Male Repro - Med Surg

benign enlargement of the prostate gland

inner part of the prostate

no

endocrine changes associated with aging

1. excessive accumulation of dihydroxytestosterone (androgen)

2. decreased testosterone which leads to a greater proportion of estrogen to testosterone

location of the enlargement

• 1. family Hx
• 2. obesity- especially large waste
• 3. decreased physical activity
• 4. DM
• 5. age >50
• 6. smoking
• 7. drinking

1. increases fat & --> fat stores estrogen --> increased estrogen

2. acts as a diuretic --> dehydration

constricts smooth muscle (muscle in BVs & urinary system) -->issues with the urinary system & blood flow to the urinary system

urinary obstruction

altered urination pattern

obstructive s/s & irritative s/s

• 1. decreased size/force of urinary stream
• 2. hesitancy - difficulty initiating
• 3. intermittency - stopping & starting
• 4. dribbling at the end of urination

• 1. frequency
• 2. retention
• 3. urgency
• 4. dysuria
• 5. nocturia
• 6. incontinence - stress incontinence
• 7. bladder pain

• 1. WBC, bacteria, hematuria on UA
• 2. other s/s of UTI:  burning, fever, etc

• 1. acute urinary retention
• 2. UTI
• 3. pyelonephritis
• 4. sepsis
• 5. calculi
• 6. bladder damage r/t calculi or retention
• 7. renal failure r/t hydronephrosis -

• catheter insertion to drain the bladder -
• surgery may be required

incomplete bladder emptying --> residual urine --> favorable conditions for bacterial growth

urinary retention --> urine backs up into the kidneys --> distention of pelvis & calyces of the kidney

• 1. H & P
• 2. DRE - digital rectal exam
• 3. UA with C&S
• 4. PSA - prostate specific antigen
• 5. serum creatinine
• 6. postvoid residual
• 7. transrectal ultrasound - TRUS
• 8. uroflowmetry
• 9. cystoscopy
• 10. AUA symptom index

MD does it

prostate will be enlarged, firm, and symmetrical

may cause vagal response:  HR & BP drop --> may pass out or change cardiac rhythm

monitor & educate patient

0-4

prostate cancer

BPH & other prostate problems

if kidney had been effected

tests for urinary retention

usually done with a TRUS - transrectal ultrasound

gives accurate assessment of prostate size & differentiates BPH from prostate cancer

may do a biopsy during the ultrasound

measures volume of urine expelled from the bladder per second

watch the person pee using radiography

to show extent of urine flow obstruction/ urine retention

internal visualization of the urethra & bladder

a camera is put up through urethra & into the bladder

will be done if Dx is uncertain & in pt who are scheduled for prostatectomy

• 1. restore bladder drainage
• 2. relieve s/s
• 3. prevent or Tx complications of BPH

• 1. yearly DRE
• 2. adequate fluids
• 3. avoid alcohol, caffeine, & smoking
• 4. nutrition:  avoid irritating foods:  spicy, acidic, artificial sweeteners
• 5. weight mgmt/loss
• 6. s/s to report

• 1. v/s r/t vagal response
• 2. bleeding & irritation

• 1. hematuria
• 2. pain
• 3. v/s for hypovolemia r/t bleeding
• 4. make sure pt can pee

• 1. "watchful waiting" -
• 2. meds
• 3. transurethral microwave therapy
• 4. transurethral needle ablation
• 5. laser prostatectomy
• 6. intraprostatic urethral stents
• 7. transurethral resection of the prostate (TURP)

used when no-mild s/s

• 1. dietary changes:  decreasing caffeine & artificial sweeteners & limiting spicy/acidic
• 2. avoiding some meds:  decongestants & anticholinergics
• 3. restricting evening fluid intake
• 4. timed voiding scedule

• 1. 5 alpha-reductase inhibitors
• 2. alpha adrenergic receptor blockers

proscar & avodart

blocks enzyme(5 alpha-reductase) that is needed for conversion of testosterone to dihydroxytestosterone --> suppresses androgens --> causes prostate to reduce in size

moderate to severe s/s

• 1. takes about 6 mo to be effective
• 2. if used with ED meds may cause orthostatic hypotension
• 3. women of child-bearing age who may become pregnant or are pregnant should not handle tablets

• 1.decreased libido
• 2. decreased volume of ejaculate
• 3. ED

decreases PSA levels & lowers the risk of low-grade early-stage prostate cancer

• (zosins/osins)
• 1. silodosin/Rapaflo
• 2. alfuzosin/Uroxatral
• 3. doxazosin/Cardura
• 4. prazosin/Minipress
• 5. terazosin/Hytrin
• 6. tamsulosin/Flowmax

Tx s/s of BPH by promoting smooth muscle relaxation in the prostate --> facilitates urinary flow through the urethra (do not Tx hyperplasia just the s/s)

effective b/c there are many adrenergic receptros in the prostate that are increased when the prostate is enlarged

2 to 3 wks

• 1. orthostatic hypotension
• 2. dizziness
• 3. retrograde ejaculation
• 4. nasal congestion

ejaculate goes into the urinary bladder instead of out the urethra

herbal remedy

some ppl think it helps but it has no effect

• 1. transurethral microwave thermotherapy
• 2. transurethral needle ablation
• 3. laser prostatectomy
• 4. intraprostatic urethral stents

