The male reproductive system (Figure 40.1) consists of essential and accessory organs. The essential organs, or gonads, are the testes. Accessory organs consist of a series of ducts or passageways, supportive sex glands and external structures.

Figure 40.1 The male reproductive system

ESSENTIAL ORGANS

The testes are two glands that lie suspended outside the body in the scrotum. First formed in the upper abdominal cavity, they gradually descend into the scrotum before birth. The temperature in the testes is about 1°C below normal body temperature, an important requirement for the normal production of sperm. Each of the testes is divided into 250–300 wedge-shaped lobes, each containing a coiled seminiferous tubule. The tubule consists of a central passageway inside a long duct. Sperm production (spermatogenesis) takes place inside the walls of the tubule. Specialised endocrine cells between the seminiferous tubules (interstitial cells) produce testosterone, the male sex hormone.

SPERMATOGENESIS

Sperm cells, or spermatozoa (Figure 40.2), are produced continuously throughout life from puberty onwards under the influence of the hormones testosterone and follicle-stimulating hormone (FSH). The anterior pituitary gland secretes FSH. Sperm cells originate from primordial cells that appear in the embryo early in gestation but are not functional until puberty. Before puberty the testes produce stem cells called spermatogonia. These cells multiply by mitotic division. At puberty, under the influence of FSH, spermatogonia undergo both mitotic and meiotic cell division, which results in sperm production. A mature sperm consists of a head, mid-piece and tail. The head contains the nucleus, with its genetic material (DNA). The mid-piece contains mitochondria to provide energy for the rapid tail movements. The tail propels the sperm with a lashing movement through the female reproductive tract.

Figure 40.2 The structure of a sperm cell

ACCESSORY ORGANS

The ductal system transports sperm from the testes to outside the body. It is composed bilaterally of the epididymis, the ductus (vas) deferens and ejaculatory duct. The urethra is the single passage for sperm to exit the body during ejaculation. The epididymis, a tightly coiled tube, about 6 m in length, is attached to the posterior portion of the testis. It provides a temporary storage site for immature sperm. Within the epididymis sperm mature and become fully functional.

The vas deferens is the tube that transports sperm from the epididymis to the ejaculatory duct. It passes up through the inguinal canal into the pelvic cavity, over the top and down the posterior side of the bladder. For most of its length it is suspended and contained within the spermatic cord. The vas deferens joins the duct from the seminal vesicle to form the ejaculatory duct. Each ejaculatory duct receives secretions from the seminal vesicles. Sperm and secretions pass through the ejaculatory duct, prostate gland and into the urethra. The urethra passes through the penis and is a passageway for both semen and urine.

ACCESSORY GLANDS

Two seminal vesicles, two bulbourethral (Cowper’s) glands and the prostate gland produce secretions to nourish and support the sperm. The seminal vesicles are situated behind the bladder at the base of the prostate gland. They secrete a thick nutritive fluid that contributes to sperm motility and viability and makes up about 60% of the seminal fluid. Situated just below the bladder, the prostate gland encircles the upper part of the urethra. It secretes a thin, milky alkaline fluid that forms about 30–40% of the semen. Alkaline fluid protects against the acid environment of the female vagina and assists sperm motility. The bulbourethral glands are two pea-sized glands on either side of, and opening into, the urethra. They produce a small amount of mucus that neutralises the pH of any residual urine and lubricates the tip of the penis. Semen, or seminal fluid, is the fluid ejaculated by the male and consists of spermatozoa plus secretions from the accessory glands. Sperm are transported through the male reproductive system in semen. The average amount of semen ejaculated is about 3–5 mL, with each millilitre containing about 100 000 000 sperm.

EXTERNAL STRUCTURES

The penis and scrotum are the male external reproductive structures. The penis is a pendulous soft tissue structure attached to the walls of the pubic arch by muscles and ligaments. It has three columns of erectile tissue in the shaft, the central corpus spongiosum and the corpus cavernosa on either side. Skin covering the penis extends from its base to the glans penis, or tip, where it folds inwards and backwards on itself to form the prepuce, or foreskin. When erectile tissue becomes filled with blood during sexual arousal, the penis becomes enlarged, firm and erect. In the erect state the penis can be inserted into the female vagina. During ejaculation, sperm is transported through the male urethra into the vagina.

