Week 9 Reproductive System Flashcards
The importance of reproductive health includes sexual education, prevention of STIs, early detection and management of reproductive disorders and family planning. Developing a deeper understanding of reproductive health is multifactorial and requires comprehensive knowledge of the differing components affecting men, women, non-binary and gender diverse people. This week we will explore many of these facets that contribute to reproductive health.
Sexual and reproductive health (SRH) refers
to a person’s right to a healthy body; encompassing complete physical, mental, and social well-being related to the reproductive system, and it’s functions and processes.
It includes the ability to freely decide when and how to have a safe and satisfying sex life, the capacity and freedom to have a child, the autonomy to make informed choices and the ability to have a healthy pregnancy.
SRH also relates to the knowledge and access to healthcare products to avoid sexually transmitted infections (STIs). SRH is an integral part of overall health and well-being, ensuring our population is free from discrimination, free of coercion and free from health risks.
The female reproductive system is broken down into primary and secondary organs.
The primary organs are the ovaries
Secondary organs include the uterus, fallopian tubes, the vagina, Bartholin’s gland, the breasts and the external genitalia.
Those that were assigned female at birth, women who have transitioned to a man and non-binary people can also have, or have had, female reproductive organs and be impacted by disorders related to this body system.
There are 3 primary roles of the female reproductive system:
Production of eggs (ova)
Secretion of hormones
Protection and facilitation of the development of a foetus
Dysmenorrhea
Dysmenorrhoea is pain or discomfort associated with menstruation. More than 50% of women who menstruate will experience dysmenorrhoea for 1-2 days every month. Often, the pain is reported as being mild and manageable in nature. For many others, the pain associated with menstruation is severe and debilitating, impacting lifestyle by preventing typical activity.
Clinical Manifestations
Dysmenorrhea
Can be associated with:
Nausea & vomiting
Headaches
Fatigue
Dizziness
Diarrhoea
There are 2 types of dysmenorrhoea:
Primary Dysmenorrhoea
Secondary Dysmenorrhoea
Primary Dysmenorrhoea
Cramping, abdominal pain that can radiate to lower back and thighs
Occurs prior to the onset of menses or after bleeding has commenced from elevated prostaglandins levels → causes uterine muscles and blood vessels to contract
Pain can last 12-48 hours → prostaglandin levels decrease once the uterine lining starts to shed → pain will then start decreasing
Usually commences with menarche and becomes less intense with advancing age
Also associated with headaches, nausea, vomiting diarrhoea, fatigue, and breast tenderness.
Secondary Dysmenorrhoea
Caused by disorders of the reproductive organs
Onset of pain and associated clinical manifestations usually a few days prior to menstruation and will intensify over the duration of the period → pain may not resolve by the time menstruation has ceased
Clinical manifestations will be related to the identified disease.
Disorders responsible for secondary dysmenorrhoea endometriosis, uterine fibroids, adenomyosis, defects of the reproductive organs, Crohn’s disease, urinary disorders
Dysmenorrhea
Treatment
Pharmacological management → NSAIDs and paracetamol → NSAIDs reduce prostaglandins → decrease cramping
Non-pharmacological management → acupuncture, acupressure, heat packs, nerve stimulation therapies
Dysfunctional Uterine Bleeding
Defined as painless, excessively heavy, prolonged, or frequent bleeding of the uterus that is not due to typical menstrual patterns, pregnancy, or a systemic disorder. Dysfunctional uterine bleeding (DUB) is one of the most common reasons for a woman to be referred to a gynaecologist for further investigation and management.
Can occur at any age but more likely with menarche or during perimenopause.
Usually not a symptom of a serious underlying condition
Disorders that can lead to DUB → uterine fibroids, adenomyosis, endometriosis, cancer, pelvic inflammatory disease, intrauterine device implantation, inflammation of the cervix
Some medications can result in DUB → OCP, antiplatelets, anticoagulants
Dysfunctional Uterine Bleeding
Clinical Manifestations
Typically associated with:
Fatigue
Anaemia
Dizziness
Headaches
Nausea
Vaginal discharge
Bowel and urinary symptoms
Can lead to menstrual changes → irregular cycles, bleeding post menopause, amenorrhoea, prolonged bleeding, spotting
Dysfunctional Uterine Bleeding
The types of DUB include:
Types
Amenorrhoea → absence of menstruation
Oligomenorrhoea → scant or irregular menses
Menorrhagia → excessive or prolonged bleeding
Metrorrhagia → bleeding between menstrual periods
Polycystic ovarian syndrome (PCOS)
Although poorly understood with no clear aetiology, PCOS is considered one of the most common hormonal disorders that affects 1:10 women of reproductive age. Most women are diagnosed between 20-30 years, when they are attempting to get pregnant but are experiencing difficulties conceiving.
