Chapter 34: Caring for Male Clients with Reproductive System Disorders

1
Chapter 34 Caring for Male Clients with
Reproductive System Disorders

• J. Davis BSN RN
• 08-09

2
Benign Prostatic Hyperplasia (BPH)
pathophysiology

• Enlarg. of prostate-affects most men gt 50 tends
  to develop earlier in African-American males
• Testes converts testosterone into
  dihydrotestosterone (DHT) in the prostate gland.
• DHT stimulates growth of prostate
• Increase levels of estrogen in relation to
  testosterone may contribute to DHT
• BPH develops as nodules form grow in the
  prostate which surrounds the urethra obstructs
  the bladder neck
• BPH- aka Benign Prostatic Hypertrophy

3
BPH Symptoms

• Urethral obstruction is the cause of the symptoms
  of BPH weak urinary stream difficulty
  initiating urine flow (hesitancy) dribbling
  urinary retention frequency nocturia (early
  symptom) hematuria bladder distention
  overflow incontinence
• bladder pressure can cause urine to backlow to
  the kidneys causing hydronephrosis

4
BPH Diagnostic Tests

• Diagnostic Tests
• Digital rectal exam (DRE)-insertion of a
  lubricated gloved finger into the rectum to
  palpate size shape consistency of prostate
  gland client may be placed in side-lying
  position or may bend over the exam table
  BPH-enlarged elastic Prostate CA-hard palpable
  irregularities
• Urinalysis-done to detect UTI
• PSA levels
• 0-4 ng/mL is normal range
• 5-10 ng/mL is typically seen in BPH
• 10-80 ng/mL suggests prostate cancer
• Greater than 80 ng/mL indicates advanced
  metastatic disease

5
BPH Diagnostic Tests (cont)

• Diagnostic Tests
• Uroflowmetry Client voids into a toilet equipped
  with a funnel a flowmeter (measures volume
  rate of urine flow)
• Needle aspiration or biopsy of the prostate is
  used to definitively diagnose or rule out
  prostate cancer
• CT scans MRIs bone scans may be used to
  assess for metastases from prostate cancer

6
BPH Medications

• Medications
• Proscar Avodart (hormonal agents)
• Inhibits conversion of testosterone into DHT
  therefore causes gland to shrink
• Side Effects loss of libido impotence
  ejaculate adverse effect on fetal development
• Nsg. Cons. Pregnant women should avoid handling
  the drug instruct to use a condom to prevent
  fetal exposure any sexual changes will reverse
  when drug is discontinued

7
BPH Medications (cont)

• Medications
• Hytrin Cardura Flomax (alpha-adrenergic
  blockers)
• Reduces the tone of smooth muscles in the bladder
  neck
• Side Effects low BP dizziness urinary
  frequency incontinence edema fatigue H/A
• Nsg Cons monitor output BP changes pt should
  change positions slowly

8
BPH Herbal Therapies

• Complementary Therapy
• Saw Palmetto (herbal from fruit of palm
  tree)-reduces symptoms of BPH by interfering w/
  the enzyme that converts testosterone to DHT
• Pygeum africanum (herb from bark of African
  evergreen) Echinacea pollen extract a few
  others are reported to ease symptoms
• Surgery
• See Handout

9
BPH Surgery Transurethral Approaches

• TUIP-Transurethral incision of the prostate
• Small incisions are made in the prostate
  bladder neck to widen the urethra NO TISSUE is
  removed can be done on outpatient basis
• TURP-Transurethral resection of prostate
• A resectoscope is inserted through the urethra a
  hot wire loop removes overgrown prostate tissue
  irrigation flushes tissue out
• Retrograde ejaculation is common after surgery
• Fluid volume excess hyponatremia (AKA
  transurethral syndrome) is potential complication
  from excessive irrigation watch for labs VS
  changes confusion change in mental status

