Nursing Management

Male Reproductive Problems

Only a life lived for others is a life worthwhile.

Reviewed by Debra Backus, RN, PhD, CNE, NEA-BC, Associate Professor of Nursing, State University of New York, Canton, New York; and David J. Derrico, RN, MSN, Assistant Clinical Professor, University of Florida, Gainesville, Florida.

This chapter discusses problems of the male reproductive system. These involve a variety of structures, including the prostate, penis, urethra, ejaculatory duct, scrotum, testes, epididymis, ductus (vas) deferens, and rectum (Fig. 55-1).

FIG. 55-1 Areas of the male reproductive system in which problems are likely to develop.

Problems of the Prostate Gland

Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland. It is the most common urologic problem in male adults. About 50% of all men in their lifetime will develop BPH. Of these men, almost half of them will have bothersome lower urinary tract symptoms.¹ Research is not clear about whether having BPH leads to an increased risk of developing prostate cancer.^2,3

eNursing Care Plan 55-1 Patient Having Prostate Surgery

Nursing Diagnosis*

Impaired urinary elimination related to postoperative bladder irritation, inflammatory urinary obstruction, and sensory motor impairment as evidenced by dysuria, retention, urgency, and incontinence

Patient Goal

Reports improved urinary function with no pain or incontinence

Outcomes (NOC)	Interventions (NIC) and Rationales
Urinary Elimination • Urine color _____ • Urine clarity _____ • Fluid intake _____ • Empties bladder completely _____ • Recognition of urge _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised • Pain with urination _____ • Urinary frequency _____ • Urinary retention _____ • Urgency with urination _____ • Urinary incontinence _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Urinary Elimination Management • Monitor urinary elimination including frequency, consistency, odor, volume, and color to evaluate urinary elimination function. • Monitor for signs and symptoms of urinary retention to plan appropriate interventions. • Identify factors that contribute to incontinence episodes to plan appropriate interventions. • Instruct patient/caregiver to record urinary output to identify urinary retention. • Teach patient to drink 8 oz of liquid with meals, between meals, and in early evening to produce dilute, nonirritating urine. • Instruct patient to respond immediately to urge to void to prevent involuntary leakage. Bladder Irrigation • Set up sterile irrigating supplies maintaining sterile technique to prevent infection, per agency protocol. • Instill irrigating fluid, per agency protocol. • Monitor and maintain correct flow rate, because a rate too fast causes bladder spasms but a rate too slow does not prevent clot formation. • Record amount of fluid used, characteristics of fluid, amount returned, and patient responsiveness to monitor for bleeding and urinary retention.

Outcomes (NOC)

Interventions (NIC) and Rationales

Urinary Elimination

• Urine color _____

• Urine clarity _____

• Fluid intake _____

• Empties bladder completely _____

• Recognition of urge _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

• Pain with urination _____

• Urinary frequency _____

• Urinary retention _____

• Urgency with urination _____

• Urinary incontinence _____

Urinary Elimination Management

• Monitor urinary elimination including frequency, consistency, odor, volume, and color to evaluate urinary elimination function.

• Monitor for signs and symptoms of urinary retention to plan appropriate interventions.

• Identify factors that contribute to incontinence episodes to plan appropriate interventions.

• Instruct patient/caregiver to record urinary output to identify urinary retention.

• Teach patient to drink 8 oz of liquid with meals, between meals, and in early evening to produce dilute, nonirritating urine.

• Instruct patient to respond immediately to urge to void to prevent involuntary leakage.

Bladder Irrigation

• Set up sterile irrigating supplies maintaining sterile technique to prevent infection, per agency protocol.

• Instill irrigating fluid, per agency protocol.

• Monitor and maintain correct flow rate, because a rate too fast causes bladder spasms but a rate too slow does not prevent clot formation.

• Record amount of fluid used, characteristics of fluid, amount returned, and patient responsiveness to monitor for bleeding and urinary retention.

Nursing Diagnosis

Acute pain related to bladder irritability, irrigations, distention, and surgical trauma as evidenced by reports of pain; nonverbal signs of pain such as moaning, crying, legs drawn to abdomen

Patient Goal

Reports satisfactory pain control

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Control • Reports pain controlled _____ • Uses analgesics as recommended _____ • Uses nonanalgesic relief measures _____ • Reports uncontrolled symptoms to health care professional _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Patient-Controlled Analgesia (PCA) Assistance • Teach patient and caregiver to monitor pain intensity, quality, and duration to evaluate effectiveness of PCA. • Validate that the patient can use PCA device: is able to communicate, comprehend explanations, and follow directions. • Teach patient and caregiver how to use PCA device. • Teach patient and caregiver the action and side effects of pain-relieving agents. Pain Management • Teach the use of nonpharmacologic techniques (e.g., relaxation, guided imagery, distraction, and breathing exercises) before, after, and if possible, during painful activities along with other pain relief measures to alleviate pain through a variety of methods. • Encourage patient to use adequate pain medication for best pain control. • Provide the patient optimal pain relief with prescribed analgesics before pain becomes severe. • Evaluate the effectiveness of the pain control measures used through ongoing assessment of the pain experience. Tube Care: Urinary • Maintain patency of urinary catheter system because clots cause obstruction of urine flow resulting in painful bladder spasms.

