Chapter 26 Female Genitourinary System

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The external genitalia are called the Vulva, or pupendum. The Mons Pubis is a round, firm pad of adipose tissue covering the symphysis pubis. After puberty, it is covered with hair in the pattern of an inverted triangle. The Labia Majora are two rounded folds of adipose tissue extending from the Mons pubis down and around to the peritoneum. Inside the labia majora are two smaller, darker folds of skin, the Labia Minora. The clitoris is a small pea shaped erectile body and is highly sensitive to tactile stimulation. The Vaginal Ori i!e is posterior to the urethral meatus. It appears either as a thin median slit or as a large opening with irregular edges, depending on the presentation of the membranous "ymen. The hymen is a thin, circular or crescent shaped fold that may cover part of the vaginal orifice or maybe absent completely. #nternal Genitalia The vagina has walls that are in thick transverse folds, or $ugae, enabling the vagina to dilate widely during childbirth. The %terus is a pear shaped, thick walled, muscular organ that is freely movable, not fixed, and usually tilts forward and superior to the bladder. The fallopian tubes are two pliable, trumpet shaped tubes, ! cm in length, extending from the uterine fundus laterally to the brim of the pelvis. There they curve posteriorly, their fimbriated ends located near the Ovaries. The two ovaries are located one on each side of the uterus at the level of the anterior superior iliac spine. "ach is oval shaped, # cm long by $ cm wide by cm thick, and serves to develop ova %eggs& and the female hormones. &he 'ging (oman In contrast to the slowly declining hormones in the aging male, the females hormonal milieu decreases rapidly. Menopause is cessation of the menses. 'sually this occurs around () to * years, although a wide variation of ages from #* to +! years exists. The stage of menopause includes the preceding to $ years of decline in ovarian function, shown by irregular menses that gradually become farther apart and produce a lighter flow. ,varies stop producing progesterone and estrogen. -ecause cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes. The uterus shrinks in si.e because of decreased myometrium. The ovaries atrophy to to $ cm and are not palpable after menopause. The vagina becomes shorter, narrower, and less elastic because of increased connective tissue. /ecreased vaginal secretions leave the vagina dry and at risk for irritation and pain with intercourse %dyspareunia&. The vaginal p0 becomes more alkaline, and glycogen content decreases from the decreased estrogen. These factors also increase the risk for vaginitis because they create a suitable medium for pathogens. Culture 'n) Geneti!s The increased use of the 1apanicolaou %1ap& test in the 'nited 2tates has resulted in a 3(4 decline in the cervical cancer death rate between 5** and 55$. Today, however, cervical cancer occurs most often in 0ispanic woman6 their incidence is over twice that of white woman. African7American woman have *!4 higher incidence rate than white women. 8elative to white woman, 0ispanic woman are less likely to die of cervical cancer despite their lower socioeconomic status %2"2&, known as the 90ispanic paradox.: ;emale circumcision, known as infibulations or female genital mutilation, is an invasive surgical procedure that is performed on girls before puberty. It is practiced within Aboriginal, <hristian, and Muslim families will have emigrated to the 'nited 2tates from =estern and 2outhern Asia, the Middle "ast, and large areas of Africa. Menstrual "istory Taking the history is usually nonthreatening6 thus it is a good place to start. LMP 7 last menstrual period. Menar!he > mean age at onset at $ to # years6 delayed onset suggests endocrine or underweight problem. Cy!le > normally every ) to (* days. 'menorrhea 7 absent menses. *uration > average # to 3 days. Monorrhagia > heavy menses.