Imbalance of reproductive hormones → excessive androgen production triggered by inappropriate secretion of gonadotropin
Prevents ovulation → causing enlarged ovaries, cyst formation on the ovaries and excessive endometrial proliferation
Polycystic ovarian syndrome (PCOS)
Clinical Manifestations
Associated with a range of clinical manifestations that vary between women, including:
Anovulation
Elevated testosterone
DUB → amenorrhoea, oligomenorrhoea
Persistent acne
Hirsutism → excessive female hair growth in areas where hair growth is usually minimal
Male pattern baldness
Darkening of the skin → along neck creases, groin and underneath the breasts
Infertility
Excessive amount of skin tags
Obesity
Additionally, women can experience numerous long-term, cardio-metabolic issues, including:
Hyperinsulinaemia key role in androgen excess and anovulation
Hyperandrogenemia → increases risk of glucose intolerance and diabetes → both type 2 and gestational
Dyslipidaemia
Systematic inflammation
Non-alcoholic fatty liver disease
Cardiovascular disease → hypertension
Coagulation disorders
T2D & glucose intolerance
Polycystic ovarian syndrome (PCOS)
Diagnostic Criteria
Menstrual irregularity
Clinical hyperandrogenism
Ultrasound confirmation of polycystic ovaries
Polycystic ovarian syndrome (PCOS)
Treatment
Hormonal contraception → suppresses androgen production and decreases endometrial hyperplasia
Insulin sensitisers → metformin → increases fertility and decreases risk of T2D
Endometriosis
A condition that occurs when endometrial cells implant outside of the pelvic cavity through retrograde menstruation. Each of these endometrial implantations respond to hormonal changes, breaking down and bleeding with each menstrual cycle, causing inflammation and pain to surrounding structures.
1:9 women of reproductive age (50% of infertile women) are affected
Inflammation can lead to fibroids, benign tumours, scarring and adhesions
Mostly affects reproductive organs and surrounding structures → endometrial cells can be picked up and transported through the vascular system → can implant on any surface anywhere in the body → rectum, bowel, bladder, brain, ligaments, skin, joints, lungs, and liver
Endometriosis can be very debilitating with significant physical, emotional, financial, and psychosocial impacts, including severe pain, depression, anxiety, and social isolation
Symptoms often improve after menopause
Endometriosis
Risk factors
Early menarche
Shortened menstruation → cycle <27 days
Menorrhagia
Increased menstrual pain
Family history of endometriosis
Delayed childbearing
Endometriosis
Clinical Manifestations
The clinical manifestations of endometriosis vary in frequency and intensity:
Heavy, throbbing pelvic pain → radiation can occur down the thighs and around to her back
Feeling of heaviness and discomfort in the rectum when having a bowel movement.
Dyspareunia
DUB
Dysmenorrhoea
Infertility
Dyschezia → pain with defaecation → occurs with bleeding from endometrial implantation on the rectosigmoid musculature and subsequent fibroids
Constipation
Endometriosis
Diagnosis
Aim is for improved awareness, earlier diagnosis, and patient-focused care in primary settings
On average, it takes 6.5 years for diagnosis, as per Endometriosis Australia
Diagnostic delay due to barriers:
→ Difficulty establishing disorder symptoms from normal menstruation → symptoms fluctuation and are varied in severity some → symptoms mimic other disorders such as irritable bowel syndrome
→ Normalisation of menstrual pain → women delay seeking review as they believe their symptoms are ‘normal’ and ‘to be expected’
→ Use of self-care techniques to manage symptoms
→ Menstrual stigma → medical professional may dismiss symptoms or attribute symptoms to a psychological disorder
→ Some women can be asymptomatic and only become aware of diagnosis when being investigated for infertility
→ Lack of education for healthcare team
Only diagnostic available to confirm endometriosis is laparoscopic surgery with biopsy, under general anaesthetic
Endometriosis treatment
There is no cure for endometriosis → focus on symptom management
Hormone treatment → oral contraceptive pill (OCP), or intrauterine device (IUD)
Surgery for severe cases → hysteroscopy, laparoscopy, hysterectomy
Analgesic
TENS machine
Complementary and alternative medicine
Endometriosis
Nursing Management
When caring for a woman with reproductive health disorders, nurses play a pivital role in ensuring person-centered care is delivered. As reproductive health disorders can result in devastating physical, emotional and psychosocial issues, women not only require their gynaecological problems addressed, but also their unique needs, preferences, and concerns. Nurses can provide empathetic support, actively listen and tailor plans accordingly.
