19. Patients requiring surgery on the male reproductive system
Aoife Donoghue
CHAPTER CONTENTS
Anatomy and physiology of the male reproductive system375
Urological investigations and assessment377
Carcinoma of the prostate gland377
Surgery on the prostate gland378
Cancer of the penis385
Penile conditions and surgery385
Scrotal conditions and surgery388
Nursing care for penile and scrotal surgery390
Surgery on the male urethra392
Conclusion394
After reading the chapter the reader should be able to:
• give an overview of the anatomy and physiology of the male reproductive system
• describe the pre- and postoperative nursing care for individuals undergoing surgery on the prostate gland
• explain discharge advice that would be given following surgery on the prostate gland
• describe the pre- and postoperative nursing care for individuals undergoing surgery for penile and scrotal conditions
• explain discharge advice that would be given following penile and scrotal surgery
• have greater understanding of the psychological impact of surgery.
Introduction
This chapter addresses the management and treatment of men with specific conditions of the genitourinary tract. Nursing care related to these specific conditions will be discussed, including the psychological needs of the patient when addressing sexuality and altered body image, and the need for sensitive and empathetic management of this client group. Where necessary, cross references are made to Chapter 18 with regard to investigations and nursing assessment of the individual requiring surgery.
Anatomy and physiology of the male reproductive system
The male reproductive system is made up of essential and accessory organs. The main structures of the male genitourinary system are:
• the testes and associated ducts
• the accessory glands, e.g. the prostate gland
• the penis.
The testes and associated ducts
The testes are the sex glands of the male. They have two functions:
• to produce androgens, which are the male sex hormone (testosterone)
The paired testicles sit within the scrotum and a mid-line septum divides the two compartments. The scrotum is suspended outside the body below the penis. The testicles are suspended in the scrotum by the spermatic cord; the blood, nerve supply and lymphatic drainage run through this structure. Arterial blood supply is via the testicular artery and drainage is via the testicular vein. The testes are surrounded by two layers of connective tissue, the tunica albuginea and the tunica vaginalis: they help protect the testicle against injury and also cushion the structures during movement.
There are two distinct cell types within the testicle:
• the Sertoli cells: responsible for the production of spermatozoa and found within the seminiferous tubules of the testes
• the Leydig cells: found in the interstitial tissue between the seminiferous tubules and responsible for the production of testosterone.
The tubules and ducts from each testis converge at the posterior aspect of the gland and form the epididymis, where the sperm is stored and matures. The epididymis is a coiled tube approximately 6 m in length and is divided into the head, body and tail. The head of the epididymis receives sperm from the testis and storage occurs within the body and tail regions. The epididymis expands near its tail to become the vas deferens.
The vas deferens is a small muscular tube approximately 45 cm long that begins in the scrotum, travels a course through the inguinal canal into the pelvic cavity and ends where it joins with the duct of the seminal vesicle to form the ejaculatory duct. The ejaculatory ducts open into the urethra on either side of the verumontanum, which is a raised structure found on the posterior wall of the prostatic urethra. The two seminal vesicles are located behind the prostate gland beneath the bladder base and are approximately 5–7 cm in length. Seminal fluid, secreted by the seminal vesicles, is viscous, alkaline, and yellowish in colour, and contains nutrients and enzymes. The fluid is thought to aid sperm motility and makes up around 60% of the ejaculatory volume.
The prostate gland
The prostate gland surrounds the urethra just inferior to the bladder neck. The size of the prostate varies considerably – it increases in size at puberty, and in the adult is approximately 15 g in weight. It is described as being doughnut shaped and has a diameter of approximately 3 cm. The outer zone of the prostate (the lateral and posterior portions) consists of glandular tissue, and the inner zone (the middle of the gland) is made up of mucosal glands. The prostate is surrounded and encased by an outer fibrous capsule.
The gland produces milky, slightly acidic secretions which contain enzymes (e.g. acid phosphatase, hyaluronidase and fibrinolysin) and many additional components (e.g. citrate, calcium and prostate-specific antigen (PSA)). The fluid makes up approximately 10–20% of the ejaculate and is thought to help neutralize the acidity of the vagina and to stimulate the mobility of the sperm (Blandy, 1998); it is also thought to be responsible for the characteristic smell of semen. The prostate gland is reliant on the levels of circulating testosterone for it to function effectively.
The prostate gland can often undergo benign hyperplastic change, which can result in urinary outflow obstruction. The precise science to how this occurs is still unknown, but changes in hormone levels in ageing can lead to these changes.