10
Nursing Care of TURP client Pre-op

• Pre-op Pre-op teaching client will return from
  surgery w/ a catheter in place

11
Nursing Care of TURP client Post-Op Care CBI

• Post-op
• An indwelling 3-way catheter will be placed for
  CBI
• If CBI is not ordered or if catheter becomes
  obstructed follow physician orders for catheter
  irrigation (sterile) usually 50 mL using large
  piston syringe call physician if clot cannot be
  dislodged
• Catheter drains urine allows continuous
  irrigation of NS or other solution to keep
  catheter free of clots/obstruction maintain
  irrigating flow rate to keep output light pink or
  colorless (if clots are observed CBI needs to be
  )
• Accurately record amt of irrigating solution
  instilled (will be very lg. amount) and the
  amount drained the difference b/w the instilled
  amt output is actual urinary output

12
Nursing Care of TURP client Post-op

• Post-op (cont)
• Catheter has lg balloon (30-45 mL) that is kept
  pulled tight w/ traction (this bleeding)
  client will feel a constant sense of pressure
  keep leg straight (usually taped to thigh)
• Monitor for hemorrhage (frank blood in urine
  large blood clots decreased UOP increased
  bladder spasm decreased H/H tachycardia
  hypotension BP changes)
• Assess pain urethral discomfort bladder spasms
  abdominal cramping distention

13
Nursing Care of TURP client Post-op

• Post-Op (cont)
• Maintain accurate IO (be sure to count
  irrigation fluid) output should be 150-200 mL q
  3-4 hr
• Frequently assess catheter patency light red to
  red urine w/ small clots is expected for up to 24
  hrs after surgery. Urine should gradually clear
  of clots become light pink to yellow after
  24-48 hours
• Apply antiembolism stockings ambulate
• If present monitor incision change dressing
  monitor suprapubic cath site if applicable
• Administer meds analgesics (pain)
  antispasmodics (bladder spasms) antibiotics
  (infection) stool softeners (prevent straining)

14
Nursing Care of TURP client Client Education

• Avoid heavy lifting strenuous exercise
  straining sexual intercourse for length of time
  (about 2-8 weeks) dont drive for 2 weeks
  walking is encouraged
• Drink 10-12 or more glasses of water/day
• Avoid caffeine alcohol (overstimulates the
  bladder)
• If urine becomes bloody (after being clear) stop
  activity rest increase fluids
• Contact physician if bleeding persists or if
  unable to void (or insufficient output or
  distention)

15
Nursing Care of TURP client Client Education

• You may shower but do not take tub baths if a
  catheter is still in place
• Avoid aspirin NSAIDS for _at_ least 2 weeks
• Drink fruit juices take stool softeners to keep
  bowel mvmts soft
• When sex is resumed retrograde ejaculation may
  occur causing in semen
• Call doctor if unable to void bleeding is
  excessive you have fever/chills scrotum becomes
  swollen tender pain in one calf chest pain or
  difficulty breathing

16
Nursing Care of TURP client Complications/Nursin
g Implications

• TURP Complications
• Urethral trauma urinary retention bleeding
  infection regrowth of prostate tissue
  reoccurance of bladder/urethral obstruction
• Untreated BPH Complications
• Hydronephrosis bladder muscle weakness UTIs

17
Nursing Care of TURP ClientNursing Care Plan
Diagnosis Interventions

• Ineffective Therapeutic Regimen
• Pt information increase fluids restrict alcohol
• Excess Fluid Volume
• Monitor for s/s of fluid overload daily weights
  if necessary restrict fluids administer
  diuretics
• Impaired Urinary Elimination
• May need larger drng bag monitor leg straps
  keep bag emptied
• Pain
• Monitor address pain encourage activity
  monitor for bladder distention

18
Nursing Care of TURP client Gerontological
Considerations

• Incidence of prostate cancer increases with age
• Surgery poses greater risk for older adult client

