Nursing Challenge in Caring for a Patient with Cryptorchidism

Galutan, Janina Roshane Macabio, Evangeline

OUR LADY OF FATIMA UNIVERSITY (Valenzuela City)

Nursing Challenge 1

INTRODUCTION Cryptorchidism is the most common abnormality of male sexual development. In this condition, the testis is not located in the scrotum. The testis can be ectopic, incompletely descended, retractile, and absent or atrophic. The term cryptorchidism is translated from a Greek term that means hidden or obscure testis. Sir John Hunter, the British anatomist, reported this condition in 1786. In 1877, Annandale performed the first successful orchidopexy. In 1899, Bevan published the principles of testicular mobilization, separation of the processus vaginalis, and repositioning of the testis into the scrotum. Testicular maldescent has been the subject of many clinical studies, but its embryology, effects on fertility, and ultimate clinical impact still remain a topic of discussion and research.

In United States, a palpable undescended testis is found in 3%-5% of newborns, and bilateral undescended testis is found in 15% of newborns with cryptorchidism. Most undescended palpable testes later spontaneously descend within the first 4 months of life; only 0.7%-1% of 1-year-old infants have a persistent undescended testis. Studies have shown that spontaneous descent does not occur after age 9 months. The incidence does not change

Nursing Challenge 2 between age 1 year and adulthood. However, some testes that were descended in early childhood may ascend later in life. Nonpalpable testes account for approximately 20% of all undescended testes. Approximately 40% of the nonpalpable testes are intra-abdominal, 40% are inguinal, and 20% are atrophic or absent.

Cryptorchidism is found in 30% of babies born prematurely. Other predisposing factors include low birth weight, small size for gestational age, twin pregnancy, and maternal estrogen exposure. Cryptorchidism is found in 7% of siblings and in about 2% of fathers of babies with this condition. Cryptorchidism has not been associated with any factors for mortality. However, testicular maldescent has been associated with a slight increase in the risk of testicular cancer, infertility, trauma, and testicular torsion. If not treated, testicular maldescent may also affect the psychological well-being of young men in whom negative self-esteem issues may arise. Cryptorchidism affects only males.

Orchiopexy is a procedure in which a surgeon fastens an undescended testicle inside the scrotum, usually with absorbable sutures. It is done most often in male infants or very young children to correct cryptorchidism, which is the medical term for undescended testicles. Orchiopexy is also occasionally performed in adolescents or adults, and may involve one or both testicles. In

Nursing Challenge 3 adults, orchiopexy is most often done to treat testicular torsion, which is a urologic emergency resulting from the testicle's twisting around the spermatic cord and losing its blood supply. Other names for orchiopexy include orchidopexy, inguinal orchiopexy, repair of undescended testicle, cryptorchidism repair, and testicular torsion repair.

To understand the reasons for performing an orchiopexy in children, it is helpful to have an outline of the normal pattern of development of the testes in a male infant. The gubernaculum is an embryonic cord-like ligament that attaches the testes within the inguinal (groin) region of a male fetus up through the seventh month of pregnancy. Between the 28th and the 35th week of pregnancy, the gubernaculum migrates into the scrotum and creates space for the testes to descend. In normal development, the testes have followed the gubernaculum downward into the scrotum by the time the baby is born. The normal pattern may be interrupted by several possible factors, including inadequate androgen (male sex hormone) secretion, structural abnormalities the boy's genitals, and defective nerves in the genital region.

Hormonal therapy using gonadotropins to stimulate the production of more testosterone is effective in some children in causing the testes to descend

Nursing Challenge 4 into the scrotum without surgery. This approach, however, is usually successful only with undescended testes that are already close to the scrotum; its rate of success ranges from 1050%. Undescended testes that are located higher almost never respond to hormonal therapy. In addition, treatment with hormones has several undesirable side effects, including aggressive behavior. Some surgeons will, however, prescribe hormonal treatment before an orchiopexy in order to increase the size of the undescended testis and make it easier to identify during surgery. (http://www.surgeryencyclopedia.com/LaPa/Orchiopexy.html)

Nursing Challenge in Caring for a Patient with Cryptorchidism

Galutan, Janina Roshane Macabio, Evangeline

OUR LADY OF FATIMA UNIVERSITY (Valenzuela City)

Nursing Management 1

INTRODUCTION

Mr. LMS is 25-a year old male, military personnel with a rank of Corporal has been serving the military for 4 years. He was admitted at August 2, 2011 1600 H with a chief complaint of episodes of right inguinal pain and an empty right scrotal sac. Initial diagnosis upon admission is an undescended right testis. He was placed on Ward 4C (Urology Ward) and his admitting officer was LTC Cortes.

