Male Sexual/Reproductive Dysfunction and STI’s

UNAE&S – 2009

Reviewed by Gabrielle Metelli 2009

UANE&S - 2009 1

Benign Prostatic Hypertrophy (BPH)

ƒ An enlargement of the
prostate gland

ƒ Not cancerous, but

ƒ Typically occurs in over

the age of 50 when
testosterone levels fall.

ƒ Most common disorder

encountered in the aging
male client.

(LeMone & Burke, 2008)

UANE&S - 2009 2
 Pathophysiology of BPH
ƒ BPH is believed to develop due
ƒ Benign prostatic cells replicate in the
to a fall in the levels of
central or transition zone that
testosterone.
surrounds the urethra.

ƒ Testosterone is converted to
ƒ Leads to compression of urethra and
Dihydrotestosterone (DHT) in
obstruction of urine outflow.
the prostate.

ƒ Detrusor muscle hypertrophies to

ƒ DHT stimulates prostatic cells
compensate for increased resistance to
to enlarge.
urinary flow.

ƒ Also a relative increase in

oestrogen levels may stimulate
cell growth.

UANE&S - 2009 3

Lower Urinary Tract Diagnosis of BPH

Symptoms (LUTS)
ƒ Digital rectal examination (DRE)
ƒ Frequency, hesitancy,
nocturia, decreased urine ƒ Urinalysis & MSU
stream
ƒ Assessment of renal function
ƒ Lower abdo pain, enlarged (urea & creatinine levels)
bladder, altered bowel
patterns
ƒ Prostate-Specific Antigen (PSA)
& Acid phosphatase levels
ƒ May require urgent
admission due to acute
ƒ Urodynamic studies
urinary retention

ƒ Cystoscopy

UANE&S - 2009 4
 Medical/Pharmacological Management of BPH

ƒ Finasteride – inhibits the conversion of testosterone to DHT

ƒ Alpha-adrenergic blockers – Minipress (Prazosin)

ƒ Eventually most patients will require surgical intervention

UANE&S - 2009 5

Surgical Management
ƒ Transurethral Microwave Thermotherapy (TUMT)
ƒ Trans Urethral Resection of Prostate (TURP) via a cystoscope
ƒ Subrapubic prostatectomy
ƒ Retropubic prostatectomy
ƒ Perineal prostatectomy (LeMone & Burke, 2008)

UANE&S - 2009 6
 Continuous Bladder
Irrigation 3-Way IDC

(Elkin, Perry, & Potter, 2004)

UANE&S - 2009 7
(Elkin, Perry, & Potter, 2004)

(Elkin, Perry, & Potter, 2004)

Spinal Anaesthetic

ƒ strict bedrest for 24 hrs

ƒ 1/24 extremity obs until

movement & sensations
return, then 4/24.

UANE&S - 2009 8
 Patient Education - TURP
ƒ Long car rides and strenuous exercise should be avoided due to causing
secondary urinary bleeding.

ƒ Oral fluids must still be increased.

ƒ Spicy foods, alcohol and coffee may cause discomfort when voiding.

ƒ Symptoms of urinary retention or infection should be reported to the doctor.

ƒ A poor stream, dribbling & frequency are common until complete healing has
occurred.

ƒ Impotence is often avoided but retrograde ejaculation is common.

UANE&S - 2009 9

Prostate Cancer
ƒ 29/100,000 males died from Pathophysiology
cancer of the prostate in 2005
ƒ Mostly adenocarcinomas
(Australian Bureau of Statistics,
2008)

ƒ Begin in posterior or
ƒ 5th leading cause of males deaths
in 2005 (Australian Bureau of Statistics, 2008) posterolateral regions (different
to BPH)

ƒ Mostly in older men (rarely

under 40 yrs of age) ƒ Most likely due to DHT

ƒ If diagnosed earlier and confined ƒ Often no symptoms until

to prostate then almost 100% metastasized
survival rate at 5 yrs.
ƒ (83% of all men with prostate
cancer will be alive after 5 yrs).