The scrotum, a thin-walled pouch of skin, is suspended from the groin. The interior is divided into two sacs, each of which contains a testis, an epididymis and a ductal system. Under normal conditions the scrotum hangs loosely, keeping the testes at a temperature suitable for sperm viability. When the external temperature is cold, or during tactile stimulation, the scrotum draws the testes closer to the body.

DISORDERS OF THE MALE REPRODUCTIVE SYSTEM

Many male reproductive disorders are developmental or age related. Abnormalities of the genitourinary system may be present at birth. Congenital or structural defects of the genitourinary tract can cause physical and psychological effects for a child. Both urinary and reproductive function can be compromised. Early corrective surgical treatment is necessary to minimise the possibility of these effects occurring. Nursing interventions aim to provide support for the child and family before and after surgery. The nurse can assist the child and family by educating them about procedures and allowing them time and opportunity to express any fears or concerns. Fact sheets that explain the condition without overuse of medical jargon can be given to parents to reinforce information given by the health care team.

Disorders of the male reproductive system are referred to as genitourinary disorders because of the shared anatomical structures of the urinary and reproductive systems. Common problems, which vary according to the type and severity of the disorder, include alterations in:

• Urinary elimination: the individual may experience alterations in the pattern of urinary elimination, related to urinary tract obstruction and retention. These include dysuria, difficulty in initiating or stopping the flow of urine or acute or chronic retention of urine

• Urethral discharge: this is most commonly associated with sexually transmitted diseases (STDs). Discharge may be thin or thick, scant or profuse, clear or mucoid, yellow, green or purulent

• Sexual dysfunction: sexual dysfunction includes impotence, premature ejaculation, dyspareunia (painful intercourse) and priapism (a state of constant erection not associated with sexual desire).

CONGENITAL DEFECTS

CANCER OF THE TESTES

Cancer of the testes generally affects males between the ages of 15 and 40. Most cancers are of germ-cell origin. The aetiology of testicular cancer is unknown and therefore precludes preventive strategies being implemented. Hypotheses include early puberty, exposure to environmental oestrogens, occupational exposure and smoking. Known risk factors include a history of cryptorchidism, genitourinary abnormalities, a history of mumps orchitis, white race, high socioeconomic status and family history. Early diagnosis and improved treatment modalities have given a cure rate of over 90%. However, 50% are only diagnosed in the advanced stage, when the cure rate is about 70%. An early stage indicator is the presence of a smooth painless lump in the scrotum. Later metastatic symptoms include general abdominal and inguinal aching. Other metastatic symptoms include bowel or urinary obstruction and abdominal pain.

Diagnostic evaluation is based on physical examination, blood serum markers and scrotal ultrasound. Elevated levels of alpha-fetoprotein (AFP) and human chorionic gonadotrophin (hCG) are present in testicular cancer. Ultrasonography differentiates between a solid and a cystic lesion. Tests to detect potential metastases include chest X-ray and computerised tomography (CT) scans of the chest, abdomen and pelvis.

Management of the client depends on the type and stage of the disease. Chemotherapy is used to treat primary and metastatic tumours. Surgical intervention generally involves a unilateral orchidectomy to remove the testis, tunica and spermatic cord, and retroperitoneal lymph node dissection. Radiotherapy to lymph node pathways is often used after surgery.

Testicular cancer affects young, mostly well men during prime reproductive years. Some treatments can lead to infertility. Sensitivity to the individual’s loss and fears about sexuality and mortality are key components of nursing management. The nurse can discuss possible sperm banking and reassure the client that surgery does not diminish virility. The client may be referred to support services outside the hospital and should be educated in testicular self-examination. It is recommended that he carry out periodic examinations, as there is an increased risk of a second tumour occurring.