Outcomes (NOC)

Interventions (NIC) and Rationales

Pain Control

• Reports pain controlled _____

• Uses analgesics as recommended _____

• Uses nonanalgesic relief measures _____

• Reports uncontrolled symptoms to health care professional _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Patient-Controlled Analgesia (PCA) Assistance

• Teach patient and caregiver to monitor pain intensity, quality, and duration to evaluate effectiveness of PCA.

• Validate that the patient can use PCA device: is able to communicate, comprehend explanations, and follow directions.

• Teach patient and caregiver how to use PCA device.

• Teach patient and caregiver the action and side effects of pain-relieving agents.

Pain Management

• Teach the use of nonpharmacologic techniques (e.g., relaxation, guided imagery, distraction, and breathing exercises) before, after, and if possible, during painful activities along with other pain relief measures to alleviate pain through a variety of methods.

• Encourage patient to use adequate pain medication for best pain control.

• Provide the patient optimal pain relief with prescribed analgesics before pain becomes severe.

• Evaluate the effectiveness of the pain control measures used through ongoing assessment of the pain experience.

Tube Care: Urinary

• Maintain patency of urinary catheter system because clots cause obstruction of urine flow resulting in painful bladder spasms.

Nursing Diagnosis

Deficient knowledge related to unfamiliarity with information resources, information misinterpretation, and reluctance to ask about effects of prostatectomy as evidenced by inaccurate comments and behavior concerning postoperative activity

Patient Goal

Describes necessary follow-up care and activity restrictions

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Treatment Regimen • Description of self-care responsibilities for ongoing treatment ____ • Description of prescribed activity _____ • Description of self-monitoring techniques _____ Measurement Scale 1 = None 2 = Limited 3 = Moderate 4 = Substantial 5 = Extensive	Discharge Planning • Formulate a maintenance plan for postdischarge follow-up. • Coordinate referrals relevant to linkages among health care providers. • Assist patient/family/significant other in planning for supportive environment necessary to provide for patient’s posthospital care. Teaching: Disease Process • Discuss lifestyle changes that may be required to prevent future complications and/or control disease process (e.g., avoid heavy lifting, straining during defecation, prolonged periods of travel, stair climbing, driving, and sexual activity—until surgeon approves such activity) to prevent increases in intraabdominal pressure and the possibility of bleeding.

Outcomes (NOC)

Interventions (NIC) and Rationales

Knowledge: Treatment Regimen

• Description of self-care responsibilities for ongoing treatment ____

• Description of prescribed activity _____

• Description of self-monitoring techniques _____

• Formulate a maintenance plan for postdischarge follow-up.

• Coordinate referrals relevant to linkages among health care providers.

• Assist patient/family/significant other in planning for supportive environment necessary to provide for patient’s posthospital care.

Teaching: Disease Process

• Discuss lifestyle changes that may be required to prevent future complications and/or control disease process (e.g., avoid heavy lifting, straining during defecation, prolonged periods of travel, stair climbing, driving, and sexual activity—until surgeon approves such activity) to prevent increases in intraabdominal pressure and the possibility of bleeding.

Nursing Diagnosis

Sexual dysfunction related to surgical alterations in body structure and function as evidenced by comments indicating a loss of masculinity, an inability to achieve sexual satisfaction, and verbalization of a sexual problem.

Patient Goal

Reports acceptable sexual function

Outcomes (NOC)	Interventions (NIC) and Rationales
Sexual Functioning • Uses assistive device as needed _____ • Adapts sexual techniques as needed _____ • Expresses ability to perform sexually despite physical imperfections _____ • Expresses comfort with sexual expression _____ • Expresses comfort with body _____ • Expresses ability to be intimate _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Sexual Counseling • Establish a therapeutic relationship, providing privacy and ensuring confidentiality to develop trust. • Preface questions about sexuality with a statement that tells the patient that many people experience sexual difficulties to promote normalcy of problems. • Discuss the effects of the illness/health situation on sexuality so patient will know the extent of the problem. • Encourage patient to verbalize fears and to ask questions to identify specific concerns of patient. • Discuss alternative forms of sexual expression that are acceptable to patient to help maintain intimacy and sexual role. • Include the spouse/sexual partner in the counseling as much as possible to promote mutual understanding of problems. • Use humor and encourage patient to use humor to relieve anxiety or embarrassment. • Refer the patient to a sex therapist as needed for extended treatment.

Outcomes (NOC)

Interventions (NIC) and Rationales

Sexual Functioning

• Uses assistive device as needed _____

• Adapts sexual techniques as needed _____

• Expresses ability to perform sexually despite physical imperfections _____

• Expresses comfort with sexual expression _____

• Expresses comfort with body _____

• Expresses ability to be intimate _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Sexual Counseling

• Establish a therapeutic relationship, providing privacy and ensuring confidentiality to develop trust.

• Preface questions about sexuality with a statement that tells the patient that many people experience sexual difficulties to promote normalcy of problems.

• Discuss the effects of the illness/health situation on sexuality so patient will know the extent of the problem.

