Male Reproductive Disorders Understanding Med-Surg Nsg. Ch.43 Pharmacology Clear and Simple, Ch 20 Intro. To Maternity & Pedi Nsg. Objectives: Explain the pathophysiology associated with male GU & reproductive disorders. Discuss the etiologies, S&S and treatments for prostate, testicular, and penile disorders, Explain causes for erectile dysfunction & infertility. Describe pathogens involved with each of the common STDs. Discuss preventions and treatments for STDs. Explain nursing interventions that are effective.

Anatomy Review Testes (testicles)-The 2 oval testes _______ are enclosed in the ________, a sac-like structure which lies suspended from the exterior abdominal wall. This position keeps the temperature in the testes below normal body temperature which is necessary for viable sperm production and storage. Each teste contains 1-3 coiled ________ tubules that produce the sperm cells. The testes also produce the hormone________which is responsible for the development of male secondary sex characteristics.

Ductal System The __________is a tightly coiled tube structure that lies superior to the testes and extends posteriorly. With sexual stimulation, the walls of the epididymis contract forcing the sperm along the __________ tubules of the testes to the __________ _________. The ______ _________ is approximately 18 inches long and rises along the posterior wall of the testes. As it moves upward, it passes through the _________canal into the pelvic cavity and loops over the urinary bladder.

Accessory Glands Produce seminal fluid and include the________ ________, __________, and _________ _________. With each ejaculation of 2 to 5 ml, 200 to 500 million sperm are released. The _______ _________ are paired structures that lie at the base of the bladder and produce 60% of the volume of semen. The fluid is released into the ejaculatory ducts to meet with the sperm.

Accessory Glands Con’t The _________ gland is doughnut-shaped and surrounds the neck of the bladder and urethra. A firm structure about the size of a chestnut composed of muscular and glandular tissue. The ejaculatory duct passes obliquely through the posterior part of the gland. The ________often hypertrophies with age, expanding to surround the urethra thus making voiding difficult.

Accessory Glands Con’t. There are 2 pea sized glands under the male urethra known as ________ glands. They provide lubrication during intercourse.

AGE RELATED ∆’S Testosterone production declines after age 50 (male climacteric) Slower to arouse with longer period between erections Spermatogenesis lasts entire life Chronic medical diseases (HTN, DM), medication

Lifestyle issues: Dietary habits Alcohol consumption Obesity AGE RELATED ∆’S WHICH MAY CONTRIBUTE TO A LOSS OF SATISFACTORY SEXUAL EXPERIENCE Lifestyle issues: Dietary habits Alcohol consumption Obesity

Male Assessment History Medication Use Family History Personal Habits Health Promotion Mental Health Circulatory Respiratory Gastrointestinal Musculoskeletal Neurological Metabolic/Endocrine Genitourinary Sexual Practices

Physical Examination Clinical Breast Exam Penis Glans and Shaft Scrotum Testes Spermatic Cord Inguinal Ring & Lymph Nodes Digital Rectal Examination

Diagnostics 1. Testicular Biopsy- a means to detect abnormal cells and the presence of sperm. Can be done by aspiration or through an incision. The anesthetic used depends on the choice of technique. Post Biopsy- Nursing Care Scrotal Support Ice pack Analgesics as ordered Warm sitz baths may be helpful Call MD if bleeding occurs

Diagnostics Con’t. 2. Semen Analysis-Performed to substantiate the effectiveness of a vasectomy, to detect semen on the body or clothing of a suspected rape victim, and to rule out paternity. **Is generally the first test to evaluate male fertility.**

Diagnostics Con’t. 3. Prostatic Smears- Obtained to detect and identify microorganisms and tumor cells in the prostate. The physician massages the prostate by way of the rectum, and the patient voids into a sterile container prepared with additive preservative. The specimen is collected and a smear is prepared in the lab It is possible to detect some cases of cancer and even TB of the prostate gland by this method.

Diagnostics Con’t. 4. Cystoscopy-A man’s prostate and bladder can be examined by passing a lighted cystoscope through the urethra of the bladder. The exam is usually performed without anesthesia but a local anesthetic may be instilled into the bladder. Cystoscopy can be done for both men and women to detect bladder infections and tumors.

