Transcript Male Reproductive Disorders

MALE REPRODUCTIVE DISORDERS
Megan McClintock, MS, RN
Fall 2011
BENIGN PROSTATIC HYPERTROPHY (BPH)
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Occurs in 50% of men > age 50, 90% of men > age 80
BPH does not increase risk of prostate cancer
Cause – endocrine changes associated with aging
Patho – develops in the inner part of the prostrate
(cancer is usu. in the outer part), enlargement
compresses the urethra
Risk factors – obesity, physical activity level, alcohol
consumption, smoking, diabetes, family hx of BPH, aging
BPH
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S/S – gradual in onset, worsen as obstruction
increases, symmetrically enlarged, firm, smooth
Obstructive – decrease in force of stream, difficulty
starting stream, intermittency in stream, dribbling
 Irritative – frequency, urgency, painful urination,
bladder pain, nocturia, incontinence
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Cx – fairly uncommon, but could have urinary
incontinence, UTI that could lead to sepsis,
bladder stones, renal failure from hydronephrosis,
pyelonephritis, bladder damage
BPH DIAGNOSIS
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History and physical exam
Digital rectal exam (DRE)
UA with culture (r/o infection)
PSA (r/o cancer)
Serum creatinine (r/o renal insufficiency)
Transrectal ultrasound (TRUS) w/ biopsy
(r/o cancer)
Uroflometry (extent of blockage)
Postvoid residual urine volume (degree of
obstruction)
Cystoscopy (confirm diagnosis if
uncertain)
BPH TREATMENT
Based on how much symptoms bother the pt or
presence of cx (not the size of the prostate)
 Watchful waiting if mild symptoms
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 Diet
changes (decrease caffeine & artificial
sweeteners, limit spicy/acidic foods)
 Avoid decongestants and anticholinergics
 Restrict evening fluid intake
 Timed voiding schedule
BPH TREATMENT
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Drugs
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5 alpha-reductase inhibitors (ie. Proscar, Avodart)
 Prevent
the conversion of testosterone to
dihydroxytestosterone (reduces the size of the prostate)
 Takes 6 months to be effective
 Side effects – decreased libido, ED, orthostatic hypotension
with use of ED drugs, women should not handle the tablets
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Alpha-adrenergic receptor blockers (ie. Cardura, Hytrin,
Flomax)
 Often
used for HTN but for BPH are used to promote smooth
muscle relaxation in the prostate (symptomatic relief but no
change to prostate size)
 Works within 2-3 weeks
 Side effects – orthostatic hypotension, dizziness, retrograde
ejaculation, nasal congestion
BPH TREATMENT (MINIMALLY INVASIVE TX)
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Transurethral Microwave
Thermotherapy (TUMT)
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Use of transurethral probe to raise
the temp of the prostate tissue to
113 F, can cause post procedure
urinary retention so need a
catheter for 2-7 days
Transurethral Needle Ablation
(TUNA)
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Increases heat again, but with lowwave radiofrequency, allows more
precision than TUMT, have very
little pain, some pts require a
catheter for a short time, may have
hematuria for up to a week
BPH TREATMENT (MINIMALLY INVASIVE TX)
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Laser Prostatectomy
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Laser is delivered transurethrally through a fiber
instrument, several procedures, may need a catheter
for 8-48 hrs after
Intraprostatic Urethral Stents
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Provides relief of symptoms in pts who are poor surgical
candidates, can cause some complications
BPH TREATMENT (INVASIVE TX)
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Transurethral Resection of
the Prostate (TURP)
Removal of prostate tissue
using a resectoscope inserted
in the urethra
 “Gold standard” surgical
treatment with low risk of
