Nursing 2 GU

Nephrotic Syndrome Clinical Manifestations

The major manifestation of nephrotic syndrome is edema. It is usually soft and pitting and commonly occurs around the eyes (periorbital), in dependent areas (sacrum, ankles, and hands), and in the abdomen (ascites). Patients may also exhibit irritability, headache, and malaise.

Epididymitis Pathophysiology

A causative organism can be identified in 80% of patients. In prepubertal males, older men, and men who are homosexual, the predominate causal organism is E. coli, although in older men, the condition may also be a result of urinary obstruction. In sexually active men 35 years and younger, the pathogens usually are related to bacteria associated with STIs (e.g., C. trachomatis, N. gonorrhoeae). The infection moves in an upward direction, through the urethra and the ejaculatory duct, and then along the vas deferens to the epididymis.

Other Studies

A multiple-test dipstick often includes testing for WBCs, known as the leukocyte esterase test, and nitrite testing. Tests for sexually transmitted infections may be performed because acute urethritis caused by sexually transmitted organisms (i.e., Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex) or acute vaginitis infections (caused by Trichomonas or Candida species) may be responsible for symptoms similar to those of UTIs. X-ray images, computed tomography (CT) scan, ultrasonography, and kidney scans are useful diagnostic tools. A CT scan may detect pyelonephritis or abscesses. Ultrasonography and kidney scans are extremely sensitive for detecting obstruction, abscesses, tumors, and cysts

Chronic Glomerulonephritis Assessment and Diagnostic Findings

A number of laboratory abnormalities occur. Urinalysis reveals a fixed specific gravity of about 1.010, variable proteinuria, and urinary casts (proteins secreted by damaged kidney tubules). As kidney disease progresses and the GFR falls below 50 mL/min, the following changes occur: Hyperkalemia due to decreased potassium excretion, acidosis, catabolism, and excessive potassium intake from food and medications Metabolic acidosis from decreased acid secretion by the kidney and inability to regenerate bicarbonate Anemia secondary to decreased erythropoiesis (production of RBCs) Hypoalbuminemia with edema secondary to protein loss through the damaged glomerular membrane Increased serum phosphorus level due to decreased renal excretion of phosphorus Decreased serum calcium level (calcium binds to phosphorus to compensate for elevated serum phosphorus levels) Mental status changes Impaired nerve conduction due to electrolyte abnormalities and uremia Chest x-rays may show cardiac enlargement and pulmonary edema. The electrocardiogram (ECG) may be normal or may indicate left ventricular hypertrophy associated with hypertension and signs of electrolyte disturbances, such as tall, tented (or peaked) T waves associated with hyperkalemia. Computed tomography (CT) and magnetic resonance imaging (MRI) scans show a decrease in the size of the renal cortex.

Prostatitis Clinical Manifestations

Acute prostatitis is characterized by the sudden onset of fever, dysuria, perineal prostatic pain, and severe lower urinary tract symptoms: dysuria, frequency, urgency, hesitancy, and nocturia. Approximately 5% of cases of type I prostatitis (acute bacterial prostatitis) progress to type II prostatitis (chronic bacterial prostatitis). Patients with type II disease are typically asymptomatic between episodes. Patients with type III prostatitis often have no bacteria in the urine in the presence of genitourinary pain. Patients with type IV prostatitis are usually diagnosed incidentally during a workup for infertility, an elevated PSA test, or other disorders.

Acute Nephritic Syndrome ( Acute Glomerulonephritis)

Acute nephritic syndrome is a type of kidney disease with glomerular inflammation. Glomerulonephritis is an inflammation of the glomerular capillaries that can occur in acute and chronic forms.

Long-Term Pharmacologic Therapy

Although brief pharmacologic treatment of UTIs for 3 days is usually adequate in women, infection recurs in about 20% of women treated for uncomplicated UTIs. Infections that recur within 2 weeks of therapy do so because organisms of the original offending strain remain. Relapses suggest that the source of bacteriuria may be the upper urinary tract or that initial treatment was inadequate or given for too short a time. Recurrent infections in men are usually caused by persistence of the same organism; further evaluation and treatment are indicated. If infection recurs after completing antimicrobial therapy, another short course (3 to 4 days) of full-dose antimicrobial therapy followed by a regular bedtime dose of an antimicrobial agent may be prescribed. If there is no recurrence, medication is taken every other night for 6 to 7 months. Long-term use of antimicrobial agents decreases the risk of reinfection and may be indicated in patients with recurrent infections. If recurrence is caused by persistent bacteria from preceding infections, the cause (i.e., kidney stone, abscess), if known, must be treated. After treatment and sterilization of the urine, low-dose prophylactic therapy (trimethoprim with or without sulfamethoxazole) each night at bedtime may be prescribed. One group of researchers reported that daily consumption of cranberry juice over an 8-week period decreased symptoms (i.e., urgency, frequency, nocturia, dysuria, and pain) in women diagnosed with a UTI in an ambulatory setting

Testicular Cancer

Although only accounting for about 1% of all cancers in men, testicular cancer is the most common cancer diagnosed in men between 15 and 35 years of age; approximately 8400 new cases and 380 deaths occur in the United States annually. It is the second most common malignancy in those 35 to 39 years of age. For unknown reasons, worldwide incidence of testicular tumors has more than doubled in the past 40 years. Because of advances in cancer therapy, testicular cancer is a highly treatable and usually curable form of cancer. The 5-year relative survival rate for all testicular cancers is more than 95% and approaches 99% if the cancer has not spread outside of the testes. After treatment, most patients with testicular cancer have a near-normal life expectancy.

Reflux

An obstruction to free-flowing urine is a condition known as urethrovesical reflux, which is the reflux (backward flow) of urine from the urethra into the bladder. With coughing, sneezing, or straining, the bladder pressure increases, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine flows back into the bladder, bringing into the bladder bacteria from the anterior portions of the urethra. Urethrovesical reflux is also caused by dysfunction of the bladder neck or urethra. The urethrovesical angle and urethral closure pressure may be altered with menopause, increasing the incidence of infection in postmenopausal women. Reflux is most often noted in young children, and treatment is based on its severity. Ureterovesical or vesicoureteral reflux refers to the backward flow of urine from the bladder into one or both ureters. Normally, the ureterovesical junction prevents urine from traveling back into the ureter. The ureters tunnel into the bladder wall so that the bladder musculature compresses a small portion of the ureter during normal voiding. When the ureterovesical valve is impaired by congenital causes or ureteral abnormalities, the bacteria may reach the kidneys and eventually destroy them.

Acute Pyelonephritis Assessment and Diagnostic Findings

An ultrasound study or a CT scan may be performed to locate an obstruction in the urinary tract. Relief of obstruction is essential to prevent complications and eventual kidney damage. An IV pyelogram may be indicated with pyelonephritis if functional and structural renal abnormalities are suspected. Radionuclide imaging with gallium citrate and indium-111 (111In)-labeled WBCs may be useful to identify sites of infection that may not be visualized on CT scan or ultrasound. Urine culture and sensitivity tests are performed to determine the causative organism so that appropriate antimicrobial agents can be prescribed.

Gerontologic Considerations

As men age, the prostate gland enlarges; prostate secretion decreases; the scrotum hangs lower; the testes decrease in weight, atrophy, and become softer; and pubic hair becomes sparser and stiffer. Changes in gonadal function include a decline in plasma testosterone levels and reduced production of progesterone. Libido and potency often decrease in as many as two thirds of men older than 70 years. Vascular problems cause about half of the cases of impotence in men older than 50 years. However, male reproductive capability is maintained with advancing age. Although degenerative changes occur in the seminiferous tubules and sperm production decreases, spermatogenesis continues, allowing men to produce viable sperm throughout their lives. Male hypogonadism (decreased function of the testes) starts gradually at approximately 50 years of age, resulting in decreased testosterone production. The older man notices that the sexual response slows, erection takes longer, full erections may not be attained, and ejaculation takes longer to occur and control or resolution may occur without orgasm. Sexual function can be affected by psychological problems, illnesses, and medications. In general, the entire sexual act takes longer. Sexual activity is closely correlated with the man's sexual activity in his earlier years; if he was more active than average as a young man, he will most likely continue to be more active than average in his later years. Men older than 50 years are at increased risk for genitourinary tract cancers, including those of the kidney, bladder, prostate, and penis. The digital rectal examination (DRE), prostate-specific antigen (PSA) test, and urinalysis, which screens for hematuria, may uncover a higher percentage of malignancies at earlier stages and lead to lower treatment-associated morbidity as well as a lower mortality. Urinary incontinence occurs in one fifth of community-dwelling older men and rises to nearly 50% in men in long-term care settings. Older adults admitted to acute care settings should be screened for this problem. Urinary incontinence may have many causes, including medications, neurologic disease, or benign prostatic hyperplasia (BPH). Incontinence may also be linked to erectile dysfunction when there is damage to the neural pathways that initiate an erection. Diagnostic tests are performed to exclude reversible causes. New-onset urinary incontinence is a nursing priority that requires evaluation.

BPH Clinical Manifestations

BPH may or may not lead to lower urinary tract symptoms; if symptoms occur, they may range from mild to severe. Severity of symptoms increases with age, and half of men with BPH report having moderate to severe symptoms. Obstructive and irritative symptoms may include urinary frequency, urgency, nocturia, hesitancy in starting urination, decreased and intermittent force of stream and the sensation of incomplete bladder emptying, abdominal straining with urination, a decrease in the volume and force of the urinary stream, dribbling (urine dribbles out after urination), and complications of acute urinary retention and recurrent UTIs. Normally, residual urine amounts to no more than 50 mL in the middle-aged adult and less than 50 to 100 mL in the older adult. Ultimately, chronic urinary retention and large residual volumes can lead to azotemia (accumulation of nitrogenous waste products) and kidney failure. Generalized symptoms may also be noted, including fatigue, anorexia, nausea, vomiting, and pelvic discomfort. Other disorders that produce similar symptoms include urethral stricture, prostate cancer, neurogenic bladder, and urinary bladder stones.

