Assessment and Management of Problems Related to Male Reproductive Processes Copyright © 2008 Lippincott Williams & Wilkins. 1 Male Reproductive System • Includes conditions that affect reproduction, sexuality, and urinary elimination • Patient may experience anxiety and embarrassment • Be sensitive to cultural and emotional issues related to sexuality and the genitals to accomplish effective assessment and communication • Provide for privacy and education Copyright © 2008 Lippincott Williams & Wilkins. 2 Male Reproductive System • Testes (encased in the scrotum) – Spermatogenesis – Testosterone secretion • Penis – Copulation – Urination • Prostate gland – Produces a secretion that is suitable to the needs of spermatazoa • Vas deferens, Cowper’s gland, epididymis 3 Copyright © 2008 Lippincott Williams & Wilkins. Male Reproductive system • Age-related changes – Prostate enlarges – Prostate secretion decreases – Testes become smaller and firmer – Fibrotic changes in the corpus cavernosa (ED) – Testosterone level decreases • Hypogonadism occurs in 25% of older men • Decrease in libido • Decrease in number of viable sperm Copyright © 2008 Lippincott Williams & Wilkins. 4 Structures of the Male Reproductive Tract 5 Copyright © 2008 Lippincott Williams & Wilkins. Assessment • Urinary function and symptoms • Sexual function and manifestations of sexual dysfunction • Sexual history, including STDs • Symptoms related to urinary obstruction – Increased urinary frequency – Decreased force of stream – “Double” or “triple” voiding – Nocturia, dysuria, hematuria, and hematospermia • Medications, drug, and alcohol use • Presence of conditions that may affect sexual function (diabetes, cardiac disease, and multiple sclerosis) • History of surgeries 6 Copyright © 2008 Lippincott Williams & Wilkins. Physical Assessment • Inspection of the penis and testes • Digital rectal exam – Yearly for men over age 50 – Assess size, shape, consistency of prostate gland; assess anus for hemorroids, masses, lesions • Testicular exam – Inspection and palpation for abnormalities – Testicular self exam should begin in adolescence • Penis is inspected and palpated for ulcerations, nodules, inflammation, discharge; foreskin Copyright © 2008 Lippincott Williams & Wilkins. 7 Examination of the Prostate 8 Copyright © 2008 Lippincott Williams & Wilkins. Diagnostic Tests • Prostate specific antigen (PSA) – Blood test (0.2-4.0 mcg/L) – Levels increase with prostate cancer; but maybe nonspecific • Ultrasonography – Maybe performed if abnormalities found on DRE or to differentiate testicular mass • Prostate fluid or tissue analysis • Tests of male sexual function Copyright © 2008 Lippincott Williams & Wilkins. 9 Disorders of Male Sexual Function • Erectile dysfunction (ED) – Inability to attain or maintain an erect penis that allows for satisfactory sexual performance – Approximately 50% of men >age 40-70 – Psychogenic and organic causes – See table 55-10 for risk factors • Include anatomic, cardiorespiratory, drug induced (!), endocrine, GU, neurologic, psychologic, vascular – Treatment depends on the cause 10 Copyright © 2008 Lippincott Williams & Wilkins. Evaluation and Treatment of Erectile Dysfunction 11 Copyright © 2008 Lippincott Williams & Wilkins. Medical Management • Pharmacologic therapy – Oral medications: sildenafil, vardenafil, tadalafil Side effects include headache, flushing, dyspepsia Caution with retinopathy Contraindicated with nitrate use Review drugs – Injected vasoactive agents • Complications include priapism (persistent abnormal erection), fibrotic plaques at injection site – Urethral suppositories (alprostadil) • Penile implants • Vacuum constriction device • Sexual Couseling Copyright © 2008 Lippincott Williams & Wilkins. 12 Disorders of Male Sexual Function • Ejaculation problems – Premature ejaculation • Inability to control ejaculatory reflex and reaches orgasm before or shortly after the beginning of intercourse • Treatment often behavioral, possibly phamacologic – Retrograde ejaculation • Semen travel toward the bladder rather than exiting the body - muscles of the bladder neck do not tighten properly • Electroejaculator utilized if pregnacy is desired 13 Copyright © 2008 Lippincott Williams & Wilkins. Conditions of the Prostate • Prostatitis: inflammation of the prostate gland, often due to and infectious agent – Acute and chronic classifications – Manifestations : burning, urgency, frequency, prostadynia • Acute bacterial may also result in fever, chills, low back pain, dysuria, nocturia, prostate pain • Chronic bacterial manifests as frequency, urgency, backache, ejaculatory pain; it is a major cause of relapsing UTI; more insidious – Goal : avoid abcess formation and sepsis – Treatment includes appropriate anti-infective agents (possibly IV for acute) and measures to alleviate pain and spasm • Sitz baths, antispasmodics, analgesics • Increase fluid intake • In chronic, measure to stimulate ejaculation Copyright © 2008 Lippincott Williams & Wilkins. 