1. Male Reproductive Disorders
Chapter 48
Male Reproductive Disorders 1

2. Learning Objectives
Describe the major structures and functions of the normal
male reproductive system.
Identify data to be collected when assessing a male patient
with a reproductive system disorder.
Discuss commonly performed diagnostic tests and procedures
and the nursing implications of each.
Identify common therapeutic measures used to treat disorders
of the male reproductive system and the nursing implications of each.
For selected disorders of the male reproductive system,
explain the pathophysiology, signs and symptoms, complications,
medical diagnosis, and medical treatment.
Assist in developing a nursing care plan for a male patient

3. Anatomy and Physiology of the Male Reproductive System
Scrotum
Testes
Epididymis
Vas deferens
Seminal vesicles
Prostate gland
Cowper’s glands
Urethra
Penis
The scrotum is a thin pendulous sac on the outside of the body that encloses each of the two testicles in separate compartments.
The two testes (testicles) are the male reproductive organs.
The vas deferens are tubes of secretory ducts that serve as the primary storage sites for sperm, contribute to the fluid content of semen, and contract to help propel the mature sperm into the urethra during ejaculation.
The seminal vesicles are hollow, twisted, tubular secretory glands located on the posterior surface of the bladder.
The prostate is a walnut-sized fibromuscular gland that surrounds the neck of the urinary bladder and the first inch of the internal urethra.
Cowper’s glands (bulbourethral glands) are pea-sized structures, located just below the prostate, that secrete a clear mucus into the urethra.
The urethra extends from the bladder to the urinary meatus at the end of the penis.
What are the two functions of the male urethra?
The external penis in its flaccid state is a soft, round cylinder of spongy tissue ending in an acorn-shaped tip known as the glans. 3

4. Figure 48-1 4

5. Figure 48-2 5

6. Figure 48-3 6

7. Figure 48-4 7

8. Anatomy and Physiology of the Male Reproductive System
Spermatogenesis
Sperm are produced in seminiferous tubules of testes from about age 13 throughout the remainder of life
Erection
Parasympathetic nerves release neurotransmitters that cause the cavernosal arteriole walls to relax
Allows high-pressure arterial blood to flood the sinuses of the erectile chambers, increasing blood volume and raising cavernosal blood pressure to approximately the same as arterial blood pressure
What hormone is believed to set in motion the division of germinal cells into spermatocytes, which subsequently develop into sperm?
Cryptorchidism, or failure of the testicles to descend from the abdomen into the cooler scrotum, may result in sterility. 8

9. Anatomy and Physiology of the Male Reproductive System
Emission and ejaculation
Stimulation of internal and external sex organs initiates contractions of the vasa deferentia and prostatic capsule
Contractions move sperm to the ejaculatory ducts and expel them into the internal urethra
Filling of urethra excites nerves in sacral region of spinal cord: contractions of internal genital organs, pelvis, and body trunk and result in ejaculation (expulsion) of semen 9

10. Age-Related Changes in the Male Reproductive System
Testosterone decreases rapidly after age 50
Men in their late 40s and early 50s may be slower to arouse and have a longer refractory period between erections, but in a healthy man, spermatogenesis and the ability to have erections last a lifetime
This phenomenon has been called the male climacteric and may be associated with symptoms of hot flashes, feelings of suffocation, and psychic disorders similar to those of menopause.
What may be used to relieve the symptoms of male climacteric? 10

11. Figure 48-5 11

12. Health History Present illness
Complaints: weight loss, infertility, erectile dysfunction (impotence), alteration in self-image, scrotal masses, penile discharge, skin lesions 12

13. Health History Past medical history Family history
Chronic health problems: diabetes, thyroid or pituitary dysfunction, cardiovascular disease, neurologic injury or disease, and addictive behavior
Family history
Age and health or age at death of parents, grandparents, and siblings
Cancer, diabetes, hypertension, stroke, and blood disorders such as sickle cell anemia and hemophilia
The past medical history helps link the current problem with previous symptoms, injuries, diseases, operations, or allergies and the treatments or medications prescribed for them.
Why are spinal cord injuries significant related to male health history? 13

