Assessing Male Breasts and Reproductive System

There is strong evidence that on many health measures men are doing significantly worse than women including

lower life expectancy and increased cardiovascular mortality, rate of injury, depression, and suicide.

Men are less likely to visit a doctor, get regular preventative check-ups, or live healthier lifestyles.

Nurses can make a difference to help increase the awareness of men's health and health promotion.

Circumcision

one of the oldest and most controversial surgical procedures. Circumcision is performed for a variety of religious and cultural reasons.
Male circumcision reduces the risk that a man will acquire HIV from a HIV-positive female partner, and also lowers the risk of other STIs, penile cancer, and urinary tract infections.

Diagnostics

Prostate-specific antigen (PSA) test: blood test that measures the amount of PSA, a protein secreted by prostate epithelial cells; used as a biological marker for prostate cancer.

Prostate biopsy: procedure removes a sample of body tissue for examination under a microscope; a core needle biopsy is the main method used to diagnose prostate cancer; it is usually done by urologist, a surgeon who treats cancers of the genital and urinary tract, which includes the prostate gland.

Urethral specimens: obtained in men with penile discharge; the specimen identifies the organisms causing the symptoms; commonly collected for sexually transmitted diseases such as gonorrhea or chlamydia.

Risk Factors for Male Cancers

Testicular Cancer: Family history, undescended testicle, men infected with HIV and AIDs, tall men.

Penile Cancer: Not being circumcised, HPV infection, Phimosis, Smoking, Advancing age, Ultraviolet light treatment for psoriasis.

Prostate Cancer: Men older than 50, family history.

Male Breast Cancer: Advancing age, exposure to radiation prior to age 30, high estrogen levels, family history of breast cancer, inherited gene mutation (BRCA1, BRCA2), Klinefelter syndrome, alcohol, testicular-conditions.

Family History Questions

Do you have any family history of the following cancers?
-Bladder
-Breast
-Kidney
-Penis
-Prostate
-Testicular

Bladder cancer

4th most common cancer in men; the most common signs or symptoms include blood in the urine (hematuria), dysuria, and frequency of urination.

Breast Cancer

male breast cancer is uncommon in men under age 35, but men do get breast cancer; men have breast tissue and low levels of the estrogen hormone: breast cancer is about 100 times less common among men than women.

Kidney Cancer

found about twice as often in men as in women; Caucasian men have double the risk of African-American men. Men are more likely to be smokers and are more likely to be exposed to cancer-causing chemicals at work, which may account for some of the difference. The most common symptom is painless hematuria (blood in urine).

Penile Cancer

Cancer is rare in North America and Europe; accounts for less than 1% of cancers in men living in the US; more common in men living in parts of Asia, Africa, and South America. Most common symptom is change in the color or texture of the skin on the penis.

Prostate Cancer

One of the most common cancers among men (after skin cancer). Signs and symptoms include:
-difficulty or frequency urinating
-hematuria
-impotence (inability to have erection)
-early prostate cancer may have no symptoms

Testicular Cancer

Can develop in one or both testicles or scrotum. This cancer is more common in young and middle aged men; the average age at time of diagnosis is 33; Caucasian men have the highest risk. Worldwide, the risk of developing this disease is highest among men living in the US and Europe and lowest among men in Africa and Asia. Signs and symptoms include:
-painless lump
-swelling
-pain

Symptoms of PTSD

Pain
Nightmares, vivid memories, or flashbacks
Feeling emotionally cut off from others
Feeling numb or losing interest in things you used to care about
Becoming depressed, anxious, jittery, or irritated
Having difficulty concentrating/memory problems
Having a hard time relating to and getting along with spouse, family, friends.

Post-Deployment Syndrome

Chronic unexplained symptoms
Chronic pain
Fatigue
Traumatic brain injury
PTSD symptoms
General anxiety disorder

Military History

Illnesses of war may have unexplained symptoms. The symptoms may be gradually present within months of returning home or may take years.

