Chapter 24 Male Genitourinary System

Adults And Aging Adult The male does not experience a definite end to fertility as the female does. Around age 40 years, the production of sperm begins to decrease, although it continues into the 80s and 90s. After age 55 to 60 years, testosterone production declines ery gradually so that the resulting physical changes are not e ident until later in life. !n the aging male, the amount of pubic hair decreases and the remaining hair turns gray. "enis si#e decreases to decreased tone of the dartos muscle, the scrotal contents hang lo$er, the rugae decrease, and the scrotum loo%s pendulous. The testes decrease in si#e and are less firm to palpation. !ncreased connecti e tissue is present in the tubules, so these become thic%ened and produce less sperm. !n general, declining testosterone production lea es the older male $ith a slo$er and less intense sexual response, and an erection ta%es longer to de elop and is less full or firm. &'aculation is shorter and less forceful, and the olume of seminal fluid is less than $hen the man $as younger. The refractory state ($hen the male is physiologically unable to e'aculate) lasts longer, from *+ to +4 hours as compared $ith t$o minutes in the younger male. !n the absence of disease, a $ithdra$al from sexual acti ity may be due to loss of spouse, depression, preoccupation $ith $or%, marital or family conflict, side effects of medications such as antihypertensi es, psychotropics, antidepressants, antispasmodics, sedati es, tran-uili#ers or narcotics, and estrogens, hea y use of alcohol, lac% of pri acy (li ing $ith older children or in a nursing home), economic or emotional stress, poor nutrition, or fatigue. Culture And Genetics Circumcision . /uring pregnancy or the immediate neonatal period, parents $ill as% you about $hether to circumcise the male infant. There are religious and cultural indications for circumcision. 0ircumcision reduces 1!2 ac-uisition in men by 534 to 604, as sho$n in three randomi#ed trials and numerous obser ational studies in sub5 6aharan Africa, and it reduces 1!2 transmission to uninfected $oman sexual partners. 7urther, circumcision significantly reduce the incidence of herpes simplex irus type !! (162 . +) and the pre alence of human papilloma irus (1"2). 0ertain types of 1"2 cause cer ical cancer. The mechanism may be that the presence of the fores%in increases susceptibility to small abrasions, allo$ing more contact time bet$een pathogens and the mucosa of the partner. The ris% for other 6T!s (trichomonas aginalis, bacterial agenosis) is reduced in $omen $ith circumcised partners as $ell. !n the 8nited 6tates, the public health implications of these findings are being debated. 9outine neonatal circumcision rates ha e dropped from a high of 804 after :orld :ar !! to about 654 of ne$borns in *999, in part because the American Academy of pediatrics does not endorse the procedure. ;ecause of this, <edicaid does not co er routine neonatal circumcision costs in *6 states. 0ircumcision carries a ery small but possible ris% of complications. <ost are minor and treatable= pain, bleeding, s$elling, or inade-uate s%in remo al. 6erious complications are rare and include excess bleeding, $ound infection, and urinary retention. >eonates certainly are capable of percei ing pain, therefore parents need to be apprised of pain relief measures for the circumcision procedure. These include dorsal penile ner e bloc% and a lidocaine5prilocaine cream (&<?A). Kidney Disease . 0hronic %idney disease (0@/) is determined by blood tests, urinalysis, and imaging studies that sho$ decreased %idney function or %idney damage lasting 3 months or longer. This can lead progressi ely and irre ersibly to end stage renal disease (&69/), $hen the person sur i es only by %idney transplant or dialysis Frequency average adult voids 5 to 6 times a day, varying with fluid intake, individual habits. Polyuria excessive quantity liguria diminished quantity, less than !"" m# $er %! hours. &octuria occurs together with frequency and urgency and urinary tract disorders. ther origins' cardiovascular, habitual, diuretic medication. (loudy in urinary tract infection. )ematuria *blood in the urine+ a danger sign that warrants worku$. ,rge -ncontinence involuntary urine loss from overactive detrusor muscle in bladder. -t contracts, causing urgent need to void. .tress -ncontinence involuntary urine loss with $hysical strain, snee/ing or coughing due to weakness of $elvis floor.