INFECTIOUS AND INFLAMMATORY DISORDERS

Inflammation and infection of the urethra (urethritis) is generally caused by an ascending infection. A large number of cases are sexually transmitted and are discussed later in this chapter. Non-infective causes are associated with trauma secondary to urethral manipulation such as repeated cystoscopy.

In older men the main causes of epididymitis are bladder outlet obstruction and infection with urinary bacteria such as Escherichia coli. Clinical features include painful scrotal swelling, pain along the inguinal canal and vas deferens, a reddened scrotum, fever, chills, pyuria and bacteriuria. A midstream urine sample, urethral discharge culture and expressed prostatic secretions are collected to identify causative organisms. During the acute phase the client is encouraged to rest in bed with the scrotum supported to prevent traction on the spermatic cord, facilitate venous drainage and relieve pain. A scrotal support may be worn. Antibiotics and analgesics are administered. Intermittent ice packs or cold compresses may help decrease swelling and pain. The client is advised to avoid lifting, straining and sexual activity until the infection is completely resolved.

HYDROCELE

Hydrocele is a painless collection of fluid within the tunica vaginalis of the testis from defective or inadequate reabsorption of fluid normally produced within the testis. It causes swelling of the scrotum and may be associated with infections, trauma or tumours. The individual may experience a feeling of heaviness or pain associated with increased scrotal size and may feel embarrassed because of the appearance of the scrotum.

Ultrasound and transillumination are diagnostic tests used to differentiate between hydrocele and other causes such as tumours. If a hydrocele is present, transillumination will allow transmission of light through the scrotum. Treatment is not usually required unless there is compromised testicular circulation. However, a scrotal support can be worn to increase comfort.

VARICOCELE

Varicose veins of the spermatic cord within the scrotum are thought to be due to incompetent venous valves or obstruction of the gonadal vein. The client may experience a ‘pulling’ sensation, dull ache in the scrotum, pain and scrotal swelling. On palpation the scrotum feels like a ‘bag of worms’. Untreated it can decrease sperm count and cause atrophy of the testicle, resulting in infertility.

Surgical treatment involves spermatic vein ligation. It is used to treat younger clients to prevent infertility, or when symptoms are painful. Nursing interventions postoperatively focus on client education and relief of pain and discomfort. Application of intermittent ice packs for the first few hours and wearing a scrotal support reduces oedema and increases comfort. Strenuous activities should be avoided until cleared by the surgeon.

DISORDERS OF THE PROSTATE GLAND

The prostate gland frequently becomes enlarged as a man ages. The three most common prostate problems are prostatitis, benign prostatic hyperplasia and prostate cancer.

Prostatitis

Inflammation of the prostate gland may be bacterial or abacterial. Often the cause is unknown. Bacterial causes are usually associated with E. coli urinary tract infections. Clinical manifestations include urinary symptoms of urgency, frequency, nocturia and dysuria. Bacterial prostatitis is characterised by sudden chills and a moderate to high fever. Pain in the perineum, rectum, lower back and during ejaculation are other symptoms. Diagnosis is based upon urine, urethral and prostatic fluid cultures. Digital rectal examination frequently reveals a tender swollen prostate.

Antibiotics and analgesics are administered for bacterial causes. Oral antispasmodic agents may provide relief from urinary frequency and urgency. The nurse can support the client with comfort measures such as salt baths to relax the muscles of the pelvic floor. Stool softeners can reduce pressure on the prostate gland and are given as prescribed. Fluids should be encouraged to mechanically flush out the urinary tract.

Benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is enlargement of the prostate gland as a result of small non-cancerous growths inside the prostate that may be related to hormonal changes that occur with ageing. BPH usually does not affect sexual function but does affect urination. As the prostate enlarges it presses against the bladder and the urethra, blocking the flow of urine. Problems include difficulty initiating a urine stream or maintaining more than a dribble, frequency or urgency and nocturia. These problems can be highly distressing because of the embarrassment of hesitancy, frequency, soiling and smell.

