Chapter 48

1. Chapter 48 Male Reproductive Disorders

2. Learning Objectives • Describe the major structures and functions of the normal male reproductive system. • Identify data to be collected when assessing a male patient with a reproductive system disorder. • Discuss commonly performed diagnostic tests and procedures and the nursing implications of each. • Identify common therapeutic measures used to treat disorders of the male reproductive system and the nursing implications of each. • For selected disorders of the male reproductive system, explain the pathophysiology, signs and symptoms, complications, medical diagnosis, and medical treatment. • Assist in developing a nursing care plan for a male patient with a reproductive system disorder.

3. Anatomy and Physiology of the Male Reproductive System Scrotum Testes Epididymis Vas deferens Seminal vesicles Prostate gland Cowper’s glands Urethra Penis

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8. Anatomy and Physiology of the Male Reproductive System Spermatogenesis Sperm are produced in seminiferous tubules of testes from about age 13 throughout the remainder of life Erection Parasympathetic nerves release neurotransmitters that cause the cavernosal arteriole walls to relax Allows high-pressure arterial blood to flood the sinuses of the erectile chambers, increasing blood volume and raising cavernosal blood pressure to approximately the same as arterial blood pressure

9. Anatomy and Physiology of the Male Reproductive System Emission and ejaculation Stimulation of internal and external sex organs initiates contractions of the vasa deferentia and prostatic capsule Contractions move sperm to the ejaculatory ducts and expel them into the internal urethra Filling of urethra excites nerves in sacral region of spinal cord: contractions of internal genital organs, pelvis, and body trunk and result in ejaculation (expulsion) of semen

10. Age-Related Changes in the Male Reproductive System Testosterone decreases rapidly after age 50 Men in their late 40s and early 50s may be slower to arouse and have a longer refractory period between erections, but in a healthy man, spermatogenesis and the ability to have erections last a lifetime

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12. Health History Present illness Complaints: weight loss, infertility, erectile dysfunction (impotence), alteration in self-image, scrotal masses, penile discharge, skin lesions

13. Health History Past medical history Chronic health problems: diabetes, thyroid or pituitary dysfunction, cardiovascular disease, neurologic injury or disease, and addictive behavior Family history Age and health or age at death of parents, grandparents, and siblings Cancer, diabetes, hypertension, stroke, and blood disorders such as sickle cell anemia and hemophilia

14. Health History Review of systems Changes in appetite, weight, exercise or activity level Changes in the skin, including lesions, drainage, bleeding, itching, or pain Circulatory and pulmonary systems for hypertension, cardiac/pulmonary disease, exercise tolerance Fatigue, nervousness, heat or cold intolerance, polyphagia, polydipsia, polyuria, and medications taken for pituitary or thyroid conditions Weakness, paralysis, coordination problems, joint pain or stiffness, mood changes, and depression

15. Health History Functional assessment Diet, usual activities, sleep and rest, medications, and the use of tobacco, alcohol, and illicit drugs Sources of stress and coping strategies Frequency of intercourse, ability to have and maintain an erection, desire and ability to have children, relationship of sexual function to self-image

16. Physical Examination Height, weight, vital signs recorded, and his general appearance noted Skin inspected for lesions or discolorations and the breasts for gynecomastia (enlargement) Skin of external organs and perineum should be warm, dry, and free of lesions, edema, and odor The lower abdomen and groin are palpated for masses

17. Physical Examination Penis Normal flaccid penis is semisoft and straight Size, shape, and appearance are noted Palpated for nodules, swelling, and lesions If the patient is uncircumcised, foreskin is retracted to inspect the glans. The urethral meatus should be at the tip of the penis

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19. Physical Examination Scrotum Skin should be slightly darker, wrinkled, and loose Palpate each side for the right and left testes, epididymis, and vasa deferentia Inspect for hernias Advanced practitioner/physician examines prostate by inserting finger into anus toward anterior wall of rectum Perineum skin darker than that of buttocks; should be intact Anal area has more coarse skin and is moist and without hair. Inspect for lesions, irritation, inflammation, fissures, abscesses, and dilated veins