These veterans may be at greater risk for substance abuse disorders or major depressive disorder. Symptoms of major depressive disorder may include:
-anorexia
-chronic fatigue
-chronic aches and pains
-insomnia
-inability to work
-loss of interest in activities, including sex
-being persistently sad, anxious, or irritable
-suicidal thoughts.

When assessing veterans, it is important for nurses to remember that each war comes with its own set of health risks.

More men die of suicide than women. In high-income countries, 3x as many men die by suicide than women. Men aged 50 and over are particularly vulnerable.

Past Medical and Surgical History

Do you have a past medical or surgical history of conditions related to the kidneys, bladder, rectum, or the genital area?
-STIs are caused by bacteria and viruses; the 6 most common in men are:
1. Gonorrhea: caused by gram-neg diplococcus causing inflammation of the urethra, prostate, rectum, and/or pharynx in men; most common symptom is a yellow mucopurulent penile discharge.
2. Chlamydia: an STI caused by a bacterium; most common symptom is penile discharge and dysuria, pain with urination.
*1 in 4 men with chlamydia have no symptoms; it is the most common STI.
3. Genital herpes is an STI caused by herpes simplex viruses type 1 or type 2 (HSV-2); painful fluid-filled blisters or vesicles form anywhere on the male genitalia or rectum.
4. Human papillomavirus (HPV) is an STI caused by the human papillomavirus; there are over 40 diff types of HPV that are sexually transmitted; men may not have symptoms; some may cause genital warts.
5. Human immunodeficiency virus (HIV) is an STI viral infection caused by a retrovirus causing general flu-like symptoms in the early stages; the virus destroys the cells of the immune system and progresses and causes the acquired immunodeficiency syndrome (AIDS).
6. Syphilis: an STI caused by the spirochete Treponema pallidum; syphilis progresses through 4 diff stages; the initial symptom is a sore called a "chancre".

Medications

What prescriptive, herbal, and OTC meds are you currently taking?
-Meds have side effects; certain meds can contribute to sexual dysfunction or impotence; testosterone, a steroid hormone, may be given to men with low testosterone levels.

Health Promotion

Do you perform testicular self-examinations? If so, how often?

-Most testicular cancers are found by the patient either unintentionally, through self-exams, or routine physical examination.

-The ACS recommends a testicular examination by a doctor as part of a routine cancer-related checkup; ACS does not have a recommendation about regular testicular self-exam for all men.

-Most common symptom of testicular cancer is a painless testicular.

-Young men may have the "Superman complex" where they feel nothing can hurt them and they do not need to go see a doctor; men may also take the "it'll never happen to me" approach.

-Testicular cancer is rare but the most common cancer in men younger than age 35.

Have you had prostate cancer screening?

-Many states have laws assuring that private health insurers cover procedures to detect prostate cancer, including the prostate-specific antigen (PSA) test and the digital rectal exam (DRE).

Some of these states also assure that public employee benefit health plans provide coverage for prostate cancer screening procedures.

Most state laws assure annual coverage for men ages 50 and over and for high-risk men, ages 40 and over (African American men and/or men with a family history of prostate cancer).

Safety Questions

Do you wear protective equipment when playing sports?
-Protection of the male genitalia during sports is important to prevent permanent damage or impotence.

Pain Questions

Are you experiencing any pain or burning during urination?
-Dysuria is pain and difficulty with urination; usually described as a "burning" quality; may indicate infection or inflammation of the lower urinary tract.
-Bladder pain: may indicate cystitis, inflammation of the bladder due to infection.

Do you have any back pain (costovertebral pain)?
-Back pain elicited by costovertebral tenderness may indicate inflammation of the kidneys or possibly the presence of kidney stones.

Do you experience any pain or discomfort in your scrotum?
-Testicular pain may be r/t trauma, infection, or cancer; testicular torsion occurs when the testicle twists inside the scrotum, decreasing the blood flow to the testicle and causing severe pain in the scrotum; this is a surgical emergency.

