Male Genitourinary Deviation

Front 1

Orchitis

Back 1

*Testicular viral infection causing inflammation.
(adenovirus, Coxsackie, Epstein Barr virus)

*S/S: Assessment - edematous and tender testicles, reddened scrotal skin, fever, prostration (exhaustion)
In addition to pain, may have n/v, pain radiating to inguinal canal.

Front 2

Orchitis- Treatment

Back 2

Treated with rest, antibiotics, pain medication.

Bilateral involvement may lead to sterility.

Front 3

Mumps orchitis

Back 3

occur in 30% of men who develop mumps after puberty.

Front 4

Epididymitis

Back 4

Pathogens reach epididymis through lumen of vas deferens from infected urine, posterior uretha or seminal vesicles.
*May be nonsexually transmitted.
*Associated with UTI in men >35 with urinary tract instrumentation, surgery or anatomical abnormalities.
**Clinical presentation: scrotal pain in postpubertal males. History of sexual activity.
Sexually transmitted assoc. with urethritis.
Gradual onset of testicular pain, unilateral, dysuria, urethral discharge.
*Fever in 50% of patients. Scrotum is tender on palpation and accompanied with hydrocele.

Front 5

Epididymitis- Treatment and meds

Back 5

Heterosexual men >35 most likely cause is STD.

Treated based on symptoms before culture results: **Vibramycin 100 mg bid x 10 days, and
**Rocephin 250 mg IM single dose.
**Floxin 300 mg po bid x 10 days.
(Treatment of sexual partners, avoid sex until cured)

Front 6

Prostatitis

Back 6

Inflammation of prostate gland
Types: 1. bacterial 2. Non-bacterial

*S/S: systemic illness with fever, chills, malaise. Acute onset dysuria, frequency, inhibited urinary voiding, low back pain, suprapubic pain and perineal pain.

Front 7

Acute bacterial prostatitis

Back 7

serious and severe. Least common type.
-occurs age 40-60
*may have painful sexual intercourse
*Pain with defecating
*Initial, terminal and less often total hematuria may be present

Front 8

Chronic Bacterial Prostatitis

Back 8

uncommon type. Occurs in age 50-80 years.

*Systemic illness not present
*Symptoms slow in onset, may have bladder outflow obstruction.
*hematuria, hematospermia present, painful ejaculation present.
**Hallmark feature: recurrent urinary tract infection

Front 9

Chronic non-bacterial

Back 9

most common type. Occurs in men 30-50.
Symptoms non- distinguishable from chronic bacterial.

Front 10

All types of prostatitis can lead to...

Back 10

urinary retention, renal infection, bacteremia.

Front 11

Diagnosis of Prostatitis

Back 11

*Assess onset and course of illness
*Associated symptoms….
*Previous UTI??, sexual partner symptomatic?
*New sexual partners
*Urinalysis, urine culture - midstream voiding.

Front 12

Organisms Associated With Acute and chronic bacterial Prostatitis

Back 12

Acute and chronic bacterial - gram negative bacilli (E-coli, Proteus, less common Enterobacter, Klebsiella, Pseudomon

Front 13

Organisms Associated With Chronic non-bacterial Prostatitis

Back 13

Chronic non-bacterial prostatitis - gardnerella vaginalis, Chlamydia species.

Front 14

Treatment of Acute bacterial Prostatitis

Back 14

Acute bacterial prostatitis - treated with hospitalization with parenteral antibiotics.

**Bactrim 160/800 mg, tx. 4-6 weeks.
Alternative therapy-
**Cipro 500 bid 4-6 weeks.
Anti-inflammatory used for pain
May need to see urologist if BPH exists.

Front 15

Treatment of Chronic Non Bacterial Prostatitis

Back 15

No universally effective treatment.
*Some experts prescribe trial of antibiotics.
*Patient needs reassurance this condition is noninfectious, not contagious and not related to cancer.
*Pt teaching for prostatitis
-Warm sitz bath
-No sexual activity – for 2 weeks
-Avoid alcohol
*OTC decongestant – can worsen urinary obstruction
-Stool softener

Front 16

Benign Prostate Hypertrophy (BPH)

Back 16

Enlarged prostate and /or increase in smooth muscle tone of the prostate and bladder neck.