19
Prostate Cancer

• Higher incidence in African-American males
• Effects mostly older men is rare in men less
  than 40 yrs old
• Most common type of cancer in N. American men
• Risk Factors family history heavy metal
  exposure history of vasectomy history of STDs
  diet high in animal fat high serum testosterone
  levels
• Usually is an adenocarcinoma
• If spreads usually spreads to bladder seminal
  vesicles metastasis to pelvic nodes may occur
  distant metastasis may include bone liver lungs

20
Prostate Cancer Manifestations

• GU
• dysuria hesitancy reduced urinary stream
  frequency nocture hematuria erectile
  dysfunction hard enlarged prostate on DRE
• MS
• Bone/joint pain back pain compression fractures
• Neuro
• Lower extremity weakness bowel/ bladder
  dysfunction
• Systemic
• Weight loss (usually sign of metastasis) anemia
  fatigue (usually from bone marrow invasion)

21
Prostate Cancer Staging

• Stage A1 Cancer found incidentally with lt 5
  malignant cells tx is observation 5-yr survival
  rate 98
• Stage A2 Tumor not palpable but biopsy is
  positive tx is observation surgery or
  radiation survival rate 90
• Stage B Tumor palpable confined to prostate
  surgery or radiation therapy survival rate 77
• Stage C Local extension of tumor but no distant
  metastasis radiation therapy or combination of
  surgery radiation hormone therapy survival
  rate 60
• Stage D Distant metastasis tx is usually on
  palliative survival rate 26

22
Prostate Cancer Diagnostic Tests

• DRE
• In prostate CA the gland is usually hard
  enlarged
• PSA Levels
• gt 10 ng/mL usually indicate cancer
• Levels gt 80 indicate advanced metastasis
• ACA recommends offering an annual DRE PSA check
  after 50. However men _at_ higher risk
  (African-American males family history) may
  need them at age 45 (40 if several immediate
  family members)
• Most cases of prostate CA tend to be slow growing
  treatment may be conservative if client is
  elderly or has short life expectancy (lt 10 years)

23
Prostate Cancer Diagnostic Tests

• TRUS-Transrectal Ultrasound (Ch. 33) may be used
  to determine prostate cancer from BPH
• Tissue biopsy is done to definitely establish
  cancer diagnosis (needle biopsy or transrectal
  ultrasound-guided biopsy)
• Pre-op teaching-client awake w/ local
  anesthetic feeling of rectal fullness sharp
  pain or pinch felt when biopsy is obtained avoid
  aspirin NSAIDS for 1 week prior an enema is
  administered need signed consent
• Post-op
• Monitor VS UOP avoid strenuous activity for
  the rest of the day hematuria some bloody
  streaks in stool may occur for 24-48 hrs
  ejaculate may contain blood for 2 weeks report
  blood clots in urine bloody stools signs of
  infection rectal pain dysuria urgency

24
Prostate Cancer Hormone Therapy

• Used to treat advanced prostate CA
• Orchiectomy-removal of testes therefore effects
  of testosterone
• Drugs that block effects of testosterone inhibit
  tumor growth but do not cure prostate CA
• May be used to increase quality of life in
  advanced stages of disease
• Adverse effects of hormone therapy loss of
  libido erectile dysfunction hot flashes
  gynecomastia

25
Prostate Cancer Radiation Therapy

• Used to treat prostate CA
• Avoids many of the adverse effects of invasive
  prostate surgery such as impotence urinary
  incontinence
• Radiation can be delivered by a external beam or
  by radioactive implants (known as brachytherapy)
• May be used as palliative therapy to increase
  quality of life (reduces size of metastasis
  helps control pain may restore some function)

26
Prostate Cancer Chemotherapy Drugs

• Diethylstilbestrol (DES)
• Adverse effects fluid retention feminization
• Nursing Implications monitor VS administer
  diuretics as ordered explain reason for
  feminization monitor for bleeding