Do you have any groin (inguinal) pain?
-Inguinal pain may be r/t an inguinal hernia; part of the intestine protrudes through the abdominal wall; more evident if the pt coughs, bends over, or lifts a heavy object exerting intra-abdominal pressure.

Urinary Symptoms

Do you have difficulty starting the stream of urine?
Do you experience hesitancy of urination?
Do you feel that you do not completely empty your bladder (urinary retention)?
Do you experience frequency of urination?
-Benign prostatic hypertrophy (BPH) is a nonmalignant enlargement of the prostate gland as part of the aging process; BPH occurs only in men; approx 8% of men aged 31 to 40 have BPH. In men over age 80, more than 80% have BPH.

Penile Lesions or Discharge

Have you developed any sores or lesions on your penis?
-Lesions or sores may be indicative of a bacterial or viral infection.
Have you had any discharge from your penis? When did it start?
Ask about the:
-color of discharge
-amount of discharge
-consistency of discharge
-odor of discharge

A symptom of some STIs is penile discharge:
-Gonorrhea: yellow, white, green
-Chlamydia: a white or cloudy discharge from penis and rectum
-Urethritis: clear and white

Scrotum

Have you had any swelling or enlargement of the scrotum?

-The scrotum may become swollen, filled with fluid, or enlarged; this may be caused by inflammation of internal structures, masses, and medical conditions such as congestive heart failure.

-Hydrocele is an accumulation of fluid around the testes

-Epididymitis is swelling and inflammation of the epididymis; may be related to STI.

Sexual Health: Healthy People 2020

Goal: Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender individuals. Sexual health is a fundamental part of our being. During healthcare encounters, patients often hide sexual problems, sometime presenting to healthcare professionals with some "other" issue that is more comfortable to them.

The WHO has defined sexual health as:

-a state of physical, mental, and social well-being in relation to sexuality.
-It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence.

The best time to discuss sexual health is

toward the end of the assessment; this gives you and the patient time to build a relationship and rapport. Assure the pt that this information will remain confidential.

Sexual history includes the 4 Ps:

Partners, practices, protection, past STIs as a general guide.

Partners Questions

-Are you in a relationship?

Are you satisfied with your sex life?

Do you have sexual relationships with women, men, or both?

*Gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for boys and men, or girls and women. Gender identity refers to a person's internal sense of being male or female.

Transgender is a gender identity disorder (GID) and is used to describe someone who was assigned female or male at birth, but later realizes that label does not accurately reflect who the person feels he or she is inside.

-Do you have several partners?

Practices Questions

What types of sexual practices do you engage in?

-Types of sexual practice include:

-oral sex

-penile-vaginal sex

-penile-rectal sex

Protection Questions

What types of precautions or protection do you use during sexual activity?
-Latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV and reduce the risk of other STDs. Condom use may reduce the risk for genital HPV infection and HPV associated diseases such as genital warts and cervical cancer in women.
Have you had the hep A or B immunizations?
-Men who have sex with other men are at higher risk for contracting hep A, hep B, and although uncommon, hep C.
*There is no vaccine fore hep C, and testing for it is not recommended for men who have sex with men unless they were born from 1945-1965, have HIV, or are engaging in risky behaviors.

Past STIs Questions

Do you have a past history of STIs? If so, were you treated and when?

Do you have any concerns about having HIV?

Erectile dysfunction (ED)

Are you able to achieve or maintain an erection?

How long have these symptoms been present? Did they begin gradually or suddenly?

-ED is when a man has trouble getting or keeping erection.

-ED becomes more common as men get older.

-ED is not a natural part of aging.

-Risk factors for ED include side effects of some medications.

-ED is strongly linked to a number of other common diseases in men, such as diabetes, heart disease, high blood pressure, high cholesterol, vascular disease, neurologic conditions, chronic liver or kidney disease.

