Chapter 43: Disorders of the Male Reproductive System

While teaching a health class to junior and senior male high school students, the school nurse educates them that the first sign of testicular cancer is: A. one testicle lower than the other in the scrotal sac. B. enlargement of the testicle. C. back pain. D. coughing bloody sputum.

Answer: B Rationale: Often the first sign of testicular cancer is a slight enlargement of the testicle that may be accompanied by some degree of discomfort. Back pain and hemoptysis are last signs leading to a metastatic lesion. It is normal for one testicle to hang lower than the other.

Two nursing students are debating the merits and demerits of infant circumcision. Which statement is most accurate? A. "Circumcised men tend to have a lower incidence of penile cancer." B. "Getting circumcised basically rules out the possibility of getting Peyronie disease later in life." C. "Circumcision reduces pressure on the deep dorsal vein and the dorsal artery, making erection easier later in life." D. "The odds of getting infant priapism fall with circumcision."

Answer: A Rationale: A correlation between circumcision and lower incidence of penile cancer has been noted. Circumcision is unlikely to affect the development of Peyronie disease or priapism, and is not noted to influence the ease of attaining or maintaining erection.

Of the following list of medications, which would likely be prescribed to a client with benign prostatic hyperplasia (BPH) as a way to decrease the prostate size by blocking the effects of androgens on the prostate? A. Finasteride, a 5-alpha-reductase inhibitor B. Isosorbide mononitrate, a vasodilator C. Birth control pills containing both estrogen and progestin D. Leuprolide, a gonadotropin-releasing hormone analog

Answer: A Rationale: Finasteride, a 5-alpha-reductase inhibitor, reduces prostate size by blocking the effect of androgens on the prostate. Vasodilators, BCPs, and GnRH analogs do not decrease prostate size.

The nurse must insert an indwelling urinary catheter in an uncircumcised male client. What action should the nurse take to prevent paraphimosis? A. Replace the foreskin over the glans after catheter is is in place. B. Retract the foreskin and perform hygiene every shift while catheter is in place. C. Apply generous amounts of lubricant into the meatus prior to catheterizing. D. Use the smallest catheter size possible.

Answer: A Rationale: In paraphimosis, the foreskin becomes constricted at the base of the glans and can restrict blood supply to the glans, which could lead to ischemia and necrosis. This can result from the foreskin being retracted for an extended period, as in the case of catheterized uncircumcised males; therefore, the nurse should replace the foreskin after catheterizing. Proper hygiene is important but is not related to paraphimosis. Proper lubrication will help with tolerance of the procedure, as will using a smaller sized catheter, but these are unrelated to paraphimosis.

A 34-year-old male has been diagnosed with testicular cancer after he visited his family physician reporting an enlarged, painful testicle. Biopsy has indicated his tumor is malignant, and his oncologist believes the tumor arose in the seminiferous epithelium and is producing a uniform population of cells. What is the client's most likely specific diagnosis? A. Seminoma B. Choriocarcinoma C. Germ cell tumor D. Nonseminoma

Answer: A Rationale: Seminomas are the subtype of germ cell tumors that are most common in the fourth decade and are thought to originate with the seminiferous epithelium and produce a uniform cell population. Nonseminomas tend to produce a variety of cell types, and choriocarcinoma is rare variant of nonseminoma testicular cancer that originates in the placental tissue.

A 40-year-old black client is at increased risk of developing prostate cancer, because his father was diagnosed with the disease at age 60 and his brother at age 56. What diagnostic measures should be undertaken? A. PSA and DRE starting before the age of 50 B. Transrectal ultrasonography starting immediately C. PSA and DRE starting at age 50 D. Transrectal MRI starting at age 45

Answer: A Rationale: The current recommendation of the American Cancer Society and the American Urological Association is that men at increased risk of prostate cancer, such as this client who has two risk factors (his race and his family history), should begin screening with an annual digital rectal exam (DRE) and prostate-specific antigen (PSA) measurement starting at age 45. The general population is advised to undergo this process starting at age 50. It is important to note that PSA levels can be a marker of either benign prostatic hyperplasia or cancer, and there is some degree of controversy regarding the benefit of screening for it. Although transrectal ultrasonography may detect small cancers, its prohibitive cost excludes its routine use in screening.