The penis
The penis is an elongated organ consisting of three spongy cylindrical bodies – two dorsal corpora cavernosa and one corpus spongiosum – which surrounds the urethra. The corpora act as storage reservoirs for blood and are surrounded by the Buck’s fascia, a tough connective tissue layer. The enlarged head of the penis is known as the glans penis and the urethra opens at its end. The glans penis is covered by the prepuce or foreskin, which is removed during the procedure of circumcision.
Penile erection occurs when there is an increased activity of the sacral parasympathetic nerves, causing vasodilatation of the arterioles and constriction of the dorsal veins of the penis. The corpora cavernosa and spongiosum fill with blood, and the penis becomes erect. At ejaculation, detumescence occurs and the penis returns to the flaccid state.
All of the above structures are key to the production and transportation of viable sperm. At ejaculation, approximately 3 mL of semen is produced, which contains around 200 million sperm. The whole process of sperm production from inception to completion takes around 74 days.
Urological investigations and assessment
For investigations and nursing assessment of the individual with a urological problem requiring surgery, refer to Chapter 18. Specific preoperative investigations are outlined in Table 19.1.
| Surgical intervention | Investigation |
|---|---|
| Transurethral resection of the prostate gland (TURP) | Blood tests – group and crossmatch 2 units – urea and electrolyte estimation – full blood count – prostate-specific antigen Urinary flow rate Midstream specimen of urine ECG Chest X-ray Ultrasound of urinary tract |
| Retropubic prostatectomy (open) | As above |
| Urethroplasty | Blood for: – full blood count to detect anaemia – urea, creatinine and electrolytes, to assess renal function – crossmatch so that blood will be available for transfusion if required Urethroplasty – urinary flow rate, cystourethroscopy Urethrogram – to determine site and length of stricture Midstream specimen of urine – to detect and treat urinary infection |
| Penile surgery for impotence | Blood tests – blood glucose estimation – hormone levels: testosterone, follicle-stimulating hormone, luteinizing hormone Doppler ultrasound Cavernosogram |
Scrotal surgery – vasectomy – vasovasectomy Exploration for suspected torsion of testes | Semen analysis Scrotal ultrasound if indicated |
Carcinoma of the prostate gland
Prostate cancer has become a major men’s health issue. Kirby et al (1995) estimate that the risk of developing microscopic disease stands at 30%; however, clinical disease is only evident in 10% of men. This in turn has both ethical and economic implications. The main risk factors proposed include ageing (60% are over the age of 70) and race (West African men and black men from the Caribbean have a higher risk, whereas men born in Asia have a lower risk, compared with men in the UK) (Powell, 2007). Genetic predisposition is relevant to first-degree relatives, especially if the relative was diagnosed before the age of 60 (Eeles, 1999). Other risk factors include androgen activity, saturated fat intake and possible environmental factors. Diagnosis may result as a consequence of visiting a GP, or following presentation with lower urinary tract symptoms similar to those seen in men with benign prostatic disease. Currently in the UK, there is no voluntary screening programme designed for prostate cancer.
For organ-confined prostate cancer there are several potential treatment options: active surveillance, medical and surgical. Radical prostatectomy is the only surgical intervention and the procedure is generally only undertaken in major urological units. This procedure is now done laparoscopically and the newest edition is the use of robot-assisted prostatectomy (for further information on the da Vinci® prostatectomy, see http://www.davinciprostatectomy.com/index.aspx [accessed 11 January 2009]). Other treatments include external beam radiotherapy and radioactive seed implantation (brachytherapy). Medical treatment can include hormone injections, which are pituitary down-regulators or gonadotrophin-releasing hormone analogues (GnRH analogues). These injections are usually given monthly to begin with and then 3 monthly.
Much of the nursing management of patients undergoing radical prostatectomy involves a similar plan of care provided to those undergoing a retropubic prostatectomy. However, clear instruction on the time the catheter will stay in situ should be sought and reflected in local policy, as it differs in some units. The possibility of erectile dysfunction needs to be discussed prior to any surgery taking place and this counselling is usually undertaken by a clinical nurse specialist or a sexual therapist. Psychological support is important for all pre- and postoperative patients, but is paramount for men on active surveillance as they live with their cancer day to day.
Surgery on the prostate gland
Almost every man over the age of 40 years old has some degree of benign prostate hyperplasia (BPH), but only 1 in 10 will get outflow obstruction requiring surgery. The incidence of BPH varies from race to race, being more common in Caucasian and black men, while rare in Chinese and Japanese men (Kirby et al, 1995).