The risk of testicular cancer in Caucasian men is about 5x higher than

African American men and more than 3x greater than Asian American and American Indian men.

Prostate cancer occurs more often in African-American men than in men of other races. African American men are also more likely to be diagnosed at an advanced stage, and more than twice likely to die of prostate cancer as Caucasian men.

Prostate cancer occurs less often in Asian-American and Hispanic/Latino men than in non-Hispanic whites.

Male breast cancer is more common among African-American men.

Renal cell carcinoma is the most frequently occurring kidney cancer in adults; risk factors include being a male and smoking.

Bladder cancer is more common in Caucasian men.

Inspecting and Palpating Male Breasts

Purpose: to assess for lumps, nipple discharge or abnormalities.

Steps:
1. Explain the technique to pt
2. With pt lying in the supine position, inspect the male breasts for
-symmetry
-Color
-contour (dimpling, retraction)
-edema
-lesions
-ulcerations
-texture of the skin
3. Inspect the areola for:
-shape
-color
4. Inspect nipples for:
-size
-position
-shape
-discharge
-scaling or crusting.
5. Ask pt to raise his arms over his head and inspect the lateral aspect of the breasts toward the mid-axillary line for skin changes.
6. Gently palpate each breast and axillary area using the finger pads of your second, third, and fourth fingers using the vertical strip pattern assessment technique, assessing for lumps or masses.
*The most common presentation of male breast cancer is a painless, palpable, subareolar lump or mass.
-Palpate any lump or mass and note:
-shape
-size
-consistency (hard, soft, rubbery)
-mobility (mobile or immobile)
-Location (document by using clock method)
7. Put on gloves and palpate each areola area
8. Gently palpate and press each side of the nipple at the base noting any discharge; if discharge is present, assess
-color
-consistency
-odor
9. Remove and discard gloves.
10. Document findings

Normal Findings of Male Breast

-Breasts are symmetric
-Skin has even color
-There are no lesions, dimpling, or puckering
-There are no lumps or masses
-Axillary area has no lumps or masses
-Areola is smooth, has uniform color, and is without skin changes
-Nipple is everted, skin intact, and without drainage.

Abnormal Findings of Male Breast

-Lump or mass is palpated

-Gynecomastia is enlarged or overdeveloped fibroglandular breast tissue; term comes from Greek words gyne "woman" and mastos "breast"; may be r/t decreased testosterone levels in the aging male or a medication side effect; frequently associated with devastating social and emotional trauma; 60% of males worldwide have some degree of gynecomastia.

-Breast cancer may present as a hard painless lump, erythema of the skin, scaling of the nipple, or nipple discharge.

Inspecting the External Genitalia

Purpose: to assess the external male genitalia for lesions, edema, and masses
Equipment: gloves, tangenital lighting

Assessment Steps
1. Explain to the pt that this technique requires 2 positions: lying supine and standing up.
2. Ask the pt to lie on the exam table in the supine position.
3. Put on gloves
4. Drape the pt so that only the genital area being examined is exposed.
5. Inspect the skin of the male genitalia assessing for
-color
-lesions
-drainage
-edema
-hair distribution
6. Assess the following structures:
-penis: assess the ventral, lateral, and dorsal sides
-prepuce: note whether the pt is circumcised or not; if uncircumcised ask the pt to retract the foreskin.
*tip: you may observe a white cheesy substance called smegma; this is a clean substance that moisturizes the glans and keeps it smooth, soft, and supple; it has antibacterial and antiviral properties and is normal.
-Pubic hair: assess pattern of distribution
-Skin: assess for irritation, erythema, or pubic lice (Phthirus pubis), more commonly known as crabs, derive their name from crab-shaped insects that sometimes take up residence in the pubic hair; itching is the most common symptom reported.
7. Gently lift up the scrotum to assess the posterior side.
8. Ask the pt to turn on his side with his upper leg slightly bent, and gently spread the buttocks apart to inspect the anus.
9. Maintaining the pt's dignity, ask the pt to stand. Ask the pt to hold his penis up for this next part. While sitting on a stool or squatting at eye level, compare right and left scrotal sacs.
10. Assess the groin area for inguinal bulging; if suspected, ask the pt to cough for better visualization of any suspected bulging.
11. Remove and discard gloves.
12. Document your findings.

