Primary and preventive gynecologic care for the disabled women

The care of all women has to be tailored to the needs of the individual patient. The care of the disabled women is more challenging because of the additional areas that need to be addressed for a successful patient visit.

The care is also more challenging because 27.4% of disabled patients reported financial barriers to obtaining health care. This patient population has lower employment and wages; this is associated with greater reliance on public health insurance (Medicaid and Medicare in the United States) and has a higher number of uninsured patients.[7]

The care of the disabled patient begins prior to the actual patient visit. The office must have scheduling capability that will allow the hearing impaired patients to make appointments using a telecommunication device for the deaf (TDD) or teletypewriter (TYY) or telephone relay service (TTY). (See Box 47-1.)

The staff should inquire about special needs at the time an appointment is scheduled so that arrangements can be made to assist the patient with deaf interpreters, transportation, directions for use of handicapped accessible entrances, elevators to accommodate stretchers, and recommendation to empty the bladder, rectum, and ostomy bags before the visit in patients with neurogenic dysfunction/stomas, etc. (See Figures 47-2, 47-3, and 47-4.) The staff should determine if the disabled patient gives consent for exam and treatment. If the patient does not give consent the guardian or authorized caregiver should be instructed to accompany the patient. The guardian will be required to give written consent for the care provided to the patient.[10, 22]

Upon arrival, the staff should make inquiries regarding the level of assistance required by the patient. Transportation difficulties are common for patients with disabilities and flexibility regarding appointment time should be considered at the time the appointment is made. Some patient’s will need assistance completing registration and history forms and this should be done in a way that is private for each patient. The reception desk should have a location with wheel chair height to facilitate communication with wheel chair bound patients.

Some patients will need help when called to the consultation or examination room in the office. The staff should ask for guidance from the patient regarding the type of assistance she would like to receive. (See Table 47-1.)

The history for a new patient should be comprehensive with special attention to a complete medication history. A dialogue should occur between the patient and provider regarding chronic medical problems and the type and severity of the disability, past gynecologic exams and the patient’s concerns about the current visit. The health-care providers may need to familiarize themselves with the patient’s disability prior to the visit to allow for maximum efficiency on the day of the visit. Patients who require an interpreter or the help of an assistant for the history should be addressed by the provider and care should be taken to avoid focus on the interpreter/assistant.

Visually impaired patients should be asked for guidance regarding their method of orientation to a new environment. They will need help to find the exam room and the exam gown.

The staff should be trained in safe methods for transfer from wheelchair or stretcher to the examination table. Positioning of patients for the pelvic exam will be a challenge for patients with joint restrictions, contractures, and spasticity. The use of water resistant pads, draw sheets, padded stirrups, bootleg stirrups, rolled pillows/towels, and wedge may be helpful. Positioning other than the standard lithotomy position may be needed to comfortably position some patients. Use of diamond, knee chest, M-shape, V-shape, lateral, elevation of hips on a roll, and McRoberts positioning may be helpful in facilitating the pelvic exam. (See Figure 47-5.) Some patients with negative previous experiences or spasticity may benefit from a small dose of an anxiolytic or analgesic before the pelvic examination. Pap smear and genital polymerase chain reaction (GC Chlamydia PCR) can be obtained without a speculum. Some patients have to be examined on a stretcher or bed and the pelvic exam can be performed with the hips elevated on a roll or bedpan with the speculum inverted to facilitate visualization of the cervix. A subset of patients may require pelvic examination under sedation or general anesthesia.

Figure 47-5

Positions for gynecological exam of the disabled woman.

Care is indicated to choose the appropriate-sized warm speculum and the selective use of lidocaine gel will facilitate the pelvic examination.

Patients with cognitive impairment, past sexual abuse, or previous painful pelvic examinations may need the annual gynecologic visit separated into two or three visits. The history followed by a general physical examination can be done as a single visit, leaving the pelvic exam for a separate visit. Multiple visits may allow the patient to develop familiarity and comfort with the office environment and staff.[22]

Examination of the perineum for signs of poor hygiene, vulvovaginitis, and signs of sexually transmitted diseases (STD) and for cuts, burns, and bruises is indicated; these may be suggestive of sexual abuse.[11] Sexually transmitted disease (STD) screening should be done in the same frequency as for able females. Women who are disabled may have limitations in barrier method use and may be therefore be at increased risk for STD acquisition. Urine STD screens are helpful in women for whom speculum exam are difficult or impossible in the office setting. Education about STD prevention should be a priority. Prior education may be suboptimal due to false assumptions about the sexual behavior of disabled women.

Cancer screening is performed less often in women with disabilities. Fewer Pap smears and slightly fewer mammograms are performed (a 72.3% prevalence of mammography screening has been reported) in this patient population. Changes in Pap smear screening recommendations decrease the number of pap smears required for most women. The schedule of the three-to-five-year cervical cancer screening falls in line with the recommendation of ACOG’s Special Issues in Women’s’ Health which suggests a pelvic exam every three years for patients with disabilities that require general anesthesia for the pelvic examination.[12, 13]

Breast cancers are the leading cause of cancer-related deaths among all women in the United States. Many women with disability face substantial barriers in obtaining mammograms. According to the CDC, women 50–74 years of age with a disability were less likely to obtain breast cancer screening due to limited health literacy, less self-efficacy, lack of provider recommendation, lack of access to the service, and communication barriers. The primary reasons for failure to receive a mammogram were physical limitations, lack of referral, and patient underestimation of risk. Mammography equipment is now available that can facilitate mammogram examination in women with mobility issues. The equipment is not available in all locations, but resources can be identified at www.bhawd.org. Patients with mobility issues that prevent breast self-exam have the option of having a partner or caregiver trained to perform the examination.

Autonomic stress syndrome/autonomic dysreflexia

Patients with high spinal cord injuries present a special challenge for health-care providers because of the risk of autonomic dysreflexia.[9]

Autonomic dysreflexia (AD) is a syndrome where afferent impulses triggered by painful stimuli enter the spinal cord and start reflex arcs that are not modulated by higher centers. The syndrome occurs in patients with spinal cord lesions at or above T10 particularly those above T6. Lesions at these levels prevent the normal hypothalamic control over sympathetic spinal reflexes.[14]

Symptoms include severe hypertension with headache, respiratory distress, bradycardia, arrhythmia, diaphoresis, tingling, flushing, piloerection in dermatomes above the spinal cord lesions and nasal stuffiness.

Blood pressure can be affected by AD. The severity of the hypertension can be extreme with blood pressure elevations in excess of 300/150. Untreated AD can lead to intracranial hemorrhage, coma, and death.

Multiple stimuli can trigger AD including any manipulation of the cervix, bladder or rectum, as well as strong suprapubic pressure, bladder distention, disimpaction of the rectum, excessive deep breathing, and immersion of the feet in cold water.

The best management of this syndrome is avoidance. The best ways to prevent AD is to have the patient empty the bladder to avoid over distention and to empty the rectum to avoid fecal impaction.

The pelvic examination can be performed using a speculum coated with anesthetic jelly and the use of nifedipine 30 mg sublingual before office procedures that can elicit AD.

Treatment of AD involves the use of rapid acting antihypertensive, cardiac and blood pressure monitoring and transfers from the ambulatory facility to the hospital setting.