0arly sym$toms of enlarging $rostate may be tolerated or ignored. #ater sym$toms are more dramatic' hematuria urinary tract infection. Assessing Male Genitalia Aour demeanor should be confident and relaxed, unhurried yet businessli%e. /o not discuss genitourinary history or sexual practices $hile you are performing the examination. This may be percei ed as 'udgmental. 8se a firm, deliberate touch, not a soft, stro%ing one. !f an erection does occur, do not stop the examination or lea e the room. This only focuses more attention on the erection and increases embarrassment. 9eassure the male that this is only a normal physiologic response to touch, 'ust as $hen the pupil constricts in response to bright light. "roceed $ith the rest of the examination. Inspect And Palpate The Penis The s%in normally loo%s $rin%led, hairless, and $ithout lesions. The dorsal ein may be apparent. The glans loo%s smooth and $ithout lesions. As% the uncircumcised male to retract the fores%in, or you retract it. !t should mo e easily. 6ome cheesy smegma may ha e collected under the fores%in. After inspection, slide the fores%in bac% to the original position. The urethral meatus is positioned 'ust about centrally. At the base of the penis, pubic hair distribution is consistent $ith age. 1air is $ithout pest inhabitants 5 Phimosis 1 narrowed o$ening of $re$uce so cannot retract the foreskin. )y$os$adias 1 venture location of meatus. 0$is$adias 1 dorsal location of meatus. Inspect And Palpate The Scrotum "alpate gently each scrotal half bet$een your thumb and the first t$o fingers. The scrotal contents should slide easily. 2estes normally feel oval, firm and robbery, smooth and equal bilaterally and are freely movable and slightly tender to moderate $ressure. Inspect And Palpate or !ernia "alpate the inguinal canal. 7or the right side, as% the male to shift his $eight onto the left (unexamined) leg. "lace your right index finger lo$ on the right scrotal half. "alpate up the length of the spermatic cord, in aginating the scrotal s%in as you go, to the external inguinal ring 5 Pal$able herniating mass bum$s your fingerti$ or $ushes against the side of your finger. Palpate Inguinal "ymph #odes !t is normal to palpate an isolated node on occasion, it then feels small (less than * cm), soft, discrete, and mo able 1 enlarged, hard, matted, fixed nodes. Sel$ Care Testicular Sel$%&'amination (TS&) &ncourage self care by teaching e ery male (from *3 to *4 years old through adulthood) ho$ to examine his o$n testicles. The o erall incidence of testicular cancer is rare, accounting for about 8000 ne$ cases annually. !t is rare before age *5 years, pea%s during ages +0 to 39 years, and then declines. &arly detection is enhanced the mail familiar $ith his normal consistency. "oints to include during health teaching are= T B timing, once a month S B sho$er, $arm $ater relaxes scrotal sac & B examine, chec% for changes, report changes immediately Phrase *our Teaching Something "i+e This= A good time to examine the testicles is during the shower or bath, when your hands are warm and soapy and the scrotum is warm. Cold hands stimulate a muscle (cremasteric) reflex, retracting the scrotal contents. The procedure is simple. Hold the scrotum in the palm of your hand and gently feel each testicle using your thumb and first two fingers. If it hurts, you are using too much pressure. The testicle is egg shaped and mo able. It feels a robbery with a smooth surface, li!e a peeled hard"boiled egg. The epididymis is on top and behind the testicle# it feels a bit softer. Abnormal lumps are ery rare and usually not worrisome. $ut, if you e er notice a firm, painless lump, a hard area, or an o erall enlarged testicle, call your physician for a further chec!.

Assess ,rinary unction A urinalysis sho$s a color of pale yello$ to amber due to the presence of urochrome pigments. &ormal urine is clear and slightly acidic with a $) range of !.5 to 3." 1 cloudiness suggests $resence of white blood cells, bacteria, casts. ,nderstanding Prostate Changes The discussion of prostate health and the examination of the prostate gland are uni-ue aspects of male health assessment. The prostate gland goes through t$o main periods of gro$th. The first occurs early in puberty, and the second begins after age +5. Although the prostate continues to gro$ during most of a manCs life, the enlargement rarely causes symptoms before age 40. 1o$e er, more than half of men in the 60s and as many as 904 of men in the D0s $ill ha e some symptoms. The gradual enlargement is considered to be a normal part of aging and is often referred to as benign prostatic hyperplasia (;"1). ;y itself, ;"1 does not raise an indi idualCs ris% for prostate cancer, ho$e er, the symptoms of ;"1 and prostate cancer can be ery similar, including hesitant, interrupted, or $ea% urinary stream, urinary urgency, lea%ing or dribbling, and increased fre-uency of urination, especially at night. T$o groups that are increased ris% for prostate cancer are African5American men and men $hose first5degree relati es ha e had prostate cancer. !n African5American men, prostate cancer tends to start younger and gro$ faster than in men of other racial ethnic groups. <en $ho ha e a first5degree relati e (father, brother, or some) ha e a + to 3 times higher ris% for prostate cancer than those $ithout a family history of the disease. "rostate cancer is typically detected by testing the blood for prostate specific antigen ("6A) andEor on digital rectal examination (/9&) is recommended that for men $ithout other %no$n ris%s, a /9& should be offered to men yearly, beginning at age 40, and the "6A yearly, beginning at age 50. "6A is a substance made by the normal prostate gland. :hen prostate cancer de elops, the "6A le el increases. /9& in ol es a glo ed, lubricated finger being inserted into the rectum. "6A and /9& are recommended to be done together $ith screening for prostate cancer. ,rine Color And Discolorations Cloudy . 8rinary Tract !nfection . @idney 6tones -lue . <edication 6ide &ffect (Amitriptyline, !ndocin) . 7oods= Asparagus . /ye After "rostate 6urgery

