Exam 3 pages 36 - 53.pdf

7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 8/25/2022 Treatment. The basic treatment of all testicular cancers includes orchiect...

7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 8/25/2022 Treatment. The basic treatment of all testicular cancers includes orchiectomy, which is done at the time of diagnostic exploration. Surgical therapy is advantageous because it enables precise staging of the disease. Recommendations for further therapy (e.g., retroperitoneal lymph node dissection, chemotherapy, radiation therapy) are based on the pathologic findings from the surgical procedure. Treatment after orchiectomy depends on the histologic characteristics of the tumor and the clinical stage of the disease. Testicular cancer is very responsive to treatment. The NCCN practice census guidelines for testicular cancer are used to guide treatment and follow-up.32 Therapy for testicular cancer can have potentially adverse effects on sexual functioning. Males who have retroperitoneal lymph node dissection may experience retrograde ejaculation or failure to ejaculate because of severing of the sympathetic plexus. Infertility may result from retrograde ejaculation or the toxic effects of chemotherapy or radiation therapy. Sperm banking should be considered for males undergoing these treatments. Important 8/25/2022 DISORDERS OF THE PROSTATE Important 8/25/2022 Infection and Inflammation Important 1/19/2023 Acute Bacterial Prostatitis Important 8/25/2022 Most cases of acute bacterial prostatitis are caused by ascending urethral infection or intraprostatic reflux and are facilitated by numerous risk factors including benign prostate hyperplasia, genitourinary infections, history of sexually transmitted diseases, and being immunocompromised (e.g., having human immunodeficiency virus). These infections may occur from direct inoculation after transrectal prostate biopsy and transurethral manipulations (e.g., catheterization and cystoscopy).36 PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 240/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 8/25/2022 People with acute bacterial prostatitis often present with rapid onset of irritative or obstructive voiding symptoms. Whereas irritative symptoms include dysuria, urinary frequency, and urinary urgency, examples of obstructive voiding symptoms are hesitancy, incomplete voiding, straining to urinate, and weak stream. People may report suprapubic, rectal, or perineal pain.36 Painful ejaculation, hematospermia, and painful defecation may be present. Systemic symptoms—such as fever, chills, nausea, emesis, and malaise— commonly occur, and their presence should prompt physicians to determine if the patient meets the clinical criteria for sepsis. The physical examination should include an abdominal examination to detect a distended bladder and costovertebral angle tenderness, a genital examination, and a digital rectal examination. A digital rectal examination should be performed gently because vigorous prostatic massage can induce bacteremia and subsequently sepsis.36 Urine may be cloudy and malodorous because of urinary tract infection. Rectal examination reveals a swollen, tender, warm prostate with scattered soft areas. Prostatic massage produces a thick discharge with white blood cells that grows large numbers of pathogens on culture. The prostate will often be tender, enlarged, or boggy. Because acute prostatitis is often associated with anatomic abnormalities, a thorough urologic examination is usually performed after treatment is completed. If there is concern for obstructed voiding, postvoid residual urine volumes should be measured using ultrasonography. Final exam content. infection and inflammation. Clinical presentation. Important 1/19/2023 Chronic Bacterial Prostatiti PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 241/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 1/19/2023 Hyperplasia and Neoplasms Benign Prostatic Hyperplasia Benign prostatic hyperplasia (BPH) is a condition in males in which the prostate gland is enlarged but is not cancerous (Fig. 43.8).42 BPH is also called benign prostatic hypertrophy or benign prostatic obstruction. The prostate goes through two growth periods during a man’s life. The first is early in puberty when the prostate doubles in size.42 The second phase of growth begins at age 25 and continues during the remainder of a man’s life. During the second growth phase, as the prostate enlarges, the gland impinges on the urethra, obstructing urine flow. The bladder wall thickens, and eventually the bladder may weaken and lose the ability to empty completely, leaving some urine in the bladder.42 The narrowing of the urethra and subsequent urinary retention are associated with many of the signs and symptoms of