Routes of Infection

Bacteria enter the urinary tract in three ways: by the transurethral route (ascending infection), through the bloodstream (hematogenous spread), or by means of a fistula from the intestine (direct extension). The most common route of infection is transurethral, in which bacteria (often from fecal contamination) colonize the periurethral area and subsequently enter the bladder by means of the urethra (Grossman & Porth, 2014). In women, the short urethra offers little resistance to the movement of uropathogenic bacteria. Sexual intercourse forces the bacteria from the urethra into the bladder. This accounts for the increased incidence of UTIs in sexually active women. Bacteria may also enter the urinary tract by means of the blood from a distant site of infection or through direct extension by way of a fistula from the intestinal tract.

Chronic Pyelonephritis Medical Management

Bacteria, if detected in the urine, are eradicated if possible. Long-term use of prophylactic antimicrobial therapy may help limit recurrence of infections and kidney scarring. Impaired kidney function alters the excretion of antimicrobial agents and necessitates careful monitoring of kidney function, especially if the medications are potentially toxic to the kidneys.

Uropathogenic Bacteria

Bacteriuria is the term used to describe the presence of bacteria in the urine. Because urine samples (especially in women) can be easily contaminated by the bacteria normally present in the urethral area, a clean-catch midstream urine specimen is the measure used to establish bacteriuria. In men, contamination of the collected urine sample occurs less frequently. Bacteriuria is defined as 100,000 colony-forming units (CFU)/mL urine (Fischbach & Dunning, 2015; Grossman & Porth, 2014). Community-acquired UTIs are among the most common bacterial infections in women (Hopkins, et al., 2014).The organisms most frequently responsible for UTIs are those normally found in the lower gastrointestinal (GI) tract, usually Escherichia coli

Benign Prostatic Hyperplasia (Enlarged Prostate)

Benign prostatic hyperplasia (BPH), a noncancerous enlargement or hypertrophy of the prostate, is one of the most common diseases in aging men. It can cause bothersome lower urinary tract symptoms that affect quality of life by interfering with normal daily activities and sleep patterns. BPH typically occurs in men older than 40 years. By the time they reach 60 years, 50% of men have BPH. It affects as many as 90% of men by 85 years of age. BPH is the second most common cause of surgical intervention in men older than 60 years.

Bacterial Invasion of the Urinary Tract

By increasing the normal slow shedding of bladder epithelial cells (resulting in bacteria removal), the bladder can clear large numbers of bacteria. Glycosaminoglycan (GAG), a hydrophilic protein, normally exerts a nonadherent protective effect against various bacteria. The GAG molecule attracts water molecules, forming a water barrier that serves as a defensive layer between the bladder and the urine. GAG may be impaired by certain agents (cyclamate, saccharin, aspartame, and tryptophan metabolites). The normal bacterial flora of the vagina and urethral area also interfere with adherence of Escherichia coli. Urinary immunoglobulin A (IgA) in the urethra may also provide a barrier to bacteria.

Prostate Cancer Clinical Manifestations

Cancer of the prostate in its early stages rarely produces symptoms. Usually, symptoms that develop from urinary obstruction occur in advanced disease. Prostate cancer tends to vary in its course. If the cancer is large enough to encroach on the bladder neck, signs and symptoms of urinary obstruction occur (difficulty and frequency of urination, urinary retention, and decreased size and force of the urinary stream). Other symptoms may include blood in the urine or semen and painful ejaculation. Hematuria may occur if the cancer invades the urethra or bladder. Sexual dysfunction is common before the diagnosis is made. Prostate cancer can spread to lymph nodes and bone. Symptoms of metastases include backache, hip pain, perineal and rectal discomfort, anemia, weight loss, weakness, nausea, oliguria (decreased urine output), and spontaneous pathologic fractures. These symptoms may be the first indications of prostate cancer.

Chronic Glomerulonephritis

Chronic glomerulonephritis may be due to repeated episodes of acute nephritic syndrome, hypertensive nephrosclerosis, hyperlipidemia, chronic tubulointerstitial injury, or hemodynamically mediated glomerular sclerosis. Secondary glomerular diseases that can have systemic effects include systemic lupus erythematosus, Goodpasture syndrome (caused by antibodies to the glomerular basement membrane), diabetic glomerulosclerosis, and amyloidosis.

Acute Glomerulonephritis Complications

Complications of acute glomerulonephritis include hypertensive encephalopathy, heart failure, and pulmonary edema. Hypertensive encephalopathy is a medical emergency, and therapy is directed toward reducing the blood pressure without impairing renal function. This can occur in acute nephritic syndrome or preeclampsia with chronic hypertension of greater than 140/90 mmHg. Rapidly progressive glomerulonephritis is characterized by a rapid decline in renal function. Without treatment, ESKD develops in a matter of weeks or months. Signs and symptoms are similar to those of acute glomerulonephritis (hematuria and proteinuria), but the course of the disease is more severe and rapid. Crescent-shaped cells accumulate in Bowman space, disrupting the filtering surface. Plasma exchange (plasmapheresis) and treatment with high-dose corticosteroids and cytotoxic agents have been used to reduce the inflammatory response. Dialysis is initiated in acute glomerulonephritis if signs and symptoms of uremia are severe. The prognosis for patients with acute nephritic syndrome is excellent and rarely causes CKD

Chronic Pyelonephritis Complications

Complications of chronic pyelonephritis include end-stage kidney disease (from progressive loss of nephrons secondary to chronic inflammation and scarring), hypertension, and formation of kidney stones (from chronic infection with urea-splitting organisms).

Nephrotic Syndrome Complications

Complications of nephrotic syndrome include infection (due to a deficient immune response), thromboembolism (especially of the renal vein), pulmonary embolism, AKI (due to hypovolemia), and accelerated atherosclerosis (due to hyperlipidemia).

Primary Glomerular Diseases

Diseases that destroy the glomerulus of the kidney are the third most common cause of stage 5 CKD. In these disorders, the glomerular capillaries are primarily involved. Antigen-antibody complexes form in the blood and become trapped in the glomerular capillaries (the filtering portion of the kidney), inducing an inflammatory response. Immunoglobulin G (IgG)—the major immunoglobulin (antibody) found in the blood—can be detected in the glomerular capillary walls. The major clinical manifestations of glomerular injury include proteinuria, hematuria, decreased GFR, decreased excretion of sodium, edema, and hypertension

MONITORING AND MANAGING POTENTIAL COMPLICATIONS of a UTI

Early recognition of UTI and prompt treatment are essential to prevent recurrent infection and the possibility of complications, such as kidney disease, sepsis (urosepsis), strictures, and obstructions. The goal of treatment is to prevent infection from progressing and causing permanent kidney damage and injury. Thus, the patient must be educated to recognize early signs and symptoms, to test for bacteriuria, and to initiate treatment as prescribed. Appropriate antimicrobial therapy, liberal fluid intake, frequent voiding, and hygienic measures are commonly prescribed for managing UTIs. The patient is instructed to notify the primary provider if fatigue, nausea, vomiting, fever, or pruritus occurs. Periodic monitoring of renal function and evaluation for strictures, obstructions, or stones may be indicated for patients with recurrent UTIs.

UTI Early S/S in Older Adult

Early symptoms of UTI in older adults include burning, urgency, and fever (Eliopoulos, 2018). Some patients develop incontinence and delirium with the onset of a UTI.

Testicular Cancer Assessment and Diagnostic Findings

Educating young men about testicular cancer and the need for urgent evaluation of any mass or enlargement or unexplained testicular pain is key to early detection. Education about TSE, starting in adolescence, alerts men to the importance of seeking medical attention if a testicle becomes indurated, enlarged, atrophied, nodular, or painful. TSE should be performed monthly. Testicular cancers generally grow rapidly and are easily detected against a typically smooth and homogeneous texture. Annual testicular examination by a clinician can reveal signs and lead to early diagnosis and treatment of testicular cancer. Promoting awareness of this disease is an important health promotion intervention; men should seek medical evaluation for signs or symptoms of testicular cancer without delay. Any suspicious testicular mass warrants prompt evaluation with a thorough history and physical examination, focusing on palpation of the affected testicle. The tumor markers alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG) may be elevated in patients with testicular cancer. Tumor marker levels in the blood are used for diagnosis, staging, and monitoring the response to treatment. Blood chemistry, including lactate dehydrogenase, is also necessary. A chest x-ray to assess for metastasis in the lungs and a transscrotal testicular ultrasound will be performed. Microscopic analysis of tissue is the only definitive way to determine if cancer is present, but it is usually performed at the time of surgery rather than as a part of the diagnostic workup to reduce the risk of promoting spread of the cancer. Inguinal orchiectomy is the standard way to establish the diagnosis of testicular cancer. Other staging tests to determine the extent of the disease in the retroperitoneum, pelvis, and chest include an abdominal/pelvic CT scan and chest CT scan (if the abdominal CT or chest x-ray is abnormal). A brain MRI and bone scan may be obtained if indicated.

Epididymitis

Epididymitis is an infection of the epididymis, which usually spreads from an infected urethra, bladder, or prostate. The incidence is less than 1 in 1000 males per year. Prevalence is greatest in men 19 to 35 years of age. Acute epididymitis occurs bilaterally in 5% to 10% of affected patients. Risk factors for epididymitis include recent surgery or a procedure involving the urinary tract, participation in high-risk sexual practices, personal history of an STI, past prostate infections or UTIs, lack of circumcision, history of an enlarged prostate, and the presence of a chronic indwelling urinary catheter.

Epididymitis Clinical Manifestations

Epididymitis often slowly develops over 1 to 2 days, beginning with a low-grade fever, chills, and heaviness in the affected testicle. The testicle becomes increasingly tender to pressure and traction. The patient may report unilateral pain, soreness in the inguinal canal along the course of the vas deferens, and pain and swelling in the scrotum and the groin. The epididymis becomes increasingly swollen, with extreme pain in the lower abdomen and pelvis. Occasionally, there may be discharge from the urethra, blood in the semen, pus (pyuria) and bacteria (bacteriuria) in the urine, and pain during intercourse and ejaculation. The patient may report urinary frequency, urgency, or dysuria, and testicular pain aggravated by bowel movement.