Straining to empty the bladder can cause thickening of the bladder wall and loss of elasticity. This can lead to urinary tract infections and eventual renal failure. A completely blocked urethra is a medical emergency requiring immediate catheterisation. Other serious potential complications of BPH include bladder calculi, hydronephrosis and bleeding. Men with mild symptoms may simply be checked at regular intervals and treated if symptoms become worse. More severe symptoms require surgical intervention.

The type of surgery depends on the size of prostate, location of the enlargement, whether surgery on the bladder is also needed, and the client’s age and physical condition. The most common surgical procedure is transurethral resection of the prostate (TURP), used in more than 90% of cases. Surgery relieves symptoms quickly, typically doubling the urinary flow within weeks. A fibre-optic scope is passed through the urethra to the prostate. Using either a tiny blade or an electric loop, the surgeon pares away the lining of the urethra and bits of excess prostate tissue to expand the passageway.

Postoperatively the individual is usually hospitalised for several days with a urinary catheter in situ to irrigate the bladder. TURP does not usually affect a man’s ability to have an erection or an orgasm, since the nerves that control erection lie outside the prostate and are not touched by the operation. A more common side effect is dry or retrograde ejaculation, which occurs when the neck of the bladder fails to close properly during ejaculation. The result is that semen spurts backwards into the bladder rather than through the penis. Men who experience this side effect still have the sensation of an orgasm but are unable to ejaculate during intercourse.

Transurethral needle ablation (TUNA), which can be done with a local anaesthetic on an outpatient basis, uses radio-frequency energy delivered through needles to kill excess prostate tissue. A catheter that directs the needles towards the obstructing prostate tissue is inserted into the urethra. Some clinical studies have reported that TUNA improves the urine flow, with minimal side effects, compared with other procedures.

Researchers are working to develop BPH treatments that are more effective, less traumatic and have fewer side effects. These include using laser surgery, powerful electric currents and microwaves. Balloon urethroplasty and insertion of a stent into the urethra are other possible options.

Prostate cancer

Prostate cancer tends to grow slowly and may have metastasised before it is detected. Initially the man may be asymptomatic. When symptoms appear, they are often similar to those caused by BPH — difficulty urinating, a weak stream, a frequent urge to urinate, nocturia, painful or burning urination, and haematuria. Because prostate cancer tends to metastasise to the bone, bone pain, particularly in the back, can be another symptom. The major risk factor for prostate cancer is increasing age; more than 75% of prostate cancer cases are diagnosed in men aged 65 or older. Usually the younger the client the more aggressive the cancer.

Diagnostic tests include digital rectal examination, prostate-specific antigen levels, biopsy of the prostate, renal function tests and transrectal ultrasound. Prostate cancer may be treated by radiotherapy, chemotherapy, hormone therapy (palliative) or by open prostatectomy.

PROSTATE SURGERY— PROSTATECTOMY

Open prostatectomy may involve either a radical or partial procedure. A radical prostatectomy that removes the whole prostate is the treatment for cancer of the prostate. The incision is made through either the lower abdomen or the perineum. Impotence is a result of radical prostatectomy, as nerves and muscular tissue that function in penile erection are severed. When possible, nerve-sparing surgery is done to prevent this. The client is hospitalised for about 5–7 days. Partial prostatectomy, which leaves the posterior portion of the prostate intact, is used to treat BPH. The incision for a partial prostatectomy is usually through the suprapubic area of the abdomen. Open prostatectomy is used only when the prostate is extremely large.

Nursing management preoperatively requires establishment of adequate hydration and monitoring of the client’s fluid status. Insertion of an indwelling or suprapubic catheter may be necessary to establish urinary output. Alterations in urinary elimination and pain and discomfort related to bladder spasms may have caused the client to limit fluids. The client should be encouraged to drink fluids freely. Bowel preparation may include drinking 2–3 L of a cathartic and an evacuant enema. Postoperatively the nurse should maintain bladder irrigation and drainage, and monitor for clots and haemorrhage.