27
Prostate Surgery

• Simple Prostatectomy
• Only prostate tissue is removed
• Radical Prostatectomy (very invasive)
• Involves removal of prostate prostatic capsule
  seminal vesicles portion of the bladder neck
• Most clients will have urinary incontinence ED
  following radical prostatectomy
• Cryosurgery
• Guided by ultrasound cryoprobe is inserted
• Prostate is intermittently frozen
• May also lead to incontinence impotence rectal
  damage

28
Prostate Surgery Open/Pelvic Approaches

• Open/Pelvic (go in through surgical incision NOT
  through urethra)
• Suprapubic-a midline incision is made into the
  bladder to remove the prostate a suprapubic
  catheter (cystostomy tube) a foley catheter are
  inserted
• Retropubic-prostate gland is removed through an
  abdominal incision but bladder is left intact
• Perineal-prostate gland removed through incision
  made b/w the scrotum anus
• Radical Prostatectomy-when the prostate gland
  its capsule seminal vesicles lymph nodes are
  removed through a retropubic or perineal
  incision this is only done when there is cancer
  present

29
Prostate Surgery Retropubic Approach Nursing
Implications

• Assess abdominal incision for urine drainage
  there shouldnt be any urine drainage because the
  bladder is left intact
• Observe for s/s of infection redness increased
  drainage purulent drainage poor healing

30
Prostate Surgery Suprapubic Approach Nursing
Implications

• Assess urine output from suprapubic and urethral
  catheters
• Assess abdominal dressing for urine drainage
  change saturated dressings frequently
• Following urethral catheter removal clamp
  suprapubic catheter as ordered encourage
  voiding
• Assess residual urine in bladder by unclamping
  the catheter measuring urine output after
  voiding

31
Prostate Surgery Perineal Approach Nursing
Implications

• Assess perineal incision for drainage evidence
  of infection
• Avoid rectal temperatures enemas
• Use a T-binder or padded scrotal support to hold
  dressing in place
• Following dressing removal heat lamps or sitz
  baths may be used to promote healing
• Teach perineal irrigation as ordered after
  bowel movements.

32
Prostate Surgery Post-Op Care

• Routine post-op care as with Post-op TURP care
  along with the following
• If a suprapubic approach was used the client
  will also have a suprapubic catheter (in addition
  to urethral catheter) will be removed when
  residuals are lt 75 mL
• Following a radical prostatectomy surgery teach
  the client to perform perineal exercises to
  reduce urinary incontinence (Kegal exercises)

33
Prostate Surgery Complications

• Radical Prostatectomy Complications
• Irreversible erectile dysfunction due to pudendal
  nerve damage is very possible refractory postop
  urinary incontinence requiring implantation of
  artificial urinary sphincter
• The client with an artificial urinary sphincter
  must be able to manipulate the pump in the
  sccrotum to recognize when a problem with the
  appliance occurs.
• A fluid-filled cuff closes off the urethra to
  void the pump is squeezed drawing fluid from
  cuff to balloon urine will then drain after
  voiding fluid drains back to cuff closing the
  urethra.
• Promptly report leg pain chest pain or
  difficulty breathing. There is a high risk of
  DVT after pelvic abdominal surgery.

34
Prostate Surgery The Nursing Care Plan

• Impaired Urinary Elimination (Risk for
  Incontinence)
• Assess degree of incontinence teach Kegels
  refer to physical therapy teach bladder
  training encourage fluid intake use absorbent
  pads when needed Texas cath for total
  incontinence encourage expression of feelings
• Sexual Dysfunction
• Encourage discussion of sexual function (w/
  client partner physician) discuss various
  treatment options encourage discussion of
  concerns

35
Prostatitis Inflammation of the Prostate

• Common in young middle-age men
• May be caused by bacterial infection but
  nonbacterial prostatitis is most common
• Bacterial usually E. coli or other pathogens
  (i.e. chlamydia) infection through reflux into
  prostatic ducts contamination of urinary meatus
  during vaginal or anal sexual intercourse
• Nonbacterial cause unknown STD autoimmune
  disorder

