med surg #2 men.docx

**Ch. 53 Male Reproductive Process pg. 4616** Gerontologic Considerations - Prostate gland enlarges, Scrotum and testes changes, Sexual function decreases - Increased risk of GU cancer, Urinary incontinence Health History - General health history, Chronic illness or disability - **...

**Ch. 53 Male Reproductive Process pg. 4616** Gerontologic Considerations - Prostate gland enlarges, Scrotum and testes changes, Sexual function decreases - Increased risk of GU cancer, Urinary incontinence Health History - General health history, Chronic illness or disability - **KNOW Medications**: **beta blockers (antihypertensive), psychotropic (SSRI, MAOIs, TCAs)**, statins (anticholesterolemic medications) - These medications affect urinary and sexual functions - Enlarged prostate can cause men to double void or triple void to completely empty the bladder - Begin with urinary function and symptoms, Sexual activity - Extended history depends on symptoms - PLISSIT: permission, limited information, specific suggestions, intensive therapy - BETTER: Bring up the topic, explaining, telling, timing, educate, recording Physical Assessment - Digital rectal exam of prostate - **Start at 50 yr** (45 if family history) - Figure 53-2, pg 4624 - Tenderness, nodules, boggy, Position - Testicular/scrotum Exam - Palpated for nodules, masses or inflammation; penis is also evaluated - Examined for abnormalities such as hydrocele, inguinal hernia, tumor - Positions: side lying, standing/facing the bed & bending over, or lithotomy Diagnostic Evaluation - **KNOW Prostate Specific Antigen Test (PSA): protein produced by the prostate gland** - **Normal PSA is \< 4.0 ng/mL and any values \> 4 are considered elevated in men 60 years of age or younger** - **Could see elevated BPH levels in acute urinary retention, acute prostatitis, and recent ejaculation** - **Varies with age, race, and prostate volume** - It is a sensitive but NOT specific test for prostate cancer - **Prostate fluid or tissue analysis** - Obtained through prostatectomy or during TRUS - **KNOW 6-12 biopsies from all 4 prostate zones may be obtained during a TRUS-guided biopsy, making it a very infection prone procedure** - Ultrasonography (TRUS) - Lubricated, condom covered, rectal probe transducer - Non palpable/stage localized - Sexual Function Test - Nocturnal penile tumescence: assess REM sleep and erection ratio **Erectile Dysfunction** - Decreased frequency of erections, inability to achieve a firm erection, or rapid detumescence - During sexual stimulation Nitric oxide → corpus cavernosum → cyclic guanosine monophosphate → smooth muscle relaxation → blood flows into corpus cavernosum - **KNOW Causes of Erectile dysfunction** - **Psychogenic** - Anxiety, fatigue, depression - Pressure to perform - Absence of desire - Negative body issues - Relationship issues - **Organic** - **Meds Chart 53-1,** p. 4628 (, lecture) - **The main one that cause ED are Beta blockers and Statins** - CVD, Endocrine (uncontrolled diabetes and hypothyroidism), Cirrhosis, Chronic renal failure, Leukemia, Neuro disorders, and ETOH and SMOKING - **Which medication can cause erectile dysfunction? (not in our notes, but in book)** - Carbidopa/Levodopa (parkinson's disease) - **What medication can cause ED?** - Clonidine (alpha agonist/antihypertensive) - Assessment and Medical Management - Sexual and Medical history - Figure 53-3 p. 4651 - Problem identified - Medical, surgical or both - Treat underlying issue - Psychogenic cause (may need therapist) - Therapy: Pharmacology \[sildenafil\], Penile implants, Vacuum constriction devices (table 53-2 p. 4639) - Pharmacology - **Phosphodiesterase-5 (PDE-5) inhibitors** \[Vasodilator\] - **KNOW Sildenafil**, **tadalafil,** vardenafil (Table 53-3 p. 4651) - **A/E of sildenafil:** Nasal congestion - Administration: 1 hour before sexual activity; **duration is 4-6/1-2 hours???