.range . <edication 6ide &ffect= 9ifampin 7or <eningitis, "yridium, /ar$arin (Coumadin) . 6ome 7oods, 7ood /yes, ?axati es . /ehydration . 0aundice (;ilirubinemia) Tea . ?i er /isease, &specially :ith "ale 6tools, Gaundice . <yoglobinuria . 6ome <edications Fr 7ood /yes . ;lood !n 8rine

,rethritis (,rethral Discharge And Dysuria) !nfection of uretha causes painful burning urination or pruritus. <eatus edges are reddened, e erted, and s$ollen $ith purulent discharge. 8rine is cloudy $ith discharge and mucous shreds. 0ause determined by culture (*) gonococcal urethritis has thic%, profuse yello$ or gray5bro$n discharge, (+) nonspecific urethritis (>68) may ha e similar discharge but often has scanty, mucoid discharge. Ff these, about 504 are caused by 0hlamydia infection. This is important to differentiate because antibiotic treatment is different. Phimosis >on5retractable fores%in forming a pointy tip $ith a tiny orifice. 7ores%in is ad anced and so tight it is impossible to retract o er glans. <aybe congenital or ac-uired from adhesions ac-uired secondary to infection. "oor hygiene leads to retained dirt and smegma, $hich increases the ris% for inflammation, calculus formation, obstructi e uropathy. !ypospadias 8rethral meatus opens on the entral (under) side of glans, shaft, or at the penoscrotal 'unction. A groo e extends from the meatus to the normal location at the tip. This is a congenital defect that is important to recogni#e at birth. The ne$born should not be circumcised because surgical correction may use fores%in tissue to extend urethral length.

&pispadias 5 <eatus opens on the dorsal (upper) side of glans or shaft abo e a broad, spadeli%e penis. 9are, less common than hypospadias but more disabling because of associated urinary incontinence and separation of pubic bones. &arly Testicular Tumor % Discussion &arly Testicular Tumor % Clinical indings <ost testicular tumors occur bet$een the ages of *8 and 35. "ractically all are 6= "ainless, found on examination malignant. Fccur in $hites, relati ely rare in blac%s, <exican Americans, and F= "alpation . firm nodule or harder than normal section of testicle Asians. <ust biopsy to confirm. <ost important ris% factor is undescended A= 6olitary nodule testis, e en though surgically corrected. &arly detection important in prognosis, but practice of testicular self examination is currently lo$. Di$$use Tumor % Clinical indings 6= &nlarging testes (most common symptom). :hen enlarges, has a feel of increased $eight F= !nspection . enlarged, does not transilluminate "alpation . enlarged, smooth, o oid, firm !mportant . firm palpation does not cause usual sic%ening discomfort as $ith normal testes A= >ontender s$elling of testes .rchitis % Clinical indings 6= Acute or moderate pain of sudden onset, s$ollen testes, feeling of $eight, fe er F= !nspection . &nlarged, edematous, red, does not transilluminate "alpation . 6$ollen, congested, tense, and tender, hard to distinguish testes from epididymis A= Tender s$elling of testis Scrotal &dema % Clinical indings 6= Tenderness F= !nspection . &nlarged, may be reddened ($ith local irritation) "alpation . Taut $ith pitting, unable to feel scrotal contents A= 6crotal edema Scrotal &dema Discussion Accompanies mar%ed edema in lo$er half of body (e.g., congesti e heart failure, renal failure, and portal ein obstruction). Fccurs $ith local inflammation= epididymitis, obstruction of inguinal lymphatics produces lymphedema of scrotum. .rchitis % Discussion Acute inflammation of testis. <ost common cause is mumps, can occur $ith any infectious disease. <ay ha e associated hydrocele that does not transilluminate. Di$$use Tumor % Discussion /iffuse tumor maintains shape of testis.