PATHOPHYSIOLOGY The embryology of testis development is critical to understanding the most common theories that explain cryptorchidism. Shortly after 6 weeks' gestation, the testis-determining SRY gene on chromosome Y directly affects the differentiation of the indifferent gonad into a testis. Germ cells are located in the germinal ridge close to the kidney in the retroperitoneum. Around 6-7 weeks' gestation, Sertoli cells develop and secrete Mllerian inhibitory substance (MIS), which leads to the regression of the female genital organs. Around 9 weeks' gestation, Leydig cells start producing testosterone, which promotes development of the Wolffian duct into portions of the male genital tract. Concurrently, the testis organizes as a distinct organ with its distinct seminiferous tubules surrounded by vessels and encapsulated

Nursing Management 2 by the tunica albuginea. Owing to the differential growth of the fetus, the testicles move into the pelvis, close to the internal ring. The testis remains in a retroperitoneal position until 28 weeks' gestation, at which time inguinal descent of the testicle begins. Most testes have completed their descent into the scrotum by 40 weeks' gestation.

HISTORY The patient was diagnosed with undescended right testis since birth. One month prior to admission, the patient feels pain on the right inguinal area with the estimated date of onset of July 2, 2011. He was then advised to undergo a surgery. Past medical history and family history shows unremarkable data. He is a non-smoker and a non-alcoholic beverage drinker.

Nursing Management 3

NURSING PHYSICAL ASSESSMENT Upon admission a physical examination was conducted by Dr. R with the findings of pink palpebral conjunctiva, anectic sclerae, negative murmurs and full and equal pulse. Upon endorsement of the client on our care, client appears kempt, coherent and is fully aware and is well-oriented about the time and place he is in. He has black hair with brown skin. Mr. LMS has slender body, looks fit with muscular body features. Pupils are equally rounded. He was ambulatory and can perform active ROM without restriction or pain. General body systems are all normal except the associated affected part of the client. Dr. R found a non-tender undescended right testis and was advised to undergo right orchiectomy under spinal anesthesia. Radiologic exams found normal and clear lungs. Electrocardiogram report shows sinus rhythm and an early repolarization pattern. Ultrasound report shows a normal in size right testis however an abnormal position which is in the ipsilateral inguinal area while left testis is intact, both have no focal mass lesion seen. Complete Blood Count and Differential Count were conducted and found results all normal.

Nursing Management 4 RELATED TREATMENT Patient was advised that a possible right orchiectomy might be done in response to the surgical treatment for his chief complaint. Upon admission patient was moved to ward 4C with a doctors order of Chest X-ray, urinalysis and 12-lead ECG examination and vital signs monitoring and recording every 4 hours placing patient on DAT (diet as tolerated). Upon receiving the patient in the ward the nurse taught and advised practice of deep-breathing exercises and encouraged verbalization of pain. Around 2300 H of the same day of admission, patient verbalizes pain on right inguinal area with the pain scale of 3/10. August 8 is the scheduled date for patients surgical procedure, prior to the scheduled right orchiectomy as advised by the physician, the patient has undergone pre-op preparations. He was placed under NPO post-midnight and started IVF therapy of D5LR 1L to run for 8 hours via G18 cannula, ordered medications are Midazolam 1 mg IV and Omeprazole 40 mg OD. Client undergone skin testing of cefuroxime. After ANST, client was given cefuroxime 750 mg IV to be given 7 hour prior OR. Surgery done (Hernioplasty with Omentectomy; right Orchiectomy) with post-op orders. He was under IVF therapy with a D5LR 1L hooked for 8 hours via G18 cannula and was maintained on NPO. Bowel prep done and is given Dulcolax @ 0400 H. Operative site was rechecked. Dressing kept dry and intact. Other interventions include supportive measures and measures to keep client comfortable.