BPH (e.g., trouble starting urination, an interrupted urine stream, nocturia). BPH is characterized by the formation of large, discrete lesions in the periurethral region of the prostate rather than the peripheral zones, which are commonly affected by prostate cancer (Fig. 43.9). BPH is one of the most common diseases of aging men. It has been reported that more than 75% of males older than 80 years of age have BPH.2 It is uncommon for males less than 40 years of age to develop BPH. Exam three content. Disorders of the prostate. Clinical presentation. Important 8/25/2022 Pathophysiology and Clinical Manifestations. Important 8/25/2022 Lower urinary tract symptoms suggestive of BPH may include urinary frequency (urination eight or more times a day); urinary urgency (the inability to delay urination; trouble starting a urine stream; a weak or an interrupted urine stream); dribbling at the end of urination; nocturia (frequent urination during periods of sleep); urinary retention; urinary incontinence (the accidental loss of urine); pain after ejaculation or during urination; urine that has an unusual color or smell.42 Symptoms of BPH most often come from a blocked urethra or a bladder that is overworked from trying to pass urine through the blockage. The size of the prostate does not always determine the degree of the blockage or symptoms.42 Some males with greatly enlarged prostates have little blockage and few symptoms, whereas other males who have minimally enlarged prostates have greater blockage and more symptoms. PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 242/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 1/19/2023 A health care provider may refer males to a urologist, or the health care provider may diagnose BPH on the basis of symptoms and a digital rectal exam. A urologist uses medical tests to help diagnose lower urinary tract problems related to BPH. These tests may include urinalysis, a prostate-specific antigen (PSA) blood test, urodynamic tests (i.e., tests for urine flow), cystoscopy, transrectal ultrasound, and biopsy. PSA is a glycoprotein secreted into the cytoplasm of benign and malignant prostatic cells that is not found in other normal tissues or tumors. Blood and urine analyses are used as adjuncts to determine BPH complications (e.g., kidney damage, bladder stones, urinary tract infections). Urinalysis is done to detect bacteria, leukocytes, or microscopic hematuria in the presence of infection and inflammation. The PSA test is used to screen for prostate cancer. These evaluation measures, along with the AUASI, are used to describe the extent of obstruction and to determine if other diagnostic tests and/or treatment are needed. Exam three content. PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 243/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 8/25/2022 Mr. Topers’ International Prostate Symptom Score (IPSS) has increased from between 1 and 2 to 6. He explains that the increased symptoms have negatively influenced his quality of life. His PSA has also had a significant spike from 7 to 12 ng/mL within the last 6 months. Just having an increase in PSA does not warrant a cancer diagnosis by any means, but his digital rectal exam (DRE) showed an increase in prostate size to +3 to +4. Mr. Topers expressed the fear that he may have prostate cancer. The digital rectal examination is used to examine the external surface of the prostate. Enlargement of the prostate due to BPH usually produces a large, palpable prostate with a smooth, rubbery surface. Hardened areas of the prostate gland suggest cancer and should be sampled for biopsy. Residual urine measurement may be made by ultrasonography or postvoiding catheterization for residual urine volume. Uroflowmetry provides an objective measure of urine flow rate. The patient is asked to void with a relatively full bladder (at least 150 mL) into a device that electronically measures the force of the stream and urine flow rate. A urinary flow rate of greater than 15 mL/second is considered normal, and less than 10 mL/second is indicative of obstruction.42 Transabdominal or transrectal diagnostic ultrasonography can be used to evaluate the kidneys, ureters, and bladder. Urethrocystoscopy is indicated in males with a history of hematuria, stricture disease, urethral injury, or prior lower urinary tract surgery. It is used to evaluate the length and diameter of the urethra, the size and configuration of the prostate, and bladder capacity. CT scans, MRI studies, and radionuclide scans are reserved for rare instances of tumor detection. Hyperplasia and neoplasms. Diagnostic/physical exam. Important 8/25/2022 HYPERPLASIA AND CANCER OF THE PROSTATE The prostate gland surrounds the urethra and periurethral enlargement causes manifestations of urinary