10

UNIT

Nursing Management
of Patients
with Reproductive Disorders
Chapter 48 Nursing Assessment of Patients with Reproductive
Disorders 1504
Chapter 49 Caring for the Patient with Female Reproductive
Disorders 1518
Chapter 50 Caring for the Patient with Male Reproductive
Disorders 1566
LESLIE My name is Leslie and I work in the High Risk Maternity Antepartum Unit of a large medical cen-
ter in a metropolitan area. This unit is solely committed to providing antenatal care to women having compli-
cations during pregnancy. This center has been providing the community of Sacramento and its surrounding
areas with excellent maternal and pediatric services for more than 50 years.
This unit is special in that unlike other hospitals in Northern California that combine their high-risk patients
together with their laboring patients, this hospital has designated a separate unit for the unique and specialized
care of these women. Occasionally this floor will take postsurgical gynecology patients, as well as postpartum
overflow from the normal maternal newborn unit. The population spans the spectrum of pregnancy disorders.
The most common diagnoses are preterm labor, gestational diabetes, preeclampsia, and premature rupture of
membranes. Incompetent cervix is another diagnosis that is given when the cervix dilates silently, placing the
women at risk of miscarriage or preterm delivery. With advances in medicine and fertility treatment, I have seen
a large number of multiple gestations, including triplets and quads. The women I care for can stay on the unit
anywhere from hours to months before they deliver. This means separation from their homes, families, children,
pets, and spouses. Many feel a very strong loss of independence.
In addition to providing direct patient care, I precept nursing students as well as new nurses. I hold two certifi-
cations from the National Certification Center in Electronic Fetal Monitoring and Inpatient Obstetrics. I have
worked in this particular hospital for 17 years, spending the last 9 of those years with the greatest group of support-
ive and encouraging colleagues. I am a member of the professional organization American Association of Womens
Health, Obstetrics and Neonatal Nurses. My practice role includes conducting unit-based audits for performance
improvement and participating as a member of the Joint Commission preparation team and staff nurse council.
Other professional responsibilities include teaching hospital-wide classes as a service excellence adviser to improve
customer service and acting as a mentor coordinator for my unit. The mentor program is designed to ensure that
all new staff have someone to mentor and guide them through the transition of becoming a new member of the
unit team.
I made a commitment, to myself and my patients, to be the best nurse I could be. As a nurse caring for preg-
nant women, I am not only responsible for the well-being of the patient but also that of her unborn child(ren).
I strive to treat all of my patients as I would like to be treated. In doing so, I have cared for women of all child-
bearing ages from 12 to 50, the poor and wealthy, married and single, addicted or sober, and treated each one as
if she were my sister or best friend.
I have wanted to be a nurse since the first time I saw a baby born, and I am able to live my dream every work-
day. In response to my unquenchable thirst for knowledge since graduating from nursing school, I attend many
classes and seminars every year to stay up to date with the latest research and clinical practices. Wanting to im-
prove myself and my contribution to the unit, I went back to school, recently graduating with my bachelors de-
gree in nursing from California State University, Sacramento.
A typical day is anything but. I may be the charge nurse for the day, assigned to precept a nursing student or
orient a new hire. On other days, I am simply a staff nurse assigned to three patients, each with a different level
of acuity. One recent day, the patient I was most concerned about was 22 weeks pregnant with bulging mem-
branes. She was coming from the doctors office across the street after a routine ultrasound found her cervix di-
lated 5 centimeters with the bag of water bulging through into her vagina. Before she arrived, I made sure to see
my other two patients to make sure they were stable and that all their current needs had been met. I then intro-
duced myself to the new patient and told her I would be her nurse for the day as I wheeled her into her room.
She began crying as I got her into bed. After reassuring her that she was in the best place she could be, I placed
her in the Trendelenburg position in the hopes that gravity would assist with the recession of the bag of water.

1503
 b UNIT 10 Nursing Management of Patients with Reproductive Disorders

As I completed her admission and assessment, I talked to her about the plan of care. I would monitor her con-
tractions and give her medication around the clock to keep her from contracting. Antibiotics would be started
to prevent infection of the exposed amniotic sac. I explained that our first goal was to stop the continued dila-
tion of the cervix, and then to get the pregnancy to the 24-week mark that constitutes viability. The patient was
alone and had no one to call. I spent most of my time in her room talking with her and mostly just listening to
her fears.
Although I tried for several hours to stop her contractions, her bag of water ruptured. Immediately, I was
worried that she had advanced in dilation and the baby would easily pass through the cervix. I called the doctor
from the room and notified her of the changes and asked her if she would come and check the patients cervix.
While waiting for the doctor, I explained that sometimes when the bag of water breaks the cervix closes because
there is no longer pressure holding it open. I let the patient know that her plan of care would not change much
and that our primary goal was to keep her pregnant as long as possible. When the doctor arrived and checked
the patients cervix, she said she felt the babys head coming. As the doctor explained that there was nothing we
could do to prevent the birth from happening, the patient began sobbing. I held her hand and promised I would
not leave her.
The doctor wanted to transfer the patient to labor and delivery to give birth since we do not normally do that
on our unit. In all good conscience I could not let this women be moved from her surroundings where she felt
safe. I asked if there was any reason we could not let her stay in the comfort of her room with the staff she had
come to trust instead of a new group of strangers. This was a time for compassion, not routine. There was no
question, she would stay and I would help her give birth. Even though this was not an everyday occurrence on
my unit, I knew I had the competence to assist the doctor in her delivery and the confidence to provide her with
the best care I could give. I talked with the charge nurse, and she agreed to care for my other patients while I re-
mained with this patient.
The patients labor was short and I made sure she was as comfortable as possible. After a few pushes, she gave
birth to a son. He was given a name, pictures of the two of them were taken, and his mother held him until he
died. I did not leave her room for the next 2 hours. She counted his fingers and toes, kissing him while she told
him how perfect he was. I found myself crying along with my patient over the loss of her son. Throughout the
remainder of my shift, I checked on her often, but gave her private time to spend with her baby. At the end of
my shift, I stopped into her room to thank her for letting me care for her and sharing that very sacred moment
in her life. She thanked me for letting her stay and deliver with the only nurse she had come to know and trust,
instead of transferring her to labor. I was proud that my comportment had made an impression. In thinking
outside the box, I made a decision that meant the world to my patient.
At the end of each of my workdays, I look back at the people who invited me into their lives. It is with great
gratitude that I am allowed to be the hand that calms the anxious, the comforting voice that soothes the ache,
the attentive ear that listens to the worries. I am a counselor, care provider, safe haven, and friend. I am a nurse.
CHAPTER

48 Nursing Assessment
of Patients
with Reproductive Disorders
Patricia Caudle
With contribution by:
Laurie Kaudewitz

Outcome-Based Learning Objectives

After studying this chapter, the learner will be able to:
1. Describe the structures and function of the male and female reproductive systems.
2. Identify pertinent subjective and objective data related to the reproductive systems and information about the sexual
function that should be obtained.
3. Identify risk factors for reproductive system disorders.
4. Differentiate normal from abnormal findings obtained from the physical assessment for males and females.
5. Describe age-related changes in the male and female reproductive systems.
6. Discuss the implications for health promotion related to the reproductive systems of females and males.