• Encourage patient to verbalize fears and to ask questions to identify specific concerns of patient.

• Discuss alternative forms of sexual expression that are acceptable to patient to help maintain intimacy and sexual role.

• Include the spouse/sexual partner in the counseling as much as possible to promote mutual understanding of problems.

• Use humor and encourage patient to use humor to relieve anxiety or embarrassment.

• Refer the patient to a sex therapist as needed for extended treatment.

^*Nursing diagnoses listed in order of priority.

Although the cause of BPH is not completely understood, it is thought that BPH results from hormonal changes associated with the aging process.¹ One possible cause is excessive accumulation of dihydroxytestosterone (DHT) (the principal intraprostatic androgen) in the prostate cells. This can stimulate cell growth and an overgrowth of prostate tissue. Older men have a decrease in the blood’s testosterone level, but continue to produce and accumulate high levels of DHT in the prostate.

Another possible cause is an increased proportion of estrogen (as compared to testosterone) in the blood. Throughout their lives, men produce both testosterone and small amounts of estrogen. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. A higher amount of estrogen within the gland increases the activity of substances (e.g., DHT) that promote cell growth.

Typically BPH develops in the inner part of the prostate. (Prostate cancer is most likely to develop in the outer part.) This enlargement gradually compresses the urethra, eventually leading to partial or complete obstruction (Fig. 55-2). The compression of the urethra ultimately leads to the development of clinical symptoms. There is no direct relationship between the size of the prostate and the severity of symptoms or degree of obstruction. The location of the enlargement is most significant in the development of obstructive symptoms (Fig. 55-3). For example, it is possible for mild hyperplasia to cause severe obstruction, or for extreme hyperplasia to cause few obstructive symptoms.

FIG. 55-2 Benign prostatic hyperplasia. The enlarged prostate compresses the urethra.

FIG. 55-3 Views of the prostate by cystoscopy. A, Normal appearance. B, Moderate benign prostatic hyperplasia with urethral obstruction.

Risk factors for BPH include aging, obesity (in particular increased waist circumference), lack of physical activity, alcohol consumption, erectile dysfunction, smoking, and diabetes.⁴ A positive family history of BPH in first-degree relatives may also be a risk factor.

Clinical Manifestations

Manifestations of BPH are mainly associated with symptoms of the lower urinary tract.⁵ The patient’s symptoms are usually gradual in onset and may not be noticed until prostatic enlargement has been present for some time. Early symptoms are often minimal because the bladder can compensate for a small amount of resistance to urine flow. The symptoms gradually worsen as the degree of urethral obstruction increases.

Symptoms can be divided into two groups: irritative and obstructive. Irritative symptoms, which include nocturia, urinary frequency, urgency, dysuria, bladder pain, and incontinence, are associated with inflammation or infection. Nocturia is often the first symptom that the patient notices.⁵

Obstructive symptoms caused by prostate enlargement include a decrease in the caliber and force of the urinary stream, difficulty in initiating voiding, intermittency (stopping and starting stream several times while voiding), and dribbling at the end of urination. These symptoms are due to urinary retention.

The American Urological Association (AUA) symptom index for BPH (Table 55-1) is a widely used tool to assess voiding symptoms associated with obstruction. Although this tool is not diagnostic, it helps determine the extent of symptoms.⁶ Higher scores on this tool indicate greater symptom severity.

TABLE 55-1

AUA SYMPTOM INDEX TO DETERMINE SEVERITY OF PROSTATIC PROBLEMS

	AUA Symptom Score* (circle one number on each line)
Questions	Not At All	Less Than 1 Time in 5	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always
Over the past month
1. How often do you have the sensation that your bladder is not completely empty after you finish urinating?	0	1	2	3	4	5
2. How often do you have to urinate again, less than 2 hr after you finish urinating?	0	1	2	3	4	5
3. How often do you stop and start again several times when you urinate?	0	1	2	3	4	5
4. How often do you find it difficult to postpone urination?	0	1	2	3	4	5
5. How often do you have a weak urinary stream?	0	1	2	3	4	5
6. How often do you have to push or strain to begin urination?	0	1	2	3	4	5
7. How many times do you usually get up to urinate from the time you go to bed at night until the time you get up in the morning?	0 (None)	1 (1 time)	2 (2 times)	3 (3 times)	4 (4 times)	5 (5 times or more)
Sum of circled numbers (AUA Symptom Score): _____*

AUA, American Urological Association.

^*Score is interpreted as follows: 0-7, mild; 8-19, moderate; 20-35, severe.

Source: Barry MJ, Fowler FJ, O’Leary MP, et al: The American Urological Association symptom index for benign prostatic hyperplasia, J Urol 148:1549, 1992. Used with permission.

Complications

Complications of urinary obstruction are relatively uncommon in BPH. Acute urinary retention is a complication that is manifested by the sudden and painful inability to urinate. Treatment involves the insertion of a catheter to drain the bladder. Surgery may also be indicated.