Normal Findings of External Genitalia

Penis: Caucasians: Pink to light brown; African Americans: light to dark brown; smooth, no hair; dorsal vein is visible; no lesions; no discharge
Prepuce: circumcised foreskin is smooth and pink; uncircumcised foreskin easily retracts; smegma may or may not be present.
Urethra meatus: pink, smooth, located at the center of the glans
public hair: at the base of the penis the hair distribution is in a triangular pattern consistent with age; coarse hair; no nits or lice.
Scrotum: skin is a darker pigmentation; wrinkled surface, thin skin; left testis may hang lower than the right testis.
Epidermoid cysts: sebaceous cysts that are yellow or white papules, nontender cutaneous lesions.
Inguinal area: skin is smooth, free from lumps or bumps, no signs of a hernia
Anus: darker color skin, wrinkled around the orifice, no hemorrhoids

Abnormal Findings of External Genitalia

Penis: skin has lesions or sores. Lesions indicative of common STIs include:

-Syphilis chancre lesion is a painless, firm, round, and open sore that forms during the primary stage of syphilis; commonly appears on the penis or anorectal area.

-Condyloma acuminatum (genital warts) are soft, small, cauliflower-shaped growths on the skin; caused by HPV

-Herpes lesions typically develop on the penis; the painful lesions are vesicular small red bumps that change in appearance to blisters and ulcers as they progress through the 4 stages.

-Chancroid lesion is a bacterial STI; painful open sore covered with gray or yellow gray material; has irregular borders

-Tinea cruris, also known as "jock itch" is a fungal infection of the groin presenting as a bright red rash.

-Penile cancer appears as a lump, ulcerative lesion, or redness and irritation of the skin; may or may not have drainage.

-Prepuce.

Phimosis is a stenosis of the preputial orifice so that the foreskin cannot be pushed back over glans penis; may be a complication after recurrent infections; if it obstrcuts urinary flow, a circumcision may be needed.

Paraphimosis is an uncircumcised penis that may be covered with foreskin that once retracted, not cannot be returned to its original position; area becomes swollen; this requires immediate medical attention.

Balanitis is inflammation of the skin covering the glans penis.

-Public hair: distribution is not consistent with age. Skin and pubic hair are infested with lice; when the hair is infested, the surrounding skin is inflamed secondary to scratching.

-Urethra: opening has discharge; the opening to the urethra is not centrally located on the tip of the glans.

Epispdias: the urethral opening is located dorsally on the penis.

Hypospadias: urethral opening is located ventrally on the penis.

-Anus

Hemorrhoids are swollen veins protruding from the anus.

Rectal bleeding

Protrusion of rectal mucosa related to rectal prolapse

-Scrotum

Skin is swollen and stretched causing a decrease in the rugae; presence of scrotal swelling can be from several causes including edema, heart failure, renal failure, local inflammatory or infectious process.

Presence of any lesions on the scrotum is considered an abnormal finding.

Empty scrotal sac or scrotal sac with small testes

-Inguinal area

Inguinal hernia is a weakening in the abdominal cavity wall with a protrusion of abdominal contents; any activity or medical prob that increases pressure on the abdominal wall tissue and muscles may cause an inguinal hernia.

Obtaining a urethral culture

Equipment: gloves, culturette tube, protective glasses

For accurate results, the pt should not have urinated for at least 1 hour prior to obtaining the culture. Read the institutional procedure prior to obtaining culture.

