations and whether she has the psychologic resources to cope with the present crisis.

A Pap smear and colposcopic examination of the vulva (see Assessment [Cervical Cancer]) may aid in diag­nosis. A toluidine blue test may be used to identify abnormal cells for biopsy. A 1 % aqueous solution of toluidine blue is applied to the vulva and allowed to dry. Then a 1% acetic acid solution is applied. Biopsy of the areas that remain blue is performed. The test chemical stains nuclei in the superficial epithelium, where cells do not normally contain nuclei. An abnormal finding does not necessarily indicate malignancy, because ulcerations also stain.

A biopsy of the lesion is necessary for diagnosis. This is easily accomplished with a Keyes dermal punch (a device that removes a disk of tissue). Depending on the site of the lesion, one or more biopsy specimens may be taken.

 

Interventions

Nursing care of the client with vulvar cancer is similar to that for endometrial cancer; only the interventions that differ are discussed.

NONSURGICAL MANAGEMENT. Nonsurgical manage­ment of vulvar cancer depends on the extent of the spread and may include laser therapy, chemotherapy, and radiation therapy.

LASER THERAPY. If a woman has premalignant vulvar lesions, laser therapy may be used (see p. 1774). The treat­ment is usually done on an outpatient basis; local, regional, or general anesthesia is used. Healing occurs over a period of several weeks, and usually the lesions are removed without scarring.

CHEMOTHERAPY. Chemotherapy in the form of a topi­cal application of 5-FU has been used to treat carcinoma in situ successfully. However, the treatment causes severe vulvar edema and pain and is not often used.

RADIATION THERAPY. External radiation therapy to the deep pelvic nodes may be used postoperatively (see earlier discussion of endometrial cancer). Radiation treatments cause ulceration and dermatitis, which can be uncomfortable for the woman.

SURGICAL MANAGEMENT. The surgeon performs a vulvectomy to remove the cancerous vulvar lesions.

Preoperative care. The woman needs a complete explanation of the extent of the surgical procedure to be per­formed and information about preoperative and postoperative procedures (see Chapters 17 and 19). Specific preoperative care for a vulvectomy may include an abdominal or perineal shave, an enema, douching, and insertion of an indwelling catheter into the bladder.

Operative procedures. Several surgical procedures are effective for the treatment of vulvar cancer. A local wide ex­cision may be used to remove the abnormal area (for carcinoma in situ [CIS]). A simple vulvectomy (removal of the vulva, the labia majora, the labia minora, and possibly the clitoris) may also be performed for CIS, but this disfiguring surgery is used less often today. Instead, a skinning vulvectomy—the removal of superficial vulvar skin (without removal of the clitoris) and replacement of removed skin with split-thickness grafts—is performed (Figure 7). Sexual function is less affected, and the appearance of the vulva is less changed.

 

SUPERFICIAL "SKINNING" VULVECTOMY

RADICAL VULVECTOMY

 

Figure 7 Vulvectomy.

 

For invasive cancer, the surgery most often recommended is the modified radical or radical vulvectomy (removal of the entire vulva—skin, labia, clitoris, subcutaneous tissues, and possibly inguinal and femoral node dissection), depending on node involvement (see Figure 7).

Postoperative care. Postoperatively, the woman can expect to have multiple suction drains (Hemovac or Jackson-Pratt drains) in the inguinal or vulvar areas for wound drainage for 7 to 10 days. A pressure-reducing mat­tress may be placed on the bed to prevent pressure ulcers and increase comfort. A bed cradle may be used to keep linens off the incision site. The client usually wears antiembolism stock­ings or sequential compression devices to prevent throm-boembolism and leg edema.

Providing Wound Care. The major focus of nursing care is wound healing. The nurse changes the dressings over the incision frequently because of the amount of wound drainage and the risk of infection. Wound complications, such as in­fection and dehiscence, often occur after vulvectomies; sub­sequently, the healing process may take up to 6 months. Meticulous wound care is necessary and usually involves de-bridement. The nurse typically uses normal saline solution, which may be applied with an Asepto bulb syringe or a water pick (on low speed). The wound is then dried with a heat lamp or air dried with a hair dryer (using warm air). Wound care is usually done three or four times a day.

