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For a Part D compound to be considered on-formulary, all ingredients that independently meet the definition of a Part D drug must be considered on-formulary. For any non-Part D ingredient of the Part D compound, the Part D sponsor’s contract with the pharmacy must prohibit balance billing the beneficiary for the cost of any such ingredients. Sponsors treating compounds as non-formulary products should be applying the cost sharing associated with an exceptions tier, regardless of whether the compound contains brand name or generic products. For a Part D compound considered off-formulary, transition rules apply such that all ingredients that independently meet the definition of a Part D drug must become payable in the event of a transition fill and be covered if an exception under §423. For compounds containing all generic products, the generic cost-sharing should be applied. If a compound contains any brand name products, the Part D sponsor may apply the higher brand name cost-sharing to the entire compound. However, test strips, lancets and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. Insulin syringes equipped with a safe needle device, in their entirety (syringe and device), are also Part D drugs and should be managed like any other Part D drug the sponsor places on its formulary. Part D sponsors must make safety enabled insulin syringes available on their formularies for all of their institutionalized beneficiaries. The definition of medically accepted indication also means, in the case of a covered Part D drug used in an anticancer chemotherapeutic regimen, the definition of medically accepted indication in section 1861(t)(2)(B) of the Act. Thus, Part D sponsors will be required to thoroughly understand and apply Part B’s definition of an anti-cancer chemotherapeutic regimen, utilize Part B compendia, and consider peer reviewed medical literature when necessary. Part D sponsors are responsible for ensuring that covered Part D drugs are prescribed for medically-accepted indications using the tools and data available to them to make such determinations. Dispensing pharmacists are not required to contact each prescriber to verify a prescription is being used for a medically-accepted indication. Also, medically-accepted indication refers to the diagnosis or condition for which a drug is being prescribed, not the dose being prescribed for such indication. Additionally a Part D drug must be used for a medically-accepted indication that facilitates the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member (except for Part D vaccines). Consequently, if a drug works on medical equipment or devices and is not used for a medically-accepted indication of therapeutic value on the body, it cannot satisfy the definition of a Part D drug. For example, a heparin flush is not used to treat a patient for a medically-accepted indication, but rather to dissolve possible blood clots around an infusion line. Therefore, heparin’s use in this instance is not therapeutic but is, instead, necessary to make durable medical equipment work. Example: An individual receives a prescription and takes the drug within a common dosing regimen (i. Several months later, that individual’s physician writes a new prescription for an increased dosage of that drug. The second prescription triggers a quantity limit claim edit (for example, based on safety limits). As a result, the individual’s physician requests a coverage determination from the plan and submits evidence to support an exception to the quantity limit. Based on that evidence, the Part D sponsor makes a determination that the drug was not prescribed for a medically-accepted indication. In addition, Part D sponsors may only pay for drugs that satisfy the definition of Part D drug. Such products cannot be discounted under the Medicare Coverage Gap Discount Program. Coverage is not limited to single entity products such as Subutex®, but must include combination products that are Part D drugs when medically necessary (e. A Part D drug is defined, in part, as “a drug that may be dispensed only upon a prescription. State Medicaid Programs may continue to include the costs of methadone in their bundled payment to qualified drug treatment clinics or hospitals that dispense methadone for opioid dependence. Section 1860D–2(e)(1) of the Social Security Act (the Act) generally defines a Part D drug to include those drugs that may be dispensed only upon a prescription and that meet the requirements of section 1927(k)(2) of the Act. These provisions address those drugs affected by the Drug Amendments of 1962 (amending the Federal Food, Drug & Cosmetic Act), which require that a new drug be proven effective, as well as safe. Refer