The Male Reproductive System

Prostate Specific Antigen

blood test that measures the level of prostate-specific antigen in the blood Normal levels is less than 4ng/ml. Can also be used to measure the effectiveness of prostate cancer or BPH treatments (PSA would go down if the treatments were working)

Nocturnal penile tumescence (NPT)

to test for night time erections

Side effects of TURP

-ED -urinary incontinence -reaction to anesthesia -blood clots -difficulty breathing

Ejaculatory ducts

-Each one originates where the ampulla of the ductus deferens joins the duct from the seminal vesicle. -They empty into the urethra. -They receive secretions from the prostate gland to make up semen.

Prostate Gland

-Glandular prostate tissue adds an alkaline secretion to semen, which increases sperm motility. -Muscular portion of the prostate contracts during ejaculation to expel semen from the urethra.

Bulbourethral Glands

-Located between two layers of fascia just below the prostate glands. -Secrete an alkaline mucus that coats the urethra to neutralize the pH of urine residue and lubricates the penis.

Reproduction

-Produces sperm -Passes genetic information to offspring -Participates in copulation and fertilization

Seminal Vesicles

-Secretes a sticky, alkaline substance, called semen, which serves as a fluid medium for sperm.

Development of Sexual Characterisitics

-Secrets hormones that initiate puberty, mucus, spermatic fluid, and other substances -Maintains specific male characteristics

Ejaculatory fluid

-Semen mixed with various secretions.

Spermatogonia

-Stem cells of sperm cell development -Divide by mitosis and then meiosis to form spermatocytes; spermatids; eventually develop into spermatozoa. When ejacualated, male sperm can live for three days inside of a woman.

Epididymis

-Stores sperm cells -Enables sperm cells to mature, they develop a tail and gain motility. -Smooth muscles propel sperm into the ductus deferens.

Ductus Deferens/Vas Deferens

-Transport sperm from the epididymis to ejaculatory duct. -Peristaltic contractions propel sperm cells through ductus. -Each ductus deferens joins a duct from the seminal vesicles. -The spermatic cord passes through an opening in the muscular abdominal wall called the inguinal canal.

Prostatic biopsy

-Transrectal biopsy -Transurethral resection of the prostate (TURP)

Duplex Doppler Ultrasonography

Arterial problem of penis. Injection of vasodilator into penis.

Penile revascularization

5% of men with ED are candidates for this surgery. Reconstruction of the arterial blood supply or removal of the veins that drain the penis of blood too rapidly. Rarely produces a successful outcome so it is rarely performed.

Variococele

Abn dilation of the testicular veins in the scrotum. Reflex of blood down to scrotum when standing or straining. Scrotal temp is higher, which impedes spermatogenesis sand storage= low sperm counts and infertility SS: pain in testicle or radiating to other side, swelling and nagging dull pain in the scrotum. Veins in scrotum are dilated and tortuous and may feel like a bag of worms. More common left side because the spermatic vein on that side is longer than the right. If on right side it is usually a tumor that is the cause. Tx: surgery if sperm counts are low.

Priapism

Abnormal and persistant penile erection without sexual stimulation.

Hydrocele

Accumulation of fluid in the space between the membrane covering the testicle and the testicle itself. Can be infection or injury. Often asymptomatic. Tx: aspirating fluid, plication-stitching the folds or tucks in hydrocele wall to reduce its size. Can apply cold packs and emotional reassurance that it will resolve.

Peyronie's disease

Accumulation of plaques or scar tissue along the corpora cavernosa, causing a painful curvature of the penis when erect.

Emission

Accumulation of sperm or foreign matter.

Flomax

Alpha blocker that relaxes muscles in prostate and bladder neck

Signs & Symptoms of Testicular Cancer

Appear gradually, painless mass develops as testis enlarges. Scrotal heaviness. Advanced disease= backache, pain in abd, weakness, weight loss.

Neoplasms

Benign prostatic hyperplasia (BPH) -The prostate gland enlarges -Primary complications: Urinary tract infection, Acute urinary retention: can try a warm shower to relax the sphincter and muscles of the prostate

Priapism

Can be from chronic disease, medication, cancer, prolonged sexual activity, infection. SS: erection that will not subside. Emotionally upsetting. The corpora cavernosa contains thick, dark, venous blood Tx: Can be difficult. Phenylephrine into the corpora cavernosa, cavernostomy with butterfly needle to drain, caudal or spinal anesthesia, anticoagulants, fistula bw glans penis and corpus spongiousum, semi permanent diversion with a saphenous vein shunt.