36
Prostatitis Manifestations

• Pain burning on urination
• Frequency urgency
• Chills fever
• Low back perineal or genital pain
• Pain (or unusual feeling) just preceding or
  following ejaculation
• Obstructed urine flow

37
Prostatitis Treatment/Pt teaching

• 30 days of antibiotics mild analgesics sitz
  baths
• If bacterial partner may need to be treated
• Increase fluid intake void often
• Frequent ejaculation through masturbation or
  intercourse will ease congestion of the gland
• Avoid caffeine prolonged sitting and
  constipation
• NSAIDS may reduce pain anticholinergics may
  reduce voiding symptoms

38
Testicular Torsion

• Twisting of testes and/or spermatic cord- is a
  potential medical emergency because the
  testicular artery is kinked
• Boys young men lt 20 are at greatest risk
• Elevated hormone levels abnormal attachment of
  the testicles to the scrotum may contribute to
  cause
• Trauma to the scrotum may precipitate the
  condition

39
Testicular Torsion Symptoms Treatment

• Acute severe scrotal pain with sudden onset (can
  happen after crossing legs exercise after
  trauma or for no apparent reason)
• Nausea vomiting frequently occur
• Cremasteric reflex may be depressed or absent
  (retraction of the testicles whenthe skin on
  inside of thigh is stroked)
• Emergency surgery is done to relieve
  testicular and/or spermatic cord twisting to
  fix the testicle within the scrotum
• A delay in treatment can result in necrosis
  loss of testicle

40
Cryptorchidism

• Failure of one or both testes to descend through
  inguinal ring into the scrotum
• In most cases they descend without help during
  first year of life sometimes androgen therapy
  will help it come down on its own but it can be
  fixed w/ surgery
• Primarily a childhood problem
• If not addressed it can increase the risk for
  testicular cancer infertility
• Men w/ a history of cryptorchidism should be
  particularly diligent with TSE

41
Epididymitis

• Inflammation of epididymis
• Usually caused by an infection spread from the
  bladder urethra prostate gland or seminal
  vesicles
• In young men is usually an STD (chlamydia or
  gonorrhoeae) in older men usually from a UTI or
  prostatitis
• Pain swelling of scrotum fever malaise
• Sterility is a potential complication
• Antibiotics are prescribed ice packs a scrotal
  support may be applied

42
Orchitis

• Inflammation of the testicle
• Usually caused by extension of infection from
  other parts of the GU tract
• It often occurs as a complication of mumps.
• Trauma including vasectomy other scrotal
  surgeries may cause inflammation of the testes
• Severe testicular pain swelling
• Possible complications include hydrocele
  abscess which can lead to infertility
• If bacterial treatment is ATB if viral
  treatment may be symptomatic an abscess is
  surgically drained

43
Infertility Sterility

• Infertility Inability to conceive a child during
  a year or more of unprotected intercourse
• Sterility Absolute inability to conceive
• When the sperm count drops below 20 million/mL
  the client is likely to be infertile
• Male infertility usually results from a
  testicular disorder (cryptorchidism or orchitis)
  can also be from hormonal disorder obstruction
  or from unknown cause
• If there is an identifiable cause that cause
  might be able to be treated

44
Hydrocele

• Collection of fluid in the scrotum
• Cause may be from epididymitis orchitis injury
  tumor or may be unknown
• Scrotal enlargement may be only symptom although
  it may cause pain or a tight sensation
• Diagnosed by transillumination or ultrasound
• Treatment usually is not necessary however fluid
  aspiration may be performed

45
Spermatocele

• Mobile usually painless mass in the epididymis
  that contains dead sperm cells
• The cause is thought to be leakage of sperm due
  to trauma or infection
• Treatment usually not necessary will eventually
  be reabsorbed by body