Steps
1. Gather your supplies.
2. Explain the technique to the patient
3. Put on gloves
4. Open up the culturette tube and remove the swab.
5. Maintaining sterility of the swab tip, hold the shaft of the penis and gently insert the tip of the swab about 2-4 cm into the urethra.
6. Gently turn the swab clockwise for 2-3 seconds, maintaining contact with the mucosal surfaces.
7. Slowly withdraw the swab and insert into culturette tube and medium.
8. Break off the end of the swab at the score line.
9. Turn and recap tightly; document or attach preprinted label with the patient's name, date, and source of culture.
10. Remove and discard gloves.
11. Send specimen to lab.

Male breast cancer is usually found in men ages

60-70. Screening only recommended for men with a strong family history, genetic predispostion for, or the physical assessment results suggest breast cancer. Recommendations include:
-semiannual clinical breast exam starting at age 35
-baseline mammography at age 40 with further annual mammography if increased breast density is seen on a baseline mammogram
-men should be taught about breast self-awareness and how to do breast self-exam.

How to perform a male breast self-exam

1. make yourself soapy
2. place left arm above and behind your head. With the 3 middle finger pads of your right hand, press your left breast against your chest wall.
3. In a circular motion, feel small portions of your left breast, going around until you have covered the entire breast and underarm Make sure you do it slowly.
4. Repeat again on your opposite breast.

If you find lump or discharge, make appt with doctor.

Testicular Cancer Recommendations

For men over age 14, a monthly self-exam of the testicles is an effective way of becoming familiar with this area and thus enabling detection of cancer at an early and very curable stage.

Males should be taught how to check their testicles for lumps; if one is found, it should be assessed by their healthcare provider. The best time to check the testicles is after a warm shower or bath.

*There is an app by Testicular Cancer Society for directions and that sends monthly reminders. BallChecker.com

How to Perform Testicular Self-Exam

Do not press hard during the exam; if you feel pain or pressure, you are pressing too hard.
1. easier to perform while in the shower or taking a warm bath, b/c the warmth will relax the scrotal area and the water will make it easier to smoothly move over the skin surface. The examination may also be performed after a shower or bath.
2. Feel each testicle with both hands by placing the index and middle fingers under the testicle with the thumbs placed on top.
3. Roll the testicle gently b/w the thumbs and fingers.
4. Feel for the epididymis, the soft, rope-like structure behind the testicle collects and carries sperm; palpate gently for any bumps.
5. If you find a lump on your testicle or any of the other signs of testicular cancer, see your healthcare provider as soon as possible for further evaluation.

Prostate Cancer Recommendations

The ACS recommends that men should make an informed decision after getting info about the uncertainties, risks, and potential benefits of prostate cancer screening.
-A yearly screening offered to all men over 50 who have a life expectancy of at least 10 yrs.
-For African-American men, or men with an affected first-degree family member, yearly screening is recommended beginning at age 45.
-For men who have multiple first-degree relatives affected with prostate cancer at an early age, a baseline screen is advocated at age 40. There are many experts who believe all men should initiate screening at age 40,

2 leading causes of death among men

heart disease and cancer.

Sexually Transmitted Infections recommendations

Routine HIV screening for teens and adults b/w 15-65 years of age; younger adolescents and older adults who are at increased risk should also be screened.
-Advise protection through use of condoms:
Latex condoms when used consistently and correctly, are highly effective in preventing and reducing the sexual transmission of HIV, the virus that causes AIDS, and other STIs, including diseases transmitted by genital secretions, and to a lesser degree, genital ulcer diseases.

Compared to women, men are more likely to

smoke and drink, make unhealthy or risky choices, and put off regular checkups and medical care. "If it's not broken, don't fix it", not realizing that part of maintaining a healthy body is preventive maintenance.

Healthy People 2020 Goal

Promote healthy sexual behaviors, strengthen community capacity, and increase access to quality services to prevent STIs and their complications.