Chapter 70: Sexuality, Fertility and Sexually Transmitted Diseases

Refers to which gender or genders an individual finds physically and/or emotional attractive and sexually desirable.

Sexual orientation

Individuals who are attracted to the opposite sex.

Heterosexual

Individuals who are attracted to persons of the same sex.

Homosexual

Men who are sexually attracted to other men, or, women who are sexually attracted to other women.

Gays

A nurse works with many women who self-identify as lesbian or bisexual. What action by the nurse would best address this population's needs?

A. Aggressive screening for sexually transmitted infections

B. Assisting with procedures related to conception

C. Providing information on increased cancer risks

D. Using questions that do not assume sexual orientation

ANS: D

Lesbians and bisexuals are more likely to report poor physical or mental health compared with heterosexual women. Although the origins of this are not totally clear, one factor may relate to the homosexual/bisexual womans hesitancy in seeking health care. Nurses can greatly assist with this by being nonjudgmental and by using language and questions that do not assume sexual orientation. Sexually transmitted infections do occur in this population, although woman-to-woman transmission is lower than man-to-woman transmission. Some lesbian women do seek to become pregnant and bear children; they should be apprised of all available options. Lesbian women have increased risks for breast, endometrial, and ovarian cancer. Although all options are feasible, the option that has the potential to have the greatest impact is the one related to neutral language, which can be perceived as welcoming and accepting.

Observable physical injuries are documented and often photographed. Helping to collect evidence is a key nursing intervention. It is important to?

Follow hospital and police policies regarding any evidence obtained during the examination.

Support systems for the victims of SV/IPV/Rape:

- Crisis intervention centers

- Rape centers

- Special telephone services

- Group therapy

Many of the victims of violence later experience flashbacks and other symptoms of?

Posttraumatic stress disorder (PTSD)

Medications that can interact with medications used to treat ED. Significant, even fatal, side effects can occur.

- Nitrates

- Anticoagulants

- Alpha blockers

- Some antihypertensive drugs

Culmination of sexual excitement

Orgasm

Women experiencing sexual dysfunction should be referred for?

medical and psychological counseling.

Medical causes for female sexual dysfunction include:

- Dysparenunia

- Vaginismus

- Hormonal imbalances

Which nursing diagnosis could be applied to both a patient who is upset that she has developed vaginismus associated with fear of pregnancy as well as a patient with diabetes who is concerned that he cannot attain an erection?

A. Sexual dysfunction

B. Sexual arousal disorder

C. Sexual aversion disorder

D. Ineffective sexuality pattern

Answer: A. Sexual dysfunction

Painful intercourse as seen in endometriosis, ovarian cysts, or vaginitis

Dyspareunia

Painful, involuntary spasms of vaginal outlet muscles, which prevent penile penetration

Vaginismus

Loss of estrogen, as seen with menopause, hysterectomy, or some chronic illnesses (e.g., diabetes)

Hormonal imbalances

The nurse working in a family practice clinic assesses women for sexual dysfunction. Which woman would the nurse assess as having a sexual dysfunction?

A. Complains about lack of arousal but still has intercourse

B. Enjoys a platonic relationship with her "gentleman friend"

C. Needs increased foreplay in order to reach an orgasm

D. No desire for intimacy and is comfortable with the situation

ANS: A

Sexual dysfunction is defined as any sexual situation that causes personal distress for the woman herself. If the woman is comfortable with the situation, there is no dysfunction. Dysfunction can occur in the physical, emotional, or relationship aspect of sexuality. The woman who complains of lack of arousal has a dysfunction even though she still is sexually active. The other women do not manifest complaints or personal distress about their situations.

Risk Factors Affecting Male Infertility

- Azoospermia or oligospermia

- Cryptorchidism

- Orchitis after mumps

- Irradiation of the testes (exposure to x-rays)

- Exposure to toxins (eg, lead, mercury)

- Cigarette or marijuana smoke

- Alcohol consumption

- External environmental temperature exposures such as hot tubs

- Use of some types of prescription drugs

- Untreated STDs

- Obesity

- Internal adhesions

- Glandular disturbances

- Infection

- Impotence or emotional tension

- Diseases or disorders such as cystic. fibrosis and diabetes mellitus

A procedure in which oviducts are inflated with carbon dioxide to determine patency (openness) of the fallopian tubes.

