NSG210 Hinkle Ch. 53: Assessment and Management of Patients with Male Reproductive Disorders

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 53, pp. 1743-1779 (textbooks/HINKLE_MS_CH53.pdf, also in textbooks/exam04/). Week 13 reading (BPH, prostate cancer); Exam 4 content. Numbering note: the Week 13 syllabus lists “Ch. 54” (16th edition); male reproductive disorders is Ch. 53 in the 15th edition (see nsg210-textbook-chapter-crosswalk). Urinary tract infections, incontinence, and bladder cancer are in nsg210-hinkle-ch49-urinary-disorders.

Learning Outcomes

1. Describe the structures and functions of the male reproductive system.
2. Discuss nursing assessment of the male reproductive system, including diagnostic tests and their nursing implications.
3. Explain causes and management of male sexual dysfunction.
4. Compare types of prostatectomy (advantages and disadvantages).
5. Use the nursing process for patients with prostate, testicular, and penile disorders.

Key Terms

• Androgen deprivation therapy (ADT): surgical (orchiectomy) or medical (LHRH agonist) castration
• Benign prostatic hyperplasia (BPH): noncancerous enlargement of the prostate; the most common pathologic condition in older men
• Brachytherapy: radiation delivered by implants inside or next to a tumor
• Circumcision: excision of the foreskin (prepuce)
• Cystostomy: surgical opening into the bladder (suprapubic drainage)
• Epididymitis: infection of the epididymis, usually descending from an infected prostate or urinary tract; may follow gonorrhea, chlamydia, or E. coli
• Erectile dysfunction (ED): inability to achieve or maintain an erection sufficient for intercourse (impotence)
• Hydrocele: fluid collection, usually in the tunica vaginalis
• Orchiectomy: removal of one or both testes. Orchitis: acute inflammation of the testes
• Phimosis: foreskin cannot be retracted over the glans. Paraphimosis: retracted foreskin cannot be returned
• Priapism: uncontrolled, persistent erection from neural or vascular causes
• Prostatectomy: removal of the prostate (radical: prostate, prostatic urethra, seminal vesicles, ampulla of vas)
• PSA: prostate-specific antigen; used with DRE to screen for prostate cancer
• Prostatitis: inflammation of the prostate (infectious or other causes)
• Retrograde ejaculation: semen travels into the bladder instead of out the penis
• TURP: transurethral resection of the prostate; gland removed in chips with an electrical cutting loop through an endoscope
• Varicocele: dilated veins of the pampiniform plexus in the scrotum
• Vasectomy: ligation and transection of the vas deferens (male sterilization)

I. Assessment of the Male Reproductive System

A. Anatomy and Physiology

• External genitalia: testes, epididymis, scrotum, penis. Internal: vas deferens, ejaculatory duct, urethra, seminal vesicles, prostate, Cowper (bulbourethral) glands (Fig. 53-1)
• Testes: spermatogenesis and testosterone secretion; scrotum keeps them cooler than body temperature to support sperm production
• Patent peritoneal process after testicular descent leaves a sac for an indirect inguinal hernia
• Prostate: just below the bladder neck, surrounds the urethra; four zones and four lobes; secretions support sperm
• Erection: nitric oxide released into corpus cavernosum, activates cGMP, smooth muscle relaxes, blood fills the corpora

B. Gerontologic Considerations (Table 53-1)

• Prostate enlarges, testosterone declines (hypogonadism begins about age 50), testes soften and shrink, sperm count falls but spermatogenesis continues for life
• Sexual response slows; libido and potency decrease in up to two thirds of men over 70; vascular problems cause about half of ED after age 50
• Men over 50 have increased risk of GU cancers (kidney, bladder, prostate, penis); DRE, PSA, and urinalysis (hematuria) screen
• Urinary incontinence: one fifth of community-dwelling older men, nearly 50% in long-term care. New-onset incontinence is a nursing priority requiring evaluation

C. Health History

• Prostatism: frequency, decreased force of stream, “double” or “triple” voiding; also ask about dysuria, hematuria, nocturia, hematospermia
• Sexual function: chronic illness (diabetes, MS, stroke, cardiac), medications (antihypertensives, lipid-lowering agents, psychotropics), stress, alcohol
• PLISSIT model: Permission, Limited Information, Specific Suggestions, Intensive Therapy (referral)
• BETTER model: for sexuality assessment in patients with cancer
• Nurse initiating the topic signals that sexual concerns are valid; provide privacy