to chapter 7, section 60, of this manual for further discussion of this option. However, adjudication of the legend product may continue as long as the market holds residual inventory. The use of these drugs or drug classes often results in an earlier hospital discharge and reduced healthcare costs. Interested Part D sponsors must appropriately assign these costs to the Part C component of their bids to account for these bundled drugs. They must also provide, through the Formulary Submission module, a file that clearly identifies the Part D home infusion drugs that will be offered as part of a mandatory supplemental benefit under Part C for the following contract year. Waiver of the definition of a Part D drug will improve benefit coordination of home infusion therapy between Parts C and D, particularly since the services and supplies necessary for home infusion are never covered under Part D but would be provided as part of a bundle of service under a Part C mandatory supplemental benefit. However, this waiver is conditioned on the application of zero cost sharing for the bundle of home infusion services provided under a Part C supplemental benefit. This improved benefit coordination promotes continuity of care and cost avoidance of more expensive institutional care by facilitating continuous access to home infusion drugs, as well as the costs of administration and supplies associated with that therapy. Part D sponsors choosing to provide Part D home infusion drugs as part of a bundled service must indicate on their marketed formularies that certain drugs may be covered under the sponsor’s medical, rather than its prescription, benefit. In other words, the negotiated price for a Part D vaccine will be comprised of the vaccine ingredient cost, a dispensing fee (if applicable), and a vaccine administration fee. This interpretation recognizes the intrinsic linkage that exists between the vaccine and its corresponding administration, since a beneficiary would never purchase a vaccine without the expectation that it would be administered. For example, if an in- network pharmacy dispenses and administers the vaccine in accordance with State law, the pharmacy would process a single claim to the Part D sponsor and collect from the enrollee any applicable cost-sharing on the vaccine and its administration. Alternatively, if a vaccine is administered outside of the plan’s Part D pharmacy network, the provider would supply the vaccine, administer it, and then bill the beneficiary for the entire charge, including all components. The beneficiary would, in turn, submit a paper claim to the Part D sponsor for reimbursement for both the vaccine ingredient cost and administration fee. For example, Part B considers the immunizing professional’s time in physically delivering the vaccine to a beneficiary, the resources encompassing the supplies (syringe, gauze, band-aid, alcohol prep pad, etc. Drugs Excluded from Part D coverage: • Agents when used for anorexia, weight loss, or weight gain (even if used for a non- cosmetic purpose (i. Consequently, drugs covered under Parts A and B are considered available (and excluded from Part D) if a beneficiary chooses not to pay premiums or if a beneficiary has enrolled in Part B but that coverage has not yet taken effect. Drugs and biological products paid for under the Medicare Part A per-diem payments to a Medicare hospice program are excluded from coverage under Part D. See Appendix C for further explanation and clarification of specific issues regarding coverage under Medicare Part B. Drugs provided in an inpatient setting to an individual who has exhausted his or her lifetime inpatient hospital benefit under Part A are not drugs that could be covered under Part A for that individual. Unlike a beneficiary who, for example, chooses not to buy into Part B, there is no way for an individual who has exhausted his or her Part A inpatient stay benefit to obtain coverage under Part A for his or her drugs; therefore, Part D coverage may be available to a Part D enrollee who has exhausted his or her Part A inpatient stay benefit and who remains in that inpatient setting (provided the drug would otherwise be covered under Part D). However, Part D sponsors should rely upon (1) information included by the physician with the prescription, (2) information communicated by the pharmacist or included with the submitted claim, such as diagnosis information (e. Assuming the available information is sufficient to correctly assign payment to Part A or B or Part D, there is no need in such cases to require additional information to be obtained from the physician. To the extent that the Part D sponsor requires its contracted pharmacies to report the information provided on the prescription to assist in