Erectile Dysfunction

Erectile dysfunction, also called impotence, is the inability to achieve or maintain an erect penis. The man may report decreased frequency of erections, inability to achieve a firm erection, or rapid detumescence (subsiding of erection). In the United States, 30 million men experience erectile dysfunction; more than half of men 40 to 70 years of age are unable to attain or maintain an erection sufficient for satisfactory sexual performance. The physiology of erection and ejaculation is complex and involves parasympathetic and sympathetic components. Erection involves the release of nitric oxide into the corpus cavernosum during sexual stimulation. Its release activates cyclic guanosine monophosphate (cGMP), causing smooth muscle relaxation. This allows flow of blood into the corpus cavernosum, resulting in erection. Erectile dysfunction has both psychogenic and organic causes. Psychogenic causes include anxiety, fatigue, depression, pressure to perform sexually, negative body image, absence of desire, and privacy, as well as trust and relationship issues. Organic causes include cardiovascular disease, endocrine disease (diabetes, pituitary tumors, testosterone deficiency, hyperthyroidism, and hypothyroidism), cirrhosis, chronic kidney injury, genitourinary conditions (radical pelvic surgery), hematologic conditions (Hodgkin lymphoma, leukemia), neurologic disorders (neuropathies, parkinsonism, spinal cord injury [SCI], multiple sclerosis), trauma to the pelvic or genital area, alcohol, smoking, medications and drug abuse.

Urinary Tract Infection Risk Factors

Female gender Diabetes Pregnancy Neurologic disorders Gout Altered states caused by incomplete emptying of the bladder and urinary stasis Decreased natural host defenses or immunosuppression Inability or failure to empty the bladder completely Inflammation or abrasion of the urethral mucosa Instrumentation of the urinary tract (e.g., catheterization, cystoscopic procedures) Obstructed urinary flow caused by: Congenital abnormalities Urethral strictures Contracture of the bladder neck Bladder tumors Calculi (stones) in the ureters or kidneys Compression of the ureters

Lower Urinary Tract Infections Pathophysiology

For infection to occur, bacteria must gain access to the bladder, attach to and colonize the epithelium of the urinary tract to avoid being washed out with voiding, evade host defense mechanisms, and initiate inflammation. Many UTIs result from fecal organisms ascending from the perineum to the urethra and the bladder and then adhering to the mucosal surfaces.

Testicular Cancer Risk Factors

Risk factors for testicular cancer include cryptorchidism (undescended testicles), family history of testicular cancer, and personal history of testicular cancer. Other risk factors include race and ethnicity: Caucasian American men have a five times greater risk than African American men and more than two to three times greater risk than Asian, Native American, and Hispanic American men. The risk of developing testicular cancer is higher in HIV-positive men. Occupational hazards, including exposure to chemicals encountered in mining, oil and gas production, and leather processing, have been suggested as possible risk factors. No evidence has linked testicular cancer to prenatal exposure to diethylstilbestrol or to vasectomy.

Prostate Cancer Assessment and Diagnostic Findings

If prostate cancer is detected early, the likelihood of cure is high. It can be diagnosed through an abnormal finding with the DRE, serum PSA, and ultrasound-guided TRUS with biopsy. Detection is more likely with the use of combined diagnostic procedures. Routine repeated DRE (preferably by the same examiner) is important because early cancer may be detected as a nodule within the gland or as an extensive hardening in the posterior lobe. The more advanced lesion is "stony hard" and fixed. DRE also provides useful clinical information about the rectum, anal sphincter, and quality of stool. The diagnosis of prostate cancer is confirmed by a histologic examination of tissue removed surgically by TURP, open prostatectomy, or ultrasound-guided transrectal needle biopsy. Fine-needle aspiration is a quick, painless method of obtaining prostate cells for cytologic examination and determining the stage of disease. Most prostate cancers are detected when a man seeks medical attention for symptoms of urinary obstruction or are found by routine DRE and PSA testing. Cancer detected incidentally when TURP is performed for clinically benign disease and lower urinary tract symptoms occurs in about 1 of 10 cases. TRUS helps detect nonpalpable prostate cancers and assists with staging of localized prostate cancer. Needle biopsies of the prostate are commonly guided by TRUS. The biopsies are examined by a pathologist to both determine if cancer is present and to grade the tumor. The most commonly used tumor grading system is the Gleason score. This system assigns a grade of 1 to 5 for the most predominant architectural pattern of the glands of the prostate and a secondary grade of 1 to 5 to the second most predominant pattern. The Gleason score is then reported as, for example, 2 + 4; the combined value can range from 2 to 10. With each increase in Gleason score, there is an increase in tumor aggressiveness. Lower Gleason scores indicate well-differentiated and less aggressive tumor cells; higher Gleason scores indicate undifferentiated cells and more aggressive cancer. A total score of 8 to 10 indicates a high-grade cancer. Categorization of low-, intermediate-, and high-risk prostate cancer is determined by the extent of cancer in the prostate gland, whether or not the cancer is localized to the prostate, the aggressiveness of the cells, and the spread to the lymph nodes and beyond. Level of risk, in turn, is used to determine treatment options. Bone scans, skeletal x-rays, and magnetic resonance imaging (MRI) may be used to identify metastatic bone disease. Pelvic computed tomography (CT) scans may be performed to determine if the cancer has spread to the lymph nodes. The radiolabeled monoclonal antibody capromab pendetide with indium 111 (ProstaScint) is an antibody that can be used to detect either recurrent prostate cancer at low PSA levels or metastatic disease.

Acute Glomerulonephritis Assessment and Diagnostic Findings

In acute nephritic syndrome, the kidneys become large, edematous, and congested. All renal tissues, including the glomeruli, tubules, and blood vessels, are affected to varying degrees. Patients with an immunoglobulin A (IgA) nephropathy have an elevated serum IgA and low to normal complement levels. Electron microscopy and immunofluorescent analysis help identify the nature of the lesion; however, a kidney biopsy may be needed for definitive diagnosis. If the patient improves, the amount of urine increases and the urinary protein and sediment diminish. The percentage of adults who recover is unknown. Some patients develop severe uremia (an excess of urea and other nitrogenous wastes in the blood) within weeks and require dialysis for survival. Others, after a period of apparent recovery, insidiously develop chronic glomerulonephritis.

Epididymitis Assessment and Diagnostic Findings

Laboratory assessment includes urinalysis, complete blood cell count, Gram stain of urethral drainage, urethral culture or deoxyribonucleic acid (DNA) probe, and referral for syphilis and HIV testing in sexually active patients. Acute testicular pain should never be ignored, and it should be distinguished from testicular torsion, which is a surgical emergency.

Acute Glomerulonephritis Medical Management

Management consists primarily of treating symptoms, attempting to preserve kidney function, and treating complications promptly. Treatment may include prescribing corticosteroids, managing hypertension, and controlling proteinuria. Pharmacologic therapy depends on the cause of acute glomerulonephritis. If residual streptococcal infection is suspected, penicillin is the agent of choice; however, other antibiotic agents may be prescribed. Dietary protein is restricted when renal insufficiency and nitrogen retention (elevated BUN) develop. Sodium is restricted when the patient has hypertension, edema, and heart failure. In a hospital setting, carbohydrates are given liberally to provide energy and reduce the catabolism of protein. I&O is carefully measured and recorded. Fluids are given based on the patient's fluid losses and daily body weight. Insensible fluid loss through the lungs (300 mL) and skin (500 mL) is considered when estimating fluid loss. If treatment is effective, diuresis will begin, resulting in decreased edema and blood pressure. Proteinuria and microscopic hematuria may persist for many months; in fact, 20% of patients have some degree of persistent proteinuria or decreased GFR 1 year after presentation. Other nursing interventions focus on patient education about the disease process, explanations of laboratory and other diagnostic tests, and preparation for safe and effective self-care at home. Patient education is directed toward managing symptoms and monitoring for complications. Fluid and diet restrictions must be reviewed with the patient to avoid worsening of edema and hypertension. The patient is instructed verbally and in writing to notify the primary provider if symptoms of kidney disease occur (e.g., fatigue, nausea, vomiting, diminishing urine output) or at the first sign of any infection. The importance of follow-up evaluations of blood pressure, urinalysis for protein, and BUN and serum creatinine levels to determine if the disease has progressed is stressed to the patient. A referral for transitional, home, or community-based care may be indicated. A home visit from a nurse provides an opportunity for careful assessment of the patient's progress and detection of early signs and symptoms of renal insufficiency. If corticosteroids, immunosuppressant agents, or antibiotic medications are prescribed, the nurse uses the opportunity to review the dosage, desired actions, and adverse effects of medications and the precautions to be taken.