D. Physical Assessment

• DRE: annually after age 50 (age 45 for high risk: African American men, first-degree relative with prostate cancer). Assesses size, symmetry, shape, consistency, tenderness, nodules
  • Normal prostate: round, palpable median sulcus between lateral lobes, rubbery, no nodules (Fig. 53-2)
  • Position: leaning over table, side-lying with knees flexed, or supine in stirrups; deep breath and slow exhale as finger inserted
• Testicular examination: palpate scrotum for nodules, masses, inflammation (hydrocele, hernia, torsion, orchitis, epididymitis, tumor); inspect penis; retract foreskin if uncircumcised. Teach TSE (begin in adolescence)

E. Diagnostic Evaluation

• PSA: sensitive but not specific for prostate cancer
  • Less than 4 ng/mL generally normal; greater than 4 ng/mL elevated in men 60 or younger; age-specific ranges reduce unnecessary biopsies
  • Also elevated by BPH, acute urinary retention, acute prostatitis, and after ejaculation
  • ACS: PSA plus DRE for men with at least a 10-year life expectancy and high-risk men. Neither test is 100% accurate; accuracy increases when combined
  • Also used to monitor for recurrence after treatment
• TRUS (transrectal ultrasound): for abnormal DRE or elevated PSA; detects nonpalpable cancers, stages localized disease, guides needle biopsy (6 to 12 cores from all four zones)
• Prostate fluid or tissue culture/biopsy (perineal or transrectal needle, or at prostatectomy)
• Male sexual function: nocturnal penile tumescence testing (sleep lab) distinguishes organic from psychogenic ED (healthy men have erections during REM sleep)

II. Disorders of Male Sexual Function

A. Erectile Dysfunction

• 30 million US men; more than half of men 40 to 70 cannot attain or maintain an erection sufficient for satisfactory performance
• Psychogenic causes: anxiety, fatigue, depression, performance pressure, body image, relationship issues
• Organic causes: cardiovascular disease, diabetes and other endocrine disease, cirrhosis, chronic kidney disease, radical pelvic surgery, Hodgkin lymphoma/leukemia, neuropathy, Parkinson, SCI, MS, pelvic trauma, smoking, medications, substance use
• Chart 53-1 medications associated with ED: antihypertensives (clonidine, hydralazine), beta-blockers, calcium channel blockers, diuretics (thiazides, furosemide, spironolactone), antidepressants (TCAs, SSRIs), antipsychotics, anticholinergics, antihistamines, anxiolytics, H2 antagonists (nizatidine), NSAIDs, antiandrogens (flutamide, leuprolide), ketoconazole, chemotherapy, Parkinson drugs, alcohol, nicotine, opioids, cocaine, marijuana
• Workup (Fig. 53-3): history and physical including neuro exam, IIEF and SHIM questionnaires, fasting glucose, fasting lipids, thyrotropin; Doppler penile blood flow; cardiovascular workup recommended before medication
• Treatment is stepwise from least to most invasive (Table 53-2)

B. ED Treatments (Table 53-2, Table 53-3)

• PDE-5 inhibitors (sildenafil, vardenafil, tadalafil): first-line; require sexual stimulation
  • Sildenafil: take 30 min to 4 h before; once in 24 h
  • Vardenafil: take 1 h before; peak 30 to 120 min; 10 mg in 24 h
  • Tadalafil: peak 30 min to 6 h; effect lasts up to 36 h
  • Side effects: headache, flushing, dyspepsia, diarrhea, nasal congestion, lightheadedness, abnormal vision; tadalafil also back pain and myalgia
  • Contraindicated with nitrates (nitroglycerin, isosorbide) because of severe hypotension; also uncontrolled hypertension, CAD, MI within 6 months, arrhythmia, kidney or liver dysfunction. Caution with retinopathy (especially diabetic)
  • Do not combine with penile injections or urethral suppositories
• Intracavernosal injection (alprostadil, papaverine, phentolamine): 20 min before; firm erection in more than 50%; risks priapism, fibrotic plaques, injection-site pain
• Intraurethral alprostadil suppository: 10 min before; urethral/genital pain, hypertension, syncope; not with pregnant partners
• Penile implants: semirigid rod (permanent semierection, higher erosion risk, makes later cystoscopy harder) or inflatable (simulates natural erection). Complications: infection, erosion, persistent pain; healing up to 3 weeks
• Vacuum devices: cylinder plus constriction band; band must not stay on longer than 1 hour; use only devices with a vacuum limiter

