1514 Unit 10 Reproductive Function
bacteria are cultured from the urine, antibiotics,
including trimethoprim-sulfamethoxazole (TMP-
SMZ) or a fluoro- quinolone (eg, ciprofloxacin [Cipro]),
may be prescribed, and continuous therapy with low-
dose antibiotics may be used to suppress the
infection. If the patient is afebrile and has a normal
urinalysis, anti-inflammatory agents may be used.
Alpha-adrenergic blocker therapy (eg, tamsulosin
[Flomax]), may be prescribed to promote bladder
and prostate relaxation.
Factors contributing to prostatitis, including
stress, neu- romuscular factors, and myofascial pain, are
also addressed. Supportive, nonpharmacologic
therapies may be pre- scribed. These include
biofeedback, pelvic floor training, physical therapy,
reduction of prostatic fluid retention by ejaculation
through sexual intercourse or masturbation, sitz baths,
stool softeners, and evaluation of sexual partners to
reduce the possibility of cross-infection.
Nursing Management
If the patient experiences symptoms of acute
prostatitis (fever, severe pain and discomfort,
inability to urinate, malaise), he may be hospitalized
for intravenous (IV) an- tibiotic therapy. Nursing
management includes administra- tion of prescribed
antibiotics and provision of comfort measures,
including prescribed analgesic agents and sitz baths.
The patient with chronic prostatitis is usually
treated on an outpatient basis and needs to be
instructed about the im- portance of continuing
antibiotic therapy and recognizing recurrent signs
and symptoms of prostatitis.
Promoting Home and Community-Based Care
Teaching Patients Self-Care
The nurse instructs the patient to complete the
prescribed course of antibiotics. If IV antibiotics are to
be administered at home, the nurse instructs the
patient and family about correct and safe
administration. Arrangements for a home care nurse to
oversee administration may be needed. Hot sitz baths
(10 to 20 minutes) may be taken several times
daily. Fluids are encouraged to satisfy thirst but are
not “forced,” because an effective medication level
must be maintained in the urine. Foods and liquids
with diuretic ac- tion or that increase prostatic
secretions, such as alcohol, coffee, tea, chocolate, cola,
and spices, should be avoided. A suprapubic catheter
may be necessary for severe urinary retention. During
periods of acute inflammation, sexual arousal and
intercourse should be avoided. To minimize dis-
comfort, the patient should avoid sitting for long
periods. Medical follow-up is necessary for at least 6
months to 1 year because prostatitis caused by the
same or different or- ganisms can recur. The patient
is advised that the UTI may recur and is taught to
recognize its symptoms.
Benign prostatic hyperplasia (BPH) is one of the
most common diseases in aging men. It can cause
bothersome lower urinary tract symptoms that affect
quality of life by in-
terfering with normal daily activities and sleep
patterns (AUA, 2006; Kaplan, 2006). BPH typically
occurs in men older than 40 years of age. By the
time they reach 60 years of age, 50% of men have
BPH. It affects as many as 90% of men by 85 years
of age. BPH is the second most common cause of
surgical intervention in men older than 60 years of
age.
Pathophysiology
The cause of BPH is not well understood, but
testicular an- drogens have been implicated.
Dihydrotestosterone (DHT), a metabolite of
testosterone, is a critical mediator of prosta- tic
growth. Estrogens may also play a role in the cause
of BPH; BPH generally occurs when men have elevated
estro- gen levels and when prostate tissue becomes
more sensitive to estrogens and less responsive to
DHT. Smoking, heavy alcohol consumption, obesity,
reduced activity level, hyper- tension, heart disease,
diabetes, and a Western diet (high in animal fat and
protein and refined carbohydrates, low in fiber) are
risk factors for BPH (Parsons, 2007).
BPH develops over a prolonged period; changes in the
uri- nary tract are slow and insidious. BPH is a result
of complex interactions involving resistance in the
prostatic urethra to mechanical and spastic effects,
bladder pressure during void- ing, detrusor muscle
strength, neurologic functioning, and general physical
health (McCance & Huether, 2005). The hypertrophied
lobes of the prostate may obstruct the bladder neck or
urethra, causing incomplete emptying of the bladder and
urinary retention. As a result, a gradual dilation of the
ureters (hydroureter) and kidneys (hydronephrosis) can
oc- cur. Urinary retention may result in UTIs because
urine that remains in the urinary tract serves as a
medium for infective organisms.