Rubin test

An x-ray study that looks for problems within the fallopian tubes and uterus.

Hysterosalpingogram

May be performed to determine whether uterine lining is undergoing normal changes necessary to receive a fertilized ovum.

Light curettage (scraping) of uterus

Diagnosis of female infertility

Specific risk factors evaluated and treated if possible

A woman can determine when she ovulates by using this, which have small, chemically infused test sticks that monitor LH levels.

Commercial OTC ovulation kits

Symptoms of ovulation also include?

A slightly elevated temperature and changes in appearance and consistency of cervical mucus.

Percentage of infertility in both male and female treated with:

85% to 90%

Also known as in vitro fertilization (IVF), uses both eggs and sperm. The procedures involve removal of a woman's eggs, which are surgically taken from her ovaries and combined with sperm in a laboratory for fertilization.

Assisted reproductive technology (ART)

Is a more recent addition to the types of ART that uses one selected embryo taken from collected fresh or cryopreserved (frozen) embryos. The one embryo is placed in the uterus or fallopian tube. This procedure helps women to avoid the risk of multifetal pregnancies (two or more children born at the same time).

Elective single-embryo transfer (eSET)

The specific method of treating infertility depends on?

The cause or causes of the infertility.

Problems with ART include:

- Relatively high rates of multiple deliveries

- Preterm deliveries

- Low-birth-weight infants.

Public health and social concerns related to ART

Involve the costs and resources needed to care for these high-risk newborns.

The only 100% effective method of birth control and protection against sexually transmitted diseases.

Continual abstinence

An ancient form of BC. The man must be aware of the approach of his climax (ejaculation) and withdraw from the vagina prior to it. When the best techniques are used, this method has about an 80% to 90% protection against pregnancy, which is increased to nearly 100% when a condom is used. No protection against STDs.

Withdrawal (coitus interruptus)

Sometimes this technique is called natural family planning, involve determining when an egg is released from the ovary (ovulation), when a woman is most likely to be fertile. Only about 75% to 99% effective.

Fertility awareness methods (FAMs) can also be called the rhythm method or periodic abstinence.

Widely used in the United States and Canada. They are prescription drugs containing hormones.

Oral contraceptives, also called birth control pills (BCPs), or "the pill."

Rare but serious health problems can occur with BCPs. Women older than 35 years who smoke are among those at highest risk for these serious conditions.

Clients may complain of chest or abdominal pain, severe headaches, and blurred vision. Swelling or aching in the legs and thighs can be an indicator of a thrombus (blood clot) in the legs. A thrombus can break from its site of origin and become an embolus (a traveling clot). Emboli can cause serious or fatal consequences related to blockage of blood vessels in the lungs (pulmonary emboli), heart (myocardial infarction)

The nurse teaches a patient the acronym "ACHES" for the serious symptoms that must be reported immediately when taking oral contraceptive pills. Which manifestations does this include? (Select all that apply.)

A. Abdominal pain

B. Chest pain

C. Headaches

D. Eye pain

E. Sore muscles

ANS: A, B, C, D

ACHES stands for abdominal pain, chest pain (or shortness of breath), headaches, eye problems, and severe leg pain. Muscle soreness is not part of the acronym.

Non-contraceptive health benefits include decreased rates of?

- PID

- Cancers of the ovary and endometrium

- Recurrent ovarian cysts

- Benign breasts cysts

A small, T-shaped, flexible, plastic insert that a healthcare provider inserts into a woman's uterus. Prevent fertilized ovum from implanting in uterus. Offers continuous protection without active participation. No protection against STDs.

Intrauterine device (IUD)

A nurse is explaining contraceptive options to a young woman. What benefits of an IUD does the nurse describe? (Select all that apply.)