• do not require hospitalization or catheterization usually
• have few adverse effects

less effective than invasive procedures at improving urine flow

use of microwave radiating heat to produce coagulative necrosis tissue death) of the prostate

• 1. outpatient
• 2. ED & retrograde ejaculation are rare

• 1. potential for damage to surrounding tissue r/t heat
• 2. urinary catheer needed post-procedure
• 3. may need retreatment

transurethral probe is used to deliver microwaves to prostate while rectal temperature is taken during the procedure to be sure temperature is kept below 110 F to prevent rectal tissue damage

post-op urinary retention - pt will be sent home with indwelling catheter for 2 to 7 days to maintain urinary flow & facilitate passing of small clots or necrotic tissue

pt should stop anticoagulants 10 days before procedure

• 1. bladder spasm
• 2. hematuria
• 3. dysuria
• 4. retention

low-wave radiofrequency (electricity) used to heat the prostate & cause necrosis

(same as TUMT except use different method to heat the tissue)

• 1. outpatient
• 2. ED & retrograde ejaculation are rare
• 3. greater precision in removal of the target tissue
• 4. very little pain experienced

• 1. urinary retention is common
• 2. irritative voiding s/s
• 3. hamaturia
• 4. may need retreatment

local anesthesia & IV or oral sedation

30 minutes

very little pain with early return to regular activities

• 1. urinary retention
• 2. UTI
• 3. irritative voiding s/s
• 4. hematuria for up to a week

some pt requre urinary cath for a short period

procedure that uses a laser beam to cut or destroy part of the prostate

use visual or ultrasound guidance

through the urethra

• 1. cutting
• 2. coagulation
• 3. vaporization of prostatic tissue

• 1. visual laser ablation of prostate (VLAP)
• 2. contact laser technique
• 3. photovaporization of prostate (PVP)
• 4. interstitial laser coagulation (ILC)

• 1. short procedure
• 2. comparable results to TURP - very effective
• 3. minimal bleeding
• 4. rapid s/s improvement

• 1. catheter needed for up to 7 days after procedure r/t edema & urinary retention
• 2. delayed sloughing of tissue
• 3. takes severa weeks to reach optimal effect
• 4. retrograde ejaculation

laser beam produces deep coagulation necrosis of the prostate which gradually sloughs in the urinary stream

• 1. takes several weeks to reach full effect
• 2. need urinary catheter to allow for drainage post-op

direct contaxct of the laser to the prostate tissue with immediate vaporization of the prostate tissue

• 1. bleeding is rare b/c laser cauterizes blood vessels on contact
• 2. catheter is only needed for a short time post-op:  6 to 8 h
• 3. faster recovery time
• 4. may be done on a pt taking anticoagulants

uses high-power green laser light to vaprozie prostate tissue

• 1. bleeding is minimal
• 2. catheter only needed for 24 to 48 h post-op
• 3. effective with larger prostate glands

prostate viewed through a cytoscope & a laser is used to treat precise areas by placement of interstititial light guides directly into the prostate tissue

stents placed directly into the prostatic tissue

self-expandable metallic stent is inserted into the urethra where enlarged area of prostate occurs

• 1. chronic pain
• 2. infection
• 3. encrustation

tissue will continue to grow --> grows over stents

electrosurgical vaporization & desiccation are used together to destroy prostatic tissue

minimal risks

minimal bleeding & sloughing

retrograde ejaculation 

intermittent hematuria

safe & effective

low risk

• 1. stent may move
• 2. long-term effect is unknown

transurethral resection of the prostate (TURP)

transurethral incision of the prostate (TUIP)

resection or ablation- (removal of material from the surface of an object by vaporization, chipping, or other erosive processes)

• 1. decrease in urine flow sufficient to cause discomfort
• 2. persistent residual urine
• 3. acute urinary retention
• 4. hydronephrosis

intermittent or indwelling catheterization

risk for infection in catheterization

TURP- transurethral resection of the prostate

removal of prostate tissue using a resectoscope inserted through the urethra

• 1. pt will be under spinal or general anesthesia
• 2. resectoscope inserted through urethra to excise & cauterize obstructing prostatic tissue
• 3. lg 3-way indwelling cath with a 30-mL balloon is inserted
• 4. bladder is irrigated continuously or intermittently for 1st 24h approx.

no - through urethra

• 1. bleeding
• 2. clot retention
• 3. hypo or hypervolemia r/t irrigation
• 4. dilusional hyponatremia r/t irrigation

• 1. discontinue aspirin or warfarin several days before surgery
• 2. sexual functioning may be affected by surgery
• 3. Ejaculate may be decreased or absent r/t retrograde ejaculation
• 4. retrograde ejaculation is not harmful:  semen is eliminated during the next urination

• 1. urinary drainage must be restored before surgery
• 2. ABX (prophylactic or if have UTI)
• 3. Find out about pt sexual activities r/t sexual function affected by surgery
• 4. Educate
• 5. dietary:  NPO
• 6. make sure consents are signed
• 7. labs:  CBC, CMP, creatinine/BUN, clotting function, platelets, UA with C&S

catheter is inserted:  may require a coude (curved tip) catheter or urologist may insert a filiform catheter (rigid enough to pass the obstruction)

