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F.
Urinary frequency, nocturia, hematuria, and dysuria (not
12: GENITOURINARY GUIDELINES
always present in upper tract infections).
G.
Blood in urine secondary to hemorrhagic cystitis (unusual
in males with pyelonephritis).
OTHER
SIGNS AND SYMPTOMS
A.
Adults (particularly the elderly) may be asymptomatic
with cystitis.
B.
Abdominal pain and suprapubic heaviness.
C.
Pregnancy: uterine contractions.
D.
Shortness of breath.
E.
Anorexia.
F.
Children:
1.
Fever may be a child’s only presenting symptom.
2.
Nausea and vomiting.
3.
Irritability.
4.
Diarrhea.
5.
Abdominal pain/tenderness.
6.
Feeding difculty.
7.
Failure to thrive.
G.
Elderly:
1.
Mental status change.
2.
Generalized deterioration with loss of function.
SUBJECTIVE
A.
Review the onset, course, and duration of symptoms.
B.
Are there any problems with voiding, such as frequency,
DATA
urgency, and dysuria?
C.
Review the client’s history of fever and any treatment.
D.
Are there any other symptoms, odor, and nausea?
E.
Have the client point to the area of the backache. Is it uni-
lateral or bilateral? What makes the backache better?
F.
Rule out pregnancy; review rst day of last menses.
G.
Rule out sickle cell disease, diabetes, and multiple sclerosis.
H.
Review the client’s history of genitourinary tract prob-
lems, stones, UTIs, previous pyelonephritis, any previous testing, and any previous anomalies.
I.
Review the strength and characteristics of the urinary
stream, especially in older males. Ask if the client has ever
been diagnosed with BPH.
J.
Review the client’s history for active herpes lesion. Does
urine ow hurt when urine stream begins? Or is the pain
noted when urine passes over the lesion?
K.
Review drug allergies.
L.
Review all medications, including over-the-counter and
herbal products. Review medications for a recent history
of an incomplete course of antibiotics and current use of
anticholinergics.
PHYSICAL
A.
Check temperature, pulse, and blood pressure; note ortho-
EXAMINATION
static hypotension. Tachycardia may or may not be present,
depending on associated fever, dehydration, and sepsis.
B.
Inspect:
1.
Note general appearance for respiratory distress and
dehydration.
2.
Inspect the male external genitalia for redness, edema,
lesions, and discharge.
3.
Inspect the female genitalia for discharge, lesions, and
ssures; inspect cervix for cervicitis.
C.
Palpate:
1.
Palpate the back; check CVA tenderness (usually uni-
lateral over the involved kidney).
2.
Palpate the abdomen for suprapubic tenderness,
rebound masses, or pain.
3.
Perform a pelvic examination to rule out other infec-
tions and pelvic inammatory disease (PID; tenderness
of the cervix, uterus, and adnexa should be absent).
D.
Auscultate:
1.
Lungs.
2.
Heart.
E.
Pregnancy:
1.
Check fetal heart rate; fetal tachycardia may be present
with fever.
2.
Palpate for uterine tenderness and contractions.
3.
Perform pelvic examination for cervical dilation, if
indicated for increased risk of preterm labor.
F.
Males:
1.
Complete palpation of external genitalia, prostate, and
rectal examination.
DIAGNOSTIC
A.
Urine culture and sensitivity should always be performed
TESTS
before initial empiric treatment with antibiotics.
B.
Urinalysis for evaluation of pyuria. Pyuria is present in
almost all females with acute cystitis and pyelonephritis; its
absence strongly suggests an alternative diagnosis.
1.
Leukocyte esterase on dipstick detects pyuria or white
blood cells (WBCs).
2.
Signicant pyuria is greater than 2 to 5 leukocytes per
high-power microscope eld.
3.
Urine may need to be obtained from straight in-and-
out catheterization if the client is incontinent or has altered
mental status.
4.
White cell casts are indicative of pyelonephritis.
C.
Complete blood count with differential or WBC, especially
with systemic symptoms.
D.
Blood culture, if indicated.
E.
Arterial blood gas (ABG), if indicated.
F.
Consider sedimentation rate, especially with severe illness
and in the elderly.
G.
Culture for gonorrhea and chlamydia, if symptoms are
associated with sexually transmitted infections (STIs).
H.
Wet prep, if symptoms are associated with STI.
I.
Imaging studies are not routinely required for the diagno-
sis of acute pyelonephritis but can be helpful.
1.
CT scan to identify altered parenchymal perfusion,
hemorrhage, nonrenal disease, inammatory masses, and
obstruction. CT with contrast medium is considered the
imaging modality of choice for nonpregnant clients.
2.
MRI to rule out masses or obstruction.
3.
Renal ultrasonography.
4.
Scintigraphy to detect focal renal abnormalities.
5.
Voiding cystourethrogram.
6.
Intravenous pyelogram (IVP), if indicated.
7.
CT and magnetic resonance (MR) urography used in
the evaluation of hematuria.
DIFFERENTIAL
A.
Appendicitis/acute abdomen.
B.
Cholecystitis.
C.
Pancreatitis.
D.
Diverticulitis.
E.
Pneumonia.
F.
Prostatitis.
G.
Epididymitis.
H.
PID.
I.
Nephrolithiasis.
J.
Urolithiasis.
K.
Renal vein thrombosis.
DIAGNOSES
PYELONEPHRITIS
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PLAN
A.
General interventions:
1.
Optimal therapy for acute uncomplicated pyelonephri-
tis depends on the severity of the illness at presentation.
2.
Many severe infections (increased WBC, dehydration
or vomiting, high fever) may need hospital admission for
IV therapy. Risk factors include older adult, coexisting illness, pregnancy, and uncontrolled vomiting.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Urinary Tract Infection (Acute Cystitis).”
1.
Give instructions on early recognition of UTIs.
C.
Dietary management:
1.
Increase uids: Have the client drink at least one large
glass of water every hour while awake.
2.
Encourage the client to drink cranberry juice to help
ght and prevent UTIs. If the taste is objectionable, they
may mix cranberry juice, 1:1 with another juice, such as
grape juice.
3.
There are no dietary restrictions with pyelonephritis.
D.
Pharmaceutical therapy:
1.
Acetaminophen (Tylenol) for fever.
2.
Urinary analgesic as needed to relieve dysuria.
Dysuria is usually diminished fairly quickly after the start
of antibiotics.
3.
Antiemetics as needed; however, if the client is not able
to tolerate oral uids, they should be hospitalized.
4.