Chronic Glomerulonephritis Medical/Nursing Management

Management of symptoms guides the treatment. If the patient has hypertension, efforts are made to reduce the blood pressure with sodium and water restriction, antihypertensive agents, or both. Weight is monitored daily, and diuretic medications are prescribed to treat fluid overload. Proteins of high biologic value (dairy products, eggs, meats) are provided to promote good nutritional status. Adequate calories are provided to spare protein for tissue growth and repair. Urinary tract infections (UTIs) must be treated promptly to prevent further kidney damage. Dialysis is initiated early in the course of the disease to keep the patient in optimal physical condition, prevent fluid and electrolyte imbalances, and minimize the risk of complications of kidney disease. The course of dialysis is smoother if treatment begins before the patient develops complications. Whether the patient is hospitalized or cared for in the home, the nurse observes the patient for common fluid and electrolyte disturbances in kidney disease. Changes in fluid and electrolyte status and in cardiac and neurologic status are reported promptly to the primary provider. Throughout the course of the disease and treatment, the nurse gives emotional support by providing opportunities for the patient and family to verbalize their concerns, have their questions answered, and explore their options. Periodic laboratory evaluations of creatinine clearance and BUN and serum creatinine levels are carried out to assess residual renal function and the need for dialysis or transplantation. If dialysis is initiated, the patient and family require considerable assistance and support in dealing with therapy and its long-term implications. The patient and family are reminded of the importance of participation in health promotion activities, including health screening. The patient is instructed to inform all health care providers about the diagnosis of glomerulonephritis so that all medical management, including pharmacologic therapy, is based on altered renal function. The nurse has a major role in educating the patient and family about the prescribed treatment plan and the risks associated with noncompliance. Instructions to the patient include explanations and scheduling for follow-up evaluations: blood pressure, urinalysis for protein and casts, and laboratory studies of BUN and serum creatinine levels. If long-term dialysis is needed, the nurse educates the patient and family about the procedure, how to care for the access site, dietary restrictions, and other necessary lifestyle modifications. These topics are discussed later in this chapter. Periodic hospitalization, visits to the outpatient clinic or office, and home care referrals provide the nurse in each setting with the opportunity for careful assessment of the patient's progress and continued education about changes to report to the primary provider (worsening signs and symptoms of kidney disease, such as nausea, vomiting, and diminished urine output). Specific education may include explanations about recommended diet and fluid modifications and medications (purpose, desired effects, adverse effects, dosage, and administration schedule).

Negative-Pressure Devices

Negative-pressure (vacuum) devices may also be used to induce an erection. A plastic cylinder is placed over the flaccid penis, and negative pressure is applied. When an erection is attained, a constriction band is placed around the base of the penis to maintain the erection. To avoid penile injury, the patient is instructed not to leave the constricting band in place for longer than 1 hour. Only devices with a vacuum limiter are recommended for use. Although many men find this method satisfactory, others experience premature loss of penile rigidity or pain when applying suction or during intercourse.

Nephrotic Syndrome

Nephrotic syndrome is a type of kidney disease characterized by increased glomerular permeability and is manifested by massive proteinuria. Clinical findings include a marked increase in protein (particularly albumin) in the urine (proteinuria), a decrease in albumin in the blood (hypoalbuminemia), diffuse edema, high serum cholesterol, and low-density lipoproteins (hyperlipidemia). The syndrome is apparent in any condition that seriously damages the glomerular capillary membrane and results in increased glomerular permeability to plasma proteins. Although the liver is capable of increasing the production of albumin, it cannot keep up with the daily loss of albumin through the kidneys. Thus, hypoalbuminemia results.

Nephrotic Syndrome Pathophysiology

Nephrotic syndrome occurs with many intrinsic kidney diseases and systemic diseases that cause glomerular damage. It is not a specific glomerular disease but a constellation of clinical findings that result from the glomerular damage.

Orchitis

Orchitis is a rare, acute inflammatory response of one or both testes as a complication of systemic infection or as an extension of an associated epididymitis caused by bacterial, viral, spirochetal, or parasitic organisms. Micro-organisms may reach the testes through the blood, lymphatic system, or, more commonly, by traveling through the urethra, vas deferens, and epididymis; bacteria usually spread from an associated epididymitis in sexually active men. Causative organisms include Neisseria gonorrhoeae, Chlamydia trachomatis, E. coli, Klebsiella, Pseudomonas aeruginosa, Staphylococcus species, and Streptococcus species. Signs and symptoms of orchitis include fever; pain, which may range from mild to severe; tenderness in one or both testicles; bilateral or unilateral testicular swelling; penile discharge; blood in the semen; and leukocytosis. Treatment of orchitis is based on whether the causative organism is bacterial or viral. Bacterial orchitis is treated with antibiotic agents and supportive comfort measures. If the cause of the orchitis is an STI, the partner should be treated as well. Viral orchitis is treated using supportive treatments of rest, elevation of the scrotum, ice packs to reduce scrotal edema, analgesic agents, and anti-inflammatory medications. Bilateral orchitis can cause sterility in some men. Mumps vaccination is recommended for postpubertal men who have not had mumps or received inadequate immunization in childhood. Orchitis develops in approximately 30% of postpubertal men with mumps 4 to 6 days after parotitis starts, and one third of men have some testicular atrophy.

IV Pyelogram

Pagana pg. 1001

Chronic Pyelonephritis Assessment and Diagnostic Findings

The extent of the disease is assessed by an IV urogram and measurements of creatinine clearance, blood urea nitrogen, and creatinine levels

Acute Pyelonephritis Medical Management

Patients with acute uncomplicated pyelonephritis are most often treated on an outpatient basis if they are not exhibiting acute symptoms of sepsis, dehydration, nausea, or vomiting. In addition, they must be responsible and reliable to ensure that all medications will be taken as prescribed. For outpatients, a 2-week course of antibiotic agents is recommended because renal parenchymal disease is more difficult to eradicate than mucosal bladder infections. Commonly prescribed agents include many of the same medications prescribed for the treatment of UTIs. Following acute pyelonephritis treatment, the patient may develop a chronic or recurring symptomless infection persisting for months or years. After the initial antibiotic regimen, the patient may need antibiotic therapy for up to 6 weeks if a relapse occurs. A follow-up urine culture is obtained 2 weeks after completion of antibiotic therapy to document clearing of the infection. Hydration with oral or parenteral fluids is essential in all patients with UTIs when there is adequate kidney function. Hydration helps facilitate "flushing" of the urinary tract and reduces pain and discomfort.

Erectile Dysfunction Nursing Management

Personal satisfaction and the ability to sexually satisfy a partner are common concerns of patients. Men with illnesses and disabilities may need the assistance of a sex therapist to identify, implement, and integrate their sexual beliefs and behaviors into a healthy and satisfying lifestyle. The nurse can inform patients about support groups for men with erectile dysfunction and their partners.

BPH Pharmacologic Therapy

Pharmacologic treatment for BPH includes the use of alpha-adrenergic blockers and 5-alpha-reductase inhibitors. Alpha-adrenergic blockers, which include alfuzosin (Uroxatral), terazosin (Hytrin), doxazosin (Cardura), and tamsulosin, relax the smooth muscle of the bladder neck and prostate. This improves urine flow and relieves symptoms of BPH. Side effects include dizziness, headache, asthenia/fatigue, postural hypotension, rhinitis, and sexual dysfunction. Another method of treatment involves hormonal manipulation with antiandrogen agents. The 5-alpha-reductase inhibitors finasteride (Proscar) and dutasteride (Avodart) are used to prevent the conversion of testosterone to DHT and decrease prostate size. Side effects include decreased libido, ejaculatory dysfunction, erectile dysfunction, gynecomastia (breast enlargement), and flushing. Combination therapy (doxazosin and finasteride) has decreased symptoms and reduced clinical progression of BPH. The use of alternative and complementary phytotherapeutic agents and other dietary supplements (Serenoa repens [saw palmetto berry] and Pygeum africanum [African plum]) are not recommended by the medical community, although they are commonly used. They may function by interfering with the conversion of testosterone to DHT. In addition, S. repens may directly block the ability of DHT to stimulate prostate cell growth. These agents should not be used with finasteride, dutasteride, or estrogen-containing medications.

Phimosis

Phimosis is a condition in which the foreskin (prepuce) cannot be retracted over the glans in uncircumcised males. With the decrease in routine circumcision of newborns, early instruction should be given to parents about cleansing the foreskin and the need for retraction to cleanse the glans. If the glans is not cleaned, secretions accumulate, causing inflammation of the glans penis (balanitis), which can later lead to adhesions and fibrosis. Phimosis often develops in adults as a result of inflammation, edema, and constriction because of poor hygiene or underlying medical conditions such as diabetes. The thickened secretions (smegma) can become encrusted with urinary salts and calcify, forming calculi in the prepuce and increasing the risk of penile carcinoma. Treatment for phimosis secondary to inflammation is the application of steroidal cream to the foreskin to soften and correct the narrowness, resulting in decreased constriction. Although phimosis is the most common indication for adult circumcision, it is rarely necessary to surgically correct the condition by loosening or removing the foreskin. Paraphimosis is a condition in which the foreskin, once retracted over the glans, cannot be returned to its usual position. Chronic inflammation under the foreskin leads to formation of a tight ring of skin when the foreskin is retracted behind the glans, causing venous congestion, edema, and enlargement of the glans, which makes the condition worse. As the condition progresses, arterial occlusion and necrosis of the glans may occur. Paraphimosis usually can be treated by firmly compressing the glans for 5 minutes to reduce the tissue edema and size and then pushing the glans back while simultaneously moving the foreskin forward (manual reduction). The constricting skin ring may require incision under local anesthesia. Circumcision is usually indicated after the inflammation and edema subside.

Erectile Dysfunction Pharmacologic Therapy

Phosphodiesterase type 5 (PDE-5) inhibitors (oral medications that are used to treat erectile dysfunction) are first-line therapy. Currently available PDE-5 inhibitors include sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). Each of these agents has a similar mechanism of action but a different pharmacologic action and clinical use. Erection involves the release of nitric oxide in the vasculature of the corpus cavernosum as a result of sexual stimulation. This subsequently leads to smooth muscle relaxation in blood vessels supplying the corpus cavernosum, resulting in increased blood flow and an erection. During sexual stimulation, PDE-5 inhibitors increase blood flow to the penis. When PDE-5 inhibitors are taken about 1 hour before sexual activity, they are effective in producing an erection with sexual stimulation; the erection can last about 1 to 2 hours. The most common side effects of these medications include headache, flushing, dyspepsia, diarrhea, nasal congestion, and lightheadedness. These agents are contraindicated in men who take organic nitrates (e.g., isosorbide [Isordil], nitroglycerin), because taken together, these medications can cause side effects such as severe hypotension. In addition, PDE-5 inhibitors must be used with caution in patients with retinopathy, especially in those with diabetic retinopathy. For patients in whom PDE-5 inhibitors are contraindicated or ineffective, other pharmacologic measures to induce erections include injecting vasoactive agents, such as alprostadil, papaverine, and phentolamine, directly into the penis. Complications include priapism (a persistent abnormal erection) and development of fibrotic plaques at the injection sites. Alprostadil is also formulated in a gel pellet that can be inserted into the tip of the urethra with an applicator to create an erection.

