4 Conditions of the cervix, uterus.pdf

CONDITIONS OF THE CERVIX/ UTERUS M.W. Muthucumarana (BSc/ MSc)  LO1: Explain Assessment and nursing care for patient with acute and chronic conditions/ diseases of vulva, vagina and uterine corpus and provide nursing care accordingly. Content Cancer of the cervix Cance...

CONDITIONS OF THE CERVIX/ UTERUS M.W. Muthucumarana (BSc/ MSc)  LO1: Explain Assessment and nursing care for patient with acute and chronic conditions/ diseases of vulva, vagina and uterine corpus and provide nursing care accordingly. Content Cancer of the cervix Cancer of the endometrium Myomas of the uterus Endometriosis CANCER OF THE CERVIX  Cancer of the Cervix The growth of abnormal cells in the lining of the cervix. The third most common malignancy in women worldwide The most common type is squamous cell carcinoma Common between ages 35 to 55  Cancer of the Cervix cont. Risk factors History of STDs – sp. HPV - The type and duration (with high risk HPV type and persistent infection predicting a higher risk for progression) Host conditions that compromise immunity (poor nutritional status, immunocompromised, HIV infection) Smoking and vitamin deficiencies Early sexual activity Multiple sexual partners  Cancer of the Cervix cont. Signs and symptoms Diagnostic tests Typically, asymptomatic at early an abnormal Papanicolaou stages (Pap) test result. Abnormal vaginal bleeding Colposcopy Vaginal discomfort Cone biopsy Malodorous discharge Dysuria With the disease progress, constant bleeding and pain radiating to buttocks and legs  Cancer of the Cervix cont. The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used for cervical cancer: Four stages: Stage 0 – Carcinoma in-situ Stage 1 – Confined to cervix A) Identified only microscopically. B) Gross lesions, clinically identifiable.  Cancer of the Cervix cont. Stage 2 – Beyond cervix but not pelvic sidewall/ involves vagina but not lower 1/3 A) No parametrial involvement. B) Obvious parametrial involvement.  Cancer of the Cervix cont. Stage 3 – Extends to pelvic sidewall/ involves lower 1/3 vagina/ hydropnephrosis not explained by another cause. A) No extension to sidewall. B) Extension to sidewall and/or hydronephrosis.  Cancer of the Cervix cont. Stage 4 – Extends to bladder or rectum, or metastases A) Involves bladder/rectum. B) Involves distant organs  Cancer of the Cervix cont. Management Stage-Based Therapy Concerns - maintaining fertility For early invasive cancer, surgery is the treatment of choice. In more advanced cases, radiation combined with chemotherapy is the current standard of care. In patients with disseminated disease, chemotherapy or radiation provides symptom palliation.  Cancer of the Cervix cont. Cryosurgery abnormal cells on cervix are destroyed by freezing. Commonly used refrigerant - Liquid nitrous oxide (N2O). 90% effective Post procedure symptoms – Cramping/ Hydrorrhea (2-4 weeks of profuse watery discharge) /Bleeding Complications – Infection  Cancer of the Cervix cont. LEEP Loop electrosurgical excision procedure use of an electrical current passed through a thin wire hook. The hook removes the tissue. It can be used to remove microinvasive cervical cancer.  Cancer of the Cervix cont. Surgery Conization Radical Vaginal Trachelectomy – removal of most of the cervix, its contiguous parametrium, and vaginal cuff, and pelvic lymphadenectomy Total hysterectomy Conization Radical hysterectomy – removal of the uterus, cervix, upper vagina, and the tissue around the cervix Bilateral salpingo-oophorectomy removal of both fallopian tubes and both ovaries. Bilateral pelvic lymphadenectomy Pelvic exenteration Removal of uterus, vagina, bladder, rectum, lymph nodes, and part of the colon Radical Trachelectomy  Cancer of the Cervix cont. Radiotherapy External-beam radiation therapy radiation given from outside the body Intracavitary application (Brachytherapy) delivered by means of afterloading applicators that are placed in the uterine cavity and vagina usually consists of a specific number of treatments given over a set period of time Side effects - fatigue, mild skin reactions, loose bowel movements, abdominal pain and bowel obstruction usually subside after the treatment.  