Establish a rapport and communicate openly, using clear language and active listening skills → essential for you to develop a trusting, therapeutic relationship and to be able to obtain a good health history
Empowerment → by involving women in decision-making, nurses empower them to actively participate in their own health management. This collaborative approach ensures that treatments align with the woman’s values, lifestyle, and goals.
Create a safe space → some reproductive health disorders, such as PCOS or endometriosis, carry social stigma. Nurses can create a safe space where women feel comfortable discussing their experiences without judgment. This fosters trust and encourages women to seek timely care.
Education → Discuss ways to minimise clinical manifestations such as weight gain, coping with stress and impact on lifestyle
Pharmacological management → including oral contraceptives and analgesia
Non-pharmacological management → applying heat to the lower abdomen or back and physical exercise.
Reassurance & support → includes psychological support → link to support groups or specialised nurses
Encourage regular follow-up with GP / Specialist
Nursing care of the woman who has had gynaecological surgery
Preoperative Considerations
Preoperative checklists and assessments as per facility procedure.
Pregnancy test
Education
Support
Postoperative Considerations
Observations should include assessments for signs of bleeding and infection.
Bladder function should also be monitored.
Wound care and assessment.
Spontaneous Abortion
Spontaneous abortion is the medical term that relates to miscarriage.
Occurs in approximately 1:4 pregnancies in Australia
Defined as the loss of a pregnancy that occurs before 20 weeks gestation
→ 30% of pregnancy loss occurs between implantation and 6/40 (6th week gestation)
Women not only experience the physical effects of miscarriage but also psychological morbidity.
→ Feelings of grief and loss not only for the physical loss of their baby but also for the hopes and dreams that come with having a child
→ For some women, the feeling of loss and grief can lead to depression, anxiety and post-traumatic stress disorder that can require intensive psychological care
Threatened Abortion
→ unexplained vaginal bleeding in the first trimester of pregnancy
→ also called threatened early pregnancy loss
→ often associated with pelvic cramping with no cervical dilatation
→ may result in complete or incomplete abortion or the pregnancy may continue without any further concerns.
Spontaneous Abortion
→ all products of conception are spontaneously expelled within the first 20 weeks of gestation
→ also called complete abortion
→ physically and emotionally painful
→ associated with heavy vaginal bleeding, severe cramping, vaginal loss of fluid and tissues, moderate to severe pain to pelvis and lower back
Incomplete Abortion
→ same as for spontaneous abortion but with only partial expulsion of the products of conception (usually the foetus)
→ it is important to note that the term incomplete can be confusing for women and therefore providing false hope should not be encouraged.
Inevitable Abortion
→ A threatened abortion becomes an inevitable miscarriage when cervical dilation starts to occur, and the products of conception are expelled.
Septic Abortion
→ gynaecological emergency
→ severe uterine infection that occurs just prior to, immediately after, a spontaneous abortion.
Missed Abortion
→ occurs when a pregnancy stops developing and the products of conception remain in the uterus
→ also referred to as an early pregnancy failure
→ surgery is required to remove the products of conception
→ common clinical manifestations include pelvic pain and cramping, or the patient will be asymptomatic
Recurrent Abortion
→ a history of three or more abortions
Nursing Management
When caring for a woman experiencing a miscarriage, nurses play a vital role in providing both physical and emotional support.
Identification of associated clinical manifestations → you need to be vigilant in your assessments and health history to be able to promptly identify the clinical manifestations of a spontaneous abortion, such as vaginal bleeding, pelvic pain, and the passage of tissue. Prompt recognition allows for timely intervention and emotional support.
