Chapter 75: Care of Male Patients with Reproductive Problems

Question 1

Benign Prostatic Hypertrophy/Hyperplasia

Answer 1

Age associated enlargement of the prostate gland in men, may cause bladder compression and constrict urinary flow.
The patient will have increased residual urine or acute urinary retention. This may result in overflow urinary incontinence which urine links and dribbles. They can also cause urinary tract infection and bladder stones. Urine retention can lead to chronic kidney disease. Assess for bladder outlet obstruction and lower urinary tract symptoms. LUTS. Assess from hematuria.

Prostate exam: BPH is uniform, elastic, nontender enlargement. Cancer will feel stony hard. May massage it for a fluid sample to rule out prosatitis.

Question 2

hyperplasia vs hypertrophy

Answer 2

hyperplasia-increase in CELLS

hypertrophy-enlargment

Question 3

LUTS lower urinary tract symptoms

Answer 3

Difficulty in starting and continuing urination.
Reduced force and size of the urinary stream.
Sensation of incomplete bladder emptying.
Post void dribbling.

Question 4

Lab work for BPH

Answer 4

Urinalysis and culture to evaluate UTI and hematuria
CBC for systemic infection or anemia
BUN and creatnine to evaluate renal function
PSA and serum acid phosphatase if cancer is suspected
Culture of prostatic fluid

Prostate ultrasound
Tissue biopsy
Cytoscope to view bladder
Bladder ultrasound to check for residual urine

Question 5

Key features of BPH

Answer 5

Urinary frequency
Nocturia
Urinary hesitancy, difficulty starting the stream
Hematuria
Diminished force of the stream
Dribble post voiding
Bladder distention
Renal insufficiency: edema, pallor, pruritus
Uniform, elastic, nontender, palpable prostate

Question 6

Nursing DX BPH

Answer 6

Urinary retention related to blockage from the enlarged prostate. Urinary incontinence related to over distention of the bladder. Disturbed sleep pattern related to nocturia.
Risk for infection related to residual urine.
Potential for renal insufficiency or chronic kidney disease.

Question 7

Nonsurgical Treatment for BPH

Answer 7

5-alpha reductase inhibitor such as Proscar-finasteride or Avodart-dutasteride. They lower the DHT (testosterone) which can shrink the prostate and prevent further growth. May need six months before improvement. Side effects include erectile dysfunction and decreased libido

Alpha blocking agents such as tamsulsin/Flomax and alfuzosin/Uroxatral. These cause the prostrate gland to constrict reducing urethral pressure and improving urine flow. Alpha blockers such as Cardura and Hytrin are used to treat if hypertension is present. Assess for orthostatic hypotension and syncope. Bedtime dosing may decrease the risk for hypertension. Erectile dysfunction drugs can worsen the side effects. These drugs can cause liver dysfunction

CAM: saw palmetto extract and lycopene(in tomatoes)

Other: Frequent intercourse helps release prostatic fluid. Teach to avoid drinking large amounts of fluid in a short time, avoid alcohol, diuretics, and caffeinr; void as soon as he feel the urge. Avoid medications that cause urinary retention such as anticholinergics, antihistamines, and decongestants.

Thermotherapy
TUNA: transurethral needle ablation. Low radiofrequency energy shrinks the prostate
TUMT:transurethral microwave therapy. High temperatures heat and destroy excess tissue
ILC: interstitial laser coagulation. Laser energy coagulates excess tissue
Electrovaporization: High-frequency electrical current cuts and vaporizes excess tissues
Prostatic stent

Question 8

Surgical treatment for BPH

Answer 8

TURP: transurethral resection of the prostate
Possible open prostatectomy
Criteria for surgery: Acute urinary retention. Chronic urinary tract infections secondary to residual urine. Hematuria. Hydronephrosis.

Usually epidural or spinal. This allows for assessment of hyponatremia which can occur from fluid overload, water intoxication from bladder irrigation. Catheter will be present for at least a day and they will feel the urge to avoid. The patient will probably have continuous bladder irrigation and traction on the catheter that may cause discomfort. Urine will be bloody with some small clots. The surgery is performed using a rectoscope through the urethra and removes the enlarged portion. Fibrinolytic may be used to prevent excess clotting.

Disadvantages include re-enlargement of the prostate, urinary urethral strictures.

Once the catheter is removed the patient may experience burning and frequency, dribbling, which are normal and will decrease. Small clots will be passed for several days. Increased fluid intake to 2000 - 2500 mL. Watch for complications such as infection and incontinence. Sexual function should not be affected but retrograde ejaculation is possible. Monitor urine output every two hours.