A. Appropriate with dysmenorrhea

B. No interference with spontaneity

C. No daily attention required

D. No hormonal side effects associated with the Copper T 380A

E. One-time expense

ANS: B, C, D, E

Benefits of the IUD include no continued expense, no daily attention required, no interference with sexual pleasure or spontaneity, possible decrease in risk of endometrial cancer and ectopic pregnancy, and no hormonal side effects associated with the copper-bearing IUD. The IUD is not appropriate for women who have severe dysmenorrhea or menorrhagia

IUDs increased incidence of?

- PID

- Tubal pregnancies

- Infertility

- STD infection rates increase in women who have many partners

- Greatest danger is uterine or cervical perforation

Considerations Related to an Intrauterine Device (IUD)

• The client may feel a sharp pain when the IUD is inserted.

• The client may have cramps for a few days, but these should not continue.

• Menstrual flow may be heavier, or last longer than normal, after IUD insertion.

• The device may be expelled within the first few months. (If the client does not expel it within 2 to 3 months, it probably will remain in place.)

• The client should check monthly to make sure the IUD is in place. (Slender threads attached to the device can be felt protruding from the cervix.)

• The client should have a yearly Pap test and pelvic examination to assure there is no irritation from the IUD.

Interfere with conception by physically preventing sperm from fertilizing ova.

Barrier methods

The individual with the lowest risk for sexually transmitted pelvic inflammatory disease is a woman who uses

a. oral contraceptives.

b. barrier methods of contraception.

c. an intrauterine device for contraception.

d. a Norplant implant or injectable Depo-Provera for contraception.

Answer: b. barrier methods of contraception.

These consist of various types of condoms, which are thin latex or plastic sheaths designed in the shape of a penis.

Mechanical barriers - male barrier methods

These include the cervical cap, diaphragm, and female condom.

Female Barrier Methods

Brand name FemCap, is a thimble-shaped silicone cup that is inserted into the vagina to cover the cervical opening.

Cervical cap

The clinic nurse obtains a history from women who wish to use a cervical cap as their method of contraception. The nurse assesses for relative or absolute contraindications to this contraceptive device, including which of the following? (Select all that apply.)

A. Patient is a commercial sex worker.

B. Patient has history of an abnormal Pap test.

C. Patient has human papillomavirus infection.

D. Patient has silicone allergy.

E. Patient is nulliparous.

ANS: A, B, C, D

Certain women are not suitable candidates for the cervical cap. Patients who have a history of toxic shock syndrome, pelvic inflammatory disease, cervicitis, papillomavirus infection, a previous abnormal Pap test or cervical cancer, undiagnosed vaginal bleeding, or a silicone allergy should choose another contraceptive method. In addition, women who have an abnormally short or long cervix may not be able to use a cervical cap satisfactorily. Because the cervical cap can cause irritation, it is not advisable for women who are at high risk for HIV, such as commercial sex workers. Parity has no bearing on suitability for using this device.

A silicone, dome-shaped shallow cup that covers the cervix. This should not be left in for more than 24 hours.

Diaphragm

A woman who was recently fitted for a diaphragm is in the clinic for a follow-up visit. Which statement by the patient indicates that teaching was effective?

A. "An added benefit is that it contains my menstrual flow."

B. "Baby oil is a cheap and effective lubricant for the diaphragm."

C. "I leave the diaphragm in place for 6 hours after intercourse."

D. "This diaphragm will have to be replaced within 3 years."

ANS: C

The diaphragm should be left in place for 6 hours after intercourse. If intercourse occurs again before 6 hours have passed, the diaphragm must be left in place for 6 hours after the last act of intercourse. Diaphragms should not be used during a womans menstrual period. Oil-based lubricants such as baby oil can deteriorate the latex. The diaphragm should be replaced every 2 years.

Is worn inside the woman's vagina. It is a pouch made of thin latex attached to two flexible rings; one ring is inserted internally and the other left to open externally.

