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Chapter 23, 26, 27

NSE 13A/B Chapter 23, 26, 27 : NSE 13 Week 10 - ANUS, RECTUM, PROSTATE, MALE & FEMALE GU - ALL JARVIS NOTES
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Department
Nursing
Course
NSE 13A/B
Professor
Jennifer Lapum
Semester
Fall

Description
NSE 13 – Week 10 Male genitourinary (GU) – anus, rectum, prostate, Female genitourinary (GU) system and Sexuality, Sexually Transmitted Infections (STI) Readings: Jarvis Ch. 23, 26 & 27 Weekly Objectives: 1. Self-review anatomy and physiology  Anus, Rectum and Prostate Anus and Rectum o Anal Canal – outlet of GI tract, about 3.8cm long in adults o Lined w skin – no sebaceous glands or hairs, connects to rectal mucosa at anorectal junction o Canal slanted forward toward the umbilicus (R angle w rectum) o Rectum has only autonomic nerves – somatic sensory nerves allow us to detect pain in this region o Anal canal has 2 surrounding circular layers:  Internal sphincter – involuntary control by ANS  External sphincter – voluntary control, part of it goes over the internal sphincter o Intersphincteric groove – division b/w internal and external sphincters, palpable o Anal columns – vertical mucosal folds, start at rectum and end at anorectal junction (mucocutaneous junction, pectinate line or dentate line)  Each anal column as one artery and vein  Veins can enlarge and form hemorrhoid with increased pressure o Anal valve – end of each anal column, crescent fold of mucous membrane o Anal crypt – above anal valve and b/w anal columns o Rectum – about 12cm long, end of LI, from sigmoid colon starting at 3 sacral, when it dilates it becomes rectal ampulla o Valves of Houston – inside of rectum, 3 semilunar transvers folds, goes ½ way through rectum, hold feces as gas passes, lowest part can be palpated on L side o Peritoneal reflection – peritoneum covers upper 2 thirds of rectum  Rectovesical pouch – boys and men, downward about 7.5cm of anal opening  Rectouterine pouch – girls and women, goes down 5.5cm of anal opening Prostate o Prostate gland – in front of anterior wall of rectum, 2cm behind symphysis pubis, around bladder neck o Secretes thin, milky alkaline fluid, for sperm viability o Median sulcus – separates lobes (heart shaped) o Seminal vesicles – two, like ‘bunny ears’ over prostate, secrete fructose rich fluid (nourishes sperm, has prostaglandins) o Bulbourethral – “Cowper’s gland”, two, each size of pea, below prostate on sides of urethra (secrete clear, viscid mucous) Regional Structures o Girls, women – uterine cervix is in front of anterior rectal wall, palpable through wall o Anus and rectum about 16cm long  Male GU o External: penis and scrotum o Penis  3 cylindrical columns of erectile tissue – 2 corpora cavernosa (dorsal) and corpus spongiosum (ventral)  Corpus spongiosum becomes glans (cones of erectile tissue at the end) joins the shaft at the corona  Urethra – runs along corpus spongiosum and splits at the tip of the glans  Foreskin/prepuce – over glans, skin folds on top of itself making a ‘flap’  Frenulum – fold of skin over urethral meatus (ventral) o Scrotum  Loose pouch from abdominal cavity  Becomes pigmented with large sebaceous and follicles after adolescence  Wall – thin skin folds (rugae) and cremaster muscle underneath  The muscle and dartos muscle controls size depending on temperature – keep testes 3 degrees below abdominal temp which is best for synthesizing sperm  Contracts in the cold to bring it closer to the body and causes sac to wrinkle  When warm, muscle relaxes, sac hangs and skin appears smoother  Septum separates halves of scrotum inside and each side contains testes – where sperm is produced o Internal: testis, epididymis and vas deferens  Each testis have double membrane – tunica vaginalis (separation from scrotum wall) and tunica albuginea (fibrous capsule) – fluid helps testis slide easily  Lest testis slightly lower b/c left spermatic cord longer than right one  Sperm capped by epididymis (final maturation site) – continues with vas deferens which forms spermatic cord (suspends