Health Assessment NUR 103

1. Health AssessmentNUR 103 Physical Assessment of the Reproductive System

2. Objectives: • Define terminology. • Describe anatomy and physiology. • Identify equipment. • Identify positioning. • Identify techniques. • Explain process of performing assessment of male and female reproductive systems. • Recognize normal and abnormal data. • Differentiate between normal and abnormal assessment data.

3. TerminologyThe External Female Genitalia • Vulva- (or pudendum) The external genitalia. • Mons pubis- A round, firm pad of adipose tissue covering the symphysis pubis. • Labia majora- Two rounded folds of adipose tissue extending from the mons pubis down and around to the perineum. • Labia minora- Two smaller, darker folds of skin inside the labia majora. • Frenulum- A transverse fold which joins the labia minora poseriorly. • Clitoris- A small, pea –shaped erectile body, homologous with the male penis and highly sensitive to tactile stimulation. • The labial structures encircle a boat-shaped space termed the Vestible. • Urethral meatus- A dimple 2.5 cm posterior opening posterior to the clitoris.

5. Terminology The Internal Female Genitalia • Vagina- A flattened, tubular canal extending from the orifice up and backward into the pelvis. Leads into the female reproductive tract. • Rugae- Thick transverse folds which enable the vagina to dilate widely during childbirth. • Cervix- A smooth doughnut-shaped area with a small circular hole or os, found at the end of the canal that leads into the uterus. • Anterior fornix- A continuous recess, present in front of the cervix. • Posterior fornix- Continuous recess found in back of cervix. • Rectouterine pouch, or cul-de-sac of Douglas- Found behind the posterior fornix, a deep recess, formed by the peritoneum, dips down between the rectum and cervix. • Uterus- A pear-shaped, thick walled, muscular organ which a fetus develops. Flattened anteroposteriorly, measuring 5.5 to 8 cm by 3.5-4 cm wide, and 2-2.5 cm thick. • Fallopian tubes- Two pliable, trumpet-shaped tubes, 10 cm long, extending from the uterine fundus laterally to the brim of the pelvis. Transports an egg cell from the region of the ovary to the uterus. • Ovaries- The primary reproductive organ of the female; An egg-cell producing organ which is oval shaped, 3 cm long by 2 cm wide.

6. Gloves Protective clothing Vaginal Speculum Of appropriate size Large cotton-tipped applicators (rectal swabs) Materials for cytologic study: Glass slide with frosted end Sterile Cytobrush or cotton-tipped applicator Ayre’s spatula Spray fixative Specimen container for gonorrhea Cx/chlamidia Small bottle of normal saline, potassium hydroxide, and acetic acid (white vinagar) Lubricant EquipmentFor Female Examination Pederson Speculum

7. Positioning forFemale Examination • Begin with woman in sitting position to • establish equal status and trust. • Place woman in lithotomy position, with • the examiner sitting on a stool. • Help the woman into position, feet • in stirrups, knees apart, and buttocks • at edge of examination table. • Arms should be at the woman’s sides, • not across chest or over the head. • Drape the woman fully, covering the stomach, • and legs, exposing only the vulva to your • view.

8. Have woman empty bladder. Position the exam table so her perineum is not exposed to inadvertent open door. Ask if she would like a friend, family member present. Elevate her head and shoulders to a semi-sitting position to maintain eye contact Place stirrups so the legs are not abducted too far. Explain each step in the exam before you do it. Assure the woman she can stop the exam at any point she should feel uncomfortable. Use a gentle, firm, touch, and gradual movements. Communicate throughout the exam. Maintain dialogue to share information. Techniques

9. Assessment of theFemale Genitalia • Abnormal Findings: • Inspection: • Note: • Refer any suspicious lesion for biopsy • Consider delayed puberty if no pubic • hair or breast development has occurred • by age of 13. • Nits, or lice at base of pubic hair • Swelling • Normal Findings: • Inspection: • Note: • Hair distribution- usual pattern • Skin color, no lesions • of inverted triangle. • Labia Majora symmetric, plump, • and well formed. Nulliparous woman, • labia meet in midline; following • vaginal delivery, labia are gaping and • slightly shriveled.