Another complication is urinary tract infection (UTI) and potentially sepsis secondary to UTI. Incomplete bladder emptying (associated with partial obstruction) results in residual urine, which provides a favorable environment for bacterial growth. Calculi may develop in the bladder because of the alkalinization of the residual urine. Bladder stones are more common in men with BPH, although the risk of renal calculi is not significantly increased. Additional complications include renal failure caused by hydronephrosis (distention of pelvis and calyces of kidney by urine that cannot flow through the ureter to the bladder), pyelonephritis, and bladder damage if treatment for acute urinary retention is delayed.

Diagnostic Studies

The primary methods used to diagnose BPH include a history and physical examination. (Diagnostic studies are outlined in Table 55-2.) The prostate can be palpated by digital rectal examination (DRE) to estimate its size, symmetry, and consistency. In BPH, the prostate is symmetrically enlarged, firm, and smooth.

TABLE 55-2

COLLABORATIVE CARE Benign Prostatic Hyperplasia

Diagnostic

• History and physical examination

• Digital rectal examination (DRE)

• Urinalysis with culture

• Prostate-specific antigen (PSA)

• Serum creatinine

• Postvoid residual

• Transrectal ultrasound (TRUS)

• Uroflowmetry

• Cystoscopy

Collaborative Therapy

Active Surveillance

Drug Therapy

• 5α-Reductase inhibitors (e.g., finasteride [Proscar], dutasteride [Avodart], dutasteride plus tamsulosin [Jalyn])

• α-Adrenergic receptor blockers (e.g., silodosin [Rapaflo], alfuzosin [Uroxatral], doxazosin [Cardura], prazosin [Minipress], terazosin [Hytrin], tamsulosin [Flomax])

• Erectogenic drugs (e.g., tadalafil [Cialis])

Minimally Invasive Therapy*

• Transurethral microwave thermotherapy (TUMT)

• Transurethral needle ablation (TUNA)

• Laser prostatectomy

• Transurethral electrovaporization of the prostate (TUVP)

• Intraprostatic urethral stents

Invasive (Surgery) Therapy*

• Transurethral resection of the prostate (TURP)

• Transurethral incision of the prostate (TUIP)

• Open prostatectomy

^*See Table 55-3.

Additional diagnostic tests may be indicated, depending on the type and severity of symptoms and clinical findings. A urinalysis with culture is routinely done to identify any infection. Bacteria, white blood cells (WBCs), or microscopic hematuria indicate infection or inflammation.

A prostate-specific antigen (PSA) blood test may be done to rule out prostate cancer. However, PSA levels may be slightly elevated in patients with BPH. Serum creatinine levels may be ordered to rule out renal insufficiency. Because symptoms of BPH are similar to those of a neurogenic bladder, a neurologic examination may also be performed.

In patients with an abnormal DRE and elevated PSA, a transrectal ultrasound (TRUS) scan is typically indicated. This examination allows for accurate assessment of prostate size and is helpful in differentiating BPH from prostate cancer. Biopsies can be taken during the ultrasound procedure. Uroflowmetry, a study that measures the volume of urine expelled from the bladder per second, is helpful in determining the extent of urethral blockage and thus the type of treatment needed. Postvoid residual urine volume is often measured to determine the degree of urine flow obstruction. Cystoscopy, a procedure allowing internal visualization of the urethra and bladder, is performed if the diagnosis is uncertain and in patients scheduled for prostatectomy.

Collaborative Care

The goals of collaborative care are to (1) restore bladder drainage, (2) relieve the patient’s symptoms, and (3) prevent or treat the complications of BPH. Treatment is generally based on the degree to which the symptoms bother the patient or the presence of complications, rather than the size of the prostate. Alternatives to surgical intervention for some patients now include drug therapy and minimally invasive procedures.

The most conservative treatment that may be recommended for some patients with BPH is referred to as active surveillance, or watchful waiting.⁷ When the patient has no symptoms or only mild ones (AUA symptom scores of 0 to 7), a wait-and-see approach is taken. Because some patients have symptoms that disappear, a conservative approach has value. Making dietary changes (decreasing intake of caffeine, artificial sweeteners, and spicy or acidic foods), avoiding medications such as decongestants and anticholinergics, and restricting evening fluid intake may improve symptoms.

A timed voiding schedule may reduce or eliminate symptoms, thus negating the need for further intervention. If the patient begins to have signs or symptoms that indicate an increase in obstruction, further treatment is indicated.

Drug Therapy.

Drugs that have been used to treat BPH with variable degrees of success include 5α-reductase inhibitors and α-adrenergic receptor blockers. Combination therapy using both types of these drugs has been shown to be more effective in reducing symptoms than using one drug alone.

5α-Reductase Inhibitors.

These drugs work by reducing the size of the prostate gland. Finasteride (Proscar) blocks the enzyme 5α-reductase, which is necessary for the conversion of testosterone to DHT, the principal intraprostatic androgen. This drug results in regression of hyperplastic tissue through suppression of androgens. Finasteride is an appropriate treatment option for individuals who have a moderate to severe symptom score on the AUA symptom index (see Table 55-1). Although more than 50% of men who are treated with the drug show symptom improvement, it takes about 6 months to be effective. Furthermore, the drug must be taken on a continuous basis to maintain therapeutic results. Serum PSA levels are decreased by almost 50% when taking finasteride. Therefore PSA levels should be doubled when comparing the patient’s current levels to premedication levels.