Disorders of Ejaculation

Premature ejaculation (PE) is defined as the occurrence of ejaculation sooner than desired, either before or shortly after penetration, causing distress to either one or both partners. It is one of the most common complaints of men or couples, affecting 20% to 30% of men. The spectrum of responses ranges from occasional ejaculation with intercourse or self-stimulation to complete inability to ejaculate under any circumstances. Various forms of PE have been identified: (1) lifelong PE caused by neurobiologic or genetic conditions, (2) acquired PE (medical or psychological), (3) natural variable PE (normal variation), and (4) prematurelike ejaculatory dysfunction (psychological). In young men ages 18 to 25 years, factors associated with PE and erectile dysfunction include smoking, use of illegal drugs or medications without prescriptions, poor physical and mental health, lack of physical activity and lack of sexual experience. Other ejaculatory problems may include inhibited (delayed or retarded) ejaculation, which is the involuntary inhibition of the ejaculatory reflex. Retrograde ejaculation occurs when semen travels toward the bladder instead of exiting through the penis, resulting in infertility. This form of PE may occur after prior prostate or urethral surgery, with diabetes, or with the use of medications such as antihypertensive agents.Evaluation of PE involves a thorough sexual history focusing on the duration of symptoms, time to ejaculation, degree of voluntary control over ejaculation, frequency of occurrence, and course of the problem since the first sexual encounter. Treatment, which depends on the nature and severity of PE and perceived distress that it causes, includes behavioral and psychological approaches, as well as pharmacologic therapy that attempts to alter the sensory input or retard the ejaculatory response. Behavioral therapy (e.g., counseling, sex therapy, psychoeducation, and couples therapy) often involves both the man and his sexual partner. The couple is encouraged to identify their sexual needs and to communicate those needs to each other. Pharmacologic management involves selective serotonin reuptake inhibitors dapoxetine (Priligy), alpha1 adrenoceptor antagonists, the tricyclic antidepressant clomipramine (Anafranil), and topical anesthetic agents. In some cases, a combination of pharmacologic and behavioral therapy may be effective. Inhibited ejaculation is most often caused by psychological factors, neurologic disorders (e.g., SCI, multiple sclerosis, neuropathy secondary to diabetes), surgery (prostatectomy), and medications. Chemical, vibratory, and electrical methods of stimulation have been used with some success. Treatment usually addresses the physical and psychological factors involved in inhibited ejaculation. Although outpatient therapy may involve numerous sessions (12 to 18), it often results in a success rate of 70% to 80%. The outcome depends on a previous satisfying sexual experience history, a short duration of the ejaculatory problem, feelings of sexual desire, feelings of attraction to one's sexual partner, motivation for treatment, and absence of serious psychological problems. For men with retrograde ejaculation, the urine may be collected shortly after ejaculation, revealing a large amount of sperm in the urine. This urine may also be collected to obtain adequate viable sperm for use in artificial insemination. In men with SCI, techniques that may be used to obtain sperm for artificial insemination include self-stimulation, vibratory stimulation, or electroejaculation. Electroejaculation involves the use of a specially designed probe that is inserted into the rectum next to the prostate. The probe delivers a current that stimulates the nerves and produces contraction of the pelvic muscles and ejaculation. However, spontaneous or stimulated ejaculation may cause autonomic dysreflexia (overstimulation of the autonomic nervous system) in patients with SCI at T6 or higher, creating a life-threatening situation. If this disorder is not treated promptly, it may lead to seizures, stroke, and even death.

Acute Glomerulonephritis Pathophysiology

Primary glomerular diseases include postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, membrane proliferative glomerulonephritis, and membranous glomerulonephritis. Postinfectious causes are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks. It may also follow impetigo (infection of the skin) and acute viral infections (upper respiratory tract infections, mumps, varicella zoster virus, Epstein-Barr virus, hepatitis B, and human immune deficiency virus [HIV] infection). In some patients, antigens outside the body (e.g., medications, foreign serum) initiate the process, resulting in antigen-antibody complexes being deposited in the glomeruli. In other patients, the kidney tissue itself serves as the inciting antigen.

Prostate Cancer

Prostate cancer is the most common cancer in men other than nonmelanoma skin cancer. It is the second most common cause of cancer death in American men, exceeded only by lung cancer, and is responsible for 10% of cancer-related deaths in men. Among men diagnosed with prostate cancer, 98% survive at least 5 years, 84% survive at least 10 years, and 56% survive 15 years. Other risk factors for prostate cancer include increasing age; the incidence of prostate cancer increases rapidly after the age of 50 years. More than 70% of cases occur in men older than 65 years. A familial predisposition may occur in men who have a father or brother previously diagnosed with prostate cancer, especially if their relatives were diagnosed at a young age. Genes that may be associated with increased risk of prostate cancer include hereditary prostate cancer 1 (HPC1) and BRCA1 and BRCA2 mutations. The risk of prostate cancer is also greater in men whose diet contains excessive amounts of red meat or dairy products that are high in fat. Endogenous hormones, such as androgens and estrogens, also may be associated with the development of prostate cancer.

Prostatitis

Prostatitis is an inflammation of the prostate gland that is often associated with lower urinary tract symptoms and symptoms of sexual discomfort and dysfunction. The condition affects 5% to 10% of men. It is the most common urologic diagnosis in men younger than 50 years and the third most common such diagnosis in men older than 50 years. Prostatitis may be caused by infectious agents (bacteria, fungi, mycoplasma) or other conditions (e.g., urethral stricture, BPH). Escherichia coli is the most commonly isolated organism, although Klebsiella and Proteus species are also found. The microorganisms colonize the urinary tract and ascend to the prostate, ultimately causing infection. The causal pathogen is usually the same in recurrent infections. There are four types of prostatitis: acute bacterial prostatitis (type I), chronic bacterial prostatitis (type II), chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) (type III), and asymptomatic inflammatory prostatitis (type IV). Type III, which occurs in more than 90% of cases, is further classified as type IIIA or type IIIB, depending on the presence (type IIIA) or absence (type IIIB) of white blood cells in semen after prostate massage.

Nephrotic Syndrome Assessment and Diagnostic Findings

Proteinuria (predominately albumin) exceeding 3.5 g/day is the hallmark of the diagnosis of nephrotic syndrome. Protein electrophoresis and immunoelectrophoresis may be performed on the urine to categorize the type of proteinuria. The urine may also contain increased white blood cells (WBCs) as well as granular and epithelial casts. A needle biopsy of the kidney may be performed for histologic examination of renal tissue to confirm the diagnosis.

Upper Urinary Tract Infections

Pyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys. Causes involve either the upward spread of bacteria from the bladder or spread from systemic sources reaching the kidney via the bloodstream. Pathogenic bacteria from a bladder infection can ascend into the kidney, resulting in pyelonephritis. An incompetent ureterovesical valve or obstruction occurring in the urinary tract increases the susceptibility of the kidneys to infection, because static urine provides a good medium for bacterial growth. Bladder or prostate tumors, strictures, benign prostatic hyperplasia, and urinary stones are some potential causes of obstruction that can lead to infections. Systemic infections (such as tuberculosis) can spread to the kidneys and result in abscesses.

Prostate Cancer Surgical Management

Radical prostatectomy is considered first-line treatment for prostate cancer and is used with patients whose tumor is confined to the prostate. It is the complete surgical removal of the prostate, seminal vesicles, tips of the vas deferens, and often the surrounding fat, nerves, and blood vessels. Laparoscopic radical prostatectomy and robotic-assisted laparoscopic radical prostatectomy have become the standard surgical approaches for localized cancer of the prostate. Although sexual impotence is a common side effect, these laparoscopic radical prostatectomy approaches result in low morbidity and more favorable postoperative outcomes, including improved quality of life and less sexual dysfunction if the nerves are spared. Surgical approaches are discussed in detail later in this chapter.

Chronic Pyelonephritis

Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis.

Assessment and Diagnostic Findings of a UTI

Results of various tests, such as bacterial colony counts, cellular studies, and urine cultures, help confirm the diagnosis of UTI. In an uncomplicated UTI, the strain of bacteria determines the antibiotic of choice

Penis Transplants

The first successful penis transplant was performed in 2014 in Cape Town, South Africa. In the United States, a few medical centers have protocols for penis transplants. Candidates for transplantation include military veterans and other men who have suffered traumatic penile injuries. It is believed that men undergoing this surgery will have their ability to urinate and their sexual functioning restored.

Minimally Invasive Therapy

Several forms of minimally invasive therapy may be used to treat BPH. Transurethral microwave thermotherapy (TUMT) involves the application of heat to prostatic tissue. High-energy TUMT devices (CoreTherm, Prostatron, Targis) and low-energy devices (TherMatrx) are available. A transurethral probe is inserted into the urethra, and microwaves are directed to the prostate tissue. The targeted tissue becomes necrotic and sloughs. To minimize damage to the urethra and decrease the discomfort from the procedure, some systems have a water-cooling apparatus. Other minimally invasive treatment options include (transurethral needle ablation [TUNA]) by radiofrequency energy and the UroLume stent. TUNA uses low-level radiofrequencies delivered by thin needles placed in the prostate gland to produce localized heat that destroys prostate tissue while sparing other tissues. The body then reabsorbs the dead tissue. Prostatic stents are associated with significant complications (e.g., encrustation, infection, chronic pain); therefore, they are used only for patients with urinary retention and in patients who are poor surgical risks

Lower Urinary Tract Infections

Several mechanisms maintain the sterility of the bladder: the physical barrier of the urethra, urine flow, ureterovesical junction competence, various antibacterial enzymes and antibodies, and antiadherent effects mediated by the mucosal cells of the bladder. Abnormalities or dysfunctions of these mechanisms are contributing risk factors for lower UTIs

Clinical Manifestations

Signs and symptoms of UTI depend on whether the infection involves the lower (bladder) or upper (kidney) urinary tract and whether the infection is acute or chronic. Signs and symptoms of an uncomplicated lower UTI include burning on urination, urinary frequency (voiding more than every 3 hours), urgency, nocturia (awakening at night to urinate), incontinence, and suprapubic or pelvic pain. Hematuria and back pain may also be present. In older adults, these symptoms are less common (see Gerontologic Considerations section). In patients with complicated UTIs, manifestations can range from asymptomatic bacteriuria to gram-negative sepsis with shock. Complicated UTIs often are caused by a broader spectrum of organisms, have a lower response rate to treatment, and tend to recur. Many patients with catheter-associated UTIs are asymptomatic; however, any patient with a catheter who suddenly develops signs and symptoms of septic shock should be evaluated for urosepsis (the spread of infection from the urinary tract to the bloodstream that results in a systemic infection).