Antibiotics: Empiric antibiotic selection should be
guided by local antibiotic resistance patterns, allergies,
and culture results. Clients with delayed response to
therapy should also receive a longer course of antibiotics of 14 to 21 days. Oral versus IV therapy remains controversial. In order to use oral antibiotics, the client must
be able to take oral medication, food and uids, have no
indication for hospital admission, and have close monitoring nearby.
a.
Adults:
i.
First-line therapy: ciprooxacin (Cipro) 500mg
BID for 7 days, or extended-release Cipro XR 1,000
mg once a day for 7 days; or levooxacin (Levaquin)
750 mg once daily for 5 to 7 days.
ii.
Second-line therapy: trimethoprim and sulfa-
methoxazole (TMP-SMX; Septra DS, Bactrim DS)
160 mg and 800 mg, respectively, one tablet BID
for 7 to 10 days. Due to the high rate of resistance
of E. coli, the empirical use of TMP-SMX should be
avoided in clients who require hospitalization.
iii.
Alternative therapy: amoxicillin-clavulanate
(Augmentin) 500mg/125mg orally BID for 14 days
or Augmentin 250mg/125mg orally TID for 3 to 7
days.
b.
Children younger than 2 years are usually treated
for 7 to 14 days. Children older than 2 years who are
afebrile and without abnormalities of the urinary tract
or have previous episodes of UTIs are usually treated
for 5 days.
i.
Amoxicillin-clavulanate (Augmentin) 20 to
40 mg/kg orally per day in three doses for 7 to
14 days.
ii.
Sulfonamide-TMP-SMX 6 to 12 mg/kg trime-
thoprim and 30 to 60mg/kg sulfamethoxazole per
day orally in two doses for 7 to 14 days.
iii.
Cephalosporin-cefuroxime (Ceftin) 8 mg/kg/d
in one dose for 7 to 14 days.
c.
Antibiotics that should not be used for
pyelonephritis:
i.
Nitrofurantoin (Macrodantin) and fosfomy-
cin (Monurol) should not be used to treat pyelonephritis in adults or children; they are excreted in the
urine but do not achieve therapeutic serum levels.
ii.
Fluoroquinolones are not used in children
due to potential concerns for sustained injury to
thedeveloping joints.
iii.
Tetracyclines should not be used in children
due to tooth staining.
iv.
Fluoroquinolones are not used in pregnancy
due to the risk of auditory and vestibular toxicity in
the fetus.
v.
Aminoglycosides are contraindicated in preg-
nancy due to the risk of permanent ototoxicity to the
fetus.
FOLLOW-UP
A.
Follow up with the client in 24 to 48 hours depending on
the evaluation of the initial severity of symptoms.
1.
Clients with persistent fever or clinical symptoms after
48 to 72 hours of appropriate antibiotic therapy should
undergo initiation of another class of antibiotics and consider radiologic evaluation.
2.
If the client feels that they are not progressing well or
are getting worse, evaluate them emergently and consider
hospital admission and IV antibiotics.
B.
Follow-up urine cultures are not needed in clients with
acute cystitis or pyelonephritis if symptoms resolved on antibiotics; however, repeat cultures for clients with recurrent
symptoms or any complicated course of illness.
C.
Females with recurrence of pyelonephritis need further
urologic investigation.
CONSULTATION/REFERRAL
A.
Consult a physician and consider hospitalization for
infants with both lower and upper infections, children with
pyelonephritis, and children with recurrent infections.
B.
Consult or refer the client to a physician if they require
IVP, cystoscopy, or renal biopsy.
C.
IV therapy and hospitalization are needed in all cases sug-
gestive of bacteremia in children who are vomiting, children
younger than 2 years, and children with documented parenchymal damage.
D.
Males with persistent bladder infections need a urologic
consultation.
E.
Pyelonephritis in males suggests structural problems and
needs hospitalization and further evaluation (IVP).
F.
For clients with unusual or resistant pathogens, consult an
infectious disease specialist.
G.
For pregnant clients, consultation with an obstetrician is
required.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Pyelonephritis is the most common urinary tract com-
plication in pregnancy.
2.
Untreated asymptomatic bacteriuria (ASB) is a risk fac-
tor for acute cystitis and pyelonephritis in pregnancy.
3.
Based on the higher risk of complications in pregnancy,
pyelonephritis has traditionally been treated with hospitalization and IV antibiotics until the client is afebrile for
48 hours and symptoms improve.
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12: GENITOURINARY GUIDELINES
4.
Once the pregnant client is discharged from the hos-
pital, oral antibiotics should continue for 10 to 14 days of
treatment.
5.
A urine culture should be obtained 1 to 2 weeks after
completion of therapy and monthly thereafter to monitor
for recurrent infection.
6.
Aminoglycosides should be avoided due to the poten-
tial risk of ototoxicity following prolonged fetal exposure.
7.
Fluoroquinolones are contraindicated during preg-
nancy due to the risk of auditory and vestibular toxicity in
the fetus.
B.
Pediatrics:
1.
Always order urine culture and sensitivity on children
suspected of UTI.
2.
Suprapubic aspiration of the bladder should be consid-
ered in young infants.
3.
A voiding cystogram should be considered in all chil-
dren younger than 16 years with a documented UTI.
4.
Indications for hospitalization:
a.
Age less than 2 months.
b.
Clinical urosepsis or potential bacteremia.
c.
Immunocompromised client.
d.
Vomiting or inability to tolerate oral medication.
e.
Lack of adequate outpatient follow-up (e.g., no
phone and lives far from hospital).
f.
Failure to respond to outpatient therapy.
5.
Vesicoureteric reux is responsible for up to 50% of
pyelonephritis in children younger than 6 years.
6.
Assess the child for chronic constipation as a potential
cause of urinary obstruction.
7.
Children should undergo a urologic evaluation after
the rst episode to rule out structural abnormalities.
C.
Males:
1.
Consider ordering renal function tests (blood urea
nitrogen and creatinine).
2.
Males older than 50 years should consider urologic
consultation and IVP.
D.
Geriatrics:
1.
Clients may need hospitalization for IV antibiotics and
hydration.
2.
Bladder or kidney infections may be common in clients
with long-term urinary catheters and can lead to septicemia if untreated or unrecognized.
3.
Fluoroquinolone use in the elderly has the potential to
cause neuropsychiatric symptoms, including seizures to
worsening dementia.
BIBLIOGRAPHY
Fulap, T. (2021). Acute pyelonephritis: Practice essentials, background, patho-
physiology. EMedicine. https://emedicine.medscape.com/article/
245559-overview#a6
Hooton, T. M., & Gupta, K. (2019, March 13). Acute simple cystitis in women.
