1

Gynaecological conditions

2
• At the end of this lesson students should be able
to:
• Define the concepts.
• Discuss the causes .
• Describe the pathophysiology and etiology.
• Outline the clinical manifestations.
• Describe the types/classification/stages.
• Name the surgical procedures
• Recognise the possible complications.
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Ectopic pregnancy continues

4
 Ectopic Pregnancy
Definition
Ectopic Pregnancy
• Is a gestation that implants outside the uterine cavity.
Locations : the Fallopian tube (96%), ovary, cervix, or
abdominal cavity.
Etiology and pathophsiology
• Clinical or structural factors that prevent or delay the
passage of the fertilized ovum:
• Pelvic inflammatory diseases.
• Prior history of ectopic diseases.
• Prior tubal surgery or curettage.
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 Ectopic Pregnancy continues
• Diethylstilbestrol (DES) exposure.
• Adhesions or infections of the tube; salpingitis.
• Congenital and developmental anomalies of the fallopian
tube or uterus.
• Increased maternal age.
• Elective reversed sterilizations.
• Ectopic pregnancy may result in inflammation, rupture,
haemorrhage, peritonitis, or death.

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 Ectopic Pregnancy continues
Clinical Manifestations
• Abdominal or pelvic pain (typically unilateral).
• Irregular vaginal bleeding – scanty and dark .
• Amenorrhea – 75% of the cases.
• Uterine enlargement: size equates to implanted
pregnancy.
• Abdominal tenderness on palpation.
• Radiating shoulder pain
• increased pulse and anxiety.

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 Ectopic Pregnancy continues
• Nausea, vomiting, faintness, vertigo, or syncope.
• Pelvic examination may reveal a pelvic mass, posterior or
lateral to the uterus, adnexal tenderness, and cervical
pain with movement of the cervix.

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 Diagnostic evaluation
• Human chorionic gonadotropin (𝛽-hCG).
Ultrasound - confirm diagnosis

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 Ectopic Pregnancy continues
• Transvaginal ultrasound – identifies tubal mass.
• Increased serum progesterone –means pregnacy is
viability.
• Culdocentesis – aspirate blood from the Cul-de-sac of
Douglas, the posterior fornix of the vagina
• Laparoscopy – abdominal visualization of tubal
pregnancy .
• Laparotomy.

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 Ectopic Pregnancy continues
Management
Conservative Therapy
• Conservative therapy – if patient desires
children in future and in a stable condition
Administer:
• Methotrexate
• Leukovolin imi

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Ectopic Pregnancy continues

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 Ectopic Pregnancy continues

Surgical treatment
• If does not consent to or meet criteria for
methotrexate
• Salpingectomy (removal of portion of a tube with
conceptus).
• Salpingostomy- removal of ectopic pregnancy with
tubal resection.

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 Ectopic Pregnancy continues
• Salpingo-oophorectomy (removal of tube and ovary
on affected side.
• Treat shock and hemorrhage
Complications
• Infertility
• Haemorrhage and death

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 Ectopic Pregnancy continues
Nursing Assessment
• Evaluate the following:
• Maternal vital signs.
• Presence and amount of vaginal bleeding.
• Amount, type, and evolving intensity of pain
• Presence of abdominal tenderness on palpation
accampanied by radiating shoulder pain.
• Date of last menses.

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 Ectopic Pregnancy continues
• Presence of positive pregnancy test.
Nursing Diagnoses
• Deficient Fluid Volume related to blood loss from
ruptured fallopian tube.
• Acute Pain related to ectopic pregnancy or rupture and
bleeding into the peritoneal cavity.
• Anticipatory Grieving related to loss of pregnancy and
potential loss of childbearing capacity.

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 Ectopic Pregnancy continues
Nursing Interventions
• intravenous (IV) line as indicated
• blood component therapy may be prescribed.
• Obtain blood specimen .
• Monitor vital signs and urine output as the patient’s
condition warrants.
Promoting Comfort
Administer analgesics, as needed and prescribed.

