Structure and Function of the Male Reproductive System

The male reproductive system also consists of external and internal genitalia. The primary
male hormone for sexual development and function is testosterone. Testosterone production
is fairly constant in the adult male. Only a slight and gradual reduction of testosterone
production occurs in the older adult male until he is in his 80s. Low testosterone levels
decrease muscle mass, reduce skin elasticity, and lead to changes in sexual performance. The
penis is an organ for urination and intercourse consisting of the body or shaft and the glans
penis (the distal end of the penis). The glans is the smooth end of the penis and contains the
opening of the urethral meatus. The urethra is the pathway for the exit of both urine and
semen. A
continuation of skin covers the glans and folds to form the prepuce (foreskin). Surgical
removal of the foreskin (circumcision) for religious or cultural reasons is a common
procedure in the United States and other Western countries.

The scrotum is a thin-walled, fibromuscular pouch that is behind the penis and suspended
below the pubic bone. This pouch protects the testes, epididymis, and vas deferens in a space
that is slightly cooler than inside the abdominal cavity. The scrotal skin is darkly pigmented
and contains sweat glands, sebaceous glands, and few hair follicles. It contracts with cold,
exercise, tactile stimulation, and sexual excitement. The internal male genitalia are shown in
Fig. 69-3. The major organs are the testes and prostate gland. The testes are a pair of oval
organs in the scrotum that produce sperm and testosterone. Each testis is suspended in the
scrotum by the spermatic cord, which provides blood, lymphatic, and nerve supply to the
testis. Sympathetic nerve fibers are located on the arteries in the cord, and sympathetic and
parasympathetic fibers are on the vas deferens. When the testes are damaged, these
autonomic nerve fibers transmit excruciating pain and a sensation of nausea.

The epididymis is the first portion of a ductal system that transports sperm from the testes to
the urethra and is a site of sperm maturation. The vas deferens, or ductus deferens, is a firm,
muscular tube that continues from the tail of each epididymis. The end of each vas deferens is
a reservoir for sperm and tubular fluids. They merge with ducts from the seminal vesicle to
form the ejaculatory ducts at the base of the prostate gland. Sperm from the vas deferens and
secretions from the seminal vesicles move through the ejaculatory duct to mix with prostatic
fluids in the prostatic urethra. The prostate gland is a large accessory gland of the male
reproductive system that can be palpated via the rectum. The gland secretes a milky alkaline
fluid that adds bulk to the semen, enhances sperm movement, and neutralizes acidic vaginal
secretions. Men older than 50 years commonly have an enlarged prostate (benign prostatic
hyperplasia [BPH]), which can cause problems such as overflow incontinence and nocturia
(nighttime urination). Prostate function depends on adequate levels of testosterone.

With aging and increased dihydrotestosterone (DHT) levels, the glandular units in the
prostate undergo nodular tissue hyperplasia (an increase in the number of cells). This altered
tissue promotes local inflammation by attracting cytokines and other substances (McCance et
al., 2014). As the prostate gland enlarges, it extends upward into the bladder and inward,
causing bladder outlet obstruction (BOO) (Fig. 72-1). In response, urinary ELIMINATION is
affected in several ways, causing lower urinary tract symptoms (LUTS). First, the detrusor
(bladder) muscle thickens to help urine push past the enlarged prostate gland (McCance et al.,
2014). In spite of the bladder muscle change, the patient has increased residual urine (stasis)
and chronic urinary retention. The increased volume of residual urine often causes overflow
urinary incontinence, in which the urine “leaks” around the enlarged prostate, causing
dribbling. Urinary stasis can also result in urinary tract infections and bladder calculi (stones).

In a few patients, the prostate becomes very large, and the man cannot void (acute urinary
retention [AUR]). The patient with this problem requires emergent care. In other patients,
chronic urinary retention may result in a backup of urine and cause a gradual dilation of the
ureters (hydroureter) and kidneys (hydronephrosis) if BPH is not treated. These urinary
ELIMINATION problems can lead to chronic kidney disease as described in Chapter 68.

Although the cause of BPH is not completely understood, it is thought that BPH results from
hormonal changes associated with the aging process.1 One possible cause is excessive
accumulation of dihydroxytestosterone (DHT) (the principal intraprostatic androgen) in the
prostate cells. This can stimulate cell growth and an overgrowth of prostate tissue. Older men
have a decrease in the blood’s testosterone level, but continue to produce and accumulate
high levels of DHT in the prostate. Another possible cause is an increased proportion of
estrogen (as compared to testosterone) in the blood. Throughout their lives, men produce both
testosterone and small amounts of estrogen. As men age, the amount of active testosterone in
the blood decreases, leaving a higher proportion of estrogen. A higher amount of estrogen
within the gland increases the activity of substances (e.g., DHT) that promote cell growth.
Typically BPH develops in the inner part of the prostate. (Prostate cancer is most likely to
develop in the outer part.) This enlargement gradually compresses the urethra, eventually
leading to partial or complete obstruction (Fig. 55-2). The compression of the urethra
ultimately leads to the development of clinical symptoms. There is no direct relationship
between the size of the prostate and the severity of symptoms or degree of obstruction. The
location of the enlargement is most significant in the development of obstructive symptoms
(Fig. 55-3). For example, it is possible for mild hyperplasia to cause severe obstruction, or for
extreme hyperplasia to cause few obstructive symptoms. Risk factors for BPH include aging,
obesity (in particular increased waist circumference), lack of physical activity, alcohol
consumption, erectile dysfunction, smoking, and diabetes.4 A positive family history of BPH
in first-degree relatives may also be a risk factor.

