Benign Prostatic Hyperplasia and Prostate Cancer

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Benign Prostatic HyperplasiaandProstate Cancer

• 11/7/05
• N125
• Colleen OLeary-Kelley, RN, PhD, CCRN

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Overview

• Describe pathophysiology, symptoms and care of
  benign prostatic hypertrophy
• Describe pathophysiology, symptoms and care of
  patients with prostate cancer

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Benign Prostatic Hyperplasia

• Enlargement of the prostate gland resulting from
  an increase in the number of epithelial cells and
  stromal tissue

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Location of the Prostate Gland
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Etiology of BPH

• Cause not completely understood
• Increase in number of cells resulting from
  endocrine changes associated with aging
• Accumulation of dihydroxytestosterone,
  stimulation by estrogen and prostatic growth
  hormone actions

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BPH facts

• Occurs in 50 of men over 50 and in 80 of men
  over 80 have BPH
• BPH progresses differently in every individual
• Many men with BPH may have mild symptoms and may
  never need treatment
• BPH does not predispose to the development of
  prostate cancer

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Benign Prostatic Hyperplasia
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Clinical manifestations

• Voiding symptoms
• decrease in force and size of urinary stream
• difficulty in initiating voiding
• intermittency stopping and starting stream
• dribbling at the end of urination
• incomplete bladder emptying due to urinary
  retention

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Clinical manifestations

• Irritative symptoms
• urinary frequency
• urgency
• dysuria
• bladder pain
• nocturia
• incontinence
• symptoms associated with infection

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Complications

• Urinary retention
• UTI
• Sepsis secondary to UTI
• Residual urine
• Calculi
• Renal failure

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Diagnostic Tests

• History Physical
• Digital rectal exam (DRE)
• Urinalysis
• Urine culture
• BUN, Cr

• Prostate specific antigen (PSA)
• Transrectal ultrasound biopsy
• Uroflometry
• Postvoid residual

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DRE
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PSA

• Elevated levels of PSA
• 0 4 ng/ml
• Prostatic pathology
• Correlates with tumor mass
• Some men with prostate cancer have normal PSA
  levels

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Medical Management

• 5 alpha reductase inhibitor reduce size of
  prostate gland Proscar
• Blocks the enzyme of 5 alpha reductase which is
  nec, for the conversion of testosterone to
  dihydroxytestostersone
• Regression of hyperplastic growth
• Side effects decreased libido, decrease volume
  of ejaculation, and erectile dysfunction

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Medical Management

• Alpha adrenergic receptor blockers promote
  smooth muscle relaxation in the prostate
• Relaxation of the muscles facilitates urinary
  flow
• Cardura, Hytrin, Flomax
• Side effects postural hypotension, dizziness,
  fatigue,
• Other problems can occur when pt is also taking
  cardiac or other hypertensive drugs

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Medical Management

• Herbal therapy saw palmetto fruit use to
  improve urinary symptoms and urinary flow
• Problem with herbal therapy long term
  effectiveness

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Medical Management

• Avoid taking large amounts of fluid over a short
  period of time
• Avoid alcohol and caffeine because of its
  diuretic effect
• Void whenever the urge is present, every 2-3
  hours
• Maintain normal fluid intake, do not restrict
  fluid

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Invasive therapy

• Transurethral resection of the prostate
• Transurethral microwave thermotherapy
• Transurethral incision of the prostate
• Transurethral needle ablation
• Prostatectomy
• Laser Prostatectomy
• Urethral stents

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Transurethral resection of the prostate (TURP)

• Surgical procedure involving removal of prostate
  tissue using a resectoscope inserted into the
  urethra
• Spinal or general anesthesia
• 3 way catheter inserted after procedure
• Bladder continuous irrigation
• Postoperative complications bleeding, clots

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Transurethral Resection of the Prostate (TURP)
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Preoperative Goals

• Restoration of urinary drainage
• Treatment of any urinary tract infection
• Understanding of procedure, implications for
  sexual functioning and urinary control

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Preoperative care

• Antibiotics
• Allow pt to discuss concerns about surgery on
  sexual functioning
• Prostatic surgery may result in retrograde
  ejaculation

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Postoperative Goals

• No complications
• Restoration of urinary control
• Complete bladder emptying
• Satisfying sexual expression

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Postoperative Care

• Complications- hemorrhage, bladder spasms,
  urinary incontinence, and infection
• TURP continuous bladder irrigation with sterile
  normal saline

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TURP post-operative care

• Monitor IO
• Maintain patency of catheter
• Follow MD order to irrigate catheter
• If resistance is felt when introducing fluid into
  the catheter or if there is no return of fluid,
  call the MD DO NOT FORCE THE FLUID
• Blood clots and hematuria are expected for the
  first 24-36 hours