obstruction. BPH is an age-related enlargement of the prostate gland with formation of large, discrete lesions in the periurethral region of the prostate. These lesions compress the urethra and produce symptoms of dysuria or difficulty urinating. PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 244/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 8/25/2022 Screening. Because early cancers of the prostate usually are asymptomatic, screening tests are important.36 The screening tests currently available are digital rectal examination, PSA testing, and transrectal ultrasonography. However, a positive PSA test indicates only the possible presence of prostate cancer. It can also be positive in cases of BPH and prostatitis. In fact, every man who has an elevated PSA will not necessarily have prostate cancer nor will every man with a known prostate cancer diagnosis by biopsy have an elevated PSA. Measures to increase the specificity of PSA testing in terms of predicting prostate cancer are being developed and evaluated. For example, because PSA levels increase with age, age- specific ranges have been established.36 PSA velocity (a change of PSA level over time) and PSA density (i.e., PSA level/prostate volume as measured by rectal ultrasonography), kallikreins, and other molecular biomarkers are being studied to ascertain if they will be more effective predictors of indolent versus aggressive prostate cancer.36 The American Cancer Society and the American Urological Association recommend that males 50 years of age or older should undergo annual measurement of PSA and digital rectal examination for early detection of prostate cancer.43 Males at high risk for prostate cancer, such as African Americans and those with a strong family history, should undergo annual screening even at an earlier age.43 However, some controversy regarding the widespread use of PSA for screening remains. Informed decision-making regarding screening with PSA is warranted. A new approach, transrectal ultrasonography, may detect cancers that are too small to be detected by physical examination. This method is not used for first-line detection because of its expense, but it may benefit males who are at high risk for development of prostate cancer. Diagnosis. The diagnosis of prostate cancer is based on history and physical examination and confirmed through biopsy methods. Transrectal ultrasonography is used to guide a biopsy needle and document the exact location of the sampled tissue. It is also used for providing staging information. Newly developed small probes for transrectal MRI have been shown to be effective in detecting the presence of cancer in the prostate. Radiologic examination of the bones of the skull, ribs, spine, and pelvis can be used to reveal metastases, although radionuclide bone scans are more sensitive. Important 8/25/2022 In men over age 75, ED has a positive correlation with prostate and urinary problems.10 Important 8/25/2022 Age is the most important single predictor of over-diagnosis of PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created prostate cancer using PSE screening.40 by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 245/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 8/25/2022 The junction of the squamous epithelium of the exocervix and mucus- secreting columnar epithelium of the endocervix (i.e., squamocolumnar junction) appears at various locations on the cervix at different points in a woman’s life (Fig. 45.2).6 During a woman’s reproductive years, the cervix everts or turns outward, exposing the columnar epithelium to the vaginal environment. The combination of hormonal and pH changes, long-term inflammation, and mechanical irritation lead to a gradual transformation from columnar to squamous epithelium—a process called metaplasia. This area of continuous change, or process of repair, is called the transformation zone.6 Important 1/20/2023 Figure 45.2 Location of the squamocolumnar junction (transformation zone) in menarchial, menstruating, menopausal, and postmenopausal women. (A, menarchial; B, menstruating; C, menopausal; D, postmenopausal.) The transformation zone is a critical area for the development of cervical cancer. During metaplasia, the newly developed squamous epithelial cells are vulnerable to development of dysplasia and genetic change if exposed to cancer-producing agents. Dysplasia means disordered growth or development of the cells. Although initially a reversible cell change, untreated dysplasia can develop into carcinoma. The transformation zone is the area of the cervix that must be sampled to have an adequate Pap smear and the area most carefully examined during colposcopy. Colposcopy is a vaginal examination using an instrument called a colposcope that affords a well-lit and magnified