PROBLEMS OF THE MALE REPRODUCTIVE SYSTEM

NURSING 120

BENIGN PROSTATIC HYPERPLASIA  (BPH)

.    Prostate gland is major male accessory sex gland

.    Frequent site of infection and benign & malignant neoplasms

.    With age-> HYPERPLASIA -> hypertrophy

.    Gland enlarges  upward & inward -> urethral obstruction -> hypertrophy of bladder wall & hydroureter &/or hydronephrosis

ETIOLOGY: BPH

.    Etiology unknown: most likely

-   Aging

-   Hormonal alteration- testicular androgen

.    Other theories:

-   Chronic inflammation??

-   Metabolic, nutritional factors??

-   Atherosclerosis??

ASSESSMENT: BPH

.    Urinary pattern- (LUTS)

-   Hesitancy, intermittency

-   Decreased force & flow

-   Overflow incontinence

-   Post void dribble

-   Hematuria

-   Frequency

-   Nocturia

ASSESSMENT- cont'd

.     Physical assessment:

-    Signs & symptoms

-    Distended bladder

-    Digital rectal exam

.     Psychosocial assessment:

-    "Old man's disease"

-    Threat to self image

-    Include significant other

ASSESSMENT- cont'd

.      Laboratory:

-    Urinalysis: glucose, protein, occult blood, ph,     wbc's, culture

-    Blood work: cbc, bun, serum creatinine, serum         acid/alkaline phosphatase, PSA

.      Radiographic:

-    KUB, IVP

.      URODYNAMIC FLOW STUDIES:

-    Flowmetry & assessment of residual urine

.      Cystourethroscopic exam

-    Assessment of residual urine

COMMON NURSING DIAGNOSES

.    Risk for injury r/t effects of urinary obstruction

.    Urinary retention/incontinence

.    Pain

.    Risk for infection

.    Sexual dysfunction

.    Anxiety

PLANNING

 

 

.    PREVENT/ REDUCE COMPLICATIONS

NONSURGICAL MANAGEMENT: BPH

Ø  DRUG THERAPY: may include

Ø Proscar to shrink prostate

Ø Alpha blocking agents  as Hytrin, Cardura or Flomax

 

Ø  ALTERNATIVE THERAPIES:

Ø Saw Palmetto

Ø Prostate massage- release of prostatic fluid

Ø  ­ Sexual intercourse

NONSURGICAL MANAGEMENT: BPH

Ø  EDUCATION GOAL: prevent overdistention of bladder & urinary retention:

Ø  AVOID:

Ø Alcohol

Ø Diuretics

Ø Caffeine

Ø Large volumes of PO fluids at one time

Ø Anticholinergics

Ø Antihistamines/decongestants

Ø  VOID:

Ø    as soon as urge is felt

BPH: SURGICAL MANAGEMENT-EVALUATE

SIGNS/SYMPTOMS:   

.     Acute urinary retention

.     Chronic UTI's

.     Hematuria

.     Hydronephrosis

.     Sx of bladder neck obstruction

-    Frequency

-    Nocturia

CLIENT'S:

.     Age

.     Physical condition

.     Size of prostate

.     Location of      enlargement

.     Preference

BPH: SURGICAL pre op MANAGEMENT-  teaching

.    Assess & deal with anxiety

.    Knowledge re effects

.    Anesthesia

.    Foley catheter, traction

.    Probable continuous bladder irrigation

.    Monitor for catheter patency, hematuria, infection

.    Post op care varies with type of surgery

.    For TURP, need for Kegel Exercises

OPERATIVE PROCEDURES-BPH

.    DEPENDS ON:

-    Size of prostate

-    Location of enlargement

-    Age

-    Physical condition

-    Bladder involvement & whether bladder surgery also needed

 

In all approaches for benign conditions, hyperplastic tissue is removed, leaving prostatic capsule.

RECENT SURGICAL ADVANCES

.    Transurethral thermotherapy-(microwave)

.    Transurethral needle ablation

.    Visual laser ablation

.    Electrovaporization (cautery, may -> delayed hematuria &/or urinary retention

.    ADVANTAGES

-    Minimal bleeding

-    D/C with catheter within 24 hours

.    Delayed hematuria or bleeding may occur days to weeks after

SURGICAL PROCEDURES:                                 TURP

v Most common

v Closed procedure

v Resectoscope

v ADVANTAGES

vSafer

vNo incisions

vShorter hospital stay & convalescence

v DISADVANTAGES

vMay recur

vRisk of urethral trauma causing strictures

TURP: POST OP CARE

.    3 way foley with 30 to 45 ml balloon, taped with traction to prevent bleeding

.    -> feeling of urge to void, instruct pt. not to try to void around catheter

.    May -> bladder spasms, may need antispasmodic med

.    Continuous bladder irrigations

.    When catheter removed, urinary dribbling or incontinence usually temporary

CONTINUOUS BLADDER           IRRIGATION

.      First 24 hours-­ risk of hemorrhage

.      Use normal saline or as ordered

.      Adjust rate to keep output

-    colorless or light pink

-    Clear,free of clots

.      Frequent checks of drainage tubing for patency

.      Monitor urinary output q2h: color, amount consistency

.      Assess bladder spasms (obstruction?)

