Male Reproductive Disorders

1. Megan McClintock, MS, RN Fall 2011 Male Reproductive Disorders

2. Occurs in 50% of men > age 50, 90% of men > age 80 BPH does not increase risk of prostate cancer Cause – endocrine changes associated with aging Patho – develops in the inner part of the prostrate (cancer is usu. in the outer part), enlargement compresses the urethra Risk factors – obesity, physical activity level, alcohol consumption, smoking, diabetes, family hx of BPH, aging Benign Prostatic hypertrophy (BPH)

3. S/S – gradual in onset, worsen as obstruction increases, symmetrically enlarged, firm, smooth • Obstructive – decrease in force of stream, difficulty starting stream, intermittency in stream, dribbling • Irritative – frequency, urgency, painful urination, bladder pain, nocturia, incontinence • Cx – fairly uncommon, but could have urinary incontinence, UTI that could lead to sepsis, bladder stones, renal failure from hydronephrosis, pyelonephritis, bladder damage BPH

4. History and physical exam Digital rectal exam (DRE) UA with culture (r/o infection) PSA (r/o cancer) Serum creatinine (r/o renal insufficiency) Transrectal ultrasound (TRUS) w/ biopsy (r/o cancer) Uroflometry (extent of blockage) Postvoid residual urine volume (degree of obstruction) Cystoscopy (confirm diagnosis if uncertain) BPH Diagnosis

5. Based on how much symptoms bother the pt or presence of cx (not the size of the prostate) • Watchful waiting if mild symptoms • Diet changes (decrease caffeine & artificial sweeteners, limit spicy/acidic foods) • Avoid decongestants and anticholinergics • Restrict evening fluid intake • Timed voiding schedule BPH Treatment

6. Drugs • 5 alpha-reductase inhibitors (ie. Proscar, Avodart) • Prevent the conversion of testosterone to dihydroxytestosterone (reduces the size of the prostate) • Takes 6 months to be effective • Side effects – decreased libido, ED, orthostatic hypotension with use of ED drugs, women should not handle the tablets • Alpha-adrenergic receptor blockers (ie. Cardura, Hytrin, Flomax) • Often used for HTN but for BPH are used to promote smooth muscle relaxation in the prostate (symptomatic relief but no change to prostate size) • Works within 2-3 weeks • Side effects – orthostatic hypotension, dizziness, retrograde ejaculation, nasal congestion BPH Treatment

7. Transurethral Microwave Thermotherapy (TUMT) • Use of transurethral probe to raise the temp of the prostate tissue to 113 F, can cause post procedure urinary retention so need a catheter for 2-7 days • Transurethral Needle Ablation (TUNA) • Increases heat again, but with low-wave radiofrequency, allows more precision than TUMT, have very little pain, some pts require a catheter for a short time, may have hematuria for up to a week BPH Treatment (Minimally invasive tx)

8. Laser Prostatectomy • Laser is delivered transurethrally through a fiber instrument, several procedures, may need a catheter for 8-48 hrs after • Intraprostatic Urethral Stents • Provides relief of symptoms in pts who are poor surgical candidates, can cause some complications BPH Treatment (Minimally invasive tx)

9. Transurethral Resection of the Prostate (TURP) • Removal of prostate tissue using a resectoscope inserted in the urethra • “Gold standard” surgical treatment with low risk of complications • 1-2 day hospitalization with a 3 way catheter and continuous bladder irrigation (CBI) for the first 24 hours • Cx – bleeding, clot retention, dilutionalhyponatremia BPH Treatment (Invasive TX)

10. Health Promotion • Yearly DRE > age 50 • Avoid alcohol and caffeine (increases bladder distention) • Avoid pseudophedrine and phenylephrine (worsens sx of BPH) • Urinate q 2-3 hrs (prevents urinary stasis and retention) • Do not restrict fluid intake (increases chance of infection, if overhydrating can increase bladder distention) BPH Nursing Care

11. Preoperative • Must have urinary drainage • May need lidocaine gel to open the urethra, may need curved-tip (coude) catheter or filiform catheter • Antibiotics to treat any UTI • High fluid intake (2-3 L/day) to manage UTI • Teach that surgery may affect sexual functioning (usu. have retrograde ejaculation, may have decreased orgasmic sensations) BPH Nursing Care

12. Postoperative • Standard catheter or triple-lumen catheter • Bladder irrigation done to remove clotted blood from the bladder and ensure urine drainage • Can cause painful bladder spasms • Rate of infusion is based on color of drainage (ideally light pink without clots) • If outflow is less than inflow assess for kinks/clots • Careful aseptic technique BPH Nursing care