Pt. has reduced or interrupted urinary flow, inability to empty bladder and increased urination.

Front 17

BPH causes

Back 17

Increased in hormones androgens, estrogen & enzyme 5 alpha reductase
*This enzyme (5 alpha reductase) - converts testosterone to dihydrotestosterone (DHT) which stimulates prostate growth.
*Alpha receptors in prostate capsule- cause muscle contraction increase resistance to urine flow

Front 18

BPH obstructive symptoms

Back 18

Weak urinary stream, abdominal straining to void, hesitancy, intermittency, incomplete bladder emptying, terminal dribbling

Front 19

BPH complications

Back 19

*May have irritating symptoms as frequency, nocturia, urgency.
Complications: more susceptible to UTI
Long standing BPH urinary incontinence may be present
Severe prostate enlargement can block urethra, causing acute urinary retention

Front 20

BPH assessments and tests

Back 20

*Complete history: pain, discharge, urinary patterns, bone, back pain, anorexia, history of indwelling catheter.
*Medication history—cold or sinus medication worsen condition? Why? *constriction
*Physical exam, abdominal ,DRE
*Prostate exam via digital exam.

Front 21

BPH diagnostic tests

Back 21

*Elevated PSA may not mean cancer
*Uroflowmetry – used to detect lower urinary tract obstruction
*(PVR) Post void residual urine volume to detect obstruction and impaired detrusor muscle
*Bladder ultrasound- performed to determine residual urine after measurement of urinary flow rate. Non invasive
**If irritative voiding symptoms severe:
May do ureterocystoscopy-cystoscope to visualize interior of bladder, neck and urethra-normal to have dysuria, and hematuria. Note increasing amts, fever,sepsis.**

Front 22

Medical Treatment-BPH

Back 22

*Avoid OTC drugs – antihistamine
*Diet: low fat , avoid coffee , alcohol
*Active surveillance (previously termed watchful waiting) - theory to observe progression of symptoms before intervention. Uses behavioral techniques to reduce symptoms of BPH. Used for AUA score of <7.
*Latest research of BPH treatment- use of **finasteride( Proscar)in combination with alpha –blocker
**doxazosin( Cardura).

Front 23

Proscar

Back 23

5 alpha reductase inhibitor. It prevent conversion of testosterone to dihydrotestosterone (DHT) and Shrinks prostate and tissue around prostate
**Women/pregnancy- women can absorb active ingredient thru skin & should always use caution when handling.
Women of childbearing age should not touch or handle broken tablets.
**(May impact fetal development)

Front 24

Alpha blockers:
Selective alpha blocker:
Tamsulosin ( Flomax)
Less selective :
prazosin (Minipress),
doxazocin (Cardura)
terazosin (Hytrin).

Back 24

Relaxes smooth muscle of bladder neck & decrease outlet obstruction .
Give med hs to decrease S/E.
*S/E: hypotension & fatigue

Front 25

Surgical Treatment BPH
relieve symptoms assoc. with bladder neck obstruction from enlarged prostate pressing on urethra.

Back 25

**TURP – gold standard for treatment: gland resected and pieces removed to open excess prostate tissue. Post op 3 way foley with CBI

*TULIP- transurethral ultrasound laser incision of prostate. Minimal blood loss,no irrigation necessary. Outpatient tx.
*TUNA- transurethral needle ablation –needles placed into prostate and radiofrequency energy is used to provoke tissue coagulation and necrosis.
TUVP- transurethral vaporization of prostate
Laser therapy

Front 26

Resectoscope

Back 26

*Inserted thru urethra, cuts tissue and coagulates bleeding vessels with high frequency current. **Hypotonic fluid never used in irrigation of bladder.
*TUR syndrome can occur: hyponatremia/water intoxication
*Bleeding, infection, complication in post op. persistent incontinence low % post op.