C. Disorders of Ejaculation

• Premature ejaculation: 20% to 30% of men. Treat with behavioral/couples therapy and medications (SSRIs, dapoxetine, alpha-1 blockers, clomipramine, topical anesthetics)
• Inhibited (delayed) ejaculation: psychological, neurologic (SCI, MS, diabetic neuropathy), prostatectomy, medications; therapy 12 to 18 sessions, 70% to 80% success
• Retrograde ejaculation: semen into bladder causing infertility; after prostate or urethral surgery, diabetes, antihypertensives. Sperm can be retrieved from postejaculation urine for insemination
• SCI at T6 or higher: ejaculation (spontaneous or electroejaculation) can trigger autonomic dysreflexia, a life-threatening emergency

III. Infections of the Male Genitourinary Tract

• More than 20 million STIs per year in the US; nearly half in ages 15 to 24. Greatest risk factor: number of sexual partners
• Routine HPV vaccination for males since 2011 (ACIP)
• MSM: annual testing for HIV, syphilis, chlamydia, gonorrhea, hepatitis B, HSV-2; screen extragenital sites (oropharynx, anus)
• Treat partners; abstain during treatment; condoms for at least 6 months after treatment to reduce HPV transmission; test for other STIs. Nonoxynol-9 discouraged (may increase HIV risk)

IV. Prostatitis

• 5% to 10% of men; most common urologic diagnosis under 50. E. coli most common (also Klebsiella, Proteus)
• Types: I acute bacterial; II chronic bacterial; III chronic prostatitis/chronic pelvic pain syndrome (more than 90% of cases; IIIA with WBCs in semen, IIIB without); IV asymptomatic inflammatory (found incidentally)
• Acute (type I): sudden fever, dysuria, perineal prostatic pain, frequency, urgency, hesitancy, nocturia; about 5% progress to type II
• Management: culture-guided antibiotics (TMP-SMX or fluoroquinolone such as ciprofloxacin), possible low-dose continuous therapy; anti-inflammatories if afebrile with normal UA; alpha-blocker (tamsulosin) to relax bladder and prostate
• Hospitalize for unstable vitals, sepsis, intractable pain, frailty, immunosuppression, diabetes, renal insufficiency (IV antibiotics)
• Nursing and teaching:
  • Complete the full antibiotic course
  • Warm sitz baths 10 to 20 minutes several times daily
  • Fluids to satisfy thirst but not “forced” (keeps drug concentration in urine)
  • Avoid alcohol, coffee, tea, chocolate, cola, spices
  • Avoid sexual activity during acute inflammation; avoid prolonged sitting
  • Suprapubic catheter may be needed for severe retention
  • Follow-up for 6 months to 1 year (recurrence)

V. Benign Prostatic Hyperplasia

A. Epidemiology and Pathophysiology

• Usually after age 40; 50% of men by 60, up to 90% by 85; second most common cause of surgery in men over 60
• DHT (testosterone metabolite) is the key mediator of prostate growth; estrogens may contribute
• Risk factors: smoking, heavy alcohol, obesity, low activity, hypertension, heart disease, diabetes, Western diet
• Enlarged lobes obstruct bladder neck or urethra leading to incomplete emptying and retention, then hydroureter, hydronephrosis, UTIs; chronic retention can lead to azotemia and kidney failure

B. Clinical Manifestations

• Obstructive and irritative LUTS: frequency, urgency, nocturia, hesitancy, weak or intermittent stream, sensation of incomplete emptying, straining, postvoid dribbling, acute retention, recurrent UTIs
• Normal residual: no more than 50 mL in middle age; less than 50 to 100 mL in older adults
• Generalized: fatigue, anorexia, nausea, vomiting, pelvic discomfort
• Differential: urethral stricture, prostate cancer, neurogenic bladder, bladder stones

C. Assessment

• Voiding diary; DRE shows a large, rubbery, nontender prostate
• Urinalysis for hematuria and UTI; PSA if finding cancer would change management
• AUA Symptom Index or IPSS for severity
• Flow rate, postvoid residual; urodynamics, cystoscopy, ultrasound if invasive therapy planned; cardiac and respiratory evaluation (older population)

D. Medical Management

• Emergency retention: catheterize immediately; a stylet (inserted by urologist) or a metal catheter with a pronounced prostatic curve may be needed; cystostomy if catheter cannot pass
• Watchful waiting: mild symptoms or unbothered patients without complications; annual reexamination
• Alpha-adrenergic blockers (alfuzosin, terazosin, doxazosin, tamsulosin): relax bladder neck and prostate smooth muscle. Side effects: dizziness, headache, fatigue, orthostatic hypotension, rhinitis, sexual dysfunction
• 5-alpha-reductase inhibitors (finasteride, dutasteride): block testosterone to DHT conversion, shrink prostate. Side effects: decreased libido, ejaculatory dysfunction, ED, gynecomastia, flushing
• Combination doxazosin plus finasteride reduces symptoms and progression
• Saw palmetto (Serenoa repens) and Pygeum africanum: not recommended; do not combine with finasteride, dutasteride, or estrogen-containing drugs