Clinical Manifestations
BPH may or may not lead to lower urinary tract
symptoms; if symptoms occur, they may range from
mild to severe. Severity of symptoms increases with
age, and half of men with BPH report having moderate
to severe symptoms. Ob- structive and irritative
symptoms may include urinary fre- quency, urgency,
nocturia, hesitancy in starting urination, decreased and
intermittent force of stream and the sensa- tion of
incomplete bladder emptying, abdominal straining with
urination, a decrease in the volume and force of the
urinary stream, dribbling (urine dribbles out after
urina- tion), and complications of acute urinary
retention (more than 60 mL of urine remaining in the
bladder after urina- tion), and recurrent UTIs.
Ultimately, chronic urinary retention and large
residual volumes can lead to azotemia (accumulation of
nitrogenous waste products) and renal failure.
Generalized symptoms may also be noted, including
fa- tigue, anorexia, nausea, vomiting, and pelvic
discomfort. Other disorders that produce similar
symptoms include ure- thral stricture, prostate cancer,
neurogenic bladder, and uri- nary bladder stones.
Assessment and Diagnostic Findings
The health history focuses on the urinary tract,
previous sur- gical procedures, general health issues,
family history of prostate disease, and fitness for
possible surgery (AUA, 2006).
 Chapter 49 Assessment and Management of Problems Related to Male Reproductive Processes
A patient voiding diary is used to record voiding
frequency and urine volume. A DRE often reveals a
large, rubbery, and nontender prostate gland. A
urinalysis to screen for hema- turia and UTI is
recommended. A PSA level is obtained if the
patient has at least a 10-year life expectancy and for
whom knowledge of the presence of prostate cancer
would change management. The AUA Symptom
Index or Inter- national Prostate Symptom Score (IPSS)
can be used to as- sess the severity of symptoms
(AUA, 2006).
Other diagnostic tests may include urinary flow-
rate recording and the measurement of postvoid
residual (PVR) urine. If invasive therapy is considered,
urodynamic studies, urethrocystoscopy, and ultrasound
may be performed. Com- plete blood studies are
performed. Cardiac status and respi- ratory function are
assessed because a high percentage of patients with
BPH have cardiac or respiratory disorders because
of their age.
Medical Management
The goals of medical management of BPH are to
improve quality of life, improve urine flow, relieve
obstruction, pre- vent disease progression, and
minimize complications. Treatment depends on the
severity of symptoms, the cause of disease, the
severity of the obstruction, and the patient’s condition.
If a patient is admitted on an emergency basis because
he is unable to void, he is immediately catheterized.
The ordi- nary catheter may be too soft and pliable
to advance through the urethra into the bladder. In
such cases, a thin wire (stylet) is introduced (by a
urologist) into the catheter to prevent the catheter
from collapsing when it encounters resistance. A metal
catheter with a pronounced prostatic curve may be
used if obstruction is severe. An incision into the
bladder (a suprapubic cystostomy) may be needed to
provide urinary drainage.
Discussion of all treatment options by the
physician en- ables the patient to make an informed
decision based on symptom severity, the effect of
BPH on his quality of life, and preference. Patients
with mild symptoms and patients with moderate or
severe symptoms who are not bothered by them and
have not developed complications may be man- aged
with watchful waiting. With this approach, the patient is
monitored and reexamined annually but receives no ac-
tive intervention (Kaplan, 2006). Other
therapeutic choices include pharmacologic treatment,
minimally inva- sive procedures, and surgery.
Pharmacologic Therapy
Pharmacologic treatment for BPH includes use of
alpha- adrenergic blockers and 5-alpha-reductase
inhibitors (AUA, 2006). Alpha-adrenergic blockers, which
include alfuzosin (Uroxatral), terazosin (Hytrin),
doxazosin (Cardura), and tamsulosin, relax the
smooth muscle of the bladder neck and prostate. This
improves urine flow and relieves symptoms of BPH.