14. Health History Review of systems
Changes in appetite, weight, exercise or activity level
Changes in the skin, including lesions, drainage, bleeding, itching, or pain
Circulatory and pulmonary systems for hypertension, cardiac/pulmonary disease, exercise tolerance
Fatigue, nervousness, heat or cold intolerance, polyphagia, polydipsia, polyuria, and medications taken for pituitary or thyroid conditions
Weakness, paralysis, coordination problems, joint pain or stiffness, mood changes, and depression
The patient should be encouraged to use descriptive terms, such as “stinging” or “aching.”
What is the best technique to use when having the patient describe pain?
The health history should note medications the patient is taking because many drugs, including a number of antihypertensives, can impair sexual function. 14

15. Health History Functional assessment
Diet, usual activities, sleep and rest, medications, and the use of tobacco, alcohol, and illicit drugs
Sources of stress and coping strategies
Frequency of intercourse, ability to have and maintain an erection, desire and ability to have children, relationship of sexual function to self-image 15

16. Physical Examination
Height, weight, vital signs recorded, and his general appearance noted
Skin inspected for lesions or discolorations and the breasts for gynecomastia (enlargement)
Skin of external organs and perineum should be warm, dry, and free of lesions, edema, and odor
The lower abdomen and groin are palpated for masses
What distribution of pubic hair is expected? 16

17. Physical Examination Penis
Normal flaccid penis is semisoft and straight
Size, shape, and appearance are noted
Palpated for nodules, swelling, and lesions
If the patient is uncircumcised, foreskin is retracted to inspect the glans. The urethral meatus should be at the tip of the penis
What is smegma?
If there is any discharge from lesions or the urethra, a specimen may be collected for culture. 17

18. Figure 48-6 18

19. Physical Examination Scrotum
Skin should be slightly darker, wrinkled, and loose
Palpate each side for the right and left testes, epididymis, and vasa deferentia
Inspect for hernias
Advanced practitioner/physician examines prostate by inserting finger into anus toward anterior wall of rectum
Perineum skin darker than that of buttocks; should be intact
Anal area has more coarse skin and is moist and without hair. Inspect for lesions, irritation, inflammation, fissures, abscesses, and dilated veins
Because the scrotum is close to the body and may not be well ventilated, it is susceptible to irritation from heat and moisture, fungal infections, abscesses, and parasites.
What is a hydrocele? 19

20. Figure 48-7 20

21. Diagnostic Tests and Procedures
Laboratory studies
Semen analysis
Endocrinologic studies
Tumor markers
General laboratory studies
Urinalysis
Complete blood cell count
Alkaline phosphatase and serum calcium levels
Thyroid function studies and tests for diabetes 21

22. Diagnostic Tests and Procedures
Radiologic imaging studies
Computed tomography
Ultrasound
Radionuclide imaging 22

23. Disorders of the Male Reproductive System23

24. Prostatitis Inflammation of the prostate gland
Acute or chronic bacterial prostatitis
Caused by bacterial infection
Chronic prostatitis/chronic pelvic pain syndrome
Prostate pain but no evidence of infection
Asymptomatic inflammatory prostatitis
No pathogens can be detected
How long will antibiotics usually be taken for acute bacterial prostatitis? Chronic bacterial prostatitis?
Depending on the severity of the pain, anti-inflammatory drugs or opioid analgesics may be used.
Stool softeners may be prescribed to prevent constipation, which is especially painful with prostatitis. 24

25. Prostatitis Signs and symptoms Acute prostatitis Chronic prostatitis
Swelling, warmth, and tenderness
Dysuria, frequency, hematuria, and foul-smelling urine
Chronic prostatitis
Minimal symptoms or malaise 25

26. Prostatitis Diagnosis Treatment
Complaints confirmed by lab studies of prostatic secretions
Treatment
Acute and chronic bacterial prostatitis: antibiotics, analgesics, and sitz baths
Chronic prostatitis/chronic pelvic pain syndrome: short course of antibiotics, anti-inflammatory drugs; opioid analgesics
Asymptomatic prostatitis: single daily dose of alpha-adrenergic blocker 26

27. Epididymitis Inflammation of the epididymis Causes Signs and symptoms
Infections, trauma, or the reflux of urine from the urethra through the vas deferens
Signs and symptoms
Painful scrotal edema, nausea, vomiting, chills, fever
Treat with bed rest, ice packs, sitz baths, analgesics, antibiotics, anti-inflammatory drugs, and scrotal support 27