UANE&S - 2009 10

Clinical Manifestations
Similar to BPH except:
ƒ DRE – hard nodule on prostate
ƒ PSA – elevated
ƒ Pain – bone, joint, back
ƒ Systemic – weight loss & fatigue
Treatment
ƒ Watchful waiting
ƒ Surgery (similar to BPH)
ƒ Diethylstilbestrol
ƒ Bilateral orchidectomy
ƒ Radiation therapy
UANE&S - 2009
Vasectomy
ƒ Male sterilisation
ƒ Spermatic cord is removed
ƒ GP surgery or Day surgery
ƒ Watch for scrotal haematomas
ƒ Not immediately sterile as sperm
may still be in semen for up to 6
weeks.
UANE&S - 2009
Infections - Prostatitis
ƒ Inflammation of the prostate
gland
ƒ Common occurrence
ƒ Often associated with urinary
tract infections – E-coli
ƒ Pain, obstruction, dysuria, fever,
chill
ƒ Treatment with antibiotics, sitz
baths, increased fluids and
increased ejaculation
11
Cryptoorchidism
ƒ Failure of one or both testes to
descend into the scrotum.
ƒ Usually identified in childhood
ƒ Treatment is surgery
(Orchiopexy)
ƒ If not treated before
adolescence, can result in
infertility
12
 Scrotal Masses Infections – Epididymo-orchitis

ƒ Hydrocele ƒ Infection of epididymis and/or

testicle

ƒ Spermatocele ƒ Often associated with sexually

transmitted urethritis
ƒ Variocele
ƒ Pain, oedema/swollen testicle

ƒ Scrotal Trauma ƒ May need intravenous antibiotics

ƒ Pain relief

ƒ Scrotal support

UANE&S - 2009 13

Testicular Torsion Priapism

ƒ Twisting of the testes and ƒ Sustained (> 4 hrs) & painful
spermatic cord erection

ƒ Medical emergency ƒ Often not associated with sexual

ƒ Sudden onset of scrotal pain (+/-
trauma)
ƒ Surgical treatment to correct
problem and fix testes into
scrotum
arousal but more likely due to
alcohol or drug use
ƒ Rx analgesia, sedation, hydration
& ice packs
ƒ Nursing care: assess penis
(especially colour) & urine output

ƒ Can cause testicular ischaemia

and necrosis

UANE&S - 2009 14
 Phimosis/Paraphimosis
ƒ Phimosis: foreskin cannot be
retracted
ƒ Paraphimosis: retraction of
foreskin causing swelling of
glans
ƒ Must ensure foreskin is retracted
and glans cleaned (hygiene &
prior to catheterisation)
ƒ Must remember to return
foreskin to normal position
ƒ Can result in gangrene of the
glans/penis → amputation
UANE&S - 2009 ƒ Prosthetic devices
Sexually transmissible
infections – STI’s
• Definition: Any
infection transmitted
through sexual contact.
Route of transmission:
– vaginal,
– oral and/or
– anal
(Brown & Edwards, 2005; National Sexually
Transmissible Infections Strategy [NSTIS] 2005)
Erectile Dysfunction
ƒ Inability to attain and maintain an
erection sufficient to permit
satisfactory sexual intercourse
ƒ Common problem (60%
physiological, 20% psychological)
ƒ Cardiovascular disease, diabetes,
alcohol, smoking, stress
ƒ Antihypertensive drugs,
psychotropic drugs
ƒ Diagnosis:
ƒ PSA,
ƒ testosterone levels,
ƒ NPTR,
ƒ Ultrasound/Doppler
ƒ Rx:
ƒ Sildenafil (Viagra)
ƒ Intracavernous injections
ƒ Topical agents
ƒ Mechanical devices
15
STI’s in Australia
Serious public health issue
Most common infections include:
•Chlamydia (approx 51089 notifications
in 2006)
•Gonorrhoea (approx 7553 notifications
in 2006)
•Syphilis (approx 3057 notifications in
2006)
•Hepatitis B
•Trichomoniasis
•Herpes simplex virus
•Human papilloma virus (approx. 998
notifications in 2006)
(Australia’s Health, 2008)
 Women & Gonorrhoea in the
STI’s newborn
• Pregnant women may transmit
STI’s to unborn child

• Men more likely to spread STI’s to

women, than women to men

• Women who acquire STI’s are at

greater risk of complications such
as Pelvic Inflammatory Disease
(PID) and genital cancers