Cryptorchidism

Can be unilateral or bilateral. If persists past puberty they can become malformed or atrophy They should be correctly positioned early in life to allow for sperm production. Internal temp is too warm for development of viable sperm Tx: hormone therapy, orchiopexy: suturing testes to scrotal sac to secure them TSE important because they have increased risk of testicular cancer.

Penile Cancer

Cancer of the penis -Relatively rare, especially in circumcised men -HPV increases the risk -Painless ulceration that fails to heal. Advanced lesions to the shaft or inguinal lymph nodes may require penis resection or amputation. -Tends to occur in uncircumsized men who practice poor hygiene.

Prostate cancer

Cancer of the prostate Risk factors -Age greater than 50 yrs old -African American heritage -Excessive alcohol use -Diet high in animal fats -Family history of prostate cancer -Environmental exposure -PSA elevation

Testicular cancer

Cancer of the testes -Risk factors include Age 20 to 34 years, Caucasian race History of undescended testicle at birth or of testicular swelling with mumps or of maternal use of oral contraceptives and diethylstillbestrol (DES) during pregnancy. Higher social class Unmarried or married late or not sexually active Cancer of the testes -Testicular tumors: Seminoma, Nonseminoma Monthly testicular self-examination from early adolescence onward

Vasoactive Intracorporeal Pharmocotherapy

Client self injects a vasodilating med into penis Papverine (Pavabid, Cerespan) Alprostadil, Prostaglandin E1 (Caverject, Edex) Phentolamine Hcl (Regitine)

Nursing Process

Data collection -Urinary and reproductive history, general health history, and history of sexually transmitted infections or exposure. -Erectile and urinary dysfunction. -Inspection of external reproductive structures. -Prostate and testicular examination. Planning and implementation: pre and postop care Evaluation

Premature Ejaculation

Ejaculation takes place before, during, or immediately after penetration. Tx: wear condoms, lidocaine gel to desensitize penis.

Inflammatory Disorders

Epididymitis: inflammation epididymis. Usually chlamydia (esp under age 40.) Burning sensation, penile discharge, redness, pain, and swelling. Orchitis: inflammation testes. Can occur after puberty if male contracts mumps. Can cause sterility. Prostatis -Acute bacterial prostatitis -Chronic bacterial prostatitis -Nonbacterial prostatitis

Sperm survive better in an acid medium than in an alkaline medium. T/F

False Sperm survive better in an alkaline medium than in acidic medium; alkalinity helps maintain sperm motility. A woman's vagina is acidic because of its normal flora. The alkaline environment of seminal fluid helps to neutralize the acidic vaginal pH and to maintain sperm motility and viability.

Signs & Symptoms of Prostate Cancer

First sign is difficulty in voiding -decrease in force and size of urinary system -urgency -frequency -nocturia -hesitancy -hematuria -pain in lower back, pelvis, thighs ***Large nodular firm prostate usually lateral sides 1st*** Metastasis to bones, lymph nodes, brain and lungs. Bone mets are usually lower spine and hips Dx: PSA level, palpable masses on DRE, biopsy Tx: prostatectomy, radioactive seed implant, cryosurgery, radiation therapy, hormone ablation therapy. Tx may lead to ED in 70-80% of clients, incontinence is less common, 20%.

Semen analysis

First test done when evaluating fertility, also used to evaluate the effectiveness of a vasectomy. Can be used to determine if the male is suspected of rape, or to rule out/determine paternity. Collection can be by manual stimulation, coitus interruptus, or use of a condom. Must be delivered to the lab within 30 minutes and must be kept in an inside jacket pocket so it stays at body temperature.

Ejaculation

Forceful expulsion of semen from the ejaculatory ducts through the urethra.

Spermatogenesis

Formation of mature and functional spermatozoa

Male Hormones

Hormones from the hypothalamus, pituitary, and gonads influence the male reproductive system. Male hormones are called androgens. Testosterone is the major male androgen. Testosterone is responsible for secondary sex characteristics, (muscle mass, bone mass, body hair) key role in development of testes and prostate. Gonadotrophic hormones stimulate the gonads (sex glands) to secrete specific male hormones (androgens). Follicles stimulation hormone (FSH) stimulates the formation of sperm.