A client presents to their health care provider with excruciating back pain progressively getting worse, decreased sensation in his lower extremities, urinary incontinence, and problems completely emptying his bladder. He is diagnosed with advanced prostate cancer with spinal cord compression and admitted to the hospital. The nurse should anticipate administering which medications to this client? Select all that apply. A. Ketoconazole, a fungicide to lower serum testosterone levels B. Bisphosphonates, such as pamidronate, to inhibit bone loss C. Phosphate binding agents such as aluminum hydroxide D. Sulfonamides with trimethoprim to treat the urinary tract infection (UTI) E. Calcium carbonate to prevent osteoporosis

Answer: A, B Rationale: Inhibitors of adrenal androgen synthesis (ketoconazole) are used for treatment of advanced prostate cancer in clients who present with spinal cord compression because these men need rapid decreases in their testosterone levels. They prevent osteopenia, prevent and delay skeletal complications in clients with metastatic bone involvement, and provide palliation of bone pain. There is no indication that this client has a UTI. Clients with this malignancy usually have hypercalcemia and therefore administration of calcium supplements would be contraindicated. The bisphosphonates (pamidronate) act by inhibiting osteoclastic activity.

The nurse is caring for a client with hypertension and diabetes who has been diagnosed with balanoposthitis secondary to Candida albicans. What actions should the nurse make sure are in the client's plan of care? Select all that apply. A. Retract foreskin and clean all surfaces of the penis twice daily. B. Optimize glycemic control. C. Keep hypertension well-controlled. D. Apply topical corticosteroid as ordered. E. Apply topical antifungal as ordered. F. Monitor urine output.

Answer: A, B, E, F Rationale: Balanoposthitis caused by Candida albicans will require antifungal treatment and thorough cleaning of the area twice daily. Glycemic control will also be important as hyperglycemia promotes Candida growth. Because balanoposthitis can result in urethral stenosis the nurse should monitor urine output. Blood pressure will not affect this condition. Using a corticosteroid would be contraindicated in a Candida albicans infection.

The nurse is planning care for a client with acute epididymitis. Which interventions should the nurse be sure to perform? Select all that apply. A. Administer nonsteroidal anti-inflammatory medications. B. Verify culture results prior to initiating antibiotic therapy. C. Apply a supportive device to elevate the scrotum. D. Encourage frequent ambulation. E. Assess temperature four times daily.

Answer: A, C, E Rationale: Acute epididymitis is a form of acute bacterial infection. Recommended treatment includes scrotal elevation and nonsteroidal anti-inflammatory drugs (NSAIDs). Temperature should be monitored to help determine response to treatment. Antibiotics will be started empirically and should not be delayed by awaiting culture results. Bed rest is another recommendation, and thus the client should not be encouraged to ambulate.

An older adult client has a history of ischemic heart disease, MI, unstable angina controlled by transdermal nitroglycerin patch, chronic smoking requiring use of nebulizer bronchodilators, and hypertension treated with a potassium-sparing diuretic and a beta-adrenergic blocking medication. The man states that he has been unable to maintain his erection. Which aspects of the man's health problems/treatments would the nurse identify as contributing to his erectile difficulty (ED)? Select all that apply. A. Antihypertensive medications B. Use of bronchodilators C. Hypertension D. Diuretic use E. Smoking history F. Age

Answer: A, C, E, F Rationale: Hypertension, antihypertensive medications, age, and smoking are all implicated in the etiology of ED. Ischemic heart disease and bronchodilators are less likely to directly contribute to the condition.

A client calls the nurse at an urgent care center about ongoing symptoms of acute epididymitis. The client began antibiotic therapy 3 days ago but pain, swelling, and fever are still present. What is the best direction for the nurse to offer the client? A. Take nonsteroidal anti-inflammatory (NSAID) medication for the pain and fever. B. Come into the urgent care center for reevaluation as soon as possible. C. Maintain bed rest and elevate the scrotum to reduce swelling. D.Call the primary physician's office to make an appointment for follow-up.