UpToDate. https://www.uptodate.com/contents/acute-simple-
cystitis-in-women
Johnson, J. R., & Russo, T. A. (2018). Acute pyelonephritis in adults. New
England Journal of Medicine, 378(1), 48–59. https://doi.org/10.1056/n
ejmcp1702758
RENAL
CALCULI OR KIDNEY STONES
(NEPHROLITHIASIS)
DEFINITION
A.
Renal calculi, or kidney stones, are caused by the forma-
tion of crystals in the urinary system from the kidneys to the
bladder. Nephrolithiasis refers to renal stone disease; urolithiasis
refers to the presence of stones in the urinary system. The
majority of stones (80%) consist of calcium, usually as calcium oxalate, but they can contain uric acid, struvite (magnesium, ammonium, and phosphate), oxalic acid, phosphate
salts, or the amino acid cysteine. Spontaneous passage of a
stone is related to the stone size and location. Approximately
half of symptomatic clients require intervention for stone
removal. An untreated staghorn (branch-shaped) with persistent renal obstruction can destroy renal tissue, with potential
for life-threatening sepsis.
INCIDENCE
A.
Renal calculi are very common in the United States, with
a higher incidence noted in males. The overall incidence
is rising. At least 12% of males and 7% of females have one
symptomatic stone by age 70 years. Having a family member with a history of stones doubles these rates. Initial cases
typically occur between ages 20 and 49 years, with peak incidence between 35 and 45 and with theprevalence continuing
to increase with age. Idiopathic nephrolithiasis is common in
males, whereas primary hyperparathyroidism is more common in females. An initial stone attack after the age of 50 is
relatively uncommon.
B.
Most kidney stones pass spontaneously; however, 10% to
30% do not pass and can cause continuing pain, infection, or
obstruction.
C.
Nephrolithiasis is uncommon in children. The incidence
of nephrolithiasis in children has increased by approximately
6% to 10% annually over the past 25 years. In adolescents, the
incidence has reached 50 per 100,000.
D.
Stones due to infection (struvite) are more common in
females.
E.
The incidence of stones in pregnancy is 1 in every 1,500 to
3,000 pregnancies.
F.
The recurrence rate for calculi is 14% at 1 year, 35% at
5 years, and 52% at 10 years.
PATHOGENESIS
A.
The formation of uric acid stones requires continued and
excessive oversaturation of urine with stone-forming constituents, uric acid, calcium, and oxalate. Dehydration, hyperuricosuria, and signicantly acidic urine contribute to uric acid
supersaturation and stone formation. Struvite stones form
only when the urinary tract is infected with urea-splitting
organisms such as Proteus species.
B.
Hydroureteronephrosis is the most signicant renal altera-
tion in pregnancy. Dilatation is greater on the right side than
the left because of pressure due to physiologic engorgement of
the right ovarian vein and dextrorotation of the uterus.
PREDISPOSING
A.
Male.
B.
Dehydration (poor intake and immobility).
C.
Chronic obstruction with stasis of urine.
D.
Hypercalcemia caused by hyperparathyroidism; renal
FACTORS
tubular acidosis; multiple myeloma; or excessive intake of
vitamin D, milk, and alkali.
E.
Diet high in purines and abnormal purine metabolism
(gout).
F.
Pregnancy (1 per 1,500).
G.
Chronic infections.
H.
Foreign bodies.
I.
Excessive oxalate absorption in inammatory bowel dis-
ease, bowel resection, or ileostomy.
J.
Previous stone formation.
K.
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ID:c0012-p7985
ID:c0012-p7990
ID:c0012-p7995
ID:c0012-p8000
ID:c0012-p8005
ID:c0012-ti0795
ID:c0012-p8010
ID:c0012-p8015
ID:c0012-p8020
ID:c0012-p8025
ID:c0012-p8030
ID:c0012-p8035
ID:c0012-p8040
ID:c0012-p8045
ID:c0012-p8050
ID:c0012-p8055
ID:c0012-ti0800
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Family history of nephrolithiasis.
L.
Medications:
1.
Vitamins A, C, and D.
2.
Loop diuretics.
3.
Acetazolamide.
4.
Ammonium chloride.
5.
Calcium-containing medications, including alkali and
antacids.
6.
Indinavir.
7.
Sulfadiazine.
8.
Atazanavir.
9.
Guaifenesin.
10.
Sulfa drugs.
11.
Topiramate.
12.
Acyclovir.
M.
Obesity.
N.
Gastric bypass/bariatric surgical procedures.
O.
Diabetes.
P.
Anatomic abnormalities.
COMMON
A.
B.
C.
D.
E.
OTHER
A.
COMPLAINTS
Severe ank pain.
Pelvic pain.
Groin pain.
Blood in urine.
Asymptomatic (dependent on the size of the stone).
SIGNS AND SYMPTOMS
The symptoms of kidney stone are related to their location,
whether it is in the kidney, ureter, or urinary bladder.
1.
Unilateral ank pain that radiates to the groin.
2.
Sudden onset of colicky pain.
3.
Hematuria.
RENAL CALCULI OR KIDNEY STONES (NEPHROLITHIASIS)
G.
Ask the client to describe any hematuria or blood clots
passed.
H.
Ask about recent trauma to the back or abdomen.
I.
Is there a family history of stone formation?
J.
Is the client pregnant?
PHYSICAL
A.
Check temperature, blood pressure, and pulse (may have
EXAMINATION
tachycardia). In children, check growth measurements to evaluate poor weight gain and/or failure to thrive (congenital and
chronic conditions).
B.
Inspect:
1.
Inspect general appearance for discomfort before and
during examination. Clients with renal colic are extremely
restless and exhibit active movement on presentation.
2.
During the examination, evaluate voluntary guarding
of the abdominal musculature.
3.
Inspect external genitalia (male or female) for lesions,
discharge, inammation, and ulcerations.
4.
Assess for peripheral edema.
C.
Auscultate:
1.
Abdomen, noting bruits if present.
2.
Bowel sounds.
D.
Palpate:
1.
“Milk” the urethra for discharge.
2.
Palpate the abdomen for masses and tenderness,
organomegaly, and suprapubic tenderness.
3.
Palpate the groin; check lymph nodes.
4.
Palpate the back and abdomen.
5.
Check for the presence of costovertebral angle
tenderness.
E.
Perform pelvic or bimanual examination, if indicated, to
rule out pelvic inammatory disease (PID).
471
The
timing and appearance of hematuria are important. Hematuria
seen at the beginning of the urine stream may indicate bleeding in the
urethra. Terminal hematuria, or blood at the end of the urine stream,
denotes bladder neck or the prostate as the source. Finally, blood
throughout the entire urine stream suggests a lesion.
4.
Nausea and vomiting.
5.
Restlessness.
6.
Symptoms common with cystitis or inammatory
lesions of the lower tract are usually absent, such as frequency, dysuria, urgency, and suprapubic pain.