Assess bleeding:
Arterial bleed: urinary drainage is bright red or ketchup like with numerous clots. Notify the surgeon immediately and increase irrigation. Surgical intervention maybe needed.
Venous bleed: urine output is burgundy with out vital sign changes. Inform the surgeon. May possibly apply traction on the catheter and prescribed analgesics or anti-spasmodics. Monitor the H&H.
Encourage mobility but watch for fall risk. Anticipate mental status change. Reorient frequently. Use normal saline for bladder irrigation. Check tubing frequently.

Question 9

Prostate cancer

Answer 9

Most common type of cancer in men in the US. Second-leading cause of death. DHT is in the prostate gland and causes it to grow very rapidly leading to noncancerous high-grade prosthetic intraepithelial neoplasia. HGPIN. They are higher risk for cancer.

The cancer is slow-growing and metastasis to the nearby lymph nodes, bones, lungs, and liver.

Blood in the urine is the most common clinical manifestation. Check for swollen lymph nodes. Unexpected weight loss is common. The prostate will be stony heart and irregular.

Question 10

Risk factors for prostate cancer

Answer 10

Low if castrated before puberty. Advancing age. Men older than 65 are at greatest risk. Diet high in animal fat. Viruses, family history, vitamin D and E deficiencies, genetics, exposure to environmental toxins. In the US it affects African men most and at an earlier age.

Question 11

Prostate screening

Answer 11

Annual digital rectal exam and PSA test to men beginning at age 50,
men who have a life expectancy of at least 10 years,
African men beginning at age 45, men with one in family at 45
Age 40 if 2 or more in family

Abnormal PSA is above 4.0

Promotion: Decrease animal fats and redmeat. Eat more fish and omega-3 fatty acids. Increase fruits and vegetables. Tomatoes, watermelon, grapefruit, papaya, broccoli, cauliflower, cabbage, kale. Other foods include selenium, vitamin D, catechin found in green tea. Exercise. Do not get too much calcium. Tobacco and alcohol increase growth.

Question 12

Tests for prostate cancer

Answer 12

PSA (normal is 4 or under) with DRE. Draw the PSA before the exam.

EPCA-2

Ultrasound TRUS: Complications include humanity urea with clots, infection, perineal pain. Report fever, chills, bloody urine, difficulty voiding. Avoid physical activity and drink plenty of fluids for 24 hours.
Biopsy

Cancer is determined, more tests are done.
Lymphnode biopsy, CT of pelvis and abdomen, MRI, bone scan, liver functions, serum phosphatase

Question 13

Nursing diagnosis for prostate cancer

Answer 13

Impaired urinary elimination related to urinary tract infections caused by bladder outlet obstruction.
Anxiety and fear.
Acute or chronic pain.
Risk for sexual dysfunction.
Dysfunctional grieving or anticipatory grieving.
Potential for metastasis

Question 14

Surgical Treatment for prostate cancer

Answer 14

Usually treatment is 10 years after diagnosis because of its slow growing. Surgery for a cure is a prostatectomy. Bilateral orchiectomy which is removal of both testicals helps slow the growth of cancer.

Advantages of LRP-laparascopic radcial prostatectomy:
To qualify PSA must be under 10, never had hormone therapy or abdominal surgery. Decreased hospital stay, minimal bleeding, smaller incisions, less pain, decreased catheter time, fewer complications, faster recovery, nerve sparing advantages. Resume activities in about a week

Open: The patient will be sterile and have retrograde ejaculation. Temporary erectile dysfunction may last for 3 to 18 months. Resume activities in about 3-5 weeks. Potential long-term complications include urinary incontinence and erectile dysfunction. Keagle exercises may help. Teach exercises such as tightening the perennial muscles for 3 to 5 seconds and then relax. Bear down as if having a bowel movement and relax.

Question 15

Post operative care after an open prostatectomy

Answer 15

Use a PCA pump.
Ambulate the night of surgery.
Wear SCDs.
Monitor for DVT.
Intake and output including drainage devices.
Keep urinary meatus clean using soap and water.
Avoid rectal procedures or treatments
Teach the patient how to care for the catheter which will be in place for 7 to 14 days.
Teach the patient how to use a leg bag.
Do not strain during bowel movements. Avoid suppositories and enemas. Possible stool softener
Follow-up appointments
Lift no more than 15 pounds for six weeks. Do not walk bent over. Vigorous exercise avoided for 12 weeks. Shower for 2 to 3 weeks and do not bathe.
May have peyronie’s disease

Question 16

Hormone therapy for prostate cancer

Answer 16

Radiation therapy: is an alternative curative treatment to surgery for locally contain tumors, an adjunct to radical prostatectomy when lymph nodes show cancer, palliation of the patient’s symptoms.
External beam: 5 days a week for 6-9 weeks. Usually causes ED. Acute radiation cystitis which is persistent pain and hematuria, and usually goes away in 6 weeks. Avoid caffeine and increase water

Radiation proctitis: rectal mucosa inflammation which includes rectal urgency and cramping, passes mucous and blood. Goes away in 4-6 weeks. Avoid spicy, fatty, caffeine, and dairy.