Diagnostics Con’t. 5.Digital Rectal Exam (DRE)- palpation of the anus, rectum, and prostate gland with a gloved finger. Used in the diagnosis of intestinal bleeding, anorectal pain, and both benign and malignant diseases of the prostate

Diagnostics Con’t. 6. Prostate-Specific Antigen (PSA)- a highly sensitive blood test. Is normally secreted and disposed of by the prostate; however, it will show up in the blood stream in cancer and a harmless condition known as BPH. Increased levels means the prostate needs to be checked by a physician. < 4 is considered normal

Peyronie’s disease The development of fibrous scar tissue inside the penis that causes curved, painful erections. Symptoms may appear suddenly or may develop gradually. Scar tissue. A significant bend to the penis. Erection problems. Shortening of the penis. Pain.

TESTICULAR TORSION http://www.youtube.com/watch?v=HBOPY6jjqic Testicle is mobile & spermatic cord twists Cuts off blood supply to testicles Intense pain Occasional nausea & vomiting Acute surgical emergency requires immediate release of torsion or Testicle may be removed

PRIAPISM Prolonged penile erection not r/t sexual stimulation Caused by injury to penis, sickle cell crisis, neoplasms of the brain or spinal cord, drugs May obstruct blood flow to penis May be painful Is an emergency – must be resolved within 12-24 hr. or may result in penile ischemia, gangrene, fibrosis, or erectile dysfunction

TX OF PRIAPISM D/C offending med Correction of neurological or coagulation problems Aspiration of blood from erectile chamber Injection of drugs that cause contractions of smooth muscles, thereby inhibiting inflow of blood & allowing outflow Emergency surgery

PHIMOSIS Inability to retract the penile foreskin Often caused by inflammation under the foreskin which causes edema Often related to poor hygiene (smegma) Treated with antimicrobials & cleansing Circumcision may be recommended If able to retract foreskin, but not return foreskin, leads to edema of the glans http://www.youtube.com/watch?v=Ud3kqOeYACk

INFECTIONS & INFLAMMATORY CONDITIONS Causes: bacteria, viruses, protozoa, fungi, & ectoparasites (through sexual contact) Most common: prostatitis & epididymitis

Prostatitis Etiology Acute Bacterial Chronic Bacterial Chronic Prostatitis/Chronic Pelvic Pain Syndrome Asymptomatic Inflammatory Prostatitis Signs and Symptoms Pain Urgency Frequency Dysuria Urine Retention Fever, Chills

Prostatitis (cont’d) Diagnosis Digital Rectal Exam Urine Culture EPS Interventions Antibiotics Anti-inflammatory Agents Interventions (cont’d) Stool Softeners Sitz Baths Prostatic Massage Avoid Alcohol and Spicy Foods Surgery

Nursing Diagnoses: Prostatitis Urinary Retention Risk for Ineffective Self-Health Management Acute Pain Anxiety

EPIDIDYMITIS Inflammation of the epididymis caused by infection, STD, trauma, or reflux of urine from urethra through the vas deferens Usually seen in young, sexually active males < 35 yrs. old (STDs usual cause) May occur in elderly after cystoscopy

EPIDIDYMITIS S&S = painful scrotal edema, nausea, vomiting, chills, & fever May have dysuria & pyuria Tx = bedrest, ice packs, sitz baths, analgesics, anti-inflammatory drugs, & scrotal support (to elevate the scrotum)

ORCHITIS Inflammation of one or both testes May be r/t trauma or infection (mumps, pneumonia, or TB) 20% of males who contract mumps develop S&S = fever, tenderness, swelling of affected testicle, & scrotal redness May lead to reduced fertility or sterility

TX OF ORCHITIS Analgesics Antipyretics Bedrest Scrotal support Local heat to scrotum

Benign conditions of the scrotum Hydrocele-is an accumulation of fluid between the membranes covering the testicle and the membranes enclosing the testicle. Usually occurs over the age of 21. The cause is unknown but may be due to trauma, or abnormal lymph drainage from an infection that may be present(Orchitis, Epididymitis). S/S- The scrotum slowly enlarges as the fluid accumulates. If the fluid accumulates too quickly, pain develops. Usually afebrile with VS within normal limits Diagnostics-Scrotal/imaging ultrasound is used to identify abnormalities in the testes. Translumination-a light source shined through the scrotum causes the hydrocele to illuminate.