E. Minimally Invasive and Surgical Options

• Transurethral microwave thermotherapy: heat makes tissue necrotic and slough; some systems water-cooled
• Transurethral needle ablation: low-level radiofrequency heat via needles
• Prostatic stents: only for retention in poor surgical candidates (encrustation, infection, pain)
• Surgery for moderate to severe LUTS, acute retention, or complications. Correct clotting defects and hold anticoagulants first (bleeding risk)
• TURP is the benchmark surgical treatment for BPH; no external incision
• TUIP: for small prostates; 1 or 2 cuts, no tissue removed
• Open prostatectomy (suprapubic, retropubic, rarely perineal) for large glands; laparoscopic and robotic options

VI. Cancer of the Prostate

A. Epidemiology and Risk

• Most common cancer in men (excluding nonmelanoma skin cancer); second most common cause of cancer death in men (after lung), about 10% of male cancer deaths
• Survival: 98% at 5 years, 84% at 10 years, 56% at 15 years
• African American men: high risk and more than twice as likely to die of it; offer culturally sensitive education
• Other risks: age (incidence rises after 50; more than 70% of cases over 65), father or brother with prostate cancer (especially young at diagnosis), HPC1, BRCA1/BRCA2, diet high in red meat and high-fat dairy, endogenous hormones

B. Clinical Manifestations

• Early disease rarely causes symptoms; obstruction symptoms usually mean advanced disease
• Obstruction: difficulty and frequency, retention, decreased stream; hematuria or hematospermia, painful ejaculation
• Metastasis (lymph nodes, bone): backache, hip pain, perineal/rectal discomfort, anemia, weight loss, weakness, nausea, oliguria, pathologic fractures (may be the first sign)

C. Diagnosis and Staging

• DRE (ideally same examiner): early cancer is a nodule or hardening in the posterior lobe; advanced lesion is “stony hard” and fixed
• Concept Mastery Alert: abnormal DRE and elevated PSA raise suspicion, but diagnosis requires biopsy
• Biopsy: TRUS-guided needle biopsy, TURP or prostatectomy specimen; fine-needle aspiration. Cancer is found incidentally in about 1 of 10 TURPs done for presumed BPH
• Gleason score: primary pattern grade (1 to 5) plus secondary pattern grade (1 to 5), total 2 to 10. Higher score means less differentiated, more aggressive; 8 to 10 is high grade
• Risk (low, intermediate, high) depends on extent, localization, aggressiveness, node spread; guides treatment
• Metastatic workup: bone scan, skeletal x-ray, MRI; pelvic CT for nodes; capromab pendetide (indium 111) for recurrence or metastasis

D. Medical Management

• Based on life expectancy, symptoms, recurrence risk, tumor size, Gleason, PSA, complications, preference; NCCN risk stratification; multidisciplinary
• Watchful waiting: life expectancy less than 5 years and low-risk cancer. Pros: no treatment side effects, avoids unnecessary treatment. Cons: missed chance for cure, metastasis risk, anxiety, frequent monitoring
• Sipuleucel-T: first FDA-approved therapeutic cancer vaccine; for metastatic cancer no longer responding to hormone therapy; minimal side effects
• Abiraterone acetate and cabazitaxel: metastatic castration-resistant prostate cancer

E. Surgical Management

• Radical prostatectomy is first-line for cancer confined to the prostate: removes prostate, seminal vesicles, tips of vas deferens, often surrounding fat, nerves, vessels
• Laparoscopic and robotic-assisted laparoscopic radical prostatectomy are now standard; less sexual dysfunction when nerves are spared

F. Radiation Therapy

• EBRT (teletherapy): example 28 treatments over about 5.5 weeks; for low-risk disease outcomes similar to prostatectomy; intermediate/high risk get higher doses, possibly with pelvic node irradiation and ADT
• IMRT (limits dose to surrounding tissue) and CyberKnife stereotactic radiosurgery
• Brachytherapy: 80 to 100 radioactive seeds placed by ultrasound guidance; home same day
  • Avoid close contact with pregnant women and infants for up to 2 months
  • Strain urine for seeds; condom during intercourse for 2 weeks
  • Poor option for high-risk patients
• Side effects: proctitis, enteritis, cystitis; irritative and obstructive urinary symptoms; rectal urgency, diarrhea, tenesmus. Late: proctitis, rectal bleeding or fistula, painless hematuria, chronic interstitial cystitis, urethral stricture, ED, rarely secondary rectal or bladder cancers

