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Chapter 46 Male Reproductive System Cont


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Benign Postatic Hypertrophy "BPH"
*enlargement of prostate gland
*common age related change
*exact cause is unknow, but possibly related to hormone levels, diet, chronic inflammation, heredity and race.
*classification: obstructive or irritative
*s/s obstructive: decrease in size/force of urine stream, urine retention, post void dribbling
*s/s irritative:urgency, frequency, dysuria, nocturia, hematuria, and urge incontinence
*early s/s: nocturia, urgency and frequency
*late s/s: hematuria and chronic UTI's
Diagnostic Procedures for BPH
*rectal exam and PSA (2 most common)
* cystoscopy (light scope is passed through urethra and bladder to view prostatic urethra)
*radiographs, endoscopy and ultrasounds
Treatment of BPH
*testosterone-ablating agents, testosterone-sparing agents and alpha adrenergic-receptor blocking agents
*sex, hot sitz bath, prostatic massage all stimulate release of prostatic fluid and decrease symptoms
*antibiotics (for bacterial prostatitis)
*surgery: transurethral rescetion, superpubic postatectomy, retropubic prostatectomy, perineal prostatectomy, radical prostatectomy, bryoablation and transurethral laser treatment
Transurethral Resection
There is no external incision
Superpubic Prostatectomy
Through the bladder with a lower abdominal incision
Retropubic Postatectomy
Lower abdominal incision with out cutting the bladder
Perinal Prostatectomy
incision is between the scrotum and the anus
Radical Postatectomy
*removal of prostate gland, outer capsule, seminal vesicles, section of vas deferens and sometimes a portion of the bladder neck
*used for Bph only and not for prostate cancer
*freezing of prostate tissue
*used mainly as treatment for prostate cancer
*associated with significant incidence of post operative complications including necrosis
Transurethral Laser Treatment
*used only for treatment of BPH not prostate cancer
*post op patient may have foley catheter or super pubic catheter placed and may undergo bladder irrigation
Complications of BPH
*risk for UTi, incontinence, erectile dysfunction, hemorrhage, urinary leakage, inflammation of the pubic bone, retrograde ejaculation (semen enters the bladder instead of being injected through the urethra and then later voided with uring)
**teach pt retrograde ejaculation is not harmful but can result in sterility
Nursing Care of Patient with BPH
*have patient give complete description of urinary symptoms including frequency, urgency, hesitancy and changes in stream size/force and nocturia
*note patient pain or hematuria
*palpate lower abdomen to detect bladder distention before and or after urination
*instruct pt to void when urge is felt
*space fluid intake through out day
*do not restrick fluid as long as patient is able to void
*avoid, alchol and antihistamines
*if patient is unalbe to void and bladder becomes distended notify physician
*catheritization is ordered, but be sure not to force tube if resistance is felt or if patient c/o pain
Assessment of patient with prostatectomy
*vital signs
*assess pain level
*take mental note of what patient looks like and what patient feels like
*assess/record amount of blood and if clots are present in urine
*note color of urine
*strick I/O
*inspect dressing for any drainage or excess bleeding
Nursing Interventions for Prostatectomy
*acute pain:assess for clots, kinks, and possibility of bladder spasams (ditropan and pro-banthine are drugs of choice for bladder spasams)
*risk for infection:strict aseptic technigques.
*monitor:closed drainage system is intact and closed. provide wound care following strict physician order. monitor temperature, wound drainage and site of wound for any sign of infection.
*watch for fluid volume deficit:restlessness and increased heart rate
*measures to control bleeding:surgical interventions, pressure to prostate area (done by physician only)
*inspect tubing:for free drainage, if not draining resposition tube or irrigate if this does not correct problem notify physician.
*incontinence/dribbling:common problemafter catheter is removed. Teach patient to preform perineal exercises 10-20 times per day.
*counseling for sexual dysfunction may be required for low self esteem
Patient Teaching Post-prostatectomy
*retrograde ejaculation is not harmful
*s/s to report:inability to void, bladder distention, renewed bleeding, fever, cloudy or foul smelling urine
*encourage walking, no heavy lifing (over 10-20 lbs) for 4-6 weeks post op.
*diet high in fiber and stool softeners to prevent staining
*wash hands and keep drainage system closed
*no driving or sex until cleared by physician usually 6 weeks.
Impotence-Erectile Dysfunction
*inability to produce and maintain erection required for sex
Note* an adequae erection requires intact neurologic capability to initiate the rection process, vigorous and unimpeded inflow of blood to fill the copus cavernosa and a leak proof storage mechanism for maintaining the erection.
Possible causes of Impotence
*vascular disorders: ateriosclerosis (hardening of an artery due to injury) narrows artery and may decrease blood flow through narrowed area, most often caused by cross bar on bycicle, horse back riding, or blows. Atherosclerosis (hardening or stiffening of arterial wall due to systemic insult) caused by high cholesterol levels, smoking, excessive alchol consumption illicit drugs and inadequate exercise.
*endocrine disorder: DM due to atherosclerosis
*neurologic disorder: spinal cord injury (the more complete the injury the more likely it is for the ability for erection to be affected. Higher injuries cause more paralysis and loss of sensation.
*medication side effects: antihypertensives, digoxin, cimetidne, anticholinergic, antihistamines all may block neurotransmitters that cause relaxation of the smooth muscle
Treatment for erectile dysfunction
*viagra: failure to fill or store
*alprostadil (caverject):vasodilator given by intracavernosal injection or suppositories
*papaverine:for failure to initiate, fill or store
*testosterone:for low hormone levels that cause decreased desire and failure to initiate
*vacuum constriction device: failure to initiate, fill or store draws blood into the penis.