** - **Side Effects: flushing, dyspepsia,** diarrhea, nasal congestion, lightheadedness, dyspepsia, HA - **KNOW Don't take with organic nitrates \[isosorbide mononitrate or nitroglycerin\] bc will cause severe hypotension** - Injectable vasoactive medications: alprostadil (injectable) - Urethral suppository - Alternative Methods - - - **Prostatitis** - Inflammation of the prostate gland that is often associated with lower urinary tract symptoms and symptoms of sexual discomfort and dysfunction - Most common urologic diagnosis in those \< 50 yrs old; 3rd most common in those \> 50 yrs old - Cause - Infectious agents: bacteria, fungus, mycoplasma **KNOW (E-Coli)** - Other bacteria: Klebsiella and Proteus - Other: urethra stricture, BPH - Types - Acute bacterial prostatitis (type 1) - Chronic bacterial prostatitis (type 2) - Chronic prostatitis/pelvic pain syndrome (type 3) **(most common)** - Asymptomatic inflammatory prostatitis (type 4) - **KNOW Risk Factors:** Prior hx, Recurrent UTI, Recent catheter use, Enlarged prostate, Rectal intercourse, Dehydration, STD (not in book) - **Clinical Manifestations** - **KNOW s/s: Sudden onset of fever, [dysuria \[MCC\], perineal prostatic pain], and severe lower urinary tract s/s including frequency, urgency, hesitancy, and nocturia** - Type II: asymptomatic b/t episodes - Type III: no bacteria in urine but GU pain - Type IV: incidental dx during other male reproductive workup - **KNOW Nursing Management: Self-Care** - **Sitz baths, Encourage PO fluids** - **Avoid periods of long sitting** - **Reduce or eliminate chocolate, tea, alcohol, cola, and spices b/c it increases prostatic secretions** - **Avoid foods or beverages with diuretic qualities** - Avoid sex or masturbation during acute phase - Possible suprapubic catheter if severe - Medical management: - **KNOW Abx: Trimethoprim-sulfamethoxazole (Bactrim) OR ciprofloxacin** - **Cipro is 14-30 days (lecture)** - Specific tx depends on c/s - In-patient if they have unstable VS, sepsis, or unrelieved pelvic pain - Afebrile & a normal UA = tamsulosin \[relaxes prostate muscle\] and anti-inflammatory agent will be used **Benign Prostatic Hyperplasia (BPH) (NOT MALIGNANT)** - **Most common problem: impedes urine flow** - Most often times associated with older age (lecture) - Cause: DHT (dihydrotestosterone) and estrogen (not on exam) - **Develops over a longer period of time (lecture)** - **KNOW Risk Factors** - **Smoking, heavy ETOH**, obesity, reduced activity level, HTN, heart disease, DM, and **western diet** (high in animal fat and protein and low in fiber) - **Clinical manifestations \[also s/s urinary retention\]** - **Increased urinary frequency, urge, nocturia, hesitancy, dribbling** - **Incomplete bladder empty, Decrease in volume and force of stream** - **Urinary retention, Recurrent UTIs, post void residual** - **Azotemia (accumulation of waste products in the blood)** - Complete blockage of urine flow - Assessment - **DX: Post void residual** - Medical Management + Pharmacology (pg. 4646) - Alpha adrenergic blockers: alfuzosin, **KNOW terazosin, doxazosin (used most commonly)** - **A/E**: **postural hypotension,** dizzy, H/A, fatigue, sexual dysfunction - MOA: relaxes smooth muscle - 5-alpha-reductase inhibitors: **finasteride and dutasteride (Advodart)** - **KNOW Finasteride is best used in combination w/ doxazosin to decrease prostate size** - A/E: decreased libido, erectile dysfunction, gynecomastia and flushing - MOA: prevent the conversion of testosterone and decreases prostate size - Saw palmetto and African plum - Surgical Resection **(just know that there are lots of surgeries that can be done)** - Transurethral microwave heat treatment (reduces size of prostate) - Transurethral needle ablation (thin needles placed into the prostate) - Transurtheral incision of the prostate - Open prostatectomy - **KNOW Transurethral resection (TURP):** endoscopy inserted into urethra and the inner part of prostate removed **Prostate Cancer (2nd most common cause of cancer death in men)** - **KNOW Risk factors:** African Americans, increased incidence after the age of 50, diet high in red meat and high fat diet - Clinical Manifestations - **1st sign is urinary obstruction** - Difficulty and frequency, Retention, Hematuria, Painful ejaculation, Sexual dysfunction - Spread to lymph nodes and bones (this is the biggest issue) - Assessment and Diagnosis - Digital rectal exam (DRE), elevated PSA, and TRUS with biopsy - Nodule or hardening in the posterior lobe - **KNOW DX confirmation: tissue biopsy removed by TURP, can make the patient at a greater risk for infection** - Other dx tests: bone scans, MRI, pelvic CT - **KNOW Cancer can metastasize to the bones and this is why we do bone scans and skeletal x-rays. We do MRIs to look for metastasis to the lymph nodes** - **Gleason Score (just know there are two scores; architectural and predominant)** - 1-5 for the most predominant **architectural pattern** of the gland - 1-5 for the secondary most **predominant pattern** - Scores added together to grade/stage cancer - Higher score = worse - Medical management - Based off of patient's life expectancy, symptoms, risk of recurrence, size, Gleason score, PSA level, complications and patient preference - **Nonsurgical: watchful waiting** - Surgical - **Radical Prostatectomy (1st line)** - Disease has to be confined to prostate with no node involvement - Removal prostate, seminal vesicles, the tips of the vas deferens, surrounding fat, nerves, and blood vessels - ED common after - **KNOW Complications: Sexual dysfunction, possible urinary dysfunction** - **Laparoscopic radical prostatectomy** - Robotic-assisted laparoscopic radical prostatectomy - **Brachytherapy (internal)** - Internal implantation of interstitial radioactive seeds under anesthesia - **KNOW Avoid contact with pregnant women and infants for 2 months due to radiation** - Strain urine/condom - S/E inflammation of rectum, bladder, bowels, diarrhea - Pharmacology: Androgen deprivation therapy (ADT) ("hormone therapy") - Luteinizing hormone releasing hormone (LHRH) - **Leuprolide (Lupron)**, goserelin (Zoladex) - Antiandrogen receptor antagonists - Flutamide (Eulexin), bicalutamide (Casodex) - Adrenal ablating drugs - Ketoconazole (Nizoral) - MOA: inhibits androgen production - **Chemotherapy of choice: Docetaxel** - A/E: Flushing, Decreased libido and bone density, Anemia, fatigue, decreased muscle mass, Gynecomastia and mastodynia - Other therapies: - Cryosurgery, multiple TURPs, bone lesions (pain meds, prednisone, bisphosphonates, blood transfusions), and complementary/alternative medicines **Prostate Surgery** - **KNOW Transurethral Resection of the Prostate (TURP)** - **The prostate gland is removed in small portions with an electrical cutting loop** - **A/E → retrograde ejaculation (occurs when the semen enters the bladder instead out through the penis during ejaculation)** - **KNOW Transurethral Resection Syndrome (chart 53-4, pg. 4673): absorption of excessive irrigation fluid due to TURP procedures** - Electrolyte imbalances: Hyponatremia - **KNOW Stop irrigation, give diuretics, hang NS, Monitor I&O, VS, LOC** - Suprapubic, Perineal, Retropubic Prostatectomy - TUIP, Pelvic Lymph Node Dissection - Complications - Hemorrhage, clots, catheter obstruction, sexual dysfunction - **KNOW Continuous Bladder Irrigation for post prostate surgery** - Used after prostate surgery to help prevent blood clot formation to ensure the bladder stays clear of any blockages - Need CBI → urine expected to be a little bloody at first, but not for a long time - If there is bright red drainage after an hour → call surgeon - Nursing Care → Postoperative - Acute pain r/t surgical incision, catheter, bladder spasms - **KNOW Flavoxate (Urispas) and oxybutynin (Ditropan) for bladder spasms** - Deficient knowledge - A patient post-TURP is constipated. Which treatment is contraindicated? - Milk of molasses enema (not in book) **Testicular Cancer** - **KNOW Most common cancer men 15-35 yo** - Risk Factors: - **Caucasian, Undescended testicle**, family hx of testicular cancer - **KNOW Occupational Hazards such as mining, oil, gas, and leather processing** - Clinical Manifestations - Appear gradually - **Mass or lump, Heavy scrotum, inguinal area or lower abdomen** - **Backache, abdominal pain, Weight loss, General weakness** - **KNOW painless enlargement of the testes** - Assessment and Diagnostic - No screening for testicular cancer recommended - **TSE should be performed monthly, usually easily detected (chart 53-6 p. 4690)** - **KNOW Tumor markers: used for staging, and monitoring the response to tx** - **Alpha-fetoprotein (AFP)** - **Beta Human chorionic gonadotropin (HcG)** - Medical management - **Surgical removal of affected testis, retroperitoneal lymph node dissection to rule out lymphatic spread** - Remove affected testis: Can have an implant - Discuss fertility issues - Chemotherapy: seminomas, nonseminomas and advanced metastatic disease→ cisplatin + etoposide (Toposar), bleomycin (Blenoxane), paclitaxel (Taxol) - Late ADRs rom treatment → Renal insufficiency from kidney damage, hearing problems, peripheral neuropathy **Vasectomy** - Male sterilization, Vas Deferens resection (cut or burned) - No effect on sexual potency, erection or ejaculation - **What education is needed post Vasectomy?** - No change in sex function or amount of ejaculate - **Very little change in ejaculation after vasectomy** - **Complications** → Bruising and swelling, infection, hematomas, pain - Nursing Management - Teach swelling management, Snug cotton underwear for support - Sexual intercourse: after one week BUT most often still fertile - **KNOW 10-20 ejaculations to reach full sterility** - **KNOW Get sample → need to use contraception until negative sample (could take several weeks to get a ZERO sperm level)**