HYDROCELE Dx – transillumination (shining light through scrotom in a darkened room. Hydrocele glows red) Tx – surgical excision of sac, pressure dressing, drain, wearing athletic support

Hydrocele Con’t. Treatment-1. Aspiration of the fluid from the sac. The fluid will be a clear amber. This will relieve the pain 2. Bedrest with the scrotum elevated. This is a palliative treatment for the elderly, no cure 3. Surgical excision of the sac is performed to avoid constriction of the circulation of the testes. Nursing care post-op-There will be a drain present. Assess incision, and presence of the drain. The pt. will have a scrotal support in place. Analgesics. Monitor for infection. Strict I&O!

VARICOCELE Dilation & lengthening of scrotal veins (varicosed veins) Blood pools and veins dilate Causes a dull ache along the cord May be visible as bluish discoloration Tx – scrotal support or surgical ligation of spermatic vein if fertility affected, ice, pain med

Benign Prostatic Hyperplasia (BPH) ↑ in # of Cells Signs & Symptoms Urinary Retention Dribbling Nocturia Dysuria Urgency Diagnosis DRE BUN, Creatinine PSA Urodynamic Flow Studies Transrectal U/S Cystoscopy

Therapeutic Interventions Watchful Waiting TUMT, TUNA Surgery Prostatectomy Symptom Control Catheterization Fluids Antibiotics

Therapeutic Interventions May prescribe: Hormone Blockers testosterone-ablating agents testosterone-sparing agents Alpha-adrenergic agents

tamsulosin (Flomax) to treat the symptoms of an enlarged prostate (benign prostatic hyperplasia or BPH) alpha blockers: works by relaxing the muscles in the prostate & bladder so that urine can flow easily. Swallow capsules whole; do not split, chew, crush, or open Avoid the use of heavy machinary

NURSING IMPLICATIONS FOR CARING FOR A PT POST-TURP CBI (continuous bladder irrigation): 2 liter bags of NS Tubing connected to 3 way foley cath Regulate flow with roller clamp DO NOT LET IRRIGATION RUN DRY!!! NOTIFY MD IMMEDIATELY IF URINE NOT DRAINING!!!

NURSING IMPLICATIONS FOR CARING FOR POST-TURP cont’d. Intermittent bladder irrigations – prevents catheter from clotting Blood clots cause bladder spasms Catheter is removed when urine becomes clear

Prostate Surgery Pre-op Nursing Diagnoses Impaired Urinary Elimination Knowledge Deficit

Postoperative Nursing Diagnoses Risk Bleeding Monitor Urine Output & Bleeding Encourage Fluids Teach Patient to Avoid Constipation Lifting Aspirin & NSAIDS

Acute Pain: Bladder Spasm Monitor Pain Irrigate Catheter as Ordered Administer Analgesics, Antispasmodics Teach Relaxation & Deep Breathing

Urge Urinary Incontinence Teach Kegel Exercises Offer Condom Catheter or Pads Encourage to Continue Fluids Discuss Prolonged Incontinence with Physician

Risk for Ineffective Self-Health Management Teach to Avoid (About 6 Weeks) Heavy Lifting Stairs Driving Strenuous Exercise Straining Sexual Activity Aspirin & NSAIDS

Ineffective Therapeutic Regimen Management Teach Patient Catheter Care Report Signs &Symptoms of UTI Report ↑ in Bleeding

Anxiety: Sexual Function Explain Retrograde Ejaculation Talk with Physician if Erectile Dysfunction Occurs

Prostate Cancer Risk Factors Over 65 High Testosterone High Fat Diet Family History Occupational Exposures Incidence rate is 40% higher in African American men

Signs & Symptoms Rare in Early Stages Later Stages Urinary Obstruction Hematuria Urinary Retention Advanced Bone Pain Anemia Weakness Wt. Loss