Front 27

Suprapubic prostatectomy

Back 27

Access prostate thru abdomen.
May be used:
*Prostate too large for resection
*Large middle lobe
*Bladder abnormality needs correction
*Abdominal surgical exploration necessary
post op -will have catheter in suprapubic and urethral catheter.
Bladder spasms, urinary leakage in to abd. Wound around suprapubic catheter.
Uncomfortable recovery. May suffer from erectile dysfunction (ED) after this procedure

Front 28

Retropubic prostatectomy

Back 28

Surgical procedure spares bladder incision. Low abd. Incision which allows direct visualization of prostate. Other bladder problems cannot be treated. Pubic bone inflammation may occur.

Front 29

Minimally invasive therapies - TUIP

Back 29

used for small prostate causing obstruction.
High client satisfaction.

Front 30

TULIP

Back 30

transurethral ultrasound laser incision of prostate. Minimal blood loss, no irrigation necessary. Outpatient tx.

Front 31

TUNA

Back 31

transurethral needle ablation – needles placed into prostate and radiofrequency energy is used to provoke tissue coagulation and necrosis.

Front 32

Post Op Care- Complications

Back 32

risk for injury related to presence of urinary catheters, hematuria, irrigation or suprapubic drains

Front 33

Nursing Diagnosis

Back 33

acute pain related to surgery and bladder spasms

Front 34

Nursing intervention post-op

Back 34

GOAL/OUTCOME = the client will not experience hemorrhage, as seen by gross bleeding, infection, water intoxication, maintain urinary output of at least .5 ml/kg/hr.
*Keep output at least 50 ml/hr

Front 35

Nursing intervention post-op

Back 35

Maintain closed bladder irrigation
Never remove catheter which is occluded.
Call MD if resistance met with irrigating fluid.
Practice good foley care. Wash soap/water b.i.d.

Front 36

Nursing intervention post-op

Back 36

Monitor for bleeding- note color, amount, clots. If arterial bleed, vitals, ER surgical intervention may be necessary.
Retention balloon or applying traction on catheter to control venous bleeding.
**Traction on 24 hrs, usually MD releases.
Prevent catheter dislodgement - secure with velcro catheter strap .
At Trinitas – use Statlock Foley Cath Securement Device w/Swivel

Front 37

Nursing intervention post-op

Back 37

Prevent infection, avoid introduction of microrganisms. Frequent drsg changes around suprapubic tube.
Monitor for urinary retention post catheter removal. I and O mandatory.
Provide education to pt about temporary incontinence, voiding frequency. Etc. Embarrassment for men.

Front 38

Nursing intervention post-op w/ meds:

Back 38

Monitor for bladder spasms, may be caused by blocked drainage system. May be caused by too rapid bladder irrigation.
Medicate with antispasmodic meds…
**propantheline bromide (probantine) or **ditropan.
**Belladonna and opium used also.
S/E: dry mouth, drowsiness, acute confusion in elderly.
Disch from hosp. 4-6 days.

Front 39

Risk Factors Prostate Cancer

Back 39

*African men have highest incidence in world
*Asia has low incidence
*Increases with advancing age
*First degree relative with prostate ca
*Fat intake in diet. Japanese men lowest rate
-Fats may increase androgen levels - which increase risk.
*Cadmium exposure- occupational hazard
*Dioxin exposure - environmental hazard
*Genetic inheritance

Front 40

Thought to decrease risk Prostate cancer

Back 40

*Diet rich in vegetables - betacarotene
*Diet rich in fish (omega- 3 fatty acids)
*Adequate selenium intake
*Adequate intake of antioxidant- a tocopherol (vit. E)
*Regular use of NSAIDs
*Regular use of statin drugs to lower cholesterol

Front 41

Manifestations of Disease/Prostate Ca

Back 41

*More than 90% of cancers of prostate are adenocarcinomas.
*Gleason grading system used to stage (2-10)
8-10 poorly differentiated tissue
*Transrectal untrasound guided biopsy used for abnormal DRE or PSA of >10 ng/ml
*>10 PSA associated with CA.
*Digital rectal exam (DRE) may reveal hard nodules, asymmetry
*Asymmetry between lobes of prostate.