10. Normal Findings: No lesions, except for occ. Sebaceous cysts. (with gloved hand sep- arate labia majora to inspect). Clitoris Labia minora- dark pink, and moist, usually symmetric. Urethral opening appears stellate or slitlike, midline. Vaginal opening (introits) may appear as narrow, vertical slit or as a larger opening. Perineum-smooth. A well-healed episiotomy scar, midline or mediolateral following vaginal birth. Anus- course skin of increased pigmentation. Abnormal findings: Excoriation, nodules, rash, or lesions. Inflammation or lesions. Polyp Foul-smelling, irritating discharge.

11. Normal Findings: Assess the urethra & Skene’s glands with gloved finger. Asses vagina, gently milk the urethra by applying pressure up and out. Assess Bartholin’s glands, post. Of labia majora with index finger inside and thumb outside. Should feel soft and homogeneous. Assess pelvic musc. by 1. Palpate perineum, should feel thick, smooth, and musc. In nulliparous, thin and rigid in multi-parous. 2. Ask woman to squeeze vaginal opening around fingers, should feel tight in nulliparous. 3. Separate the vaginal orifice and ask pt. to strain down. No bulging of vaginal walls or urinary incontinence. Abnormal Findings: Tenderness Induration along urethra, pain, urethral discharge Swelling, induration, pain with palpation, erythema around or discharge from duct opening Tenderness, paper thin perineum, absent or decreased tone may diminish sexual satisfaction. Bulging of vaginal walls indicates cystocele, rectocele, or uterine prolapses. Urinary incontincence Palpation:

12. Internal Genitalia • Speculum Examination: Select proper-sized speculum Grave’s Speculum Pederson Speculum

13. Speculum Examination • Warm and lubricate speculum under warm running water. • Avoid gel lubricant – bacteriostatic, distorts cell in cytology specimen collected. • Insert by asking woman to bear down. Relaxes perineal muscles and opens introitus. • Insert speculum at 45-degree angle downward toward the small of woman’s back. • After blades are fully inserted, open them by squeezing handles together. • Cervix should be in full view. • Try closing blades by tightening the thumbscrew.

14. Normal Findings: Color: normally pink,even; 2nd month preg. Blue (Chadwick’s sign); past menopause-pale. Position: midline,anterior or post. Projects 1-3 cm into vagina. Size: Diameter-2.5 cm (1”). OS: Small, round in nulliparous, horizontal irreg. slit, may show healed laceration on sides. Abnormal Findings: Redness, inflammation Pallor wit anemia, cyanotic other than with pregnancy. Lateral position- adhesion or tumor. Projection >3 cm may be prolapse. Hypertrophy > 4 cm occurs with inflammation or tumor. Inspect the cervix and its os

15. Surface: Smooth, eversion, or ectropion, past vaginal delivery; Endocervial canal everted or rolled out. Red, beefy halo inside the pink cervix surrounding os. Surface reddened, granular, asymmetric, around os. Friable, bleeds easily. Any lesions: white patch on cervix, strawberry spot. Refer any suspicious, red, white, or pigmented lesion for biopsy.

16. Normal Findings: As you remove the speculum, inspect vaginal wall. Pink, deeply rugated, moist, smooth, normal discharge thin, clear, opaque, stringy, odorless. Abnormal Findings: Inflammation, lesions. Leukoplakia, appears as spot of dried paint. Vaginal discharge: thick, white, curdlike with candidiasis, profuse, watery, gray-green, frothy with trich.; or gray, green-yellow, white, or foul odorous discharge. Inspect the Vaginal Wall

17. Bimanual Exam

18. Technique of exam: 1.Lithotomy position, 2.lubricate fingers of gloved hand. 3. Insert fingers into vagina posteriorly. 4. Use both hands to palpate internal genitalia to assess location, size, & mobility, screen for tenderness or mass. 5. One hand is on the abdomen, the other into the vagina. 6. Palpate the vaginal wall. Should feel smooth, no area of induration or tenderness. 7. Locate cervix in midline. Palpate using palmar surface of fingers. Note consistancy. Bimanual Exam

19. Normal findings of cervix: Consistency: smooth, firm, tip of nose. Softens, feels velvety at 5-6 wks gest. (Goodell’s sign). Contour: Evenly rounded. Mobility: With finger on either side, move cervix gently from side to side. No pain. Abnormal findings of cervix: Nodule, Tenderness. Hard with malignancy, Nodular, Irregular, Immobile with malignancy.