stereoscopic view of the cervix. A colposcopy is often done when there is an abnormal PAP smear result. During colposcopy, acetic acid solution and sometimes an iodine-based solution called Lugol’s are used to accentuate topographic or vascular changes that can differentiate normal from abnormal tissue.6 A biopsy sample may be obtained from suspect areas and examined microscopically, as is discussed later in the chapter. Exam three content. Chapter 45. Disorders of the Uterine Cervix. PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 246/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 1/20/2023 Cervicitis and Cervical Polyps Cervicitis is an acute or chronic inflammation of the cervix. Acute cervicitis may result from the direct infection of the cervix or may be secondary to a vaginal or uterine infection. It may be caused by a variety of infective agents, including Streptococcus, Staphylococcus, Enterococcus, C. albicans, T. vaginalis, Neisseria gonorrhoeae, Gardnerella vaginalis, Chlamydia trachomatis, Ureaplasma urealyticum, and herpes simplex virus type 2.1 C. trachomatis is the organism most commonly associated with mucopurulent cervicitis. With acute cervicitis, the cervix becomes reddened and edematous. Irritation from the infection results in copious mucopurulent drainage and leukorrhea.1 Depending on the causative agent, acute cervicitis is treated with appropriate antibiotic therapy. Untreated cervicitis may extend to include the development of pelvic cellulitis, dyspareunia, cervical stenosis, and ascending infection of the uterus or fallopian tubes as is discussed later in the chapter. Exam three content: What is cervicitis? Clinical manifestations PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 247/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 1/20/2023 Cancer of the Cervix Cervical cancer is readily detected and, if detected early, is the most easily cured of all the cancers of the female reproductive system. According to the American Cancer Society, an estimated 13,240 new cases of invasive cervical cancer will be diagnosed in the United States in 2018, with approximately 4170 deaths predicted from cervical cancer during the same period.24 Over the past 40 years, deaths due to cervical cancer have decreased by 50%, indicating that a large number of potentially invasive cancers are cured by early detection and effective treatment.24 Risk Factors. Risk factors for cervical cancer include early age at first intercourse, multiple sexual partners, smoking, and a history of sexually transmitted infections (STIs). Women who have sex with women may have a higher incidence of abnormal Pap smears as they often delay screening. Women who have sex with women should follow the same guidelines for Pap smear screening that heterosexual women follow.23 HPV is an STI passed through genital or skin-to-skin contact. HPV is highly prevalent; at least 50% of people will contract HPV in their life.24 Specific strains, HPV type 16 and HPV type 18, have been associated with cervical cancer.1 Other HPV types that are linked with cervical cancer include HPV types 31, 33, 35, 39,45, 51, 52, 56, 58, 59, and 68.1 Other factors such as smoking, nutrition, and coexisting sexual infections such as C. trachomatis, herpes simplex virus type 2, and HIV may play a contributing role in determining whether a woman with HPV infection develops cervical cancer.24 Preventing Cervical Cancer. The HPV vaccine has decreased the risk of cervical cancer by 97%.1 Gardasil is one type of HPV vaccine to prevent infection with the HPV subtypes 16, 18, 6, and 11. This vaccine has been approved for girls and boys between 9 and 26 years of age (prior to them becoming sexually active) to prevent HPV 6 and HPV 11 genital warts. The vaccine targets the two strains of HPV (HPV 16 and 18) responsible for 70% of cervical cancer, and the two most common benign strains (HPV 6 and 11), which account for up to 90% of genital warts. Clinical studies have confirmed that the vaccine appears safe and effective in inducing a sustained immunity response to HPV.24,25 Gardasil 9 vaccine offers the same protection against the HPV strains that Gardasil does, but additionally, this vaccine protects against five more high risk strains: 31, 33, 45, 52, and 58. These nine strains contribute to 90% of cervical cancers.24 The other FDA approved HPV vaccine is Cervarix, which is recommended to be given to girls between 9 and 25 years of age, prior to becoming sexually active. Cervarix protects against HPV 16 and 18.26 Pathogenesis. With Pap smear cytological screening, precancerous lesions can be detected and treated before cancer develops. Pap smears may note atypical cells. Atypical cells differ from normal cervical squamous epithelium. There are changes in the nuclear and cytoplasmic parts of the cell and more variation in cell size and shape (i.e., dysplasia). These precancerous changes represent a continuum of morphologic changes with indistinct boundaries that may gradually progress to cancer in situ and then to invasive cancer, or they may spontaneously regress.1 A system of grading devised to describe the histopathological findings of dysplastic changes of cancer precursors uses the term cervical PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created intraepithelial neoplasia (CIN).