59
Male Reproductive Problems
Anthony Lutz
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cellular Regulation Reproduction
Infection Sexuality
Pain
LEARNING OUTCOMES
1. Describe the pathophysiology, clinical manifestations, 5. Explain the clinical manifestations and interprofessional
and interprofessional and nursing management of benign care of testicular cancer.
prostatic hyperplasia. 6. Describe the pathophysiology, clinical manifestations, and
2. Describe the pathophysiology, clinical manifestations, and interprofessional and nursing management of problems
interprofessional care of prostate cancer. related to male sexual function.
3. Explain the nursing management of prostate cancer. 7. Discuss the psychologic and emotional implications related
4. Specify the pathophysiology, clinical manifestations, and to male reproductive problems.
interprofessional and nursing management of prostatitis
and problems of the penis and scrotum.
KEY TERMS
benign prostatic hyperplasia (BPH) prostatitis
epididymitis radical prostatectomy
erectile dysfunction (ED) testicular cancer
orchitis testicular torsion
paraphimosis transurethral resection of the prostate (TURP)
phimosis vasectomy
prostate cancer
This chapter discusses male reproductive system problems. urine from the bladder through the urethra. Half of men will
These involve a variety of structures, including the prostate, have some signs of BPH by the age of 50. That number increases
penis, urethra, testes, epididymis, and rectum (Fig. 59.1). Many to more than 70% for men 60 to 69 years old.1
of these problems can profoundly affect sexuality and reproduc-
tion. Sexual dysfunction from prostate problems or erectile dys- Etiology and Pathophysiology
function (ED) can cause psychologic and body image problems. There are several factors that may play a role in the development
The patient may have anxiety because of a perceived loss of his and progression of BPH. We think that hormonal changes associ-
sex role, self-esteem, or quality of sexual interaction with his ated with aging are a contributing factor. Dihydroxytestosterone
partner. Patient teaching and counseling are essential for pro- (DHT), one of several sex hormones, stimulates prostate cell
moting health and optimal sexual well-being. growth. Excess DHT can cause overgrowth of prostate tissue.
As men age, they continue to make and accumulate high levels
of DHT, resulting in prostate enlargement.
PROBLEMS OF THE PROSTATE GLAND Another possible cause of BPH is an increased proportion of
estrogen as compared with testosterone. Throughout their lives,
BENIGN PROSTATIC HYPERPLASIA men make testosterone and small amounts of estrogen. As men
Benign prostatic hyperplasia (BPH) is a condition in which age, the amount of testosterone they make decreases, leaving
the prostate gland increases in size, disrupting the outflow of a higher proportion of estrogen. A higher amount of estrogen
1434
, CHAPTER 59 Male Reproductive Problems 1435
Prostate Ejaculatory
Rectum gland duct
Urinary
bladder
Pubic
symphysis
Ductus
deferens
(vas deferens)
Urethra A B
Fig. 59.3 Views of the prostate by cystoscopy. (A) Normal appearance.
Penis (B) Moderate BPH with urethral obstruction. (From Townsend CM,
Epididymis
Beauchamp RD, Evers BM, et al.: Sabiston textbook of surgery, ed 19,
Testis Glans Philadelphia, 2012, Saunders.)
Scrotum
Fig. 59.1 Areas of the male reproductive system in which problems are symptoms may not cause many problems because the bladder
likely to develop. can compensate for a small amount of resistance to urine flow.
As the severity of urethral obstruction increases, symptoms
Bladder gradually worsen.
We place symptoms into 2 groups: irritative and obstruc-
Enlarged tive. Irritative symptoms include nocturia, urinary frequency,
prostate urgency, dysuria, bladder pain, and incontinence. These symp-
gland
toms are related to inflammation or infection. Nocturia is often
the first symptom that the patient notices. Obstructive symp-
Compressed
urethra
toms, caused by prostate enlargement, include a decrease in the
caliber and force of the urinary stream, difficulty in starting a
Rectum stream, intermittency (stopping and starting stream several
times while voiding), and dribbling at the end of urination.
These symptoms are due to the increased effort of the bladder as
it tries to empty through the decreased diameter of the urethra.
As a group, both irritative and obstructive symptoms are con-
sidered lower urinary tract symptoms (LUTS).