Internal radiation/brachytherapy: implants low dose seeds. Not harmful. ED, incontinence and rectal problems are small. Fatigue for several months.

Drug therapy:
ADT: androgen deprivation therapy can be done by B-orchiectomy, and-or luteinizing hormone-releaseing hormone agonists or antiandrogens.
LH agonists stimulate the pituitary gland to release LH which it runs out of in about three weeks. This then reduces testosterone production. Side effects include hot flashes, erectile dysfunction, and decreased libido. Some will also get gynecomastia, and osteoporosis.
Anti-androgens block the bodys ability to use androgens. These are used when there is metastatic disease. They inhibit tumor progression by blocking the uptake of testicular and adrenal androgen at the prostate tumor site. They may be used in combination with LH agonists.

Question 17

Chemotherapy for prostate cancer

Answer 17

Is used when cancer has spread and other therapies have not worked. Taxotere, a drug used to treat breast cancer is used.

Question 18

Cryotherapy for prostate cancer

Answer 18

Is used if cancer is confined to the prostate gland. A transrectal ultrasound probe is placed in the rectum. Liquid nitrogen freezes the gland and results in cell death. It is associated with a high risk for urinary incontinence and erectile dysfunction. It is not commonly used in patients can resume activity in about one week

Question 19

CAM therapy for prostate cancer

Answer 19

Soy protein may help slow the growth and spread. An eight herb combination is used to decrease testosterone and PSA. Green tea and garlic.

Question 20

Peyronie’s disease

Answer 20

An abnormal bending of the penis during erection that is caused by fibrous plaque/scar tissue that forms in the penis. Some men may have a lump or pain. Report this problem

Question 21

Erectile dysfunction/impotence

Answer 21

Organic ED is a gradual deterioration of function. First noticing a diminishing firmness and a decrease in frequency. Causes include inflammation of the prostate, urethra, or seminal vesicles. Surgical procedures. Pelvic fracture. Lumbosacral injuries. Vascular disease including hypertension. Chronic neurological condition such as Parkinson’s or NPS. In the print disorders such as diabetes mellitus or thyroid. Smoking and alcohol. Antihypertensives. poor health.

Functional (psychological) cause. Usually have normal nighttime and morning erections. Onset is sudden and usually after stress. Hormone testing of testosterone, gonadotropins, LH, and FSH are measured. Ultrasound will check blood flow to the penis. Nocturnal penile tumescence test can determine if it is functional or organic.

Question 22

Drug therapy for erectile dysfunction

Answer 22

PDE-5 inhibitors Relax the smooth muscle so bloodflow to the penis is increased. The veins exiting are compressed limiting outward bloodflow resulting in penile swelling (tumescence). Take the pill one hour before intercourse. Viagra and Levitra need sexual stimulation in one hour to promote erection. Cialis has a longer time period. Abstain from alcohol. Side effects include dyspepsia (heartburn), Headaches, facial flushing, stuffy nose. If taking more than one pill a day you may have leg and back cramps, nausea and vomiting. Avoid these drugs if taking nitrates which will cause hypotension and reduced blood flow to organs.

Question 23

Alternative therapies for erectile dysfunction

Answer 23

Vacuum constriction device fits over the penis and will draw blood into the penis to maintain erection. A rubber ring is placed at the base to maintain the erection. Remove the ring after one hour or tissue may be damaged.

Injecting the penis with vasodilating drugs may help. Inject them into the side using a 27 or 30 gauge needle. Adverse effects include priapism, scarring, fibrosis, bleeding, bruising, pain, Infection, and vasovagal responses.

Alprostadil (Muse) is a urethral suppository which causes erection in 10 minutes, lasting 30-60 minutes.

Penile implants Are used when other options fail. They may be semirigid, flexible, inflatable.