ASSESSMENT OF the female and male reproductive systems
requires an understanding of the anatomy, open communica-
tions, a nonjudgmental attitude, gentleness, and a high degree of
empathy and compassion. Most women and men consider the
genital area very private, and many may be reluctant to talk
about concerns or to allow examination by the nurse. The nurse
should not be offended if the patient asks for an examiner of the
same gender. Privacy and confidentiality are very important and
should be maintained at all times.
The reproductive systems of the female and male include sex-
ual organs, the lower urinary system, and the anorectal area. This
means that assessment of the reproductive system is complex and
must include history and physical examination that is inclusive
of the three systems. This chapter outlines the important compo-
nents of the female and male reproductive system assessment.
Concepts discussed here introduce the learner to assessment
skills needed to care for patients with disorders of the female and
male reproductive systems discussed in Chapters 49 and 50 . during lactation. The connective tissue provides support via liga-
8
muscle (Figure 481 ). The skin over the breasts is the same
color as other skin and may have striae (stretch marks). The nip-
ples are on the anterior surface of each breast, surrounded by the
areola (pigmented skin around the nipple). The areola has seba-
ceous glands that may be raised and more active during preg-
nancy (Montgomerys tubercles). Sebaceous glands help to
moisturize the nipple to make it more pliable (Stables & Rankin,
2005). Occasionally, supernumerary nipples are seen along a
line (the milk line) from the axilla to the upper thigh on either
side (Figure 482 ). These small nipples may be mistaken for
moles. They are considered normal variants and are benign
(Bickley & Szilagyi, 2007).
Each breast is made up of glandular, connective, and adipose
(fatty) tissue. The glandular tissue includes 15 to 20 lobes sus-
pended from ducts that drain into sinuses. The sinuses are near the
nipple and are drained by smaller ducts on the nipple surface. The
lobes are further divided into lobules where the milk is produced

ments within the breast (also called Coopers ligaments). Adipose

Female Reproductive System
The female breast tissue extends from the second to the sixth rib
on either side of the sternum and covers the pectoralis major
1504
tissue completes the structure of the breasts and determines the
size of the breast (see Figure 481 ) (Bickley & Szilagyi, 2007).
Physiologically, breast tissue responds to estrogen (steroid fe-
male hormone produced by the ovary and placenta),
 CHAPTER 48 Nursing Assessment of Patients with Reproductive Disorders 1505

Thoracic branch
of axillary artery
Adipose tissue
(lobules of fat)
Cooper's ligaments
(suspensory)
Glandular tissues
(alveolar glands)
Lactiferous
ducts
Areola
Nipple
Ampulla
Alveolar
duct
Branches of
intercostal
and internal
thoracic artery
Subcutaneous fat
of the breast
Cooper's ligaments
Inframammary fold

FIGURE 481 The female breast.

breasts as they prepare for lactation, even though a pregnancy

Polythelia
(third nipple)
Milk lines
FIGURE 482 Supernumerary nipples.
progesterone (steroid female hormone produced by the ovary
and placenta), prolactin (hormone produced in the anterior pi-
tuitary), and oxytocin (hormone produced in the hypothala-
mus and released by the posterior pituitary) in the processes of
galactogenesis (the manufacture of milk from available nutri-
ents) and lactation (breast-feeding). The cyclic changes in estro-
gen and progesterone levels each month cause changes in the
does not always occur. This cyclic exposure to hormonal change
is thought to be a factor in the development of breast cancer
(American Cancer Society, 2006).
Lymph nodes drain the breasts to the axilla, clavicular area,
mediastinum, the opposite breast, and into glands in the liver
(Stables & Rankin, 2005). The lymph nodes of the axilla and clav-
icular area are accessible to physical examination.
The female external genitalia depicted in Figure 483
(p. 1508) have several components that are important to recog-
nize during examination. These include the mons, the vulva
(labia majora and labia minora), the clitoris (erectile tissue at
apex of labia minora), the urinary meatus (urinary opening
above the vaginal opening), and the introitus (opening to the
vagina). The introitus is surrounded by an elastic line of connec-
tive tissue called the hymenal ring (Stables & Rankin, 2005).
Internally, the female reproductive organs include the uterus
(muscular, hollow organ where the embryo matures before
birth), the fallopian tubes (hollow tube from the uterus to the
ovaries, where fertilization occurs), and the ovaries (female go-
nad). The uterus sits between the rectum and the bladder. The
opening to the uterus is the cervix, found at the internal end of
the vagina (Stables & Rankin, 2005) (Figure 484 , p. 1508).
The lymph nodes of the female external and internal repro-
ductive organs that are accessible to examination are the super-
ficial inguinal nodes, including the horizontal grouping and the
vertical grouping. These nodes are found in the groin on each
side. The horizontal group is below the inguinal ligament, and
the vertical group lines up along the great saphenous vein. The
horizontal group drains the lower abdomen, the superficial
external genitalia, the anal canal, the perineum, and the lower
vagina. The vertical group drains the upper leg (Bickley &
Szilagyi, 2007).
 1506 UNIT 10 Nursing Management of Patients with Reproductive Disorders

Mons Prepuce Infundibulo-pelvic

pubis ligament
Clitoris Labium Oviducts Uterus
majus Ovaries
Round Rectouterine
ligaments cul-de-sac

Frenulum

Urethral
meatus

Hymenal
tags

Vaginal Labium
orifice minus
Bladder
Anterior Cervix
Perineal body vaginal wall
Rectum
Fossa
Vagina
navicularis
Anus
Urethra
Fourchette

FIGURE 484 Female internal genitalia.

complex signals) recognizes a need to secrete gonadotropin-

Prepuce releasing hormone (GnRH). This hormone stimulates the ante-
rior pituitary to release follicle-stimulating hormone (FSH),
Crus Glans clitoris which in turn stimulates a few of the follicles that exist on the
Vestibular
bulb Labium majus ovary. From the follicles that first respond to the FSH, one be-
comes dominant. This growing follicle produces and secretes es-
Bartholin Urethral meatus
gland trogen. When estrogen peaks, it signals the anterior pituitary to
Labium minus release luteinizing hormone (LH). When LH peaks, ovulation oc-
Skene's ducts curs. That is, the dominant follicle extrudes the ovum. The ovum
travels to the fallopian tube and into the uterus (Hughes, Steele, &
Anterior
vaginal wall Leclaire, 2006).
Under the influence of estrogen, the uterine lining has been
Duct openings
from Bartholin thickening before ovulation. After ovulation, the lining begins to
glands proliferate; that is, it gets even thicker. It now has more nutrients
available should the ovum be fertilized and implantation into the
endometrial lining occur (Hughes et al., 2006).
Anal After ovulation, the follicle remnants become the corpus lu-
sphincter Alternate
position of
teum (yellow body), which secretes progesterone. Progesterone
Skene's causes the fluffing of the endometrial lining. If a fertilized
ducts ovum does not implant, then at the end of 12 to 14 days the cor-
Urethra pus luteum regresses and progesterone decreases. When this
happens, the endometrial lining sloughs and menses begins
(Hughes et al., 2006). Figure 485 is a graph that shows when
in the cycle each event occurs.
FIGURE 483 Female vulva including anus.