• Women and children mostly

affected by STI’s

Photo accessed from: www.smu.edu/…STI2005

3 Major Classifications Chlamydial infections -

(cervical infection syndrome)

• Cervical infection •Caused by a gram –ve

syndromes bacterium
• Genital ulcer syndromes •More common in women
• Epidermal syndromes aged15-29 years who:
•Have new or multiple sexual
partners
Other STI’s that are also •Have a H/O prior STI’s
blood borne include: •Inconsistently use barrier
• Hepatitis B & C contraception
• AIDS/HIV
(Pregler & De Cherney, 2002)
(Pregler & De Cherney, 2002)
 Clinical manifestations

Incubation period 1-3

weeks
May be asymptomatic
but also associated with:
•Cervicitis
•Urethritis
•Bartholinitus
•PID
•Perihepatitis
•Salpingitis

(Brown & Edwards 2005; Pregler

& De Cherney, 2002)

Picture accessed at: www.moondragon.org/…/std/chlamydia

Chlamydia and the eye

• Inflammatory reaction
results in scar tissue on
conjunctiva

• May cause eye lid to turn

inward

• Eye lash contact with

cornea may result in
corneal abrasion
 Gonorrhoea
Sequelae
• More prevalent in isolated
Aboriginal and Torres Strait
Islander populations

• Organism initially targets

cervix

• PID – may result in ectopic

pregnancy & / or infertility

• Endometritis

• Salpingitis

• Pelvic peritonitis
Purulent vaginal discharge may indicate gonorrhoea
(LeMone & Burke, 2004; NSTIS, 2005; Pregler & De
Cherney, 2002) in women

Gonorrhoea: Signs &

symptoms
Gonorrhoea In Men
• Organism targets urethra
**80% women remain
• Acute & painful inflammation of epididymis,
asymptomatic until disease
is well advanced** prostate, & periurethral glands
• May lead to dysuria & infertility
• Abnormal PV discharge
• Infection may spread to blood & joints
• Itching
• Increased susceptibility / transmission of
• Dysuria HIV
• Urinary Frequency
• 20% remain asymptomatic until
• Urinary tract infections disease is well advanced
• Abnormal menses • Serous, milky or purulent penile
• Dyspareunia discharge
• Dysuria
• Lower abdominal pain
• Urethritis
(Farrell, 2005; LeMone & Burke 2004) • Epididymitis
• Some men experience
lymphadenopathy
UANE&S - 2009 22
 Herpes Simplex Virus Syphilis
•Highly infectious -caused by a
•Common STI – caused by herpes spirochete
simplex virus type 2
•Rare - in most developed
•Mild flu-like symptoms countries
•Dysuria •Primary stage - chancres
•Vulvar tenderness •Secondary stage – rash, fever,
•Episodic genital ulcers alopecia, sore throat, headache,
weight loss, lethargy
•Rarely causes significant physical
morbidity •Latent – Absence of signs or
symptoms
•No cure
•Tertiary stage – chronic
•Treatment of signs & symptoms – destructive lesions, cardiovascular
Acyclovir effects, neurosyphylis
(NSTIS, 2005; Pregler & De Cherney, 2002)
(Brown & Edwards 2005; NSTIS, 2005; Pregler & De
Cherney, 2002)

Genital Warts
•HPV – various types
•Some linked with cancers
•Highly contagious
•Discrete single or multiple
papillary growths
•Usually no other signs &
symptoms
•May have itchiness or
bleeding on defecation with
anal warts.
(Brown & Edwards, 2005; Pregler & DeCherney,
2002)

(LeMone & Burke, 2008.

Accessed from: www2.bc.cc.ca.us/.../24-14_GenitalWarts_1.jpg)
 Prevention & treatment Pharmacological
of STI’s management
Chlamydia:
• Abstinence or monogamous Erythromycin (PO)
relationships – Azithromycin (PO)
– Doxycycline (PO)
• Barrier contraception
Gonorrhoea:
• Postponing age of sexual – Ceftriaxone (IM / IV)
activity – Ciprofloxacin (PO)
– Metronidazole (PO)
• Annual screening Genital Warts:
• Pharmacological – Trichloroacetic acid (TOP)
– Podophyllin (TOP)
management
– Laser treatment or cryotherapy
• Prophylactic prescriptions PID:
• Education, counselling and – Cefoxitin (IV)
support – Doxycycline (IV / PO)
– Ofloxacin (PO)
(Brown & Edwards, 2005; Pregler & DeCherney, 2002;
Farrell, 2005) – Metronidazole (PO)