Dutasteride (Avodart) has the same effect on prostatic tissue as finasteride and is a dual inhibitor of 5α-reductase type 1 and 2 isoenzymes. (Finasteride inhibits only the type 2 isoenzyme.) The combination of a 5α-reductase inhibitor (dutasteride) and an α-adrenergic receptor blocker (tamsulosin) is now available in a single oral medication (Jalyn).

In addition to decreasing the symptoms of BPH, finasteride, dutasteride, and Jalyn (finasteride plus tamsulosin) may also lower the risk of prostate cancer.⁸ However, the use of these drugs in prevention of prostate cancer has not been advised because of the increased risk of developing aggressive prostate cancer. Patients with an increased PSA level while taking these medications should be referred to their health care provider. The need for regular prostate cancer screening should also be discussed with the provider.

Drug Alert

Finasteride (Proscar)

• Patient should be aware of the increased risk of orthostatic hypotension with concomitant use of erectile dysfunction drugs.

• Women who may be or are pregnant should not handle tablets due to potential risk to male fetus (anomaly).

α-Adrenergic Receptor Blockers.

α-Adrenergic receptor blockers are another drug treatment option for BPH. These agents selectively block α₁-adrenergic receptors, which are abundant in the prostate and are increased in hyperplastic prostate tissue. Although α-adrenergic blockers are more commonly used for treatment of hypertension, these drugs promote smooth muscle relaxation in the prostate, facilitating urinary flow through the urethra. These agents demonstrate a 50% to 60% efficacy in improvement of symptoms, which occurs within 2 to 3 weeks.

Several α-adrenergic blockers are currently in use, including silodosin (Rapaflo), alfuzosin (Uroxatral), doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin), and tamsulosin (Flomax). Note that although these drugs offer symptomatic relief of BPH, they do not treat hyperplasia.

Erectogenic Drugs.

Tadalafil (Cialis) has been used in men who have symptoms of BPH alone or in combination with erectile dysfunction (ED). The drug has shown to be effective in reducing symptoms for both these conditions (see erectile dysfunction later in this chapter).⁹

Herbal Therapy.

Herbal extracts have been used in the management of lower urinary symptoms associated with BPH. In particular, some patients take plant extracts such as saw palmetto (Serenoa repens). However, research indicates that saw palmetto has no benefit over a placebo.10,11 In a limited number of small trials, herbal preparations such as saxifrage, beta-sitosterol, Pygeum africanum, and Cernilton have shown some success in reducing the symptoms of BPH. Advise patients to tell their health care provider about all herbal supplements that they use.

Minimally Invasive Therapy.

Minimally invasive therapies are becoming more common as an alternative to watchful waiting and invasive treatment (Table 55-3). They generally do not require hospitalization or catheterization and are associated with few adverse events. Many minimally invasive therapies have outcomes comparable to those of invasive techniques.¹²

TABLE 55-3

TREATMENT FOR BENIGN PROSTATIC HYPERPLASIA

Description	Advantages	Disadvantages
Minimally Invasive
*Transurethral Microwave Thermotherapy (TUMT)*
Use of microwave radiating heat to produce coagulative necrosis of the prostate.	Outpatient procedureErectile dysfunction, urinary incontinence, and retrograde ejaculation are rare	Potential for damage to surrounding tissueUrinary catheter needed after procedure
*Transurethral Needle Ablation (TUNA)*
Low-wave radiofrequency used to heat the prostate, causing necrosis.	Outpatient procedureErectile dysfunction, urinary incontinence, and retrograde ejaculation are rarePrecise delivery of heat to desired areaVery little pain experienced	Urinary retention commonIrritative voiding symptomsHematuria
*Laser Prostatectomy*
Procedure uses a laser beam to cut or destroy part of the prostate. Different techniques are available: • Visual laser ablation of prostate (VLAP) • Contact laser • Photovaporization of prostate (PVP) • Interstitial laser coagulation (ILC)	Short procedureComparable results to TURPMinimal bleedingFast recovery timeRapid symptom improvementVery effective	Catheter (up to 7 days) needed after procedure due to edema and urinary retentionDelayed sloughing of tissueTakes several weeks to reach optimal effectRetrograde ejaculation
*Transurethral Electrovaporization of Prostate (TUVP)*
Electrosurgical vaporization and desiccation are used together to destroy prostatic tissue.	Minimal risksMinimal bleeding and sloughing	Retrograde ejaculationIntermittent hematuria
*Intraprostatic Urethral Stents*
Insertion of self-expandable metallic stent into the urethra where enlarged area of prostate occurs.	Safe and effectiveLow risk	Stent may moveLong-term effect is unknown
Invasive (Surgery)
*Transurethral Resection of Prostate (TURP)*
Use of excision and cauterization to remove prostate tissue cystoscopically. Remains the standard for treatment of BPH.	Erectile dysfunction unlikely	BleedingRetrograde ejaculation
*Transurethral Incision of Prostate (TUIP)*
Involves transurethral incisions into prostatic tissue to relieve obstruction. Effective for men with small to moderate prostates.	Outpatient procedureMinimal complicationsLow occurrence of erectile dysfunction or retrograde ejaculation	Urinary catheter needed after procedure
*Open Prostatectomy*
Surgery of choice for men with large prostates, bladder damage, or other complicating factors. Involves external incision with two possible approaches (see Fig. 55-6).	Complete visualization of prostate and surrounding tissue	Erectile dysfunctionBleedingPostoperative painRisk of infection