20. Palpate Uterus with intravaginal fingers in ant. fornix. Palpate with abdom. Hand midway between umb. And sympthysis. Palpate uterine wall with fingers in fornices, firm, smooth, with contour of fundus rounded, freely movable, nontender. Palpate Adnexa on lower quadrant inside ant. Illiac spine with intravaginal fingers in lateral fornix. May not be palpable. Abnormal findings: Painful with inflammation or ectopic pregnancy. Enlarged uterus, lateral displacement, nodular mass, irregular, asymmetric uterus, fixed, immobile, tenderness. Enlarged adnexa, nodules or mass. Immobile, marked tenderness, pulsation, palpable fallopian tube. Palpation of pelvic organs:

21. Retrovaginal Exam Technique: • Use this tech. when assessing rectovaginal septum, post. Uterine wall, cul-de-sac, and rectum. • Change gloves- avoids spreading poss. Infection. • Lubricate first two fingers. • Instruct pt. poss. Feeling of discomfort. • Ask pt. to bear down as fingers are inserted into vagina, middle finger is gently inserted into rectum, while pushing with abdominal hand. • Note: Rectovaginal spetum-smooth, thin, firm, pliable. • Rectovaginal pouch, or cul-de-sac- not palpated. • Uterine wall and fundus feel firm, smooh. • Rotate intrarectal finger to check rectal wall and anal sphincter tone. • Give pt. tissue to wipe area, help her up. Remind her to slide hips back from edge before sitting up.

22. Abnormal Findings of External Genitalia • Pediculosis Pubis (Crab Lice): Severe perineal itching, excoriations, erythematous areas. May see little dark spots, nits (eggs) adherent to pubic hair near roots.

23. Syphilitic Chancre • Begins as small, solitary silvery papule, erodes to red, round • or oval, superficial ulcer with yellowish serous discharge. • Palpation- nontender indurated base; can be lifted like button • between thumb and finger.

24. Herpes Simplex Virus- Type 2 • Episodes of local pain, dysuria, fever. • Clusters of small, shallow vesicles with surrounding erythema, erupt on genital areas, inner thigh. Vesicles on labia rupture in 1-7 days, leaving painful ulcurs. Initial infection lasts 7-10 days. Virus remains dormant indefinitely; recurrent infections last 3-10 days with milder symptoms.

25. Red Rash- Contact Dermatitis • History of skin contact with allergenic • substance in environment, intense • pruritus. • Primary lesion- red, swollen, vesicles. • May have weeping of lesions, crusts, • scales, thickening of skin, excoriations • from scratching. May result from reaction • to feminine hygiene spray, synthetic • underclothing.

26. Genital Human Papillomavirus (HPV, Condylomata Acuminata, Genital Warts • Painless warty growths, may • Be unnoticed by woman. • Pink or flesh-colored, soft, • pointed, moist, warty papules. • Single or multiple in cauli- • flowerlike patch. Occur around • vulva, introitus, anus, vagina, • cervix.

27. Terminology related to assessment of male reproductive systems: • Penis: External reproductive organ of the male through which the urethra passes. Composed of three cylindrical columns of erectile tissue: two corpora cavernosa on dorsal side, one corpus spongiosum ventrally. • Glans: (Corpus spongiosum) Cone of erectile tissue, found at the distal end of shaft. • Urethra: Tube leading from urinary bladder to outside of body, transverses the corpus spong., and its meatus forms a slit at the glans tip. • Frenulum: A fold of forskin extending from urethral meatus ventrally. • Scrotum: A loose, protective sac, encloses testes. • Epididymis: Highly coiled tubule that leads from the seminiferous tubules of the testis to the vas deferens. Main storage site of sperm.