.      Notify MD stat if obstruction not resolved by hand irrigation or if urine bright red, "ketchupy" (may have ­ clots)

.      Amicar or surgical intervention if needed

.      Traction for venous bleeding

TURP: POST OP                          BLEEDING

v 1^ST  24h

v "ketchupy"- arterial

v  burgundy-venous

v  Analgesics, antispasmodics (bladder spasms can -> bleeding)

v Traction, continuous irrigations, or surgery to resolve

v Monitor Hgb, Hct

TURP: POST OP

.    Client may pass small clots & tissue debris for several days

.    ­ fluid intake- 200-2500 qd (careful in heart disease)

.    By discharge, void 150-200ml clear yellow urine, q3-4h

 SURGICAL PROCEDURES:
 SUPRAPUBIC PROSTATECTOMY

v  Transvesical

v DISADVANTAGES:

v Requires low transverse abdominal & bladder incisions

v Post operative suprapubic & foley catheters

v ­ risk of UTI, incontinence, bladder spasms, hemorrhage

v ­ pain

v ­ time for convalescence

SUPRAPUBIC                    PROSTATECTOMY: post op care

.     Foley & suprapubic catheters to separate drainage systems

.     More at risk for bladder spasms

.     Traction will not help bleeding, needs brisk CBI or surgical intervention

.     Remove foley catheter 2^nd post op day, clamp suprapubic, measure residual after voiding

.     Remove suprapubic catheter when residual 75 ml or <, may be discharged with suprapubic catheter

.     Check dressing, change often, may be saturated with urine until bladder heals

   SURGICAL PROCEDURES:
 RETROPUBIC PROSTATECTOMY

 

 

v No bladder involvement or incision

   SURGICAL PROCEDURES:
  PERINEAL PROSTATECTOMY

v  Not commonly used

v  Remove prostate calculi, treat abscesses, repair previous damage

v  Clients poor surgical risks

v  Radical procedure may cause damage to pudendal nerve & impotence

v  Can -> infection, damage to anal sphincter, urinary incontinence

v  No rectal temps, tubes, enemas

PROSTATE SURGERY: NURSING CARE & TEACHING

q  When foley removed:

q Burning on urination,  frequency, dribbling, leakage, small clots=normal, usually temporary

q  Increase fluid intake to 2000-2500 ml (depending on overall health)

q  Possible changes in sexual function (retrograde ejaculation)

q  Avoid strenuous exercise for several weeks

q  Bleeding may continue after discharge, rest, notify MD if does not subside

PROSTATE CANCER

.    Most common invasive cancer in males

.    95% adenocarcinoma, slow growing

.    Metastasizes 1st to lymph nodes, bone marrow, & pelvic & spinal bones

.    Intact hypothalamic, pituitary-testicular pathway must be present

PROSTATE CANCER: Risk Factors

.    ­ in:

-   African-Americans

-   Aging

-   + family hx

-   Hx STD's or vasectomy

-   Exposure to heavy metals

PROSTATE CANCER: ASSESSMENT

.    1^st symptoms related to bladder neck obstruction, recurrent infections, & urinary retention

-   gross, painless hematuria often presenting sx

.    Sx of urinary obstruction & bone pain may indicate advanced disease

PROSTATE CANCER:         SCREENING

.    Screening annually, begin no by age 50 (unless high risk)

.    DRE

-    prostate hard with palpable irregularities or indurations

-    PSA

-    Should be < 4, but 25% ca pts have < 4

-    BPH, prostatic infarction, prostatitis may also ­

.    Transrectal or prostate ultrasound with biopsy

PROSTATE CANCER:         BIOPSY

.    Complications:

-    Hematuria with clots

-    Signs of infection- report

.   Fever

.   Chills

.   Difficulty voiding

.   Bloody urine

-    Perineal pain    

.    Follow up:

-    Often antibiotics

-    1^st 24 hours post bx- avoid strenuous activity & ­ fluid intake

PROSTATE CANCER:
 ASSESSMENT-

vAFTER DIAGNOSIS:

vTumor grading-Gleason score indicates tumor aggressiveness

vX ray

vCT, MRI pelvis &abdomen

vBone scan

vBlood studies including liver function, acid/alkaline phosphatase

PROSTATE CANCER:
 MANAGEMENT

.    Based on extent of disease, are options

-   Watchful waiting for up to 10 years

-   Surgery- radical, nerve sparing,   robotic

-   Radiation therapy

-   Drug therapy

PROSTATE CA: SURGICAL PROCEDURES- nursing care

.    PCA

.    Bedrest day of surgery

.    SCD's

.    Monitor for DVT & PE

.    Strict I&O, including drainage devices

.    Foley catheter, keep urinary meatus clean, instruct in home care (p. 1870)

.    Avoid rectal procedures or rx or straining in bowel movements

.    Shower, not tub bath

PROSTATE CA: SURGICAL COMPLICATIONS (LONG TERM)

 

.    Urinary incontinence

-   Teach Kegel & perineal exercises

 

.    Erectile dysfunction

PROSTATE CANCER:
 MANAGEMENT

.    Nerve sparing procedures may be used:

-   With no evidence of lymph node involvement or cancer extension

-   Serum acid phosphatase levels ¯

-   Sexual function usually returns in 3-12 months

-   Urinary incontinence may occur: teach exercises

 PROSTATE CANCER:
CRYOSURGICAL ABLATION

v   Transrectal ultrasound probe

v   Liquid nitrogen freezes gland

v   Advantages:

v   Minimally invasive

v   ¯ blood loss

v   ¯ pain

v   ¯ risk for incontinence

v   ¯ hospital stay

 

PROSTATE CANCER:
BILATERAL ORCHIECTOMY

 

v   Palliative

v   Not to cure but to arrest

PROSTATE CANCER:
NONSURGICAL MANAGEMENT

vRadiation therapy

v May be done:

vFor palliation (relieve back pain & bladder obstruction)

vFor cure in locally contained tumors

vAs adjunct to surgery if lymph nodes +

v May be External or interstitial (radioactive seed implantation)

vDrug therapy

v Hormonal- androgen deprivation (estrogen or GnRH agonist analogs)

v Chemotherapy- not usually effective

PROSTATE CANCER:
NONSURGICAL MANAGEMENT

vTargeted therapy

vAntibodies target cellular element of Ca cell

vTarget at gene level (antisense)

 

        OTHER MALE                      REPRODUCTIVE                     DISORDERS

ERECTILE DYSFUNCTION

.    Cannot achieve or maintain erection

.    Organic ED

-    Physical, gradual onset- (many causes, 50% of diabetic men)

-    Absence of nocturnal erections or emissions

.    Functional ED

-    Psychological-acute onset, often with stress

-    Have nocturnal erections

       
ERECTILE DYSFUNCTION:                 ASSESSMENT

.    Causes- p. 1870

.    Diagnostic testing to R/O organic causes  & hormonal testing

ü    Doppler ultrasound arterial flow studies of penile arteries

ü    Nocturnal penile tumescence test

ERECTILE DYSFUNCTION:         MANAGEMENT

v Counseling

v Drug rx -(Viagra, Levitra Cialis

v Contraindicated with nitrates

v Vacuum pump with rubber ring

v Intracorporal injections- (Regitine)

v Intraurethral applications (suppository)

v Prostheses/ implants

TESTICULAR CANCER

.    < 2% Of all cancers in Males

.    1 of most curable if detected in time

.    Rarely bilateral as primary sites

.    Risk factors:

-    Cryptorchidism (80% Ca develop in undescended testis, but  ® ­ risk in both testes)

-    + Family history

-    History of trauma or infection

-    Caucasians ages 15-35

TESTICULAR TUMORS -         GERM CELL (95%)

 SEMINOMAS

-    Most common

-    Slow growing, metastasize late

-    Orchiectomy & radiation® 95% (5) year survival rate

    

 

                 (may have

                  mixed cell           types)

              

.   NONSEMINOMAS

-    Spread earlier

-    Not as sensitive to radiation, treated with surgery &/or chemotherapy

-    Choriocarcinoma most lethal

TESTICULAR CANCER- NON-GERM CELL TUMORS

.    5% of tumors

 

.    Rare, usually benign

 

.    May secrete ­:

-   Androgen -> early puberty

-   Estrogen -> feminization & gynecomastia

TESTICULAR CANCER;
         ASSESSMENT

.    PHYSICAL with palpation, may à oligospermia or azoospermia

.    PSYCHOLOGICAL including childbearing desires & measures

.    LABORATORY for tumor markers

-    Alphafetoprotein

-    hCG

.    ULTRASOUND

.    RADIOGRAPHIC- CT, MRI

COMMON NURSING DIAGNOSES

.    Risk for sexual dysfunction related to disease or treatment

.    Dysfunctional grieving or anticipatory grieving related to loss of a body part or changes in body image

.    Body image disturbance, altered role performance related to dx of Ca

.    Pain related to tumor

.    Anxiety related to dx of Ca

TESTICULAR CANCER:
                PLANNING

v EXPECTED OUTCOMES:

.    Client will identify potential or actual alterations in reproductive fx & alternate methods of meeting needs if indicated

.    Client will not experience complications of tumor, including metastasis or recurrence

TESTICULAR CANCER:    NONSURGICAL MANAGEMENT

.    Chemotherapy rx

 

.    External bean radiation rx- often with surgery (seminomas highly sensitive)

 

.    Stem cell transplantation being studied

TESTICULAR CANCER: SURGICAL MANAGEMENT

 

.    UNILATERAL ORCHIECTOMY

                   

                  or

 

.    RADICAL RETROPERITONEAL LYMPH NODE DISSECTION, possibly with DEBULKING

MALE REPRODUCTIVE SYSTEM                OTHER PROBLEMS

.    HYDROCELE- usually painless, fluid filled cystic mass around testes

.    SPERMATOCELE- sperm containing cyst on epididymitis

.    VARICOCELE- cluster of dilated veins above testes, may -> infertility

.    SCROTAL TORSION- painful twisting of spermatic cord -> N&V, is a surgical emergency

.    CRYPTORCHIDISM- undescended testicle- usually repaired or removed

TESTICULAR SURGERY:
        POST OP CARE

.    May have drain present &/or serosanguineous drainage for 1^st 24-48 hours

.    Use rolled towel under scrotum or wear scrotal support to keep dressing in place & ¯ edema

.    Assess client for complications of major abd. surgery

.    Ice; Pain management; scrotal support

.    Deal with psychosexual questions & needs

TESTICULAR SURGERY:
        POST OP CARE

v TEACHING:

v Sperm storage

v Ice to scrotum as indicated, often 72 hrs.

v S/S Infection

v Complications of wound healing

v Avoidance of heavy lifting, stair climbing, heavy physical activity 4-6 wks

v Scrotal support

v Availability of prosthesis if indicated

v Importance of testicular self exam

v Follow up studies- minimum of 3 years

MALE REPRODUCTIVE SYSTEM:         OTHER PROBLEMS

.     CARCINOMA OF PENIS- <1% of all malignancies in males

-    May look like venereal wart or reddened lesion with plaque

-    May require partial or total penectomy

-    CIRCUMCISION- almost eliminates possibility of penile cancer

-    Post op, barbiturates may be given to inhibiting REM sleep & prevent erections

.     PHIMOSIS- cannot retract foreskin, also corrected by circumcision

.     PARAPHIMOSIS- prepuce forms constricting band

MALE REPRODUCTIVE SYSTEM:         OTHER PROBLEMS

.    PRIAPISM- maintained erection

-    Urologic emergency

-    Demerol due to hypotensive effect

-    Warm enemas to -> venous dilation

-    Catheterization if cannot void

.    PROSTATITIS-can -> epididymitis or cystitis

-    Acute bacterial

-    Chronic bacterial

-    Chronic pelvic pain syndrome (prostatodynia)- may follow viral illness or STD

-    Asymptomatic inflammatory prostatitis

MALE REPRODUCTIVE SYSTEM:         OTHER PROBLEMS

.     PROSTATITIS-can -> epididymitis or cystitis

-    Types:

.  Acute bacterial

.  Chronic bacterial

.  Chronic pelvic pain syndrome (prostatodynia)- may follow viral illness, STD

.  Asymptomatic inflammatory prostatitis

.     Antibiotic rx as long as several months (tissue penetration of antibiotics poor)

.     Sitz baths; donut cushions; NSAIDS; stool softeners; avoid alcohol, coffee, tea; OTC cold preps may -> urinary retention

MALE REPRODUCTIVE SYSTEM:         OTHER PROBLEMS

.    EPIDIDYMITIS, ORCHITIS -

-    Painful, may -> abscess

-    May be complication of infection or trauma

-    < 35 years old main cause STD's

-    RX:

.   Bedrest

.   Scrotal elevation

.   Analgesics, antibiotics

.   If mumps orchitis, sterility can result, often given gamma globulin if no hx mumps

         THE END

 

 

.    NOW, WHAT QUESTIONS????