BPHSurgical Resection

Surgical resection of the prostate gland is another option for patients with moderate to severe lower urinary tract symptoms of BPH and for those with acute urinary retention or other complications. The specific surgical approach (open or endoscopic) and the energy source (electrocautery vs. laser) are based on the surgeon's experience, the size of the prostate gland, the presence of other medical disorders, and the patient's preference. If surgery is to be performed, all clotting defects must be corrected and medications for anticoagulation withheld because bleeding is a potential complication of prostate surgery. Transurethral resection of the prostate (TURP) remains the benchmark for surgical treatment for BPH. It involves the surgical removal of the inner portion of the prostate through an endoscope inserted through the urethra; no external skin incision is made. It can be performed with ultrasound guidance. The treated tissue either vaporizes or becomes necrotic and sloughs. The procedure is performed in the outpatient setting and usually results in less postoperative bleeding than a traditional surgical prostatectomy. Other surgical options for BPH include transurethral incision of the prostate (TUIP), transurethral electrovaporization, laser therapy, and open prostatectomy. TUIP is an outpatient procedure used to treat smaller prostates. One or two cuts are made in the prostate and prostate capsule to reduce constriction of the urethra and decrease resistance to flow of urine out of the bladder; no tissue is removed. Open prostatectomy involves the surgical removal of the inner portion of the prostate via a suprapubic, retropubic, or perineal (rare) approach for large prostate glands. Prostatectomy may also be performed laparoscopically or by robotic-assisted laparoscopy. Nursing management of patients undergoing these procedures is described later in this chapter.

Chronic Glomerulonephritis Pathology

The kidneys are reduced to as little as one fifth their normal size (consisting largely of fibrous tissue). The cortex layer shrinks to 1 to 2 mm in thickness or less. Bands of scar tissue distort the remaining cortex, making the surface of the kidney rough and irregular. Numerous glomeruli and their tubules become scarred, and the branches of the renal artery are thickened. The resulting severe glomerular damage can progress to stage 5 CKD and require a renal replacement therapy.

Testicular Cancer Medical Management

Testicular cancer—one of the most curable solid tumors—is highly responsive to treatment. Early-stage disease is curable more than 95% of the time; thus, prompt diagnosis and treatment are essential. The NCCN practice consensus guidelines for testicular cancer are used to guide diagnostic workup, primary treatment, follow-up, and salvage therapy (treatment given when the cancer does not respond to standard treatment) for both seminomas and nonseminomas. The goals of management are to eradicate the disease and achieve a cure. Therapy is based on the cell type, the stage of the disease, and risk classification tables (determined as good, intermediate, and poor risk). Primary treatment includes removal of the affected testis by orchiectomy through an inguinal incision with a high ligation of the spermatic cord. The patient is offered the option of implantation of a testicular prosthesis during the orchiectomy. Although most patients experience no impairment of endocrine function after unilateral orchiectomy for testicular cancer, some patients have decreased hormonal levels, suggesting that the unaffected testis is not functioning normally. Retroperitoneal lymph node dissection (RPLND) may be performed after orchiectomy to diagnose and prevent lymphatic spread of the cancer. Alternatives to the more invasive open RPLND for early-stage germ cell testicular cancer include nerve-sparing and laparoscopic RPLND, which improve sexual function and promote rapid recovery. Although libido and orgasm are usually unimpaired after RPLND, ejaculatory dysfunction with resultant infertility may develop. Two thirds of men who are newly diagnosed with testicular cancer may be considering future fatherhood, and sperm quality is reduced in men with testicular cancer; therefore, sperm banking before treatment may be considered. Half of patients will not recover fertility as a result of radiation therapy, cytotoxic therapy, unilateral excision of a testis, and RPLND. Counseling about fertility issues may help the patient make the appropriate choices.

Testicular Torsion

Testicular torsion is a surgical emergency requiring immediate diagnosis to avoid loss of the testicle. Torsion of the testis is rotation of the testis, which twists the blood vessels in the spermatic cord and therefore impedes the arterial and venous supply to the testicle and surrounding structures in the scrotum. The patient presents with sudden pain in the testicle, developing over 1 to 2 hours, with or without a predisposing event. Nausea, lightheadedness, and swelling of the scrotum may develop. On physical examination, testicular tenderness, an elevated testis, a thickened spermatic cord, and a swollen, painful scrotum may be present. If the torsion cannot be reduced manually, surgery to untwist the spermatic cord and anchor both testes in their correct position to prevent recurrence should occur within 6 hours of the onset of symptoms in order to save the testis. After 6 hours of impaired blood supply, the risk of loss of the testicle increases.

BPH Pathophysiology

The cause of BPH is not well understood, but testicular androgens have been implicated. Dihydrotestosterone (DHT), a metabolite of testosterone, is a critical mediator of prostatic growth. Estrogens may also play a role in the cause of BPH; BPH generally occurs when men have elevated estrogen levels and when prostate tissue becomes more sensitive to estrogens and less responsive to DHT. Smoking, heavy alcohol consumption, obesity, reduced activity level, hypertension, heart disease, diabetes, and a Western diet (high in animal fat and protein and refined carbohydrates, low in fiber) are risk factors for BPH. BPH develops over a prolonged period; changes in the urinary tract are slow and insidious. BPH is a result of complex interactions involving resistance in the prostatic urethra to mechanical and spastic effects, bladder pressure during voiding, detrusor muscle strength, neurologic functioning, and general physical health. The hypertrophied lobes of the prostate may obstruct the bladder neck or urethra, causing incomplete emptying of the bladder and urinary retention. As a result, a gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis) can occur. Urinary retention may result in UTIs because urine that remains in the urinary tract serves as a medium for infective organisms.

Erectile Dysfunction Assessment and Diagnostic Findings

The diagnosis of erectile dysfunction requires a sexual and medical history; an analysis of presenting symptoms; a physical examination, including a neurologic examination; a detailed assessment of all medications, alcohol, and drugs used; and various laboratory studies. Nocturnal penile tumescence tests are conducted to monitor changes in penile circumference. This test can help to determine if erectile impotence has an organic or a psychological cause. In healthy men, nocturnal penile erections closely parallel rapid eye movement (REM) sleep in occurrence and duration. Organically impotent men show inadequate sleep-related erections that correspond to their waking performance. Arterial blood flow to the penis is measured using a Doppler probe. In addition, nerve conduction tests and extensive psychological evaluations may be carried out.

Prostatitis Nursing/Medical Management

The goal of treatment is to eradicate the causal organisms. Hospital admission may be necessary for patients with unstable vital signs, sepsis, or intractable pelvic pain; those who are frail or immunosuppressed; or those who have diabetes or renal insufficiency. Specific treatment is based on the type of prostatitis and on the results of culture and sensitivity testing of the urine. If bacteria are cultured from the urine, antibiotic agents, including trimethoprim-sulfamethoxazole (Bactrim) or a fluoroquinolone (e.g., ciprofloxacin [Cipro]), may be prescribed, and continuous therapy with low-dose antibiotic agents may be used. If the patient is afebrile and has a normal urinalysis, anti-inflammatory agents may be used. Alpha-adrenergic blocker therapy (e.g., tamsulosin [Flomax]), may be prescribed to promote bladder and prostate relaxation. Factors contributing to prostatitis, including stress, neuromuscular factors, and myofascial pain, are also addressed. Supportive, nonpharmacologic therapies may be prescribed. These include biofeedback, pelvic floor training, physical therapy, reduction of prostatic fluid retention by ejaculation through sexual intercourse or masturbation, sitz baths, stool softeners, and evaluation of sexual partners to reduce the possibility of cross-infection. If the patient experiences symptoms of acute prostatitis (fever, severe pain and discomfort, inability to urinate, malaise), he may be hospitalized for intravenous (IV) antibiotic therapy. Nursing management includes administration of prescribed antibiotic agents and provision of comfort measures, including prescribed analgesic agents and sitz baths. The patient with chronic prostatitis is usually treated on an outpatient basis and needs to be educated about the importance of continuing antibiotic therapy and recognizing recurrent signs and symptoms of prostatitis.

BPH Medical Management

The goals of medical management of BPH are to improve quality of life, improve urine flow, relieve obstruction, prevent disease progression, and minimize complications. Treatment depends on the severity of symptoms, the cause of disease, the severity of the obstruction, and the patient's condition. If a patient is admitted on an emergency basis because he is unable to void, he is immediately catheterized. The ordinary catheter may be too soft and pliable to advance through the urethra into the bladder. In such cases, a thin wire (stylet) is introduced (by a urologist) into the catheter to prevent the catheter from collapsing when it encounters resistance. A metal catheter with a pronounced prostatic curve may be used if obstruction is severe. A cystostomy (incision into the bladder) may be needed to provide urinary drainage. Discussion of all treatment options by the primary provider enables the patient to make an informed decision based on symptom severity, the effect of BPH on his quality of life, and preference. Patients with mild symptoms and patients with moderate or severe symptoms who are not bothered by them and have not developed complications may be managed with "watchful waiting." With this approach, the patient is monitored and reexamined annually but receives no active intervention.