The American Urological Association (AUA) symptom
Fig. 59.2 BPH. The enlarged prostate compresses the urethra. index (AUA-SI) for BPH (Table 59.1) is a widely used tool to
assess voiding symptoms from obstruction.4 This tool is not
within the prostate gland increases the activity of substances diagnostic. It helps determine the extent of symptoms and guide
(including DHT) that promote prostate cell growth. treatment. Higher scores on this tool mean greater symptom
BPH usually develops in the inner part of the prostate, severity.
called the transition zone. As the transition zone of the prostate
enlarges, it gradually compresses the urethra, leading to partial or Complications
complete obstruction (Fig. 59.2). This compression of the urethra Some men may have acute urinary retention. They will have the
leads to the development of clinical manifestations. There is no sudden and painful inability to urinate. Treatment involves the
direct relationship between overall prostate size and the severity inserting a catheter to drain the bladder. Surgery may be needed
of manifestations or degree of obstruction.2 The location of the in severe situations. Bladder damage can occur if treatment is
enlargement is most significant in the development of obstructive delayed.
symptoms (Fig. 59.3). For example, it is possible for mild prostate Urinary tract infection (UTI) can be a complication of BPH.
enlargement to cause severe obstructive symptoms or for extreme Since the bladder is unable to empty completely, bacteria can
prostate enlargement to cause few obstructive symptoms. grow in the residual urine that remains in the bladder and cause
Risk factors for BPH include aging, obesity (especially infection. In more severe cases, infection can progress into the
increased waist circumference), lack of physical activity, a high kidney and cause pyelonephritis. In severe cases, infection can
intake of red meat and animal fat, alcohol use, ED, smoking, and spread into the bloodstream and sepsis can develop. Bladder
diabetes.3 A family history of BPH in a first-degree relative also calculi (stones) may develop because of the alkalinization of the
may be a risk factor. residual urine. So, the finding of bladder stones often indicates
obstruction related to BPH.
Clinical Manifestations Renal failure can occur due to hydronephrosis (distention of
Manifestations occur gradually. They may go unnoticed until the renal pelvis and calyces by urine that cannot flow through
prostate enlargement has been present for some time. Early the ureter to the bladder).
, 1436 SECTION 11 Problems Related to Regulatory and Reproductive Mechanisms
TABLE 59.1 AUA Symptom Index to Determine Severity of Prostatic Problems
AUA SYMPTOM SCOREa (CIRCLE 1 NUMBER ON EACH LINE)
Not At Less Than Less Than About Half More Than Almost
Questions All 1 Time in 5 Half the Time the Time Half the Time Always
Over the Past Month
1. How often do you have the sensation that your bladder is not 0 1 2 3 4 5
completely empty after you finish urinating?
2. How often do you have to urinate again, less than 2 hr after 0 1 2 3 4 5
you finish urinating?
3. How often do you stop and start again several times when you 0 1 2 3 4 5
urinate?
4. How often do you find it difficult to postpone urination? 0 1 2 3 4 5
5. How often do you have a weak urinary stream? 0 1 2 3 4 5
6. How often do you have to push or strain to begin urination? 0 1 2 3 4 5
7. How many times do you usually get up to urinate from the 0 (None) 1 (1 time) 2 (2 times) 3 (3 times) 4 (4 times) 5 (5 times
time you go to bed at night until the time you get up in the or more)
morning?
Sum of circled numbers (AUA Symptom Score): _____
aScoreis interpreted as follows: 0–7, mild; 8–19, moderate; 20–35, severe.
Source: Barry MJ, Fowler FJ, O’Leary MP, et al.: The AUA symptom index for benign prostatic hyperplasia, J Urol 148:1549, 1992. Used with
permission.
Diagnostic Studies pressure flow studies can help evaluate bladder function and
A detailed history and physical assessment are important. assess for obstruction.
Diagnostic studies are outlined in Table 59.2. A digital rectal
examination (DRE) is done to estimate the prostate size, sym- Interprofessional Care
metry, and consistency. In BPH, the prostate is symmetrically The goals of care are to (1) restore bladder drainage, (2) relieve
enlarged, firm, and smooth. symptoms, and (3) prevent or treat the complications of BPH.
A urinalysis (UA) and urine culture with sensitivities can Treatment is based on the degree to which the symptoms bother
detect bacteria, nitrites, leukocyte esterase, white blood cells the patient or the presence of complications rather than the size
(WBCs), or microscopic hematuria (RBCs), which could indi- of the prostate. Alternatives to surgery include surveillance,
cate infection or inflammation. drug therapy, and minimally invasive procedures.