The client is encouraged to talk about concerns related to urinary control and sexual functioning before discharge from the health care facility. Nurses working in this area need to adopt a holistic approach, including the man’s partner in discussions if necessary. Nurses need to recognise that sexual activity does not necessarily stop with age, and nursing care planning and delivery should take account of this. Discharge education needs to take physical and psychosocial factors into consideration.

Discharge education

After a radical prostatectomy, an indwelling urinary catheter (IDC) may remain in situ for about 2 weeks. The client is taught how to manage the IDC at home. They need to maintain a high fluid intake to reduce the risk of clot formation, practise good perineal hygiene to decrease the risk of urinary tract infection, and recognise indicators of catheter blockage, dislodgement or urinary tract infection.

The client is advised that:

• Frequency and burning on urination are common after removal of the indwelling catheter but usually disappear within a few weeks

• Urinary incontinence can follow any type of prostate surgery

• Dribbling and cloudy urine may persist for a period of time

• Perineal exercises assist in regaining urinary control but this may take weeks to achieve

• Sexual functioning is not adversely affected by a simple prostatectomy, but retrograde ejaculation will be experienced

• Sexual activity may be resumed about 6–8 weeks after an open prostatectomy

• There are penile prostheses that may be used to achieve erection after a radical prostatectomy.

CANCER OF THE PENIS

Cancer of the penis is rare in Australia but is more common in south-east Asia, parts of Africa and in India. It is more likely to affect non-circumcised men aged over 60 and may be related to poor personal hygiene. The cancer occurs in the skin of the penis as a painless wart type growth or ulcer. Diagnostic tests include biopsy to confirm the diagnosis, chest X-ray, CT scan and lymph node biopsy to check for metastases. Surgery, internal and external radiation and chemotherapy are used alone or in combination to treat the condition. Surgical procedures can range from circumcision, laser or cryotherapy treatment to partial or total amputation of the penis.

The nurse can provide counselling and emotional support based on the needs of the individual. Education is offered about physical and psychological changes to sexual functioning. Awareness that the client may be affected by many different emotions, including anger, guilt, anxiety and depression, can assist management.

DISORDERS OF MULTIPLE CAUSE

Erectile dysfunction

Erectile dysfunction is defined as the inability to achieve and maintain an erection sufficient to permit satisfactory sexual intercourse. It may result from psychological, neurological, hormonal, arterial or cavernosal impairment or from a combination of these factors. The condition can be classified as psychogenic, organic, or mixed psychogenic and organic. Psychogenic factors may include performance anxiety, lack of arousability, relationship difficulties or mental health disorders such as depression and schizophrenia.

Organic causes of erectile dysfunction

Neurogenic

Decreased libido or difficulty initiating an erection can be due to diseases such as Alzheimer’s or Parkinson’s disease, cerebrovascular accident and cerebral trauma. In the case of spinal cord injury the degree of erectile dysfunction will depend on the nature of the injury.

Hormonal

A deficiency of androgens or an increase in prolactin secretion can both cause sexual dysfunction.

Vascular

Hypertension is associated with arterial stenotic lesions, while hyperlipidaemia is associated with athero-sclerosis. Both conditions prevent adequate blood supply to the penile artery. Cigarette smoking, diabetes mellitus and pelvic irradiation are other vascular causes of erectile dysfunction. Damage to the common penile artery may be due to blunt trauma to the pelvis or perineum.

Drugs

A variety of drugs is associated with erectile dysfunction, including antipsychotic, antidepressant and anti-hypertensive medications, and drugs that are antagonists to androgens, such as oestrogens and ketoconazole. Cigarette smoking is associated with vasoconstriction and has a contractile effect on the smooth muscle of the corpus cavernosa. Alcohol has varying effects according to the amount consumed. A small amount improves erection and decreases anxiety. Larger amounts can cause central nervous system depression and transient erectile dysfunction. Chronic alcoholism can lead to polyneuropathy and affect penile nerve function.