Erectile Dysfunction (ED)

Inability to achieve or maintain an erection sufficient to complete sexual intercourse. Causes -Drug use: alcohol, amphetamines, barbiturates, cocaine, marijuana, methadone, nicotine, opiates, many meds used for tx of depression such as SSRI. -Chronic diseases: DM, hypertension, renal disorders, cancer, organ transplants, CABG. -Atonic ED: ALS, MS, cord compression d/t herniated disk, spina bifida, advance syphilis. -Endocrine disorders -Trauma -Cardiovascular disorders -Surgery: TURP, radical prostatectomy -Stress, depression, other mental concerns ED can be psychogenic or organic in origin. If psychogenic= counseling organic= counseling and treatment

Cryosurgery

Incision in perineum and tool is used to freeze the cancerous tissue.

Some postop teaching

Incontinent until can train their external urethral sphincter to do the work of both internal and external sphincters. Instruct on kegel exercises Sitz baths after perineal prostatectomy. Must cleanse perineal area meticulously to avoid wound contamination. Bladder spasms common after prostate surgery. May need antispasmodics. Pain relief for incisions. Avoid aspirin.

Prostate-specific antigen (PSA)

Inflammation of prostate gland, BPH, adenocarcinoma

Cardura

Inhibits alpha adrenergic receptor. Lowers BP and improves urination in BPH

Proscar

Inhibits conversion of testosterone to DHT (involved in development of BPH)

BPH

Initial SS of BPH= urinary difficulties Frequent voiding during the night d/t incomplete elimination. Difficult and painful urination can develop, traces of blood in urine, cystitis. Dx: PSA test, DRE, Ultrasound of prostate, endoscopy to rule out cancer, Urinalysis, urine cx, creatinine and BUN can be affected Tx: watchful waiting. Use of PSA to monitor progression. Oral medications to help with urinary elimination. Surgical tx to decrease size of prostate such as a TURP. ***Large boggy prostate centrally positioned***

Male Climacteric "male menopause"

Less pronounced in men, gradual onset. Occurs between age 55-70. Gradual decrease in testosterone levels and seminal fluid production. Impact of this is mostly psychological because men recognize a decline in sexual activity and interest. SS: erections require more time, penis not as firm, loss of hair from the head, chest, axillae, and pubis, muscle tone decreased.

Bladder Irrigation

Maintain patency of urethra after prostate surgery.

Cystoscopy

Man's prostate and bladder can be examined by passing a lighted cystoscope through the urethra to the bladder. Usually performed without anesthesia. Post: pink tinged urine common, greater urinary frequency, and burning on urination. Sitz baths, heat, and mild analgesics can be given post to help with the pain.

Penile Implants

May be malieable or a 2-3 piece inflatable prosthesis Malleable makes the penis look erect at all times Must give surgical area time to heal post procedure before having intercourse.

Radiation therapy

May follow removal of cancerous prostate to destroy any remaining malignant cells.

Erectile Dysfunction Cont'd

Medical and surgical treatment -Oral medications -Intraurethral suppositories -Vasoactive intracorporeal pharmacotherapy -Mechanical devices -Penile implants -Penile revascularization Method used is partially determined by the patient

Neoplasms (Cont'd)

Medical treatments for cancer of the prostate -Radiation therapy: radioactive seed implantation, radiation cystitis, proctitis -Hormone ablation therapy: removing testosterone Pain management in advanced disease Prostate cancer screening may not be desirable or effective for all men. Lupron decreases the amount of testosterone in men. Treats the symptoms of prostate cancer but not the cancer itself. Given by subq or IM injection.

Seminoma

More common, remains local until late in disease. Tx is unilateral orchiectomy.

Erection

Nervous impulses from the spinal cord and brain cause vasodilation of the arteries of the penis.

Transdermal Agents

Nitroglycerin paste- vasodilator, can give for ED

TSE

testicular self-examination, from the age fo 13-14 should be performed monthly after a bath or shower.