SUBJECTIVE
A.
Review the onset, duration, and course of symptoms.
B.
Review other signs and symptoms of urinary tract infec-
DATA
tion (UTI) or pyelonephritis: frequency, dysuria, and fever.
C.
Have the client describe pain (colicky). Note intensity (use
a 1- to 10-point scale, with 10 being the worst pain) and the
characteristics of pain (constant, intermittent).
D.
Has the client ever had a stone before? How was it
treated? What tests were performed? Has the client ever seen
a urologist?
E.
Review dietary intake of high animal protein in the diet,
milk, and other calcium-containing products for excessive
intake.
F.
Review the client’s medication history, including excessive
vitamin C or D supplements, antacids that contain calcium,
and other medications noted in the “Predisposing Factors”
section.
DIAGNOSTIC
A.
The diagnosis of nephrolithiasis can be made on the basis
TESTS
of clinical symptoms alone, but diagnostic testing is needed to
conrm.
1.
Laboratory tests:
a.
Serum blood urea nitrogen.
b.
Creatinine.
c.
Calcium.
d.
Uric acid.
e.
Serum electrolytes; consider fasting serum calcium
and phosphorus and parathyroid hormone.
f.
Pregnancy test (if indicated) to rule out an ectopic
pregnancy.
2.
Stone for analysis.
3.
Urinalysis:
a.
Urine dipstick for a gross screen.
b.
pH determination (pH greater than 7.5 is compat-
ible with infection lithiasis, while pH less than 5.5
favors uric acid lithiasis).
c.
Red cell casts strongly suggest glomerulonephritis.
d.
Evaluate urine sediment for crystalluria.
4.
Urine culture, if indicated.
5.
24-hour urine for creatinine, calcium, uric acid, oxalate,
pH, and sodium measurement:
a.
Client should be on their usual diet before taking
24-hour specimen.
Collection should be 1 to 2 months after any inter-
b.
ventions, including shock-wave lithotripsy, ureteroscopy, or percutaneous stone removal.
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6.
12: GENITOURINARY GUIDELINES
Noncontrast helical CT scan is the imaging standard to
assess the urinary tract in acute renal colic.
7.
Renal ultrasound is the procedure of choice for
pregnancy.
8.
X-ray of the kidney, ureter, and bladder is often ordered
with the pelvic CT or ultrasound.
9.
Intravenous pyelogram.
10.
Nuclear renal scan.
DIFFERENTIAL
A.
UTI: Passage of large, bulky blood clots implicates the
DIAGNOSES
bladder as the source, whereas long, shoestring-shaped specks
or thin, stringy clots suggest an upper urinary tract or ureteral
origin.
B.
Acute abdomen/appendicitis.
C.
Cholecystitis.
D.
Pyelonephritis: Pyelonephritis is associated with dull ank
pain with fever and chills. In evaluating urine sediment, the
presence of white blood cells and bacteria favors a diagnosis
of pyelonephritis or interstitial nephritis.
E.
PID.
F.
Inammatory bowel disease.
G.
Urinary tract obstruction.
H.
Constipation.
I.
Ectopic pregnancy.
J.
Rupture of ovarian cyst.
K.
Narcotic seeker with possible self-inicted hematuria.
PLAN
A.
General interventions:
1.
Increase uids to allow passage of stone. Strain all
urine to recover stone for analysis.
2.
Reduce possibility of recurrence with dietary
modications.
3.
Clients are usually referred for imaging after evalua-
tion of creatinine.
4.
Clients can be managed on an outpatient basis with
close follow-up if stones are small (less than 6 mm).
B.
Client teaching/dietary management:
1.
Force uids to maintain a daily output of 2 to 3 L of
urine. Fluid intake that increases urinary production of at
least 2 L of urine per day increases the ow rate and lowers
the urine solute concentration.
2.
Dietary consultation may be needed secondary to stone
analysis.
C.
Pharmaceutical therapy:
1.
Pain medication (narcotic and nonnarcotic) is a priority.
a.
Nonsteroidal anti-inammatory drugs should be
discontinued 3 days before shock-wave lithotripsy to
reduce the risk of bleeding.
2.
Antibiotics should be given for infection.
3.
Antiemetics if needed.
4.
Other medical/pharmaceutical management depends
on the etiology of the stone.
5.
In clients with ureteral stones >5 mm and ≤10mm in
diameter, treatment with the alpha-blocker tamsulosin
(0.4 mg once daily) for up to 4 weeks can help facilitate
spontaneous stone passage. Alpha-blockers have higher
stone expulsion rate than calcium channel blockers.
D.
Surgical options are dependent on stone size and location.
1.
Percutaneous nephrolithotomy is the rst treatment
option for most clients and is considered the treatment of
choice for clients with staghorn calculi.
2.
Extracorporeal shock-wave lithotripsy is the least
invasive of the surgical methods.
3.
Percutaneous nephrostomy should be the last proce-
dure for most clients.
4.
Open nephrostomy may also be used.
FOLLOW-UP
A.
Reevaluate the client in 24 hours by phone or in the clinic.
B.
Evaluate sooner if pain increases due to the potential to
progress to complete obstruction.
C.
Recurrent stone formation is a manifestation of a sys-
temic disease; evaluate for management of the metabolic
abnormality.
CONSULTATION/REFERRAL
A.
Clients with severe pain, nausea, and vomiting need hospi-
talization for intravenous hydration and pain control. Consult
with a physician.
B.
Clients with severe symptoms and persistent obstruction
beyond 3 to 4 days should be referred for urologic evaluation.
C.
Refer to urology for surgical interventions: Litho tripsy,
urethroscope interventions, extracorporeal shock-wave lithotripsy, and percutaneous ultrasonic lithotripsy may be indicated. Treatment varies based on the location and size of the
stone. Laparoscopy may be indicated for removal of large or
severely impacted ureteral calculi.
D.
Refer to outpatient urology if stone is >10mm.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Urolithiasis is the most common cause of nonobstet-
rical abdominal pain that requires hospitalization during
pregnancy.
2.
Approximately 80% to 90% are diagnosed in the rst
trimester.
3.
Renal ultrasound is the rst-line screening test for
pregnant clients. A transvaginal ultrasound may also be
performed.
4.
Low-dose CT is reserved for complex cases in the sec-
ond and third trimesters.
5.
Conservative treatment is used: bedrest, hydration,
and analgesia.
6.
Invasive measures include stent placement, ureteros-
copy, and percutaneous nephrostomy.
7.
Upon presentation, rule out:
a.
Ectopic pregnancy.
b.
Abruptio placentae.
c.
Preterm labor.
B.
Pediatrics:
1.