Male Reproductive System

Physiology of the Menstrual Cycle
The menstrual cycle is a complex physiological process that in-
volves the hypothalamus, pituitary gland, ovaries, and en-
dometrium. The cycle begins with the first day of menses. Menses,
or vaginal bleeding, is the result of the thickened endometrial lin-
ing that was constructed during the previous cycle that is being
sloughed or shed. As this occurs, the hypothalamus (through
The male breast is a small nipple and areola. There is a small
amount of undeveloped breast tissue that may enlarge (gyneco-
mastia) in response to certain drugs or illicit drug use. Breast
cancer rarely occurs in male breast tissue (Slovik, 2006).
The male external genitalia are pictured in Figure 486 .
External genitalia include the penis and scrotum (skin pouch
that contain the testes). The penis is made up of erectile tissue
 CHAPTER 48 Nursing Assessment of Patients with Reproductive Disorders 1507

Anterior pituitary
hormones
LH

FSH

Ovarian hormones
Progesterone

Estradiol

Ovulation

Corpus luteum Corpus

Follicle Ovulation albicans
Ovary

Recruitment Dominance Recruitment

Selection
endometrium
Uterine

2 4 6 8 10 12 14 16 18 20 22 24 26 28 2

FIGURE 485 The menstrual cycle.

(Stables & Rankin, 2005), and into the prostate (a gland at the
Seminal
bladder neck; the urethra passes through it) to be mixed with
vesicle prostate fluid before ejaculation during intercourse. The
Urinary prostate is about 2.5 centimeters long with a median sulcus
bladder (groove) between two lateral lobes. A third, anterior, lobe is not
Vas deferens palpable. The prostate is fibrous and firm to touch (Bickley &
Szilagyi, 2007).
Pubic bone
The inguinal canal (tunnel for vas deferens) is medial to the in-
guinal ligament and has two openings: the external and internal
Penis
inguinal rings. The external inguinal ring is accessible to examina-
tion. The inguinal canal is the site for direct and indirect inguinal
hernias, which are common in men (Bickley & Szilagyi, 2007).
Epididymis
Chapter 50 includes an in-depth discussion of hernias.
8