A prostate-specific antigen (PSA) blood test can screen for The most conservative treatment is called active surveillance,
prostate cancer. Patients with BPH may have slightly increased or watchful waiting. When the patient has mild symptoms
PSA levels. PSA is released into the bloodstream by both benign (AUA symptom scores of 0 to 7), we usually take a wait-and-see
and malignant prostate cells. Serum creatinine levels can assess approach. Teaching patients to make lifestyle changes can help
for renal insufficiency. If creatinine levels are high, a renal ultra- relieve early or mild symptoms. Making diet changes (decreas-
sound may show hydronephrosis. Because symptoms of BPH ing intake of bladder irritants, like caffeine, alcohol, carbon-
and neurogenic bladder are similar, a neurologic examination ated drinks, artificial sweeteners, and spicy or acidic foods),
may be done. avoiding certain drugs (e.g., decongestants, anticholinergics),
In patients with an abnormal DRE and high PSA, a transrectal and restricting evening fluid intake may improve symptoms. A
ultrasound (TRUS) can be ordered as a stand-alone imaging test. timed voiding schedule (also called “bladder retraining”) may
We more often do a TRUS-guided prostate biopsy. An alternative reduce symptoms and eliminate the need for further treatment.
option is a pelvic MRI with attention to the prostate. If abnormal If the patient begins to have signs or symptoms that indicate an
areas are seen on MRI, these areas can be targeted on a TRUS increase in obstruction, further treatment is needed.
prostate biopsy (MRI-fusion targeted biopsy). Insurance cover-
age of pelvic MRI is sometimes an issue. Studies have shown that Drug Therapy
assessment with MRI prior to biopsy and MRI-targeted biopsy The 2 main classes of drugs to treat BPH include 5α-reductase
are better than standard TRUS biopsy in men at risk for prostate inhibitors and α-adrenergic receptor blockers. Combination
cancer.5 therapy using both types of drugs may be more effective in
Uroflowmetry (measures the volume of urine expelled from reducing symptoms than using 1 drug alone. An erectogenic
the bladder) is helpful to determine the extent of urethral block- drug can also be used to help treat BPH.
age and the treatment needed. Postvoid residual urine volume 5α-reductase inhibitors. 5α-Reductase inhibitors work
can determine the degree of urine flow obstruction. Cystoscopy by reducing the size of the prostate gland. They block the
is done if the diagnosis is unclear or to see the degree of prostatic 5α-reductase type 1 and 2 isoenzymes, which are necessary
enlargement. If the diagnostic picture is unclear, urodynamic/ for the conversion of testosterone to DHT (main intraprostatic
Male Reproductive Problems
Anthony Lutz
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cellular Regulation Reproduction
Infection Sexuality
Pain
LEARNING OUTCOMES
1. Describe the pathophysiology, clinical manifestations, 5. Explain the clinical manifestations and interprofessional
and interprofessional and nursing management of benign care of testicular cancer.
prostatic hyperplasia. 6. Describe the pathophysiology, clinical manifestations, and
2. Describe the pathophysiology, clinical manifestations, and interprofessional and nursing management of problems
interprofessional care of prostate cancer. related to male sexual function.
3. Explain the nursing management of prostate cancer. 7. Discuss the psychologic and emotional implications related
4. Specify the pathophysiology, clinical manifestations, and to male reproductive problems.
interprofessional and nursing management of prostatitis
and problems of the penis and scrotum.
KEY TERMS
benign prostatic hyperplasia (BPH) prostatitis
epididymitis radical prostatectomy
erectile dysfunction (ED) testicular cancer
orchitis testicular torsion
paraphimosis transurethral resection of the prostate (TURP)
phimosis vasectomy
prostate cancer
This chapter discusses male reproductive system problems. urine from the bladder through the urethra. Half of men will
These involve a variety of structures, including the prostate, have some signs of BPH by the age of 50. That number increases
penis, urethra, testes, epididymis, and rectum (Fig. 59.1). Many to more than 70% for men 60 to 69 years old.1
of these problems can profoundly affect sexuality and reproduc-
tion. Sexual dysfunction from prostate problems or erectile dys- Etiology and Pathophysiology
function (ED) can cause psychologic and body image problems. There are several factors that may play a role in the development
The patient may have anxiety because of a perceived loss of his and progression of BPH. We think that hormonal changes associ-
sex role, self-esteem, or quality of sexual interaction with his ated with aging are a contributing factor. Dihydroxytestosterone
partner. Patient teaching and counseling are essential for pro- (DHT), one of several sex hormones, stimulates prostate cell
moting health and optimal sexual well-being. growth. Excess DHT can cause overgrowth of prostate tissue.
As men age, they continue to make and accumulate high levels
of DHT, resulting in prostate enlargement.