testis) which runs into inguinal canal into the abdomen  Vas deferens continues behind bladder joining with seminal vesicle (of the bladder) to form ejaculatory duct which will empty into urethra  Lymphatic vessels of external structure drain into inguinal lymph but internal structure drain into abdominal lymph node (not examinable) o Inguinal Area – aka groin  Lower abdomen + thigh  Diagonal to ASIS and symphysis pubis – separated by inguinal ligament  Above this is the inguinal canal – opens into an internal ring (above midpoint of inguinal ligament) and external ring (above lateral side of pubis)  Below IL is the femoral canal – parallel to femoral artery  All of these can be sites of hernia – part of it protrudes through the wall (weak spot in muscles)  Female GU o External Genetalia – aka vulva  Mons pubis – round, firm, adipose tissue over the symphysis pubis (covered with hair after puberty)  Labia majora – 2 rounded folds, adipose tissue, from mons pubis and around perineum (hair covers outside of folds only after puberty; inside smooth, moist with sebaceous follicles)  Labia minora – inside labia majora, 2 smaller and darker folds, join together at clitoris (similar to penis, easily stimulated by touch) and at the frenulum  Vestibule – middle of labial folds and has various openings:  Urethral meatus – below the clitoris, dimple shaped  Paraurethral (Skene’s) glands – numerous, not visible, below urethra  Vaginal orifice – below urethral meatus, thin slit or large opening (depends on hymen presentation)  Hymen – thin, circular fold, may/may not be present, covers vaginal orifice partially  Vestibular (Bartholin’s) glands – behind and on both sides of vaginal orifice, secrete lubricating mucus during SI, duct cannot be seen, opens between labia minora and hymen o Internal Genetalia  Vagina – flat, tubular canal from orifice up to the pelvis, about 9cm long (between rectum in the back and bladder/urethra in the front)  Rugae – makes up walls of the vagina, thick folds, allows for dilation during childbirth  Cervix – top of the vagina (smooth, round and circular with small whole – os; in nulliparous women – os enlarges after childbirth)  Vagina and cervix covered with smooth, pink, stratifies squamous epithelium, os lined with columnar epithelium (red and rough)  Tissues meet at the squamocolumnar junction  Anterior fornix and posterior fornix – goes around opening into cervix (recess)  Rectouterine pouch/cul-de-sac of Douglas – behind posterior fornix, recess, beside peritoneum, between rectum and cervix  Uterus – pear shape, thick wall, muscular, flattened at anteroposterior side, movable, tilts forward and over top of bladder  Fallopian tubes – pliable, about 10cm long, from top of uterus to side of pelvis, curve towards the back and end near ovaries – at the level of the ASIS, oval, about 3cm long and 2cm wide, 1cm thick, site of egg and female hormone development 2. Outline developmental and cultural considerations and health promotion strategies  Anus, Rectum and Prostate o First newborn stool – dark green meconium; sign of anal patency  24-48h after birth  Stool after each feed afterwards o Peristalsis called gastrocolic reflex – passing stool is reflexive  Voluntary control of external sphincter around 1 ½ to 2 years when nerves fully myelinated  Male puberty – prostate enlargement then constant in adulthood  Enlarge again during middle adulthood in 1 in 10 men by age 40 – called benign prostatic hypertrophy (BPH), hormone imbalance  Health promotion: Colon cancer screening rd  3 most common cancer in Canadians  Risk factors: older age (especially over 50), polyps, family history (developed before age 45), IBD (ulcerative colitis or Crohn’s disease), high red/processed meat diet, alcohol, smoking, sedentary lifestyle, obesity, Ashkenazi Jewish ancestry  Can still occur without these factors  High fruit/veggie, fibre and low fat diet lowers risk  May not have initial symptoms until tumor causes bleeding or blockage  Signs: BM changes (i.e. constipation, diarrhea), abdominal discomfort, blood in stool, narrow stool, strong