1. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Elimination: The Urological System and Male Hormones

2. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Physiology Hormones are natural or synthetic steroidal compounds that produce the masculinizing and tissue-building properties of testosterone, the main male sex hormone. Penis has a dermal layer of smooth muscle, under which is loose connective tissue. – The parasympathetic system innervates the penile arteries. – Normal erection involves the release of nitric oxide, secondary to sexual stimulation, in the erectile tissue of the penis.

3. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Physiology (cont.) Urethra and prostate: Passing through the penis is the urethra, which in men transports both urine and semen. – The prostate gland is a small, muscular, rounded organ that encircles the proximal portion of the urethra as it leaves the urinary bladder.

4. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Male Urological and Reproductive Anatomy

5. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathophysiology Hormonal problems: deficiency in endogenous sex hormones causes abnormal sexual development. Erectile dysfunction: the inability to achieve or maintain an erection in at least every three of four attempts at intercourse Benign prostatic hypertrophy (BPH): occurs spontaneously in men as they age, which results in an enlargement of the prostate gland Prostate cancer: a malignant metastasizing cancer and the second most common cause of cancer death in men

6. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Core Drug Knowledge Pharmacotherapeutics – Replacement therapy Pharmacokinetics – High first-pass effect; Highly protein bound Pharmacodynamics – Effects of external testosterone in males are the same as effects of endogenous testosterone. Male Sex Hormones (Androgens) Prototype drug: Testosterone

7. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Testosterone: Core Drug Knowledge Contraindications and precautions – Serious cardiac, hepatic, or renal disease Side effects – Excessive frequency and duration of penile erections, and oligospermia (decrease in sperm) Adverse effects – Gynecomastia – Emotional reactions Drug interactions – Anticoagulants

8. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Testosterone: Planning and Interventions Maximizing therapeutic effects – Administer the drug at regular intervals to maintain therapeutic testosterone levels. Minimizing adverse effects – When prepubescent boys undergo testosterone therapy, radiographs should be taken every 6 months to assess bone age.

9. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Challenge Question Testosterone can be used in women with advanced breast cancer to slow the progression of the disease. A. True B. False

10. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Challenge Question Testosterone can be used in women with advanced breast cancer to slow the progression of the disease. A. True B. False A. True Rationale: Testosterone in women slows the growth of advanced breast cancers, which are estrogen dependent.

11. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Drugs Used to Treat Erectile Dysfunction Agents to treat erectile dysfunction work to mimic the body’s natural methods of achieving an erection. This drug class is considered the standard first- line therapy for erectile dysfunction. Prototype drug: sildenafil (Viagra)

12. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Sildenafil: Core Drug Knowledge Pharmacotherapeutics – Used to treat erectile dysfunction Pharmacokinetics – Administered: oral. Metabolism: liver. Excreted: urine and feces. Pharmacodynamics – This drug is a cGMP-specific phosphodiesterase type 5 (PDE5) inhibitor.

13. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Sildenafil: Core Drug Knowledge (cont.) Contraindications and precautions – Current use of nitrates (e.g. nitroglycerin) Adverse effects – Facial flushing, headache, nasal congestion, and heartburn Drug interactions – Drugs metabolized by liver CYP3A4 and CYP2C9 isoenzymes

14. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Sildenafil: Teaching, Assessment, and Evaluation Patient and family education – Drug is not effective without sexual stimulation. – Administer PRN - 1 hour before sexual activity. – Inform patients that sexual activity increases the risk of cardiovascular problems. Ongoing assessment and evaluation – Sildenafil therapy is considered effective if the patient reports decreased problems with erectile dysfunction.

15. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Challenge Question Sildenafil is contraindicated for which of the following patients? A. 80-year-old male with diabetes mellitus B. 54-year-old male with hypertension C. 63-year-old male with hyperlipidemia D. 73-year-old male with history of unstable angina

16. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Challenge Question Sildenafil is contraindicated for which of the following patients? D. 73-year-old male with history of unstable angina Rationale: Sildenafil is contraindicated if the patient is currently using nitrates because its vasodilating effects potentiate the hypotensive effects of nitrates. This patient would be taking nitrates to treat his symptoms of unstable angina.

17. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Drugs to Treat Benign Prostatic Hypertrophy Because the prostate gland depends on dihydrotestosterone (DHT) for growth, interference with this process is helpful in reducing prostate size. Prototype drug: tamsulosin (Flomax)

18. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Tamsulosin: Core Drug Knowledge Pharmacotherapeutics – Treat BPH and androgenetic alopecia (male pattern baldness) Pharmacokinetics – Administered: oral. Highly protein bound. Metabolism: liver. Excreted: urine and feces. Pharmacodynamics – Inhibits the steroid 5-alpha reductase and consequently blocks the peripheral conversion of testosterone to DHT

19. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Tamsulosin: Core Drug Knowledge Contraindications and precautions – Women and children Side effects – decreased libido, and decreased volume of ejaculate Adverse effects – Erectile dysfunction Drug interactions – Decreases PSA levels even in prostate cancer

20. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Challenge Question Tamsulosin (Flomax) is used to treat A. BPH B. Androgenetic alopecia C. Pulmonary hypertension D. Both A and B E. All of the above

21. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Challenge Question Tamsulosin (Flomax) is used to treat A. BPH B. Androgenetic alopecia C. Pulmonary hypertension D. Both A and B E. All of the above D. Both A and B Rationale: Finasteride is used to treat BPH and androgenetic alopecia (male pattern baldness). The dose used for male hair loss is much smaller than that used for BPH.

22. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Drugs to Treat Male Pattern Baldness Male pattern baldness may respond to drug therapy. Prototype drug: minoxidil (Rogaine, Minoxidil)* Pharmacotherapeutics – Used topically to treat androgenetic alopecia Pharmacokinetics – Administered: topically Pharmacodynamics – The exact mode of action for topical minoxidil is unknown. * Not on prototype drug list

23. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Minoxidil: Core Drug Knowledge (cont.) Contraindications and precautions – Hypersensitivity Adverse effects – Irritant dermatitis and allergic contact dermatitis Drug interactions – Topical minoxidil should not be used with other topical agents.

24. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Anticholinergic Agents Anticholinergic drugs affect bladder contraction because acetylcholine (cholinergic) receptors are found in the bladder. When the receptors are blocked, bladder contraction cannot occur, and urinary output decreases. Anticholinergics are used to treat overactive bladder. Prototype drug: oxybutynin (Ditropan) tolterodine (Detrol)

25. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Oxybutynin: Core Drug Knowledge Pharmacotherapeutics – Used to treat overactive bladder and incontinence Pharmacokinetics – Administered: oral. Protein bound. Excreted: urine and stool Pharmacodynamics – Competitive cholinergic muscarinic antagonist

26. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Oxybutynin : Core Drug Knowledge (cont.) Contraindications and precautions – Urinary retention, gastric retention, uncontrolled narrow- angle glaucoma Side effects – Dry mouth, constipation, abnormal vision, urinary retention, and xerophthalmia (conjunctival dryness) Adverse effects – Confusion (esp. in the elderly) Drug interactions – Fluoxetine, erythromycin, clarithromycin, and antifungal agents

27. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Oxybutynin : Teaching, Assessment, and Evaluations Patient and family education – Teach signs and symptoms to report. Ongoing assessment and evaluation – Treatment is effective if urinary incontinence and frequency are decreased and the patient does not develop serious adverse effects.

28. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Challenge Question Patients with renal impairment should receive half a normally prescribed dose of tolterodine. A. True B. False

29. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Challenge Question Patients with renal impairment should receive half a normally prescribed dose of tolterodine. A. True B.False A. True Rationale: Tolterodine has anticholinergic effects which can decrease the ability of the bladder to contract.

30. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study Ryan Halstead is a 15-year-old who has been diagnosed as having low levels of testosterone with delayed onset of puberty. Six weeks ago, he started treatment with testosterone (short- acting) at the outpatient center. He returns for his third visit. Data from the nursing assessment include the following: Vital signs: 124/68, HR-72, RR-16, T-98.4 F Height increased by one-half inch Beginning to show signs of facial hair growth Voice “cracking” occasionally

31. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study The patient is currently on testosterone, 50 mg IM q 2 weeks. 1.Which of the findings from the nursing assessment demonstrate the effectiveness of drug therapy? 2.Which of the findings from the nursing assessment would demonstrate side or adverse effects from drug therapy? 3.What teaching is required for Ryan regarding his drug therapy?