PROBLEMS OF THE PROSTATE GLAND Another possible cause of BPH is an increased proportion of
estrogen as compared with testosterone. Throughout their lives,
BENIGN PROSTATIC HYPERPLASIA men make testosterone and small amounts of estrogen. As men
Benign prostatic hyperplasia (BPH) is a condition in which age, the amount of testosterone they make decreases, leaving
the prostate gland increases in size, disrupting the outflow of a higher proportion of estrogen. A higher amount of estrogen
1434
, CHAPTER 59 Male Reproductive Problems 1435
Prostate Ejaculatory
Rectum gland duct
Urinary
bladder
Pubic
symphysis
Ductus
deferens
(vas deferens)
Urethra A B
Fig. 59.3 Views of the prostate by cystoscopy. (A) Normal appearance.
Penis (B) Moderate BPH with urethral obstruction. (From Townsend CM,
Epididymis
Beauchamp RD, Evers BM, et al.: Sabiston textbook of surgery, ed 19,
Testis Glans Philadelphia, 2012, Saunders.)
Scrotum
Fig. 59.1 Areas of the male reproductive system in which problems are symptoms may not cause many problems because the bladder
likely to develop. can compensate for a small amount of resistance to urine flow.
As the severity of urethral obstruction increases, symptoms
Bladder gradually worsen.
We place symptoms into 2 groups: irritative and obstruc-
Enlarged tive. Irritative symptoms include nocturia, urinary frequency,
prostate urgency, dysuria, bladder pain, and incontinence. These symp-
gland
toms are related to inflammation or infection. Nocturia is often
the first symptom that the patient notices. Obstructive symp-
Compressed
urethra
toms, caused by prostate enlargement, include a decrease in the
caliber and force of the urinary stream, difficulty in starting a
Rectum stream, intermittency (stopping and starting stream several
times while voiding), and dribbling at the end of urination.
These symptoms are due to the increased effort of the bladder as
it tries to empty through the decreased diameter of the urethra.
As a group, both irritative and obstructive symptoms are con-
sidered lower urinary tract symptoms (LUTS).
The American Urological Association (AUA) symptom
Fig. 59.2 BPH. The enlarged prostate compresses the urethra. index (AUA-SI) for BPH (Table 59.1) is a widely used tool to
assess voiding symptoms from obstruction.4 This tool is not
within the prostate gland increases the activity of substances diagnostic. It helps determine the extent of symptoms and guide
(including DHT) that promote prostate cell growth. treatment. Higher scores on this tool mean greater symptom
BPH usually develops in the inner part of the prostate, severity.
called the transition zone. As the transition zone of the prostate
enlarges, it gradually compresses the urethra, leading to partial or Complications
complete obstruction (Fig. 59.2). This compression of the urethra Some men may have acute urinary retention. They will have the
leads to the development of clinical manifestations. There is no sudden and painful inability to urinate. Treatment involves the
direct relationship between overall prostate size and the severity inserting a catheter to drain the bladder. Surgery may be needed
of manifestations or degree of obstruction.2 The location of the in severe situations. Bladder damage can occur if treatment is
enlargement is most significant in the development of obstructive delayed.
symptoms (Fig. 59.3). For example, it is possible for mild prostate Urinary tract infection (UTI) can be a complication of BPH.
enlargement to cause severe obstructive symptoms or for extreme Since the bladder is unable to empty completely, bacteria can
prostate enlargement to cause few obstructive symptoms. grow in the residual urine that remains in the bladder and cause
Risk factors for BPH include aging, obesity (especially infection. In more severe cases, infection can progress into the
increased waist circumference), lack of physical activity, a high kidney and cause pyelonephritis. In severe cases, infection can
intake of red meat and animal fat, alcohol use, ED, smoking, and spread into the bloodstream and sepsis can develop. Bladder
diabetes.3 A family history of BPH in a first-degree relative also calculi (stones) may develop because of the alkalinization of the
may be a risk factor. residual urine. So, the finding of bladder stones often indicates
obstruction related to BPH.
Clinical Manifestations Renal failure can occur due to hydronephrosis (distention of
Manifestations occur gradually. They may go unnoticed until the renal pelvis and calyces by urine that cannot flow through
prostate enlargement has been present for some time. Early the ureter to the bladder).
, 1436 SECTION 11 Problems Related to Regulatory and Reproductive Mechanisms
TABLE 59.1 AUA Symptom Index to Determine Severity of Prostatic Problems
AUA SYMPTOM SCOREa (CIRCLE 1 NUMBER ON EACH LINE)
Not At Less Than Less Than About Half More Than Almost
Questions All 1 Time in 5 Half the Time the Time Half the Time Always
Over the Past Month
1. How often do you have the sensation that your bladder is not 0 1 2 3 4 5
completely empty after you finish urinating?