Young children generally do not present with the clas-
sic acute onset of ank pain; instead, they may present with
abdominal pain. Stone may be detected when abdominal
imaging is performed.
2.
Hematuria can present as the sole symptom or in con-
junction with abdominal pain.
3.
Ten percent of children present with symptoms of dys-
uria and urgency.
4.
Shock-wave lithotripsy and percutaneous-based ther-
apy may be considered in children.
BIBLIOGRAPHY
Alelign, T., & Petros, B. (2018). Kidney stone disease: An update on current
concepts. Advances in Urology, 1–12. https://doi.org/10.1155/2018/
3068365 2018
SEXUAL DYSFUNCTION MALE: ERECTILE DYSFUNCTION
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American Urological Association. (2014). Medical management of kid-
ney stones. https://www.auanet.org/guidelines/kidney-stones-
medical-mangement-guideline
Curhan, G., Aronson, M., & Preminger, G. (2021, July 9). UpToDate. Www.
uptodate.com. https://www.uptodate.com/contents/kidney-stonesin-adults-diagnosis-and-acute-management-of-suspected-nephrolithi
asis#H1824843422
Curhan, G. C., Aronson, M. D., & Preminger, G. M. (2018, September 21).
Diagnosis and acute management of suspected nephrolithiasis in adults.
UpToDate. https://www.uptodate.com/contents/diagnosis-and-
acute-management-of-suspected-nephrolithiasis-in-adults
Dave, C. (2018, February 4). Which age groups have the highest prevalence of
nephrolithiasis? https://www.medscape.com/answers/437096-155529
/which-age-groups-have-the-highest-prevalence-of-nephrolithiasis
SEXUAL
DYSFUNCTION MALE: ERECTILE DYSFUNCTION
DEFINITION
A.
Erectile dysfunction, also known as impotence, is the per-
sistent inability to achieve or maintain penile erection sufcient for satisfactory sexual performance. Erectile dysfunction
occurs with reduced blood ow to the penis or nerve dam-
age, as well as psychological triggers. Low self-esteem, performance anxiety, depression, stress, and effects on quality of
life occur secondary to erectile dysfunction. Erectile dysfunction is noted to be a precursor to symptomatic coronary artery
disease (CAD).
B.
Age-associated changes in sexual function in males
include delay in erection, diminished intensity and duration
of orgasm, and decreased force of seminal emission. Erectile
dysfunction lasting 3 months or longer should have further
evaluation and consideration of treatment.
C.
Multiple male sexual dysfunction questionnaires are
available for order through the website at www.pzerpcoa.
com/disease-area/sexual-health, sponsored by Pzer, Inc.
Questionnaires include:
1.
Erectile Dysfunction Inventory of Treatment
Satisfaction is used in the evaluation of satisfaction with
medical treatment modalities for erectile dysfunction.
2.
Erectile Hardness Scale.
3.
International Index of Erectile Function (IIEF) is avail-
able in two versions. Version 1 is applicable to heterosexual males. Version 2 is an updated version so that it
is applicable to heterosexual and homosexual males. The
IIEF assesses ve dimensions relevant to sexual function:
a.
Erectile function (six items).
b.
Orgasmic function (two items).
c.
Sexual desire (two items).
d.
Intercourse satisfaction (three items).
e.
Overall satisfaction (two items).
4.
Index of Premature Ejaculation assesses control over
ejaculation, sexual satisfaction, and distress.
5.
Premature Ejaculation Diagnostic Tool was developed
to screen for premature ejaculation (PE), including control,
frequency, minimal sexual stimulation, distress, and interpersonal difculty.
6.
Quality of Erection Questionnaire evaluates satisfac-
tion with the quality of erections, including hardness,
onset, and duration.
7.
Self-Esteem and Relationship Questionnaire assesses
condence, self-esteem, and relationships.
8.
Sexual Health Inventory for Men (SHIM) is a ve-item
abridged version of the 15-item IIEF.
9.
Sexual Quality of Life–Men was developed to assess
sexual condence, emotional well-being, and relationship
issues. This questionnaire has been validated for males
with erectile dysfunction and PE.
INCIDENCE
A.
Erectile dysfunction can occur at any age; however, it is
more common in males older than 60 years.
B.
It is estimated that 18 to 30 million American males have
erectile dysfunction, that is, approximately 52% of males aged
40 to 70 years.
C.
By 2025, it is estimated that 322 million males worldwide
will have erectile dysfunction.
D.
Males with erectile dysfunction have a 65% to 85%
increased risk of subsequent CAD.
E.
Reduced libido is estimated as affecting 5% to 15% of
males.
PATHOGENESIS
A.
Normal pathology: The dorsal nerve of the penis provides
innervation, the dorsal somatic nerve provides sensation, and
the autonomic nervous system, via the cavernosal nerves, regulates blood ow to the penis, allowing for erection to occur.
The ability to maintain an erection relies on the dorsal nerve,
the peripheral nerves, penile vasculature, and biochemical
releases within the corpora.
B.
Multiple factors may contribute to erectile dysfunction:
1.
Vascular (most common):
a.
This system is responsible for delivering and trap-
ping the blood in the corporal sinusoids. Usually, the
blood owing in is not the problem; rather, the erectile dysfunction is the result of venous leaking from the
corporal sinusoids.
b.
Arterial insufciency contributes to decreased blood
ow to the cavernosal sinuses, which prevents an effective enlargement and rigidity of the penis. The dysfunction of the corporal bodies might cause leakage of
blood from the expanded sinusoids, which interrupts
the retention of blood in the penis. These impairments
result in the client’s inability to attain and/or maintain
an erection long enough to complete the sexual act.
c.
Other causes of erectile dysfunction:
i.
Chronic diseases such as cardiovascular (CV)
disease, hypertension (HTN), dyslipidemia, and
obesity can causeerectile dysfunction.
ii.
Certain medications can contribute to this phys-
iologic effect.
iii.
Smoking is also a contributing factor, especially
in the presence of existing CV disease, due to the
vasoconstrictive effects it causes.
2.
Psychological:
a.
Direct inhibition of the spinal erection center and/
or excessive sympathetic nervous system biochemical
release occurs, which increases the smooth muscle tone
of the penis, preventing erection.
i.
Age-related decline.
ii.
Lack of sexual response.
iii.
Personal intimacy-related issues.
iv.
Partner-specic intimacy issues.
v.
Performance anxiety.
vi.
Depression or life stress-related.
3.
Neurologic:
a.
Any disease affecting the brain, spinal cord, and
cavernous and penile nerves can impair the ability to
achieve erection, such as spinal cord injury, stroke, or
diabetes.
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12: GENITOURINARY GUIDELINES
b.
