1elsevier items and derived items © 2007 by saunders, an imprint of elsevier, inc. chapter 48 male...

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Chapter 48

Male Reproductive Disorders


Learning Objectives

• Describe the major structures and functions of the normalmale reproductive system.

• Identify data to be collected when assessing a male patientwith a reproductive system disorder.

• Discuss commonly performed diagnostic tests and proceduresand the nursing implications of each.

• Identify common therapeutic measures used to treat disordersof 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 patientwith a reproductive system disorder.


Anatomy and Physiology of the Male Reproductive System

• Scrotum • Testes

• Epididymis

• Vas deferens • Seminal vesicles • Prostate gland • Cowper’s glands • Urethra • Penis


Figure 48-1


Figure 48-2


Figure 48-3


Figure 48-4



• 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



• 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


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


Figure 48-5


Health History

• Present illness • Complaints: weight loss, infertility, erectile

dysfunction (impotence), alteration in self-image, scrotal masses, penile discharge, skin lesions


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


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


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


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



• 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


Figure 48-6



• 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


Figure 48-7


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


Diagnostic Tests and Procedures

• Radiologic imaging studies• Computed tomography• Ultrasound • Radionuclide imaging


Disorders of the Male Reproductive System


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


Prostatitis

• Signs and symptoms • Acute prostatitis

• Swelling, warmth, and tenderness • Dysuria, frequency, hematuria, and foul-smelling urine

• Chronic prostatitis• Minimal symptoms or malaise


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


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


Epididymitis

• Nursing care • Monitor temperature, edema, and comfort • Carry out prescribed treatments


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


Orchitis

• Nursing care • Pain management, assistance with activities of daily

living, patient teaching, and anxiety reduction


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



• 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)



• 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



• 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



• 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



• 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


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



• Drug therapy • Phosphodiesterase type 5 inhibitors

• Sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra)

• Alprostadil • Intracavernosal injection (Caverject) or urethral

suppositories (MUSE)

• Papaverine• Testosterone



• 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


Figure 48-8



• 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



• Interventions• Listen and be careful not to dismiss the issue as

unimportant • Provide factual information and resources


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


Figure 48-9


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


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


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


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


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


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


Infertility: Etiology and Risk Factors

• Infections • Mumps, tuberculosis, pneumonia, and syphilis• Chlamydia trachomatis and Neisseria gonorrhoeae



• Cryptorchidism • Testis in other than a dependent scrotal position • Because the abdominal cavity is warmer than the scrotum,

excessive warmth can damage the seminiferous epithelium of undescended testes and result in decreased spermatogenesis

• Medical treatment • If testes within normal path but do not descend or cannot be

pulled into scrotum, usually do not respond to hormonal therapy, and surgery is needed


Figure 48-10



• Testicular torsion • Occurs unilaterally when testicle is mobile and the spermatic

cord twists, cutting off blood supply to testicle• Acute surgical emergency requiring immediate release of the

torsion or removal of the testicle • Usually in adolescents and when the scrotum is warm and

relaxed but may occur for no apparent reason • Symptoms: intense pain, often accompanied by nausea and

vomiting • After testicular torsion is corrected, lowered sperm counts and

infertility may follow


Figure 48-11



• Varicocele • A lengthening and enlargement of the scrotal portion of the

venous system that drains the testicle• Caused by incompetent or absent valves in the spermatic

venous system; allows pooled blood and the resulting increased pressure to dilate the veins

• Treatment includes scrotal support or surgical ligation and is indicated when fertility is thought to be affected

• Fertility or ability to conceive may/may not improve



• Vasectomy • Surgical removal of a portion of the vasa • Erection, ejaculation, and intercourse are unaffected • Postoperative pain/swelling managed with application of an ice

bag, mild analgesics, and scrotal support • Patient can resume intercourse as soon as he feels

comfortable; important to use other methods of birth control until analysis of semen determines that there is a complete absence of sperm

• Nursing care should include preoperative teaching about the procedure itself and the resultant infertility


Figure 48-12


Penile Cancer

• Relatively rare; almost exclusively in uncircumcised men • Risk factors: chronic irritation, poor hygiene, a history of multiple

sexual partners, sexually transmitted infection, and long-term tobacco use

• A dry, wartlike painless growth on the penis that does not respond to antibiotic therapy

• Can be removed surgically if treated in early stages • Advanced stages may ulcerate and involve the foreskin and

penile shaft • Extensive resection or amputation as well as resection of nearby

lymph nodes may be necessary


Testicular Cancer

• Testicular germ cell carcinoma occurs most often in men between ages of 18 and 34

• Three established risk factors: cryptorchidism, white race, and previous testicular cancer

• Other factors: history of orchitis, HIV infection, and in utero exposure to diethylstilbestrol

• Patients most often present with hard, painless tumors


Figure 48-13


Testicular Cancer

• Early detection • Education about the need for self-examination

• Monthly examination of the penis, scrotum, and perineal area

• Medical diagnosis • Ultrasound and blood studies to measure tumor markers:

alpha-fetoprotein and human chorionic gonadotropin • Radiographs and CT scans

• Medical treatment • Orchiectomy, radical orchiectomy, radiation, and

chemotherapy


Figure 48-14


Testicular Cancer

• Assessment• Fears or concerns related to the effects of surgery and other

treatment

• Interventions• Anxiety• Acute Pain • Impaired Urinary Elimination • Risk for Injury • Constipation• Situational Low Self-Esteem • Deficient Knowledge


Prostatic Cancer

• Cause is unknown• Risk factors

• Age >50 years, African American, overweight, high-fat diet, and family history

• Medical diagnosis • Typically slow-growing; confined to prostatic capsule • Rectal examination, transrectal ultrasound, serum tumor

markers, and needle aspiration/biopsy • Radiographs, radionuclide imaging, bone scans, excretory

urography, transurethral ultrasound, CT, and MRI


Prostatic Cancer

• Medical treatment • “Watchful waiting” • Conventional radiotherapy• Brachytherapy• Cryosurgery• Radical prostatectomy• Chemotherapy useful in limited cases • Hormonal therapy


Prostatic Cancer

• Nursing care• Encourage annual screening for prostate cancer • Stress value of early diagnosis and treatment • Specific problems may require special interventions

after prostate surgery: bladder spasms, erectile dysfunction, urinary incontinence, and body image disturbances associated with changes in the reproductive system

1elsevier items and derived items © 2007 by saunders, an imprint of elsevier, inc. chapter 48 male...

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