Glans
penis
Scrotum
Testicle Prostate
FIGURE 486 Male genitalia.
and contains the urethra. At the tip of the penis is the urinary
meatus (opening of the urethra to the outside). Within the
scrotum are the testis, the epididymis (anatomic structure on
the posterior of the testicle), and the spermatic duct. The sper-
matic duct is surrounded by blood vessels and together they
form the spermatic cord (Bickley & Szilagyi, 2007). As the
spermatic cord ascends into the abdomen via the inguinal
canal, it becomes the vas deferens (duct that carries sperm and
semen to the seminal vesicles and prostate). Sperm pass
through the vas deferens to the seminal vesicles (finger-like
structures behind the prostate), which produce 60% of semen
Inguinal lymph nodes are located below the inguinal ligament
in a horizontal configuration at the groin and along the femoral
and great saphenous veins vertically on the upper thigh. The hor-
izontal group drains the lower abdomen, buttock, external geni-
talia, anal canal, and perianal area. The vertical group drains the
upper thigh. The testicles drain into lymph nodes in the ab-
domen. The abdominal lymph nodes are not accessible to palpa-
tion (Bickley & Szilagyi, 2007).
Physiology of Male Reproduction
Male reproductive physiology begins with an interaction be-
tween the hypothalamus, the pituitary gland, and the testis. The
hypothalamus secretes gonadotropin-releasing hormone
(GnRH) based on signals from the central nervous system and
blood levels of testosterone. The GnRH travels to the anterior
pituitary gland and causes the release of luteinizing hormone
(LH) and follicle-stimulating hormone (FSH). LH stimulates
testosterone and other hormone synthesis in the Leydig cells of
 1508 UNIT 10 Nursing Management of Patients with Reproductive Disorders
the testicle. The role of FSH in the male is not fully understood.
It appears to be necessary for spermatogenesis. Leydig cells of
the testis produce testosterone. Sertoli cells of the testis support
and provide nutrients for spermatids (immature sperm) as they
grow to become spermatozoa (mature sperm). Information
about sex chromosome disorders is presented in the Genetic
Considerations box.
History
History, or what the patient can tell you about himself and his
health concerns, is the most important component of assess-
ment. Much of what nurses do is based on what the patient is
able to convey about how he or she feels and the symptoms he
or she is having. In this section, the health history related to the
reproductive system is discussed.
Biographical and Demographic Data
After introductions are completed, the patient is asked about
age, marital status, occupation, address, and other data that will
identify this history as specifically for this patient. It is impor-
tant to date and time the history and to note the reliability of the
person providing the information. From this interview clues be-
gin to emerge related to reproductive system problems. For in-
stance, the older the female patient, the higher the risks are for
breast, endometrial, and uterine cancer. See Chapter 49 for
8
more about risks for cancer in women. The older the male pa-
tient, the higher the risks are for sexual dysfunction, prostate
GENETIC CONSIDERATIONS for Sex
Chromosome Disorders
Normal sperm occur in two types. One type has 22 autosomes and an
X chromosome, and the other has 22 autosomes and a Y
chromosome. Only one type of ovum is ready for fertilization, and it
has 22 autosomes and an X chromosome. Therefore, it is the sperm
contribution to the coupling that will determine the sex of the child. In
the assessment of the female and the male, the examiner may
examine individuals who have a sex chromosome disorder. The two
most common examples are Klinefelters syndrome and Turners
syndrome.
Klinefelters syndrome occurs in about 1 in 1,000 births and is
usually an extra one or two X chromosomes (XXY or XXXY). This is
generally not identified until puberty when the secondary sexual
characteristics do not occur. These individuals will have decreased
testosterone, testicular atrophy, long legs and arms, feminine hair
distribution, gynecomastia, a feminine voice, infertility, and mental
retardation (Banasik, 2005).
Turners syndrome is a monosomy disorder in which the sex
chromosome has only one X chromosome and no corresponding X or
Y. The phenotype (how the person will look or will display the
abnormality) is female, but the ovaries do not develop and secondary
sex characteristics such as breast development and pubic hair do not
appear. This abnormality is rare, occurring in about 1 in 3,000 live
births (Banasik, 2005). Other physical characteristics include short
stature, webbing of the neck, amenorrhea (no menses), a wide chest,
and heart defects.
Sources: Banasik, J. (2005). Genetic and developmental disorders. In L. Copstead & J.
Banasik, Pathophysiology (3rd ed., pp. 123148). Philadelphia: W. B. Saunders; and
Moore, K., & Persaud, T. (2003). Before we are born: Essentials of embryology and birth
defects (6th ed.). Philadelphia: W. B. Saunders.
problems, and bladder cancer. See Chapter 50 for more
8
about risk factors for cancer in men.
Chief Complaint
This section begins with the chief complaint. The patient is asked
to describe the reproductive concern that has brought her or him
into the health care system. The chief complaint is usually
recorded in the patients own words (Bickley & Szilagyi, 2007).
Once the chief complaint is established, a description of the
health concern follows. It is important to ask about the onset, lo-
cation, duration, associated symptoms, any treatments tried, ag-
gravating factors, and factors (other than treatments) that may
alleviate the problem. For example, a male may complain of uri-
nary frequency, urgency, difficulty beginning the urinary stream,
and nocturia with gradual onset when he is describing symptoms
of benign prostatic hyperplasia (BPH). See Chapter 50 for a
8
complete description of BPH. Chart 481 lists specific questions
that can be used to elicit history of present illness from a man
with benign prostatic hyperplasia.
Current Medications
This section of the history should include a list of prescribed
medications, illicit drugs, herbal remedies, over-the-counter
drugs, home remedies, or vitamins that the patient is taking. It is
important to record the name of the drug or herb, the dosage, and
how often it is being taken. Some women who are taking birth
control pills may forget to mention this, so it is a good habit to ask
women of childbearing age about birth control pills. Ask men
with prostate problems whether they are taking saw palmetto.
Men who are taking viagra may be hesitant to discuss this with
the nurse. This drug has the potential for interacting with other
drugs, such as cardiac medications, and causing harm, so it is im-
portant to ask about it.
Allergies
All patients should be asked about allergies to drugs, latex,
foods, and environmental substances. For those patients with al-
lergies, the chart should be clearly marked so that the health care
team is alerted.
Examination of a patient using latex gloves when that patient
has a latex allergy increases the risk for an adverse reaction,
including anaphylactic shock. Be sure to ask about possible
allergy before the examination begins.
Interview Questions for History
CHART 481
of Present Illness
After introductions, Mr. Davis tells you he has come to the hospital for sur-
gery on his prostate. Here are some questions that would be asked to find
out about his symptoms:
Have you been troubled with frequency of urination?
How often do you have to urinate?
Is this keeping you up at night?
Do you have difficulty starting the urinary stream?
Have you had to be catheterized because you could not void?
Does dribbling of urine occur after you void?
Are you ever incontinent?
 CHAPTER 48
Past Medical History
This section of the history includes childhood and adult ill-
nesses; comorbid conditions; immunizations; hospitalizations;
surgeries; and menstrual, obstetric, sexual, and social histories.
Here the discussion is about some parts of the patients past his-
tory that may affect reproductive health.
Childhood Illnesses and Immunizations
For women, childhood diseases that would have affected her
health, fertility, or the health of her children would need to be
considered. For instance, any communicable disease that af-
fected her health severely would affect her ability to have chil-
dren. This could mean that she would need to prevent
pregnancy or to have special care if she were to become preg-
nant. Another example is the woman of childbearing age who
has not had rubella or immunization for rubella. If she develops
rubella while she is pregnant, this could cause birth defects in
her child.
The childhood disease of concern for men is mumps. This vi-
ral illness has the potential for affecting the testicles, causing steril-
ity. See Chapter 50 for further discussion of mumps orchitis.
8
Previous Illnesses and Hospitalizations
Medical comorbidities that may impact the reproductive system
would include diabetes, hypertension, hepatitis, and HIV. The
male with diabetes or hypertension treated with certain antihy-
pertensive drugs may experience impotence. Hepatitis and hu-
man immunodeficiency virus (HIV) are sexually transmitted
infections (STIs) that may be life threatening. Patients (female or
male) who have hepatitis or HIV may pass these diseases to their
sexual partners. The nurse should determine whether the pa-
tient has been diagnosed and treated for a sexually transmitted
infection such as chlamydia, gonorrhea, syphilis, or herpes. For
women, it is also important to ask whether they have ever had
pelvic inflammatory disease (Narrigan, 2006). Ask about hospi-
talizations for any reproductive health concerns or chronic
health problems. Find out when the hospitalization occurred,
what the problem was, and how it was treated.
Diagnostic Procedures and Surgeries
Past surgeries that may affect the woman with a reproductive sys-