Surgery in the pelvic region, including prostatec-
tomy, perineal resection, and sphincterotome.
4.
Endocrine:
a.
Decreased testosterone level.
b.
Increased prolactin level.
c.
Hyperthyroidism.
d.
Hypothyroidism.
PREDISPOSING
A.
CV disease.
B.
Diabetes (neurologic and vascular problems).
C.
HTN.
D.
Hyperlipidemia.
E.
Advanced age (greater than 60 years).
F.
Peripheral neuropathy.
G.
Obesity.
H.
Neurologic disorders:
1.
Spinal cord injuries.
2.
Brain injuries.
3.
Multiple sclerosis.
4.
Parkinson disease.
I.
Alcohol/tobacco abuse.
J.
Drug abuse:
1.
Heroin.
2.
Cocaine.
3.
Marijuana.
K.
Side effect of medication (e.g., serotonin reuptake inhibi-
FACTORS
tors, antihypertensives, antihistamines, diuretics, nonsteroi-
dal anti-inammatories, muscle relaxants).
L.
Surgical/radiation therapy for cancers of the pelvis or pel-
vic trauma.
M.
Hypogonadism.
N.
Psychological and psychiatric disorders.
O.
Peyronie disease (deformity of the penis).
P.
Obstructive sleep apnea.
Q.
Physical inactivity.
COMMON
A.
B.
C.
D.
E.
F.
OTHER
A.
B.
C.
D.
E.
F.
SUBJECTIVE
A.
History
COMPLAINTS
Inability to achieve or sustain an erection.
Erection is not rm enough for penetration.
Absent or delayed ejaculation.
Inability to control the timing of ejaculation.
Lack of interest or desire (most common).
Pain with intercourse.
SIGNS AND SYMPTOMS
Diminished self-esteem.
Depression.
Anxiety.
Reduced libido.
Relationship difculties.
PE.
DATA
Sexual
history:
taking for erectile dysfunction includes sexual, medical, surgical,
emotional, and medication evaluations.
1.
Did the onset of erectile dysfunction coincide with a
specic event?
2.
How long has the client had trouble attaining or main-
taining an erection?
3.
Are they able to obtain an erection in order to pene-
trate? On a scale of 0 to 10, how hard is the erection?
4.
Is the erectile dysfunction getting worse?
5.
Is the client about to achieve orgasm and ejaculate?
6.
How long is the client able to have intercourse before
ejaculation?
7.
Is there pain or discomfort with ejaculation?
8.
Does the client have nocturnal or morning erections?
9.
How frequently does the client have sexual activity?
a.
Is the activity planned or does it occur spontaneously?
b.
How much foreplay occurs?
c.
Do the client and partner agree on the frequency of
intercourse?
d.
Is the client’s partner satised?
10.
Has the client tried any treatment(s) for erectile dysfunction?
a.
What treatments have been tried?
b.
Inquire about the client’s desire to try any particular
therapy. Are they opposed to try any particular therapy?
B.
Medical history:
1.
Does the client have HTN? When was HTN diagnosed?
What is the client’s usual blood pressure?
2.
Does the client have diabetes?
a.
Are they insulin-dependent?
b.
Do they have any peripheral neuropathy?
3.
Does the client have heart disease? When was their
heart disease diagnosed?
4.
Has the client ever had cancer, including any surgery,
chemotherapy, and radiation?
5.
Does the client have dyslipidemia? What were the
results of their last laboratory tests?
6.
Does the client have a sleep disorder?
7.
Does the client smoke? How much, including the num-
ber of pack-years?
8.
Does the client drink? How much, how often?
9.
Does the client have penile curvature (Peyronie disease)?
10.
Does the client have any neurologic disorders?
C.
Surgical history:
1.
Has the client had any prior surgeries, including pel-
vic, prostate, or trauma?
2.
Has the client had any invasive cardiac procedures or
surgery?
D.
Emotional history:
1.
Has the client ever had a traumatic sexual experience?
2.
Has the client had a loss of libido?
3.
Does the client have a history of depression or mood
disorders?
4.
Is the client experiencing any problems related to work
and/or family?
5.
Does the client have any intrapartner problems such as
separation or divorce?
E.
Medication history:
1.
Ask the client to list all medications currently being
taken, particularly substances not prescribed, including
herbal products and illicit drugs. Multiple drug classications have medications that contribute to erectile dysfunction. Review medications from the following drug classes:
a.
Nitrates.
b.
Antihypertensives (particularly alpha-blockers).
c.
Antiulcer medications.
d.
Lipid-lowering medications.
e.
5-alpha-reductase inhibitors (e.g., nasteride or
dutasteride).
f.
Antidepressants.
g.
Herbal products.
h.
Illicit drugs.
i.
Caffeine.
SEXUAL DYSFUNCTION MALE: ERECTILE DYSFUNCTION
ID:c0012-ti0880
ID:c0012-p9190
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ID:c0012-p9280
ID:c0012-p9285
ID:c0012-p9290
ID:c0012-p9295
ID:c0012-p9300
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ID:c0012-p9310
ID:c0012-p9315
ID:c0012-p1702767
ID:c0012-p9320
ID:c0012-p1702768
ID:c0012-p9325
ID:c0012-ti0885
ID:c0012-p9330
ID:c0012-p9335
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ID:c0012-p9350
ID:c0012-p9355
ID:c0012-p9360
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ID:c0012-p9370
ID:c0012-p9375
ID:c0012-p9380
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ID:c0012-ti0890
ID:c0012-p9390
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ID:c0012-ti0895
ID:c0012-p9410
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ID:c0012-p9420
ID:c0012-p9425
ID:c0012-p9430
ID:c0012-p9435
ID:c0012-p9440
ID:c0012-p9445
ID:c0012-p9450
ID:c0012-p9455
ID:c0012-p9460
ID:c0012-p9465
ID:c0012-p9470
ID:c0012-p9475
ID:c0012-p9480
ID:c0012-p9485
ID:c0012-p9490
ID:c0012-p9495
ID:c0012-p9500
ID:c0012-p9505
ID:c0012-p9510
ID:c0012-p9515
ID:c0012-p9520
ID:c0012-p9525
ID:c0012-p9530
https://t.me/med1917
PHYSICAL
A.
Check vital signs: blood pressure, height, and weight.
EXAMINATION
Calculate body mass index.
B.
Inspect:
1.
Inspect general appearance, noting dyspnea and
weakness.
2.
Inspect skin for jaundice, pallor, and diaphoresis.
3.
Inspect legs for edema, cyanosis, and venous stasis.
4.
Perform a funduscopic examination.
5.
Evaluate visual eld defects (present in hypogonadal
males with pituitary tumors).
6.
Inspect for penile plaques (indicates Peyronie disease).