Question 24

Testicular Self exam

Answer 24

Examine monthly immediately after shower when the scrotum is relaxed. Gently roll each testical between your thumb and finger. Tumors are usually deep in the center. Look and feel for any lumps. Smooth rounded masses or any change in the size shape or consistency of the testes. Report any lump or swelling

Question 25

Testicular cancer

Answer 25

Not common. The most common cancer in white men from 13 to 34 years old. There are two groups.

Germs cell tumors arise from the sperm producing cells. Most common and has 2 types. Seminomas is most common, usually localized, and metastasize late. Respond to radiation.
Nonseminomatous have 3 types: embryonal carcinoma, teratoma, and choriocarcinoma. Spread quicker and require surgery and-or chemo.

Non germ cell tumors arise from the stroma, interstitial, or leydig cells that produce testosterone. Interstitial cell tumors or androblastomas (testicular adenomas). Most these tumors do not metastasize. They secrete excessive amounts of hormones which caused early puberty. Some secrete estrogen which cause gynecomastia.

The risk is higher in males who have cryptorchidism. Testicular cancer is usually unilateral. If it is in both testicles it may be from metastasis from another cancer.

The most common manifestation is swelling or a lump that is painless. Before treatment they may want to consider sperm donation and storage. 3-6 ejaculations, 2-4 days apart. This may delay treatment, which may not be good.

The presence of pain, lymph node swelling, abdominal masses, Hydrocele or gynecomastia often indicates metastatic disease

Question 26

Tests for testicular cancer

Answer 26

Usually and elevated tumor markers
AFP: alpha-fetoprotein
hCG: beta human chorionic gonadotropin
LDH: lactate dehydrogenase

Testosterone levels (for cancer in cells of leydig)

Ultrasound:  fluid filled or solid mass.
CT of abdomen and chest
Lymphangiography
MRI
Bone scans

Question 27

Nursing diagnosis for testicular cancer

Answer 27

Risk for sexual dysfunction. Dysfunctional grieving or anticipatory grieving. Disturbed body image. Acute or chronic pain. Anxiety.

Question 28

Oligospermia

Answer 28

Low sperm count

Question 29

Azoospermia

Answer 29

The absence of living sperm

Question 30

Surgery for testicular cancer

Answer 30

Unilateral orchiectomy removes the intact testicle to prevent spread. May also remove lymph nodes which may make the surgery last up to 6 hours. May replace with a gell filled prosthesis.

Open radical has incision from the xiphoid process to the pubis. Pt normally sterile after, but maintains erection and orgasm. Usually in hospital for 3-4 days.
May also opt for MIS with laparoscope. Hospital for 1-2 days.

A jockstrap maybe needed for several days. If having an open retroperitoneal lymph node dissection they recover slowly and should not lift over 15 pounds, should avoid stairs, should not drive a car. Routine follow-up and lab work should be done at least for three years.

Question 31

Nonsurgical treatment for testicular cancer

Answer 31

Chemo and radiation

If Cisplatin Is used long term problems include hypertension, hyperlipidemia, Raynaud’s phenomenon, and coronary artery disease.

Advantage of radiation instead of lymph node dissection is that reproductive function is usually preserved. The remaining testes is shielded with a lead cup. May have low sperm count for 24 to 30 months.

Question 32

hydrocele

Answer 32

A cystic mass filled with straw-colored fluid that forms around the testis. It is from impact lymphatic drainage. They are usually painless. It may be drained or excised. It may have a drain in place with serosanguineous drainage for 24 to 48 hours. Wear a jockstrap. Rest for several days and limit physical activity for one week.

Question 33

Spermatocele

Answer 33

Sperm containing cyst develops on the epididymis alongside the testicle. Trauma, infection, congenital abnormalities, or no reason results in the widening of a portion of the epididymis creating a small cavity where sperm collects. If they start causing discomfort, They may need to be excised. Drainage and swelling are minimal.

Question 34

Variocele

Answer 34

A cluster of dilated veins behind and above the testes. Diagnosis is made by palpation while performing the Valsalva maneuver. The scrotum feels wormlike when palpated. Most are unilateral occurring on the left side. They are usually asymptomatic, but if painful they may need removal. They can cause infertility from increased temperature. A rare complication of removal is testicular atrophy because of decreased blood supply.

Question 35

Cancer of the penis

Answer 35

Usually it is found on the foreskin or the glans. When confined to the skin it is called carcinoma in situ. Circumcision almost eliminates the cancer risk. Usually a painless, wartlike growth are Olster on the glands under the foreskin. Maybe control using excisional biopsy. If not controlled by biopsy or radiation a partial or total (if invades the shaft) penectomy may be required. Watch for suicide attempts

Question 36

Phimosis

Answer 36

prepuce is constricted so that it cannot be retracted over the glans. Teach uncircumcised men the importance of cleaning the prepuce. It is corrected by circumcision. Following circumcision normal activities can be resumed in one week and sex in 1 to 2 weeks. Soak in a bath to remove the dressing.