the determination of Part A or B versus Part D coverage, the sponsor should rely on the pharmacist’s report of appropriate information to appropriately adjudicate the claim under Part D. For example, for cases in which prednisone is prescribed for a condition other than immunosuppression secondary to a Medicare-covered transplant, and this is either documented on the prescription, or evident based on the prescriber’s specialty, a known diagnosis, or concomitant therapies, a sponsor may cover the drug under Part D without seeking further information from the prescribing physician. This clarification should not be construed to indicate that a Part D sponsor may not impose prior authorization or other procedures to ensure appropriate coverage under the Medicare drug benefit. Part D sponsors may apply prior authorization to establish appropriate payment under Part A or B or Part D, even if the beneficiary is currently taking the drug. For more information on Coverage Determination requirements, see Medicare Prescription Drug Benefit Manual, chapter 18, available at https://www. Such exclusions are coverage determinations or redeterminations pursuant to chapter 18 of this manual, and are subject to appeal. Unlike other Part D drugs that may be excluded when not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, Part D vaccines may only be excluded when their administration is not reasonable and necessary for the prevention of illness.
Since the scrotal contents are usually paired structures menstrual cycle pregnancy order discount female viagra, you should be able to breast cancer uk cheap female viagra 100 mg on line feel similar structures in each half of the scrotum menstrual cup 7 fold order female viagra without a prescription. Next fsh 87 menopause generic female viagra 50 mg online, check each half of the scrotum for a testicle (which feels like a large ovoid mass), epididymis (which feels like a ridge of tissue lying vertically on the posterolat- eral surface of the ovoid mass), and spermatic cord (which feels like a firm, nontender column of blood vessels and tissue ascending through and leaving the scrotal sac near the groin). Note: If the scrotal sac is empty on one or both sides, this indicates cryptorchidism or temporary migration of the testicle, which is caused by the cremaster muscles draw- ing the testicle up toward the inguinal canal. Use your other hand to capture the testicle, and gently palpate it to check its width and length. If testicular cancer is indicated, refer the client to a urologist or surgeon immediately. A small or abnormally soft testicle may indicate an endocrine disorder or testicular atrophy. In acute epididymitis, the epididymis is enlarged and tender compared to the other side. In severe epididymo-orchitis, the testes and epididymis may not be distinguishable from each other through palpation. Chronic, painless induration of the epididymis indicates tuberculosis, schistosomiasis (also called bilharzia), or nonspecific chronic epididymitis. Cystic masses near the upper pole of the testicle that are separate from the testicle and epididymis are usually spermatoceles, which contain thin, milky fluid and sperm; spermatoceles usually are not clinically significant. The cord, which consists of blood vessels, tissue, and the vas deferens, is palpable between the upper border of the testicle and the external inguinal ring. When palpating the spermatic cord, you can identify the vas deferens by feeling for a firm tube approximately 3 mm in diameter in a posterio- medial location within the spermatic cord. A swollen area in the spermatic cord may be cystic (indicating, for example, a hydrocele or hernia) or solid (indicating, for example, a lipoma or rare connective tissue tumor). Diffuse swelling and induration of the spermatic cord are present with filariasis. If the client does the Valsalva maneuver, palpating the spermatic cord may reveal a varicocele. Palpating the spermatic cord may also reveal bead-like enlargements of the vas deferens, which indicates tubercu- losis, or the absence of the vas deferens, which, if bilateral, causes infertility. During the genital examination, teach the client how to perform a genital self-examination (see Appendix F). The genital self-examination also helps the client become more aware of his body’s functions and promotes responsible health behaviors. Self-examination of the testes is particularly important for men between 15 and 40 years old, and those with a history of undescended testicle. When palpating for an inguinal hernia, use only your smallest finger or index finger. Gently insert the examining finger in to the scrotal wall just above and lateral to the testicle. Note: A fold of the scrotal skin covers your finger as you push