Diet in the postoperative period should include foods rich in vitamin C, iron, and protein to promote wound healing.

Promoting Urinary and Bowel Elimination. The Foley catheter remains in the bladder for 7 to 10 days to prevent ureteral stenosis and incontinence. After the catheter is re­moved, the urine stream may be deflected down the leg as a result of edema or even may be uncontrolled. Having the woman stand while voiding may decrease the incidence of these annoying problems. Antiperistaltic medications are usually given for 7 to 10 days to prevent defecation and de­crease the risk of wound infection. Then stool softeners may be given to prevent straining and decrease discomfort related to bowel movements. Perineal care or sitz baths after void-ings or bowel movements may prevent contamination of the incision site.

Managing Pain. Postoperative discomfort is usually con­trolled with analgesics during the first couple of days after surgery. Medicating for pain before wound care may help the woman relax and tolerate the procedure with less distress.

Addressing Sexuality. The woman needs complete ex­planations of the changes that occur as a result of surgery. If a radical vulvectomy is done, the clitoris is removed and loss of orgasm usually occurs. Dyspareunia may result from any of the surgical procedures. Vaginal dilators may be useful to stretch the remaining vaginal tissues. Discomfort can also be reduced during sexual intercourse by having the couple use water-soluble lubricants or a side-lying position. The couple may need counseling about alternatives to vaginal inter­course. The woman may need to be encouraged to express feelings of grief related to her loss of normal sexual function.

A vulvectomy can be devastating to a woman's self-concept. She often has a grief reaction related to the loss of the vulva and subsequent disfigurement. She may fear rejec­tion from her sexual partner or significant others and may be reluctant to make herself vulnerable by getting involved in any relationship. Fears of recurrence or metastasis may be present. The nurse's role is one of support. The woman needs encouragement to vent her feelings and concerns about her perceived or actual losses and body changes. Family mem­bers or significant others should be encouraged to share their feelings and concerns with the woman. A visit by a woman who has successfully recovered from similar surgery could be beneficial.


VAGINAL CANCER

Primary invasive vaginal cancer is rare, accounting for less than 2% of all gynecologic cancers. Usually vaginal cancer is an extension of cervical, endometrial, or vulvar cancers. Most vaginal cancers are squamous cell carcinomas that develop in the upper one third of the vagina. They occur most often in women older than 50 years of age; 90% of cases are found postmenopausally. Adenocarcinoma of the vagina is found in females between the ages of 14 and 30 years and is associated with intrauterine exposure to diethylstilbestrol (DES) as a re­sult of maternal ingestion during pregnancy.

The cause of vaginal cancer is unknown. Predisposing fac­tors include repeated pregnancies; vaginal trauma; sexually transmitted diseases (STDs), especially syphilis and herpes simplex virus type 2 and papillomavirus infections; and prior radiation.

The spread of vaginal cancer depends on the location of the tumor. Upper vaginal lesions spread in the same manner as cervical cancer, whereas lower lesions spread similarly to vulvar cancer. Because of the rich lymphatic drainage in the vaginal area, metastasis can occur early.

 

COLLABORATIVE MANAGEMENT

Assessment

Premalignant lesions (vaginal intraepithelial neoplasia) are usually asymptomatic. An abnormal Pap smear is the most common presenting problem. Uncommon or late symptoms include pain, foul-smelling vaginal discharge, painless vagi­nal bleeding, pruritus, and urinary symptoms attributable to the pressure of the lesion on the bladder.

A pelvic examination may reveal a lesion. Premalignant changes are diagnosed through colposcopic examination and biopsy.

Interventions

Both nonsurgical and surgical interventions may be used to treat women with vaginal cancer.

NONSURGICAL MANAGEMENT. Noninvasive malig­nancy and early-stage vaginal cancers may be treated non-surgically with a variety of techniques.