2% lidocaine gel is injected into the urethra before insertion

• 1. lubrication
• 2. local anesthesia
• 3. opens urethral lumen

• 1. ABX
• 2. restoring urinary drainage
• 3. encouraging a high fluid intake of 2 to 3 L/day if not contraindicated

• 1. some degree of retrograde ejaculation
• 2. decreased orgasmic sensations

• 1. bladder irrigated intermittently/manually or via continuous bladder irrigation (CBI) with steril NS
• 2. monitor inflow & outflow of catheter
• 3. Catheter care
• 4. Monitor for hemorrhage, bladder spasms, urinary incontinence, infection, & DVT
• 5. Meds:  Tx bladder spasms, ABX
• 6. monitor VS for hypo/hypervolemia s/s
• 7. Teach pt to practice Kegel exercises 10 to 20 times per hour while awake
• 8. diet (high fiber) & stool softeners to prevent straining
• 9. prevent increased abd pressure:  straining, sitting or walking for prolonged periods, sneezing, coughing, etc

instill 50mL NS then withdraw with a syringe to remove clots

may cause painful bladder spasms

the appearance of the drainage

light pink without clots  (blood clots are expected for the first 24 to 36 hours)

3-way 18 to 22 french foley catheter with a 30mL bulb that is used to drain & irrigate the bladder

• large balloon provides hemostasis at the surgery site & irrigating facilitates urinary drainage by preventing obstruction from mucus & blood/blood clots

about 24 h

check the catheter patency for kinks or clots

must stop CBI (cont irrigation) & call the MD

cannot replace the catheter!

• 1. aseptic technique to prevent infection
• 2. prevent urethral irritaion & minimize risk of bladder infection by securing the catheter to the leg
• 3. connect to a closed-drainage system & do not diconnect unless it is being removed, changed, or irrigated
• 4. cleanse secretions around meatus with soap & water daily

check the catheter for clots & remove by irrigation

• 1. s/s of hypovolemia
• 2. lg amnts of bright red blood in the urine

• 1. displacement of catheter
• 2. dislodging a lg clot
• 3. increases in abd pressure

may apply traction on the catheter to provide counterpressure (tamponade) to the bleeding site

local necrosis can occur if pressure is applied for too long

pressure is relieved on a sceduled basis

teach pt not to urinate around the catheter because it increases likelihood of spasms

• 1. make sure urine is flowing freely from catheter
• 2. meds: belladonna & opium suppositories or other antispasmotics (oxybutynin/Ditropan)
• 3. relaxation techniques

2 to 4 days after surgery

within 6 hours

reinsert a catheter for a day or 2 - if problem continues will instruct pt in clean intermittent self-catheterization

sphincter tone is decreased by the surgery

• 1. 10-20 kegel exercises per hour while awake
• 2. practice starting & stopping the stream several times during urination
• 3. use a penile clamp, condom catheter, or incontinence pads/briefs
• 4. may implant an occlusive cuff that acts as an artificial sphincter

may take several weeks or may never be regained

can improve for up to 12 months

• 1. increased risk for infection r/t proximity of anus
• 2. rectal procedures should be avoided:  temp, enemas
• 3. insertion of well-lubricated belladonna & opium suppositories is acceptable

• 1. caring for indwelling catheter if still in place
• 2. managing urinary incontinence
• 3. maintaining oral fluids b/t 2-3L per day
• 4. observing for s/s of UTI & wound infections
• 5. preventing constipation
• 6. avoiding lifting heavy objects (>10lb)
• 7. refraining from driving or intercourse after surgery
• 8. continue to have yearly DRE unless complete prostate removal has been performed

trauma to the internal urethral sphincter

• 1. semen is decreased or absent
• 2. urine is cloudy when urinating after orgasm

nerves may be cut/damaged during surgery

anxiety may occur r/t change in sex role, self-esteem, & quality of sexual interaction with his partner

up to 1 year

takes up to 2 months

• 1. drink at least 2L fluid per day
• 2. avoid bladder irritants:  caffeine, citrus juices, alcohol, artificial sweeteners

urethral strictures

teaching intermittent clean self-cath or having a urethral dilation

excess absorption of irrigation fluid --> FVE

• 1. altered LOC/confusion
• 2. agitation
• 3. decreased HR
• 4. increased RR & BP
• 5. vomiting
• 6.  HA
• 7.  tremors

report to MD immediately

surgical procedure done under local anesthesia that is done for men with small prostates & moderate to severe symptoms that are not a condidate for TURP

is as effective as TURP

• 1. suprapubic
• 2. retropubic
• 3. perineal

• androgen-dependent
• adenocarcinoma

slow growing

• 1. direct extension
• 2. lymph system
• 3. bloodstream

• seminal vesicles (secrete seminal fluid)
• urethral mucosa
• bladder wall
• external sphincter

will later spread through lymph system

• 1. bones: pelvic, head of femur, & lower lumbar spine
• 2. liver
• 3. lungs

• 1. age: rise after age 50 then again after age 65
• 2. ethnicity:  higher in african americans:  more agressive tumors with higher mortality
• 3. family Hx
• 4. diet:  high in red meat & high-fat dairy & low in veggies & fruits