TURP is performed under a spinal or general anesthetic and requires a 1- to 2-day hospital stay. No external surgical incision is made. A resectoscope is inserted through the urethra to excise and cauterize obstructing prostatic tissue (Fig. 55-4). A large three-way indwelling catheter with a 30-mL balloon is inserted into the bladder after the procedure to provide hemostasis and to facilitate urinary drainage. The bladder is irrigated, either continuously or intermittently, usually for the first 24 hours to prevent obstruction from mucus and blood clots.

FIG. 55-4 Transurethral resection of the prostate.

The outcome for 80% to 90% of patients is excellent, with marked improvements in symptoms and urinary flow rates. Quality of life is also improved. TURP is a surgical procedure with a relatively low risk. Postoperative complications include bleeding, clot retention, and dilutional hyponatremia associated with irrigation. Because bleeding is a common complication, patients taking aspirin, warfarin (Coumadin), or other anticoagulants must discontinue these medications several days before surgery.

Transurethral Incision of the Prostate.

Transurethral incision of the prostate (TUIP) is a surgical procedure done under local anesthesia for men with moderate to severe symptoms. Several small incisions are made into the prostate gland to expand the urethra, which relieves pressure on the urethra and improves urine flow. TUIP is an option for patients with a small or moderately enlarged prostate gland. TUIP has similar patient outcomes to TURP in relieving symptoms.

Nursing Management Benign Prostatic Hyperplasia

Because you will be most directly involved in care of patients with BPH having invasive therapies, the focus of nursing management in this section is on preoperative and postoperative care.

Nursing Assessment

Subjective and objective data that should be obtained from a patient with BPH are presented in Table 55-4.

TABLE 55-4

NURSING ASSESSMENT Benign Prostatic Hyperplasia

Subjective Data

Important Health Information

Medications: Estrogen or testosterone supplementation

Surgery or other treatments: Previous treatment for BPH

Functional Health Patterns

Health perception–health management: Knowledge of the condition

Nutritional-metabolic: Voluntary fluid restriction

Elimination: Urinary urgency, diminution in caliber and force of urinary stream; hesitancy in initiating voiding; postvoid dribbling; urinary retention; incontinence

Sleep: Nocturia

Cognitive-perceptual: Dysuria, sensation of incomplete voiding; bladder discomfort

Sexuality-reproductive: Anxiety about sexual dysfunction

Objective Data

General

Older adult male

Urinary

Distended bladder on palpation; smooth, firm, elastic enlargement of prostate on rectal examination

Possible Diagnostic Findings

Enlarged prostate on ultrasonography; vesicle neck obstruction on cystoscopy; residual urine with postvoiding catheterization; white blood cells, bacteria, or microscopic hematuria with infection; ↑ serum creatinine levels with renal involvement

Nursing Diagnoses

Nursing diagnoses for the patient with BPH preoperatively may include, but are not limited to, the following:

• Acute pain related to bladder distention secondary to enlarged prostate

• Risk for infection related to an indwelling catheter, urinary stasis, or environmental pathogens

Nursing diagnoses for the patient with BPH who has invasive therapy (surgery) are presented in eNursing Care Plan 55-1 (available on the website for this chapter).

Planning

The overall preoperative goals for the patient having invasive procedures are to have (1) restoration of urinary drainage; (2) treatment of any UTI; and (3) understanding of the upcoming procedure, implications for sexual function, and urinary control. The overall postoperative goals are to have (1) no complications, (2) restoration of urinary control, (3) complete bladder emptying, and (4) satisfying sexual expression.

Nursing Implementation

Health Promotion.

The cause of BPH is largely attributed to the aging process.¹⁴ Health promotion focuses on early detection and treatment. The American Cancer Society, along with the AUA, recommends a yearly medical history and DRE for men over 50 years of age in an effort to detect prostate problems early. When symptoms of prostatic hyperplasia are present, further diagnostic screening may be necessary (see Table 55-2).

Some men find that the ingestion of alcohol and caffeine tends to increase prostatic symptoms because the diuretic effect increases bladder distention. Compounds found in common cough and cold remedies such as pseudoephedrine (in Sudafed) and phenylephrine (in Allerest PE and Coricidin D) often worsen the symptoms of BPH. These drugs are α-adrenergic agonists that cause smooth muscle contraction. If this happens, the patient should avoid these drugs.

Advise patients with obstructive symptoms to urinate every 2 to 3 hours and when they first feeling the urge. This will minimize urinary stasis and acute urinary retention. Fluid intake should be maintained at a normal level to avoid dehydration or fluid overload. The patient may believe that if he restricts his fluid intake, symptoms will be less severe, but this only increases the chances of an infection. However, if the patient increases his intake too rapidly, bladder distention can develop because of the prostatic obstruction.