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 Ectopic Pregnancy continues
Encourage the use of relaxation techniques.

Providing Support through the Grieving Process

• Be available to patients and provide emotional support;
listen to concerns of patients and significant others.
• Be aware that patient/family may be experiencing denial
or other stages of grief; grief counseling may be
appropriate.
• Note: The term family may refer to a nontraditional group
of person, such as the patient and significant others,
friend, sibling, parent, or grandparent.
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 Ectopic Pregnancy continues
Patient education and Health Maintenance
• Teach signs and symptoms of ectopic pregnancy to
women at risk: increased vaginal bleeding, moderate to
severe abdominal pain (typically unilateral and low),
shoulder pain, nausea, and vomiting.
• Instruct women to report relative signs and symptoms to
primary practitioner or emergency department
immediately.
• Encourage grief counselling and supportive care at home.
• Discuss contraception.

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 Ectopic Pregnancy continues
Evaluation: Expected Outcomes
• Vital signs stable.
• Verbalizes pain relief.
• Patient and support person express appropriate grief
response.

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Picture of uterus

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Ectopic pregnancy

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Ectopic vs Normal pregnancy

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 Gestational trophoblastic (leave)
Providing Emotional Support
1. Encourage frequent visiting and allow as much parental
participation in the child’s care as much as possible.
Hospitalization, if necessary, is usually grief.
2. Allow the child as much activity as tolerated.
a. Balance periods of rest, recreation, and quiet activities
during the convalescent phase.
b. Allow the child to eat meals with the family or other
children.
3. Encourage the child and family to verbalize fears,
frustration and questions.
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 continues
a. Be aware that young children frequently fear
abandonment by their parents.
b. Allow parents to express frustration regarding the
uncertainties associated with the cause of the disease,
the clinical course, and the prognosis.
c. Explain the difference between nephritis and nephrosis if
parents have questions.
4. Help the child adjust to changes in body image, such as
cushingoid appearance, by explaining changes ahead of
time.
5. Discuss the problems of discipline with the parents.
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Encourage them to set consistent limits and reasonable
expectations of the their child’s behaviour.
6. Suggest parents et involved with a support group for families
of children with chronic illnesses, as needed.

Family Education and Health Maintenance

1. Prepare the family for home management of the child’s care
plan.
a. Have the dietitian discuss special diets with the parents.
b. Teach the parents about the child’s medication – the
desired effects and the potential adverse effects.
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c. Demonstrate urine testing for protein.
d. Initiate a community health nursing referral, if necessary,
for reassessment and reinforcement of teaching.
2. Encourage continued medical follow-up visits.
3. Emphasize the necessity of taking medication according
to the prescribed schedule and for an extended time.
Discuss complications encountered with steroid therapy.
4. Teach prevention and recognition of signs and symptoms
of infection.
5. Advise family on necessary activity restrictions.

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6. Teach signs and symptoms of relapse (proteinuria on urine
dipstick at home, increased edema, decreased urine output)
and whom and when to call with questions.
7. Teach signs and symptoms of fluid imbalances (excess or
dehydration).

Evaluation: Expected Outcomes

• Decreased edema ascites; adequate urine output.
• Exhibits no signs of infection.
• Family verbalizes and follows dietary restrictions as
demonstrated by appropriate weight gain/loss.
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• Family verbalizes concerns regarding child’s illness as
demonstrated by open communication with staff and
other family members.

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 Urinary Tract Infection
Definition
• Urinary tract infection (UTI) is defined as bacteria
that exists anywhere between the renal cortex and
the urethral meatus.
• UTI refers to any microorganisms anywhere within
the urinary tract.
• UTIs are categorized as cystitis or urethritis .
• UTI can affect the upper tract causing pyelonephritis

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 Urinary Tract Infection continue
Pathophysiology and Etiology
Causative organisms – E. coli (80%), Klebsiella pneumoniae,
Proteus mirabilis, Staphylococcus, Enterococcus.
Route of Entry:
• ascent from the urethra (most common).
• circulating blood (rare).
Contributing causes:
• female specific.
• perineal location of urethral orifice and shorter urethra.
• sexual intercourse (mechanics of vaginal penetration).
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 Pathophysiology and Etiology cont

• Vaginal voiding – reflux of urine into the vaginal while

voiding, and dribbling of urine.
Male specific – foreskin (prepuce can be a reservoir for
bacteria.
• Abnormal bladder or voiding with or without
incontinence.