46
Varicocele

• Abnormal dilation of spermatic veins above the
  testes
• Caused by incompetent or absent valves in the
  veins almost always occurs on the left side
• Dilated veins forma soft mass (often described as
  a bag of worms)
• Varicoceles are thought to be an underlying cause
  of male infertility may be surgically repaired

47
Vasectomy-Related Problems

• Vasectomy-sterilization procedure that removes a
  portion of the spermatic cord
• It may take several weeks or more after surgery
  before the ejaculatory fluid is free of sperm
  (need to use reliable method of contraception
  until sperm are no longer present) may be
  determined after 10 or more ejaculations
• On rare occasion the client may complain of
  impotence although the procedure does not affect
  erection

48
Care After a Vasectomy

• Apply ice packs to scrotum to reduce swelling
  remove ice packs after 20 minutes reapply when
  skin is warm
• Wear an athletic support for comfort
• Resume usual activities in 2-3 days avoid
  strenuous exercise for up to 5 days
• May resume sexual activity when comfort allows
  (usually 1 week)
• Report severe pain fever or swelling

49
Testicular Cancer

• Most common cancer in men b/w ages of 15 and 35
• Cause is unknown most men who develop testicular
  CA have no risk factors
• Risk factors cryptorchidism family history
• Beginning _at_ age 15 all men should perform
  monthly testicular self-exams
• Seminomas-involve immature sperm-forming germ
  cells
• Nonseminomas-involve mature germ cells (grow more
  rapidly treat aggressively)

50
Testicular Self-Exam

• Examine testicles during or just after a warm
  shower or bath. Soap allows easy manipulation of
  tissue
• Gently roll each testicle b/w your thumb
  fingers testicles should normally feel smooth
  rounded walnut-sized freely moveable
• If one testicle is significantly larger than the
  other or if you feel any hard lumps contact
  your physician right away
• Do exam on same day each month to help you
  remember

51
Testicular Cancer Manifestations

• Usually only one testicle is affected
• May spread through lymph (to retroperitoneal
  lymph nodes) blood vessels (to bone lungs or
  liver)
• Classic presenting symptom is a painless hard
  nodule
• May have a dull ache in the pelvic or scrotum
  swelling of testes increase in size of one
  testicle heavy or dragging feeling in scrotum
  diminished sensitivity to testicular pressure
• First sign may also be signs of metastasis (ex
  abdominal masses gynecomastia back pain
  general weakness)

52
Testicular Cancer Staging

• Stage I Tumor confined to the testis tx is
  orchiectomy retroperitoneal lymph node
  dissection 5-yr survival rate is 95
• Stage II Involvment of testes plus
  retroperitoneal nodes tx is orchiectomy
  retroperitoneal lymph node dissection possible
  chemotherapy 5-yr survival rate is 93
• Stage III Distant metastasis tx is
  orchiectomy retroperitoneal lymph node
  dissection 4 cycles of chemotherapy surgery to
  resect residual masses 5-yr survival rate 70

53
Testicular Cancer Diagnostic Tests

• Alpha-fetoprotein (AFP) human chorionic
  gonadotropin (HCG) alkaline phosphatase and
  lactic dehydrogenase (LDH) may all be elevated in
  testicular cancer
• These values are normally present in pregnant
  women however tumors of the testes cause
  elevations
• Ultrasounds may rule out other causes of a mass
• CT scans detect metastasis
• Biopsies are done cautiously (if done at time of
  surgery) due to the possibility of spreading
  cancerous cells

54
Testicular Cancer Chemotherapy Drugs

• Bleomycin (Blenoxane)
• Adverse cutaneous ulcerations alopecia n/v
  chills fever pulmonary fibrosis
• Nsg Imp monitor for fever monitor CXR assess
  respiratory status assess for infection monitor
  hydration nutrition status
• Vinblastine (Velban)
• Adverse areflexia alopecia N/V bone barrow
  depression
• Nsg Imp assess neuromuscular function monitor
  CBC administer antiemetics assess for infection
  bleeding