DIAGNOSIS OF PROSTATE CANCER Digital rectal exam Needle biopsy Serologic markers (PSA, prostatic acid phosphatase) Transurethral U/S with Biopsy Metastatic Workup- CXR, IVP, CT, MRI, Bone scan

Therapeutic Interventions Early Testosterone-Suppressing Medications Later Stages TURP or Open Prostatectomy Radiation Therapy Metastatic Orchiectomy, Estrogen Therapy Chemotherapy, Radiation Radical Prostatectomy

Testicular Cancer Risk Factors Cryptorchidism Family History DES Use by Mother Caucasian High Socioeconomic Status

Signs & Symptoms Early Painless Lump Swelling Late Symptoms of Metastasis

Diagnosis Ultrasound Chest X-Ray Blood for Tumor Markers Biopsy Staging

Therapeutic Interventions Surgery Radiation Chemotherapy .

Nursing Care Teach Testicular Self-Examination Provide Emotional Support Discuss Sperm Bank Deposit Offer CA Support Group

Cancer of the Penis Risk Factors Not Circumcised as Baby HPV Therapeutic Interventions Surgery Radiation Chemotherapy

PENILE CANCER Relatively rare, occurs primarily in the glans Most cases occur in men over 50; 20% in men under 40 Occurs exclusively in uncircumcised men who have chronic irritation & poor hygiene with accumulation of smegma under the foreskin

PENILE CANCER Other risk factors include: Hx of multiple sexual partners, venereal disease, HPV, long-term tobacco use May appear as dry, wart-like, painless growths that do not respond to antibiotics or skin thickening or accumulation of tissue, ulceration & bleeding, or swollen lymph nodes

DIAGNOSIS OF PENILE CANCER Swelling at end of penis Biopsy, fine needle aspiration Ultrasound CT scan MRI

Penile Cancer Signs and Symptoms Painless ulcer or growth on the penis Changes in color, skin thickening or accumulation of tissue Ulceration and bleeding A persistent discharge with a foul odor Swollen lymph nodes

TREATMENT OF PENILE CANCER Surgery Cryosurgery Radiation &/or chemo

Staging of Penile Cancer Stage 0-1- disease is limited to the foreskin, can usually be treated with circumcision and removal of a margin of benign skin Stage II- usually requires a partial or total penectomy with or without radiation therapy Stage III- total penectomy, and lymph node removal or penectomy followed by radiation therapy Stage IV- is not considered curable. Rx is palliative

Vasectomy Interruption of Vas Deferens Provides Permanent Birth Control Effective About 3 Months Following Surgery

Erectile Dysfunction Problem Obtaining or Maintaining Erection

Pathophysiology/Etiology Physical Circulation Nerve Supply Hormone Balance Limbic System Psychosocial Stress Illness Fatigue Alcohol/Drugs

Diagnosis History Blood Tests Glucose Testosterone Evaluation of Circulation Psychosocial Evaluation

Therapeutic Interventions Medication ∆’s Oral Medication Tadalafil Sildenafil Vardenafil Hormone Therapy Herbal Remedies Medication Injection Transurethral Devices Surgery Implants Vascular Surgery

Nursing Diagnosis Risk for Ineffective Self Health Management

Critical Thinking Mr. Jones is a 46-y.o. man admitted with exacerbated multiple sclerosis. As you are collecting his admission data, you ask if he is married. He replies, “Yeah, if you can call it that.” 1. How can you respond to his comment? 2. Mr. Jones tells you he has been impotent for more than a year. What additional questions can help you plan his care? 3. What is the nurse’s role in treatment of erectile dysfunction? 4. Mr. Jones tells you that his older brother had testicular cancer several years ago. What teaching should you provide?

Infertility Causes Pretesticular Endocrine Testicular Varicocele Idiopathic Post-testicular Surgery

Infertility Cigarette smoking Back injury High blood pressure Cirrhosis of the liver Diabetes mellitus

Diagnosis Sexual Practices Lifestyle Practices Occupation Medical-Surgical History Physical Examination Semen Analysis

Therapeutic Interventions ∆’s in Lifestyle Practices Surgery if Indicated In Vitro Procedures