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 Pathophysiology and Etiology cont

• High pressure in the bladder.

• Incomplete bladder emptying, infrequent
voiding.
• Difficulty relaxing pelvic floor.
• Constipation.

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 Pathophysiology and Etiology cont
• Congenital urinary tract anomalies – vesicoureteral
reflux, posterior urethra valves, prune belly syndrome,
hydronephrosis, bladder exstrophy.
• Neurogenic bladder (spina bifida, spinal injury).
• Catheterization, urinary drains/tubes.
• Bacterial colonization.

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 Pathophysiology
• Inflammatory changes occur in: kidneys,
ureters, or bladder and urethra.
• Clumps of bacteria may be present.
• Inflammation results in urine retention and
stasis of urine in the bladder.
• Results in vesicoureteral reflux (VUR)--
backflow of urine into the kidneys via ureters;

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 Urinary Tract Infection continue

• Inflammatory changes ocurs in: renal pelvis, and entire

kidney.
• in chronic UTI scarring of the kidney parenchyma
results thus, interferes with kidney function.
• Untreated UTI - the kidney may become small, tissue
may be destroyed, and renal function could fail.

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 Urinary Tract Infection continues
Clinical Manifestation
Onset : abrupt or gradual or asymptomatic.
Failure to thrive in infancy.
Young children:
• may be non specific with :
• vomiting, irritability,
• poor feeding, diarrhoea
• fever - often the only presenting complaint.

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 Clinical Manifestation cont

Older children and adolescents:

• Urinary frequency
• Urgency or voiding hesitancy,
• Dysuria, suprapubic tenderness, dribbling, and
nocturnal enuresis (common in lower UTI).
• Hematuria: often occurs with viral cystitis.

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 Clinical Manifestation cont
• Fever
• May be moderate or severe.
• May fluctuate rapidly.
• May be accompanied by chills or convulsions.
• Anorexia and general malaise.
• Foul odor or change in the appearance of urine.

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 Clinical Manifestation cont
• Abdominal or suprapubic pain (more common
in upper-tract diseases).
• Tenderness over one or both kidneys.
• Systemic symptoms: flank pain, fever, chills,
nausea.
• Vomiting may occur with pyelonephritis.

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 Clinical Manifestation cont

Diagnostic evaluation
Urine culture
Urinalysis
Urologic and radiologic studies :
• Renal ultrasound,
• voiding cystourethrogram (VCUG).
• Dimercaptosuccinic acid scan – evaluates renal function
and scarring.

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 Management
• Depends on:
age, severity of infection,
• and antimicrobial resistance.
• Oral antibiotic therapy for uncomplicated UTIs.
• IV antibiotic for complicated UTI.
• Repeat culture after Rx in case Of:
• symptomatic, chronic renal disease, or
• known colonization of bacteria.

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 Urinary Tract Infection continues

Management

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 Urinary Tract Infection continues
Complications
• Recurrent infection exist.
• highest risk for kidney damage --Children with
obstructive lesions of the urinary tract and those with
severe UTI.
• These patients may need prophylactic oral antibacterial
therapy.

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 Urinary Tract Infection continues
Nursing Assessment
• Obtain history to determine if UTI is initial or recurrent
and to determine if there may be other disease processes
contributing to this infection.
• Focus assessment on identifying clinical manifestation and
determining location of infection, such as presence and
appearance of urethral discharge, high-grade fever (more
common with lower UTI).
• Determine urinary pattern (ie, amount and frequency) and
associated discomfort.
• Determine bowel pattern and possibility of constipation
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 Urinary Tract Infection continues
Nursing diagnoses
• Impaired Urinary Elimination related to infection.
• Acute pain related to inflammatory changes and fever.
• Anxiety related to exposure and manipulation of the
genitourinary tract.