7.
Inspect the testicles:
a.
Check for presence of atrophy.
b.
Assess asymmetry.
c.
Evaluate the cremasteric reex by stroking the
inner thighs and observe ipsilateral contraction of the
scrotum.
C.
Palpate:
1.
Palpate abdomen for masses, tenderness, bounding
pulses, and organomegaly.
2.
Palpate peripheral pulses in legs.
3.
Palpate femoral pulses.
4.
Examine breasts to detect gynecomastia.
5.
Palpate the testicles for masses.
6.
Perform a rectal examination to evaluate the prostate.
D.
Auscultate:
1.
Carotid arteries for bruits.
2.
Abdomen for bruits and bowel sounds.
3.
Heart for murmurs, rubs, clicks, irregularities, or extra
sounds.
4.
Femoral bruits (possible pelvic blood occlusion).
5.
All lung elds.
E.
Observe ipsilateral contraction of the scrotum.
F.
Mental status:
1.
Assess for depression.
G.
Perform neurologic examination:
1.
Perform a neurologic examination if neurologic etiol-
ogy is suspected.
DIAGNOSTIC
A.
Hormonal testing and treatment of erectile dysfunction
TESTS
should be individualized based on clinical presentation,
including libido, PE, fatigue, testicular atrophy, and muscle
atrophy that suggests a hormonal abnormality.
B.
Serum laboratory tests:
1.
Lipid prole.
2.
Triglycerides.
3.
Glucose or hemoglobin A1C (Hgb A1C).
4.
Prostate-specic antigen testing (if on testosterone
replacement).
5.
Hematocrit (if on testosterone replacement).
6.
Testosterone (performed in the morning) and other
hormone levels, such as luteinizing hormone, or prolactin
level, if high index of suspicion for prolactinoma, including visual disturbances or headache.
7.
Urinalysis for protein and glucose.
C.
Duplex ultrasound of the cavernous arteries and other vascu-
lar testing as indicated. Penile perfusion ultrasound may be done
to evaluate arterial perfusion of the penis (not commonly used).
D.
Nocturnal penile tumescence as indicated. This deter-
mines the quality and number of nighttime erections. This test
is not routinely used and is typically used in younger, more
complicated clients.
E.
Other tests as indicated for abnormal ndings on physical
examination.
DIFFERENTIAL
A.
Testosterone deciency.
B.
Decreased libido.
C.
Anorgasmia.
D.
Peyronie disease.
DIAGNOSES
PLAN
A.
General interventions:
1.
A prolonged erection (priapism) lasting more than
4 hours is a medical emergency often requiring immediate
urologic attention.
2.
Lifestyle modications should include weight loss,
increased physical activity, limited alcohol consumption,
and smoking cessation.
3.
Control of comorbidities, including CV disease, diabe-
tes, and HTN, is desired.
B.
Client teaching:
1.
Educate client about modifying controllable risk fac-
tors such as keeping diabetes and HTN under control,
diet, exercise, and smoking cessation.
2.
Failure to respond to phosphodiesterase-5 (PDE5)
inhibitor treatment may result from improper instructions
or an inadequate dosage of medication (see Table 12.5 for
dosing and side effects).
3.
The initial administration of an alprostadil intraure-
thral suppository should be done in the ofce in order to
demonstrate correct administration.
4.
Stepwise therapy for erectile dysfunction includes
pharmaceuticals and surgery.
C.
Pharmaceutical therapy:
1.
First-line therapy: Treatment with PDE5 inhibitors is the
rst-line therapy for erectile dysfunction. PDE5 inhibitors
are not initiators of erection and require sexual stimulation
for an erection to occur. Evidence shows that PDE5 inhibitors improve erections and successful intercourse, with
approximately 80% success rate. The use of PDE5 inhibitors
has been extensively studied; however, they are not without
side effects (see Table 12.5 for dosing and side effects).
a.
Contraindications to PDE5 inhibitors include
high-risk conditions and concomitant use of nitrites. If
the client develops angina while using a PDE5 inhibitor, other antianginal agents should be used instead of
nitroglycerin.
b.
High-risk clients/conditions are dened as:
i.
Unstable or refractory angina.
ii.
Refractory angina.
iii.
Uncontrolled HTN.
iv.
Classes of heart failure (New York Heart
Association classes III and IV).
v.
Myocardial infarction or a CV accident within
the previous 2 weeks.
vi.
High-risk arrhythmias.
vii.
Hypertrophic obstructive and other
cardiomyopathies.
c.
Before proceeding to other erectile dysfunction
therapies, clients reporting failure of PDE5 inhibitors
should be evaluated to determine whether the medication trial was adequate. Evaluate:
Food/drug interactions.
i.
ii.
Timing and frequency of dosing.
iii.
Lack of adequate sexual stimulation.
iv.
Heavy alcohol use.
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TABLE
12: GENITOURINARY GUIDELINES
12.5 DOSING AND SIDE EFFECTS OF ORAL PDE5 INHIBITORS
Dosing
Instructions Sildenafil Citrate (Viagra) Vardenafil HCl (Levitra) Tadalafil (Cialis) Avanafil (Stendra)
Doses 25, 50, and 100mg doses 2.5, 5, 10, and 20mg doses 2.5 and 5 mg: available
for continuous daily use
10 and 20mg doses
Instructions Recommended starting dose is
50mg
Take on an empty stomach
Maximum dosing once a day
Titrate according to client
response/side effects
Effective 30–60 minutes from
administration
A heavy fatty meal may reduce
or prolong absorption
Recommended starting dose is
10mg (5 mg initial dose for
the elderly)
Take on an empty stomach
Titrate according to client
response/side effects
Effective 60 minutes from
administration
A fatty meal reduces its effect
Recommended starting
dose is 10mg
Titrate according to client
response
Maximum dosing once
a day
Effective 30–60 minutes
from administration
Peak efficacy occurs after
2 hours; efficacy is
maintained for up to 36
hours
Not affected by food
Has been approved for
continuous, daily use in
2.5 and 5 mg doses
Also prescribed for BPH
Common Side
Sildenafil Citrate (Viagra) Vardenafil HCl (Levitra) Tadalafil (Cialis)
Effects
Headache
Flushing
Nasal congestion/
× × ×
× × ×
× × ×
rhinitis
50, 100, and
200mg doses
Recommend starting
dose is 100mg
Titrate according to
client response
Effective 15–30
minutes from
administration
Maximum dose is
1 g/d.