Manifestations of BPH are mainly associated with symptoms of the lower urinary tract.5 The
patient’s symptoms are usually gradual in onset and may not be noticed until prostatic
enlargement has been present for some time. Early symptoms are often minimal because the
bladder can compensate for a small amount of resistance to urine flow. The symptoms
gradually worsen as the degree of urethral obstruction increases. Symptoms can be divided
into two groups: irritative and obstructive. Irritative symptoms, which include nocturia,
urinary frequency, urgency, dysuria, bladder pain, and incontinence, are associated with
inflammation or infection. Nocturia is often the first symptom that the patient notices.
Obstructive symptoms caused by prostate enlargement include a decrease in the caliber and
force of the urinary stream, difficulty in initiating voiding, intermittency (stopping and
starting stream several times while voiding), and dribbling at the end of urination. These
symptoms are due to urinary retention.

Complications of urinary obstruction are relatively uncommon in BPH. Acute urinary

retention is a complication that is manifested by the sudden and painful inability to urinate.
Treatment involves the insertion of a catheter to drain the bladder. Surgery may also be
indicated. Another complication is urinary tract infection (UTI) and potentially sepsis
secondary to UTI. Incomplete bladder emptying (associated with partial obstruction) results
in residual urine, which provides a favorable environment for bacterial growth. Calculi may
develop in the bladder because of the alkalinisation of the residual urine. Bladder stones are
more common in men with BPH, although the risk of renal calculi is not significantly
increased. Additional complications include renal failure caused by hydronephrosis
(distention of pelvis and calyces
of kidney by urine that cannot flow through the ureter to the bladder), pyelonephritis, and
bladder damage if treatment for acute urinary retention is delayed.

History.
When taking a history, several standardized assessment tools are used to help the health care
provider determine the severity of lower urinary tract symptoms (LUTS) associated with
prostatic enlargement. One of the most commonly used assessments is the International
Prostate Symptom Score (I-PSS), which incorporates the American Urological Association
Symptom Index (AUA-SI) (Fig. 72-2) as questions 1 through 7. The additional question
included on the I-PSS is the effect of the patient's urinary symptoms on quality of life. Most
patients complete the questions as a selfadministered tool because it is available in many
languages. If the patient is illiterate (does not read) or does not feel like reading the questions,
the nurse or health care provider can ask them. Be sure that older men wear their glasses or
contact lenses if needed.

Physical Assessment/Signs and Symptoms.

Ask about the patient's current urinary ELIMINATION pattern. Assess for urinary frequency and urgency.
Determine the number of times the patient awakens during the night to void (nocturia). Other symptoms of
LUTS include:
• Difficulty in starting (hesitancy) and continuing urination
• Reduced force and size of the urinary stream (“weak” stream)
• Sensation of incomplete bladder emptying
• Straining to begin urination
• Post-void (after voiding) dribbling or leaking
If frequency and nocturia do not occur with restricted urinary flow, the patient may develop an infection or other
bladder problem. Ask whether the patient has had hematuria (blood in the urine) when starting the urine stream
or at the end of voiding. BPH is a common cause of hematuria in older men due to infection. The health care
provider examines the patient for physical changes of the prostate gland. Remind him to void before the
physical examination. Inspect and palpate the abdomen for a distended bladder. The primary health care
provider may percuss the bladder. If the patient has a sense of urgency when gentle pressure is applied, the
bladder may be distended. Obese patients are best assessed by percussion or bedside ultrasound bladder scanner
rather than by inspection or palpation. Prepare the patient for the prostate gland examination. Tell him that he
may feel the urge to urinate as the prostate is palpated. Because the prostate is close to the rectal wall, it is easily
examined by digital rectal examination (DRE). If needed, help the patient bend over the examination table or
assume a side-lying fetal position, whichever is the easiest position for him. The primary health care provider
examines the prostate for size and consistency. BPH presents as a uniform, elastic, nontender enlargement;
whereas cancer of the prostate gland feels like a stonyhard nodule. Advise the patient that, after the prostate
gland is palpated, it may be massaged to obtain a fluid sample for examination to rule out prostatitis
(inflammation and possible infection of the prostate), a common problem that can occur with BPH. If the patient
has bacterial prostatitis, he is treated with broad-spectrum antibiotic therapy to prevent the spread of infection
(McCance et al., 2014).

A urinalysis and urine culture are typically obtained to diagnose urinary tract infection and microscopic
hematuria. If infection is present, the urinalysis measures the number of white blood cells (WBCs). Other
laboratory studies that may be performed include:
• A complete blood count (CBC) to evaluate any evidence of systemic infection (elevated WBCs) or anemia
(decreased red blood cells [RBCs]) from hematuria
• Blood urea nitrogen (BUN) and serum creatinine levels to evaluate renal function (both are usually elevated
with kidney disease)
• A prostate-specific antigen (PSA) and a serum acid phosphatase level if prostate cancer is suspected (both are
typically elevated in patients who have prostate cancer)
• Culture and sensitivity of prostatic fluid (if expressed during the examination)