Question 37

Paraphimosis

Answer 37

prepuce has not returned to normal position after being retracted and constricts around the glands. This constricts lymph drainage causing the penis to swell. Bloodflow is decreased and tissue death can occur. This is an emergency situation. Causes include infection, Not returning to original position, poor hygiene, vigorous sexual intercourse, penile piercing.

Question 38

Priapism

Answer 38

Uncontrolled, long maintained erection without sexual desire, Causes the penis to become large, hard, and painful. Can occur from neural, vascular, or pharmacological causes including thrombosis of the veins of the corpora cavernosa, leukemia, sickle cell disease, diabetes mellitus, malignancies. It is an emergency because the circulation may be compromised and the patient may not be able to void. Outcome is to improve the venous drainage which may involve prostatic massage, sedation, ice packs, bedrest. Demerol maybe given because of it’s hypotensive effect. Urinary catheterization may be required. If those therapies are unsuccessful it may need aspiration of the corpora cavernosa with a large core needle or surgical intervention. They should be resolved within the first 24 to 30 hours.

Question 39

Prostatitis

Answer 39

Inflammation of the prostate gland. There are four types. Acute bacterial, chronic bacterial, nonbacterial, chronic pelvic pain syndrome, and asymptomatic inflammatory.

Bacterial prostatitis occurs with urethritis or infection of the lower urinary tract. Most common organisms are E. coli, Enterobacter, Proteus, and group B strep. Manifestations include fever, chills, dysuria, urethral discharge, a boggy tender prostate.

Chronic bacterial occurs in older men. Manifestations include hesitancy, urgency, dysuria, difficulty initiating and terminating the flow, decreased strength and volume of urine, discomfort in the perineum, scrotum, and penis.

May occur after a viral disease of STD. Autoimmune disorders, neuromuscular etiologies, allergy mediated reactions, and pyschosexual problems may contribute to it.

Urgency, dysuria, rectal, perineal, ejaculatory pain and decreased libido may be present. There is often an elevated WBC and PSA level. Complications include epididymitis, and cystitis. A rare complication is an abscess. Early diagnosis and treatment with antimicrobials are important. Therapy may last from weeks to months because there is poor penetration of antibiotics in the prostate tissue. May require aggressive IV antibiotics.

Teach importance of long-term therapy and increasing fluid intake. Activities that help drain the prostate include sexual intercourse and masturbation. It is not infectious or contagious

Question 40

Prostatodynia

Answer 40

Pain in the prostate with manifestations of prostate tightest but no inflammation of the prostate and a negative urine culture. The patient may have low back pain with unilateral testicular pain, a narrow stream with decreased force, and griddle.

Question 41

Epididymitis

Answer 41

Inflammation of the epididymis possibly from an infection or noninfectious sources such as trauma. Bacterial infection is the most common. It can be a complication of an STD. Organisms such as Staphylococcus and E. coli are common as well as chlamydia and gonorrhea.

Manifestations include pain along the inguinal canal and the vas deferens followed by pain and swelling in the scrotum and groin. If untreated the epididymis becomes swollen and painful along with fever. An abscess may form requiring an orchiectomy.

Treatment involves remaining in bed with the scrotum elevated to prevent traction and facilitate drainage. Wear support when ambulating. Antibiotic specific to the organism after culture. Cold compresses and sitz bath may help. Avoid lifting, straining, sex until infection is controlled. Always rule out a tumor. Recurrent or chronic may require an epididymectomy.

Question 42

Orchitis

Answer 42

Acute testicular inflammation resulting from trauma or infection. May be from direct spread of bacteria or by an infection elsewhere in the body. Usually both testes and the epididymis is involved. Risk factors include UTIs, recurrent STDs, congenital abnormalities of the urogenital tract, instrumentation, chronic urinary catheterization. There is an increased risk first sterility because of atrophy and fibrosis. Manifestations include scrotal pain, edema, heavy feelings involving the testicles, dysuria, pain on ejaculation, blood in the semen, discharge. You may also have nausea and vomiting, and pain radiating to the inguinal canal. Treatment is the same as epididymis which includes bedrest and elevation, ice, analgesics and antibiotics.

Mumps orchitis occurs in 20% of males who have mumps after puberty, is bilateral. They may be given gamma globulins.