28. Vas Deferns: A muscular duct or tube that leads from the epididymis to the urethra of the male reproductive tract. • Spermatic cord: Ascends along the posterior border of the testes and runs through the tunnel of the inguinal canal into the abdomen. • Ejaculatory duct: A duct of the seminal vesicle behind the bladder which empties into the urethra. • Lymphatics: Where the penis and scrotal surface drain into the inguinal lymph nodes, those of testes drain into the abdomen.

29. Gloves- Wear gloves during every male genitalia exam. Occasionally: glass slide for urethral specimen Materials for cytology Flashlight Examination Equipment Needed for Male Anatomy:

30. Positioning for Male Examination: • Position male standing with undershorts down, with appropriate draping. • Examiner should be sitting. (Male may be supine for first part of exam, standing for hernia check. 3. Take time for pt. to discuss genitourinary history.

31. Normal Findings: Penis: skin wrinkled, hairless, no lesions. Glans: smooth, no lesions. Retract uncircumcised forskin. Cheesy smegma uncer foreskin may be noted. Always slide foreskin back to original position. Abnormal Findings: Inflammation, solitary ulcer, grouped vesicles, superficial ulcers, wartlike papules. Inflammation, lesions on glans or corona. Phimosis- unable to retract foreskin. Paraphimosis- unable to return forskin to original pos. Hypospadias- ventral location of meatus. Epispadias- dorsal location of meatus Pubic lice or nits- excoriated skin Stricture- narrowed opening Edges that are red, everted, edematous, purulent discharge (urethritis). Nodule, induration, tenderness Inspection and palpation of male reproductive system:

32. Normal Findings: Inspect scrotum as male holds penis. Scrotal size varies with room temp. Should be asymmetrical with left scrotal half lower than right. Spread rugae out between fingers, Inspect post. surface. Palpate gently ea. Half between thumb and first two fingers. Contents should easily slide. Testes palpable, oval, firm, rubbery, smooth, equal bilat. Freely movable. Epididymis feels discrete, softer than testis, smooth, nontender Abnormal Findings: Scrotal swelling (edema) taut and pitting. (Heart failure, renal failure, local inflammation. Lesions Inflammation Absent testes, temporary migration, true cryptorchidism Atrophied testes-small, soft Fixed testes Nodules on testes or epididymides Marked tenderness Indurated, swollen, tender epididymis (epididymitis) Inspection and palpation of scrotum

33. Inspect each spermatic cord between thumb and forefinger, along its length from epidiymis to external inguinal ring. Should feel smooth, nontender cord. Any mass? Note tenderness, distal or proximal to testes, can you place finger over it?, does it reduce when pt. lies down, can you auscultate bowel sounds over it. Transillumination: Perform this maneuver if you note swelling or mass. Darken room, shine flashlight from behind scrotal contents, normal scrotal contents do not illuminate. Abnormal findings: Thickened cord, soft, swollen, tortuous. Abnormalities in scrotum: hernia, tumor, orchitis, epididymitis, hydrocele, spermaatocele, varicocele. Serous fluid does trasilluinate and shows red glow, e.g., hydrocele, or spermatocele. Solid tissue and blood do not transilluminate, e.g., hernia, epidiymitiis, or tumor.

34. Normal Findings: Technique- 1. Inspect inquinal region for bulge as pt. stands and strains. Normally, none is present. 2.Palpate right side of inquinal canal by asking pt. to shift wt. onto left leg. Place right index finger low in the right scrotal half. Palpate up length of spermatic cord, invaginating scrotal skin as you go, to external inguinal ring. Feels like triangular slitlike opening, may go easier if you ask pt. to bear down. Normally, there is no change. Repeat procedure to left side. 3. Palpate inguinal lymph nodes by palpating horizontal chain along groin inferior to ligament and vertical chain along inner thigh. Normal- feels small, soft, discrete, and movable. Abnormal Findings: Bulge at external inguinal ring or femoral canal (hernia may be present but easily reduced and may appear only intermittently with increase in intraabdominal pressure.) Palpable herniating mass bumps your fingertip or pushes against the side of your finger. Enlarged, hard, matted, fixed nodes. Inspect for hernia

35. Always encourage self care by: Teaching every male from 13-14 years old through adulthood to perform testicular self-examination (TSE).