BPH Assessment and Diagnostic Findings

The health history focuses on the urinary tract, previous surgical procedures, general health issues, family history of prostate disease, and fitness for possible surgery. A patient voiding diary is used to record voiding frequency and urine volume. A DRE often reveals a large, rubbery, and nontender prostate gland. A urinalysis to screen for hematuria and UTI is recommended. A PSA level is obtained if the patient is without a terminal disease and for whom knowledge of the presence of prostate cancer would change management. The American Urological Association (AUA) Symptom Index or International Prostate Symptom Score (IPSS) can be used to assess the severity of symptoms. Other diagnostic tests may include recording urinary flow rate and the measurement of postvoid residual urine. If invasive therapy is considered, urodynamic studies, urethrocystoscopy, and ultrasound may be performed. Complete blood studies are performed. Cardiac status and respiratory function are assessed because a high percentage of patients with BPH have cardiac or respiratory disorders due to their age.

Acute Pharmacologic Therapy

The ideal medication for treatment of UTI is an antibacterial agent that eradicates bacteria from the urinary tract with minimal effects on fecal and vaginal flora, thereby minimizing the incidence of vaginal yeast infections. The antibacterial agent should be affordable and should have few adverse effects and low resistance. Because the organism in initial, uncomplicated UTIs in women is most likely E. coli or other fecal flora, the agent should be effective against these organisms. Various treatment regimens have been successful in treating uncomplicated lower UTIs in women: single-dose administration, short-course (3-day) regimens, or 7-day regimens (Hopkins et al., 2014). The trend is toward a shortened course of antibiotic therapy for uncomplicated UTIs, because most cases are cured after 3 days of treatment. Medications commonly used to treat UTIs are listed in Table 55-1. Regardless of the regimen prescribed, the patient is instructed to take all doses prescribed, even if relief of symptoms occurs promptly. Longer medication courses are indicated for men, pregnant women, and women with pyelonephritis and other types of complicated UTIs. Hospitalization and intravenous (IV) antibiotics are occasionally necessary (Hopkins et al., 2014).

Gerontologic Considerations

The incidence of bacteriuria in older adults differs from that in younger adults. Bacteriuria increases with age and disability, and women are affected more frequently than men. UTI is the most common infection of older adults and increases in prevalence with age. UTIs occur more frequently in women than in men at younger ages but the gap between the sexes narrows in later life, which is due to reduced sexual intercourse in women and a higher incidence of bladder outlet obstruction secondary to benign prostatic hyperplasia in men. In older adults, structural abnormalities secondary to decreased bladder tone, neurogenic bladder (dysfunctional bladder) secondary to stroke, or autonomic neuropathy of diabetes may prevent complete emptying of the bladder and increase the risk of UTI. When indwelling catheters are used, the risk of UTI increases dramatically. Older women often have incomplete emptying of the bladder and urinary stasis. In the absence of estrogen, postmenopausal women are susceptible to colonization and increased adherence of bacteria to the vagina and urethra. Oral or topical estrogen has been used to restore the glycogen content of vaginal epithelial cells and an acidic pH for some postmenopausal women with recurrent cystitis. The antibacterial activity of prostatic secretions that protect men from bacterial colonization of the urethra and bladder decreases with aging. The use of catheterization or cystoscopy in evaluation or treatment for prostatic hyperplasia or carcinoma, strictures of the urethra, and neuropathic bladder may contribute to the higher incidence of UTIs in men. The incidence of bacteriuria also increases in men with confusion, dementia, or bowel or bladder incontinence. The most common cause of recurrent UTIs in older males is chronic bacterial prostatitis. Resection of the prostate gland may help reduce its incidence.

Prostatitis Educating Patients About Self-Care

The nurse educates the patient about the importance of completing the prescribed course of antibiotic therapy. If IV antibiotic agents are to be given at home, the nurse educates the patient and family about correct and safe administration. Arrangements for a home care nurse to oversee administration may be needed. Warm sitz baths (10 to 20 minutes) may be taken several times daily. Fluids are encouraged to satisfy thirst but are not "forced," because an effective medication level must be maintained in the urine. Foods and liquids with diuretic action or that increase prostatic secretions, such as alcohol, coffee, tea, chocolate, cola, and spices, should be avoided. A suprapubic catheter may be necessary for severe urinary retention. During periods of acute inflammation, sexual arousal and intercourse should be avoided. To minimize discomfort, the patient should avoid sitting for long periods. Medical follow-up is necessary for at least 6 months to 1 year, because prostatitis caused by the same or different organisms can recur. The patient is advised that the UTI may recur and is educated to recognize its symptoms.

Acute Glomerulonephritis Clinical Manifestations

The primary presenting features of an acute glomerular inflammation are hematuria, edema, azotemia (an abnormal concentration of nitrogenous wastes in the blood), and proteinuria (excess protein in the urine). The hematuria may be microscopic (identifiable only through microscopic examination) or macroscopic (visible to the eye). The urine may appear cola colored because of red blood cells (RBCs) and protein plugs or casts; RBC casts indicate glomerular injury. Glomerulonephritis may be mild and the hematuria discovered incidentally through a routine urinalysis, or the disease may be severe, with AKI and oliguria.

Relieving pain of a UTI

The pain associated with a UTI is quickly relieved once effective antimicrobial therapy is initiated. Antispasmodic agents may also be useful in relieving bladder irritability and pain. Analgesic agents and the application of heat to the perineum help relieve pain and spasm. The patient is encouraged to drink liberal amounts of fluids (water is the best choice) to promote renal blood flow and to flush the bacteria from the urinary tract. Urinary tract irritants (e.g., coffee, tea, citrus, spices, colas, alcohol) should be avoided. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely, because doing so can lower urine bacterial counts, reduce urinary stasis, and prevent reinfection

Chronic Pyelonephritis Nursing Management

The patient may require hospitalization or may be treated as an outpatient. When the patient requires hospitalization, fluid intake and output are carefully measured and recorded. Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. The nurse assesses the patient's temperature every 4 hours and administers antipyretic and antibiotic agents as prescribed. Patient education focuses on prevention of further infection by consuming adequate fluids, emptying the bladder regularly, and performing recommended perineal hygiene. The importance of taking antimicrobial medications exactly as prescribed is stressed, as is the need for keeping follow-up appointments.

Acute Pyelonephritis Clinical Manifestations

The patient with acute pyelonephritis has chills, fever, leukocytosis, bacteriuria, and pyuria. Low back pain, flank pain, nausea and vomiting, headache, malaise, and painful urination are common findings. Physical examination reveals pain and tenderness in the area of the costovertebral angle. In addition, symptoms of lower urinary tract involvement, such as urgency and frequency, are common.

Chronic Pyelonephritis Clinical Manifestations

The patient with chronic pyelonephritis usually has no symptoms of infection unless an acute exacerbation occurs. Noticeable signs and symptoms may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Persistent and recurring infection may produce progressive scarring of the kidney, resulting in chronic kidney disease

Acute Glomerulonephritis Clinical Manifestations

The primary presenting features of an acute glomerular inflammation are hematuria, edema, azotemia (an abnormal concentration of nitrogenous wastes in the blood), and proteinuria (excess protein in the urine). The hematuria may be microscopic (identifiable only through microscopic examination) or macroscopic (visible to the eye). The urine may appear cola colored because of red blood cells (RBCs) and protein plugs or casts; RBC casts indicate glomerular injury. Glomerulonephritis may be mild and the hematuria discovered incidentally through a routine urinalysis, or the disease may be severe, with AKI and oliguria. Some degree of edema and hypertension is present in most patients. Marked proteinuria due to the increased permeability of the glomerular membrane may also occur, with associated pitting edema, hypoalbuminemia, hyperlipidemia, and fatty casts in the urine. Blood urea nitrogen (BUN) and serum creatinine levels may increase as urine output decreases. In addition, anemia may be present. In the more severe form of the disease, patients also complain of headache, malaise, and flank pain. Older patients may experience circulatory overload with dyspnea, engorged neck veins, cardiomegaly, and pulmonary edema. Atypical symptoms include confusion, somnolence, and seizures, which are often confused with the symptoms of a primary neurologic disorder.

Epididymitis Nursing/Medical Management

The selection of an antibiotic depends on the causative organism; if epididymitis is associated with an STI, the patient's partner should also receive antimicrobial therapy. The spermatic cord may be infiltrated with a local anesthetic agent to relieve pain if the patient is seen within the first 24 hours after onset of pain. Supportive interventions also include reduction in physical activity, scrotal support and elevation, ice packs, anti-inflammatory agents, analgesics (including nerve blocks), and sitz baths. Urethral instrumentation (e.g., catheter insertion) is avoided. The patient is observed for scrotal abscess formation as well. In chronic epididymitis, a 4- to 6-week course of antibiotic therapy for bacterial pathogens is prescribed. An epididymectomy (excision of the epididymis from the testis) may be performed for patients who have recurrent, refractory, incapacitating episodes of this infection. With long-term epididymitis, the passage of sperm may be obstructed. If the obstruction is bilateral, infertility may result. Bed rest is prescribed, and the scrotum is elevated with a scrotal bridge or folded towel to prevent traction on the spermatic cord, to promote venous drainage, and to relieve pain. Antimicrobial agents are given as prescribed until the acute inflammation subsides. Intermittent cold compresses to the scrotum may help ease the pain. Later, local heat or sitz baths may help resolve the inflammation. Analgesic medications are given for pain relief as prescribed. The nurse instructs the patient to avoid straining, lifting, and sexual stimulation until the infection is under control. He should continue taking analgesic agents and antibiotics as prescribed and using ice packs if necessary to relieve discomfort. He needs to know that it may take 4 weeks or longer for the inflammation to resolve.