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21. Diagnostic Tests and Procedures Laboratory studies Semen analysis Endocrinologic studies Tumor markers General laboratory studies Urinalysis Complete blood cell count Alkaline phosphatase and serum calcium levels Thyroid function studies and tests for diabetes

22. Diagnostic Tests and Procedures Radiologic imaging studies Computed tomography Ultrasound Radionuclide imaging

23. Disorders of the Male Reproductive System

24. Prostatitis Inflammation of the prostate gland Acute or chronic bacterial prostatitis Caused by bacterial infection Chronic prostatitis/chronic pelvic pain syndrome Prostate pain but no evidence of infection Asymptomatic inflammatory prostatitis No pathogens can be detected

25. Prostatitis Signs and symptoms Acute prostatitis Swelling, warmth, and tenderness Dysuria, frequency, hematuria, and foul-smelling urine Chronic prostatitis Minimal symptoms or malaise

26. Prostatitis Diagnosis Complaints confirmed by lab studies of prostatic secretions Treatment Acute and chronic bacterial prostatitis: antibiotics, analgesics, and sitz baths Chronic prostatitis/chronic pelvic pain syndrome: short course of antibiotics, anti-inflammatory drugs; opioid analgesics Asymptomatic prostatitis: single daily dose of alpha-adrenergic blocker

27. Epididymitis Inflammation of the epididymis Causes Infections, trauma, or the reflux of urine from the urethra through the vas deferens Signs and symptoms Painful scrotal edema, nausea, vomiting, chills, fever Treat with bed rest, ice packs, sitz baths, analgesics, antibiotics, anti-inflammatory drugs, and scrotal support

28. Epididymitis Nursing care Monitor temperature, edema, and comfort Carry out prescribed treatments

29. Orchitis Inflammation of one or both testes Related to trauma or infections such as mumps, pneumonia, or tuberculosis Signs and symptoms Fever, tenderness, and swelling of the affected testicle and scrotal redness Treatment Analgesics, antipyretics, bed rest, scrotal support, and local heat to the scrotum

30. Orchitis Nursing care Pain management, assistance with activities of daily living, patient teaching, and anxiety reduction

31. Benign Prostatic Hypertrophy Enlargement of the prostate gland Common age-related change, but exact cause is unknown Signs and symptoms Obstructive symptoms: decreasing size and force of the urinary stream, urine retention, and postvoid dribbling Irritative symptoms: urgency, frequency, dysuria, nocturia, hematuria, sometimes urge incontinence

32. Benign Prostatic Hypertrophy Medical diagnosis Based on rectal examination, laboratory and radiographic studies, endoscopy, ultrasound, catheterization for residual urine, and sometimes urodynamic testing Urine specimen and prostatic secretions obtained and examined for infection Medical treatment Finasteride (Proscar) and dutasteride (Avodart) Tamsulosin (Flomax), doxazosin (Cardura), and terazosin (Hytrin)

33. Benign Prostatic Hypertrophy Surgical/invasive treatments Types of prostatectomy Transurethral resection of the prostate Suprapubic prostatectomy Complications Urinary infection and incontinence, hemorrhage, urinary leakage, inflammation of the pubic bone, erectile dysfunction Alternative invasive procedures Microwave thermotherapy or transurethral needle ablation Stents Balloon dilation

34. Benign Prostatic Hypertrophy Assessment Urinary symptoms: frequency, urgency, hesitancy, a change in stream size or force, and nocturia Record pain or hematuria Palpate lower abdomen to detect bladder distention Interventions Impaired Urinary Elimination Fear Ineffective Management of Therapeutic Regimen

35. Benign Prostatic Hypertrophy Assessment of prostatectomy patient Compare vital signs with preoperative measurements Inspect urine, dressings, and wound drainage for excess bleeding Carefully record fluid intake and output to avoid overdistention of the bladder Input and output should be balanced; record urine color and any clots Check intravenous fluids and regulate rate of flow Monitor patient’s level of comfort for incisional pain and bladder spasms