it in to the scrotal wall. Feel for the vas deferens, and follow the vas upward and laterally to the inguinal ring (which feels like a sphincter) or inguinal canal. Instead, gently hold your finger against the inguinal ring, and ask the client to do the Valsalva maneuver. But if the client has an inguinal hernia, you feel pressure from a soft mass pushing through the inguinal canal on to the tip of your finger; this may be abdominal tissue or the bowel. When abdominal tissue penetrates the inguinal canal through the internal inguinal ring, the client has an indirect hernia. If abdominal tissue penetrates the inguinal canal through an abnormal opening in the abdominal wall, you feel a direct hernia pressing against the more proximal portion of your examining finger, away from the tip. When palpating for an inguinal hernia, also palpate the inguinal lymph nodes for swelling and tenderness. Infection and cancers of the penis and scrotal wall, as well as those of the legs, can spread to the inguinal and subinguinal nodes. When assessing a client with these conditions, remember to check for inguinal node enlargement and tenderness. Overview: Palpating for an Inguinal Hernia When you palpate for an inguinal hernia, keep in mind the following important points: • Palpating for an inguinal hernia may routinely be performed as part of an abdom- inal or genital examination. Ask the client (who is wearing a drape) to assume the lateral recumbent position, with both knees flexed, with the upper knee flexed more than the lower knee; or ask the client to bend forward, place his elbows on the examination table, and place his feet comfortably apart (you will sit behind him). Next, look at the perineum, which should be smooth and unbroken, and should have a regular contour with no significant discoloration or bulges. Then check the anal orifice, which should be brown or pinkish-brown and should not have any visible protruding masses. After explaining to the client what you are about to do, obtain the rectal specimen. Then slowly and gently insert a cotton swab in to his anus, and gently rotate the swab to capture the purulent dis- charge on the swab. Before you continue the rectal examination, check for rectal fissures (deep cracks), hemorrhoids, and anal herpes. If the client has any of these conditions, use an anes- thetic gel to lessen his pain before proceeding with the rectal examination. Wait at least five minutes after applying the gel to ensure that the anesthetic has time to work. If the client has a history of pain or bleeding with defecation, carefully examine the anus for rectal fissures, which may be hidden between the skin folds. If the client has a history of erectile dysfunction (particularly if he also has a history of possible neurological disease, injury, pelvic surgery, or diabetes), check for the bulbocavernosus reflex before touching the anal area. Overview: Obtaining a Rectal Specimen When you obtain a rectal specimen, keep in mind the following information: • Lubricant gels contain phenols to keep them free of bacteria, and the phenols can inhibit accurate results from collected rectal specimens. To prevent false negatives even when an infection is present, use lubricants that do not contain phenols. Checking the urethral meatus (if prostatitis is indicated) Note: Before you begin the prostate examination, tell the client that he does not have to change position. Tell the client that it enables you to inspect the prostate gland and to check for tumors and other possi- ble disorders. Remind the client that he may feel the urge to defecate or urinate, that this is normal, and that he will not lose bowel or bladder control. Before inspecting the prostate gland, place your nonexamining hand on the client’s hip or against his buttock to stabilize him and to enable him to prepare himself psycho- logically for the examination. Place the ball (the soft, fleshy part of the tip) of your well-lubricated, gloved finger flat against the anus. Ask the client to do the Valsalva maneuver as you slowly insert your finger in to the anus. Note: Rarely, a client may have a spasm of the rectal sphincter, which can be very painful. If this occurs during the prostate examination, hold your finger still and wait for the spasm to subside. This usually takes at least one minute but may last several minutes, especially if the examination is not gentle or unhurried or if the client is anxious. Next, with your finger pressing against the anterior wall of the rectum, feel for the prostate gland. The prostate gland is a roughly heart-shaped, symmetric organ, with two halves (lobes) that may be separated by an indentation through the rectal canal. The base of the prostate gland is wider than its apex and will be farther away from