Answer: B Rationale: Clients with epididymitis should have a reduction of symptoms within 48 hours of the initiation of treatment. Signs and symptoms that do not subside within 3 days require reevaluation. Instructing the client to make an appointment for follow-up could result in the client waiting for too long to be evaluated given 3 days have already passed. Delaying reevaluation could result in chronic pain or infertility as complications of undertreated epididymitis. While NSAIDs and scrotal elevation are part of the treatment of this condition, the priority is to have the client reevaluated; the nurse should direct the client to come into the urgent care center for this purpose.

A 20-year-old male has been diagnosed with testicular cancer and is seeking information about his diagnosis from a number of websites. Which statement that he has read is most plausible? A. "Testicular cancer is a leading cause of death among males who should be in the prime of their life." B. "Men with cryptorchidism — the term for an undescended testicle — are known to have a higher risk of developing testicular cancer." C. "For most men with testicular cancer, bloody urine is their first sign that something is wrong." D. "Recent developments in the treatment of testicular cancer mean that few men now need to have a testicle removed."

Answer: B Rationale: Cryptorchidism is an identified risk factor for the development of testicular cancer. The diagnosis is no longer a leading cause of death. Hematuria is not a common symptom and orchiectomy is still the standard treatment modality.

A nurse practitioner has a 30-year-old male client presenting with fever/chills, urinary frequency/urgency and pain with urination. A urine sample displays cloudy and foul-smelling urine. During digital rectal exam of the prostate, the nurse notes a thick white discharge. A likely diagnosis would be: A. urinary tract infection requiring a prescription of sulfur drugs. B. acute bacterial prostatitis requiring antimicrobial therapy. C. testicular cancer requiring appointment with a urologist. D. inflammation of the epididymis requiring scrotal elevation.

Answer: B Rationale: Manifestations of acute bacterial prostatitis include fever and chills, malaise, frequent and urgent urination, and dysuria. The urine may be cloudy and malodorous because of urinary tract infection. Rectal examination reveals a swollen, tender prostate. During exam, prostatic massage produces a thick discharge with WBCs that grows a large numbers of pathogens on culture.

A medical student is assessing a 22-year-old male who has come to the emergency department because of pain and swelling in his scrotum over the past 36 hours. The attending physician has told the student that she suspects epididymitis. Which of the medical student's following questions is most likely to be useful in the differential diagnosis of epididymitis? A. "Do you know if your vaccinations for mumps are up to date?" B. "Have you had unprotected sex in the past?" C. "Do you have a sensation of heaviness in the left side of your scrotum?" D. "Has it been painful when you get an erection lately?"

Answer: B Rationale: Sexually transmitted infections are a common contributing factor to epididymitis. Mumps are more often a precursor to orchitis, and heaviness on the left side is associated varicocele. Pain with an erection is not a noted symptom of epididymitis.

Following a long history of intermittent back pain and urinary urgency, a 50- year-old client has been diagnosed with chronic bacterial prostatitis. Which factor is most likely to influence his health care provider's choice of treatment? A. The diagnosis is thought to have an autoimmune etiology with limited response to steroid treatments. B. Antibacterial drugs penetrate poorly into the chronically inflamed prostate. C. Urethral catheterization provides symptom relief and contributes to resolution of the underlying infection. D. There are no proven treatments for chronic prostatitis that address the infectious process.

Answer: B Rationale: The fact that antibacterial drugs penetrate poorly into the chronically inflamed prostate makes treatment difficult. Inflammatory prostatitis, not chronic prostatitis, is believed to be an autoimmune problem. Urethral catheterization does not provide resolution of the underlying infection, though treatment modalities do exist.