1? $ -egin cervical can@s cer screening within # years after first vaginal intercourse or age $ years, and continue annually until age #!. After age #!, if there are three consecutive normal 1ap tests, woman may be screened every $ to # years. Maternal ingestion of diethylstilbestrol %/"2& causes cervical and vaginal abnormalities in female offspring reAuiring freAuent follow7up. %rinary Symptoms %rge #n!ontinen!e 7 involuntary urine loss from overactive detrusor muscle in bladder. It contracts, causing urgent need to void. Stress #n!ontinen!e > involuntary urine loss with physical strain, snee.ing, or coughing. Position or +,amination ;or the examination, the woman should be placed in the lithotomy position, with the examiner sitting on a stool. 0elp the woman into the lithotomy position, with the body supine, feet in stirrups and knees apart, and buttucks at edge of the examining table. 0elp the woman relax, by decreasing her anxiety, and retain a sense of control by using these measuresB 7 "levate her head and shoulders to a semisitting position to maintain eye contact. 7 1lace the stirrups so that the legs are not abducted too far. Palpation /ip your gloved finger in a bowl of warm water to lubricate. Then insert your index finger into the vagina, and gently milk the urethra by applying pressure up and out. This procedure should produce no pain. If any discharge appears, culture it. 'sses the -artholin.s glan)sB palpate the posterior parts of the labia majora with your index finger in the vagina and your thumb outside. Cormally the labia feels soft and homogenous 7 s/elling0 in)uration0 pain /ith palpation0 erythema aroun) or )is!harge rom )u!t opening1 'ssess the support o pelvi! mus!ulature by using these maneuvers2 . 1alpate the perineum. Cormally, it feels thick, smooth, and muscular in the nulliparous woman and thin and rigid in the multiparous woman. $. Asked the woman to sAuee.e the vaginal opening around your fingers6 it should feel tight in the nulliparous woman and have less tone in the multiparous woman. #nternal Genitalia 3 Spe!ulum +,amination 2elect the proper si.e speculum. =arm and lubricate the speculum under warm running water. 8egarding 1ap test cytology, evidence shows applying a small amount %dime si.e& of water7soluble gel lubricant on the outer inferior blade increases patient comfort and yields no more unsatisfactory slides then does water only lubricant. #nspe!t &he Cervi, Color 7 Cormally the !ervi!al mu!osa is pin4 an) even. /uring the second month of pregnancy, it looks blue, and after menopause, it is pale. 5abothian Cysts > These are benign growths that commonly appear on the cervix after childbirth. They are small, smooth, yellow nodules that may be single or multiple. Dess than cm, they are retention cysts caused by obstruction of cervical glands. 'bnormal Fin)ings O &he Cervi, 3 Foul smelling0 imitating0 /ith yello/0 green0 /hite0 or gray )is!harge1

1? # Cervi!al Smears 'n) Cultures Cervi!al S!rape 7 Insert the bifid end of the Ayre spatula into the vagina with the more pointed bump into the cervical os. 8otate it #+! to 3$! degrees, using firmer pressure. The rounded cervix fits snugly into the spatula@s groove. The spatula scrapes the surface of the sAuamocolumnar junction %2<E& and cervix as you turn the instrument. +n)o!ervi!al Spe!imen 7 insert a cytobrush %instead of a cotton applicator& into the os. A cytobrush gives a higher yield of endocervical cells at the 2<E and is safe for use during pregnancy. 8otate the brush 3$! degrees in ,C" direction in the endocervical canal, either clockwise or counterclockwise. ;or a woman after a hysterectomy whose cervix has been removed, collect a scrape from the end of the vagina and a vaginal pool. Dabel the frosted ends of the slides or the vial with the woman@s name. To screen for 2TIs note any abnormal vaginal discharge, obtain the gonorrhea 6GC78!hlamy)ia culture. Insert a sterile cotton applicator into the os, rotated it #+! degrees, and leave it ! to $! seconds for a complete saturation. Insert into labeled container. ,ccasionally you will need the following samplesB Saline Mount0 or 9(et Prep: 7 spread a sample of the discharge onto a glass slide and add one drop of normal saline solution and a coverslip. ;O" Prep 7 A sample of the discharge on a glass slide, add one drop of potassium hydroxide and a coverslip. 'nal Culture 7 Insert a sterile cotton swab into the anal canal about cm. 8otate it, and move it side to side. Deave in place ! to $! seconds. If the swab collects feces, discard it and begin again. Insert into specimen container. '!eti! '!i) (ash 7 Acetic acid %white vinegar& screens for asymptomatic human papilloma virus %01F&, which causes genital warts. After all other specimens are gathered, soak a thick7tipped cotton rectal swab with acetic acid and 9paint: the cervix. Acetic acid dissolves mucous. And temporarily causes intracellular dehydration and coagulation of protein. A normal response %indicating no 01F infection& is no change in the cervical epithelium 3 rapi) a!eto/hitening or blan!hing0 espe!ially /ith irregular bor)ers0 suggests "PV in e!tion1 #nspe!t the vaginal /all 5ormally the /all loo4s pin40 )eeply rugate)0 moist an) smooth0 an) ree o in lammation or lesions1 5ormal )is!harge is thin an) !lear or opa<ue an) stringy but al/ays o)orless1 Cervi, 3 locate the cervix in the midline, often near the anterior vaginal wall. The cervix points in the opposite direction of the fundus of the uterus. 