the examining finger than from the apex. The prostate gland usually feels rubbery and smooth; it should not feel hard, nodular, irregular, enlarged, or tender. Note: Most clients feel a mild-to-severe burning sensation in the penis when the ex- amining finger pushes on the prostate gland. To do this, you must know the length and width of your examining finger in centimeters. Typically, a prostate gland is palpable 2 to 5 cm inside the anal sphincter through the anterior rectal wall. With your examining finger, find the median sulcus, move your finger from the sulcus to the lateral borders of the right and left lobes, and assess the size of each lobe. Typically, a prostate gland is approx- imately 3 cm wide and 4 cm long, and its two lobes are symmetrical in size and shape.
Internal Male Genitals For a detailed review of the male reproductive system menstruation quiz discount female viagra on line, see Appendix A breast cancer breakthrough generic female viagra 50 mg visa. The Sexual Response Cycle in Men The human body’s physiologi- cal response to menstruation with large blood clots female viagra 100mg on line sexual stimula- tion begins with sexual arousal and may continue just after or- gasm women's health center kalgoorlie buy on line female viagra. This cycle con- sists of five main phases: desire (also called libido), excitement (also called arousal), plateau, orgasm, and resolution. The chart below pro- vides a brief description of each phase in the sexual response cycle in men. The Sexual Response Cycle in Men Phase Brief Description Body Changes Desire • Men’s minds and bodies can respond • No change sexually to a variety of stimuli—including sight, sound, smell, touch, taste, movement, fantasy, and memory. Excitement • Excitement is the body’s physical response • The penis becomes erect; the to desire. Initial physical excitement may be lost and • Erection of the penis is the key regained many times without progression indicator of sexual excitement to the next phase. Plateau • If physical or mental stimulation (especially • The ridge of the glans penis stroking and rubbing of an erogenous becomes more prominent; the zone or sexual intercourse) continues Cowper’s glands secrete pre- during full arousal, the plateau phase may ejaculatory fluid; the testes rise be achieved. At the moment of orgasm, the sex- thra, anus, and muscles of the ual tension that has been building pelvic floor contract three to throughout the body is released, and the six times at 0. Resolution • Resolution is the period following orgasm, • Nipples lose their erection; the during which muscles relax and the body penis becomes softer and begins to return to its pre-excitement smaller; the scrotum relaxes; state. Immediately following orgasm, men the testes drop farther away experience a refractory period, during from the body; heart rate and which erection cannot be achieved. For some men, it may involve intense spasm and loss of awareness; for others, it may be signaled by as little as a sigh or subtle relaxation. Sexual thoughts or feelings may trigger erections, as may either direct stimulation on or near the penis or other types of physical touch on the body. Erection occurs naturally during sleep and has even been observed on male fetuses in utero. Male Sexual Response and Aging Men have the capacity for sexual desire and sexual activity throughout their lives—there is no reason why they cannot express their sexuality well beyond the “reproductive years” (the ages during which men are fertile). In fact, men who have been sexually active throughout their adult lives seem to be more sexually responsive in old age than those who have not. The key to maintaining sexual function in later years is to continue a pattern of regular sexual activity over a lifetime. Many cultures have strong biases against sexual activity among middle-aged and elderly men, and expressions of sexual attraction among elderly men are sometimes treated with disdain. In much of the world, “sexy” is synonymous with “young”—media images of young, sexually vibrant men abound, while images of healthy sexuality among those mid- dle aged and beyond are nearly nonexistent. These attitudes can keep middle-aged and elderly men from receiving adequate health care. Similarly, pro- viders who do not consider the effects of chronic medical conditions and medications on sexual response when dealing with older clients may not anticipate these clients’ dissatis- faction with services and discontinuation of treatment if side effects occur. Normal Changes in Response with Age Although sexual activity can continue well in to a man’s 90s and beyond, the aging process does have an effect on male sexual response and function. Generally, the sexual response cycle in men slows