Nursing Interventions
Promoting Urinary Elimination
Obtain a clean urinary specimen for urinalysis or culture
(see page 1457).
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 Urinary Tract Infection continues
• Obtain freshly voided early morning specimen, if possible
(most accurate). This urine is usually acidic and
concentrated, which tends to preserve the formed
elements.
• Provide fluids to help the child void.
• Perform catheterization, if necessary, to obtain a sterile
specimen; however, this procedure may cause emotional
trauma and the accidental introduction of additional
bacteria.
• Send urine to the laboratory immediately or refrigerate
to avoid a falsely high bacterial count.
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 Urinary Tract Infection continues
• Administer antibiotics, as ordered by the health care
provider (after specimen has been obtained for culture).
• Antibiotic therapy is generally determined by the results
of the urine cultures and sensitivities and by the child’s
response to therapy; however, empirical therapy may be
started before culture results are back.
• Become familiar with toxic effects of antimicrobial agents
and assess the child regularly for any signs and
symptoms.

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 Urinary Tract Infection continues
Maintaining Comfort and Providing Symptomatic Relief
• Administer analgesic and antipyretics, as ordered.
• Maintain child on bed rest while febrile.
• Encourage fluids to reduce the fever and dilute the
concentration of the urine. (Water is the best clear fluid.)
• Administer IV fluids, if necessary.

Promoting Self-Esteem
Reinforce medical explanations of the disease and

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 Urinary Tract Infection continues
Its therapy.
• Prepare the child and family for discharge and begin
discussions of rest, fluids, and medications.
•

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 Urinary Tract Infection continues

Family Education and Health Maintenance

1. Review long-term antibiotic therapy, if prescribed, to
prevent recurrence of UTI. Schedules for prolonged
therapy vary from several months to continuous
prophylaxis.
2. Encourage scheduled follow-up visits because of the
possibility of disease recurrence.
a. Emphasize that even though this disease may have few
-

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 Urinary Tract Infection continues
• Symptoms, it can lead to serious, permanent disability.
• Advise family that subsequent suspected UTIs should be
assessed and followed by health care provider.
Teach measures of prevention:
• Minimise spread of bacteria from the anal and vaginal
areas to the urethra in female children by cleansing the
perianal area from the urethra back towards the anus.
• Encourage adequate fluid intake, especially water.
• Avoid carbonated and caffeinated beverages because of
their irritative effect on bladder mucosa.

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 Urinary Tract Infection continues
• Encourage the child to void frequently and to empty the
bladder completely with each voiding (double voiding).
• Encourage a high-fiber diet to avoid constipation.

Evaluation: Expected Outcomes

• Voids regularly in adequate amounts.
• No complaints of pain during or after voiding; aferbrile.
• Shows less anxiety about hospitalization; appears more
relaxed about appearance, body image, tests.

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 Abnormalities of the Genitourinary tract
that require surgery
Definition
Bladder exstrophy :is an abnormality present at birth in
which the bladder and associated structures are
improperly formed. Rather than being its normal round
shape, the bladder is flattened. The skin, muscle, and
pelvic bones joining the lower part of the abdomen did
not form properly so the inside of the bladder is exposed
outside the abdomen. There are also associated
deficiencies of the abdominal muscles and pelvic bones.
There are also associated deficiencies of the abdominal
muscles and pelvic bones. This occur in
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 Bladder exstrophy continues
approximately 1 in 30,000 to 50,000 deliveries, with the
male-to-female