G. Hormonal Strategies (Androgen Deprivation Therapy)

• About one third of 2 million US survivors receive ADT; causes prostatic epithelial atrophy
• Bilateral orchiectomy: removes about 93% of circulating testosterone (7% adrenal); significant emotional impact; testicular prostheses may be offered
• LHRH agonists (leuprolide, goserelin): suppress testicular androgen
  • Testosterone flare on initiation can cause bone pain with bony metastases; antiandrogen for the first 7 days reduces it
• Antiandrogen receptor antagonists (flutamide, bicalutamide, nilutamide): adrenal androgen suppression; added if testosterone not suppressed (chapter states “less than 50 ng/mL”; castrate level is conventionally expressed as less than 50 ng/dL, so treat the unit as a likely typo)
• Ketoconazole (high dose): second-line, inhibits androgen synthesis; requires steroid supplementation to prevent adrenal insufficiency
• ADT adverse effects (hypogonadism): hot flashes, loss of libido, decreased bone density (osteoporosis, fractures), anemia, fatigue, increased fat mass, lipid changes, decreased muscle mass, gynecomastia, mastodynia; increased risk of diabetes, metabolic syndrome, cardiovascular disease

H. Chemotherapy and Other Therapies

• Docetaxel-based chemotherapy improves survival in non-androgen-dependent disease
• Cryosurgery: transperineal freezing probes for patients who cannot tolerate surgery or with recurrence
• Palliation of bone metastases: opioid and nonopioid analgesics, EBRT to lesions, IV strontium or samarium, prednisone, pamidronate (bisphosphonate) to reduce fracture risk, transfusions when marrow is replaced
• Repeated TURP or suprapubic/urethral catheter to keep urethra patent
• More than one third use complementary therapies; direct patients to NCCIH evidence

I. Plan of Nursing Care (Chart 53-3) Highlights

• Anxiety and knowledge: assess understanding, explain tests, community resources
• Urinary retention: voiding 20 to 30 mL frequently with output less than intake suggests retention; normal voiding position, catheterization as ordered
• After prostatectomy avoid prolonged sitting, straining, lifting, and sexual activity for 6 to 8 weeks (bleeding)
• Bladder control: void every 2 to 3 hours, avoid voiding supine, limit cola and caffeine, evening fluid cutoff, perineal exercises every hour
• Nutrition: small frequent meals, antiemetics around the clock if needed, oral hygiene
• Pain from bone metastasis: firm mattress or bed board, fall precautions, support extremities, scheduled (not PRN) analgesics, bowel program
• Report after discharge: continued bloody urine or clots, pain or burning around catheter, frequency, decreased output, increasing loss of bladder control

VII. The Patient Undergoing Prostate Surgery

A. Surgical Approaches (Table 53-4, Fig. 53-4)

• Open prostatectomy blood loss 500 to 900 mL vs about 150 mL robotic
• Pelvic lymph node dissection: staging; dissection anterior/lateral to external iliac vessels raises lymphedema risk

B. Complications Overview

• Hemorrhage, clot formation, catheter obstruction, sexual dysfunction
• All prostatectomies carry ED risk (pudendal nerve damage); high after total (radical) prostatectomy
• Sexual activity may resume in 6 to 8 weeks (prostatic fossa healing)
• Retrograde ejaculation from posterior urethral changes; vasectomy may be done to prevent epididymitis

C. Transurethral Resection (TUR) Syndrome (Chart 53-4)

• Rare (about 2% of TURPs); absorption of irrigating fluid causes hyponatremia, hypervolemia, occasionally hyperammonemia
• Signs: headache, lethargy and confusion, nausea and vomiting, muscle spasms, seizures, hypotension, tachycardia, collapse
• Interventions: stop irrigation; give diuretics as prescribed; replace irrigation with normal saline; I&O; VS and LOC; distinguish from postoperative disorientation; safety during confusion; auscultate for pulmonary edema and heart failure as fluid shifts

D. Preoperative Care

• Assess urinary symptoms in patient’s own words, back/flank/suprapubic pain, sexual function, family history, functional status
• Indwelling catheter for ongoing retention or azotemia; decompress gradually over several days in older hypertensive patients (BP and kidney function may fluctuate). Suprapubic catheter if urethral catheter not tolerated
• Antiembolism stockings (especially with lithotomy positioning); enema the night before or morning of surgery to prevent postoperative straining
• Stop aspirin, NSAIDs, and platelet inhibitors 10 to 14 days before surgery