complications
 1-2 day hospitalization with a 3
way catheter and continuous
bladder irrigation (CBI) for the
first 24 hours
 Cx – bleeding, clot retention,
dilutional hyponatremia
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BPH NURSING CARE
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Health Promotion
Yearly DRE > age 50
 Avoid alcohol and caffeine (increases bladder
distention)
 Avoid pseudophedrine and phenylephrine (worsens sx
of BPH)
 Urinate q 2-3 hrs (prevents urinary stasis and retention)
 Do not restrict fluid intake (increases chance of
infection, if overhydrating can increase bladder
distention)
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BPH NURSING CARE
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Preoperative
 Must
have urinary drainage
 May
need lidocaine gel to open the urethra, may need
curved-tip (coude) catheter or filiform catheter
 Antibiotics
to treat any UTI
 High fluid intake (2-3 L/day) to manage UTI
 Teach that surgery may affect sexual functioning
(usu. have retrograde ejaculation, may have
decreased orgasmic sensations)
BPH NURSING CARE
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Postoperative
Standard catheter or triple-lumen
catheter
 Bladder irrigation done to remove
clotted blood from the bladder and
ensure urine drainage
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 Can
cause painful bladder spasms
 Rate of infusion is based on color of
drainage (ideally light pink without
clots)
 If outflow is less than inflow assess
for kinks/clots
 Careful aseptic technique
BPH NURSING CARE
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Postoperative
 Watch
for hemorrhage
 Blood
clots expected for first 24-36 hours
 Provide traction on the catheter for a short time
 Avoid Valsalva maneuver
 Avoid prolonged walking or sitting
 Prevent
 Teach
bladder spasms
pt not to urinate around the catheter
 Check the catheter for clots, remove by irrigation
 Belladonna and opium suppositories
 Antispasmodics (Ditropan)
BPH NURSING CARE
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Postoperative
 Removal
of catheter after 2-4 days
 Must
urinate within 6 hours of removal
 May have incontinence or dribbling (may take several
weeks to resolve)
Kegel exercises 10-20 times/hour
 Penile clamp
 Condom catheter
 Incontinence pads or briefs
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 Risk
for infection
 Be
especially careful if they have a perineal incision
BPH NURSING CARE
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Discharge instructions
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Oral fluids 2-3 L/day
Prevent constipation
No lifting > 10 lbs
No driving or intercourse until released by dr
May have cloudy urine from retrograde ejaculation
May have ED problems
May take up to 1 year for full sexual functioning
Bladder may take 2 months to increase capacity
Urinate every 2-3 hours to flush the urinary tract
Avoid caffeine, citrus, alcohol to prevent bladder irritation
Need a yearly DRE unless the prostate has been completely
removed
PROSTATE CANCER
One in every 5 men will develop prostate cancer
 Usually slow growing – men live and die with
prostate cancer, but not from it
 Risk factors – age, ethnicity (African American
men at most risk), family history, diet high in red
meat and high-fat dairy with a low intake of
veggies/fruits
 S/S – asymptomatic in early stages, eventually
develops s/s like BPH, may have pain in
lumbosacral area radiating to hips/legs; prostate
is hard, nodular, assymetric on exam
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PROSTATE CANCER
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Diagnosis
 Annual
DRE and PSA for men > age 50 at average
risk (neither are definitive diagnostic tests)
 Elevated PSA does not always mean cancer
 Elevated
with aging, BPH, recent ejaculation, prostatitis,
long bike rides
 PSA
is also used to monitor effectiveness of tx
 Biopsy is the definitive test
PROSTATE CANCER TREATMENT
In early stage is usually curable