tem problem may include breast surgeries, hysterectomy, bilat-
eral tubal ligation, cervical laser or cryosurgery, or any surgery
for endometriosis (presence of uterine lining in sites other than
within the uterus). See Chapter 49 for further discussion of
8
surgeries of the reproductive system.
Procedures of particular interest in this section of the history
for women include screenings or tests for breast cancer and cer-
vical cancer. Mammograms, lump biopsies, or any other proce-
dures for breasts would need to be dated and recorded in the
history. It is also important to note the date of the last cervical
cancer screening and the results of the Papanicolaou (Pap) smear.
If the patient has ever been diagnosed with cervical dysplasia or
treated for an abnormal Pap smear, it should be documented.
Men who have had prostate surgery may have increased in-
continence or impotence. Other surgeries that may impact the
reproductive system or lower urinary system include orchidec-
tomy, vasectomy, or penile reconstruction due to epispadias (the
urinary meatus is at the top or dorsal surface of the penis, be-
tween the penis and bladder) or hypospadias (the urinary
Nursing Assessment of Patients with Reproductive Disorders 1509
opening is on the ventral or bottom of the penis, between the
scrotum and the distal end of the penis). See Chapter 50 for
8
further discussion of surgeries of the reproductive system.
Menstrual History
For women, the menstrual and obstetric history should be in-
cluded in the health history. The menstrual history should in-
clude age at menarche (first menstruation), length of time from
first day of menstrual flow to first day of next menstrual flow
(one cycle), number of days and characteristics of menses, reg-
ularity of cycles, molimenal symptoms (symptoms accompany-
ing menstruation), and the first day of her last menstrual period.
For older women, ask about menopause including age at onset
and symptoms such as hot flashes, vaginal dryness, night sweats,
and insomnia (Narrigan, 2006).
Obstetric History
Obstetric history includes the number of pregnancies, premature
and term births, and spontaneous and therapeutic abortions. It is
also important to determine whether the deliveries were sponta-
neous vaginal births or cesarean sections and whether there were
any complications (Narrigan, 2006).
Sexual History and Risks
for Sexually Transmitted Infection
Healthy People 2010 set 10 high-priority public health issues for
this decade. Responsible sexual behavior is number 5 on this list
of the most important changes people can make to help every-
one in the United States be healthier (U.S. Department of Health
and Human Services [DHHS], 2007). The steps toward achiev-
ing this goal include identifying people who are engaging in
risky sexual behavior and helping them to choose safer prac-
tices. In working toward this goal, the examiner can ask the pa-
tient about the last time the patient had intimate physical
contact or sex with someone; whether the patient is happy with
her or his sex life; whether the patient has sex with men, women,
or both; and any concerns the patient may have about sexual
health. If the patient is in a mutually monogamous relationship,
then the risks are decreased for sexually transmitted infection
(Narrigan, 2006).
In settings where the patients may be at risk for sexually trans-
mitted infection or HIV, more in-depth exploration of sexual
practices may be indicated. The Centers for Disease Control and
Prevention (CDC) has published a list of five areas to be explored
along with counseling about the prevention of sexually transmit-
ted infection and HIV. Chart 482 (p. 1512) lists specific questions
that the CDC suggests be used to elicit this history.
Family History
Explore the family history of women for mother, sister, mater-
nal grandmother, or aunts with breast cancer. The occurrence of
breast cancer in any of these relatives increases the risks for the
patient (Lashley, 2005). This is also true of about 10% of cases
of ovarian cancer.
There is the possibility that there may be women who are
daughters of women who took diethylstilbestrol (DES) to pre-
vent a miscarriage during that pregnancy. These daughters are
at 40 times the risk of developing cancer of the vagina and
cervix (Wallace & Sanford, 2006). Therefore, it is important to
ask women born between 1940 and 1971 whether they were ex-
posed to DES while in utero.
 1510 UNIT 10 Nursing Management of Patients with Reproductive Disorders
Exploring the Five Areas of Concern
CHART 482 in the Prevention of Sexually
Transmitted Infection (STI)
PARTNERS
Do you have sex with men, women, or both?
In the past 12 months, how many partners have you had sex with?
PREVENTION OF PREGNANCY
Are you or your partner trying to get pregnant? If no:
What are you doing to prevent pregnancy?
PROTECTION FROM STIS
What do you do to protect yourself from STIs?
PRACTICES
To understand your risks for STIs, I need to understand the kind of sex
you have had recently.
Have you had vaginal sex, meaning penis in vagina sex? If yes:
Do you use condoms: never, sometimes, or always?
Have you had anal sex, meaning penis in anus sex? If yes:
Do you use condoms: never, sometimes, or always?
Have you had oral sex, meaning mouth on penis/vagina sex?
For Condom Answers
If never: Why do you not use condoms?
If sometimes: In what situations or with whom, do you not use
condoms?
PAST HISTORY OF STIS
Have you ever had an STI?
Have any of your partners had an STI?
Additional Questions to Identify Human Immunodeficiency Virus
(HIV) and Hepatitis Risk
Have you or any of your partners ever injected drugs?
Have any of your partners exchanged money or drugs for sex?
Is there anything else about your sexual practices that I need to know
about?
Source: Workowski, K., & Berman, S. (2006). Sexually transmitted disease treatment
guidelines. Morbidity and Mortality Weekly Report, 55(RR-11), 23.
Men should be asked whether their father or brother has
prostate cancer. Early onset prostate cancer seems to occur in
some families. African American men are particularly suscepti-
ble. See further discussion of inheritance of susceptibility to
prostate cancer in Chapter 50 .
8
Social History
Occupations or hobbies by which patients have been exposed to
hazardous materials increase their risks for infertility (female
and male) and prostate cancer. Ask the patient whether he works
around hazardous materials such as excessive heat, radiation,
heavy metals, or organic solvents and how he protects himself
(Quallich, 2006).
Cigarette Smoking and Substance Abuse
Habits such as cigarette smoking, alcohol use, or illicit drug use
should be explored. There is evidence from cohort and case-
control research that cigarette smoking and secondhand smoke
increase the risks for cervical cancer (National Cancer Institute,
2007). Alcohol and illicit drug use have been shown to increase
the incidence of sexually transmitted infection and HIV (Fogel,
2006b).
It is best to ask directly, Tell me about your use of alcohol, or
When was your last drink of alcohol? If the patient answers in
such a way that the examiner is suspicious of problem drinking,
then screening questions such as the CAGE questionnaire (Chart
483) can be used to help identify alcohol abuse. CAGE stands for
cutting down, annoyance if criticized, guilty feelings, eye-openers
(Bickley & Szilagyi, 2007).
The same direct approach should be used in questioning
about illicit drug use. Direct questions, such as Have you ever
used any drugs other than those required for medical reasons?
and Have you ever injected a drug? work best to elicit this in-
formation from the patient (Bickley & Szilagyi, 2007).
Domestic Violence
Violence affects people of all ages, both genders, and of all reli-
gions, races, and socioeconomic groups. Domestic violence,
whereby intimate partners inflict physical, sexual, or emotional
injury, is very prevalent (Harley, 2006; Mick, 2006). In fact,
Healthy People 2010 lists injury and violence as number 7 of the
top 10 high-priority health issues in the United States (DHHS,
2007). People who suffer intimate partner violence are more
likely to abuse alcohol and drugs, and to have HIV or a sexually
transmitted infection (Fogel, 2006b; Wingood, 2006).
Domestic violence is difficult to discuss, but questions about
abuse should be asked of all patients, both women and men. The
only way to begin to change behavior is to uncover the abuse.
Make it a habit to ask patients questions, such as Are there times
in your relationship that you feel unsafe or afraid?orWithin the
last year, have you been hit, kicked, punched or otherwise hurt by
someone you know? (Bickley & Szilagyi, 2007). Try to conduct
the interview in private, away from family or the abusive partner
(Harley, 2006).
Physical Examination
After the history is completed, the examiner should ask the pa-
tient to disrobe and put on a gown for the physical examination.
The gown should open in front for better access to the breasts
and genitals of both the female and male patient. Assemble the
equipment needed for the pelvic examination. The examiner
should step out of the room while the patient changes. Hand
washing and donning of gloves by the examiner needs to occur
in the room, in front of the patient.
CHART 483 The CAGE Questionnaire
1. Have you ever felt the need to Cut down on drinking?
2. Have you ever felt Annoyed by criticism of your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever taken a drink first thing in the morning (Eye-opener)
to steady your nerves or get rid of a hangover?
Source: Mayfield, McCleod, and Halls CAGE questionnaire, as cited in Bickley, L., & Szilagyi,
P. (2007). Bates guide to physical examination and history taking (9th ed.). Philadelphia:
Lippincott Williams & Wilkins, p. 50.
 CHAPTER 48
Female Examination
Chart 484 lists the equipment needed for the female examina-
tion. The nurse examiner should be accompanied by an assistant