28. Epididymitis Nursing care Monitor temperature, edema, and comfort
Carry out prescribed treatments 28

29. Orchitis Inflammation of one or both testes
Related to trauma or infections such as mumps, pneumonia, or tuberculosis
Signs and symptoms
Fever, tenderness, and swelling of the affected testicle and scrotal redness
Treatment
Analgesics, antipyretics, bed rest, scrotal support, and local heat to the scrotum 29

30. Orchitis
Nursing care
Pain management, assistance with activities of daily living, patient teaching, and anxiety reduction 30

31. Benign Prostatic Hypertrophy
Enlargement of the prostate gland
Common age-related change, but exact cause is unknown
Signs and symptoms
Obstructive symptoms: decreasing size and force of the urinary stream, urine retention, and postvoid dribbling
Irritative symptoms: urgency, frequency, dysuria, nocturia, hematuria, sometimes urge incontinence
What factors may trigger urinary retention? 31

32. Benign Prostatic Hypertrophy
Medical diagnosis
Based on rectal examination, laboratory and radiographic studies, endoscopy, ultrasound, catheterization for residual urine, and sometimes urodynamic testing
Urine specimen and prostatic secretions obtained and examined for infection
Medical treatment
Finasteride (Proscar) and dutasteride (Avodart)
Tamsulosin (Flomax), doxazosin (Cardura), and terazosin (Hytrin) 32

33. Benign Prostatic Hypertrophy
Surgical/invasive treatments
Types of prostatectomy
Transurethral resection of the prostate
Suprapubic prostatectomy
Complications
Urinary infection and incontinence, hemorrhage, urinary leakage, inflammation of the pubic bone, erectile dysfunction
Alternative invasive procedures
Microwave thermotherapy or transurethral needle ablation
Stents
Balloon dilation
How are the two types of prostatectomies different? 33

34. Benign Prostatic Hypertrophy
Assessment
Urinary symptoms: frequency, urgency, hesitancy, a change in stream size or force, and nocturia
Record pain or hematuria
Palpate lower abdomen to detect bladder distention
Interventions
Impaired Urinary Elimination
Fear
Ineffective Management of Therapeutic Regimen 34

35. Benign Prostatic Hypertrophy
Assessment of prostatectomy patient
Compare vital signs with preoperative measurements
Inspect urine, dressings, and wound drainage for excess bleeding
Carefully record fluid intake and output to avoid overdistention of the bladder
Input and output should be balanced; record urine color and any clots
Check intravenous fluids and regulate rate of flow
Monitor patient’s level of comfort for incisional pain and bladder spasms 35

36. Benign Prostatic Hypertrophy
Interventions for prostatectomy patient
Risk for Deficient Fluid Volume
Acute Pain
Risk for Infection
Risk for Injury
Urge Urinary Incontinence
Sexual Dysfunction and Situational Low Self-Esteem
Deficient Knowledge 36

37. Erectile Dysfunction (Impotence)
Inability to produce and maintain an erection for sexual intercourse
Erection requires intact neurologic function, sufficient inflow of blood to fill the corpus cavernosa, leakproof storage mechanism for maintaining the erection. Factors are
Vascular disorders
Endocrine disorders
Neurologic disorders
Medication side effects
Psychological
Systemic or local changes in blood flow can impair the ability to achieve an erection.
Patients with diabetes mellitus are at risk for erectile dysfunction due to atherosclerosis and autonomic neuropathy.
Spinal cord injuries and other neurologic disorders may cause erectile dysfunction.
Medications used to treat a variety of conditions may cause or contribute to erectile dysfunction.
What medications frequently cause erectile dysfunction?
Psychogenic erectile dysfunction is often the result of anxiety about performance. 37

38. Erectile Dysfunction (Impotence)
Drug therapy
Phosphodiesterase type 5 inhibitors
Sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra)
Alprostadil
Intracavernosal injection (Caverject) or urethral suppositories (MUSE)
Papaverine
Testosterone 38

39. Erectile Dysfunction (Impotence)
Vacuum constriction devices
A vacuum draws blood into the penis
Revascularization
Surgical procedure that bypasses blocked arteries, removes or ties off incompetent veins, and tightens the surrounding tissue
Penile implants
Silicon cylinders placed in the erection chambers that keep the penis firm at all times 39