13. Postoperative • Watch for hemorrhage • Blood clots expected for first 24-36 hours • Provide traction on the catheter for a short time • Avoid Valsalva maneuver • Avoid prolonged walking or sitting • Prevent bladder spasms • Teach pt not to urinate around the catheter • Check the catheter for clots, remove by irrigation • Belladonna and opium suppositories • Antispasmodics (Ditropan) BPH Nursing care

14. Postoperative • Removal of catheter after 2-4 days • Must urinate within 6 hours of removal • May have incontinence or dribbling (may take several weeks to resolve) • Kegel exercises 10-20 times/hour • Penile clamp • Condom catheter • Incontinence pads or briefs • Risk for infection • Be especially careful if they have a perineal incision BPH Nursing Care

15. Discharge instructions • Oral fluids 2-3 L/day • Prevent constipation • No lifting > 10 lbs • No driving or intercourse until released by dr • May have cloudy urine from retrograde ejaculation • May have ED problems • May take up to 1 year for full sexual functioning • Bladder may take 2 months to increase capacity • Urinate every 2-3 hours to flush the urinary tract • Avoid caffeine, citrus, alcohol to prevent bladder irritation • Need a yearly DRE unless the prostate has been completely removed BPH Nursing Care

16. One in every 5 men will develop prostate cancer Usually slow growing – men live and die with prostate cancer, but not from it Risk factors – age, ethnicity (African American men at most risk), family history, diet high in red meat and high-fat dairy with a low intake of veggies/fruits S/S – asymptomatic in early stages, eventually develops s/s like BPH, may have pain in lumbosacral area radiating to hips/legs; prostate is hard, nodular, assymetric on exam Prostate Cancer

17. Diagnosis • Annual DRE and PSA for men > age 50 at average risk (neither are definitive diagnostic tests) • Elevated PSA does not always mean cancer • Elevated with aging, BPH, recent ejaculation, prostatitis, long bike rides • PSA is also used to monitor effectiveness of tx • Biopsy is the definitive test Prostate cancer

18. In early stage is usually curable • Watchful waiting if life expectancy is < 10 years or tumor is low-grade, low-stage • Radical prostatectomy for Stage B or C • Remove entire prostate gland, seminal vesicles, part of the bladder neck, also may have lymph node dissection • Can do retropubic, perineal (much higher risk of infection), or laparoscopic • Cx – ED, urinary incontinence Prostate Cancer Treatment

19. Nerve-Sparing prostatectomy • Decreases risk of ED • Not done if cancer is outside of the prostate gland • Cryotherapy • Done as an initial tx or if radiation therapy fails • No incision, done under general or spinal anesthesia Prostate cancer Treatment

20. Radiation therapy • External beam – most common, outpatient 5 days/week for 4-8 weeks, side effects resolve 2-3 weeks after tx ends • Brachytherapy – radioactive seed implants into the prostate gland, one-time outpatient procedure, best for stage A or B cancer Prostate cancer Treatment

21. Hormonal - androgen deprivation therapy (ADT) – tumors become resistant after a few years, side effects – osteoporosis, fractures • Luteinizing Hormone-Releasing Hormone (LH-RH) Agonists and Antogonists • Antiandrogens, ultimately is a chemical castration, Lupron is most common, given SC or IM regularly and must be taken indefinitely • Androgen Receptor Blockers • These drugs compete with circulating androgens at the receptor sites, usu. combined with LH-RH agonist • Estrogen – rarely used b/c of its side effects Prostate cancer Treatment

22. Orchiectomy – bilateral removal of testes • Can be done alone or in combo with prostatectomy • Also helps relieve bone pain • Can be used when prostate surgery is not an option • Side effects – weight gain, loss of muscle mass • Chemotherapy – usu. only for late stage disease since it is not very effective, usu. for palliation only Prostate cancer Treatment

23. Same as care for BPH Prostate cancer nursing care

24. May be inflammatory or noninflammatory Can be acute or chronic S/S – fever, chills, back pain, perineal pain, acute urinary symptoms, cloudy urine, postejaculation pain, ED; prostate is very swollen, very tender, firm with exam (chronic usu. has milder symptoms Can be confused with UTI Prostatitis

25. Prostatitis diagnosis & care • Diagnosis • UA with culture • PSA (r/o cancer) • Micro and culture of prostate secretion • Care • Oral abx for 4 weeks (acute) up to 12 weeks (chronic) • Antiinflammatories for pain • Warm baths • No catheters • No prostatic massage (acute) • Masturbation and intercourse encouraged • Increase fluids (2-3 L/day)

26. Hypospadius – urethral meatus on the ventral surface of the penis Epispadius – urethral meatus on the dorsal surface of the penis, often associated with other genitourinary defects Congenital Penis Problems