because of the sexual nature of this examination. This is true re-
gardless of the gender of the nurse. During the physical assess-
ment, the nurse should teach the patient about healthy lifestyles
and choices.
Breasts
The breast examination is best done with the woman sitting at
the end of the examination table. For inspection of the breast,
she should be asked to open the gown so that her breasts are fully
visible to the examiner. The examiner should inspect the breasts
for size, shape, contour, dimpling, and inverted nipples; areas of
increased vascularity; and erosion or inflammation of the nip-
ple or areola. The inspection should be carried out while the pa-
tients arms are at her side, then again when she raises her arms
above her head or presses her hands to her hips to contract the
pectoralis muscle. These maneuvers will move the breast and
pull the suspensory ligaments in such a way that a tumor would
cause dimpling or a bulge. If the woman has large, pendulous
breasts, a bimanual (palpating breast tissue between the two
hands of the examiner) examination of the breasts as she leans
forward will help to palpate any masses (Narrigan, 2006).
The next portion of the breast examination is palpation. Ask
the patient to lie down and raise one arm over her head. Place a
small pillow or folded towel beneath the shoulder on the side of
the breast to be examined, and palpate all the breast tissue. Pal-
pate in a circular pattern, in smaller circles as you near the cen-
ter of the breast. Be sure to include all four quadrants of the
breast, including the upper outer quadrant and the tail of
Spence (a section of breast tissue that extends toward the axilla).
End the palpation with a gentle pressure on the nipple between
the thumb and forefinger to determine whether there is dis-
charge from the nipple. Repeat the procedure for the other
breast. Palpate for masses or tenderness. If there is nipple
drainage, collect a specimen on a slide and send it to the labora-
tory for evaluation (Narrigan, 2006).
Inspect the axilla for lesions, masses, or inflammation. Hold
the patients arm in a relaxed position and palpate for the axil-
lary nodes by grasping the axillary fold and feeling for pectoral
nodes along the pectoral muscle. Reach high in the axilla and
feel along the humerus for the lateral lymph nodes. Then,
change hands so that the arm is supported and the opposite
hand can examine for subscapular nodes by feeling inside the
Equipment Needed for the Female
CHART 484
Genitalia Examination
1. Examination gloves (latex or nonlatex, depending on patient
allergy)
2. A good light source (gooseneck lamp or light that attaches to the
speculum)
3. Speculum (choose size most appropriate for the patient)
4. Water soluble lubricant
5. Pap smear equipment
6. Culture tubes for STIs or other bacterial infection
Nursing Assessment of Patients with Reproductive Disorders 1511
posterior axillary fold. Examine along the top and below the
clavicle for supra- and infraclavicular nodes. Repeat the entire
procedure for the opposite adnexa (Bickley & Szilagyi, 2007).
External Genitalia
While the patient is still lying down, examine the groin for
swollen inguinal lymph nodes. When this is completed on both
sides, help her move down on the table and to put her feet into
the stirrups for the external genitalia and internal genitalia ex-
aminations. Her buttocks should be right at the edge of the end
of the examination table with her knees flexed and legs spread
so that the external genitalia are accessible to examination. This
is the lithotomy position (Figure 487 ). Raise the head of the
examination table to help her be more comfortable and drape
her lower body and legs.
The nurse examiner should sit on a stool for the examina-
tion and lower the drape so that the nurse can see the patients
face during the examination. Inspect the external genitalia. The
nurse tells the patient the nurse is going to touch her before the
nurse moves a gloved hand to the vulva to spread the tissues for
inspection of the entire vulva and perineum. Look for lesions,
warts, vesicles, changes in pigmentation, signs of abuse such as
bruises or lacerations, swollen Bartholin glands, or vaginal dis-
charge or blood at the introitus. Figure 488 (p. 1514) illus-
trates the technique for examining the Bartholin glands. Ask
the patient to bear down as if to move her bowels, and observe
for any bulges of cystocele (relaxation of the anterior vagina
wall under the urinary bladder) or rectocele (relaxation of the
posterior vaginal wall over the rectum) or prolapsed uterus at
the introitus. Cystocele and rectocele are discussed in Chapter
49 . Palpate bulges to differentiate the cystocele from the
8
rectocele. Palpate the Bartholin glands at 7 and 5 oclock to the
introitus. Palpate with one finger for the location of the cervix
within the vagina (Bickley & Szilagyi, 2007).
Discovery of very painful swelling of the Bartholin gland
should be referred immediately to a gynecologist for
treatment (Birnbaum, 2006).
Vagina and Cervix
The nurse places a small amount of water soluble lubricant on
the speculum and tells the patient that the nurse is about to in-
sert the speculum to visualize the cervix. Grasp the speculum in
the dominant hand, spread the labia with the opposite hand, and
FIGURE 487 Female lithotomy position.
 1512 UNIT 10 Nursing Management of Patients with Reproductive Disorders
Bartholins
gland
FIGURE 488 Palpation of the Bartholin glands.
insert the speculum, pointing it down and back toward the
cervix (Figure 489 ). Open the speculum to visualize the
cervix. Look for any lesions, warts, or increased vascularization
on the cervix or the vaginal walls. Look at the cervical os (open-
ing) for drainage. Obtain specimens for Pap smear or STI cul-
tures as appropriate (Figure 4810 ). Note whether the cervix
bleeds slightly on contact with the specimen collector. If blood
is present, this means that the cervix is friable (easily damaged).
Rotate the speculum to visualize the remainder of the vagina be-
fore removing it. Discard the speculum appropriately (Bickley &
Szilagyi, 2007).
Uterus and Adnexa
Lubricate the forefinger and long finger of the dominant hand
for the bimanual examination. Explain to the patient that the ex-
amination of the uterus and ovaries is next. Insert the lubricated
fingers into the vagina and palpate the cervix for motion tender-
ness by moving it side to side. Perform a bimanual examination
with one hand on the lower abdomen just above the symphysis
FIGURE 489 Speculum insertion.
Pap smear
Bladder Uterus
Speculum
Swab
Cervix
Rectum
FIGURE 4810 Obtaining Pap smear.
(pubic bone) and the fingers in the vagina pressing the cervix
and uterus upward toward the abdominal hand to determine
uterine tenderness, position, size, and shape. Figure 4811
shows the bimanual exam of the female. Move the hands to the
right adnexa and examine bimanually for masses or tenderness.
Move the hands to the left adnexa and repeat the examination
for masses or tenderness. Figure 4812 (p. 1515) depicts the
palpation of the adnexa (Bickley & Szilagyi, 2007).
Rectum
If the womans history or examination indicates a reason, then a
rectal examination should be done. Put on clean examination
gloves. Inspect the anal area for hemorrhoids, fissures, lesions, or
warts. Lubicate the index and long fingers of the dominant hand,
and then place the long finger over the anus and ask the patient
to bear down as if for a bowel movement. Insert the finger as the
anus opens. Place the forefinger into the vagina. Palpate for le-
sions, a retroverted uterus, or a fistula between the vagina and
rectum. Remove the forefinger from the vagina and palpate the
entire rectal wall with the long finger for rectal lesions. After re-
moval of the long finger, place any stool obtained on a hemocul-
ture card and test for occult blood (Bickley & Szilagyi, 2007).
Help the patient to move back on the table before sitting up,
so that she is supported by the examination table. Help her
down from the examination table, give her some tissue to re-
move the excess lubricant from the genitalia, and leave the room
to give her privacy to dress.
Male Examination
The male breast should be inspected for lesions, piercing, or gy-
necomastia. If the history or inspection has revealed a problem
with the male breast, palpation for masses and tenderness is
indicated.
 CHAPTER 48
Uterus
Symphysis
pubis
FIGURE 4811 Bimanual exam female.
The male external genital examination should occur in a
warm, private room after the examiner has washed and warmed
the examining hands. The patient should be asked whether the
room is warm enough. A cold room or cold examining hands
will activate the cremasteric reflex (testicles rise in the scrotum
to the abdominal cavity when the thigh is stroked or the room is
cold). The nurse should introduce herself or himself and ask
permission before proceeding. This will give the patient an op-
portunity to ask for a same-sex examiner, if he wishes. During
the examination, the patient may be standing or lying down.
Drape and gown the patient so that the genitalia can be visual-
ized by having the patient hold up the gown if he is standing or
FPO
FIGURE 4812 Palpation of adnexa.
Nursing Assessment of Patients with Reproductive Disorders 1513
Fornix
Cervix
to have a cover over his chest and legs if he is lying down. The
examiner should be accompanied by an assistant or the patients
wife because of the sexual nature of the examination (Ceo,
2006). The Cultural Considerations box notes the importance of
respecting cultural attitudes about privacy.
External Genitalia
The examination of the male external genitalia is completed by in-
spection followed by palpation. Chart 485 (p. 1516) lists the
equipment that may be needed. With the male standing, the exam-
iner can sit on a stool in front of him and inspect the genitalia for
lesions in the pubic hair, on the penis, or on the front or back of the
FPO
 1514 UNIT 10 Nursing Management of Patients with Reproductive Disorders