A client is undergoing testing for testicular cancer. Which tumor markers should the nurse include in the teaching plan for this client? Select all that apply. A. Prostate specific antigen B. Alpha-fetoprotein C. Beta-human chorionic gonadotropin D. Gonadotropin-releasing hormone E. Dihydrotestosterone

Answer: B, C Rationale: Two tumor markers commonly used for clients with testicular cancer are alpha-fetoprotein, a glycoprotein that is normally present in fetal serum in large amounts, and beta-human chorionic gonadotropin (beta-hCG), a hormone that is normally produced by the placenta in pregnant women. The reappearance of these protein markers in the adult suggests activity of undifferentiated cells in a testicular germ cell tumor. Prostate specific antigen is used as a marker in prostate cancer. Dihydrotestosterone is another hormone implicated in prostate cancer growth promotion. Gonadotropin-releasing hormone stimulates the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) and is not used as a tumor marker.

When explaining to a client why his prostate is enlarging, the nurse will mention that which hormones may contribute to the prostatic hyperplasia? Select all that apply. A. Glucocorticoids B. Testosterone C. Dihydrotestosterone D. Estrogens E. Progesterone

Answer: B, C, D Rationale: Both androgens (testosterone and dihydrotestosterone) and estrogens appear to contribute to the development of BPH. Testosterone is the most important factor for prostatic growth. DHT, the biologically active metabolite of testosterone, is thought to be the ultimate mediator of prostatic hyperplasia, with estrogen serving to sensitize the prostatic tissue to the growth-producing effects of DHT. Glucocorticoids do not play a role in making the prostate gland enlarge.

During clinical skills lab, a student walks away from the "client" the student just catheterized. The faculty assesses the student's ability to clean up after the procedure and finds the student has not replaced the client's foreskin over the glans. Which problem will the faculty review with this student? A. proper sterile technique B. how to remove excess betadine from the penile tip C. that tight foreskin can lead to ischemia at the penile tip D. advantages of the foreskin in adult males

Answer: C Rationale: A tight foreskin can constrict the blood supply to the glans and lead to ischemia and necrosis. Many cases of paraphimosis result from the foreskin being retracted for an extended period, as in the case of catheterized uncircumcised males. No information is presented as to whether sterile technique is a problem during insertions. Betadine is frequently used to cleanse the tip of the penis just prior to catheterization. By adulthood, an uncircumcised male should have received education on how to care for the foreskin to keep it clean and retractable. If not, the nurse should provide this information to the client.

A 51-year-old man is receiving his annual physical exam and his care provider is explaining the rationale for performing a digital rectal exam (DRE). Which statement best captures the rationale for the procedure? A. DRE, combined with a measurement of prostate-specific antigen (PSA), is the easiest way to confirm or rule out benign prostatic hyperplasia (BPH). B. The presence of an enlarged prostate provides a definitive diagnosis of prostate cancer. C. If the prostate is hardened on examination, a biopsy is indicated for further investigation. D. DRE is a screening test recommended for men who are experiencing either reduced urine flow or pain on urination.

Answer: C Rationale: Abnormalities detected during a DRE provide a rationale for further investigation by biopsy. PSA is used to screen for prostate cancer; however, it is also positive in BPH. Therefore, the combination of an elevated PSA and hardened prostate cannot differentiate BPH from prostate cancer. The anatomic location of the prostate at the bladder neck contributes to the pathophysiology and symptomatology of BPH. A BPH is not a definitive sign of prostate cancer. DRE is recommended annually for all men over age 50.

Which teaching point by an oncologist is most appropriate for a 33-year-old male who will begin treatment shortly for his testicular cancer? A. "Thanks to new treatment advances, there's a very good chance that I won't have to remove a testicle." B. "If steroid treatment fails, then we can consider surgery and/or chemotherapy." C. "You should know that there might be adverse effects on your sexual function after treatment is finished." D. "The advantage of performing an orchiectomy over other treatments is that it rules out recurrence."

Answer: C Rationale: Orchiectomy is the standard treatment for testicular cancer. Steroidal treatments are not used and sexual function is commonly affected. Recurrence is possible even after orchiectomy.