Front 42

S/S Prostate Cancer

Back 42

*Early, none
*Often advanced at time of detection
*Later signs– dysuria, hesitancy, dribbling, frequency, urgency, hematuria, nocturia, urinary retention
**Metastasis common to bone, hip, vertebrae, perineal and rectal pain.

Front 43

Prostate CA Treatment options

Back 43

*Active surveillance
*Radical surgery- advised for pt with a life expectancy > 10 years : retropubic, perineal , laparoscopic
*Radiation therapy- external beam radiation
*Brachytherapy – implantation of radioactive sources (seeds) into gland.
**Metastatic- lower testosterone by medical or surgical means; palliation

Front 44

Treatment Options: Prostate Cancer

Back 44

**Bilateral orchiectomy - removal of both testes. “gold standard” - least accepted by patients . Can cause considerable emotional distress.
*Radium implants
*External radiation-causes radiation cystitis
*Surgery- TURP -
Treatment depends on age, stage,grade of tumor. Must R/O (rule out) metastasis.

Front 45

Medical Therapies Prostate CA

Back 45

Testosterone lowering agents:
Leuprolide- 7.5 mg IM monthly

Front 46

Types of Prostate Surgery

Back 46

Transurethral resection
Suprapubic
Retropubic
Perineal
Radical Perineal Resection

Front 47

Nursing Process: The Care of the Patient Undergoing Prostatectomy—Assessment

Back 47

Assess how the underlying disorder (BPH or prostate cancer) has affected the patient’s lifestyle
Urinary and sexual function
Health history
Nutritional status
Activity level and abilities

Front 48

Nursing Process: The Care of the Patient Undergoing Prostatectomy— Diagnoses

Back 48

Anxiety
Acute pain preoperatively
Acute pain postoperatively
Deficient knowledge

Front 49

Collaborative Problems/Potential Complications -Prostatectomy

Back 49

Hemorrhage and shock
Infection
DVT
Catheter obstruction
Sexual dysfunction

Front 50

Nursing Process: The Care of the Patient Undergoing Prostatectomy—Planning

Back 50

Major goals preoperatively include adequate preparation and reduction of anxiety and pain.
Major goals postoperatively include maintenance of fluid volume balance, relief of pain and discomfort, ability to perform self-care activities, and absence of complications.

Front 51

Relief of Pain -Prostatectomy

Back 51

Monitor urinary drainage and keep catheter patent
Assessment of pain
Bladder spasms cause feelings of pressure and fullness, urgency to void, and bleeding from the urethra around the catheter.
Medication and warm compresses or sitz baths to relieve spasms
Administer analgesics and antispasmodics as needed
Encourage patient to walk, but to avoid sitting for prolonged periods.
Prevent constipation
Irrigate catheter as prescribed

Front 52

Rehabilitation and Home Care after Prostatectomy

Back 52

Patient and family teaching for home care including care of urinary drainage devices and recognition and prevention of complications
Regain bladder continence
Information that regaining control is a gradual process (dribbling may continue for up to 1 year depending upon type of surgery)
Perineal exercises
Avoidance of straining, heavy lifting, long car trips (6–8 weeks)
Diet: encourage fluids and avoid coffee, alcohol, and spicy foods
Assessment and referral of sexual issues
**TSE and follow-up care

Front 53

Laboratory Studies: serum creatinine

Back 53

Serum creatinine- normal 0.6-1.2 mg/dl
**Critical value >4

-Creatinine is catabolic product of creatine phosphate which is used in skeletal muscle contraction. Level depends on muscle mass with little fluctuation. Used to diagnose impaired renal function. Elevation in creatinine suggest chronic condition of the disease
Process.
Increased in glomerulonephritis, acute tubular necrosis, reduced renal blood flow, nephropathy, rhabdomyolysis**

Front 54

Rhabdomyolysis

Back 54

is a serious syndrome due to a direct or indirect muscle injury. It results from a breakdown of muscle fibers and release of their contents into the bloodstream. This can lead to complications such as kidney (renal) failure. This occurs when the kidneys cannot remove waste and concentrated urine.
**In rare cases, rhabdomyolysis can even cause death.