proscar

• 1. may be asymptomatic in early stages
• 2. will progress to s/s similar to BPH
• 3. pain in lumbosacral area that readiates down to hips or legs indicates metastasis to bones

pain

bone cancer causes severe pain especially in the back & legs r/t compression of the SC & destruction of bone

age 50 to age 75 (after age 75 there is little benefit to screening/Tx)

annual DRE & PSA

• 1. DRE:  hard, nodular, & asymmetric
• 2. PSA:  elevated
• 3. prostatic acid phosphatase (PAP):  elevated r/t bone metastasis
• 4. if DRE or PSA are abnormal -> do PAP & if that is elevated -> will do biopsy for definitive DX
• 5. CT, bone scan, & MRI to see location & extent of spread
• 6. TRUS

radiography (MRI & CT) to test for metastasis

• 1. aging
• 2. BPH
• 3. recent ejaculation
• 4. chronic prostatitis
• 5. long bike rides
• 6. prostate cancer - will be higher than others usually

proscar or avodart

PSA level:  should fall if Tx is successful

can also monitor for return of CA

use TRUS to visualize prostate & find abnormalities --> biopsy needle inserted into prostate

using an endorectal probe

• 1. Whitmore-Jewett
• 2. TNM

• Stage A:  clinically unrecognized
• * A1:  <5% of prostatic tissue neoplastic
• *A2:  >5% of prostatic tissue neoplastic
• Stage B:  clinically intracapsular
• B1:  nodule <2cm & surrounded by palpably normal tissue
• B2:  nodule >2cm or multiple nodules
• Stage C:  clinically extracapsular
• C1:  minimal extracapsualr extension
• C2:  large tumors involving seminal vesicles, adjacent structures, or both
• Stage D:  metastatic disease
• D1:  pelvic lymph node metastases
• D2:  distant metastases to bone, viscera, or other soft tissue structures

graded on basis of tumor histology using the Gleason scale that grades from 1 to 5 based on degree of glandular differentiation - the 2 most commonly occurring patterns of cells are graded & grades are added together to get Gleason score of 2-10

grade 1 is most well-differentiated

to predict how quickly cancer will progress

BPH develops on the inside of the prostate & prostate cancer develops on the outside

• 1. "watchful waiting"
• 2. surgery
• 3. radiation & chemo
• 4. drug therapy

1. life expectancy <10 years = low risk of dying of the cancer

2. presence of a low-grade, low-stage tumor:  monitor progress with DRE & PSA

• 1. watchful waiting with annual PSA & DRE
• 2. radical prostatectomy
• 3. radiation therapy :  external beam & brachytherapy

• 1. radical prostatectomy
• 2. radiation therapy

• 1. radical prostatectomy
• 2. radiation therapy
• 3. hormone therapy
• 4. orchiectomy

• 1. hormone therapy
• 2. orchiectomy
• 3. chemotherapy
• 4. radiation therapy to metastatic bone areas

entire prostate gland, seminal vesicles, & part of the bladder neck(ampulla) are removed with lymph node dissection usually done as a separate procedure

stage D

• 1. retropubic
• 2. perineal
• 3. laparoscopic

• 1. radical prostatectomy
• 2. cryotherapy
• 3. orchiectomy
• 4. nerve-sparing procedure

low midline abd incision made --> access prostate gland & disect pelvic lymph nodes

incision made b/t scrotum & anus - cannot remove lymph nodes

4 small incisions made in abd & surgeon uses computer & cameras

• 1. less bleeding
• 2. less pain
• 3. faster recovery

• similar to TURP care:
• 1. will have same catheter as with TURP
• 2. monitor for infection, bleeding, hypovolemia, DVT, & PE
• 3. monitor incision site
• 4. ABX

drains are left in surgical site & usually removed after a couple of days

increased risk for infection r/t proximity to anus

careful dressing changes & perineal care after each BM

1 to 3 days depending on type of surgery

• 1. ED
• 2. urinary incontinence
• 3. infection complications:  hemorrhage, DVT/PE, infection
• 4. wound dehiscence
• 5. urinary retention

• 1. pt age
• 2. preoperative sexual functioning
• 3. whether nerve-sparing surgery was performed
• 4. expertise of the surgeon

returns gradually over at least 24 months or more

may give meds like viagra

prostate removed while preserving neurovascular bundles that maintain erectile function that are in close proximity to the prostate

CI for pt with cancer outside of the prostate gland

if the pt is younger than 50 & has low-stage prostate cancer return of potency is expected but not guaranteed

surgical technique - destroys cancer cells by freezing the tissue

• 1. transrectal ultrasound probe is inserted to visualize the prostate
• 2. probes containing liquid nitrogen are inserted into prostate & freeze the prostate --> destroys the tissue

takes about 2 h under general or spinal anesthesia

no abd incision is made

surgical removal of testes

used for stage D advanced prostate cancer for cancer control & rapid relief of bone pain

may also shrink the prostate

• loss of testosterone:  altered physical appearance
• 1. weight gain
• 2. loss of muscle mass