E. Postoperative Care

• Fluid balance: irrigation fluid can be absorbed (water intoxication); record I&O including irrigation; watch for hyponatremia, rising BP, confusion, respiratory distress (higher risk in older adults with cardiac or respiratory disease)
• Activity: dangle legs day of surgery, ambulate next morning; avoid prolonged sitting (raises intra-abdominal pressure and bleeding)
• Bladder spasms: urgency, pressure, bleeding around catheter; treat with oxybutynin or flavoxate (anticholinergic/antispasmodic), warm compresses, sitz baths
• Irrigation: usually 50 mL at a time; the same amount must be recovered
• Bowel: prune juice and stool softeners; enema only with caution (rectal perforation)
• Hemorrhage:
  • Normal drainage reddish-pink, clearing to light pink within 24 hours; change from pink to amber indicates reduced bleeding
  • Arterial bleeding: bright red, more viscous, numerous clots; usually needs surgery
  • Venous bleeding: darker, less viscous; controlled with catheter traction (catheter taped to thigh, balloon presses on prostatic fossa)
  • Watch for restlessness, diaphoresis, pallor, falling BP, rising pulse
• Three-way catheter for continuous bladder irrigation (common after TURP) to prevent clots (Fig. 53-5)
• Catheter obstruction after TURP distends the prostatic capsule and causes hemorrhage; furosemide may be given to promote diuresis. Rounded suprapubic swelling means overdistended bladder; use bladder scanner
• Quality and Safety Alert: fluid recovered must equal fluid instilled; overdistention stretches coagulated vessels and causes secondary hemorrhage
• Secure drainage tube (not catheter) to inner thigh; cystostomy tube to abdomen. Urge to void is from catheter and spasms; do not pull on catheter
• Infection: perineal wound needs strict asepsis (T-binder or athletic supporter); avoid rectal thermometers, rectal tubes, enemas; watch for UTI and epididymitis
• VTE: early ambulation; antithrombotics if high risk
• Incontinence after catheter removal usually subsides; better continence with younger age, bilateral nerve sparing, no anastomotic stricture, smaller prostate. Pelvic floor exercises, biofeedback, electrical stimulation; pads; long term collagen injections, artificial sphincter, male sling
• Sexual dysfunction: PDE-5 inhibitors help after nerve-sparing surgery; private discussion; sex therapist referral

F. Discharge Teaching (Chart 53-5)

• Hospital stay 1 to 2 days robotic, 3 to 5 days open; robotic patients return to usual activity in about 7 to 10 days
• Perineal exercises: tense buttocks together, hold, relax, 10 to 20 times each hour; interrupt stream mid-void; continue until full control. Void at first urge
• Dribbling should gradually diminish (usually within 1 year); urine may be cloudy for several weeks
• For 6 to 8 weeks avoid Valsalva (straining, heavy lifting), long car trips, strenuous exercise
• Spicy foods, alcohol, and coffee may irritate the bladder; drink enough fluid to avoid dehydration and clot formation
• Report: bleeding or clots, decreased stream or output, retention, UTI symptoms, fever, wound drainage change, calf tenderness

VIII. Disorders of the Testes and Adjacent Structures

A. Orchitis

• Most cases viral mumps; also gonorrhea, chlamydia, E. coli, Klebsiella, Pseudomonas, staph, strep; often extends from epididymitis
• Signs: fever, testicular pain and swelling, tenderness, penile discharge, hematospermia, leukocytosis
• Bacterial: antibiotics, treat partner if STI. Viral: rest, scrotal elevation, ice, analgesics, anti-inflammatories
• Mumps orchitis in about 30% of postpubertal males with mumps (4 to 6 days after parotitis); one third have irreversible loss of spermatogenesis; bilateral orchitis can cause sterility. Mumps vaccine for unimmunized men

B. Epididymitis

• Incidence less than 1 per 1000; peak age 19 to 35; bilateral in 5% to 10%
• Risks: recent urologic procedure, high-risk sex, STI history, prostate infection or UTI, uncircumcised, enlarged prostate, chronic indwelling catheter
• Organisms: E. coli in prepubertal, older, and gay men; C. trachomatis and N. gonorrhoeae in sexually active men 35 and younger. Infection ascends urethra to ejaculatory duct to vas to epididymis
• Develops over 1 to 2 days: low-grade fever, chills, heaviness, increasing tenderness, unilateral scrotal and groin pain, urethral discharge, pyuria, pain aggravated by bowel movement
• Acute testicular pain should never be ignored; distinguish from torsion
• Management: antibiotics (treat partner if STI); spermatic cord block if seen within 24 hours; avoid urethral instrumentation; watch for scrotal abscess. Chronic: 4 to 6 weeks of antibiotics; epididymectomy for refractory cases; bilateral obstruction can cause infertility
• Nursing: bed rest, scrotal elevation (scrotal bridge or folded towel), intermittent cold early, then heat or sitz baths; avoid straining, lifting, sexual stimulation; resolution may take 4 weeks or longer