Side effects include dizziness, headache, asthenia/
fatigue, postural hypotension, rhinitis, and sexual
dysfunc- tion (Kaplan, 2006; Lepor, 2007).
Another method of treatment involves hormonal
manip- ulation with antiandrogen agents. The 5-alpha-
reductase inhibitors, finasteride (Proscar) and
dutasteride (Avodart), are used to prevent the
conversion of testosterone to DHT
1515
and decrease prostate size. Side effects include
decreased libido, ejaculatory dysfunction, erectile
dysfunction, gyneco- mastia (breast enlargement), and
flushing. Combination therapy (doxazosin and
finasteride) has decreased symptoms and reduced
clinical progression of BPH (AUA, 2006; Kaplan,
2006).
Use of phytotherapeutic agents and other dietary
supple- ments (Serenoa repens [saw palmetto berry]
and Pygeum africanum [African plum]) are not
recommended, although they are commonly used. They
may function by interfering with the conversion of
testosterone to DHT. In addition, S. repens may
directly block the ability of DHT to stimulate
prostate cell growth. These agents should not be used
with finasteride, dutasteride, or estrogen-containing
medica- tions.
Surgical Treatment
Other treatment options include minimally invasive
proce- dures and resection of the prostate gland.
Minimally Invasive Therapy
Several forms of minimally invasive therapy may be used
to treat BPH. Transurethral microwave heat
treatment (TUMT) involves the application of
heat to prostatic tis- sue. High-energy TUMT
devices (CoreTherm, Prostatron, Targis) and low-
energy devices (TherMatrx) are available (AUA,
2006). A transurethral probe is inserted into the
urethra, and microwaves are directed to the prostate
tissue. The targeted tissue becomes necrotic and sloughs.
To mini- mize damage to the urethra and decrease
the discomfort from the procedure, some systems have
a water-cooling ap- paratus.
Other minimally invasive treatment options
include (transurethral needle ablation [TUNA]) by
radiofrequency energy and the UroLume stent.
TUNA uses low-level ra- diofrequencies delivered
by thin needles placed in the prostate gland to
produce localized heat that destroys prostate tissue
while sparing other tissues. The body then resorbs
the dead tissue. Prostatic stents are associated with
significant complications (eg, eucrustation,
infection, chronic pain); therefore, they are used
only for patients with urinary retention and in patients
who are poor surgical risks (AUA, 2006).
Surgical Resection
Surgical resection of the prostate gland is another
option for patients with moderate to severe lower
urinary tract symp- toms of BPH and for those with
acute urinary retention or other complications. The
specific surgical approach (open or endoscopic) and the
energy source (electrocautery versus laser) are based on
the surgeon’s experience, the size of the prostate gland,
the presence of other medical disorders, and the patient’s
preference. If surgery is to be performed, all clotting
defects must be corrected and medications for anti-
coagulation withheld because bleeding is a complication of
prostate surgery.
Transurethral resection of the prostate (TURP) re-
mains the benchmark for surgical treatment of BPH.
It in- volves the surgical removal of the inner
portion of the prostate through an endoscope inserted
through the urethra; no external skin incision is made.
It can be performed with
1516 Unit 10 Reproductive Function

ultrasound guidance. The treated tissue either

vaporizes or becomes necrotic and sloughs. The
procedure is performed in the outpatient setting and
usually results in less postoper- ative bleeding than a
traditional surgical prostatectomy.
Other surgical options for BPH include
transurethral inci- sion of the prostate (TUIP),
transurethral electrovaporiza- tion, laser therapy, and
open prostatectomy (AUA, 2006; Ka- plan, 2006). TUIP
is an outpatient procedure used to treat smaller
prostates. One or two cuts are made in the prostate and
prostate capsule to reduce constriction of the urethra
and decrease resistance to flow of urine out of the
bladder, and no tissue is removed. Open prostatectomy
involves the surgical removal of the inner portion of the
prostate via a suprapubic, retropubic, or perineal (rare)
approach for large prostate glands. Prostatectomy may
also be performed laparoscopically or by a robot-
assisted laparoscopy.
Nursing management of patients undergoing these
pro- cedures is described later in this chapter.