A 54-year-old diabetic client has come to the urology clinic complaining of erectile dysfunction. His history includes obesity, coronary artery disease which required bypass graft 3 years ago, hypertension, and gout. The nurse practitioner is reviewing his record in order to prescribe medication. The practitioner is considering prescribing sildenafil. Which home medication is contraindicated if taken concurrently with sildenafil? A. Diltiazem, a calcium channel blocker B. Amiodarone, an anti-arrhythmic C. Isosorbide mononitrate, a vasodilator D. Furosemide, a diuretic

Answer: C Rationale: Sildenafil is a selective inhibitor of phosphodiesterase type 5 (PDE-5), the enzyme that inactivates cGMP. This acts by facilitating corporal smooth muscle relaxation in response to sexual stimulation. The concomitant use of PDE-5 inhibitors and nitrates is absolutely contraindicated because of the risk of profound hypotension. The other medications listed are not nitrates and do not have this adverse reaction.

A 14-year-old boy has been brought to the emergency department by his mother in excruciating pain that is radiating from his scrotum to his inguinal area. The boy's heart rate is 122 beats per minute and he has vomited twice before arrival at the hospital. Examination reveals that his scrotum is reddened and slightly swollen and the testes are firm to touch and tender, with extensive cremaster muscle contraction noted. What is the boy's most likely diagnosis? A. Epididymitis B. Hydrocele C. Testicular torsion D. Varicocele

Answer: C Rationale: The combination of the boy's age, signs, and symptoms is indicative of testicular torsion. Epididymitis normally lacks cremaster muscle involvement and hydrocele is marked by massive distention of the scrotum. Varicocele is often asymptomatic or marked by heaviness in the scrotum.

A 71-year-old man diagnosed with a stage T2 prostate tumor 2 years ago has elected watchful waiting. Recently, his PSA has jumped considerably, as have his levels of serum acid phosphatase. Which course of action would be least appropriate at this stage? A. Combination treatment with an anti-androgen and a GnRH agonist B. Treatment with bisphosphonates C. Treatment with GnRH agonists alone D. Treatment with ketoconazole

Answer: C Rationale: The sharp rise in PSA, coupled with an increase in levels of serum acid phosphatase, is strongly indicative of metastatic cancer (which could be confirmed via molecular imaging such as MRI). Unopposed GnRH agonists initially cause LH and FSH levels to rise, stimulating the production of testosterone, which acts as fuel for the fire of prostatic metastasis. Thus, their use alone would not be appropriate. However, if these agonists are combined with anti-androgens, testosterone levels can be quelled from two different fronts simultaneously. Ketoconazole is a chemical castrating agent that could bring down testosterone levels rapidly and might be more appropriate for cases of advanced and widespread metastasis. Bisphosphonates address the effects of metastatic bone involvement and of osteoporosis resulting from anti-androgen therapy.

A 41-year-old male has presented to his family physician stating that for the last 2 years his erection "is as crooked as a dog's hind leg, and hurts too." He has subsequently been diagnosed with Peyronie disease. Which statement by his physician is most appropriate? A. "Even though it's obviously distressing, you should know that this will likely resolve on its own with time." B. "I'll refer you to a urologist who will likely want to perform a circumcision." C. "This might need surgery but it could possibly disappear over time without needing treatment." D. "There are things you can do to minimize this, such as getting more exercise, stopping smoking, and maintaining a healthy diet."

Answer: C Rationale: While spontaneous resolution is possible, surgery is sometimes necessary for the treatment of Peyronie disease. Circumcision would not be an effective treatment, and lifestyle factors are not noted to contribute to the etiology or resolution.

An older adult male resident has a grossly distended scrotum. On examination, the resident has been diagnosed with a hydrocele. What will the nurse most likely tell the resident and his family about his diagnosis? A. "We'll get you to the hospital quickly, because if this isn't treated it can result in a blockage in the blood flow to your testes." B. "This isn't a result of your intestine entering your scrotum, but an accumulation of fluid within your testes." C. "This can sometimes result from the lower level of sex hormones that comes with age, so you will likely benefit from a testosterone supplement." D. "While distressing to look at, this condition usually doesn't have any significant consequences and won't need treatment."

Answer: D Rationale: Hydrocele in adult males is normally considered a benign condition that does not warrant treatment unless mobility is affected. Fluid accumulates in the space between the tunica vaginalis and tunica albuginea, not within the testes themselves, and hormone therapy is not indicated.