Assessment specific to STI’s

• Assess signs & symptoms & describe characteristics of

discharge & / or lesions

• Gain full past medical history, including previous

exposure to STI’s – be non-judgemental

• Be discreet & physically examine patient assessing for

rashes, lesions, drainage, discharge & /or swelling

• Examine mouth & throat for inflammation & / or exudate

 Infertility

• The failure to achieve a

pregnancy after twelve
months of unprotected
intercourse or the inability
to continue pregnancy to a
live birth (Fertility Society of
Australia [FSA], 2004; Gibson & Myers,
2000)

• One in six Australian

couples (FSA, 2004).

Image by:Dennis Kunkel Accessed at:

biology.about.com/library/weekly/aa091400a.htm

UANE&S 2009 27

Female Aetiology Male Aetiology

• Ovulation disorders
• Sperm quality
– Scarred ovaries
• Sperm production
– Hormonal
– Premature menopause
• Blockages
– Follicle problems
– PCOS • Normal sperm count = 60
• Uterine or cervical factors million - 100 million sperm / ml
of semen
– Fibroids, polyps
– Abnormal cervical mucous
• Tubal factors • Incidence of impregnation <
–Infection when sperm count < 20 million
–Abdominal diseases sperm / ml semen
–Previous surgeries
–Congenital defects - DES
• Endometriosis (Brinton et al., 2005; Gould, 2003; Huntington & Gilmour 2005; Lane,
2006; Smith, Pfeifer & Collins, 2003; Waters, Dean & Sullivan, 2006)
• Lifestyle factors
• Unknown
UANE&S 2009 28
 Management of infertility Assessment of the infertile woman
•Previous contraception and any problems
***Emotional support
•Previous pregnancies and outcome
•Related to aetiology •Medical, surgical, & gynaecological
•Assessment history
•Current medical illness & treatments
•Pharmacological, surgical, &
assisted reproductive •Diet, smoking, drug & alcohol
technology (ART) consumption
•Galactorrhoea, Hirsutism
•Natural remedies
•Menstrual problems & patterns
•Lifestyle changes
•Preovulatory cervical mucous recognition
•Coital frequency and timing
(Cahill & Wardle, 2002)

UANE&S 2009 29

Surgical
Tubal disease Pharmacological management
•Ultrasound contrast salpingography (Usually for ovulation disorders and
•Hysterosalpingogram as part of an ART regimen)
•Laparoscopy and dye
•Tubal reparative surgery Clomiphene (Clomid):
Fibroids, ovarian cysts & polyps - Stimulates ovarian follicles to release
excision FSH & LH
Endometriosis
•Laparoscopic ablation Menotropin (Pergonal):
•Laparotomy (severe cases) Combination of FSH & LH for
(Cahill & Wardle, 2002; Smith et al., 2003) women who are deficient or as part
of IVF treatment regimen
Lifestyle factors:
•Smoking Urofollitropin (Metrodin):
•Alcohol
Stimulates follicle growth
•Weight (polycystic ovarian Syndrome)
•Exercise and stress
•Diet Human Chorionic
Natural remedies Gonadotrophin:
•Acupuncture Stimulates release of ovum - may be
•Group therapy used in combination with other drugs
•Herbal remedies UANE&S 2009 30
 Ovarian Hyperstimulation Syndrome (OHSS)

Severe
Mild
•Massive ovarian enlargement
•Abdominal discomfort
•Multiple ovarian cysts
•Nausea
•Fluid shifts
•Ovarian enlargement
•Hepatic dysfunction
Moderate •Pleural effusion
•Above symptoms •Renal failure
•Vomiting and/or diarrhoea •Hypovolemic shock
•Ascites
(Braude & Rowell, 2003; Dulitzky et al., 2002; Mathur & Jenkins,
2001)
(Dulitzky, et al., 2002; Wolf, 2000).

