Anna Garner is a 44-year-old married white female with an appointment to see her nurse practitioner (NP) for her annual examination. As part of her annual physical, Anna will be having a pelvic examination including a Papanicolau test in order to screen for cervical cancer. Anna has three teenage daughters, all born by spontaneous vaginal delivery. Several years ago Anna returned to work full time at a rather sedentary job. Anna has found her weight to be increasing over these past few years and is now carrying 164 pounds on her 5 foot, 1 inch frame. Over the years Anna and her NP have developed a trusting and therapeutic relationship. As part of the history-taking process the NP asks Anna if she has ever been “hit, slapped, or forced to have sex against her wishes.” Anna states that she has not; however, she hesitates in her response. The NP senses that she may need to elicit further information from Anna without making her feel uncomfortable. She queries Anna to see if there have been any changes in the past year related to the sexual relationship that she has with her partner. Anna appears somewhat embarrassed; but, with some encouragement, she goes on to explain that in the past she and her husband have always enjoyed intercourse two to three times a week and that this is a very important part of their marriage. Anna states that for the last 9 to 10 months she has begun to “lose urine” during intercourse. Sometimes this occurs during foreplay and on other occasions it will happen during orgasm. Anna reports that she often interrupts their sexual activity to go to the bathroom. Recently, she is finding excuses to avoid sex altogether and is concerned that she is driving her husband away. The NP explains to Anna that this condition is referred to as “stress or coital incontinence” and may be the result of child-bearing, aging, and her recent weight gain. Education is provided regarding the necessity for urodynamic evaluation and the possible treatment modalities available. Anna is instructed on how to perform Kegel exercises during her pelvic examination. The NP reassures Anna that although this condition is neither uncommon nor life threatening, if left untreated it may result in other unanticipated symptomatology including depression, loss of self-esteem, altered body image, worsening of incontinence, reduced social interaction, and decreased sexual interest and activity. Anna is very reassured by this education and agrees to the treatment plan.
This case study illustrates a patient-centered relationship founded on established trust and rapport. Secondary prevention efforts include screening for cervical cancer and sexual violence. Relying on her assessment skills of the patient’s appearance and behavior in response to the interview questions, the NP pursues the history as it relates to the patient’s sexual relationship with her husband. The NP discovers the patient’s reticent demeanor is related to her stress incontinence and the subsequent feelings of embarrassment, shame, and a lack of understanding regarding the condition. This is interfering with the patient’s sexual well-being and her intimate relationship with her husband, which the patient values. The NP takes the opportunity to provide appropriate patient education with regard to stress incontinence, and although not minimizing the concern, she instead normalizes the condition for the patient. The NP has provided a tangible intervention the patient can do with ease by instructing about Kegel exercises. In addition, the NP has reinforced for Anna that she is safe to discuss her sexuality with her healthcare provider and that it is an important part of her health care.
QUESTIONS 1. In the case study, the NP asks Anna if she has ever been “hit, slapped, or forced to have sex against her wishes.” What other questions can you think of that also address the issue of whether a patient is a victim of sexual abuse? (At least five)
2. The case study states that Anna was instructed during her pelvic examination on how to perform Kegel exercises. Why is a pelvic examination a good time during which to teach Kegel exercises?