55
Testicular Cancer Chemotherapy Drugs

• Cisplatin (Platinol)
• Adverse bone marrow depression renal tubular
  damage deafness
• Nsg Imp monitor WBC platelets BUN/Creatinine
  uric acid monitor for s/s of infection or
  bleeding evaluate hearing check for tinnitus
  ensure client is well hydrated before
  administering encourage 2-3 L of fluid intake
  daily

56
Testicular Cancer Surgery Radiation

• Surgery
• Removal of affected testicle spermatic cord
  (aka radical orchiectomy)
• Lymph nodes may be removed
• Care is taken to preserve the nerves necessary
  for ejaculation
• Radiation
• Radiation used to treat CA in retroperitoneal
  lymph nodes (most frequent site of metastasis)
• Client may experience diarrhea nausea or
  decreased bone marrow function

57
Testicular Cancer Care Plan

• Knowledge Deficient
• Discuss using analgesics ice bags scrotal
  support
• Instruct to notify physician if incision gaps
  open bleeding after 24 hrs or rapid scrotal
  swelling
• Risk for Sexual Dysfunction
• Help client discuss concerns reassure client
  that erectile climactic function is rarely
  affected discuss option of sperm-banking

58
Phimosis

• Constriction of foreskin so that it cannot be
  pushed back over the glans of the penis
• May be congenital may follow an infection or
  injury may be due to swelling
• Increases the risk of infections scarring
  perhaps cancer
• Can interfere with urination may impair blood
  flow to the glans
• Circumcision may be necessary
• Teach client about hygiene measures

59
Priapism

• Sustained painful erection that is not
  associated with sexual arousal
• Caused by impaired blood flow (venous return) in
  the corpora cavernosa
• Cause may be unknown or may be caused by certain
  conditions or drugs
• If condition is not resolved there is risk of
  tissue damage impotence (gt 4-6 hrs)

60
Priapism Risk Factors

• Conditions
• Sickle cell disease leukemia metastatic cancer
  spinal cord trauma
• Drugs
• Drugs to treat erectile dysfunction papaverine
  psychotropic drugs alcohol marijuana

61
Priapism Nsg Care Treatment

• Monitor urine output report oliguria or urinary
  retention
• Provide analgesics as ordered
• Address client concerns
• Surgical shunting may be necessary
• Vasoconstrictive medications such as terbutaline
  or neosynephrine may be administered
• Needle aspiration of trapped blood may also be
  done

62
Cancer of the Penis

• Rare in. N. Am. typically occurs in men who are
  NOT circumsized
• Phimosis HPV UV light exposure unprotected sex
  w/ multiple partners cigerette smoking are
  thought to be risk factors
• Squamous cell carcinoma usually a nodular or
  wartlike growth red velvety lesion on the glans
  or foreskin lesions may ulcerate bleed
  purulent foul-smelling discharge may be present
  slow growing but may spread to lymph nodes bone
  liver or lungs
• Dx by biopsy
• Tx chemotherapy radiation surgical excision
  if total penectomy is done a perineal
  urethrostomy is created

63
Erectile Dysfunction (ED)

• AKA impotence is the inability to attain/maintain
  an erection that allows for satisfactory sexual
  intercourse
• Typically occurs in men gt 65
• May occur in men w/ diabetes atherosclerosis
  as a side effect of many drugs most often a
  physiological cause is found psychologic causes
  account for only 10-20 of cases

64
Erectile Dysfunction Pathophysiology

• Interruption of blood supply nervous system or
  hormonal actions maybe the cause
• Atherosclerosis can interfere w/ arterial blood
  supply surgeries such as radical prostatectomy
  or chronic diseases such as diabetes or multiple
  sclerosis can disrupt innervation decreased
  testosterone levels may also cause
• Drugs such as antihypertensives psychotropic
  drugs hormones others may disrupt the normal
  mechanisms of an erection