Acute Intervention.

The following discussion focuses on preoperative and postoperative care for the patient undergoing a TURP.

Preoperative Care.

Urinary drainage must be restored before surgery. Prostatic obstruction may result in acute retention or inability to void. A urethral catheter such as a coudé (curved-tip) catheter may be needed to restore drainage. In many health care settings, 10 mL of sterile 2% lidocaine gel is injected into the urethra before insertion of the catheter. The lidocaine gel not only acts as a lubricant, but also provides local anesthesia and helps open the urethral lumen. If a sizable obstruction of the urethra exists, the urologist may insert a filiform catheter with sufficient rigidity to pass the obstruction. Aseptic technique is important at all times to avoid introducing bacteria into the bladder. (Urinary catheters are discussed in Chapter 46.)

Antibiotics are usually administered before any invasive procedure. Any infection of the urinary tract must be treated before surgery. Restoring urinary drainage and encouraging a high fluid intake (2 to 3 L/day unless contraindicated) are also helpful in managing the infection.

Patients are often concerned about the impact of the impending surgery on sexual function. Provide an opportunity for the patient and the partner to express their concerns. Inform the patient that surgery may affect sexual function. The ejaculate may be decreased in amount or be totally absent. Most types of prostatic surgery result in some degree of retrograde ejaculation. This may decrease orgasmic sensations felt during ejaculation. Retrograde ejaculation is not harmful because the semen is eliminated during the next urination.

Postoperative Care.

The main complications after surgery are hemorrhage, bladder spasms, urinary incontinence, and infection. The plan of care should be adjusted to the type of surgery, the reasons for surgery, and the patient’s response to surgery.

After surgery the patient will have a standard catheter or a triple-lumen catheter. Bladder irrigation is typically done to remove clotted blood from the bladder and ensure drainage of urine. The bladder is irrigated either manually on an intermittent basis or more commonly as continuous bladder irrigation (CBI) with sterile normal saline solution or another prescribed solution. If the bladder is manually irrigated (if ordered), instill 50 mL of irrigating solution and then withdraw with a syringe to remove clots that may be in the bladder and catheter. Painful bladder spasms often occur as a result of manual irrigation.

With CBI, irrigating solution is continuously infused and drained from the bladder. The rate of infusion is based on the color of drainage. Ideally the urine drainage should be light pink without clots. Continuously monitor the inflow and outflow of the irrigant. If outflow is less than inflow, assess the catheter patency for kinks or clots. If the outflow is blocked and patency cannot be reestablished by manual irrigation, stop the CBI and notify the physician.

Use careful aseptic technique when irrigating the bladder because bacteria can easily be introduced into the urinary tract. To prevent urethral irritation and minimize the risk of bladder infection, secure the catheter to the leg with tape or a catheter strap. The catheter should be connected to a closed-drainage system. Do not disconnect unless it is being removed, changed, or irrigated. Proper care of the catheter is important. On a daily basis, cleanse the secretions that accumulate around the meatus with soap and water.

Blood clots are expected after prostate surgery for the first 24 to 36 hours. However, large amounts of bright red blood in the urine can indicate hemorrhage. Postoperative hemorrhage may occur from displacement of the catheter, dislodgment of a large clot, or increases in abdominal pressure.

Release or displacement of the catheter dislodges the balloon that provides counterpressure on the operative site. Traction on the catheter may be applied to provide counterpressure (tamponade) on the bleeding site in the prostate, thereby decreasing bleeding. Such traction can result in local necrosis if pressure is applied for too long. Therefore pressure should be relieved on a scheduled basis by qualified personnel. Activities that increase abdominal pressure, such as sitting or walking for prolonged periods and straining to have a bowel movement (Valsalva maneuver), should be avoided in the postoperative recovery period.

Bladder spasms are a distressing complication for the patient after transurethral procedures. They occur as a result of irritation of the bladder mucosa from the insertion of the resectoscope, presence of a catheter, or clots leading to obstruction of the catheter. Instruct the patient not to urinate around the catheter because this increases the likelihood of spasm. If bladder spasms develop, check the catheter for clots. If present, remove the clots by irrigation so that urine can flow freely. Belladonna and opium suppositories or other antispasmodics (e.g., oxybutynin [Ditropan]), along with relaxation techniques, are used to relieve the pain and decrease spasm.

The catheter is often removed 2 to 4 days after surgery. The patient should urinate within 6 hours after catheter removal. If he cannot, reinsert a catheter for a day or two. If the problem continues, instruct the patient to perform clean intermittent self-catheterization (see Chapter 46).

Sphincter tone may be poor immediately after catheter removal, resulting in urinary incontinence or dribbling. This is a common but distressing situation for the patient. Sphincter tone can be strengthened by having the patient practice Kegel exercises (pelvic floor muscle technique) 10 to 20 times per hour while awake. (Kegel exercises are discussed in Table 46-19.) Encourage the patient to practice starting and stopping the stream several times during urination. This facilitates learning the pelvic floor exercises.