Systemic diseases and ageing

Sexual function declines with age even in healthy men. The period between sexual stimulation and erection increases, erections are less turgid and ejaculatory force and volume is less. About 50% of men with diabetes mellitus have erectile dysfunction. Other diseases that affect erectile function are chronic renal failure, angina, myocardial infarction and heart failure.

A thorough medical, sexual and psychosocial assessment should be undertaken. Urinalysis, full blood count, and fasting serum glucose, creatinine, cholesterol, triglycerides and testosterone are recommended laboratory tests. Treatment depends upon the cause. It can include a variety of drug therapies, which may be administered orally, transurethrally, or by subcutaneous or intracavernous injection.

ASSESSMENT AND DIAGNOSTIC TESTS

The client may be anxious or embarrassed about the physical examination and discussion of his sexual history. A calm insightful approach is required, as is preservation of the client’s individuality and dignity throughout. Cultural and religious customs such as circumcision should be considered.

EXAMINATION OF EXTERNAL GENITALIA

Before the physical examination the client’s genitourinary history is obtained. A history of urinary problems may be significant because of the anatomical relationship between reproductive and urinary systems. The external male genitalia and the inguinal canal are inspected for evidence of abnormalities such as penile discharge, tenderness, lesions, swelling, hard lumps or asymmetry. Abnormalities may indicate underlying disorders such as cancer of the testes or the presence of a sexually transmitted infection.

Testicular examination

Testicular self-examination (TSE [see Clinical Interest Box 40.1]) performed on a regular basis is the inspection and palpation of the testes to detect any changes. The testes are examined for size, shape, symmetry and texture. The earlier a change is discovered, the sooner it can be investigated and treated. It is important that the correct technique is taught to men in the target age group (15–40 years). Given that testicular cancer is most widespread in an age group in which men are generally healthy, there may be limited openings to teach TSE. Health promotion and screening in primary care, such as well-man clinics, affords an opportunity for education. Nurses working in the areas of adolescent, student and sexual health are seen as strategic professionals in educating men about TSE. Occupational health nurses involved in work-based screening may also have valuable opportunities to discuss health issues with men.

CLINICAL INTEREST BOX 40.1 Client teaching — testicular self-examination

• Testicular self-examination is a quick and simple process. It is often easier after a warm bath or shower, when the skin of the scrotum is relaxed

• Both testes should be checked, one at a time. (Note: it is not unusual for one testis to be slightly larger than the other)

• Using the palm of your hand, support your scrotum. Try to become familiar with the texture and size of each testis. If there is any change to how it feels normally, see your local doctor

• Gently roll one testis between your thumb and fingers to feel for any lumps or swellings in or on the surface of the testis. Repeat with the other testis. A normal testis should be firm but not hard, and should have a smooth regular surface. The testes should be similar in shape, size and consistency

• Using your thumb and fingers, feel along the epididymis at the back of the testis. The epididymis is a soft, tightly coiled tube that carries sperm from the testis to the vas deferens. Check for any swelling in this area

• Even if you have had testicular cancer or are being treated, it is important to still perform a testicular self-examination, as there is about a 5% chance that a testicular cancer may develop in the other testis

INTERNAL AND SPECIMEN TESTING

Digital rectal examination

Rectal examination is performed to palpate the prostate gland. The examiner, usually a medical officer, inserts a gloved finger into the anus and palpates the prostate gland for size, shape and firmness. Prostatic secretions for laboratory analysis may be obtained by prostatic massage.

Prostate-specific antigen

Prostate-specific antigen (PSA) is a protein produced by cells of the prostate gland. It circulates in the blood and can be detected and measured with a relatively simple blood test. When the prostate gland enlarges, PSA levels rise. PSA levels can also rise if cancer develops. There is debate concerning whether the PSA test should be used for screening populations of men for prostate cancer in the same manner that breast screening is used to detect breast cancer. Increased levels of PSA do not necessarily indicate prostate cancer. Benign prostatic hyperplasia or prostatitis can also cause increased PSA levels. Only about one in three men with an increased PSA level who have a biopsy will be diagnosed with prostate cancer. Increased PSA testing over the last decade has led to an increase in the number of cases of prostate cancer detected, but no change to the mortality rate. This may be due to the length of time between diagnosis and death (10–15 years).