Signs and symptoms of prostate outflow obstruction are:
• urinary frequency: needing to void often, usually more than 10 times daily
• nocturia: waking at night to void, usually more than twice
• urgency: sudden and strong desire to void
• poor urinary stream: often worse early morning and may need to strain
• hesitancy: experiences a delay in voiding although desire is present
• urinary tract infection: residual urine caused by bladder obstruction increases risk of infection
• dysuria: pain on voiding, which may be caused by infection
• urinary incontinence: occurs as a result of overdistension, with overflow incontinence as a result
• acute retention of urine.
The severity of symptoms can be assessed and evaluated using the International Prostate Symptom Score (IPSS), which consists of seven questions related to the severity of symptoms (Fig. 19.1). A separate question is asked regarding the bothersomeness of symptoms. Thirty-five is the maximum possible score; a score above 20 is regarded as severe. Digital rectal examination of the prostate gland will provide useful information regarding the size, consistency and anatomical limits of the prostate gland. Examination of the abdomen should also be undertaken to detect a palpable bladder that might indicate chronic retention of urine.
 |
| Figure 19.1 • Chart for recording the International Prostate Symptom Score. |
During the investigative stage it is important to rule out carcinoma of the prostate gland. The combined results of a digital rectal examination and prostate-specific antigen (PSA) blood screen will aid in the diagnosis.
In recent years there has been an increased trend to use medications to treat and manage BPH. Alpha-1 adrenoceptor blockers, 5-alpha reductase inhibitors and occasionally hormone manipulation have had varying degrees of success, depending on the outcome measurement tools used (Kirby et al, 1995). However, surgical management remains the most successful option in terms of symptom and outcome improvement. Surgical treatment is indicated if there is upper tract obstruction with renal function impairment, and for acute or chronic retention of urine. Surgical intervention is not indicated, however, for symptoms of frequency alone, unless it interferes with the individual’s normal lifestyle (Blandy, 1998).
Surgical procedures include:
• transurethral resection of the prostate gland (TURP)
• retropubic prostatectomy (open)
• laparoscopic prostatectomy.
Transurethral resection of the prostate gland
Transurethral resection of the prostate is the operation of choice for 80–90% of men who require surgery, and remains the ‘gold standard’ treatment for BPH (Blandy, 1991 and Foley et al., 2002). The operation is performed under a general or spinal anaesthetic, and a cystoscopy is undertaken prior to transurethral resection, to allow direct visualization of the bladder and to detect any abnormalities. A resectoscope is then passed along the urethra and the obstructing part of the prostate gland is removed using a cutting loop; diathermy is also used to control bleeding. The bladder neck is excised during the procedure (resulting in retrograde ejaculation), but the prostatic capsule and tissue below the verumontanum remain intact.
Transurethral resection of the prostate gland can be a difficult procedure to perform, but in the hands of a skilled and competent urologist is generally considered safe. Controversy exists as to whether a transurethral resection or an open procedure should be performed on large prostate glands, i.e. 50 g and over (Lewis et al, 1992).
The pre- and postoperative nursing care for individuals undergoing TURP is outlined in the care plans in Tables 19.2 and 19.3.