defecation urge, nausea/vomiting, fatigue, loss of weight  Canada: age 50+ must screen using stool test every 2 years o Guaiac-based fecal occult blood test (gFOBT) – uses paper to find blood in stool o Immunochemical-based fetal occult blood test (iFOBT) – uses antibodies to trace blood in stool, more expensive  Health promotion: Prostate cancer screening  Most common cancer for men in Canada – 1 in 7 chance  Risk factors: older age (over 65), family history, high fat diet, African ancestry  Possible risks: obesity, sedentary lifestyle, exposure to cadmium  Prostate enlarges and pushes against ureter making urination painful  Prostate enlarges as normal part of aging – benign prostatic hypertrophy  PSA normally produced by prostate – with prostate cancer it increases (BPH, age and prostatitis can also cause this increase)  Ejaculation can also raise PSA – instruct not to ejaculate before testing  Two tests: digital rectum exam (DRE) and prostate-specific antigen (PSA)  Recommended to perform both as PSA levels may be normal in someone with prostate cancer  DRE – insert lubricated glove in rectum and palpate for masses  Biopsy performed in addition to confirm  Male GU o Developmental considerations:  Infants  Gestation – testis develop on abdominal cavity – move in later parts and testes descend along inguinal canal into scrotum before birth  Adolescents o First sign of puberty – testes enlarge o Then pubic hair, then penis grows  Adults and older adults o Sperm production decreases around age 40 – but continues until 80/90s o 55-60 years – testosterone declines (less muscle tone, fat and cellular metabolism) o Older men – pubic hair decreases and becomes grey o Scrotum lowers – decreased tone in dartos muscle, rugae decrease and scrotum loosely hangs, testes smaller and less firm, more connective tissue in tubules (thicken) o Cultural/Social Consideration  Circumcision – hygiene, medical, father, religious, cultural  1975 – Canadian Pediatric Society says no medical need for circumcision at birth  2002 – recommended it to not be covered by provincial health insurance  Research shows: reduces gaining of HIV by 53-60%, reduced HIV transmission to uninfected women, reduces herpes, HPV and STIs in women (trichomonas vaginalis and bacterial vaginalis)  Very small risk in procedure, serious complications rare  Advise parents of pain relief for newborn  HPV infections common in males – genital warps associated with cancers (penis, anus, head, neck)  Female GU o Infants and adolescent  Birth – external genetalia looks enlarge due to estrogen of mother – get smaller after a few weeks, small until puberty  Ovaries in abdomen during childhood, uterus small and straight  Puberty – estrogen causes cell growth in genitalia and sex characteristics  First signs – breast and pubic hair develop, may/may not be simultaneous, about 3 years until complete  Menarche occurs later on, may be irregular during adolescence due to difficulty/failure with ovulating  Menarche allows uterus to flex and ovaries to move into pelvic cavity o Pregnant women  Cervix softens – Goodell’s Sign (at 4-6 weeks)  Vaginal mucosa and cervix look cyanotic – Chadwick’s Sign (6-8 weeks)  Due to increased vascularity and edema and hypertrophy/hyperplasia of cervix  Isthmus softens – Hegar’s Sign (6-8 weeks)  Uterus grows and takes bladder’s space – leads to urinary frequency  Mucos plug forms – thick, tenacious mucus in cervical canal to protect fetus from infections  Increase in cervical and vaginal secretions – thick, white, acidic (protects against pathogens by changing glycogen to lactic acid; increase risk of yeast infection) o Older women  Hormone levels decrease rapidly (unlike slow decline in men)  Around age 48-51 years  Menopause – menses end  Begins with decline in ovary function – irregular menses (stope making estrogen and progesterone)  Cells depend on estrogen, so decline leads to physical changes (uterus shrinks, ovaries no longer palpable, sacral ligaments relax, pelvic muscles weaken, uterus drops (may come down
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