Cancer of the Cervix cont. Chemotherapy May be used in combination with radiation therapy for locally advanced / metastatic disease- E.g. - Cisplatin Complications of the cervical carcinoma Metastasis External radiation- bone marrow depression, bowel obstruction, fistula, infertility, menopause Internal radiation – cystitis, uterine perforation, vaginal stenosis (vaginal area may lose elasticity, may need to use a vaginal dilator, which is a plastic or rubber cylinder that is inserted into the vagina to prevent narrowing) CANCER OF THE ENDOMETRIUM  Cancer of the Endometrium Carcinoma of the most inner Risk Factors layers of the uterine wall. A prolonged period of anovulation Adenocarcinoma is the most Early menarche and/or late common form (epithelial tissue of menopause glandular origin) Low parity (nulliparous women) Polycystic ovarian syndrome Mostly due to the stimulation of Hormone replacement therapy the endometrial oestrogen Tamoxifen receptors, without the protective effects of progesterone Age between 65 and 75 years. (‘unopposed oestrogen’). Obesity Genetic predisposition  Cancer of the Endometrium cont. Signs and symptoms Diagnostic tests postmenopausal bleeding Transvaginal ultrasound scan - 96% (PMB), – a non-specific of women with endometrial cancer symptom will have an endometrial thickness clear or white vaginal of >5mm discharge, Speculum/Bimanual examination irregular bleeding or intermenstrual bleeding in Hysteroscopy premenopausal women Endometrial biopsy Late signs – pain, fever, bowel and bladder dysfunction MRI or CT scan  Cancer of the Endometrium cont. Staging Based on histologic grade, depth of myometrial invasion, cervical involvement and lymph node involvement FIGO Staging Stage I – Carcinoma confined to within uterine body. Stage II – Carcinoma may extend to cervix but is not beyond the uterus. Stage III – Carcinoma extends beyond uterus but is confined to the pelvis. Stage IV – Carcinoma involves bladder or bowel, or has metastasized to distant sites.  Cancer of the Endometrium cont. Management Hyperplasia (without atypia) can be treated with progestogens Atypical hyperplasia, which has the highest rate of progression to malignancy, should be treated with total abdominal hysterectomy + bilateral salpingo-oophorectomy. Stage I/ II – Radical hysterectomy (surrounding vaginal tissue and supporting ligaments of the uterus also removed), (with/ without lymphadenectomy) Stage III/ IV – Maximal de-bulking surgery (if possible), a palliative approach with low dose radiotherapy (intra-cavitatory / external), chemotherapy , high dose oral progestogens. Cancer of the Endometrium cont.  Nursing care considerations Obtain the history Menstrual history STIs Obstetric history – parity/ infertility/ contraceptives Medication/ hormone replacement Examine the client Assess previous investigation findings Response to diagnosis/ Psychological status/ social issues/stigma  Nursing care considerations cont. Relieve fear and anxiety Provide information on treatment options Prepare clients physically and psychologically for investigations/ surgical interventions/ radiotherapy/ chemotherapy Encourage discourse with family Ensure the support from family Relieve Pain Administer pain medication as prescribed. Monitor the response.  Nursing care considerations cont. Educate on The importance of life long follow up. Avoiding heavy lifting (more than 3–4 kg) for 4–6 weeks The importance of avoiding straining during bowel motions. Continue to manage constipation The importance of a well-balanced diet. Taking showers instead of baths for 4–5 weeks Avoiding sexual intercourse for up to 8 weeks after surgery Hormone changes and emotional difficulties MYOMAS OF THE UTERUS  Myomas of the uterus Leiomyomas/ fibroids Benign tumors of the uterine myometrium Commonly seen in women ages 25-50 May spontaneously regress after menopause classified according to their position in the uterine wall: a) Subserosal – protrudes into the serosal (outer) surface of the uterus. They may be pedunculated (on a stalk) b) Intramural (most common) – confined to the myometrium. c) Submucosal – develops immediately underneath the endometrium, and protrudes into the uterine cavity.  Myomas of the uterus cont. Cause – unknown/ Clinical Features thought to be stimulated by Majority are asymptomatic oestrogen Palpable mass Heavy feeling in pelvis Risk factors Irregular bleeding/ Menorrhagia Obesity Early menarche Subfertility – due to the obstructive effect of the fibroid. Increasing age Family history Pressure effects – pain/ urinary Ethnicity - African-Americans. and bowel disturbances  Myomas of the uterus cont. Management Diagnosis Medical – abdominal or bimanual examination - a Tranexamic acid – for menorrhagia solid mass or enlarged Hormonal contraceptives uterus may be palpable GnRH analogues Pelvic ultrasound Surgical - MRI (rarely) Hysteroscopy and Transcervical Cytology – to rule out Resection of Fibroid (TCRF) malignancy Myomectomy / Hysterectomy Uterine Artery Embolization  Myomas of the uterus cont. Nursing care considerations Reassure the client and help to reduce anxiety as myomas are not malignant and chance of becoming malignant is