14 Conditions of the Prostate • Benign prostatic hyperplasia (BPH; enlargement of the prostate gland) – Hypertrophied lobes of prostate may obstruct urethra, causing urinary retention – Affects half of men over age 50 and 90% of men over age 80 – Other risk factors: family history, environment, diet, obesity, excess ETOH – Manifestations : gradual onset of urinary obstruction, urinary irritation (see table 55-1) – Potential complications • Urinary obstruction • May lead to renal calculi, urinary tract infection 15 Copyright © 2008 Lippincott Williams & Wilkins. Conditions of the Prostate • BPH – Diagnosis generally made through H & P • Additional tests may include UA, PSA, rectal ustrusound, uroflowmetry – Treatment • Drug therapy – 5-a reductase inhibitors (finasteride, dutasteride) – Alpha blockers (doxazosin, terazosin, tamsulosin) symptomatic relief; do not treat hyperplasia – Herbal therapy - saw palmetto • Surgery – TURP – TUIP – Minimally invasive surgeries Copyright © 2008 Lippincott Williams & Wilkins. 16 Prostate Cancer • Second most common cancer and the second most common cause of cancer death in men • Risk factors include increasing age, familial predisposition, and African American race, ?dietary factors - fat • Manifestations – Early disease has few/no symptoms – Symptoms include urinary obstruction, blood in urine or semen, and painful ejaculation – Symptoms of metastasis may be the first manifestations 17 Copyright © 2008 Lippincott Williams & Wilkins. Prostate Cancer • Early diagnosis is vital; regular health screening is crucial – PSA and DRE for >50 years; if abnormal, biopsy • Complications: sexual dysfunction • Treatment may include – Watchful waiting (deferred treatment) – Prostatectomy • Radical prostatectomy – Radiation therapy • Teletherapy (external beam) • Brachytherapy with radioactive seeds in prostate gland – – – – Exposure to others minimal Avoid close contact with pregnant women Condom with intercourse Local side effects 18 Copyright © 2008 Lippincott Williams & Wilkins. Prostate Cancer • Hormonal therapy – Cancer may be controlled by androgen withdrawal – May be done via surgical castration (orchiectomy) or with meds • Chemotherapy – Limited to those with hormone refractory therapy 19 Copyright © 2008 Lippincott Williams & Wilkins. Nursing Process—Assessment of the Patient Undergoing Prostatectomy • Assess how the underlying disorder (BPH or prostate cancer) has affected the patient’s lifestyle • Urinary and sexual function • Health history • Nutritional status • Activity level and abilities Copyright © 2008 Lippincott Williams & Wilkins. 20 Nursing Process—Diagnosis of the Patient Undergoing Prostatectomy • Anxiety • Acute pain preoperatively • Acute pain postoperatively • Deficient knowledge • Sexual dysfunction 21 Copyright © 2008 Lippincott Williams & Wilkins. Collaborative Problems/Potential Complications • Hemorrhage and shock – High risk d/t very vascular gland – Formation of clots may obstruct catheter outflow • Infection – Includes UTI and epidydimitis • DVT • Catheter obstruction • Sexual dysfunction • Urinary incontinenceCopyright © 2008 Lippincott Williams & Wilkins. 22 Nursing Process—Planning the Care of the Patient Undergoing Prostatectomy • Major goals preoperatively include adequate preparation and reduction of anxiety and pain • Major goals postoperatively include maintenance of fluid volume balance, relief of pain and discomfort, ability to perform self-care activities, and absence of complications 23 Copyright © 2008 Lippincott Williams & Wilkins. Relief of Pain • Assessment of pain – Bladder spasms cause feelings of pressure and fullness, urgency to void, and bleeding from the urethra around the catheter • Medication and warm compresses or sitz baths relieve spasms • Administer analgesics and antispasmodics as needed • Encourage patient to walk but to avoid sitting for prolonged periods • Prevent constipation • Irrigate catheter as prescribed 24 Copyright © 2008 Lippincott Williams & Wilkins. Maintaining Catheter Patency • Continuous bladder irrigation – Rate set for light pink urine • Manual irrigation per orders – Aseptic technique • Careful I/O • Monitor for color of urine and clots – Small clots expected in first 24 hours – Bright red blood may indicate hemorrhage 25 Copyright © 2008 Lippincott Williams & Wilkins. Three-Way System for Bladder Irrigation 26 Copyright © 2008 Lippincott Williams & Wilkins. Interventions • Monitoring and managing potential complications – Hemorrhage • Observe color, amount, consistency of drainage • Report changes • VS, I&Os – Infection • Avoid rectal insertions • Aseptic technique with dressing changes • Monitor for s/sx of infection 27 Copyright © 2008 Lippincott Williams & Wilkins. • DVT Interventions – Early ambulation – Compression stockings • Obstructed catheters – – – – Careful management of 3 way bladder irrigation Assess for bladder distension Assess tubing for kinks, patency Irrigation as ordered - with NS • Sexual Dysfunction – Education about return of libido, possible ED treatements as ordered by MD – Trusting environment, encourage discussion of concerns 28 Copyright © 2008 Lippincott Williams & Wilkins. Interventions • Urinary incontinency or dribbling is common – Encourage Kegel exercises hourly – Teach to stop several times during urination – Often improves within 12 months 29 Copyright © 2008 Lippincott Williams & Wilkins. Interventions • Reduce anxiety – Be sensitive to potentially embarrassing and culturally charged issues – Establish a professional, trusting relationship – Provide privacy – Allow the patient to verbalize concerns – Provide and reinforce information • Provide patient teaching including explanations of anatomy and function, diagnostic tests and surgery, and the surgical experience 30 Copyright © 2008 Lippincott Williams & Wilkins. Rehabilitation and Home Care • Provide patient and family teaching for home care including care of urinary drainage devices and recognition and prevention of complications • Regain bladder continence – Regaining control is a gradual process (dribbling may continue for up to one year depending upon the type of surgery) – Perineal (kegel) exercises • Avoid straining, heavy lifting (10 lb) , long car trips (for 6 to 8 wks) • Diet: encourage fluids and avoid coffee, alcohol, and spicy foods (bladder irritants) • Assess sexual issues and provide referrals as needed Copyright © 2008 Lippincott Williams & Wilkins. 31 • Orchitis Testicular conditions – Inflammation of the testes (congestion or infection) – Acute onset of scrotal pain and edema – Antinfective agents, ice packs, analgesics, antiinflammatories • Epididymitis – – – – – – Infection of the epididymis Bacterial infection usually from prostate or urinary tract Pain in the inguinal canal, pyuria, fever, chills Patient and sexual partner need to be treated with antibiotics May require surgical intervention Also bed rest, scrotal elevation, cold compresses, analgesics 32 Copyright © 2008 Lippincott Williams & Wilkins. Testicular Cancer • Most common cancer in men age 15 to 34 • Highly treatable and curable; onset usually 20s • Risk factors: undescended testicles, positive family history, cancer of one testicle, Caucasian American race • Manifestations: painless lump or mass in the testes; possible dull ache; metastatic manifestations • Early diagnosis: monthly testicular self-exam (TSE) and annual testicular exam ; ultrasound • Treatment: orchiectomy, retroperitoneal lymph node dissection, radiation therapy, and chemotherapy – May consider sperm bank before treatment Copyright © 2008 Lippincott Williams & Wilkins. 33 Testicular Self-Exam 34 Copyright © 2008 Lippincott Williams & Wilkins. Nursing Management • Assess physical and psychological status • Support coping ability • Address issues of body image and sexuality • Encourage a positive attitude • Provide patient teaching • Provide TSE and follow-up care 35 Copyright © 2008 Lippincott Williams & Wilkins. Vasectomy • Procedure for male sterilization - ligation or resection of part of the vas deferens – Typically an outpatient procedure • Nursing management – Ice bags to reduce swelling – Cotton, jockey-style briefs for support – Educate that fertility remains for 4-8 weeks after procedure (until stored spermatozoa have been evacuated) 36 Copyright © 2008 Lippincott Williams & Wilkins. Conditions Affecting the Penis • Hypospadias and epispadias • Phimosis • Priapism 37 Copyright © 2008 Lippincott Williams & Wilkins.