Chronic Bacterial Prostatitis

Not acutely ill Acute episode that did not resolve Hallmark is a history of relapsing UTI Usually asymptomatic, may have back or perineal pain Dx: culture of expressedd secretions from prostate massage, WBC elevated Additional abx for 3-6 months

Nonseminoma

Orchiectomy and retroperitoneal lymph node dissection. Can impact fertility to lose a testicle but should not affect libido or orgasm.

Nsg considerations prostatitis

Pain control, warm compresses, sitz baths, encourage fluids

Neoplasms Cont'd

Prostate surgery -Preoperative nursing considerations -Transurethral resection of the prostate (TURP) -Prostatectomy: suprapubic, perineal, nerve-sparing radical, radical -Cryosurgery -Postoperative nursing considerations

Hytrin

Relaxes muscles in prostate and bladder neck, treats HTN

Radical

Removal of prostate gland, seminal vesicles, part of urethra. Complications: stress incontinence, epididymitis, uretheral strictre, fistula and ED. Will have foley for two weeks post.

Prostatectomy

Removal of prostate tissue through various approaches Suprapubic- if gland is very large. Two sections: cystostomy into the bladder to relieve retention, and then prostate tissue. Returns with two indwelling catheters in place, one in urethra and one in suprapubic wound attached to drainage containers. Wound catheter is attached to an irrigation apparatus.

The Male Reproductive System

Reproductive systems work distinctly to continue the species and to pass genetic information from parents to child. The male reproductive system -testes, ductal system, seminal vesicles, scrotum, penis, and accessory glands The area between the scrotum and anus is the perineum.

Postop Considerations

Routine postop care such as ted hose, early ambulation, TCDB, IS, encourage fluids, monitor I&O's, stool softeners to avoid straining.

Peyronie's Disease

Scar tissue builds up which cause a bend in the penis. Can cause painful erections, problems with coitus, ED.

Vasectomy

Simple surgical procedure performed under local anesthesia to prevent pregnancy. Vas deferens is cut, tied or sealed to prevent sperm from entering the ejaculate. Because some sperm are located within the body, the male must ejaculate with precaution for several months post procedure. Reversal procedures have 50% pregnancy success rate if performed within 3 years, and 30% if performed 10 years after original vasectomy.

Intraurethral Suppository

Smaller than a grain of rice which is self injected into urethra. As it melts, med is absorbed in corpora cavernosa. More tissues to vasodilate, which causes erection. More localized arteriole dilating effect than oral medications. Prostaglandin E1 (Muse). All, vasodilating meds can cause priapism (prolonged uncomfortable erection). Must seek tx if erection lasts longer than 3-4 hours.

Testosterone level

Sperm production and libido

Penis "fracture"

Sudden trauma bends the penis and causes tearing to the tunica albuginea. Most often occurs during sexual intercourse. SS: sharp pain, popping sound, bending in shape of the penis. Tx: surgery to repair the tear.

Effects of Aging

Testosterone levels decrease. Causes a reduction f testicle size, decreased sperm production, difficulty achieving and maintaining erection, and decrease in frequency of erections. The prostate gland enlarges. May be benign or cancerous. Can have difficulty voiding. Must have PSA- test and exam to detect early prostate cancer. Fibrosis, sclerosis, and vascular changes occur in penis cause decrease in frequency of erections. May need medications or surgery. "Male menopause", occurs with age. Changes in sexual function: ED, reduced desire, testes shrink, BPH Changes in sleep: insomnia or increased sleepiness Physical: increased body fat, reduced muscle bulk, decreased bone density, (20% osteoporosis men); gynecomastia, loss of body hair. Rarely hot flashes and less energy. Emotional: depression Men's risk for heart disease does not change in male meopause. Females are at increased risk during female menopause.

Secretion

The bulbourethral glands secrete a clear liquid, pre-ejaculate, which helps to lubricate the urethra and also cleans out any urine or foreign matter.

The Ductal System

The male reproductive organs have a system of ducts that store and transport sperm from the testicles to the urethra. -Epididymides -Ductus deferentia -Ejaculatory Ducts Sperm mature in the epididymis, travel through the ductus deferens, and join other secretions in the ejaculatory duct before exiting the body.

The Male Reproductive System

The male reproductive system is closely linked to the urinary system. For this reason, urologists often treat male reproductive disorders.