40. Figure 48-8 40

41. Erectile Dysfunction (Impotence)
Assessment
Patient’s health/family history of diabetes
Record surgical procedures, injuries, illness, cancer, and medications used regularly
Habits and lifestyle including daily activities, diet, use of alcohol and illicit drugs, exercise, health care beliefs, interpersonal relationships, capability for self-care, age, physical condition, and educational needs 41

42. Erectile Dysfunction (Impotence)
Interventions
Listen and be careful not to dismiss the issue as unimportant
Provide factual information and resources 42

43. Peyronie’s Disease
A hard, nonelastic, fibrous tissue (plaque) just under the skin of the penis of men between 45 and 70 years of age
Plaque develops as a result of an injury that causes inflammation and scarring of the tunica surrounding the corpora cavernosa
Loss of elasticity of the tunica results in decreased ability to fill during an erection and failure to store because of low pressure on the veins against the covering of the erectile tissue
Where is the plaque usually located? 43

44. Figure 48-9 44

45. Peyronie’s Disease Medical treatment
Topical or oral medications with vitamin E, oral para-aminobenzoic acid, tamoxifen, colchicine
Local radiation, injections into the lesions, ultrasonography, and surgical correction are other options
Treatment depends on size of the plaque and curvature and resultant degree of dysfunction 45

46. Priapism Prolonged erection not related to sexual desire Causes
Injury to the penis, sickle cell crisis, and neoplasms of the brain or spinal cord
Drugs that may be responsible include phenothiazines, alpha-adrenergic blockers, anticoagulants, alcohol, cocaine, marijuana, vardenafil (Levitra), and intracavernosal injections
Painful; constitutes an emergency situation
Failure to resolve the problem within 12 to 24 hours may result in penile ischemia, gangrene, fibrosis, and erectile dysfunction
What urinary problems may be caused by priapism? 46

47. Priapism Medical treatment
Aspirating blood from erectile chambers or injecting drugs that cause contraction of smooth muscle, inhibiting inflow of blood and allowing outflow
If these efforts fail, emergency surgery may be needed
Nursing care must be particularly sensitive to the embarrassment the patient may experience
Understanding the condition and alleviating pain are important 47

48. Phimosis
Edema that may prevent retraction of the foreskin caused by inflammation under the foreskin
Often associated with poor hygiene
Treated with antimicrobials and proper cleansing
Circumcision sometimes recommended
Uncircumcised men need to retract the foreskin for cleaning as part of daily hygiene 48

49. Infertility
Couples who have had unprotected intercourse over a 12-month period and have been unable to become pregnant
May be caused by a reproductive problem in the male, the female, or both 49

50. Infertility Etiology and risk factors
Male infertility: endocrine disorders, testicular problems, or abnormalities of the ejaculatory system
Infections can affect testicular and ejaculatory function
Drug therapy, radiation, substance abuse, and environmental hazards also can affect the testes
What structural factors may affect testicular function? 50

51. Infertility: Etiology and Risk Factors
Infections
Mumps, tuberculosis, pneumonia, and syphilis
Chlamydia trachomatis and Neisseria gonorrhoeae 51

52. Infertility: Etiology and Risk Factors
Cryptorchidism
Testis in other than a dependent scrotal position
Because the abdominal cavity is warmer than the scrotum, excessive warmth can damage the seminiferous epithelium of undescended testes and result in decreased spermatogenesis
Medical treatment
If testes within normal path but do not descend or cannot be pulled into scrotum, usually do not respond to hormonal therapy, and surgery is needed
It is a common congenital condition, being found in approximately 30% of preterm male infants and in 1.0% to 3.4% of full-term male infants.
What is the cause of cryptorchidism?
Cryptorchidism must be corrected within the first 18 months of life to give the best chance for fertility.
Men with undescended testes have a 10 to 30 times higher incidence of testicular cancer than men whose testes descended normally. 52

53. Figure 48-10 53

54. Infertility: Etiology and Risk Factors
Testicular torsion
Occurs unilaterally when testicle is mobile and the spermatic cord twists, cutting off blood supply to testicle
Acute surgical emergency requiring immediate release of the torsion or removal of the testicle
Usually in adolescents and when the scrotum is warm and relaxed but may occur for no apparent reason
Symptoms: intense pain, often accompanied by nausea and vomiting
After testicular torsion is corrected, lowered sperm counts and infertility may follow 54