1alpate using the palmer surface of the fingers. Cote these characteristics of a normal cervixB Consisten!y > ;eels smooth and firm, as the consistency of the tip of the nose. It softens and feels velvety at * to + weeks of pregnancy %?oodell sign&. G Contour > "veny rounded. Mobility >=ith a finger on either side the, move the cervix gently from side to side. Cormally, this produces no pain. #n many /omen0 the uterus is anteverte)1 &/o other positions o!!ur normally 6mi)position an) retroverte)7 ')ne,a 3 A note of caution - normal adnexal structures often are not palpable. Move both hands to the right to explore the adnexa. 1lace your abdominal hand on the lower Auadrant just inside the anterior iliac spine and your intravaginal fingers in the lateral fornix. 1ush the abdominal hand in and try to capture the ovary. ,ften, you cannot feel the ovary. =hen you can, it normally feels smooth, firm, and almond shaped and is highly movable, sliding through the fingers. It is slightly sensitive but not painful. The fallopian tube is not palpable normally. Co other mass or pulsation should be felt 7 pulsation or palpable fallopian tube suggests ectopic pregnancy; this warrants immediate referral. $e!tovaginal +,amination 'se this techniAue to assess the rectovaginal septum, posterior uterine wall, culde7sac, and rectum. <hange gloves to avoid spreading any possible infection. Dubricate the first two fingers. Instruct the woman that this may feel uncomfortable and will mimic the feeling of moving her bowels. Ask her to bear down as you insert your index finger into the vagina and your middle finger gently into the rectum. =hile pushing with the abdominal hand, repeat the steps of the bimanual examination. Try to keep the intravaginal finger on the cervix so the intrarectal finger does not mistake the cervix for a mass. CoteB 7 $e!tovaginal septum should feel smooth, thin, firm, and pliable. 7 $e!tovaginal pou!h, or cul7de7sac is a potential space H usually not palpable. 7 %terine /all an) un)us eel irm an) smooth1 8otate the intrarectal finger to check the rectal wall and anal sphincter. <heck your gloved finger as you withdraw.

1? ( &he 'ging ')ult Catural lubrication is decreased6 to avoid a painful examination, take care to lubricate instruments and the examining hand adeAuately. Menopause and the resulting decrease in estrogen production cause numerous physical changes. 1ubic hair gradually decreases, becoming thin and sparse in later use. The skin is thinner and fat deposits decrease, leaving the mons pubis smaller and the labia flatter. <litoris si.e also decreases after age +! years. Internally, the rugae of the vaginal walls decrease and the walls look pale pink because of the thinned epithelium. The cervix shrinks and looks pale and glistening. ,r, the cervix may protrude into the vagina if the uterus has prolapsed. -e aware that older woman may have special needs and will appreciate the following plans of careB for those with arthritis, taking a mild analgesic or anti7inflammatory before the appointment may ease joint pain in positionB schedule appointment times when joint pain or stiffness is at its least. =oman should continue cervical cancer screening up to age 3! years if they have an intact cervix and are in good health. After age 3!, woman may decide to stop screening if % & they have had no abnormal cytology tests in the previous ! years and %two& if the three most recent 1ap tests are documented as technically satisfactory and with normal results. =oman who have had a total hysterectomy for benign gynecologic disease do not need cervical cancer screening. -ut if the hysterectomy was for cervical neoplasia, 1ap tests should continue until a ! year history of no abnormal results. Va!!ine #n Can!er Prevention A vaccine was developed that targets the human papilloma virus %01F&, the virus responsible for most cases of cervical cancer. The 01F vaccine is recommended for girls ages to $ but can be started as early as 5 years of age. Ideally, the 01F vaccine is recommended before they become sexually active because it is not effective if the individual is already infected with 01F. 0owever, sexually active females may still benefit, you woman are affected by all four 01F types %+, , +, )& targeted by the vaccines. The 01F vaccine is given in three separate injections over a six month period. The second and third doses are $ and + months after the first dose. It is important to remind woman that obtaining the vaccine does not mean that they can forget about routine pelvic examinations and 1apanicolaou %1ap& tests.