Emotional Support → miscarriages can be emotionally distressing for the woman and their partner / family. You must develop empathetic and compassionate skills to address their feelings of grief, loss, and sadness. Providing a safe space for the patient and their family / support, to express their emotions is crucial.
Physical assessments → Monitoring and assessing the patient’s physical health is essential. This includes assessing vital signs, managing bleeding, and identifying any signs of complications. Collaboration with the interprofessional team ensures appropriate interventions are implemented.
Grief Support and Coping → You can equip your patients and their families with resources for grief counselling and support groups. Facilitating coping mechanisms helps the patient and their family to navigate the emotional aftermath of a miscarriage. Consider the interprofessional team and who you can refer to → specialised nurses, social worker, grief counsellors.
Ectopic Pregnancy
An ectopic pregnancy occurs when an embryo is growing in the wrong area by implanting outside of the uterus → usually in the fallopian tube.
Typically, for conception to occur, the ova and sperm will meet in the fallopian tube. Once fertilised, the egg continues its journey into the uterus where it will attach to the wall of the uterus which will trigger the placenta to form. Once the placenta starts to grow, human chorionic gonadotropin will start to be released in urine and blood. With an ectopic pregnancy, the fertilised egg stays and implants in the fallopian tube.
The uterus can stretch and grow with a pregnancy. However, the fallopian tube cannot expand in the same way. Ultimately, an ectopic pregnancy cannot continue to develop. The stretching of the fallopian tube that occurs when the pregnancy progresses, results in severe pain and, if the tube tears or ruptures, vaginal bleeding → most ectopic pregnancies rupture between 6-16 weeks
→ 2:100 pregnancies will be ectopic
→ In 95% of cases, the most common site of implantation are the fallopian tubes → occurs due to an obstruction such as adhesions from previous infections, congenital malformations, scars from tubal surgery or tumours
An ectopic pregnancy is a gynaecological emergency and, if left untreated, can result in maternal death. This is due to the significant internal bleeding that often occurs.
Ectopic Pregnancy
Risk
Increased risk of an ectopic pregnancy with:
In-vitro fertilisation (IVF)
History of pelvic infections → salpingitis
Previous ectopic pregnancies
Damaged fallopian tubes, e.g., from adhesions or scarring
History of previous gynaecological surgery
Woman who become pregnant while using an IUD or taking the progesterone only pill
Infertility
Ectopic Pregnancy
Clinical Manifestations
Clinical manifestations of an ectopic pregnancy usually occur 6-8 weeks after the last normal menstruation:
Abdominal pain → usually left / right lower quadrant
A missed menstrual period
Vaginal bleeding, which may be minimal
Symptoms of pregnancy → breast tenderness, frequent urination, or nausea
Feelings of dizziness or light-headedness
Signs and symptoms of haemorrhage → collapse, tachycardia, hypotension
Ectopic Pregnancy Outcomes
In some cases, the fertilised egg dies quickly and is broken down systematically before symptoms occur → ectopic pregnancy in these cases are rarely diagnosed → no treatment / management required
If the fertilised egg continues to grow, the fallopian tube will stretch → clinical manifestations will be experienced tube will rupture → internal bleeding → urgent surgery required to remove the fallopian tube and fertilised egg
Ectopic Pregnancy
Diagnosis & Treatment
Health history
Ultrasound scan
Pregnancy test
3 treatment options
→ Keyhole laparotomy → to remove fertilised egg from the fallopian tube
→ Laparotomy → to remove ectopic pregnancy option determine if pregnancy has advanced and there is significant haemorrhaging
→ IM injection of methotrexate → option for cases that are asymptomatic or mild symptoms → dissolves pregnancy to avoid surgery
Ectopic Pregnancy Nursing Care
Pre and post operative care → monitor vital signs as per guidelines, assess for shock, wound care, DVT prevention, fluid support, analgesia
Educating your patient around the procedure and any side effects, especially of using medication therapy to treat the ectopic pregnancy.
Emotional support and education.
The male reproductive system is also broken down into primary, or essential, organs and secondary organs.
The primary organs are the testes
Secondary organs include the epididymis, urethra, ejaculatory duct, prostate gland, seminal vesicles, the penis and the scrotum.
Those that were assigned male at birth, men who have transitioned to a woman and non-binary people can also have, or had, male reproductive organs and be impacted by disorders related to this body system.
