Men’s Health and Reproductive Disorders

Reproductive health requires the production of adequate quantities of various hypothalamic, pituitary, and gonadal hormones as well as the appropriate hormone receptors. It requires normal development and patency of the reproductive tract. In addition, reproductive health implies that men and women at developmentally appropriate life stages are fertile (i.e., able to produce gametes [sperm or eggs]). Finally, reproductive health entails the ability to engage in sexual intercourse with ejaculation by the male.

Androgens, or male sex hormones, control the development and maintenance of sexual processes, accessory sexual organs, cellular metabolism, and bone and muscle growth. Testosterone, an anabolic steroid, is the principal male sex hormone. It is the prototype of the androgen hormones, synthesized primarily in the testes and, to a lesser extent, in the adrenal cortex. In women, the ovaries synthesize small amounts of testosterone. In adult males, normal plasma concentrations of testosterone are 270 to 1070 ng/dL, with a slow decline of 1% per year after the age of 30 (Table 53.1). Prototype Drug Chart 53.1 lists the natural and synthetic androgens and their dosages, uses, and considerations.

Testosterone secretion is greater in men than in women in most stages of life. About 98% of circulating testosterone is bound to both sex hormone–binding globulin (SHBG) and albumin protein, leaving about 2% unbound, or circulating free in the plasma; this unbound portion is biologically active. Estrogen elevates the production of SHBG, resulting in more protein-bound testosterone in women than in men. The half-life of endogenous, or naturally occurring, free testosterone in the blood is 10 to 20 minutes.

Testosterone is responsible for the development of male sex characteristics. The biologic effects of testosterone may be mediated directly by testosterone or by its metabolites. Testosterone and dihydrotestosterone act as androgens by way of a single androgen receptor officially designated NR3A. The hormones bind to sites on certain responsive genes, causing a change to take place in the target cell. The effects of the testosterone depend on which receptor it activates and the tissues in which these effects occur. The manufacture of protein within the target cells results in the buildup of cellular tissue (anabolism), especially in muscles. This leads to development of secondary sex characteristics such as pubic hair growth, beard and body hair growth, baldness, deepening of the male voice, thickening of the skin, sebaceous gland activity, increased musculature, bone development, and red blood cell formation.

Table 53.2 lists the natural and synthetic androgens with their dosages, uses, and considerations. Androgen therapy is approved for use in androgen deficiency in males, specifically hypogonadism; replacement therapy for testicular failure in adult males; and delayed puberty in adolescents.

The clearest indication for exogenous androgen therapy is hypogonadism. Male hypogonadism is a defect of the reproductive system that results in failure of the testes to produce testosterone, sperm, or both. Deficiency of sex hormones can result in defective primary or secondary sexual development, and defective sperm development can result in infertility. Hypogonadism is either primary, reflecting testicular abnormality, or secondary, reflecting hypothalamic or pituitary failure. A combination of disorders can also occur. Inadequate pituitary function will severely affect young boys and results in infertility and a lack of secondary sex characteristics. Adult men may experience testicular atrophy, impotence, decreased libido, decreased bone density, loss of muscle mass, hair loss, gynecomastia, fatigue, difficulty concentrating, or vasomotor flushing.

Hypogonadal men on androgen therapy may experience frequent erections or priapism (painful, continuous erection), gynecomastia (mammary gland enlargement in men), or urinary urgency. Continued use of androgens by normal men can halt spermatogenesis (formation of spermatozoa). The sperm count may be low (oligospermia) for 3 or more months after therapy is stopped.

Androgen therapy may cause hypercalcemia by stimulating bone resorption in immobilized patients and those with breast cancer. The drug should be discontinued and appropriate measures instituted if signs of hypercalcemia occur; signs include nausea and vomiting, lethargy, decreased muscle tone, polyuria, and increased urine and serum calcium.

Androgen therapy is contraindicated during pregnancy and in individuals with nephrosis or those in the nephrotic phase of nephritis; it is also contraindicated in patients with hypercalcemia, pituitary insufficiency, hepatic dysfunction, benign prostatic hyperplasia (BPH), prostate cancer, or history of myocardial infarction. Men with breast cancer are not treated with androgens, nor are women whose breast cancer is not estrogen dependent.

Androgens potentiate the effects of oral anticoagulants, necessitating a decrease in anticoagulant dosage. Androgens antagonize calcitonin and parathyroid hormones. Because androgens can decrease blood glucose in patients with diabetes, dosages of insulin or other antidiabetic agents may need to be reduced. Concurrent use of corticosteroids exacerbates the edema that can occur with androgen therapy. Barbiturates, phenytoin, and phenylbutazone decrease the effects of androgens.

Anabolic steroids, or anabolic-androgenic steroids (AASs), are a class of steroid hormones related to the hormone testosterone. They increase protein synthesis within cells, which results in the buildup of cellular tissue (anabolism), especially in muscles. Anabolic steroids also have androgenic and virilizing properties, including the development and maintenance of masculine characteristics such as the growth of the vocal cords and body hair. While the American College of Sports Medicine notes that AASs, combined with sufficient diet and exercise, can contribute to increased lean body mass in some individuals, they also note it is in the best interest of all sports to eradicate the use of AASs by athletes, due to the risk of serious harm or death in those who use AASs. See Chapter 7, Drugs in Substance Use Disorder, for further information.

Antiandrogens, or androgen antagonists, block the synthesis or action of androgens (Table 53.3). These drugs are used in the treatment of BPH, advanced prostatic cancer, and as hormonal therapy in the treatment of endometriosis. They may also be used to treat male-pattern baldness (MPB), acne, hirsutism, virilization syndrome in women, and precocious puberty in boys, although their effectiveness is not well established.