Prostate cancer is the most common cancer in men
other than nonmelanoma skin cancer. It is the second
most com- mon cause of cancer death in American
men, exceeded only by lung cancer, and is
responsible for 10% of cancer- related deaths in men.
Among men diagnosed with prostate
cancer, 98% survive at least 5 years, 84% survive at least 10
years, and 56% survive 15 years (ACS, 2009).
Prostate cancer is common in the United States
and northwestern Europe but is rare in Africa,
Central America, South America, China, and other
parts of Asia. African American men have a high risk
of prostate cancer; further- more, they are twice as
likely to die of prostate cancer than men of any other
racial or ethnic group. The findings of the African-
American Hereditary Prostate Cancer Study suggest
that a strong genetic link increases the risk of early-
onset disease (Jones, Underwood & Rivers, 2007).
Other risk fac- tors in African American men include
their lower level of engagement in the health care
system, disparities in health care, and cultural and
structural barriers. These findings sup- port the need
for education about prostate cancer and screening
in African American men (Weinrich, Vijayaku- mar,
Powell, et al., 2007). Culturally sensitive promotional
campaigns, teaching and counseling about prostate cancer,
screening, and treatment are important in increasing
aware- ness of the high incidence of prostate cancer
and mortality rates in African American men (Chart
49-2).
Other risk factors for prostate cancer include increasing
age; the incidence of prostate cancer increases rapidly
after the age of 50 years. More than 70% of cases
occur in men older than 65 years of age. A familial
predisposition may oc- cur in men who have a father
or brother previously diag- nosed with prostate
cancer, especially if their relatives were

CHAR NURSING RESEARCH PROFILE

T
Knowledge About Hereditary Prostate Cancer in African American Men
49-
2
Weinrich, S., Vijayakumar, S., Powell, I. J., et al. (2007). participant, an average of 2.5 calls was needed; each call lasted
Knowl- edge of hereditary prostate cancer among high-risk an average of 15 minutes.
African American men. Oncology Nursing Forum, 34(4),
854–860.
Purpose
Because African American men develop prostate cancer 50%
to 60% more often than Caucasians and die from it at twice
the rate of any other ethnic group, it is critical for this group
to be aware of their increased risk and the need for
screening for early detection of prostate cancer. The purpose
of this study was to measure the level of knowledge about
hereditary prostate cancer in a group of high-risk African
American men.
Design
For this cross-sectional, correlational pilot study, investigators
recruited a sample of 79 high-risk African American men (de-
fined as those with four or more men in their families with
prostate cancer) from four geographic areas. These men,
who were also participants in the African American
Hereditary Prostate Cancer Study, came from all educational
levels, and their average age was 54 years. Almost half (n =
38, 48%) of them had received a diagnosis of prostate can-
cer. Researchers conducted telephone interviews using a
scripted telephone protocol and a true-false, nine-item ques-
tionnaire, called the “Knowledge of Hereditary Prostate Can-
cer Scale,” developed by the first author. Each man’s individ-
ual answers were scored as correct or incorrect, with a range
of possible total scores ranging from 0 to 9. To reach each
Findings
Data analysis revealed a range of scores from 3.5 to 9,
with a mean score of 6.34 (standard deviation = 1.11).
The authors interpreted this as a low level of
knowledge about hereditary prostate cancer;
answering six of nine questions correctly would
produce a score of 67%.
Nursing Implications
The authors interpreted the high percentage of incorrect
re- sponses to questions about genetic testing,
prevention, and risk based on a positive family history
as indicating a need for education. They proposed that
cancer fatalism (eg, the belief that death is inevitable
when cancer is present) may account for a high
percentage of incorrect or unanswered re- sponses to a
question measuring risk probability based on a positive
prostate cancer test. In the current genomic health care
system, a critical need exists for nurses to have a sound
understanding of genetics and to educate high-risk
African American men and their families about
hereditary prostate cancer. The lack of knowledge
exhibited by the participants in this study suggests a
decreased likelihood of prostate can- cer screening. The
American Cancer Society recommends prostate cancer
screening at 45 years of age for African American men
and men with a positive family history
(5 years earlier than the recommended age for men in
the general population). Nurses can encourage early
prostate screening. They have a valuable role in
promoting healthy behaviors among high-risk African
American men through education and other innovative
strategies.