27. Phimosis – tightness or constriction of the foreskin around the head of the penis, usu. caused by poor hygiene Paraphimosis – tightness of the foreskin resulting in the inability to pull it forward from a retracted position, can get an ulcer Prepuce problems

28. Priapism – erection lasting longer than 6 hrs, medical emergency! Peyronie’s disease – curved or crooked penis caused by plaque formation in the corpus cavernosa, not dangerous but can be embarrassing Erectile Problems

29. Very rare Occurs in men with HPV or men not circumcised as infants Looks like a venereal wart Treatment depends on the extent of the disease Cancer of the penis

30. Epididymitis – acute, painful inflammation of epididymis, usu. unilateral, usu. STD • Tx – antibiotics, bed rest, scrotal elevation, ice packs, analgesics • Orchitis – acute inflammation of the testis, usu. occurs after bacterial or viral infxn (ie. Mumps, TB, syphillis, pneumonia), can cause infertility after mumps Inflammation of scrotum & testes

31. Cryptorchidism (undescended testes) • Can occur bilaterally or unilaterally • Will cause infertility if not corrected by age 2 • Increases risk of testicular cancer if not corrected by puberty Congenital problems of Testes

32. Hydrocele – nontender, fluid-filled mass of the scrotum, caused by impaired lymph drainage, requires no tx if not large, visible with transillumination Spermatocele – firm, sperm-containing, painless cyst of the epididymis, visible with transillumination, requires surgical removal to distinguish from cancer Acquired scrotal & testicular Problems

33. Acquired scrotal & testicular problems • Varicocele – dilation of the veins that drain the testes, scrotum feels wormlike, surgery if having problems with fertility • Testicular torsion – twisting of the spermatic cord, seen in age < 20, no cremasteric reflex, s/s – severe scrotal pain, tenderness, swelling, n/v, surgical emergency if blood supply is not restored within 4-6 hrs

34. Rare, but most common type of cancer in young men age 15-34 More common in white males, more common in right testicle Risk factors – undescended testes, family hx of testicular cancer or anomalies S/S – may have slow or rapid onset, painless, firm lump in scrotum, scrotal swelling, feeling of heaviness, will not transilluminate Dx – Ultrasound, labs, chest xray, CT/MRI Tx – orchiectomy, lymph node dissection, chemo, radiation, careful follow up, cryopreservation of sperm Testicular Cancer

35. Warm area (bath or shower) to make testes hang low Use both hands to feel, roll testis between thumb and first 3 fingers, palpate each testis separately Testis should feel like hard-boiled egg, locate spermatic cord which goes up toward groin, feel for lumps, irregularities, pain *One testis is usually larger than the other, more concerned about texture Examine once/month Testicular self exam

36. Bilateral surgical ligation of vas deferens to prevent impregnation permanently Outpatient under local anesthesia *Must use alternate form of contraception until semen has no sperm (about 6 weeks) Does not affect hormone production, ability to ejaculate, physiologic ability to have erection or orgasm Vasectomy

37. Inability to maintain or attain an erect penis that allows satisfactory sexual performance • Causes • Younger men – alcohol or drugs • Middle-aged men – diabetes, HTN, renal or *CV disease • Other – side effects of meds, surgery side effects, trauma, chronic illness, stress, depression Erectile dysfunction (ED)

38. S/S – gradual onset indicates physiologic factors, rapid onset indicates psychologic issues Dx – physical exam, DRE, International Index of Erectile Function (IIEF), CV exam, hormone levels, can do several diagnostic tests Tx – No option will restore ejaculation or tactile sensations if they were already absent, want to be sure ED is actually reversible Erectile Dysfunction (ED)

39. Oral drugs – Viagra, Cialis, Levitra – cause increased blood flow, take an hour before sex • *Do not take with nitrates or if hypotensive • Vacuum Constriction Devices – suction device that pulls blood into the penis, can secure with constrictive band • Intraurethral Devices – vasoactive drugs, penis injection, medication pellet • Penile implants – inflatable implant • Sexual counseling – should be done for all pts ED Treatment options

40. Gradual decline in androgen secretion as men age Can begin as early as age 40 S/S – loss of libido, fatigue, ED, can lead to osteoporosis, decreased muscle mass Dx – low testosterone levels Tx – no oral replacement option, can use IM or transdermal hormone replacement Andropause

41. About 33% of cases are due to male problems • Pretesticular causes – rare • Testicular causes – 50%, most common cause is varicocele • Posttesticular causes – rare • Remaining causes are unknown or idiopathic • Need to do a careful health history and exam • First step is a semen analysis to determine sperm concentration, motility, and morphology • For many men, fertility and masculinity are equated so be sensitive Male Infertility