C. Testicular Torsion

• Surgical emergency: rotation of testis twists spermatic cord vessels
• Sudden testicular pain over 1 to 2 hours, nausea, lightheadedness, scrotal swelling; elevated testis, thickened cord
• Surgery to untwist and anchor both testes within 6 hours of onset to save the testis

D. Testicular Cancer

• About 1% of male cancers but the most common cancer in men 15 to 35; second most common at 35 to 39
• 5-year survival more than 95% (about 99% if localized); early-stage cure more than 95%
• Risk factors: cryptorchidism (undescended testis), family history, personal history; White men about 5 times the risk of African American men; HIV-positive; possible occupational chemicals. Not linked to vasectomy or prenatal DES
• Types:
  • Germinal (about 90%): seminomas (slow growing, men in 30s and 40s, usually localized, radiation sensitive) and nonseminomas (more common, faster growing; choriocarcinoma, embryonal carcinoma, teratoma, yolk sac)
  • Nongerminal/stromal (less than 10%): Leydig cell and Sertoli cell
  • Secondary: lymphoma most common; poor prognosis
• Manifestations: painless enlargement of the testis or a lump (significant finding), scrotal or lower abdominal heaviness; metastasis causes backache (retroperitoneal nodes), abdominal pain, weight loss, weakness; spreads to retroperitoneal nodes and lungs
• Diagnosis: tumor markers AFP and beta-hCG (diagnosis, staging, response), LDH, chest x-ray, transscrotal ultrasound, abdominal/pelvic CT. Inguinal orchiectomy is the standard diagnostic step (biopsy avoided to prevent spread). Discuss sperm banking before orchiectomy
• Treatment: radical inguinal orchiectomy with high ligation of the cord (prosthesis offered); retroperitoneal lymph node dissection (ejaculatory dysfunction and infertility possible; libido and orgasm usually preserved)
  • Radiation works better for seminomas; other testis shielded
  • Cisplatin-based combination chemotherapy (etoposide, bleomycin, paclitaxel, ifosfamide, vinblastine)
  • Half of patients do not recover fertility after treatment
• Long-term effects: renal insufficiency, hearing loss, gonadal damage, peripheral neuropathy, secondary cancers; also cardiotoxicity, pulmonary toxicity, metabolic syndrome
• Nursing: body image and sexuality, follow-up adherence (recurrence most often within 2 years; most common site retroperitoneum), TSE on the remaining testis, healthy behaviors, birth control for 18 to 24 months after last chemotherapy

E. Testicular Self-Examination (Chart 53-6)

• Monthly, after a warm bath or shower (scrotum relaxed)
• Both hands; index and middle fingers under, thumb on top; roll gently; feel for lumps
• Locate epididymis (cordlike structure on top and back) and spermatic cord; repeat on other side
• One testis being larger is normal; report a pea-sized lump or swelling

F. Hydrocele

• Fluid between layers of tunica vaginalis; most common cause of scrotal swelling; 1 in 10 newborns (usually resolves in first year)
• Acute in adults over 40 with inflammation, infection, epididymitis, injury, mumps
• Painless, transilluminates (hernia does not); ultrasound to rule out tumor if large
• Treatment only if large, tense, uncomfortable, or compromising circulation: hydrocelectomy (ice first 24 hours, bulky dressing, scrotal support) or needle aspiration with sclerosing agent

G. Varicocele

• Dilated pampiniform plexus and internal spermatic vein; 15% to 20% of healthy men, 40% of infertile men; 95% left side (incompetent valves)
• Often asymptomatic; may cause heaviness, pain, infertility
• Mild without fertility concern: scrotal support. Surgery if distressing or fertility issue: ice for first few hours, dressing off after 48 hours, scrotal support