36. Benign Prostatic Hypertrophy Interventions for prostatectomy patient Risk for Deficient Fluid Volume Acute Pain Risk for Infection Risk for Injury Urge Urinary Incontinence Sexual Dysfunction and Situational Low Self-Esteem Deficient Knowledge

37. Erectile Dysfunction (Impotence) Inability to produce and maintain an erection for sexual intercourse Erection requires intact neurologic function, sufficient inflow of blood to fill the corpus cavernosa, leakproof storage mechanism for maintaining the erection. Factors are Vascular disorders Endocrine disorders Neurologic disorders Medication side effects Psychological

38. Erectile Dysfunction (Impotence) Drug therapy Phosphodiesterase type 5 inhibitors Sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) Alprostadil Intracavernosal injection (Caverject) or urethral suppositories (MUSE) Papaverine Testosterone

39. Erectile Dysfunction (Impotence) Vacuum constriction devices A vacuum draws blood into the penis Revascularization Surgical procedure that bypasses blocked arteries, removes or ties off incompetent veins, and tightens the surrounding tissue Penile implants Silicon cylinders placed in the erection chambers that keep the penis firm at all times

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41. Erectile Dysfunction (Impotence) Assessment Patient’s health/family history of diabetes Record surgical procedures, injuries, illness, cancer, and medications used regularly Habits and lifestyle including daily activities, diet, use of alcohol and illicit drugs, exercise, health care beliefs, interpersonal relationships, capability for self-care, age, physical condition, and educational needs

42. Erectile Dysfunction (Impotence) Interventions Listen and be careful not to dismiss the issue as unimportant Provide factual information and resources

43. Peyronie’s Disease A hard, nonelastic, fibrous tissue (plaque) just under the skin of the penis of men between 45 and 70 years of age Plaque develops as a result of an injury that causes inflammation and scarring of the tunica surrounding the corpora cavernosa Loss of elasticity of the tunica results in decreased ability to fill during an erection and failure to store because of low pressure on the veins against the covering of the erectile tissue

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45. Peyronie’s Disease Medical treatment Topical or oral medications with vitamin E, oral para-aminobenzoic acid, tamoxifen, colchicine Local radiation, injections into the lesions, ultrasonography, and surgical correction are other options Treatment depends on size of the plaque and curvature and resultant degree of dysfunction

46. Priapism Prolonged erection not related to sexual desire Causes Injury to the penis, sickle cell crisis, and neoplasms of the brain or spinal cord Drugs that may be responsible include phenothiazines, alpha-adrenergic blockers, anticoagulants, alcohol, cocaine, marijuana, vardenafil (Levitra), and intracavernosal injections Painful; constitutes an emergency situation Failure to resolve the problem within 12 to 24 hours may result in penile ischemia, gangrene, fibrosis, and erectile dysfunction

47. Priapism Medical treatment Aspirating blood from erectile chambers or injecting drugs that cause contraction of smooth muscle, inhibiting inflow of blood and allowing outflow If these efforts fail, emergency surgery may be needed Nursing care must be particularly sensitive to the embarrassment the patient may experience Understanding the condition and alleviating pain are important

48. Phimosis Edema that may prevent retraction of the foreskin caused by inflammation under the foreskin Often associated with poor hygiene Treated with antimicrobials and proper cleansing Circumcision sometimes recommended Uncircumcised men need to retract the foreskin for cleaning as part of daily hygiene

49. Infertility Couples who have had unprotected intercourse over a 12-month period and have been unable to become pregnant May be caused by a reproductive problem in the male, the female, or both

50. Infertility Etiology and risk factors Male infertility: endocrine disorders, testicular problems, or abnormalities of the ejaculatory system Infections can affect testicular and ejaculatory function Drug therapy, radiation, substance abuse, and environmental hazards also can affect the testes