can affect SE & lead to grief & depression

• has more AE than other surgeries
• 1. damage to the urethra
• 2. urethrorectal fistula (opening b/t urethra & rectum)
• 3. urethrocutaneous fistula (b/t urethra & skin)
• 4. tissue sloughing
• 5. ED/nerve damage
• 6. urinary incontinence
• 7. prostatitis
• 8. hemorrhage

external beam radiation- applied to skin

brachytherapy- place radioactive seed implants into the cancerous area (prostate gland)

few minutes of outpatient Tx for 5 days/week X 4 to 8 wks

immediately to years


burns skin wherever it is used

• 1. skin:  dryness, irritation, redness, pain
• 2. GI:  diarrhea, abd cramping, bleeding
• 3. GU:  dysuria, frequency, hesitancy, urgency, nocturia
• 4. sexual functioning:  ED
• 5. fatigue
• 6. bone marrow suppression:  decreased RBC, WBC, & platelets

withing 2 to 3 weeks after completion of therapy

as effective as prostatectomy in localized prostte cancer

depending on the implant the pt may have minimal radiation precautions or more:

• 1. limit time spent with pt
• 2. tell pt why you have to limit time with them to decrease anxiety
• 3. use shielding & must wear film badge that indicates cumulative radiation exposure
• 4. urine contains radiation

can deliver higher doses of radiation directly to tissue while sparing surrounding tissue

radioactive seeds placed in prostate gland via a needle through a grid template guided by TRUS

one-time outpatient procedure

more convenient than external beam & does't affect adjacent tissues

A or B

development of urinary irritative or obstructive problems

ED

hormones, chemotherapy

prostate cancer is largely depndent on presence of androgens - androgen deprivation therapy (ADT) is used

resistance to ADT therapy that occurs withing a few years of therapy

elevated PSA levels?

1. LHRH agonist & 2. LHRH antagonsists

admin SQ or IM injections & must take indefinitely  - Viadur is an implant placed SQ for 1 year

• 1. drugs that interfere with androgen production:  LHRH agonists (orchiectomy has same effect)
• 2. androgen receptor blockers

leuprolide, goserelin, triptorelin, buserelin

reduce secretion of LH & FSH --> decreases testosterone production

(LH & FSH are reduced by increasing LHRH release until down-regulation of LHRH receptors occurs at the pituitary)

increase in LH, FSH, & testosterone - called a "flare"

• 1. hot flashes
• 2. gynecomastia
• 3. decreased libido
• 4. ED
• 5. depression & mood chages

degarelix & abarelix

advanced prostate cancer

SQ injection

blocks LH receptors --> immediate testosterone suppression

• 1. pain, swelling, redness at injection site
• 2. elevated liver enzymes

• 1. bicalutamide
• 2. flutamide
• 3. nilutamide

block action of testosterone by competing at receptor sites

admin po daily

similar to LHRH agonists

diethylstibuestrol (DES)

• 1. inhibits LH secretion
• 2. decreases testosterone production
• 3. blocks circulating testosterone

• 1. breast enlargement
• 2. CV complications:  MI, DVT, cerebrovascular disease

unlikely to be compliant with hormone therapy r/t side effects

used in hormone refractory prostate cancer in late-stage disease usually for palliation

hormone refractory (HRPC) - progresses despite Tx with hormones

docetaxel combined with prednisone, estramustine, or mitoxantrone

• 1. N
• 2. alopecia
• 3. reduced L ventricular ejection
• 4. bone marrow suppression

provenge - given in advance prostate cancer

stimulates pt system against the cancer

• 1. monitor catheter drainage for increased blood or clots
• 2. increase flow of irrigating solution to maintain light pink color in outflow
• 3. admin antispasmodics & analgesics prn

• 1. clean around catheter daily
• 2. record I & O

• 1. decisional conflict r/t alternatives in Tx options
• 2. acute pain
• 3. urinary retention
• 4. impaired urinary elimination
• 5. constipation or diarrhea r/t Tx
• 6. sexual dysfunction
• 7. anxiety

45 years old

• 1. catheter care:  clean meatus daily with soap & water;  keep bag below bladder; anchored to inner thigh or abd
• 2. adequate fluid intake
• 3. s/s of bladder infection - report bladder spasms, fever, or hematuria
• 4. kegel exercises at every urination & throughout the day

• 1. fatigue
• 2. bladder outlet obstruction
• 3. ureteral obstruction
• 4. severe  bone pain & fractures
• 5. spinal cord compression
• 6. leg edema:  lymphedema, DVT, etc

painful downward curve o the penis during erection

pain mgmt

book pg 1392 - group of inflammatory & noninflammatory conditions affecting the prostate gland

Mrs. Wake:  inflammation of the prostate

• 1. acute bacterial prostatitis
• 2. chronic bacterial prostatitis
• 3. chronic prostatitis/chronic pelvic pain syndrome
• 4. asymptomatic inflammatory prostatitis

organisms reaches prostate gland by these routes:

• 1. ascends from urethra
• 2. descends from bladder
• 3. via bloodstream or lymph

chronic involves recurring episodes of infection

syndrome of prostate & urinary pain in the absence of an obvious infectious process


may occur after having a virus or with STI's

culture shows no causative organisms

may have leukocytes in prostatic secretions

pt has no s/s but has inflammatory process in the prostate:  leukocytes are present in seminal fluid but cause is unclear