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TURP

• Monitor for signs of bleeding
• Ask MD for specific guidelines in monitoring the
  pt
• Bladder spasms check patency of catheter, meds.
  Belladonna, Ditropan

• Clots can cause obstruction and pain catheter
  may need to be irrigate
• Narcotics for pain
• After catheter is removed check for urinary
  retention and urinary stream

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TURP

• Sphincter tone may be poor after catheter is
  removed. Kegal exercise pelvic muscle floor
  technique is encouraged. Starting and stopping
  the urinary stream is helpful.
• Stool softeners to avoid straining
• Sitting and walking for long periods should be
  avoided

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Laser Prostatectomy

• A laser beam is used to destroy part of the
  prostate
• A laser beam is delivered transurethrally through
  a fiber instrument
• Pt send home with catheter

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Post- Laser Prostatectomy

• Monitor for infection- redness, heat, swelling,
  drainage
• Avoid straining

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Discharge planning

• Catheter care
• Managing urinary incontinence
• Oral fluid intake 2,000-3,000 cc per day
• Observe for s/s of urinary tract and wound
  infection
• Prevent constipation
• Avoid lifting
• No driving or intercourse after surgery as
  ordered by MD
• Assess need for home care nurse

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Nursing Diagnosis

• Preoperative
• Acute pain
• Risk for infection
• Fear

• Postoperative
• Acute pain
• Urinary incontinence
• Risk for infection
• Potential complication
• hemorrhage

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PROSTATE CANCER
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Prostate Cancer

• Most common cancer among men
• One of every five men will develop prostate
  cancer
• Second leading cause of cancer death
• Incidence of cancer rises after age 50
• African American men have a higher incidence than
  Caucasian men

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Prostate Cancer

• Is an androgen-dependent adenocarcinoma
• Slow growing
• Spread by direct extension, lymph system, and
  bloodstream
• Heredity

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Clinical Manifestations

• Asymptomatic in early stages
• May experience symptoms similar to BPH- dysuria,
  hesitancy, dribbling, frequency, urgency,
  hematuria, nocturia, poor urinary stream,
  inability to urinate
• Low back, hip and leg pain
• Cancer can spread to pelvic lymph nodes, bones,
  bladder, lungs and liver.

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Diagnostic Studies

• History Physical
• DRE
• PSA
• Prostatic Acid Phosphatase
• Biopsy
• Transrectal ultrasound
• CT scan
• MRI
• Bone scan

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Prostate Cancer Staging

• Stage A tumor microscopic and intracapsular
• Stage B tumor palpable on rectal exam but
  confined to prostate
• Stage C tumor extended beyond the capsule of
  prostate
• Stage D tumor met. to distant organs

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Medical Management

• Drug therapy
• Radiation
• Surgery

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Hormones or Antiandrogens

• Luteinizing hormone-releasing hormone agonist
  Lupron, Eligard, Viadure
• Androgen receptor blocker Eulexin, Nilandron
• Estrogen

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Side Effects of Hormones

• Hot flashes
• Loss of libido
• Erectile dysfunction
• Breast pain
• Gynecomastia
• Estrogen side effects- DVT, CVA, MI

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Chemotherapy

• Mitoxantrone, Cytoxan, Idamycin, Ellence
• Biphosphonates pt with advanced cancer develop
  bone complications such as fractures and spinal
  cord compression, Actonel, Fosamax, Zomex

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Radiation

• External radiation 5 days a week for 6-8weeks
• Side effects skin (redness, irritation, pain,
  GI tract ( diarrhea, abd. Cramping, bleed),
  Urinary track (dysuria, frequency, hesitancy,
  fatigue, urgency, nocturia), fatigue, bone marrow
  suppression,

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Brachytherapy

• Implantation of radioactive implants in to the
  prostate
• Side effect - urinary irritative or obstruction
  problems
• Effective with Stage A and Stage B
• See notes from cancer lectures

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Prostate Brachytherapy
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Surgery

• Radical prostatectomy
• Removal or prostate, seminal vesicles and part of
  the bladder neck
• Orchiectomy removal of testis, side effects
  hot flashes, erectile dysfunction, loss of
  libido, irritability
• Cryosurgery freezing tissue

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Prostatectomy

• Surgery of choice for men with large prostates
• Involves external incision with three possible
  choices retropubic midline abd. incision,
  perineal an incision between the scrotum and
  anus, suprapubic- an abd. incision
• Complications bleeding, postoperative pain, risk
  for infection, erectile dysfunction

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Surgical approaches for prostatectomy

• Retropubic
• Midline abd. incision
• Perineal
• Incision between the scrotum and anus
• Suprapubic
• Abdominal incision

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Prostate Screening

• prostate screening guidelines
• PSA and DRE starting at the age of 50 or younger
  if risk factors present

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