(18a) This term describes premalignant by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's changes in the epithelial tissue. CIN is categorized as: CIN I prior permission. Violators will be prosecuted. (dysplasia or atypical changes in the cervical epithelium) CIN II about:blank 248/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology (moderate dysplasia) CIN III (severe dysplasia)25 Diagnosis. As discussed earlier, abnormal cells can be detected on a PAP smear. Abnormal Pap smear results will return as: atypical squamous cells of undetermined origin (ASC-US); atypical squamous cells of undetermined origin, cannot exclude high-grade squamous intraepithelial lesion (ASC-H); low-grade squamous intraepithelial lesion (LGSIL); high-grade squamous intraepithelial lesion (HGSIL); or squamous cell cancer. If abnormal results are detected, a colposcopy may be done to look for abnormal lesions on the cervix. Biopsies are taken of these potential abnormal lesions or areas of increased vascularity, as well as a curettage of the endocervical canal that may not be fully seen on colposcopy, and sent to pathology. The abnormal PAP smear finding of LGSIL is often CIN I on biopsy, whereas HGSIL on a PAP smear is more likely CIN II or CIN III on a biopsy27 (Fig. 45.3). Exam three content. Prevention of cervical cancer. Testing and interpretation of Papanicolaou Smear. Important 8/25/2022 In its early stages, cervical cancer often manifests as a poorly defined lesion of the endocervix. Frequently, women with cervical cancer present with abnormal vaginal bleeding, spotting, and discharge. Although bleeding may assume any course, it is reported most frequently after intercourse. Women with more advanced disease may present with pelvic or back pain that may radiate down the leg, hematuria, fistulas (rectovaginal or vesicovaginal), or evidence of metastatic disease to supraclavicular or inguinal lymph node areas. Early treatment of cervical cancer involves removal of the lesion by one of various techniques. Biopsy or local cautery may be therapeutic in and of itself. Electrocautery, cryosurgery, or carbon dioxide laser therapy may be used to treat moderate to severe dysplasia that is limited to the exocervix (i.e., squamocolumnar junction clearly visible). Therapeutic conization becomes necessary if the lesion extends into the endocervical canal and can be done surgically or with LEEP in the physician’s office. Important 8/25/2022 Endometrial cancer is the most common cancer found in the female pelvis, occurring more than twice as often as cervical cancer. Most cases of endometrial cancer are adenocarcinomas, with fewer than 1% being sarcomas.37 In 2017, the American Cancer Society estimated that approximately 61,380 women were diagnosed with endometrial cancer and 10,920 died of the disorder. Endometrial cancer occurs more frequently in older women (average age of 60) and less commonly in women under 45 years of age.38 PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 249/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 8/25/2022 The major symptom of endometrial hyperplasia or overt endometrial cancer is abnormal, painless bleeding. In menstruating women, this takes the form of bleeding between periods or excessive, prolonged menstrual flow. In postmenopausal women, any bleeding is abnormal and warrants investigation. Important 8/25/2022 Abnormal bleeding is an early warning sign of the disease, and because endometrial cancer tends to be slow growing in its early stages, the chances of cure are good if prompt medical care is sought. Important 8/25/2022 Although the Pap smear can identify a small percentage of endometrial cancers, it is not a good screening test for this type of gynecologic cancer. Endometrial biopsy (tissue sample obtained in an office procedure by direct aspiration of the endometrial cavity) is far more accurate. Important 8/25/2022 Dilation and curettage (D&C), which consists of dilating the cervix and scraping the uterine cavity, is the definitive procedure for diagnosis because it provides a more thorough evaluation. Transvaginal ultrasonography (TVS) used to measure the endometrial thickness is being evaluated as an initial test for postmenopausal bleeding because it is less invasive than