Transrectal ultrasound

A small probe that emits and picks up high-frequency sound-waves is inserted into the rectum. The reflected waves are detected and a visual image displayed on a monitor. The test does not provide sufficient information to make it a good screening tool by itself but is useful as a follow-up to a suspicious digital rectal examination or PSA test. It is also used to guide biopsies in sampling abnormal areas of the prostate, to estimate the volume of the prostate for calculating PSA density, and to situate radiotherapy implants.

Biopsy

Biopsy of the prostate gland may be performed to detect abnormal cells. A needle is inserted through the perineal skin and a quantity of prostate tissue is aspirated. Biopsy specimens of tissue are sent for cytological examination.

Urethral culture

A small swab is inserted 3–5 cm into the urethra to obtain a specimen for microbiological analysis.

Semen analysis

A sample of semen is obtained and the sperm examined for motility, morphology, quantity and quality.

Urological tests

A series of tests may be performed to evaluate the urinary tract. These include cystoscopy, intravenous pyelogram, urine flow studies, urogram and ultrasound.

Blood samples

Specific blood tests include hormone levels for infertility; alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) for testicular cancer; and blood urea nitrogen (BUN), creatinine and urea to evaluate renal function.

NURSING INTERVENTIONS IN MALE REPRODUCTIVE HEALTH

Men have specific health needs, experiences and concerns related to their gender as well as their biological sex. This is a relatively new concept in medical and nursing literature. Psychosocial factors related to male health are poorly understood and frequently ignored by many health practitioners. Men engage in less healthy lifestyles and adopt fewer health-promotion strategies than women, for reasons that are complex. An awareness of men’s health issues and poor health practices has led to the establishment of an international men’s health movement — the International Society for Men’s Health (www.ismh.org/). The aim of the movement is to increase awareness about current men’s health issues and promote men’s health initiatives.

A man with a reproductive system disorder may experience anxiety about sexual dysfunction, infertility, urinary problems and other implications of the disorder. He may suffer low self-esteem and encounter difficulties in accepting his condition and will often delay seeking health interventions. Nurses need to actively explore opportunities to promote health and to encourage and support men to make healthier lifestyle choices. To make appropriate health and lifestyle choices an individual must be provided with adequate information about his condition and its possible outcomes. He should also be offered opportunities to express his feelings, explore treatment options and, if necessary, be referred for sex counselling.

THE FEMALE REPRODUCTIVE SYSTEM

The female reproductive system functions to secrete hormones, produce ova, receive sperm and allow for fertilisation, implantation, development and birth of the baby. The female reproductive system (Figure 40.3) consists of essential and accessory organs. The essential organs, or gonads, are the ovaries. Accessory organs consist of a series of ducts, additional sex glands and external structures.

Figure 40.3 The female reproductive system A: Sagittal section of the female reproductive system B: External genitalia of the female

ESSENTIAL ORGANS

The primary sex organs of the female are the ovaries — two almond-shaped organs, one on either side of the uterus and attached by ligaments. Each is composed of an inner portion that contains nerves and lymph vessels, and an outer portion that contains follicles and ova. At birth a female has about two million ovarian follicles in the ovaries. Every follicle contains an immature female gamete called an oocyte. By puberty this number has reduced to about half a million primary follicles. The number decreases throughout the female reproductive years until about the age of 50 (menopause) when there are none. Only about 350–500 of the primary follicles will develop into mature follicles that release ova. Follicles that do not mature are reabsorbed by ovarian tissue.