Testicular Cancer Clinical Manifestations

The symptoms appear gradually, with a mass or lump on the testicle and usually painless enlargement of the testis. The patient may report heaviness in the scrotum, inguinal area, or lower abdomen. Backache (from retroperitoneal node extension), abdominal pain, weight loss, and general weakness may result from metastasis. Enlargement of the testis without pain is a significant diagnostic finding. Some testicular tumors tend to metastasize early, spreading from the testis to the lymph nodes in the retroperitoneum and to the lungs.

Chronic Glomerulonephritis Clinical Manifestations

The symptoms of chronic glomerulonephritis vary. Some patients with severe disease have no symptoms at all for many years. The condition may be discovered when hypertension or elevated BUN and serum creatinine levels are detected. Most patients report general symptoms, such as loss of weight and strength, increasing irritability, and an increased need to urinate at night (nocturia). Headaches, dizziness, and digestive disturbances are also common. As chronic glomerulonephritis progresses, signs and symptoms of CKD may develop. The patient appears poorly nourished, with a yellow-gray pigmentation of the skin and periorbital and peripheral (dependent) edema. Blood pressure may be normal or severely elevated. Retinal findings include hemorrhage, exudate, narrowed tortuous arterioles, and papilledema. Anemia causes pale mucous membranes. Cardiomegaly, a gallop rhythm, distended neck veins, and other signs and symptoms of heart failure may be present. Crackles can be heard in the bases of the lungs. Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with a pericardial friction rub and pulsus paradoxus (difference in blood pressure during inspiration and expiration of greater than 10 mmHg).

Classification of Testicular Tumors ( Testicular Cancer)

The testicles contain several types of cells, each of which may develop into one or more types of cancer. The type of cancer cell determines the appropriate treatment and affects the prognosis. Testicular cancer is classified as germinal or nongerminal (stromal). Secondary testicular cancers may also occur.

Erectile Dysfunction Medical Management

Treatment can be medical, surgical, or both, depending on the cause. Treatment of erectile dysfunction includes therapy for associated disorders (e.g., alcoholism, diabetes) or adjustment of medications. Endocrine therapy instituted to treat erectile dysfunction secondary to hypothalamic-pituitary-gonadal dysfunction may reverse the condition. Insufficient penile blood flow may be treated with vascular surgery. Patients with erectile dysfunction from psychogenic causes are referred to a health care provider or therapist who specializes in sexual dysfunction. Patients with erectile dysfunction secondary to organic causes may be candidates for penile implants. Currently available therapies for the treatment of erectile dysfunction include pharmacologic therapy (including urethral suppositories), penile implants, and vacuum constriction devices. These options should be considered in a stepwise fashion, with increasing invasiveness and risk balanced against the likelihood of efficacy. The patient and, if possible, his partner, should be informed of the relevant treatment options and their associated risks and benefits. The choice of treatment is made jointly by the primary provider, patient, and partner, taking into consideration patient preferences and expectations.

Prostate Cancer Medical Management

Treatment is based on the patient's life expectancy, symptoms, risk of recurrence after definitive treatment, size of the tumor, Gleason score, PSA level, likelihood of complications, and patient preference. Therapy is often guided by the use of a nomogram or risk stratification scheme suggested by the clinical practice guidelines. A multidisciplinary team approach is essential for the development of appropriate treatment. Management may be nonsurgical and involve watchful waiting or be surgical and entail prostatectomy. For patients with prostate cancer who choose nonsurgical watchful waiting, this approach involves actively monitoring the course of disease and intervening only if the cancer progresses or if symptoms warrant other intervention. It is an option for patients with life expectancy of less than 5 years and low-risk cancers. Advantages include absence of side effects of more aggressive treatment, improved quality of life, avoidance of unnecessary treatment, and decreased initial costs. Disadvantages include missed chance at cure, risk of metastasis, subsequent need for more aggressive treatment, anxiety about living with untreated cancer, and need for frequent monitoring. Therapeutic vaccines kill existing cancer cells and provide long-lasting immunity against further cancer development. In 2010, the U.S. Food and Drug Administration (FDA) approved the first therapeutic cancer vaccine, sipuleucel-T (Provenge), for use in men with metastatic prostate cancer that is no longer responding to hormone therapy. In addition, two other medications, abiraterone acetate (Zytiga) and cabazitaxel (Jevtana injection) are treatments options for patients requiring care for the management of metastatic castration-resistant prostate cancer, which does not respond to sipuleucel-T or the usual treatment options.

Nephrotic Syndrome Nursing/Medical Management

Treatment is focused on addressing the underlying disease state causing proteinuria, slowing progression of CKD, and relieving symptoms. Typical treatment includes diuretic agents for edema, ACE inhibitors to reduce proteinuria, and lipid-lowering agents for hyperlipidemia. In the early stages of nephrotic syndrome, nursing management is similar to that of the patient with acute glomerulonephritis, but as the condition worsens, management is similar to that of the patient with ESKD (see the following section). Patients with nephrotic syndrome need adequate instruction about the importance of following all medication and dietary regimens so that their condition can remain stable as long as possible. Patients must be made aware of the importance of communicating any health-related change to their primary providers as soon as possible so that appropriate medication and dietary changes can be made before further changes occur within the glomeruli.

Penile Implants

Two general types of penile implants are available: the malleable, noninflatable, nonhydraulic prosthesis (also called the semirigid rod) and the inflatable, hydraulic prostheses. The semirigid rod (e.g., the Small-Carrion prosthesis) results in a permanent semierection but can be bent into an unnoticeable position when appropriate. The inflatable prosthesis simulates natural erections and natural flaccidity. Complications after implantation include infection, erosion of the prosthesis through the skin (more common with the semirigid rod than with the inflatable prosthesis), and persistent pain, which may require removal of the implant. Subsequent cystoscopic surgery is more difficult with a semirigid rod than with the inflatable prosthesis. Factors to consider in choosing a penile prosthesis are the patient's activities of daily living, social activities, and the expectations of the patient and his partner. Ongoing counseling for the patient and his partner is usually necessary to help them adapt to the prosthesis.

UROLITHIASIS AND NEPHROLITHIASIS

Urolithiasis and nephrolithiasis refer to stones (calculi) in the urinary tract and kidney, respectively. Urinary stones predominantly occur in the third to fifth decades of life and affect men twice as often as women. Stones may develop in one or both kidneys and yearly episodes are increasing.

Priapism

a relatively uncommon disorder, is defined as a persistent penile erection that may or may not be related to sexual stimulation. The penis becomes large, hard, and painful. Priapism results from either neural or vascular causes, including sickle cell disease, leukemic cell infiltration, polycythemia, spinal cord tumors or injury, and tumor invasion of the penis or its vessels. It may also occur with use of vasoactive agents that affect the central nervous system, antihypertensive agents, antipsychotic and antidepressant medications, substances injected into the penis to treat erectile dysfunction, alcohol, and cocaine. There are three forms of priapism: ischemic (veno-occlusive; low flow), nonischemic (high flow), and stuttering (intermittent). The ischemic form, which is described as nonsexual, persistent erection with little or no cavernous blood flow, must be treated promptly to prevent permanent damage to the penis. The goal of therapy is to improve venous drainage of the corpora cavernosa to prevent ischemia, fibrosis, and impotence. The initial treatment is directed at relieving the erection, preventing penile damage and simultaneously treating the underlying disease. Recommended treatment is aspiration of the corpora cavernosa (with or without irrigation) or intracavernous injection of sympathomimetic agents (e.g., phenylephrine). Repeated injections may be needed to resolve priapism. Surgical shunts are used to reestablish penile circulation if repeated injections of the sympathomimetic are ineffective. Nonischemic priapism and stuttering are generally not considered emergencies and often resolve without treatment. Conservative treatment (e.g., application of ice and site-specific compression to the injury) may be used. If repeated episodes occur, surgical shunting is considered. Patients with the intermittent form of priapism may be instructed in intracavernosal self-injection of phenylephrine.

Peyronie's Disease

is an acquired, benign condition that involves the buildup of fibrous plaques in the sheath of the corpus cavernosum. These plaques are not visible when the penis is relaxed. However, when the penis is erect, curvature occurs that can be painful and can make sexual intercourse difficult or impossible. Peyronie's disease typically begins between 45 and 65 years of age. Medical management in the first year of active disease includes systemic, topical, intralesional, or extracorporeal techniques, with 50% of men experiencing spontaneous resolution. Surgical removal of mature plaques is used to treat severe disease. Patients should be fully informed of available treatment options and their likely outcomes

Pyelonephritis

may be acute or chronic. Acute pyelonephritis usually leads to enlargement of the kidneys with interstitial infiltrations of inflammatory cells. Abscesses may be noted on or within the renal capsule and at the corticomedullary junction. Eventually, atrophy and destruction of tubules and the glomeruli may result. When pyelonephritis becomes chronic, the kidneys become scarred, contracted, and nonfunctioning. Chronic pyelonephritis is a cause of chronic kidney disease that can result in the need for renal replacement therapies such as transplantation or dialysis.

transurethral resection of the prostate (TURP):

resection of the prostate through endoscopy; the surgical and optical instrument is introduced directly through the urethra to the prostate, and the gland is then removed in small chips with an electrical cutting loop remains the benchmark for surgical treatment for BPH. It involves the surgical removal of the inner portion of the prostate through an endoscope inserted through the urethra; no external skin incision is made. It can be performed with ultrasound guidance. The treated tissue either vaporizes or becomes necrotic and sloughs. The procedure is performed in the outpatient setting and usually results in less postoperative bleeding than a traditional surgical prostatectomy.

Transurethral Incision of the Prostate

transurethral electrovaporization, laser therapy, and open prostatectomy. TUIP is an outpatient procedure used to treat smaller prostates. One or two cuts are made in the prostate and prostate capsule to reduce constriction of the urethra and decrease resistance to flow of urine out of the bladder; no tissue is removed. Open prostatectomy involves the surgical removal of the inner portion of the prostate via a suprapubic, retropubic, or perineal (rare) approach for large prostate glands. Prostatectomy may also be performed laparoscopically or by robotic-assisted laparoscopy. Nursing management of patients undergoing these procedures is described later in this chapter.