endometrial biopsy and less costly than D&C when biopsy is not possible. Important 8/25/2022 Pelvic Inflammatory Disease PID is a disease NPs need to be familiar with, it is seen more often in the ER, urgent care, and in clinics where adolescent and young women are common patients (college health centers, for example). PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 250/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 1/20/2023 PID is a polymicrobial infection of the upper reproductive tract (uterus, fallopian tubes, or ovaries) associated with the sexually transmitted organisms such as N. gonorrhoeae or C. trachomatis as well as endogenous organisms, including anaerobes, such as Haemophilus influenzae, enteric Gram-negative rods, and streptococci.1,4 Exam three content. Important 1/20/2023 ID is a polymicrobial infection of the upper reproductive tract (uterus, fallopian tubes, or ovaries) associated with the sexually transmitted organisms such as N. gonorrhoeae or C. trachomatis as well as endogenous organisms, including anaerobes, such as Haemophilus influenzae, enteric Gram-negative rods, and streptococci.1 Important 8/25/2022 Factors that predispose women to the development of PID include an age of 16 to 24 years, nulliparity, history of multiple sexual partners, and previous history of PID.42 Important 8/25/2022 Clinical Manifestations The symptoms of PID include lower abdominal pain, dyspareunia, back pain, purulent cervical discharge, and the presence of adnexal tenderness and exquisitely painful cervix on bimanual pelvic examination. Fever (>101°F), increased erythrocyte sedimentation rate, multiple leukocytes on wet mount vaginal microscopy, and coinfection with chlamydia and/or gonorrhea are commonly seen and further support the diagnosis of PID. Elevated C-reactive protein levels equate with inflammation and can be used as another diagnostic tool.42 PID can be so severe that patients develop abdominal abcesses with fistulae formation. These patients require hospitalization. PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 251/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 8/25/2022 Diagnosis and Treatment Laparoscopy, which allows for direct visualization of the ovaries, fallopian tubes, and uterus, is one of the most specific procedures for diagnosing PID, but is costly and carries the inherent risks of surgery and anesthesia.12 Minimal criteria for a presumptive diagnosis of PID require the presence of lower abdominal pain, adnexal tenderness, and cervical motion tenderness on bimanual examination with no other apparent cause.43 Outpatient antibiotic therapy is usually sufficient. However, treatment may involve hospitalization with intravenous administration of antibiotics in some cases. A Important 8/25/2022 The CDC recommends empiric treatment with a presumptive diagnosis of PID, while waiting for confirmation by culture or other definitive test results.42 Important 1/20/2023 Ectopic Pregnancy Although pregnancy is not discussed in detail in this text, it is reasonable to mention ectopic pregnancy because it represents a true gynecologic emergency and should be considered when a woman of reproductive age presents with the complaint of pelvic pain. Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity, the most common site being the fallopian tube (Fig. 45.8). Updated estimates for ectopic pregnancy incidence rates are difficult to determine because many women are now treated on an outpatient basis, so data from hospital discharge records are no longer representative of the scope of the problem. Although ectopic pregnancy is the leading cause of maternal mortality in the first trimester, the death rate has steadily declined as a result of improved diagnostic methods. Exam three content. Ectopic pregnancy. PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 252/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 8/25/2022 The cause of ectopic pregnancy is delayed ovum transport, which may result from decreased tubal motility or distorted tubal anatomy (i.e., narrowed lumen, convolutions, or diverticula). Risk factors most strongly associated with ectopic pregnancy include previous tubal surgery, tubal ligation or reversal, previous ectopic pregnancy, and a tubal lesion or abnormality.44 Smoking, current IUD use, history of PID or therapeutic abortion, and the use of fertility drugs to induce ovulation have also been associated with an increased risk for ectopic pregnancy. Clinical Manifestations The site of implantation in the tube (e.g., isthmus, ampulla) may determine the onset of symptoms and the timing of diagnosis. As the tubal pregnancy progresses, the surrounding tissue is stretched. The pregnancy eventually outgrows its blood supply, at which point the pregnancy terminates or the tube