Puberty is considered to be delayed when testicle enlargement, followed by penile growth and pubic hair development, has not begun by age 14. Delay in growth may be a normal part of the maturation process, but the cause could also be androgen deficiency or a deficiency of growth hormone. Secretion of GnRH, LH, or FSH is insufficient in up to 5% of cases of delayed puberty. Treatment is only begun after 14 years of age, following a full evaluation, including serum LH, FSH, thyroid-stimulating hormone (TSH), and testosterone levels. Therapy with testosterone cyprionate 50 mg IM every month, for 3 to 6 months or less before epiphyseal closure, may result in linear growth without adverse permanent effects on hypothalamic, pituitary, or gonadal maturation.

Inadequate pituitary function can be another cause of hypogonadism. Menotropins are purified combination preparations of the human pituitary gonadotropins FSH and LH. These drugs are indicated when both LH and FSH levels are low. When given in combination with hCG, the drug stimulates testosterone production in men to encourage spermatogenesis when injected three times a week for 4 to 9 months to ensure adequate spermatozoa production. One ampule of a menotropin contains 75 international units each of LH and FSH. The initial dose is 75 to 150 international units subcutaneously (subcut) or 3 times per week. Subsequent doses are adjusted according to individual response but not exceeding 75 to 150 international units per adjustment; the maximum dose is 300 units 3 times per week. Use the lower abdomen (alternating sides) for subcut administration. Menotropin must be used immediately after reconstitution and must be protected from light. Advise patients to discard unused drug. Adverse effects include nausea, vomiting, diarrhea, gynecomastia, and fever.

Sexual dysfunction is the inability to experience sexual desire, erection, ejaculation, and/or detumescence—the four phases of the sexual response cycle in men. Inhibited sexual desire can result from androgen deficiency, an affective disorder, or discord in the sexual relationship. Many drugs can also cause sexual dysfunction (Table 53.4).

To self-treat sexual problems or to enhance sexual performance, consumers use a wide variety of herbs and plant-derived compounds (phytochemicals). Despite new science-based therapies, men are attracted to phytochemicals because they are easy to obtain and may be cheaper than prescription drugs and therapies, procedures, or surgeries not covered by insurance. Consumers may mistakenly perceive natural products as providing health benefits beyond sexual performance because they can be purchased at nutrition centers or health food stores. Common herbs used for sexual health and performance include Pausinystalia yohimbine, Panax quinquefolius, ginkgo biloba, saw palmetto, muira puama, Lepidium meyenii, Mandia whitei, and Tribulus terrestris. Limited studies have been conducted on these products; all studies have yielded mixed results. As such, there is insufficient evidence to recommend any complementary or alternative medicine (CAM). Its benefits appear to reflect popular or cultural beliefs. Reports in health magazines and advertising are anecdotal and based on a small number of users. However, it is important for the nurse to be aware of CAM, as ED affects 50% of men between the ages of 50 and 70, but only 10% seek medical attention. These statistics indicate men may be choosing to use CAM to avoid the discomfort of discussing this sensitive topic with their health care provider.

Drugs used to treat acute or chronic prostatitis, orchitis, or epididymitis are the same as those used to treat urinary tract infections (see Chapter 48).

As a man ages, the glandular units in the prostate gland begin to undergo tissue hyperplasia, an abnormal increase in the number of cells, which results in prostatic hypertrophy, or enlargement of the gland. The exact cause of BPH is unknown, but its development is almost universal in older men. The enlarged prostate gland contributes to overall lower urinary tract symptoms either through direct bladder outlet obstruction or from resistance within the enlarged gland itself. The man experiences storage and/or voiding disturbances, such as a sensation of bladder fullness, frequency, nocturia, hesitation when trying to begin urinating, dribbling of urine, and erectile dysfunction. Although BPH is not a life-threatening condition, the impact of symptoms on quality of life can be significant. Because these are the same symptoms that prostate cancer may cause, the patient should have a prostate-specific antigen (PSA) blood test and may undergo a prostate biopsy to make sure no cancer is present. Traditionally, the primary goal of treatment has been to alleviate bothersome symptoms. More recently, treatment has also been focused on the alteration of disease progression and prevention of complications. Drugs from several pharmacologic classes are used; they include alpha-adrenergic antagonists (alpha blockers), 5-alpha-reductase inhibitors (5-ARIs), anticholinergics (only used in men without large post-void residuals), and the PDE-5 inhibitor tadalafil. Choosing the correct medical treatment for BPH is complex (Table 53.6). The American Urological Association 2010 Guidelines are a useful reference on the effective evidence-based management of lower urinary tract symptoms caused by BPH. The guidelines advise a discussion of benefits and risks of each recommended treatment alternative (e.g., watchful waiting; medical, surgical, or minimally invasive surgical treatments). The choice of treatment is reached in a shared decision-making process between provider and patient.

Prostatic cancer accounts for about 10% of all cancer deaths among American men. Most prostatic cancers are adenocarcinomas. Metastasis to lymph nodes, bone, lungs, liver, and adrenal glands is common. Prostatic cancer is often asymptomatic, but urinary obstruction is commonly the first sign. Treatment may include a combination of surgical resection, cryotherapy, antiandrogen administration, radiation therapy, chemotherapy, and pain management.

MT, age 16 years, is a high school junior who is 59.3 inches tall and weighs 126 pounds. He is having increased feelings of discomfort about not fitting in with the other students at school because he has not yet begun sexual maturation. He is a good student and an accomplished violinist in the school orchestra. His father states that he also was a “late bloomer,” but both parents are concerned about MT’s increasing social withdrawal and seem determined to seek medical intervention for him. The nurse at the clinic assesses the needs and status of MT and his parents.