Nursing Management 5

NURSING INTERVENTION Patient verbalizes on and off pain on operative site; therefore the primary area of concern for nursing interventions is directed towards relief of pain Patient is advised to feel no hesitation of verbalization of pain especially on operative site. Ambulation such as walking is advised to aid in promoting good circulation for faster wound healing. Patient was also advised to eat healthy/ nutritious foods to aid in strengthening immune system for fighting any threat of infection and to avoid strenuous exercises and activities such as lifting heavy objects. Wound site is frequently checked to keep clean, dry and intact to prevent possible cause of infection. Analgesics were administered as ordered by the physician.

NURSING CARE PLAN Within 2 hours of nursing intervention, the above mentioned nursing interventions aim to be implemented with the expected therapeutic outcomes primarily on verbalization of clients relief from pain.

Nursing Management 6

EVALUATION After the 2-hour of nursing intervention, the patient was able to verbalize relief from pain through compliance and adherence primarily to the prescribed medication which has faster effect from relief of patients experienced pain and secondarily due to the advised interventions. RECOMMENDATIONS Undergoing orchiectomy decreases the chances of the client to produce enough sperm cells, thus reducing the sperm count which could affect ability to fertilize egg upon copulation. Health teaching regarding the changes and effects undergoing such procedure must be well-explained to the client. Promoting healthy lifestyle, avoiding too much alcohol consumption and smoking could enhance production of healthy sperm cells capable of fertilizing the egg. Further, health teaching on how to keep wound site clean and intact is advised. And strenuous exercise must be avoided until wound is completely healed. Importance of complying on follow-up check-ups is also advised especially on semen analysis to examine the sperms motility.

REFERENCES Doenges, M. E., France, M. M., & Mur, A. C. (2008). Nurse's Pocket Guide 11th Edtion. F. A. Davis Company. Dogra, Vikram S., and Hamid Mojibian. "Cryptorchidism." eMedicine, June 21, 2002 [April 4, 2003]. http://www.emedicine.com/radio/topic201.htm Rothenberg, R. E. (1999). The New American Medical Dictionary and Health Manual 7th Edition Tsujihata, M., et al. "Laparoscopic Diagnosis and Treatment of Nonpalpable Testis." International Journal of Urology, 8 (December 2001): 692696. Websites http://www.surgeryencyclopedia.com/La-Pa/Orchiopexy.html http://www.surgeryencyclopedia.com/LaPa/Orchiopexy.html#ixzz1VNQkCmSB Orchiopexy - procedure, test, blood, pain, adults, time, infection, operation, medication, pregnancy, risk, children, cancer, nausea, rate, Definition, Purpose, Demographics http://emedicine.medscape.com/article/1017420-overview#showall

REFERENCES Chang, B., L. S. Palmer, and I. Franco. "Laparoscopic Orchidopexy: A Review of a Large Clinical Series." BJU International, 87 (April 2001): 490493. Docimo, S. G., R. I. Silver, and W. Cromie. "The Undescended Testicle: Diagnosis and Management." American Family Physician, 62 (November 1, 2000): 20372044, 20472048. Jawdeh, Bassam Abu, and Samir Akel. "Cryptorchidism: An Update." American University of Beirut Surgery, (Summer 2002) [April 3, 2003]. http://www.staff.aub.edu.lb/~websurgp/sc0a.html Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddarth's Textbook of Medical Surgical Nursing. J. B. Lippincott Company Websites http://www.surgeryencyclopedia.com/La-Pa/Orchiopexy.html http://www.surgeryencyclopedia.com/LaPa/Orchiopexy.html#ixzz1VNQkCmSB Orchiopexy - procedure, test, blood, pain, adults, time, infection, operation, medication, pregnancy, risk, children, cancer, nausea, rate, Definition, Purpose, Demographics http://emedicine.medscape.com/article/1017420-overview#showall