1. Assessment and Management of Problems Related to Male Reproductive Processes

2. 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

3. 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

4. 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

5. Structures of the Male Reproductive Tract

6. 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

7. 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

8. Examination of the Prostate

9. Diagnostic Tests Prostate specific antigen (PSA) Ultrasonography
Blood test ( 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
Hormone level, psych eval

10. 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 for risk factors
Include anatomic, cardiorespiratory, drug induced (!), endocrine, GU, neurologic, psychologic, vascular
Treatment depends on the cause

11. Evaluation and Treatment of Erectile Dysfunction

12. Medical Management Pharmacologic therapy Penile implants
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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Prostate Cancer Hormonal therapy Chemotherapy
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

20. 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

21. Nursing Process—Diagnosis of the Patient Undergoing Prostatectomy
Anxiety
Acute pain preoperatively
Acute pain postoperatively
Deficient knowledge
Sexual dysfunction

22. 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 incontinence

23. 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

24. 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

25. 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

26. Three-Way System for Bladder Irrigation

27. 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

28. Interventions DVT Obstructed catheters Sexual Dysfunction
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

29. Interventions Urinary incontinency or dribbling is common
Encourage Kegel exercises hourly
Teach to stop several times during urination
Often improves within 12 months

30. 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

31. 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

32. Testicular conditions
Orchitis
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

33. 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

34. Testicular Self-Exam

35. 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

36. 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)

37. Conditions Affecting the Penis
Hypospadias and epispadias
Phimosis
Priapism