| Problem | Expected outcome | Action/rationale |
|---|---|---|
| Communication | ||
| Potential anxiety due to hospital and impending surgery | Patient is able to express anxieties and fears and will feel safe and informed about his operation | Discuss preoperative and anticipated postoperative care Provide a non-threatening relaxed environment in which the patient will feel able to express his anxieties and ask questions Provide information, using diagrams if necessary (Hayward, 1975) Ensure that informed consent is obtained before administration of a premedication Provide environment conducive to restful sleep |
| Breathing, eating/drinking | ||
Potential respiratory problems due to: – inhalation of gastric contents while unconscious – underlying respiratory disease | Gastric content will not be inhaled Respiratory problems will not be exacerbated | Report any breathing problems the patient may be experiencing Reinforce deep breathing exercises taught by the physiotherapist Fast for 6 hours (diet), 2 hours (fluid) prior to general anaesthetic (Phillips et al, 1993) |
| Mobility | ||
| Decreased mobility could lead to circulatory problems and increase the risk of pressure ulcer occurrence | The patient will remain as mobile as condition permits, and risk of deep vein thrombosis and pressure ulcer occurrence will be minimized | Perform pressure ulcer risk assessment Perform mobility risk assessment as per local policy Encourage mobility during preoperative period Reinforce physiotherapist’s teaching of leg exercises Measure and fit with anti-embolism stockings |
| Controlling body temperature | ||
| Potential postoperative infection, e.g. urine | Temperature will be between 35.5°C and 37.5°C Early detection and treatment if infection occurs | Record temperature preoperatively and report if outside normal parameters Perform urinalysis – obtain MSU if nitrates present on dipstick (Laker, 1994) Prophylactic antibiotics to be given as prescribed Bath or shower to be taken prior to theatre Clean theatre gown/bed linen to be provided |
| Elimination | ||
| Potential risk of incontinence due to loss of voluntary muscle control when unconscious | Patient will remain continent during anaesthesia | Ensure patient has had a bowel action within 24 hours of theatre Give patient the opportunity to void prior to administration of voluntary muscle premedication/transfer to theatre |
| Maintaining a safe environment | ||
| Inability to maintain own safety while sedated/unconscious | The safety of the patient will not be compromised | Ensure the following: – Correctly labelled identity band is in place – Patient’s consent form is signed – Wedding ring is taped – Prostheses are removed, e.g. dentures, contact lenses – Baseline observations and weight are recorded – Any allergies are documented – Patient’s medical notes, blood results, X-rays and nursing documentation are available – Patient is positioned correctly on canvas |
| Problem | Expected outcome | Action/rationale |
|---|---|---|
| Breathing | ||
| Potential risk of problems with breathing due to anaesthetic/surgical intervention | Patient’s airway will remain clear Early detection of hypoventilation | Position patient ensuring clear airway is maintained Observe and record respiratory rate ½–1 hourly initially and decrease as patient’s condition dictates Administer oxygen therapy as prescribed Follow anaesthetist’s instructions regarding position if patient has had a spinal anaesthetic, i.e. length of time patient is to lie flat Encourage deep breathing exercises |
| Maintaining a safe environment | ||
| Inability to maintain own safety after surgery | Patient’s safety will be maintained | Observe and record pulse and blood pressure ½–1 hourly and decrease as patient’s condition dictates Report to nurse in charge/doctor if blood pressure and pulse are outside normal parameters Monitor colour/consistency of urine for blood loss or blood clots Administer blood transfusion if prescribed and follow local protocol Report changes in patient’s peripheral colour and responsiveness |
| Potential risk of shock and haemorrhage, e.g. due to blood loss | Early detection of signs of shock/haemorrhage | |
| Communication | ||
| Potential risk of pain and discomfort due to surgical intervention and presence of urethral catheter | Pain/discomfort will be controlled to a level acceptable to the patient | Assess degree of discomfort/pain experienced by use of verbal/non-verbal communication Position patient as he feels comfortable Ensure catheter is patent – observe urinary drainage Secure urethral catheter to avoid traction Give analgesics as prescribed and evaluate effectiveness |
| Controlling body temperature | ||
| Potential difficulty maintaining body temperature in immediate postoperative period | Temperature will be between 35.5°C and 37.5°C | Monitor temperature 1 hourly, and decrease as condition dictates Observe urine for signs of infection, i.e. note colour, consistency and odour Inspect IV cannula site for signs of infection; note any discomfort, redness, discharge Instruct patient regarding catheter toilet using soap and water; to be performed twice daily Give antibiotics as prescribed |
| Potential infection following surgical intervention and presence of urethral catheter | Early detection and treatment should infection occur | |
| Eating and drinking | ||
| Potential risk of nausea and vomiting due to anaesthetic | Patient will not feel nauseated and will not vomit | Observe patient for signs of nausea Administer antiemetic as prescribed and evaluate effectiveness Monitor IV fluids as prescribed Commence oral fluids when fully awake (if general condition allows) and increase as tolerated Discontinue IV fluids when oral intake is 2–3 L in 24 hours and diet is tolerated |
| Potential risk of dehydration following surgery | ||
| Elimination | ||
| Potential risk of clot retention following surgery | Urethral catheter will remain patent | Maintain an accurate fluid balance chart Maintain bladder irrigation – rate to correspond to colour of urine Discontinue bladder irrigation on the 1st postoperative day if blood loss in the urine is decreasing Observe colour and consistency of urine – if clot retention occurs, perform bladder washout using an aseptic technique, following local protocol Ensure patient does not strain to have his bowels open Administer aperients as prescribed and evaluate effectiveness Remove urethral catheter as directed by doctor at midnight on the 2nd postoperative day (Chillington, 1992) or the morning of the 3rd postoperative day Instruct patient to use a urinal when he voids and maintain an accurate record of urinary output
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