It usually takes several weeks to achieve urinary continence. In some instances, control of urine may never be fully regained. Continence can improve for up to 12 months. If continence has not been achieved by that time, refer the patient to a continence clinic. A variety of methods, including biofeedback, have been used to achieve positive results.

You can also instruct the patient to use a penile clamp, a condom catheter, or incontinence pads or briefs to avoid embarrassment from dribbling. In severe cases, an occlusive cuff that serves as an artificial sphincter can be surgically implanted to restore continence. Assist the patient in finding ways to manage the problem that allow him to continue socializing and interacting with others.

Observe the patient for signs of postoperative infection. If an external wound is present (from an open prostatectomy), assess the area for redness, heat, swelling, and purulent drainage. Special care must be taken if a perineal incision is present because of the proximity of the anus. Avoid rectal procedures, such as taking rectal temperatures and administering enemas. The insertion of well-lubricated belladonna and opium suppositories is acceptable.

Dietary intervention and stool softeners are important in the postoperative period to prevent the patient from straining while having bowel movements. Straining increases the intraabdominal pressure, which can lead to bleeding at the operative site. A diet high in fiber facilitates the passage of stool.

Ambulatory and Home Care.

Discharge planning and home care issues are important aspects of care after prostate surgery. Instructions include (1) caring for an indwelling catheter (if one is left in place); (2) managing urinary incontinence; (3) maintaining adequate oral fluid intake; (4) observing for signs and symptoms of urinary tract and wound infection; (5) preventing constipation; (6) avoiding heavy lifting (more than 10 lb [4.5 kg]); and (7) refraining from driving or intercourse after surgery as directed by the physician.

The patient may experience a change in sexual function after surgery. Many men experience retrograde ejaculation because of trauma to the internal urethral sphincter. Semen is discharged into the bladder at orgasm and may produce cloudy urine when the patient urinates after orgasm. ED may occur if the nerves are cut or damaged during surgery. The patient may experience anxiety over the change because of a perceived loss of his sex role, self-esteem, or quality of sexual interaction with his partner.

Discuss these changes with the patient and his partner and allow them to ask questions and express their concerns. Sexual counseling and treatment options may be necessary if ED becomes a chronic or permanent problem. (ED is discussed later in this chapter.)

Point out that although some patients experience concerns regarding change in sexual function, this is not a universal concern. Recovery depends on the type of surgery performed and the interval of time between when symptoms first appeared and the date of surgery. It may take up to 1 year for complete sexual function to return.

The bladder may take up to 2 months to return to its normal capacity. Instruct the patient to drink at least 2 to 3 L of fluid per day and urinate every 2 to 3 hours to flush the urinary tract. Teach the patient to avoid or limit the amounts of bladder irritants such as caffeine products, citrus juices, and alcohol. Because the patient may experience incontinence or dribbling, he may incorrectly believe that decreasing fluid intake will relieve this problem.

Urethral strictures may result from instrumentation or catheterization. Treatment may include teaching the patient intermittent clean self-catheterization or having a urethral dilation.

Advise the patient to continue having a yearly DRE if he has had any procedure other than complete removal of the prostate. Hyperplasia or cancer can occur in the remaining prostatic tissue.

Evaluation

The expected outcomes are that the patient with BPH who has surgery will

• Report satisfactory pain control

• Report improved urinary function with no pain or incontinence

Additional information on expected outcomes for the patient with BPH is presented in eNursing Care Plan 55-1.

Prostate Cancer

Prostate cancer is a malignant tumor of the prostate gland. It is estimated that 241,740 new cases of prostate cancer are diagnosed and 28,170 men die annually from the disease in the United States.¹⁵ One of every six men will develop prostate cancer at some point during his life. Prostate cancer is the most common cancer among men, excluding skin cancer. It is the second leading cause of cancer death in men (exceeded only by lung cancer). The majority (more than 60%) of cases occur in men over age 65. However, many cases occur in younger men who sometimes have a more aggressive type of cancer. Almost 2.8 million men in the United States are survivors of prostate cancer.¹⁶

Etiology and Pathophysiology

Prostate cancer is an androgen-dependent adenocarcinoma that is usually slow growing. It can spread by three routes: direct extension, through the lymph system, or through the bloodstream. Spread by direct extension involves the seminal vesicles, urethral mucosa, bladder wall, and external sphincter. The cancer later spreads through the lymphatic system to the regional lymph nodes. The bloodstream seems to be the mode of spread to pelvic bones, head of the femur, lower lumbar spine, liver, and lungs.

Age, ethnicity, and family history are known risk factors for prostate cancer. (Additional information on ethnicity is presented in the Cultural & Ethnic Health Disparities box on this page.) The incidence of prostate cancer rises markedly after age 50 with a median age at diagnosis of 67 years old.¹⁶ The incidence of prostate cancer worldwide is higher in African Americans than in any other ethnic group (except Jamaican men of African descent).¹⁵ The reasons for the higher rate are unknown. In addition, African American men are likely to have more aggressive tumors at diagnosis and have higher mortality rates from prostate cancer. Differences in survival may be due to body composition, dietary factors, and endogenous hormones.

Cultural & Ethnic Health Disparities