itself ruptures because it can no longer contain the growing pregnancy. Symptoms can include lower abdominal discomfort—diffuse or localized to one side—that progresses to severe pain caused by rupture, spotting, syncope, referred shoulder pain from bleeding into the abdominal cavity, and amenorrhea. Physical examination usually reveals adnexal tenderness; an adnexal mass is found in only about half of cases. Although rarely used today, culdocentesis (needle aspiration from the cul-de-sac) may reveal blood if rupture has occurred. Diagnosis and Treatment Diagnostic tests for ectopic pregnancy include a urine pregnancy test, ultrasonography, and β-human chorionic gonadotropin (hCG; a hormone produced by placental cells) levels. Serial hCG tests may detect lower than expected hCG rise. Transvaginal ultrasonographic studies after 5 weeks gestation may demonstrate an empty uterine cavity or presence of the gestational sac outside the uterus.44 Definitive diagnosis may require laparoscopy. Differential diagnosis for this type of pelvic pain includes ruptured ovarian cyst, threatened or incomplete abortion, PID, acute appendicitis, and degenerating fibroid. Treatment is aimed at resolving the problem with minimal morbidity and protecting future fertility where possible. Important 8/25/2022 Cysts are the most common form of ovarian tumor. Important 8/25/2022 Many are benign. PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 253/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 1/20/2023 Polycystic Ovary Syndrome Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 6% to 15% of women of reproductive age, and is a frequent source of chronic anovulation. The diagnosis of PCOS is made after other endocrine diseases are ruled out and the person has some of the following symptoms: Oligomenorrhea (irregular infrequent periods) Signs of hyperandrogenism (acne and excess body hair [hirsutism]) Elevated testosterone levels on blood testing Polycystic appearing ovaries in which there are numerous small cysts at the periphery of the ovary.47 Unfortunately, we can't cover everything in this course but this is a diagnosis that is being seen more in the clinic. Consider creating a notebook to use in the clinical setting that includes diagnoses with the expected findings. This is helpful , it's impossible to remember everything, a notebook or some other source will facilitate your learning in the clinical setting. Important 1/20/2023 The association between hyperandrogenism and hyperinsulinemia has been recognized. It has been shown that the cause of hyperinsulinemia is insulin resistance. The frequency and degree of hyperinsulinemia in women with PCOS are often amplified by the presence of obesity. Insulin may cause hyperandrogenism in several ways, although the exact mechanism has not been well defined. It has been shown that the ovary possesses insulin receptors and there is evidence that insulin may act directly on the ovary.50 Important 1/20/2023 In addition to its clinical manifestations, long-term health problems including cardiovascular disease and diabetes have been linked to PCOS. There is also concern that women with PCOS who are anovulatory do not produce progesterone. Although there is a reported association with breast, endometrial, and ovarian cancer, PCOS has not been conclusively shown to be an independent risk factor for any of these malignancies.47 Important 1/20/2023 Benign and Functioning/Endocrine Active Ovarian Tumors PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 254/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 1/20/2023 Ovarian Cancer Ovarian cancer is often lethal. According to the American Cancer Society, it is the fifth leading cause of female cancer deaths. The rate of ovarian cancer has declined slowly over the last 20 years. However, in 2017, there were still an estimated 22,440 new cases of ovarian cancer in the United States, with 14,080 deaths.52 Ovarian cancer is difficult to diagnose because symptoms mimic many other benign health issues. Because of this, the disease has often spread before the time of discovery.53 Exam three content. Important 8/25/2022 Epithelial tumors account for approximately 90% of cases.21 Important 8/25/2022 No good screening tests or other early methods of detection exist for ovarian cancer. TVS has been used to evaluate ovarian masses for malignant potential. Although TVS has demonstrated high sensitivity and specificity as a screening tool, cost precludes its use as universal screening method. The serum tumor marker CA-125 is a cell surface antigen. Most ovarian tumors do not secrete hormones, but the cancer antigen CA-125 is detectable in the serum of about half of epithelial tumors confined to the ovary and 90% of those that have spread. PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 