Laser therapy may be used. The health care provider stains the ab­normal tissues with an iodine solution to identify the area for treatment. A vaginal discharge may be present for several days after treatment, and healing normally takes a few weeks. Close follow-up is necessary and includes a Pap smear and colposcopic examination every 4 months for 1 year and then every 6 to 12 months.

Local application of 5-fluorouracil (5-FU) cream to the vagina daily for 1 week is another treatment option. This chemotherapeutic agent is irritating to the skin, and often zinc oxide ointment is recommended for application to the vulvar area. The treatment is repeated in 3 to 4 weeks, and follow-up is the same as that for laser therapy.

Radiation therapy can be used for all stages of vaginal can­cer. Intracavitary radiation therapy (IRT, brachytherapy) is usually used alone for the treatment of cancer limited to the vaginal wall, and external radiation therapy is combined with IRT for the treatment of cancer that extends beyond the vaginal wall. Complications of radiation therapy include vaginal stenosis, adhesions, and discharge. Women need to use vagi­nal dilators after treatment, and assessment for sexual dys­function is suggested.

Chemotherapy may be used for recurrent disease, although there is no effective therapy.

SURGICAL MANAGEMENT. A local wide excision may be performed for localized lesions. A partial or total vaginec-tomy (removal of part or all of the vagina) may be done for invasive disease. Vaginectomy affects sexual function. With­out surgical reconstruction, vaginal intercourse is impossible. The woman and her sexual partner need counseling about al­ternative activities for achieving sexual satisfaction. A radical hysterectomy or pelvic exenteration may also be performed, depending on the extent of the cancer.

Preventive and early detection measures for vaginal cancer are to avoid taking DES during pregnancy (to prevent one's daughter from developing cancer) and to continue to have Pap screening and pelvic examinations after menopause on a reg­ular basis.


FALLOPIAN TUBE CANCER

OVERVIEW

Fallopian tube cancer is the rarest of gynecologic cancers; it is associated with an incidence of less than 1%. It occurs in women older than 50 years of age; 80% to 90% of cases re­sult from metastasis from ovarian and endometrial cancers.

The cause of squamous cell fallopian tube cancer is un­known. It has been suggested that pelvic inflammatory disease (PID) and chronic salpingitis may be associated with adenocar-cinomas of the fallopian tubes. Nulliparity and infertility (in­ability to conceive) have also been cited as risk factors.

The initial lesion is confined to the lumen of the tube. From there, it invades the serosa and spreads intraperitoneally to the bowel, omentum, and peritoneum. Lymphatic spread is to the para-aortic and retroperitoneal lymph nodes.

 

COLLABORATIVE MANAGEMENT

Women are usually asymptomatic until the tumor is in a late stage. In 50% of the cases, bleeding is present. Other symp­toms include clear vaginal discharge, lower abdominal pain or distention, and feelings of pressure. A history of abnormal bleeding, adnexal pain, and watery vaginal discharge in a postmenopausal woman may suggest fallopian tube cancer, and further evaluation is needed.

Diagnosis is rare preoperatively. Pap smears have reportedly been abnormal in only 10% of cases. A mass may be felt on ex­amination in late stages. Vaginal ultrasonography, computed to­mography (CT), or laparoscopy may be used to confirm a mass.

Chemotherapy may be used postoperatively in later stages or for recurrence. The lesions respond to alkylating agents. External radiation therapy has also been used postoperatively for late-stage tumors. The usual treatment of cancer limited to the fallopian tube is a total ab­dominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy (removal of the connective tissues cover­ing these organs). Care of the woman with fallopian tube cancer is similar to that described earlier for cancer of the ovary (see Interventions [Ovarian Cancer]).

 

CRITICAL THINKING CHALLENGE

As you are admitting a middle-aged woman to your hospital unit for cellulitis, she mentions that she thinks she is going through menopause. She complains that she gets hot flashes, is very moody, and cries a lot. She has been hesitant to tell her physician because she kept hoping that the symp­toms would cease.

  How should you respond to the woman at this time?

  What other data should you obtain during the nursing history?

  What options will the health care provider have in treating the client's symptoms?