down: The phase of response take longer to achieve, the intensity of sen- sation may be reduced, and the genital organs become somewhat less sensitive. Erectile dysfunction is more common with aging due to changes in penile blood flow. The presence and/or treatment of these disorders can result directly or indirectly in urinary, erectile, or libido problems. The chart on the next page shows the range of typical age-related changes in male sexual response. Service providers and health care facilities are strongly encouraged to supplement this ma- terial with appropriate medical reference books that present information about these and other conditions in greater depth. Chronic anal fissures may require sim- ple surgical treatment to reduce the pressure in the anal canal and allow the fissures to heal. For ex- ample, the consumption of refined carbohydrates and animal fats and proteins is much higher in the United States and Europe than in Africa and Asia. Generally, colon cancer is a disease of older individuals who have had little vegetable fiber in their diets or have familial polyposis or chronic ulcerative colitis. Al- though the specific bleeding lesions may vary considerably, the initial therapeutic and diagnostic approach to a client remains largely the same. The condition usually produces dramatic clinical signs and symptoms that bring a client to a service provider’s urgent attention. Hematemesis is caused by peptic ulcer, gastritis, esophageal varices or lesions, stomach cancer, benign tumors, traumatic postoperative bleeding, and swallowed blood from lesions in the nose, mouth, or throat. Diagnosis of hematemesis is usually made from the client’s history and the physical examination findings; an endoscopic or ear, nose, and throat examination may be required to confirm the diagnosis. Meletemesis is vomiting of material with gastric juice for at least two hours, which changes the bright red blood present with hematemesis to a brownish color. Clients who present with vomit that looks like “coffee grounds” are usually bleeding at a slower rate than those who have obviously bloody emesis. Hematochezia is caused by colon cancer or polyps, ulcera- tive colitis, diverticulitis, large hemorrhoids, anal tears, and Crohn’s disease. Management • Management varies depending on the cause of bleeding and the amount and rate and amount of blood loss. If the amount and rate of blood loss cause hemodynamic instabil- ity, resuscitative measures, including intravenous line and volume replacement, will be required. Thrombosis of external hemorrhoids (see below) is usually seen in young men and is often related to strenuous exercise. This type of exercise results in a temporary increase in intra-abdominal pressure, as well as more pressure on the dilated hemorrhoid veins, which makes them larger, with more stasis. If the pain does not subside within 48 hours, the thrombosed hemorrhoid should be excised under local anesthesia. Exter- nal hemorrhoids rarely cause symptoms by themselves, but they may eventually be as- sociated with pain, itch, and bleeding. External hemorrhoids increase in size when prolapsing internal hemorrhoids are present because of increased pressure from the in- ternal hemorrhoids. In addition, the anal sphincter contracts and reduces blood flow back in to the general circulation, which confines it to the hemorrhoids. If the con- dition is not treated promptly, it can lead to bleeding, pelvic abscess, peritonitis, and death. Mortality rises dramatically if the injury is penetrative, especially above the lev- ator ani, and causes infection. Management • Apply 25% podophyllin solution in compound benzoin tincture, or • Refer the client to a surgeon for fulguration with electrocautery or surgical excision. Disorders of the Breast § Signs and Symptoms Firm mass (either painless or painful) in the breast area Physical Examination Findings • Distortion of the shape of the breast and/or nipple • Change in the appearance of the skin, which may make it look like the skin of an orange Differential Diagnosis Breast cancer Comments • This condition is rare in men, but it does exist. Management Refer the client to a surgeon for biopsy and possible removal of the mass. If the condition is not treated promptly, it can lead to ischemia of the penis and then to gangrene or necrosis of the glans and foreskin. It usually occurs after cleansing of the glans (which requires prior foreskin retraction, after which the foreskin fails to go back to its usual position and act as a hood for the glans) or catheter insertion (which also requires prior foreskin retrac- tion). After foreskin retraction, the constricting phimotic ring causes progressive edema, impairs venous return, and threatens the viability of the