255/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology Important 1/20/2023 VAGINAL INFECTIONS After completing this section of the chapter, the learner will be able to meet the following objectives: State the difference between wet-mount slide and culture methods of diagnosis of STIs. Compare the signs and symptoms of infections caused by Candida albicans, Trichomonas vaginalis, and bacterial vaginosis. Candidiasis, trichomoniasis, and bacterial vaginosis are vaginal infections that may be associated with sexual activity. Trichomoniasis is the only form of vaginitis that is known to be sexually transmitted and requires partner treatment. The male partner usually is asymptomatic. Candidiasis Also called yeast infection, thrush, and moniliasis, candidiasis is the second leading cause of vulvovaginitis in the United States. Approximately, 75% of reproductive age women in the United States experience one episode in their lifetime: 40% to 45% experience two or more infections.13 Candida albicans is the most commonly identified organism in vaginal yeast infections. However, other Candida species, such as Candida glabrata and Candida tropicalis, may also be present and be responsible for complicated candidiasis.13 Although vulvovaginal candidiasis usually is not transmitted sexually, it is included in the CDC STI treatment guidelines because it often is diagnosed in women being evaluated for STIs.3 The possibility of sexual transmission has been recognized for many years. However, candidiasis requires a favorable environment for growth of the organism. The gastrointestinal tract also serves as a reservoir for this organism, and candidiasis can develop through autoinoculation in women who are not sexually active. Although studies have documented the presence of Candida on the penis of male partners of women with vulvovaginal candidiasis (Fig. 46.4), few men develop balanoposthitis that requires treatment.13 Figure 46.4 Candidiasis—Women will have vaginal pruritus and usually thick, white, curdlike secretions, but the secretions could be thin. (From Jensen S. (2015). Nursing health assessment: A best practice approach (2nd ed., p. 770). Philadelphia, PA: Lippincott Williams & Wilkins.) Etiology and Clinical Manifestations Reported risk factors for the overgrowth of C. albicans include recent antibiotic therapy, which suppresses the normal protective bacterial flora; high hormone levels owing to pregnancy or the use of oral contraceptives, which cause an increase in vaginal glycogen stores; and uncontrolled diabetes mellitus or HIV infection, because they compromise the immune system.2 Women with vulvovaginal candidiasis commonly complain of vulvovaginal pruritus accompanied by irritation, erythema, swelling, dysuria, and dyspareunia. The characteristic discharge, when present, is usually thick, white, and odorless. In obese people, Candida may grow in skin folds underneath the breast tissue, the abdominal flap, and the inguinal folds. Concept Mastery Alert The person with vulvovaginal candidiasis will have redness, swelling, and painful urination. Discharge will be thick and white because of yeast overgrowth and will be odorless. Diagnosis and Treatment Accurate diagnosis is made by identification of budding yeast filaments (i.e., hyphae) or spores on a wet-mount slide using 20% potassium hydroxide. The pH of the discharge, which is checked with litmus paper, typically is less than 4.5. When the wet-mount technique is negative but the clinical PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created manifestations are suggestive of candidiasis, a culture may be by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's necessary. Antifungal agents such as clotrimazole, miconazole, prior permission. Violators will be prosecuted. butoconazole, and terconazole, in various forms, are effective in about:blank 256/288 7/19/24, 6:06 PM Highlights & Notes: Lippincott CoursePoint for Norris: Porth's Pathophysiology treating candidiasis. These drugs, with the exception of terconazole, are available without prescription for use by women who have had a previously confirmed diagnosis of candidiasis. Oral fluconazole has been shown to be as safe and effective as the standard intravaginal regimen.3 Chronic vulvovaginal candidiasis, defined as four or more mycologically confirmed episodes within 1 year, affects approximately 5% of women and is difficult to manage.13 Subsequent prophylaxis (maintenance therapy) often is required for long-term management of this problem.13 Exam three content. Candidiasis. PRINTED BY: [email protected]. Printing of Notes and Highlights is for personal, private use only. Notes created by user are not part of publisher content. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. about:blank 257/288