x
x
x
Dyspepsia
Priapism
× × ×
×
Rare Rare Rare
Myalgia
Sinusitis
×
Backache
Limb pain
Prolonged erection
Tachycardia
×
×
Visual disturbance Blue-green color tinge to vision,
light sensitivity, and blurred
vision (lasts 2–3 hours)
Hypotension with
alpha-blockers
Should be stable on
alpha-blocker before initiating
a PDE5 inhibitor; use lowest
recommended PDE5 inhibitor
dose
Should be stable on
alpha-blocker before
initiating a PDE5 inhibitor;
use lowest recommended
PDE5 inhibitor dose
Sudden vision loss Discontinue if vision loss occurs Discontinue if vision loss
occurs
Sudden hearing loss Discontinue if hearing loss occurs Discontinue if hearing loss
occurs
×
×
×
Should be stable on
alpha-blocker before
initiating a PDE5
inhibitor; use lowest
recommended PDE5
inhibitor dose
Discontinue if vision loss
occurs
Discontinue if hearing loss
occurs
x
x
x
x
Should be stable
on alpha-blocker
before initiating,
start at 50mg/24
hours
Discontinue if vision
loss occurs
Discontinue if hearing
loss occurs
(continued)
SEXUAL DYSFUNCTION MALE: ERECTILE DYSFUNCTION
ID:c0012-p9535
ID:c0012-p9540
ID:c0012-p9545
ID:c0012-p9550
ID:c0012-p9555
ID:c0012-p9560
ID:c0012-p9565
ID:c0012-p9570
ID:c0012-p9575
ID:c0012-p9580
ID:c0012-p9585
ID:c0012-p9590
ID:c0012-p9595
ID:c0012-ti0900
ID:c0012-p10115
ID:c0012-p10120
ID:c0012-ti0905
ID:c0012-p10125
ID:c0012-p10130
ID:c0012-p10135
ID:c0012-p10140
ID:c0012-p10145
ID:c0012-p10150
ID:c0012-p10155
ID:c0012-ti0910
ID:c0012-p10160
ID:c0012-p10165
ID:c0012-p10170
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477
TABLE 12.5 DOSING AND SIDE EFFECTS OF ORAL PDE5 INHIBITORS (CONTINUED)
Dosing
Instructions Sildenafil Citrate (Viagra) Vardenafil HCl (Levitra) Tadalafil (Cialis) Avanafil (Stendra)
Use with nitrates
(includes
Contraindicated due to
hypotension
Contraindicated due to
nitroglycerin,
isosorbide dinitrate,
amyl nitrate,
and sodium
nitroprusside)
Not to be used in clients with
BPH,
benign prostatic hyperplasia; PDE5, phosphodiesterase-5.
v.
Relationship issues.
vi.
Using a licensed PDE5 inhibitor medication.
d.
After evaluation and reeducation and counseling
on the medications and partner–partner expectations,
titrate to the maximum dosing or prescribe a different
PDE5 inhibitor.
e.
Discuss other options for erectile dysfunction if the
client has a contraindication to, or an unsuccessful trial
of, PDE5 inhibitors.
f.
Testosterone therapy is not indicated in the treat-
ment of erectile dysfunction if the client has a normal
serum testosterone level.
2.
Second-line therapy: Pharmaceutical therapy with
intracavernous injection is the second-line therapy for
treatment of erectile dysfunction. Penile injection therapy
involves injection of alprostadil, a vasoactive drug, into the
corpora cavernosa of the penis to expand the blood vessels
and increase the blood ow to produce an erection. The
most common side effects of alprostadil are burning and
a prolonged erection lasting over 4 hours. Hypotension
is also a potential side effect. Prolonged erections require
medical intervention to reverse the erection.
a.
Alprostadil intracavernosal injections are titrated
according to the client’s erection response, within the
healthcare clinic setting. Precise dosing requirements
exist for intracavernosal therapy and are specic to
the brand name. Adverse effects include penile pain,
hematoma, penile brosis, and a high potential for
priapism.
b.
Alprostadil MUSE (alprostadil urethral supposi-
tory) urethral pellet: 125 to 250 mcg is to be used before
intercourse. Duration of 30 to 60 minutes is followed;
use only twice in each 24-hour period.
D.
Surgical alternatives:
1.
Penile implant is the third-line therapy for treatment
of erectile dysfunction. Penile prostheses (implants) are
surgically implanted items, semirigid rods or a hydraulic
device, to ensure a rigid erection. The prosthesis does not
usually affect urination, sex drive, orgasm, or ejaculation.
Pain and/or reduced sensation, infection, or mechanical
failure may occur from the prosthesis.
2.
Vacuum erection devices are external cylinders used
to pump the penis into the cylinder and produce an erection by drawing blood into the penis. An occluding band is
then placed at the base of the penis in order to prevent the
blood from leaving, with subsequent loss of the erection.
Only vacuum constrictor devices containing a vacuum
hypotension
congenital QT prolongation
limiter should be used. The occluding band to maintain
the erection should be limited to 30 minutes.
3.
Penile arterial revascularization is indicated for young
males (younger than 45 years) with no known risk factors
for atherosclerosis. The goal of the surgery is to correct
injury by rerouting the blood vessel around a blockage or
injured blood vessel. Clients with insulin-dependent diabetes or widespread atherosclerosis are not candidates for
this surgery.
4.
Venous ligation surgery is rarely used. Males with
insulin-dependent diabetes or widespread atherosclerosis
are also not candidates for venous surgery.
FOLLOW-UP
A.
Follow up in 1 to 3 weeks after treatments are initiated to
monitor client satisfaction and the quality of erections.
B.
At the time of prescription renewal, clients prescribed
PDE5 inhibitors should have a review of the effectiveness, side
effects, and any signicant change in health status, including
a review of all medications.
CONSULTATION/REFERRAL
A.
Clients should be directed to go to the ED if an erection
lasts for more than 4 hours.
B.
Clients whose CV risk is indeterminant for PDE5 inhib-
itors should undergo further evaluation by a cardiologist
before receiving therapies for sexual dysfunction.
C.
Surgical consultation: Males with penile deformities may
require surgical correction.
D.
Urologist consultation should be considered for surgical
therapies, including implantation of penile prosthesis.
E.
Endocrinology consultation for complex endocrine
disorders.
F.
Psychosexual counseling may be considered for the client
and/or couple.
G.
Psychotherapy is recommended when erectile dysfunction
is related to anxiety and/or depression.
INDIVIDUAL
A.
Adults:
1.
A mild prolongation of the QT interval has been
observed with vardenal. The product labeling for vardenal recommends that caution be used in clients with
known history of QT prolongation or in clients who are on
current medications that prolong the QT interval.
2.
Testosterone therapy is not indicated in the treatment
of erectile dysfunction if the client has a normal serum testosterone level.
Contraindicated due to
hypotension
CONSIDERATIONS
Contraindicated due
to hypotension
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