glans. Management • After providing adequate local anesthesia to the penis, attempt manual reduction: Ap- ply gentle, steady pressure on the glans with the thumbs, while placing the other fingers of both hands behind the phimotic ring and foreskin. Management • Biopsy any lesion that does not resolve in the expected period of time. Management • Most clients require a retrograde urethragram to rule out urethral injury. Management • If the client is asymptomatic, fibrous-tissue formation does not require treatment. If the condition needs to be treated and is not managed promptly, it can lead to kidney damage, urinary tract ob- struction, and death. As normal secretions accumulate and there is sloughing of the skin, smegma (see Photograph 5 in Appendix H on page H. In severe cases, the opening of the foreskin may be completely closed, inhibiting urination and leading to urinary tract obstruction. School-age boys sprinkle some of this fluid under the foreskin to make their penises bigger, which stay enlarged for a couple of days because of severe inflammation, especially of the foreskin. This practice occasionally results in the boys’ acute inability to pass urine and sometimes requires surgery for emergency urinary diversion.
If so women's health clinic kilkenny generic female viagra 50mg overnight delivery, do not massage the prostate gland pregnancy x ray risk buy cheap female viagra 50 mg online, because this may cause the epididymitis to women's health clinic jackson wy purchase 50mg female viagra visa worsen pregnancy 0-40 weeks purchase female viagra 100 mg online. Management • General measures are complete bed rest and scrotal elevation with ice applied for 10 minutes three times a day. If the condition is not treated within 24 hours, it can lead to necrosis of the scrotal wall. Clients who have diabetes, use steroids, or abuse alcohol are also at higher risk for Fournier’s gangrene. Management • Refer the client to a surgeon immediately; a delay in treatment can significantly increase mortality. It is also caused by the mumps virus in postadolescent males, by tuberculosis, and by syphilis (see page 1. This condition is hard to distinguish from testicular tumors, and it can be diagnosed only after orchiectomy. Spermatogenesis is irreversibly damaged in about 30% of testes after mumps orchitis. If the condition is not treated promptly, it can lead to the permanent loss of re- productive function. Blunt trauma can be accompanied by scrotal swelling, and severe blunt trauma can involve rupture of the testicle. Management Refer clients with suspected testicular trauma to a surgeon immediately. A painless mass in the testicle should be presumed to be cancer until proven otherwise. Management Refer clients with suspected testicular cancer to a urologist immediately for surgery, ra- diotherapy, and/or chemotherapy, depending on the stage of the disease. If the condition is not treated promptly, it can lead to ischemia and necrosis of the testicle. The condi- tion is also caused by cold weather, sexual arousal, and scrotal trauma. Testicular torsion should be highly suspected and treated promptly because of the seri- ous consequences. Referred pain to the abdomen, diag- nosed as a stomach virus, is a common misdiagnosis. Management • Testicular torsion should be the primary consideration for any scrotal complaint in young boys and adolescent males. Generally, surgery within six to 12 hours of occurrence is necessary to prevent necrosis of the testicle and to salvage it. To perform the maneuver, stand on the client’s right side and help him assume a lithotomy position. Proceed with manual detorsion from medial to lateral—this action is similar to opening a book—because most testes twist in a lateral-to-medial position. Disorders of the Urethra § Signs and Symptoms • Painful, curved erection that makes sexual intercourse difficult or impossible • Deviation of the urinary stream • Urethra that does not open at the glans of the penis Physical Examination Findings • Urethral opening on the dorsal surface of the penis, between the pubis and glans • Groove that extends on the shaft of the penis from the actual urethral opening to the tip of the glans • Hooded foreskin • Dorsal scar tissue on the shaft of the penis that may be palpable • In severe cases, a visible, malformed scrotum Differential Diagnosis Epispadias Comments • This condition is a congenital displacement of the location of the urethral opening on the dorsal surface of the penis. Management • Explain to the parents or client that surgery corrects epispadias and that some follow-up is necessary to ensure the expected outcome of the surgery. Management • Explain to the parents or client that surgery corrects hypospadias and that no follow-up is necessary. The