Female condom

A nurse is working with a young couple whose contraceptive choice is latex condoms. What statement by either partner indicates the need for more teaching?

A. Man: "I don't carry these in my wallet in my pants pockets."

B. Man: "I make sure I am using the correct size of condom."

C. Woman: "I ask him to check the expiration dates each time."

D. Woman: "I buy nonoxynol-9 spermicide to use with condoms."

ANS: D

Nonoxynol-9 (N-9) spermicide is no longer recommended for use with condoms because of higher costs, shorter shelf life, and lack of additive benefit when compared to other spermicides. Also, N-9 can cause genital lesions and increases the womans risk of acquiring HIV and other sexually transmitted infections, especially when the condoms are used often. The other statements are correct. Condoms should be stored in a cool place, which makes placing them in wallets or pants pockets an incorrect action. Men should be sure to use the correct size. Condoms should be discarded if they are past their expiration date.

A combination method of BC using a barrier, made of polyurethane foam, and a spermicide, nonoxynol-9. A risk of toxic shock syndrome (TSS) exists if it is left in for more than 30 hours. The sponge does not protect against STDs or HIV/AIDS.

Vaginal sponge

The family planning clinic nurse reviews the signs and symptoms of toxic shock syndrome (TSS) with a patient who is being fitted for a diaphragm. The nurse explains that the patient should promptly seek medical attention if she develops which of the following manifestations? (Select all that apply.)

A. Develops a generalized red rash

B. Develops a fever over 101.1°F (38.4°C)

C. Experiences difficulty breathing

D. Feels lightheaded, is dizzy, or has chills

E. Has swelling of the face or neck

ANS: A, B, D

The diaphragm should not be used during menses due to the risk of toxic shock syndrome (TSS), a rare, sometimes fatal disease caused by toxins produced by certain strains of the bacterium Staphylococcus aureus. Common signs of TSS include fever of sudden onset greater than 38.4C (101.1F), rash, and hypotension with a systolic blood pressure less than 90 mm Hg, leading to dizziness or lightheadedness. Shortness of breath and facial swelling do require medical attention but are not related to TSS.

Involve the use of a spermicide.

Chemical barriers

Spermicides are chemicals that immobilize or kill sperm and block the cervix to inhibit sperm from traveling to an egg. They are available in a variety of forms, including:

- Spermicidal creams

- Vaginal foams

- Film

- Gels

- suppositories

- Tablets

Discouraged by healthcare providers

Induced abortion

Permanent BC

Sterilization

Vas deferens (ductus deferens) is ligated (tied off) and sometimes partially removed. Reversals (reattaching the vas deferens) not uncommon but often unsuccessful.

Vasectomy

The most common and effective procedure for permanent sterilization in women. Ligating (tying off) the fallopian tubes. Outpatient procedure via laparoscopy. Performed after vaginal delivery, abdominal surgery and may be done vaginally.

Tubal ligation

Side effects of tubal ligation

- Mild postoperative cramping

- Referred pain to shoulder

Lifetime Considerations Related to STDs. Sexually transmitted diseases may:

• Increase your chances of infection with human immunodeficiency virus (HIV).

• Increase your chances of infection with other STDs (co-infections).

• Have significant side effects for the individual including minor symptoms that range from irritation, discharge, or pain to significant permanent consequences such as PID, inability to reproduce, and death.

• Have few, inconsistent, confusing, or no symptoms.

• Cause significant side effects and/or death in newborns.

• Cause infections that lead to pelvic inflammatory disease (PID) and/or infertility.

• Cause infections of the mouth, throat, respiratory tract, urethra, and reproductive organs in both men and women.

• Cause infections that reoccur when re-exposed by a partner who has not been diagnosed or who had incomplete treatment.

• Can occur at any age, but are most common in sexually active young adults.

• Are less common in individuals who are tested for STDs and are in monogamous relationships.