Patient Education and Health Maintenance

1. Encourage compliance with antibiotic therapy for full
length of prescription.
2. Stress the need for sexual abstinence and pelvic rest
(nothing in vagina, including no douching or tampons)
until completion of patient’s and partner’s antimicrobial
regimens, resolution of patient’s and partner’s symptoms,
and follow-up visit.
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 Bladder exstrophy continues
3. Advice testing and empiric treatment of gonorrhea and
chlamydia for all sexual partners (within past 60 days or
more). Tell patient that diagnosis of chlamydia or gonorrhea
necessitates reporting to the public health department and
partners will be traced.
4. Repeat patient and partner testing for gonorrhea and
chlamydia is recommended 3 to 6 months after treatment
completion.
5. Discuss STDs and methods of prevention – abstinence,
monogamy, proper use of female and male condoms. See
page 855.
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 Bladder exstrophy continues
Evaluation: expected Outcomes
• Verbalizes relief of pain.
• Vital signs stable; intake equals output.
• Reports abstinence during treatment period for self and
partner and continued plan to prevent STDs.

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Picture of kidneys

58
Picture of a kidney

59
• Brunner,L,S.,& Suddaarth,(1992).The textbook
of Adult Nursing: London ,Chapman Hall.
• Sandra,M.N.(2010)Lippincott:Manual of
Nursing practice.(9th Ed)Lippincott:New york.
• Mogothlane,S,mots
• chedish C. ,Mokgadi,M.,Joyce ,M.,& Young,A.
(2014)Juta ‘s complete text book of medical
Surgical Nursing.Cape Town:Lebone Publisher

60
 Endometriosis
Definition
Endometriosis is the abnormal proliferation of uterine
endometrial tissue outside the uterus.

Pathophysiology and Etiology

May also be found outside the pelvic cavity
Increases in women ages 25 to 45.
may occur at any age.
Increased risk in siblings.

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 Pathophysiology and Etiology cont

• Women with shorter menstrual cycles, and

longer duration of flow.
More common in:
• white women than black women,
• women who do not exercise, and
• obese women.(Sandra 2010:880).

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 Endometriosis continues
• Responds to ovarian hormonal stimulation – estrogen
increases it; progestin decrease it.
Bleeding during uterine menstruation leads to:
• Accumulated blood and inflammation and subsequent
adhesions and pain.
Regresses during amenorrhea:
pregnancy and menopause and hormonal contraceptive
and androgen use.
Theories of origin:
May be embryonic tissue remnants - spread via

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 Endometriosis continues
• lymphatic or venous channels.
• May be transferred via surgical instruments.
• May be caused by retrograde menstruation through
fallopian tubes into peritoneal cavity.
• Genetic predisposition .
• Via Lymphatic or vascular distribution.

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 Endometriosis continues
Clinical Manifestation
• Depends on sites of implantation; may be asymptomatic.
• Pelvic pain – especially during or before menstruation.
• Dyspareunia.
• Painful defection – if implants are on sigmoid colon or
rectum.
• Abnormal uterine bleeding.
• Persistent infertility (in 30% to 40% of women with
endometriosis).
• Hematuria, dysuria, flank pain – if bladder involved.
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 Endometriosis continues
Diagnostic Evaluation
• Pelvic and rectal examinations
• Transvaginal ultrasound.
• MRI and CT -for inconclusive ultrasound results.
Laparoscopy
• for definitive diagnosis -
view implants,
• obtain tissue for histologic analysis, and determine
extent of disease.

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 Endometriosis continues
Management
Medical
Goal : to decrease pain.
• if therapy is stopped, pain recurs.
• Medical therapies are ineffective for infertility associated
with endometriosis.
• Hormonal contraceptives – combination oral
contraceptives (OCs)

67
• maximum amount of progestin and androgen
effect to decrease implant size.
• Ocs to be used for more than 24 months
effectively decreases endometriosis
recurrence and
• decrease the frequency and intensity of
dysmenorrhea.
•

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 Endometriosis continues
• Progestin – such as depo medroxyprogesterone acetate;
create a hypoestrogenic environment .
• Nonsteroidal anti-inflammatory drugs e.g. ibuprofen,
naproxen sodium – decrease dysmenorrhea .
• IF NSAIDs treatment has not provided adequate pain
relief, then gonadotropin-releasing hormone (GnRH)
agonist (leuprolide) injections – createhypoestrogenic
environment

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 Endometriosis continues
.