CULTURAL CONSIDERATIONS for Genital
Examinations
Before proceeding with a male genital examination with the wife
present, ask the wife whether she would prefer to leave. In certain
cultures, the wifes presence during a genital examination of her
and the blood vessels of the spermatic cord. This structure is pal-
pated up to the inguinal ring where it enters the abdomen.
Varicocele (varicosities of the veins of the scrotum) may be iden-
tified here. These bag of worms abnormalities are more likely
to occur on the patients left side. Both sides of the scrotum and
both testicles should be palpated (Ceo, 2006). See Chapter 50

8
husband would be considered taboo or against cultural mores (Ceo, for more information about varicoceles.
2006).
Hernia and Inguinal Lymph Nodes
Femoral and inguinal hernias may be detected by inspection of
the inguinal and femoral areas for bulges. These bulges can be
intensified by asking the patient to strain down or cough. To pal-
Equipment Needed for the Male pate for an inguinal hernia that has not presented as a loop of
CHART 485
Genitalia Examination
bowel in the scrotum, the examiner should use the right forefin-
1. Examination gloves (latex or nonlatex, depending on patient ger to examine the patients left external inguinal ring and the
allergy) left forefinger to examine the patients right. This maneuver
2. Water soluble lubricant should start low enough in the scrotum to assure that the finger-
3. Flashlight or other light source for translumination tip will reach the inguinal ring. While the examining finger is
held against the ring, the patient should cough or strain down.
4. Stethoscope
This will bring a mass against the examining finger. Figure
4813 demonstrates this maneuver.
The superficial inguinal lymph nodes are palpated, and if the
scrotum. The dorsal vein of the penile shaft may be normally nodes in the horizontal or vertical group are swollen or tender,
prominent. If the male is not circumcised, ask the patient to retract this may indicate inflammation or malignancy of the scrotum or
the foreskin so that the glans can be inspected. Lesions that may be penis. Cancer or inflammation of the testicles would affect
seen include chancres (ulcers of syphilis), abnormal contour of the intra-abdominal lymph nodes that cannot be palpated (Bickley
scrotum, cancer, warts, herpetic vesicles, or infestation by lice or & Szilagyi, 2007).
other insects in the pubic hair. Smegma (white, cheesy material) is
Prostate
a normal finding under the foreskin. Inflammation of the glans is
To palpate the prostate, a rectal examination is required. The pa-
called balanitis. Inspection for the location of the urinary opening
tient will need to lean over the examining table or lie on his left
follows. Normally, it will be at the end of the penis and free of dis-
side with his right knee drawn up (Figure 4814 ). The anal area
charge. If the patient has reported discharge, but it is not visible, he
is inspected by spreading the buttocks. The examiner should look
should be asked to strip the penis to bring discharge to the meatus
for lesions, external hemorrhoids, or warts in this area. The ex-
for culture (Bickley & Szilagyi, 2007).
aminer should lubricate the forefinger of the dominant hand
Palpation of the penis is reserved for any abnormalities such
generously. To decrease discomfort, the nurse should tell the pa-
as tenderness or plaque formation. The nurse should be aware
tient what is about to be done, have the patient bear down as if
that the male patient may have an erection during the examina-
moving his bowels, and move the examining finger into the anal
tion. This is often beyond his control, and he should be assured
canal as it opens. The posterior surface of two lobes of the
that this is a normal occurrence (Bickley & Szilagyi, 2007).
prostate is palpated through the anterior rectal wall. The exam-
If the contour of the scrotum is suspicious, palpation for
iner should identify the median sulcus and note the size and firm-
cryptorchidism (an undescended testicle), scrotal hydrocele
ness of the prostate, and the presence of any masses or tenderness.
(swelling due to fluid accumulation in the scrotum), or hernia
When the examination is complete, the examiner removes the
should be done. A hernia with a loop of bowel in the scrotum can
be differentiated from hydrocele by translumination (with a light
source behind the swelling, look for a glow of clear fluid or no light
penetrance). One can also auscultate the scrotal mass with the aid
of the stethoscope for bowel sounds (Ceo, 2006).
Discovery of an undescended testicle in a teenager would
warrant immediate referral to an urologist. The incidence of
testicular cancer is increased when the testicle is
undescended (Goroll & Mulley, 2006).
Palpation of the testis is accomplished by grasping it between
the thumb and forefinger and feeling for nodules or masses. The
examiner should be aware that too much pressure on the testis
can cause deep pain. The epididymis is found on the posterior
surface and is palpated in the same way. Cysts or tumors may be
identified on the testicle or epididymis. Cysts or tumors in this
area may be malignant or benign. From the epididymis, a cord
will ascend upward toward the abdomen. This is the vas deferens FIGURE 4813 Palpation for inguinal hernia.
 CHAPTER 48
FIGURE 4814 Digital rectal exam prostate.
finger and wipes the excess lubricant from the anus (Bickley &
Szilagyi, 2007; Ceo, 2006).
Gerontological Considerations
As with all systems of the body, the reproductive system under-
goes changes with aging. Psychologically, there is reduced libido
and decreased sexual satisfaction. This does not mean that men
and women over age 65 are not sexual or that they do not enjoy
sexual activity. It just means that sex is not as intense or frequent
(Fogel, 2006a). On the other hand, libido and sexual feelings may
decrease due to loss of a significant other, social isolation related
to loss of mobility, or other factors. Some elders experience in-
continence of urine, which decreases their willingness to exercise
or to socialize with others (Stanley, Blair, & Beare, 2005).
Women experience menopause and the loss of estrogen usu-
ally in the early part of the fifth decade. The decrease in estrogen
may cause symptoms such as hot flashes (which usually come
and go during the first 5 years of menopause) and drying of the
vaginal mucosa. Drying of the vaginal mucosa will make sexual
intercourse and vaginal examinations uncomfortable. Less fre-
quently, the woman may experience sleep disturbances, de-
creased ability to concentrate, and depression. Over time,
decreased estrogen will contribute to loss of muscle mass and
bone, and increased fat of the abdomen. The breast will atrophy
as the glandular tissue is replaced by fat. The vulva will lose fat
and the mons and vulva will lose hair. There may also be graying
of the pubic hair (Ebersole, Hess, Touhy, & Jett, 2005).
Changes in mobility brought on by aging may necessitate a
change in the positioning for vaginal examinations. For those
women who cannot open their legs at the hips for the lithotomy
position, alternate positioning may be needed. A side-lying posi-
tion with the top leg drawn up will allow for small speculum ex-
amination of the vagina and cervix. Another option is to have
two assistants support the patients legs during the examination
(Bickley & Szilagyi, 2007).
Nursing Assessment of Patients with Reproductive Disorders 1515
Men experience andropause (decrease in testosterone) be-
ginning gradually in about the third decade. This causes de-
creased spermatogenesis and a shortening of the penis; the penis
is slower to erection, and the scrotum hangs lower. Chronic dis-
ease may affect the testicles, causing them to shrink. Depression
and a decrease in cognition may occur, just as with women in
menopause. Men may have loss of muscle mass and bone mass,
but not as much as seen in women (Stanley et al., 2005).
Loss of mobility or inability to stand for long periods may ne-
cessitate that the patient lie down for the prostate examination.
Lying on the left side, bending at the hips, and drawing the right
leg up so that the anal area is accessible to the examiner, is the
recommended position (Bickley & Szilagyi, 2007).
Health Promotion
Health promotion means following a lifestyle that is conducive to
health. Sexual health requires a healthy mind and body, open
communications with the partner, and capacity to enjoy and con-
trol sexual impulses according to social norms (Fogel, 2006a). To
be sexually healthy is to have a good body image and sexual iden-
tity. Sexual health is promoted by mutually monogamous rela-
tionships with uninfected partners. It also entails the avoidance of
substances such as alcohol or illicit drugs that would decrease in-
hibitions and cause the female or male to engage in risky sexual
behaviors.
National Guidelines for Disease Screening
and Self-Examination
Early detection of disease through screening examinations is a
tactic for health promotion. For women, cervical and breast can-
cer screening are recommended. The United States Preventive
Services Task Force (USPSTF) recommends that sexually active
women have annual Pap smears until age 65. At this point, the
benefit of screening seems to diminish (USPSTF, 2003a). For
breast screening, the USPSTF recommends screening mam-
mography every 1 to 2 years for women age 40 and older (USP-
STF, 2003b). According to the USPSTF, the research to date
(worldwide) has not demonstrated that breast self-examination
reduces mortality from breast cancer. The USPSTF does not rec-
ommend routine screening for ovarian cancer with serum CA-
125 levels or transvaginal ultrasound, because research has not
established that the benefits outweigh the potential harm (USP-
STF, 2003d). The American Cancer Society, however, recom-
mends that women with a strong family history of ovarian
cancer be screened with both transvaginal ultrasound and
serum CA-125 levels (American Cancer Society, 2006b).
For adolescents and young men, the USPSTF recommends
against testicular self-examination and routine screening by cli-
nicians (USPSTF, 2003c). Studies demonstrate that routine ex-
amination of the testicles has caused more harm than benefit.
For older men, the USPSTF has found that there is insuffi-
cient evidence to recommend for or against routine screening
for prostate cancer with serum levels of prostate-specific antigen
(PSA) and digital rectal examination (DRE) of the prostate
(USPSTF, 2003e). Routine screening has been shown to cause
unnecessary anxiety, biopsies, and treatments with severe side
effects for a cancer that may never have affected the patient. In
addition, there continue to be many false-positive PSAs.
 1516 UNIT 10 Nursing Management of Patients with Reproductive Disorders