Signs and symptoms of HIV

- Rapid weight loss

- Dry cough

- Fever, night sweats

- Profound fatigue

- Enlarged lymph nodes

- Severe diarrhea lasting more than 1 week

- White spots or unusual blemishes on the tongue or mouth, or in the throat

Is caused by invasion of the bacteria Neisseria gonorrhoeae, also known as gonococcus (GC).

Gonorrhea

Gonorrhea initial symptoms for men

- Burning sensation during urination

- Yellowish-white discharge from penis

- Painful or swollen testicles are common.

- Prostatitis Sterility

-Without treatment progresses to the epididymis

A client has exposure to the Neisseria gonorrhoeae organism and becomes infected. Which symptom would be noted in the client immediately after the infection?

Dysuria

A 48-year-old male patient who has been diagnosed with gonococcal urethritis tells the nurse he had recent sexual contact with a woman but says she did not appear to have any disease. In responding to the patient, the nurse explains that

a. women do not develop gonorrhea infections but can serve as carriers to spread the disease to males.

b. women may not be aware they have gonorrhea because they often do not have symptoms of infection.

c. women develop subclinical cases of gonorrhea that do not cause tissue damage or clinical manifestations.

d. when gonorrhea infections occur in women, the disease affects only the ovaries and not the genital organs.

ANS: B

Many women with gonorrhea are asymptomatic or have minor symptoms that are overlooked. The disease may affect both the genitals and the other reproductive organs and cause complications such as pelvic inflammatory disease (PID). Women who can transmit the disease have active infections.

Is caused by a highly contagious, destructive bacterial spirochete (Treponema pallidum) that can have grave consequences throughout the body.

Syphilis

The end stage of the disease. Dementia, lack of muscle coordination, paralysis, gradual blindness, and death occur.

Tertiary syphilis

Are the causes of genital herpes, sexually transmitted viral infections.

Herpes simplex virus type 1 (HSV-1) and the more common STD, herpes simplex virus type 2 (HSV-2)

Pregnant women can shed the virus at the time of delivery, causing potentially fatal infections in the newborn. What is commonly scheduled if a mother has active, or history of, genital herpes?

A cesarean delivery

Genital herpes infection makes individuals more susceptible to HIV infection.

Persons with existing HIV infection are more likely to become infected with HSV, as well as other STD.

Risk factors for genital herpes infections include:

• Multiple sexual partners

• Age ranging from 14 to 50 years

• Low socioeconomic status

• Minority ethnic origin

• Female gender

• Same gender sexual activity

• HIV infection

Client teaching about HSV includes:

- Instruction on use of standard precautions and restricting others from using items that come in contact with the lesions, such as a toothbrush.

- During active outbreaks, an infected person should not share food or engage in kissing.

- Meticulous handwashing is necessary to prevent the spread of the lesions to another part of the body.

Linked with abnormal Pap smears, indicating cancer of cervix. Cancer of anus and penis also possible.

Genital Human Papillomavirus

HPV infections are very common, but have?

very few signs or symptoms

Sexually active person at risk for getting Genital HPV:

- Male is often the carrier of HPV

- Infects and causes cervical cancer in females

- Third most common malignancy in women

Is caused by the parasitic protozoan Trichomonas vaginalis. Second most common vaginitis.

Trichomoniasis, also known as trichomonas or "trich"

In women, signs and symptoms of trichomoniasis include:

Itching and burning of the vulva accompanied by a copious, foul-smelling, greenish-yellow or gray, frothy or bubbly discharge.

Factors that trigger growth of trichomoniasis include:

• Pregnancy

• Sexual activity

• Irritation of vaginal walls

• Trauma to the vaginal walls

• Systemic illness

• Menstruation

• Emotional upsets

A nonspecific term that implies inflammation and possible bacterial infection of the vagina.

Bacterial vaginosis (BV) or vaginitis

BV causes a "stale fish" vaginal odor with a vaginal discharge, generally no itching or burning. The discharge is a?

Thin, gray-white leukorrhea that may be mild or profuse.

Diagnosis of BV

- Vaginal smear

- KOH prep of microscope slide