 Watchful waiting if life expectancy is < 10 years
or tumor is low-grade, low-stage
 Radical prostatectomy for Stage B or C
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 Remove
entire prostate gland, seminal vesicles,
part of the bladder neck, also may have lymph node
dissection
 Can do retropubic, perineal (much higher risk of
infection), or laparoscopic
 Cx – ED, urinary incontinence
PROSTATE CANCER TREATMENT
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Nerve-Sparing prostatectomy
 Decreases
risk of ED
 Not done if cancer is outside of the prostate gland
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Cryotherapy
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as an initial tx or if radiation therapy fails
 No incision, done under general or spinal
anesthesia
PROSTATE CANCER TREATMENT
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Radiation therapy
 External
beam – most common,
outpatient 5 days/week for 4-8
weeks, side effects resolve 2-3
weeks after tx ends
 Brachytherapy – radioactive seed
implants into the prostate gland,
one-time outpatient procedure,
best for stage A or B cancer
PROSTATE CANCER TREATMENT
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Hormonal - androgen deprivation therapy (ADT)
– tumors become resistant after a few years,
side effects – osteoporosis, fractures
 Luteinizing
Hormone-Releasing Hormone (LH-RH)
Agonists and Antogonists
 Antiandrogens,
ultimately is a chemical castration,
Lupron is most common, given SC or IM regularly and
must be taken indefinitely
 Androgen
Receptor Blockers
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drugs compete with circulating androgens at the
receptor sites, usu. combined with LH-RH agonist
 Estrogen
– rarely used b/c of its side effects
PROSTATE CANCER TREATMENT
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Orchiectomy – bilateral removal of testes
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be done alone or in combo with prostatectomy
 Also helps relieve bone pain
 Can be used when prostate surgery is not an option
 Side effects – weight gain, loss of muscle mass
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Chemotherapy – usu. only for late stage
disease since it is not very effective, usu. for
palliation only
PROSTATE CANCER NURSING CARE
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Same as care for BPH
PROSTATITIS
May be inflammatory or
noninflammatory
 Can be acute or chronic
 S/S – fever, chills, back pain,
perineal pain, acute urinary
symptoms, cloudy urine,
postejaculation pain, ED; prostate is
very swollen, very tender, firm with
exam (chronic usu. has milder
symptoms
 Can be confused with UTI
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PROSTATITIS DIAGNOSIS & CARE
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Diagnosis
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UA with culture
PSA (r/o cancer)
Micro and culture of
prostate secretion
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Care
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Oral abx for 4 weeks (acute)
up to 12 weeks (chronic)
Antiinflammatories for pain
Warm baths
No catheters
No prostatic massage
(acute)
Masturbation and
intercourse encouraged
Increase fluids (2-3 L/day)
CONGENITAL PENIS PROBLEMS
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Hypospadius – urethral meatus
on the ventral surface of the
penis
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Epispadius – urethral meatus on
the dorsal surface of the penis,
often associated with other
genitourinary defects
PREPUCE PROBLEMS
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Phimosis – tightness or
constriction of the foreskin
around the head of the
penis, usu. caused by poor
hygiene
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Paraphimosis – tightness of
the foreskin resulting in the
inability to pull it forward
from a retracted position,
can get an ulcer
ERECTILE PROBLEMS
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Priapism – erection lasting
longer than 6 hrs, medical
emergency!