• 1. flu-like s/s: fever, chills, back pain
• 2. perineal pain
• 3. acute urinary s/s:  similar to BPH s/s
• 4. cloudy urine
• 5. acute urinary retention r/t prostate swelling
• 6. DRE:  swollen, very tender, & firm

• 1. epididymitis & cystitis
• 2. sexual functioning affected:  postejaculation pain, libido probs, & ED
• 3. prostatic abscess (uncommon)

• similar s/s to acute bacterial prostatitis but milder - obstructive s/s are uncommon
• DRE:  enlarged, firm, & slightly tender

recurrent UTIs

UTI - but acute cystitis is not common in men

• 1. UA with C&S:  usually has WBC & bacteria
• 2. blood:  WBC & cultures for infection
• 3. PSA to rule out prostate cancer:  may be elevated r/t prostatitis
• 4. microscopic eval & culture of expressed prostate secretion
• 5. transabdominal ultrasound or MRI to rule out an abscess on the prostate

use pre-massage & post-massage test:  void into a specimen cup just before & just after prostate is massaged

when there is an acute bacterial prostatitis b/c it is very painful and cause spread of infection

• 1. ABX
• 2. pain mgmt:  antiinflammatory meds, opioids
• 3. physical therapy
• 4. warm baths
• 5. alpha-adrenergic blockers to relax muscles
• 6. bladder drainage with suprapubid catheter if urinary retention develops
• 7. repetitive prostatic massage (except acute bacterial)
• 8. ejaculation to drain prostate
• 9. adequate fluids to prevent UTI & prevent dehydration r/t fever & infection

• 1. bactrim
• 2. cipro
• 3. floxin
• 4. doxycycline
• 5. tetracycline (doxycycline & tetracycline given if pt has mult. sex partners)

Acute:  po for up to 4 weeks OR if high fever etc. will be hospitalized with IV ABX

Chronic:  po for 4 to 12 weeks - may have lifetime therapy if pt is immunocompromised

when the infection is treated

tamsulosin/Flomax & alfuzosin/Uroxatral

catheterization through an inflamed urethra in acute prostatitis is contraindicated

adequate fluid intake

• urethral meatus on ventral/underside of the penis
• b/t glans & scrotum

not unless associated with chordee or if it prevents intercourse or normal urination

may also be done for cosmetic reasons

complex birth defect usually associated with other genitourinary tract defects:  urethral meatus on dorsal/top of penis

corrective surgery will be done to place the urethra in a normal position - usually in early childhood

• 1. phimosis
• 2. paraphimosis
• 3. cancer of the penis

foreskin becomes tight around the head of the penis -> retraction becomes difficult

edema or inflammation of the foreskin usually r/t poor hygiene that allows bacterial & yeast organisms to become trapped under the foreskin

can also be caused by external beam radiation r/t tissue damage & adhesions

unable to pull forskin back from a retracted position

may occur if forskin is pulled back (when bathing, inserting catheter, or intercourse) & not placed back in the forward position

• 1. ABX
• 2. warm soaks
• 3. circumcision or dorsal slit may be needed

careful cleaning & replacement of forskin over glans

ulcer can develop if the foreskin remains contracted

painful erection lasting longer than 5 h

• obstruction of the venous outflow in the penis: 
• 1. thrombosis of the corpora cavernasal veins
• 2. leukemia
• 3. sickle cell anemia
• 4. DM
• 5. degernative lesions of the spine
• 6. neoplasms of the brain or spinal cord
• 7. vasoactive meds injecting into the corpora cavernosa & meds

• 1. sildenafil
• 2. cocaine
• 3. trazodone
• others

• 1. sedatives
• 2. injection of smooth muscle relaxants into penis
• 3. aspiration & irrigation of corpora cavernosa with a lg-bore needle
• 4. surgical creation of a shunt to drain

• 1. penile tissue necrosis r/t lack of blood flow
• 2. hydronephrosis from bladder distention
• 3. after episode of priapism pt may be unable to achieve normal erection

curved or crooked penis caused by plaque formation in one of the corpora cavernosa of the penis (plaque prevents adequate blood flow into the spongy tissue --> curvature)

palpable, nontender, hard plaque usually found on posterior surface of penis

• 1. usually r/t trauma to penil shaft
• 2. can occur spontaneously

• 1. painful erections
• 2. ED
• 3. embarrassment

surgery may be needed

• 1. HPV
• 2. uncircumcized

may appear as a superficial ulceration or pimple-like nodule (could be mistaken for venereal wart)

well-differentiated squamous cell carcinomas

• 1. surgery:laser removal of the growth (early stages); radical resection of penis (if cancer has spread)
• 2. radiation
• 3. chemo