There are 3 primary functions of the male reproductive system:
Produce and secrete male sex hormones
Produce and maintain sperm and semen
Transport semen into the female reproductive tract
Benign Prostatic Hyperplasia
Benign prostatic hyperplasia (BPH) is an age related condition in which there is abnormal prostate cell proliferation, resulting in an abnormally enlarged prostate with associated prostatic tissue expansion. Due to the enlargement of this prostatic tissue, prostatic urethra compression occurs resulting in urinary system dysfunction and lower urinary tract symptoms (LUTS). This will include thickening of the bladder wall, interrupted urine flow and incomplete bladder emptying.
Exact aetiology is unknown
Mortality rate is low
Associated with severeLUTS and sexual dysfunction
Significant impact on quality of life
Sadness
Depression
Anxiety
Body image changes
Benign Prostatic Hyperplasia
Risk Factors
Age >50 → risk will continue to rise with age → hormonal changes associated with aging
Male family member with BPH
Obesity and sedentary lifestyle
Erectile dysfunction
Metabolic syndrome
Frequent urinary tract infections
History of cardiovascular disease and T2D
Benign Prostatic Hyperplasia
Clinical Manifestations
The clinical manifestation associated with BPH occur gradually and can be dividing into 2 categories:
Obstructive → voiding related issues → urethral constriction from enlarged prostate gland:
Reduced flow
Feelings of incomplete emptying
Post-void dribbling
Straining to void
Urinary intermittency
Hesitancy
Irritative → bladder and urinary storage issues → increased force required to urinate → detrusor muscle hypertrophy → thickening and hardening of the bladder wall → loss of elasticity and reduction in compliance:
Nocturia
Urinary frequency
Urgency
Dysuria
Bladder pain
Urge incontinence
Benign Prostatic Hyperplasia
Complications
Urinary retention → sudden and painful inability to urinate → urgent intervention required → insertion of IDC
Frequent urinary tract infections → related to inability to empty bladder → bacterial growth → can result in sepsis
Bladder calculi → occurs due to alkalinisation of residual urine
Acute kidney injury → can lead to kidney failure → caused by hydronephrosis from urine unable to be voided
Benign Prostatic Hyperplasia
Diagnosis
Health history and physical assessment
Digital rectal examination (DRE) → performed to estimate size & symmetry of prostate
Urinalysis → to determine blood and presence of inflammatory cells → WBC & RBC
Prostate-specific antigen (PSA) blood test → slightly elevated with BPH → can significantly rise with prostate cancer
Routine bloods → renal function test → kidney function and inflammatory mediators → creatinine
Transrectal ultrasound→ ordered if PSA elevated and abnormalities detected with DRE → allows for accurate assessment of prostate size and for differentiating with prostate cancer
Cystoscopy → internal visualisation of the urethra and bladder → can be used to confirm diagnosis
Benign Prostatic Hyperplasia
Treatment
Goals of treatment
→ Restore bladder function, particularly drainage
→ Symptom management
→ Prevent complications
Treatment plan will be based on symptom severity and history of complications, not the size of the prostate
Active surveillance → watch & wait → chosen if the patient is relatively asymptomatic → focuses on lifestyle changes (avoiding spicy food, increase exercise, weight reduction, decrease fluid intake at night), education and routine reviews
Timed voiding → scheduling specific times for voiding → going to the toilet to void based on a fixed time as opposed to sensation to urinate → can help the individual to regain bladder control → can reduce symptoms → reduces the need for medication or more invasive interventions
Double voiding → relax before urination to reduce anxiety and tension → urinate, relax for a few minutes, then attempt again
Medication therapy → designed to reduce size of prostate and minimise symptoms
→ 5α-reductase inhibitors
→ α-adrenergic receptor blockers
→ combination therapy
Surgery
→ Transurethral resection of the prostate → removal of prostate tissue through the urethra → gold standard for surgical intervention
Postoperative complications → pain, bleeding and clot retention, transurethral resection syndrome, retrograde ejaculation
Erectile dysfunction unlikely
→ Open prostatectomy → option for men with enlarged bladders and other complicating factors
Often results in erectile dysfunction, increased risk of infection, long term urinary incontinence and significant postoperative pain, bleeding, and clot retention
Benign Prostatic Hyperplasia
Nursing Management
Nursing care is rarely required unless admission to hospital is needed for investigations or surgical intervention. Nursing care considerations relate to pre and postoperative care:
Health history → subjection and objective data collection → major illnesses, previous surgeries, medication history, previous STIs, current symptoms, urinary output history, sexual function, pain history
Symptom management and education
Preoperative
→ Education → the type of surgery, why it is needed, the benefits, complications/risks and if they have any concerns or questions.