cancer grows very quickly, and the client typically comes in after it has spread. If the condition is not treated promptly, it can lead to kidney failure and backflow of urine. Urethral stricture can be a result of gonococcal urethritis or its treatment (see page 1. Management • Explain to the client that he needs a simple dilation procedure, which is done by a urologist. If the condition is not treated promptly, it can lead to urethral stricture, erectile dysfunction, and urinary incontinence. Poste- rior urethral injuries (between the bladder and the prostate gland) are usually associ- ated with pelvic fractures. Management • Treat the client for shock and hemorrhage, if present (see “Overview: Emergency Management of Shock” on page 1. Disability Perform a brief neurological examination to determine level of consciousness. Access • Catheterize the client intravenously with two large-caliber catheters placed for fluid resuscitation. Management • A Gram stain of the discharge examined under a microscope helps to diagnose the con- dition. If the condition is not treated promptly, it can lead to infection, sepsis, morbidity, and death. Management • Treat the client for shock and hemorrhage, if present (see “Overview: Emergency Man- agement of Shock” on page 1. Male Sexual Dysfunction Sexual dysfunction is the inability to react emotionally or physically to sexual simulation in a way expected of the average healthy individual or according to one’s own standards of acceptable sexual response. Alcohol and anxi- olytics can be “disinhibiting,” removing usual psychological inhibitions against sexual EngenderHealth Men’s Reproductive Health Problems 1. Many men have occasional experiences of not being able to attain an erection when they are tired, are physically cold, or have ingested too much alcohol. Antidepressants may de- crease desire due to the action of the drug, or increase desire due to alleviation of the depression. It could get out of control and lead to distress or, at the extreme, to unsafe sexual behavior or even illegal sexual behavior such as rape. It is often possible to switch to an- other medication that will have similar therapeutic benefits, but less negative impact on sexual functioning. Common Male Sexual Dysfunctions Male sexual dysfunction can manifest in a variety of ways. Therefore, taking a good his- tory is critical to ensuring a proper diagnosis and subsequent treatment. The following dis- cussion describes common male sexual dysfunctions and their corresponding causes, signs and symptoms, and management. Erectile Dysfunction Erectile dysfunction, or impotence, occurs when a man is unable to attain or maintain a hard, erect penis satisfactory for sexual intercourse. They may, for example, still have sexual desire, as well as the ability to have orgasms and ejaculate semen. Erectile dysfunction can occur for a variety of reasons and often may have more than one cause. Psychological causes of erectile dysfunction include stress and anxiety due to marital, fi- nancial, or any other external problem. For example, a man who is having problems in his marriage may find himself unable to have an erection because of the stress and anxiety he is experiencing in his relationship. Because of anxiety about his ability to “perform,” a man finds he cannot perform—which causes more anxiety, thus completing a vicious cycle. Vascular diseases may cause problems involving blood flow in to the penis to make it erect. They can also cause problems of holding the blood in the penis to maintain the erection. Thus, hardening of the arteries and other diseases that affect the vascular system are risk factors for erectile dysfunction. Diseases that affect the nervous system, such as multiple sclerosis and alcoholism, can also cause erectile dysfunction. Some diseases associated with erectile dysfunction, such as di- abetes, can affect both the vascular and the nervous systems. Erectile dysfunction can also result from pelvic fractures or crush injuries experienced in an automobile, motorcycle, or other accident. The accident victim may be left with injured nerves and/or penile arteries that cannot supply enough extra blood to the penis for an erection. Spinal cord injuries that destroy nerve fibers are another cause of erectile dysfunction. Some types of surgery and radiation therapy, such as for treating prostate, bladder, or rectal cancer, carry a risk for erectile dysfunction. In addition, certain medications might contribute to erectile dys- function (National Kidney and Urologic Diseases Information Clearinghouse Web Site). If erectile dysfunction occurs only occasionally, the problem is probably due to psycho- logical causes, such as stress and fatigue.
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