OOGENESIS

The ovaries function to produce ova (oogenesis) and hormones. The cells of the developing ovarian follicle are stimulated to secrete oestrogen by follicle-stimulating hormone (FSH) from the anterior pituitary gland. Oestrogen enhances the growth and maturation of the follicle. As it matures, the follicle becomes distended with fluid and bulges onto the surface of the ovary. A sharp increase in the level of luteinising hormone (LH) from the anterior pituitary gland acts to trigger ovulation and the mature follicle ruptures to release an ovum. The ovum is released into the peritoneal cavity near the distal end of the uterine tube, where it is captured by the waving fimbriae. Usually one mature ovum is released each month. After ovulation the ovary undergoes structural and chemical changes. Under the influence of LH the ruptured follicle, or corpus luteum, secretes oestrogen and progesterone. If fertilisation does not occur the corpus luteum regresses to a non-functional state, the corpus albicans.

Production of ovarian hormones begins at puberty. Oestrogen influences the development of the female secondary sexual characteristics, including:

• Enlargement of the uterine tubes, uterus, vagina and external genitals

• Development of breasts

• Increased deposits of fat, particularly in the hips and breasts

• Widening of the pelvis

• Onset of the menstrual cycle

• Appearance of pubic and axillary hair.

Oestrogen also stimulates the lining of the uterus to prepare for a fertilised ovum.

The effects of progesterone are to:

• Promote the final preparation of the uterine lining to receive the fertilised ovum

• Inhibit contraction of the walls of the uterus

• Suppress further ovulation

• Stimulate the mammary glands to produce milk.

ACCESSORY ORGANS

Uterine (fallopian) tubes, each about 10 cm long, extend from either side of the upper uterus to the ovaries. The distal end of each tube curves over an ovary and fans out in a trumpet shape with finger like projections (fimbriae). An outer covering of peritoneum, a middle layer of involuntary muscle and an inner lining of ciliated mucous membrane make up the walls of the tubes. Ova are propelled through the tube by peristalsis and the sweeping action of cilia. Fertilisation of the ovum generally occurs in the distal one-third of the uterine tube.

The uterus is a hollow pear-shaped organ located in the pelvic cavity posterior to the urinary bladder and anterior to the rectum. It is suspended in the pelvis by a peritoneal fold (the broad ligament). Normally the uterus is in an anteverted position so that the upper portion rests on the bladder. The uterus consists of an upper rounded body and a lower narrow neck, the cervix. Above the point where the fallopian tubes enter is the fundus of the uterus. The walls of the uterus consist of an outer covering of peritoneum (perimetrium), a middle layer of thick involuntary muscle (myometrium) and an inner lining of mucous membrane (endometrium). The cervix is lined with mucus-secreting glands that provide lubrication. The functions of the uterus are to:

• Receive the fertilised ovum, which embeds itself in the endometrium

• Provide an optimal environment and nourishment for the fetus

• Expel the fetus at the end of pregnancy

• Shed the superficial layer of the endometrium if fertilisation of the ovum does not occur.

The vagina, an expandable passageway about 10 cm long, is situated between the urinary bladder and the rectum. It extends from the uterus to the vulva, where it opens to form the vaginal opening. The cervix projects into the upper part of the anterior vaginal wall. The vagina is acidic from menarche to menopause, and its surface moist from fluid secreted by the vaginal epithelium. Functions of the vagina are to receive the penis during sexual intercourse, provide a passageway for menstrual flow to leave the body, and provide a passageway through which the fetus is expelled from the uterus.

ACCESSORY GLANDS

Mammary glands (Figure 40.4) are accessory glands of the reproductive system. Their reproductive function is lactation. They are situated over the pectoral muscles and are attached to them by Cooper’s ligaments. The breast is a complex structure composed of a glandular and ductal network, fat, connective tissue, fascia, blood vessels, nerves and lymphatic vessels. In the centre of the breast a pigmented area, the areola, surrounds the nipple. Each breast contains 15–20 lobes that radiate around the nipple and are separated from each other by adipose tissue. Within the lobes are lobules that contain clusters of milk-producing cells called alveoli. Lactiferous ducts drain the alveoli into openings in the nipple. Breast development at puberty is influenced by ovarian hormones.