• 1. fungal infections
• 2. dermatitis
• 3. parasitic infections:  scabies, lice

acute, painful inflammatory process

• 1. infection (STI or other)
• 2. trauma
• 3. urinary reflux down the vas deferens

sexual transmission of gonorrhea or chlamydial infection

use of ABX in both partners

• 1. no sex during acute phase
• 2. use a condom if have sex
• 3. bed rest with elevation of the scrotum:  ambulation puts scrotum in dependent position & increases pain
• 4. ice packs
• 5. analgesics

tenderness usually within 1 week but swelling may last for weeks or months

acute inflammation of the testis

1. testis is painful, tender, & swollen

generally occurs after bacterial or viral infection: mumps, pneumonia, tuberculosis, or syphilis

may also occur as an AE of epididymitis, prostatectomy, trauma, infectious mononucleosis, influenza, catheterization, or complicated UTI

can cause infertility

childhood vaccination against mumps

• 1. ABX - if organism known
• 2. same Tx with epididymitis:  bed rest, elevate scrotum, ice packs, pain meds

congenital prob:  undescended testes bilaterally or unilaterally

• 1. infertility if not surgically corrected by age 2
• 2. increased risk for testicular cancer if not corrected before puberty

surgery is done to locate & suture testis or testes to the scrotum

nontender, fluid-filled mass r/t interfenrence with lymphatic dranage of the scrotum & swelling of the tunica vaginalis that surrounds the testis

transillumination - can see mass by shining a flashlight through the scrotum

no Tx needed unless swelling very lg & uncomfortable - will aspirate or surgically drain

firm, sperm-containing, painless cyst of the epididymis that may be visible with transillumination

unknown  cause

surgical removal

important for pt to see MD if he feels any scrotal lumps b/c they are indistinguishable from cancer

dilation of the veins that drain the testes

scrotum feels wormlike when palpated - usually located on left side of scrotum r/t retrograde blood flow from the left renal vein

cause unknown

surgery if pt is infertile

• 1. injection of a sclerosing agent
• 2. surgical ligation of the spermatic vein

twisting of spermatic cord that supplies blood to the testes & epididymis - ***EMERGENCY***

20

• 1. severe scrotal pain, tenderness, & swelling
• 2. pain does not usually subside with rest
• 3. NV
• 4. cremasteric reflex is absent

no urinary s/s, fever, or WBC/ bacteria in the urine

light stroking of inner thign in downward direction causes contraction of the cremaster muscle that pulls up the scrotum & testis on the side stroked

nuclear scan of the testes or dopplar ultrasound to assess blood flow - decreased or absent blood flow confirms the Dx

unless resolves spontaneously must have surgery to untwist the cord immediately to restore BF

if blood supply is not restored within 4 to 5 h ischemia to testis will occur -> necrosis & possible need for testicular removal & infertility

15 to 34

• 1. age 15 to 34
• 2. white
• 3. cryptorchidism
• 4. family Hx
• 5. orchitis
• 6. HIV
• 7 maternal exposure to DES
• 8. testicular cancer in the other testicle

seminoma & nonseminomas

most common & least aggressive

rare but very aggressive

Leydig cell & Sertoli cell tumors

• 1. slow or rapid onset depending on type of tumor
• 2. painless lump in scrotum
• 3.. scrotal swelling & feeling of heaviness
• 4. dull ache or heavy sensation in lower abd, perianal area, or scrotum
• 5. acute pain may be initial s/s

• 1. back pain
• 2. cough
• 3. hemptysis
• 4. dyspnea
• 5. dysphagia
• 6. alterations in vision or mental status
• 7. papilledema (swelling of optic disc caused by increased intracranial pressure)
• 8. seizures

• 1. palpation of scrotal contents
• 2. ultrasound
• 3. blood/CBC: tested for tumor markers, anemia, & liver function
• 4. CXR
• 5. CT scan of abd & pelvis to detect metastasis

firm, does not transilluminate (differentiates it from other masses)

• 1. alpha-fetoprotein AFP
• 2. lactate dehydrogenase LDH
• 3. human chorionic gonadotropin hCG

• 1. surgery:  orchiectomy or radical orchiectomy
• 2. retroperitoneal lymph node dissection & removal may also be done

surveillance, radiation therapy, or chemo

retroperitoneal lymph nodes

Mostly relate to toxicity from Tx:  infertility & ejaculatory dysfunction

need careful follow-up & regular phys exams, CXR, CT scans, & hCG/AFP levels to detect relapse and secondary malignancies r/t chem or radiation

testicular self-exam starting at puberty done every month

should perform frequently at first until familiar with the procedure

• 1. Use both hands to feel each testis.  Roll b/t thumb & first 3 fingers covering entire surface.  Palpate each one separately.
• 2. ID the structures:  testes, epididymis, & spermatic cord

testes feel round & smooth like a hard-boiled egg - differentiate from epididymis b/c it is not as smooth; locate spermatic cord:  usually firm & smooth & gos up toward the groin

3. Check for lumps, irregularities, pain, or a dragging sensation

during a shower or bath b/c testes hang lower in scrotum

should choose a consistent day of the month that is easy to remember

this is normal

infertility or impaired fertility

may be caused by chemo with cisplatin and/or pelvic irradiation

spermatogenesis can return, but should suggest pt cryopreserve sperm before Tx

bilateral surgical ligation or resection of the vas deferens performed for purpose of sterilization

considered permanent

15 to 30 minutes

local anesthesia

outpatient

• 1. permanent
• 2. need alternative contraception until semen exam revels no sperm:  usually requires at least 10 ejaculations or 6 wks for no sperm
• 3. sperm cells are still produced but are absorbed by the body

• 1. post-op hematoma & swelling of scrotum can occur
• 2. psychological:  ED or more sexually active r/t feeling castrated