65
Erectile Dysfunction Diagnostic Tests

• Labs such as chem profile testosterone
  prolactin thyroxine PSA levels are done to
  determine various disorders
• Nocturnal penile tumescenc rigidity (NPTR)
  -monitors erections that occur during the REM
  cycle of sleep
• Cavernosometery/cavernosography may evaluate
  blood flow

66
Erectile DysfunctionFirst-line Treatments

• Counseling dispels misconceptions about ED
• Vacuum constriction devices draws blood into
  penis producing an erection least expensive
• Oral Agents phosphodiesterase (PDE5) inhibitors
  such as sildenafil (Viagra) vardenafil
  (Levitra) and tadalafil (Cialis)
• Work w/ nitric oxide an enzyme (PDE5) to dilate
  arterial vessels in the corpus cavernosum
• Contraindicated in men taking any form of nitrate
  (for chest pain) can cause severe hypotension
  H/A flushing blurred vision nasal congestion
  sensitivity to light contraindicated in men who
  have cardiovascular disease may cause priapism
• Take drug 30-60 minutes prior to sex report
  erection lasting gt 4 hrs chest pain or SOB
  check with doctor before taking these drugs

67
Erectile Dysfunction Second-Line Treatments

• Self injection of prostaglandin E1 (Caverject)
  papaverine HCL (Pavatine) or phentolamine
  (Regitine)
• Relaxes arterial vessels allowing increased blood
  flow into penis produces erection in 5-20
  minutes lasts up to 1 ½ hrs may cause
  discomfort _at_ injection site increased chance of
  priapism
• Urethral suppository of alprostadil
• Relaxes penile muscles promoting vascular filling
  engorgement produces an erection withing 15
  minutes less effective than injection may cause
  urethral burning hypotension dizziness may
  develop
• Topical application of NTG paste has been
  reported to be effective but is not recommended

68
Erectile Dysfunction Third-line Treatment

• Surgical implantation of semirigid or inflatable
  penile prosthesis
• Provides penile rigidity sufficient for vaginal
  penetration permanent outcome with low failure
  rate produces less enlargement compared w/
  normal erections requires about weeks to recover
  from surgery before sexual activity
• Surgical complications such as infection
  perforation pain tissue damage may occur

69
Ejaculatory Dysfunction

• Premature ejaculation psychological factors
  diabetes may be the cause more common in young
  men
• Delayed ejaculation may be related to
  age-related changes (more common in older men)
  may be attributed to decrease in penile sensation
  or decreased libido
• Retrograde ejaculation semen is discharged into
  bladder often related to prostate surgeries
• Other things effecting ejaculation drugs
  depression anxiety narcotics

70
Important Gerontologic Considerations

• Sperm testosterone gradually decrease as men
  age
• Scrotum may become more pendulous is therefore
  at an increased risk of injury
• Impotence is NOT considered a normal part of aging

71
Important Pharmacologic Considerations

• Bleomycin (chemotherapy drug) can cause pulmonary
  toxicity Raynauds phenomenon
• Cisplatin (chemo drug) is extremely nephrotoxic
  client must be kept well hydrated (report wet
  lung sounds edema)
• Chemotherapy increases chance of infection
  anorexia vomiting hair loss anemia
• Epogen Neulasta can help stimulate RBC WBC
  production
• Try to administer antiemetics prior to chemo dose
• Watch for anaphylactic reactions w/ chemo drugs
• BP drugs antidepressents narcotics cimetidine
  can cause sexual dysfunction

72
References

• Burke LeMone Mohn-Brown (2007).
  Medical-Surgical Nursing Care. (2nd Ed). Upper
  Saddle River New Jersey Pearson Prentice Hall.