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Peyronie’s disease – curved or
crooked penis caused by plaque
formation in the corpus
cavernosa, not dangerous but
can be embarrassing
CANCER OF THE PENIS
Very rare
 Occurs in men with HPV or men not
circumcised as infants
 Looks like a venereal wart
 Treatment depends on the extent of the
disease
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INFLAMMATION OF SCROTUM & TESTES
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Epididymitis – acute, painful
inflammation of epididymis,
usu. unilateral, usu. STD
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Tx – antibiotics, bed rest,
scrotal elevation, ice packs,
analgesics
Orchitis – acute
inflammation of the testis,
usu. occurs after bacterial or
viral infxn (ie. Mumps, TB,
syphillis, pneumonia), can
cause infertility after mumps
CONGENITAL PROBLEMS OF TESTES
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Cryptorchidism (undescended testes)
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occur bilaterally or unilaterally
 Will cause infertility if not corrected by age 2
 Increases risk of testicular cancer if not corrected
by puberty
ACQUIRED SCROTAL & TESTICULAR PROBLEMS
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Hydrocele – nontender, fluidfilled mass of the scrotum,
caused by impaired lymph
drainage, requires no tx if
not large, visible with
transillumination
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Spermatocele – firm, spermcontaining, painless cyst of
the epididymis, visible with
transillumination, requires
surgical removal to
distinguish from cancer
ACQUIRED SCROTAL & TESTICULAR PROBLEMS
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Varicocele – dilation of the
veins that drain the testes,
scrotum feels wormlike,
surgery if having problems
with fertility
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Testicular torsion – twisting
of the spermatic cord, seen
in age < 20, no cremasteric
reflex, s/s – severe scrotal
pain, tenderness, swelling,
n/v, surgical emergency if
blood supply is not restored
within 4-6 hrs
TESTICULAR CANCER
Rare, but most common type of cancer in young
men age 15-34
 More common in white males, more common in
right testicle
 Risk factors – undescended testes, family hx of
testicular cancer or anomalies
 S/S – may have slow or rapid onset, painless, firm
lump in scrotum, scrotal swelling, feeling of
heaviness, will not transilluminate
 Dx – Ultrasound, labs, chest xray, CT/MRI
 Tx – orchiectomy, lymph node dissection, chemo,
radiation, careful follow up, cryopreservation of
sperm
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TESTICULAR SELF EXAM
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Warm area (bath or shower) to
make testes hang low
Use both hands to feel, roll testis
between thumb and first 3 fingers,
palpate each testis separately
Testis should feel like hard-boiled
egg, locate spermatic cord which
goes up toward groin, feel for
lumps, irregularities, pain
*One testis is usually larger than
the other, more concerned about
texture
Examine once/month
VASECTOMY
Bilateral surgical ligation of vas
deferens to prevent impregnation
permanently
 Outpatient under local anesthesia
 *Must use alternate form of
contraception until semen has no
sperm (about 6 weeks)
 Does not affect hormone
production, ability to ejaculate,
physiologic ability to have erection
or orgasm
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ERECTILE DYSFUNCTION (ED)
Inability to maintain or attain an erect penis
that allows satisfactory sexual performance
 Causes
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 Younger
men – alcohol or drugs
 Middle-aged men – diabetes, HTN, renal or *CV
disease
 Other – side effects of meds, surgery side effects,
trauma, chronic illness, stress, depression
ERECTILE DYSFUNCTION (ED)
S/S – gradual onset indicates physiologic
factors, rapid onset indicates psychologic
issues
 Dx – physical exam, DRE, International Index of
Erectile Function (IIEF), CV exam, hormone
levels, can do several diagnostic tests
 Tx – No option will restore ejaculation or tactile
sensations if they were already absent, want to
be sure ED is actually reversible
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ED TREATMENT OPTIONS
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Oral drugs – Viagra, Cialis, Levitra –
cause increased blood flow, take an
hour before sex
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*Do not take with nitrates or if
hypotensive
Vacuum Constriction Devices –
suction device that pulls blood into
the penis, can secure with
constrictive band
Intraurethral Devices – vasoactive
drugs, penis injection, medication
pellet
Penile implants – inflatable implant
Sexual counseling – should be
done for all pts
ANDROPAUSE
Gradual decline in androgen secretion as men
age
 Can begin as early as age 40
 S/S – loss of libido, fatigue, ED, can lead to
osteoporosis, decreased muscle mass
 Dx – low testosterone levels
 Tx – no oral replacement option, can use IM or
transdermal hormone replacement
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MALE INFERTILITY
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About 33% of cases are due to male problems
Pretesticular causes – rare
 Testicular causes – 50%, most common cause is
varicocele
 Posttesticular causes – rare
 Remaining causes are unknown or idiopathic
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Need to do a careful health history and exam
 First step is a semen analysis to determine sperm
concentration, motility, and morphology
 For many men, fertility and masculinity are
equated so be sensitive
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