Discuss procedure & outcome with pt & determine pt attitude toward it

inability to attain or maintain an erect penis that allows satisfactory sexual performance

• 1. increasing age
• 2. substance abuse (usually in younger men)
• 3. medical conditions
• 4. physical inactivity
• 5. anything that decreases blood flow

• 1. most common cause is vascular disease
• 2. DM
• 3. AE from meds or surgery
• 4. trauma:  spinal cord injuries, etc
• 5. chroniic illness
• 6. decreased gonadal hormone secretion
• 7. stress
• 8. relationship probs
• 9. depression

cardiovascular disease.

physiologic

psychological

• 1. distress & altered self-concept
• 2. anger
• 3. depression

• 1. H&P:  focus on secondary sex char
• 2. questionnaries
• 3. DRE
• 4. BP & palpation of femoral arteries & peripheral pulses
• 5. serum glucose & lipid profile to rule out DM
• 6. hormone levels:  for testosterone, prolactin, LH, & thyroid
• 7. blood chemistries:  PSA, CBC
• 8. nocturnal penile tumescence & rigidity testing
• 9. vascular studies:  penile areteriography, blood flow study & duplex dopploer ultrasound studies to assess penile blood flow

nocturnal penile tumescence & rigidtiy testing

noninvasive method - continuous measurement of penile circumference & axial rigidity during sleep

no

• 1. both partners are involved
• 2. realistic expectations of the Tx

if ED is reversible

• 1. HRT if hypogonadism is prob
• 2. counseling for psych probs
• 3. oral drug therapy
• 4. devices & implants
• 5. sexual counceling before & after Tx:  recommended for man and partner

• 1. viagra
• 2. cialis
• 3. levitra

smooth muscle relaxation & increased blood flow into the corpus cavernosum

should be taken orally about 1h prior to sex no more than once per day

• 1. HA
• 2. dyspepsia
• 3. flushing
• 4. nasal congestion
• Rare:
• 5. blurred or blue-green visual disturbances
• 6. sudden hearing loss

nitrates:  nitroglycerin

potentiates hypotensive effects of nitrates

suction devices applied to flaccid penis -> produce erection by pulling blood up into corporeal bodies

penile ring or constrictive band placed around base of penis to retain venous blood

vasoactive drugs admin onto or into penis that enhance lood flow into the penile arteries

• 1. topically as a gel
• 2. injection into penis
• 3. pellet inserted into the urethra using a MUSE device

• 1. papaverine - topical gel
• 2. caverject - topical gel, transurethral pellet, or injection
• 3. vasomax

implants of semirigid or inflatable penile prostheses - highly invasive with potential complications

• 1. mechanical failure
• 2. infection
• 3. erosions

• 1. reassure pt that confidentiality will be maintained
• 2. counseling & therapy
• 3. be caring & provide them with answers (will be highly motivated & expect immediate solutions)

gradual decline in androgen secretion that occurs in most men as they age - can start as early as age 40

• 1. loss of libido
• 2. fatigue
• 3. ED

• 1. osteoprosis
• 2. decreased muscle mass & strength

• 1. H&P
• 2. serum total testosterone - normal = 280 to 1100

testosterone replacement therapy

when testosterone is <250

• 1. lowered HDL
• 2. increased Hct
• 3. worsening sleep apnea

pt with BPH or prostate cancer

will have DRE & PSA before TRT begins

• 1. IM injection (depo-testosterone & delatest)
• 2. transdermal:  patches & gels:  androderm, testim

create a cyclic rise & fall in serum teststerone levels -> mood swings with these flutuations

skin irritation

may apply triamcinolone cream (amcort, kenalog) to skin before application of the patch to decrease irritation

inability to achieve conception X 1 year of frequent unprotected intercourse

• 1. disorders of hypothalamic-pituitary system
• 2. disorders of the testes
• 3. abnormalities of the ejaculatory system

pretesticular, testicular, & post-testicular

testicular

endocrine causes - 3% of cases

• varicocele (most common cause)
• 2. infection
• 3. congential anomalies
• 4. meds
• 5. radiation
• 6. substance abuse
• 7. environmental hazards

• 1. mumps
• 2. STDs
• 3. bacterial infections

• 1. obstruction
• 2. infection
• 3. result of surgical procedure

• starting point is Hx:
• 1. age
• 2. occupation
• 3. past injury, surgery, or infections to the genital tract
• 4. lifestyle
• 5. sexual practices
• 6. frequency of intercourse
• 7. emotional factors:  stress & desire for children
• 8. use of drugs

• 1. hot tubs
• 2. weight training
• 3. wearing tight undergarments

• 1. chemo drugs
• 2. anabolic steroids - testosterone
• 3. sulfasalazine/Azulfidine
• 4. cimetidine/Tagamet
• 5. recreational drugs:  can reduce sperm count

semen analysis:  sperm concentration, motility, and morphology

• 1. plasma testosterone
• 2. serum LH & FSH
• 3. test for sperm penetration abilities

• 1. be concerned & tactful
• 2. be sensitive to gender identity
• 3. refer to marriage counceling prn (can strain marriage)

• 1. meds
• 2. lifestyle changes:  avoid scrotal heat, substance abuse, & high stress
• 3. in vitro fertilization
• 4. corrective surgery