H. Vasectomy

• Outpatient interruption of both vas deferens; ejaculate volume drops only about 3% (fluid comes from seminal vesicles and prostate)
• No effect on potency, erection, ejaculation, or hormones; no STI protection
• Complications: ecchymosis, swelling, wound infection, vasitis, epididymitis, hematoma, chronic pain, spermatic granuloma (painless lump)
• Nursing: intermittent ice, snug cotton underwear or scrotal support, sitz baths; expected discoloration
• Resume sex after about 1 week; sterility usually after 10 to 20 ejaculations; use contraception until semen analysis confirms (usually 4 to 8 weeks)
• Vasovasostomy (reversal): 50% to 70% can impregnate; costly, not covered; should not be considered reversible
• Sperm banking: before vasectomy, chemotherapy, pelvic radiation, orchiectomy, or after SCI; rarely covered by insurance

IX. Disorders of the Penis

• Phimosis: foreskin cannot retract; poor hygiene leads to smegma, balanitis, adhesions, calculi, higher penile cancer risk; diabetes contributes. Treat with steroid cream; circumcision if needed
• Paraphimosis: retracted foreskin cannot return; tight ring causes venous congestion, edema, then arterial occlusion and necrosis. Manual reduction (compress glans 5 minutes, push glans back while pulling foreskin forward); incision if needed; circumcision after edema subsides
• Penile cancer: less than 1% of US male cancers; squamous cell is 95%; glans most often involved (48%). Risks: uncircumcised, poor hygiene, phimosis, HPV, smoking, UV treatment, age over 65
  • Presents as painless lump, ulcer, or wartlike growth, color change, late malodorous discharge; men often delay care more than a year
  • 5-year survival near 80% localized, 52% with node involvement, 18% beyond inguinal nodes
  • Treatment: organ-sparing preferred (excision, Mohs, laser, partial penectomy); total penectomy if necessary; topical 5-FU; radiation. Spread is to inguinal nodes; enlarged nodes are inflammatory in 50%, so treat with 4 to 6 weeks of antibiotics first
  • Prevention: HPV vaccine (Gardasil) for males 9 through 26; good genital hygiene (circumcision not recommended as prevention)
• Priapism: persistent, painful erection; causes include sickle cell disease, leukemia, polycythemia, spinal cord tumors/injury, antihypertensives, antipsychotics, antidepressants, penile injections, alcohol, cocaine
  • Ischemic (low flow): emergency; aspiration of corpora cavernosa or injection of phenylephrine; surgical shunt if ineffective
  • Nonischemic (high flow) and stuttering: usually not emergencies; ice and compression; stuttering may use self-injected phenylephrine
• Peyronie disease: fibrous plaques in corpus cavernosum sheath causing painful curvature with erection; onset 45 to 65; 50% resolve spontaneously; surgery for severe mature plaques
• Urethral stricture: narrowing from congenital, trauma, instrumentation, infection; spraying, postvoid dribbling; dilation or urethrotomy; antibiotics; success judged after 1 year
• Adult circumcision: for phimosis, paraphimosis, recurrent infection; petrolatum gauze dressing, observe for bleeding, analgesics

High-Yield Numbers

Priority Nursing Actions and Red Flags

• Acute urinary retention in BPH: catheterize immediately; difficult insertion goes to urologist (stylet, curved catheter, cystostomy)
• After TURP: bright red urine with clots and rising pulse, falling BP, restlessness, pallor means arterial hemorrhage; notify surgeon
• Irrigation in does not equal output, rounded suprapubic swelling, pain, or spasms: suspect obstructed catheter; check tubing, irrigate as ordered, bladder scan
• Confusion, headache, nausea, seizures, hypertension or hypotension after TURP: TUR syndrome (hyponatremia, fluid overload); stop irrigation, notify, diuretic, saline irrigation
• New-onset urinary incontinence in an older man requires evaluation
• No rectal temperatures, rectal tubes, or enemas after perineal prostatectomy
• Sudden severe testicular pain with elevated testis: torsion, surgical emergency (6-hour window)
• Painless testicular enlargement or lump: prompt evaluation for testicular cancer
• Ischemic priapism: emergency to prevent fibrosis and permanent ED
• Paraphimosis: risk of glans necrosis; reduce promptly
• Patient on nitrates asking about sildenafil, vardenafil, or tadalafil: contraindicated (severe hypotension)
• SCI at T6 or above undergoing ejaculation procedures: watch for autonomic dysreflexia
• Bone pain with prostate cancer: possible metastasis or pathologic fracture; firm mattress, fall precautions, scheduled analgesia

Medications

Related

• nsg210-hinkle-ch47-kidney-urinary-assessment
• nsg210-hinkle-ch48-kidney-disorders
• nsg210-hinkle-ch49-urinary-disorders (UTI, incontinence, bladder cancer)
• nsg210-hinkle-ch63-neurologic-trauma (autonomic dysreflexia in SCI)
• INDEX