2. How often do you have to urinate again, less than 2 hr after 0 1 2 3 4 5
you finish urinating?
3. How often do you stop and start again several times when you 0 1 2 3 4 5
urinate?
4. How often do you find it difficult to postpone urination? 0 1 2 3 4 5
5. How often do you have a weak urinary stream? 0 1 2 3 4 5
6. How often do you have to push or strain to begin urination? 0 1 2 3 4 5
7. How many times do you usually get up to urinate from the 0 (None) 1 (1 time) 2 (2 times) 3 (3 times) 4 (4 times) 5 (5 times
time you go to bed at night until the time you get up in the or more)
morning?
Sum of circled numbers (AUA Symptom Score): _____
aScoreis interpreted as follows: 0–7, mild; 8–19, moderate; 20–35, severe.
Source: Barry MJ, Fowler FJ, O’Leary MP, et al.: The AUA symptom index for benign prostatic hyperplasia, J Urol 148:1549, 1992. Used with
permission.
Diagnostic Studies pressure flow studies can help evaluate bladder function and
A detailed history and physical assessment are important. assess for obstruction.
Diagnostic studies are outlined in Table 59.2. A digital rectal
examination (DRE) is done to estimate the prostate size, sym- Interprofessional Care
metry, and consistency. In BPH, the prostate is symmetrically The goals of care are to (1) restore bladder drainage, (2) relieve
enlarged, firm, and smooth. symptoms, and (3) prevent or treat the complications of BPH.
A urinalysis (UA) and urine culture with sensitivities can Treatment is based on the degree to which the symptoms bother
detect bacteria, nitrites, leukocyte esterase, white blood cells the patient or the presence of complications rather than the size
(WBCs), or microscopic hematuria (RBCs), which could indi- of the prostate. Alternatives to surgery include surveillance,
cate infection or inflammation. drug therapy, and minimally invasive procedures.
A prostate-specific antigen (PSA) blood test can screen for The most conservative treatment is called active surveillance,
prostate cancer. Patients with BPH may have slightly increased or watchful waiting. When the patient has mild symptoms
PSA levels. PSA is released into the bloodstream by both benign (AUA symptom scores of 0 to 7), we usually take a wait-and-see
and malignant prostate cells. Serum creatinine levels can assess approach. Teaching patients to make lifestyle changes can help
for renal insufficiency. If creatinine levels are high, a renal ultra- relieve early or mild symptoms. Making diet changes (decreas-
sound may show hydronephrosis. Because symptoms of BPH ing intake of bladder irritants, like caffeine, alcohol, carbon-
and neurogenic bladder are similar, a neurologic examination ated drinks, artificial sweeteners, and spicy or acidic foods),
may be done. avoiding certain drugs (e.g., decongestants, anticholinergics),
In patients with an abnormal DRE and high PSA, a transrectal and restricting evening fluid intake may improve symptoms. A
ultrasound (TRUS) can be ordered as a stand-alone imaging test. timed voiding schedule (also called “bladder retraining”) may
We more often do a TRUS-guided prostate biopsy. An alternative reduce symptoms and eliminate the need for further treatment.
option is a pelvic MRI with attention to the prostate. If abnormal If the patient begins to have signs or symptoms that indicate an
areas are seen on MRI, these areas can be targeted on a TRUS increase in obstruction, further treatment is needed.
prostate biopsy (MRI-fusion targeted biopsy). Insurance cover-
age of pelvic MRI is sometimes an issue. Studies have shown that Drug Therapy
assessment with MRI prior to biopsy and MRI-targeted biopsy The 2 main classes of drugs to treat BPH include 5α-reductase
are better than standard TRUS biopsy in men at risk for prostate inhibitors and α-adrenergic receptor blockers. Combination
cancer.5 therapy using both types of drugs may be more effective in
Uroflowmetry (measures the volume of urine expelled from reducing symptoms than using 1 drug alone. An erectogenic
the bladder) is helpful to determine the extent of urethral block- drug can also be used to help treat BPH.
age and the treatment needed. Postvoid residual urine volume 5α-reductase inhibitors. 5α-Reductase inhibitors work
can determine the degree of urine flow obstruction. Cystoscopy by reducing the size of the prostate gland. They block the
is done if the diagnosis is unclear or to see the degree of prostatic 5α-reductase type 1 and 2 isoenzymes, which are necessary
enlargement. If the diagnostic picture is unclear, urodynamic/ for the conversion of testosterone to DHT (main intraprostatic