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 Endometriosis continues
Danazol – synthetic androgen suppresses endometrial
growth.
Surgical
Laparoscopic surgery – to remove implants and adhesions
by excision; not curative; high recurrence rate.
Carbon dioxide laser laparoscopic – for minimal to

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 Endometriosis continues
• Moderate disease; vaporizes tissue good pregnancy rate.
Laparotomy – for severe endometriosis or persistent
symptoms.
Presacral neurectomy – to decrease central pelvic pain;
preserves fertility.
• limited efficacy in relieving pain; severe constipation
results.
Hysterectomy
• If symptoms are severe
• greater pain relief is achieved when ovaries are also
removed.
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 Endometriosis continues
Complications
• Infertility.
• Rupture of cyst .
• Chronic pelvic pain.
• Dyspareunia.
• Bowel or ureter obstruction.

Nursing Assessment
Obtain history of symptoms to determine spread and
severity of disease.
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 Endometriosis continues
• Assess pain – level, location, frequency, duration,
characteristic, impact on functioning.
• Perform abdominal examination to assess for areas of
tenderness, nodules.
• Assess for impact of endometriosis and/or infertility on
patient and her relationship with significant other.

Nursing Diagnoses
• Acute and chronic pain related to hormonal stimulation,
adhesions.
• Readiness for Enhanced self-Care related to
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 Endometriosis continues
difficult management of disease, infertility.

Nursing Interventions
Reducing Pain
1. Teach use of analgesics and other prescribed medication,
with adverse effect.
2. Encourage use of heating pad to painful areas, as needed.
3. Teach patient relaxation techniques to control pain, such
as deep breathing, imagery, and progressive muscle
relaxation.

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 Endometriosis continues
4. Encourage patient to try position changes for sexual
intercourse if experiencing dyspareunia.

Fostering Enhanced Self-Care

1. Include patient in treatment planning; answer questions
about drug and surgical treatment so she can make
informed choices.
2. Encourage adequate rest and nutrition.
3. Provide emotional support and encourage patient to
discuss treatment of infertility with her physician.
4. Prepare patient for surgery, as indicated.
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 Endometriosis continues
Patient Education and Health Maintenance
1. Instruct patient in the adverse effects of prescribed
medication.
2. Refer patient to support groups such as Endometriosis
Association (www.endometriosisassn.org) and reliable
resources for information such as Endometriosis.org (
http://endometriosis.org).

Evaluation: Expected Outcomes

• Verbalizes reduced pain.
• Verbalizes increased self-care measures.
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Endometrium

78
endometriosis

79
 adhesions between liver and diphgragm

These adhesions are situated between the surface of the right diaphragm and the liver.

80
Definitions of concepts:
• Amenorhea
• Laparatomy
• Culdocentesis
• Laparoscopy
• Laparatomy
• Salpingotomy
• salpingetomy
• Salpingo-oophorectomy
• Salpingitis
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 References
• Sandra, M.N.(2010) Lippincott: Manual of
Nursing practice.(9th Ed) Lippincott: New york.
• Brunner,L,S.,& Suddaarth,(1992).The textbook of
Adult Nursing: London ,Chapman Hall.
• University of Namibia. Faculty of Health Sciences.
School of Nursing and public Health. Operating
room Nursing Science. Bachelor Nursing
Science .Compiled by:Dr A.R.E Kloppers, Ms A.E
Walters, Ms E.L Bampton. Revised: January 2013
82
• Brunner,L,S.,& Suddaarth,(1992).The textbook
of Adult Nursing: London ,Chapman Hall.
• Sandra,M.N.(2010)Lippincott:Manual of
Nursing practice.(9th Ed)Lippincott:New york.
• Mogothlane,S,mots
• chedish C. ,Mokgadi,M.,Joyce ,M.,& Young,A.
(2014)Juta ‘s complete text book of medical
Surgical Nursing.Cape Town:Lebone Publisher

83