Summary
Assessment of the reproductive systems of women and men has
been described. Readers are encouraged to use what has been
presented in this chapter in management plans for women and
men with reproductive health care concerns, as presented in
Chapters 49 and 50 .
8

NCLEX REVIEW
1. The nurse is instructing a teenage patient about 5. A 50-year-old female patient believes something is
menstruation and hormone regulation. Which of the drastically wrong because she is losing hair down there.
following should the nurse include in this instruction? Which of the following should the nurse respond to this
1. The next menstrual cycle begins on the last day of the current patient?
menses. 1. There could be something wrong.
2. The uterine lining becomes thicker because of estrogen. 2. Hair loss over the mons and vulva is a normal part of the
3. Estrogen causes ovulation. aging process.
4. After ovulation, the lining of the uterus becomes thinner. 3. I suggest you schedule a complete physical immediately.
2. A male patient seeks medical care for a new onset of 4. Hair doesnt really serve a purpose there anyway.
impotence. Which of the following should the nurse assess 6. A 70-year-old male patient tells the nurse that he hates his
in this patient? annual physical because every year he worries what his PSA
1. Any other chronic illnesses such as diabetes level is going to be. Which of the following does this anxiety
2. Past medical history including mumps suggest?
3. History of sexually transmitted diseases 1. The patient does not like his primary physician.
4. Date of first sexual experience 2. Routine screening for prostate cancer can lead to unnecessary
anxiety.
3. A 35-year-old female is having difficulty conceiving. Which
3. The patient thinks he has prostate cancer.
of the following can the nurse assess in this patient to aid in
determining the cause of the infertility? 4. The patient is hiding a health concern.
1. Smoking history
2. Occupations and hobbies
3. Amount of daily exercise
4. Amount of daily sleep and rest
4. While assessing the penis of an uncircumcised male, the
nurse notes a white cheesy substance under the foreskin. The
nurse realizes this finding indicates:
1. Smegma, a normal finding.
2. Syphilis.
3. Inflammation.
4. Discharge.

KEY TERMS
andropause p.00 galactogenesis p.00 molimenal p.00
chancres p.00 hydrocele p.00 oxytocin p.00
cremasteric reflex p.00 hypospadias p.00 progesterone p.00
cryptorchidism p.00 lactation p.00 prolactin p.00
endometriosis p.00 lithotomy p.00 varicocele p.00
friable p.00 menarche p.00

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REFERENCES
American Cancer Society. (2006a). Can ovarian cancer be found early?
Retrieved February 27, 2008, from http://www.cancer.org/docroot/
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