UANE&S 2009 31

www.medicinenet.com/infertility/page5.htm

UANE&S 2009 32
 Disorders of the Breast
• Benign - breast pain, cysts, fibrocystic Breast Abscess
breast disease, fibrous lumps, nipple
discharge, and breast infection • Collection of infected matter
• Malignant - Breast cancer (several types) • Symptoms – pain, localised
Paget's disease of the nipple inflammation
• Cystosarcoma phyllodes may or may not be • Fever / chills
cancerous.
• Generally requires drainage

Causes of Breast Pain

• Menstruation due to hormonal
Abscesses & Post
changes Menopausal Women
• Cancer (- pain not always a
symptom) • Uncommon
• Cysts • Possibly carcinogenic when
• Some Foods & beverages present outside nipple.
Mammogram & ultrasound
Breast pain generally not severe resolving
over time. necessary to exclude.
Severe pain (rare) treated with drugs.
33

Breast Cyst
• Fluid-filled sacs
• Cause unknown (possible link to
previous injury)
• Easily palpable
• May cause pain
• Fluid may be aspirated/drained to
relive pressure/pain
(1 cyst had at least 45mls drained from it)

Most women with breast cysts do not have

an increased risk of developing breast
cancer

http://www.mayoclinic.com/health/breast-
cysts/DS01071/DSECTION=symptoms

34
 Fibrocystic Breast Disease
• Common Fluid filled cysts

• Causing breast pain, cysts &

benign tumours

• Fibrous breast lumps

(fibroadenomas)

• Benign, solid lumps (fibrous &

glandular tissue)

• Lumps usually appear in young

women

• Round mobile lumps with

defined edges

• Contain collagen
– tough, fibrous protein found in
cartilage, bones, tendons, and
skin http://www.nlm.nih.gov/medlineplus/ency/imag
– causing lumps to have a epages/17185.htm
rubbery hardness

35

Fibrous Breast Lumps

• Usually removed surgically under local - often recur

• When consistently benign may decide against removing recurring lumps

• Other types of benign breast lumps include sclerosing adenosis

(a hardening of glandular tissue) & fat necrosis (scar tissue)

• Lumps diagnosed only by biopsy

36
 References
Aleman, A., Althabe, F., Belizán, J., & Bergel, E. Bed rest during pregnancy for
preventing miscarriage (Cochrane Review). The Cochrane Database of
Systematic Reviews 2005, Issue 2. Art. No.: CD003576.
DOI:10.1002/14651858.CD003576.
Australian Bureau of Statistics (2008). Yearbook Australia, 2008. Retrieved 27/08/08 from
http://www.abs.gov.au/Ausstats/abs@.nsf/7d12b0f6763c78caca257061001cc588/B4C
91079030BA853CA2573D20010735B?opendocument
Braude, P., & Rowell, P. (2003). ABC of subfertility: Assisted conception II - In vitro
fertilisation and intracytoplasmic sperm injection. British Medical Journal, 327, 852-
855.
Cahill, D., & Wardle, P. (2002). Management of infertility. British Medical Journal, 325,
28-32.
Cancer Council of Australia (2007). Prostate cancer. Retrieved 26/08/08 from
http://www.cancer.org.au/aboutcancer/cancertypes/prostatecancer.htm
Crisp, J., & Taylor, C. (2005). Potter and Perry’s fundamentals of nursing (2nd ed.). Sydney:
Mosby.

UANE&S - 2009 37

Dulitzky, M., Cohen, S., Inbal, A., Seidmen, D., Soriano, D., Lidor, A., Mashiach,
S., & Rabinovici, J. (2002). Increased prevalence of thrombophilia among
women with severe ovarian hyperstimulation syndrome. Fertility and Sterility,
77(3), 463-467.
Elkin, M. K., Perry, A. G., & Potter, P. A. (2004). Nursing interventions
and clinical skills. (3rd ed.). St Louis: Mosby.
Fink, J. (2006). Diabetes in pregnancy and beyond. RN, 69(5), 26-31.
Gibson, D. M., & Myers, J. E. (2000). Gender and infertility. Journal of
Counseling and Development,78(4), 400-410.
LeMone, P., & Burke, K. M. (2008). Medical surgical nursing: Critical
thinking in client care. (4th ed.). Upper Saddle River,N.J.:Pearson/Prentice
Hall.
Porth, C. M. (2005). Pathophysiology: Concepts of altered health states.
(7th ed.). Philadelphia: Lippincott.

UANE&S - 2009 38