55. Figure 48-11 55

56. Infertility: Etiology and Risk Factors
Varicocele
A lengthening and enlargement of the scrotal portion of the venous system that drains the testicle
Caused by incompetent or absent valves in the spermatic venous system; allows pooled blood and the resulting increased pressure to dilate the veins
Treatment includes scrotal support or surgical ligation and is indicated when fertility is thought to be affected
Fertility or ability to conceive may/may not improve
Which testicle is most often affected? 56

57. Infertility: Etiology and Risk Factors
Vasectomy
Surgical removal of a portion of the vasa
Erection, ejaculation, and intercourse are unaffected
Postoperative pain/swelling managed with application of an ice bag, mild analgesics, and scrotal support
Patient can resume intercourse as soon as he feels comfortable; important to use other methods of birth control until analysis of semen determines that there is a complete absence of sperm
Nursing care should include preoperative teaching about the procedure itself and the resultant infertility
Vasectomy is usually performed as an outpatient procedure in a physician’s office or outpatient clinic.
When will a sperm analysis be done following a vasectomy? 57

58. Figure 48-12 58

59. Penile Cancer Relatively rare; almost exclusively in uncircumcised men
Risk factors: chronic irritation, poor hygiene, a history of multiple sexual partners, sexually transmitted infection, and long-term tobacco use
A dry, wartlike painless growth on the penis that does not respond to antibiotic therapy
Can be removed surgically if treated in early stages
Advanced stages may ulcerate and involve the foreskin and penile shaft
Extensive resection or amputation as well as resection of nearby lymph nodes may be necessary 59

60. Testicular Cancer
Testicular germ cell carcinoma occurs most often in men between ages of 18 and 34
Three established risk factors: cryptorchidism, white race, and previous testicular cancer
Other factors: history of orchitis, HIV infection, and in utero exposure to diethylstilbestrol
Patients most often present with hard, painless tumors 60

61. Figure 48-13 61

62. Testicular Cancer Early detection Medical diagnosis Medical treatment
Education about the need for self-examination
Monthly examination of the penis, scrotum, and perineal area
Medical diagnosis
Ultrasound and blood studies to measure tumor markers: alpha-fetoprotein and human chorionic gonadotropin
Radiographs and CT scans
Medical treatment
Orchiectomy, radical orchiectomy, radiation, and chemotherapy
How is testicular self-examination performed?
Treatment of testicular cancer may affect fertility and erections. 62

63. Figure 48-14 63

64. Testicular Cancer Assessment Interventions
Fears or concerns related to the effects of surgery and other treatment
Interventions
Anxiety
Acute Pain
Impaired Urinary Elimination
Risk for Injury
Constipation
Situational Low Self-Esteem
Deficient Knowledge 64

65. Prostatic Cancer Cause is unknown Risk factors Medical diagnosis
Age >50 years, African American, overweight, high-fat diet, and family history
Medical diagnosis
Typically slow-growing; confined to prostatic capsule
Rectal examination, transrectal ultrasound, serum tumor markers, and needle aspiration/biopsy
Radiographs, radionuclide imaging, bone scans, excretory urography, transurethral ultrasound, CT, and MRI
Cancer of the prostate is found on postmortem examination in 30% of men older than age 50 years, and the incidence increases steadily with each decade to 100% of men in the tenth decade.
What symptoms may a large tumor cause? 65

66. Prostatic Cancer Medical treatment “Watchful waiting”
Conventional radiotherapy
Brachytherapy
Cryosurgery
Radical prostatectomy
Chemotherapy useful in limited cases
Hormonal therapy
The treatment of prostatic cancer is controversial because of the difficulty in staging tumors and the unpredictable biologic behavior of the disease.
What are the adverse effects of hormonal therapy? 66

67. Prostatic Cancer Nursing care
Encourage annual screening for prostate cancer
Stress value of early diagnosis and treatment
Specific problems may require special interventions after prostate surgery: bladder spasms, erectile dysfunction, urinary incontinence, and body image disturbances associated with changes in the reproductive system 67