The Testes

The paired testes or testicles produce spermatozoa through a process called spermatogenesis. They also secrete sex hormones. Sperm cells are produced and mature almost completely within the seminiferous tubules. Interstitial cells secrete testosterone and other androgens.

The Penis

The penis is a cylindrical organ located between the upper thighs immediately in front of the scrotum. At the time of sexual excitement, blood fills the sinuses and the penis becomes firm and raises up, known as an erection. The smooth cap of the penis is called the glans penis; it is covered by foreskin. The urethra within the penis serves as a common passageway for both the urinary and reproductive systems. An involuntary sphincter automatically inhibits micturation during semen ejaculation.

Sperm Cells and Spermatogenesis

The sperm cell is the male gamete.

The Scrotum

The two testes are enclosed in a sac-like structure called the scrotum, which is suspended behind the base of the penis. -Supports and protects the testes -Regulates the temperature of the testes -Cremasteric reflex pulls the testicles closer to the body during severe danger, in order to protect them

Perineal

Through incision in the perineum. Catheter drainage through perineal incision only. Difficult to sit up. Fecal contamination can occur b/c of incision area. Nerve sparing radical prostatectomy (retropubic) incision below umbilicus and above symphasis pubis. Causes less ED, incontinence and bleeding than do other methods

Prostatic Smears

To detect and ID microorganisms, tumor cells, and even tuberculosis of the prostate. HCP massages the prostate through the rectum and voids into a sterile container that has been prepped.

TURP

Transurethral Resection of the prostate. Most common procedure. Removes prostate tissue through a rescectoscope. Recovery is shorter than other approaches. Complications include hemorrhage, urinary retention, stressj incontinence, and ED Bladder irrigation with foley post procedure. Shut off irrigation if: c/o bladder fullness, urinary Uregency, or bladder/flank pain Drainage from the TURP tube stops Bloody drainage should steadily decrease Hemorrhage is a major postop complication Report and document any sudden increase of blood in the drainage If urine flow stops or slows, cath may require irrigation to remove tissue or clots Notify charge nurse immediately any bright red blood or gushes of fresh bleeding Strict intake and output Make sure all tubes are open and draining Traction may be placed on the three way irrigation catheter with tape. Do not remove. Output will go from "hawaiian punch" colored, and will then change to "pink lemonade" colored before returning to normal. Report any increase in bleeding, blood getting darker, or clots/bladder spasms.

An individual receiving testosterone replacement therapy will have shrunken testes. T/F

True If a man receives testosterone replacement therapy, his testes will shrink because they are no longer required to manufacture testosterone.

Torsion of the Spermatic Cord

Twisting of the testicle Interruption of blood flow to the testicle Uncommon SS: acute sudden scrotal pain, vomiting, abd pain, necrosis if not tx more than a few hours. Surgical emergency. Tx: surgical detorsion and bilateral orhiopexy. If necrosis= orchiectomy

Structural Disorders

Undescended testicle (cryptorchidism) Abnormal urethral placement -Hypocapadias-urethral meatus underside of penis -Epispadias-urethral meatus on upper surface of penis Phimosis of foreskin too tight. May need surgery to circumcise. Torsion of the spermatic cord Varicocele Hydrocele Penis fracture

Acute Bacterial Prostatitis

Usually from UTI such as E. Coli ascending urinary tract Tender, enlarged, asymmetrical prostate on DRE. Fever, chills, myalgia, malaise, scrotal and low back pain, perineal pain, pain after ejaculation. Urinary ss: hematuria, urgency, nocturia, hesitancy, dribbling Tx: abx, analgesics, sitz baths

Mechanical Devices

Vacuum erection or constriction devices. Create erection by mechanically pulling blood into the penis.

Oral Medications

Vasodilators taken in pill form that help the penis fill with blood. Contraindicated for those who use nitroglycerin can results in life threatening hypotension. Do not use with anticoagulants such as coumadin. Cannot use if also taking meds that lower blood pressure. Cialis: can work up to 36 hr Viagra: starts 30 min, lasts 4 hr Levitra: starts 30 min, lasts 5 hr Stendra: starts 15 min, lasts 6 hr Staxyn: dissolves in mouth, lasts 6 hr Most common side effects are headaches, dizziness, and dry skin

Copulation

sexual intercourse