*revasculaarization:for patients with bloced arteries
*implant: for patient with failure to initiate, fill store (these patients are not candidates for revascularization)
2 types of implants: semirigid implants and hydraulic implants
Peyronie's Disease
*hard, nonelastic, fibrous tissue (plaque) under the skin of the penis of men 45-70
*plaque is a result of injury that caused inflammation and sacrring of the tunica surrounding corpora cavernose
*plaque located on dorsal midline surface of penis resulting in and upward bend. this can be painful during erection and interfere with successful vaginal penetration.
Treatment for Peyronie's Disease
*topical or oral vitamin E, oral aminobenzoic acid, tamoxifen, colchicine
*choice of treatment depends on sixe of plaque/curvature and degree of dysfunction.
*prolonged penile erection, not a result of sexual desire
*causes: injury, sickle cell crisis, neoplasms of brain or spinal cord
*drugs responsible: phenothiazine, alpha-adrenergic blockers, anticoagulants, alcohol, cocaine, marijuana, intracavernosal injections
Complications of Priapism
*decreased blood flow to penis
*obstruction of urine flow, causing hydronephrosis
*failure to resolve with in 12-24 hours can result in ischemia, gangrene, fibrosis, and erectile dysfunction
Treatment of Priapism
*d/c use of offending drug and correct neurologicor coagulation problem
*immediate removal of blood by aspirating from erectile chamber
*if the above efforts fail surgery is needed.
*inflammation of foreskin, associated with poor hygiene this causes edema that prevents retraction of foreskin
*treatment:antimicrobials and proper cleaning or circumcision
described as couples who have had unprotected sex for 12 months or more and have not been able to conveive
Causes of Infertility
*infection, cryptochidism, testicular torsion, varicocele and vasectomy
*genitourinary infections (STD'S) such as Chlamydia trachomatis and gonorrhoea
Cryptorchidism, Infertility causes and Treatment
*possibley genetics
*abdominal cavity is warmer than scrotum, damage to seminiferous epithelium of undescended testes resulting in decreases spermatogenesis
*treatment: done within the 1st 18 months of life. This is for the best chance of fertility
Testicular Torsion
*unilaterally: testicles lacks blood supply due to twistin of the spermatic cord
*this is an acure surgical emergency that requires release of torsion or testicle
*most common happens in adolescents for no apparent reason
*s/s intense pain with n/v
*lengthening or enlargement of scrotal portion of venous system that drains testicle blood supply
*causes: incompetent or absent valves in spermatic venous system, that allow blood to pool and increase hydrostatic pressure to dilate veins
*the Left testicle is most commonly affected but can also happen in right
*the affected testicl is smaller in size and has decreased spermatogenesis
*large varicoceles are visible through the skin and appear bluish in color
*treatment: scrotal support and ligation (when fertility is affected)
*surgical removal of a portion of vas deference
*this is an out patient procedure
*post op pain and swelling are managed with ice, analgesics and scrotal support
*patient can resume sex as soon as he is feeling better but must use alternate forms of birth control until semen is found to be clear of sperm this usually occurs after 15 ejaculations
*Nursing care: be sensitive to patient's fears and anxiety about having proceudre done
*acceptance and reassurance to patient are important
Penile Cancer
*rare condition, but is exclusive to uncircumsized men who have chronic irritation and poor hygiene
*appears as dry wart like, painless growths on the penis that does not respond to therapy
*treatment: extensive resection/amputation of near by lymph nodes
*risk factors: multiple sex partners, STD'S, long term tobacco use
Testicular Cancer
*germcell carcinoma most often occurs in me b/t ages of 18-34
*risk factors: cryptorchidism, race (caucasion), previous testicular cancer
*patient usually presents with hard painless tumor
*early detection is important have patient report signs of lumps, swelling, tenderness, leisions , asymmetry, discolorization or discharge
*exam scrotum when it is warm usually after a hot shower or bath
*testicles should feel firm, not hard, smooth with no lumps
Dianosis and Treatment for Testicular Cancer
*usually confirmed by removing affected testis (orchiectomy) and submitting it for biopsy
*supported by increased tumor marker levels and findings on testicular ultrasound
*treatment is according to type of cancer: radiotherapy or chemotherapy
Nursing Interventions for patient with Testicular Cancer
*help patient with anxiety r/t self-image and esteem, be sensitive
*treat pain promptly
*monitor for impaired elimination
*possible side effects: shock, infection, bowel/bladder dysfunction, and fluid imbalance
*encourage walking, high fiber and adequate fluid
*counseling for self esteem issues might be necessary
*teaching is essential to provide patient with tools needed to cope with diagnosis
Prostatic Cancer
*exact causes are unknown but thought to be caused by: genetics, chemicals, viruses, gonorrhea, high fat diet, late puberty, frequent sex, multiple sex partners and increased fertility
*Race, african americans are at a higher risk
*lesions typically are slow growing and confined to prostatic capsule
*young men who are affected usually have very agressive tumors
*undetected until advanced and metastized to bone or liver
*rectal exam and PSA are recommended for all me <40
*diagnosis is based on: rectal exam, transrectal ultrasound, serum tumor markers, lab screenings, radiographs, radinuclide imiaging, and needle aspiration and biopsy
Treatment for patient with Prostate Cancer
*radical prostatectomy and hormone therapy
*hormone therapy includes:
**estrogenan luteninizing hormone
**lupron and zoladex
**eulexin and megace (inhibit testosterone)
**aldactone and cytadren (decrease testosterone production)

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