Front 55

Laboratory Studies: serum BUN

Back 55

Blood urea Nitrogen norm 10-20mg.dl Measures amount of urea nitrogen in blood..urea is end product of protein metabolism.
BUN directly related to metabolic function of liver, and excretory function of kidney. Changes in protein may affect BUN levels; over or under hydration may affect BUN.
**Increased in : Hypovolemia, shock, burns, dehydration, congestive heart failure, GI bleed
Excessive protein metabolism, starvation
**Decreased in: Liver failure, Over hydration by fluid overload, Negative nitrogen balance, Pregnancy,
Nephrotic syndrome

Front 56

Urinalysis

Back 56

Protein in urine is sensitive indicator of kidney function. Protein is not normally in urine, and if so, glomerular membrane is injured and allows protein to escape. Can lead to protein loss, **decreasing osmotic pressure and leads to edema. Proteinuria and edema-nephrotic syndrome.

Front 57

Nephrotic syndrome

Back 57

Nephrotic syndrome is a sign that your kidneys are not working right. You have nephrotic syndrome if you have high levels of protein in your urine, low levels of protein in the blood, and high cholesterol. It's not a disease. It is a warning that something is damaging your kidneys. Without treatment, that problem could cause kidney failure.
**Damaged kidneys let protein slip from the blood into the urine. Without enough protein in the blood, fluid builds up in the tissues. This can cause swelling.

Front 58

Leukocyte Esterase

Back 58

Screening test to detect leukocytes in urine. Positive indicates urinary tract infection.

Front 59

Nitrates in urine

Back 59

bacteria that cause a urinary tract infection (UTI) make an enzyme produces reductase, which reduce urinary nitrates to nitrites. Positive test indicates need for urine culture.
**Nitrites in urine show a UTI is present.

Front 60

Urine Culture and Sensitivity

Back 60

You will be asked to collect a clean-catch midstream urine sample for testing. The first urine of the day is preferred because bacterial levels will be higher.
Clean the area around your penis or vagina.
Begin urinating into the toilet or urinal. A woman should continue holding apart the folds of skin around the vagina while she is urinating.
After the urine has flowed for several seconds, place the collection container in the stream and collect about 60 mL (2 fl oz) of this "midstream" urine without stopping the flow.
**If you are collecting the urine at home and cannot get it to the lab within an hour, refrigerate the sample. It can be refrigerated for up to 24 hours.

Front 61

Creatinine Clearance: urine

Back 61

*24 hr urine test
Creatinine is entirely excreted by kidneys directly proportional to GFR.
**Exercise may interfere with results
Avoid tea, coffee, cooked meat or drugs on day of test. Discard first specimen– then start test. Keep on ice during test. Drink fluids

Front 62

Creatinine Clearance: urine increases and decreases

Back 62

Increased:
Exercise
Pregnancy
High cardiac outputs
Decreased:
Impaired renal disease
CHF
Cirrhosis with failure
Shock
Dehydration

Front 63

Bladder scan

Back 63

Create ultrasound image of pt bladder and calculate urine volume.
Determine volume of urine remained in the bladder-
Residual urine or post void residual (PVR) volume of urine in the bladder after a normal voiding.
-PVR – occurs in urinary retention or pt cannot empty bladder completely
Normal PVR- less than 50 ml; 2 or more PVR > 150 ml are associated with development of UTI
Distended bladder- mass above symphysis pubis, dullness on percussion