→ Assessments
→ Prophylactic antibiotics administration may be required
→ Maintaining fluid intake until NBM.
Postoperatively
→ Postoperative assessments → as per usual postoperative nursing care considerations and guidelines
→ Bladder irrigation
Aim is to reduce the risk of occlusion and urinary retention from clotted blood from the bladder and to ensure drainage of the urine → blood clots are expected in the first 24 - 36 hours postoperatively.
→ Pain management – bladder spasms are common.
→ Fluid balance management
→ Reducing risk of infection
→ Discharge planning
Bladder irrigation
Common post-surgery
Aim is to reduce the risk of occlusion and urinary retention from clotted blood from the bladder and to ensure drainage of the urine → blood clots are expected in the first 24 - 36 hours postoperatively.
May be intermittent or continuous.
Nursing care considerations:
Care as per all IDC care & considerations
Assess for bleeding & clots
Assess catheter patency
Strict FBC with input and output hourly measures
Manually irrigate if bladder spasms occur or with decreased output
If IDC becomes obstructed → discontinue and escalate to medical team
Education
Prostatitis
Prostatitis is an umbrella term that includes a group of inflammatory and non-inflammatory disorders of the prostate gland. While prostatitis can affect men of all ages, these conditions are the most common urological issue for younger men, being mostly prevalent between the ages of 36-50 years.
Can be diagnosed as either acute or chronic, bacterial, or non-bacterial
Symptoms can occur without signs of infection.
There are four classifications of prostatitis, including:
Acute bacterial prostatitis
Chronic bacterial prostatitis
Chronic prostatitis/chronic pelvic pain syndrome → urinary & prostate pain with an absence of an infectious process → may occur after a viral infection → also associated with recent STI
Asymptomatic inflammatory prostatitis → no symptoms are experienced with this type of prostatitis, but inflammatory processes of the prostate occur and are evident with medical assessment
Acute or chronic prostatitis can occur when an organism reaches the prostate gland either by ascending the urethra, descending from the bladder, or invading the bloodstream.
Most common organisms include:
Escherichia coli → most common
Klebsiella
Pseudomonas
Enterobacter
chlamydia trachomatis
Neisseria gonorrhoeae
Prostatitis
Clinical Manifestations
If infectious cause → fever, rigours, chills
Back pain
Perineal pain
Acute urinary symptoms → dysuria, urinary frequency, urgency, cloudy urine
Urinary retention
Severely inflamed prostate → swollen, boggy, painful to touch
Prostatitis
Complications
Erectile dysfunction
Epididymitis
Cystitis
Post-ejaculation pain
Decreased libido
Prostatic abscess
Irritative voiding symptoms → dysuria, urinary frequency, urgency
Recurrent UTIs
Prostatitis
Diagnosis
Health history & full physical assessment
Urinalysis
Urine culture & sensitivity
Routine bloods +/- blood cultures
Prostatitis
Nursing Management
Acute management usually involves hospital admission for administration of IV antibiotics → trimethoprim, ciprofloxacin, cefalexin, doxycycline orally for 4 weeks once discharged
Antibiotic therapy continues for 8 - 12 weeks
Infection / fever management
Pharmacological pain management → NSAID & simple analgesia → pain can last months with chronic prostatitis
Non-pharmacological pain management → sitz baths, heat packs → ejaculation can reduce pain (best not to practice while in hospital)
Repetitive prostatic massage - removes excess prostate secretions.
Education → associated with antibiotics, symptom management, encourage increased fluid intake
Hydrocele
Scrotal swelling caused by a collection of fluid within the tunica vaginalis
Hydrocele
Causes
Congenital → chronic hydrocoele → men >40 years → imbalance between production and reabsorption of fluid
Acquired → trauma, infection, tumour
Hydrocele
Clinical Manifestations
Increased scrotal mass
Usually painless but can experience a dull ache in the scrotum
Difficulty walking
Progressive heaviness