Prostate

-gland in men that surrounds neck of bladder and deepest part of urethra
-produces a fluid that becomes part of semen
-size of a chestnut
-composed of glandular and muscular tissue
-seminal fluid protects and nourishes sperm cells

BPH
-disorder of aging male
-glandular units in prostate undergo hyperplasia, results in enlargement/hypertrophy
-extends upward and inward into bladder when enlarged
-narrows protastic-urethral channel
-obstructs urine outflow
-gradual outflow resistance effects bladder:
-hyperirritable (urgency, frequency)
-retrograde, causing dilation of ureters (hydroureter)
-back up into kidneys, hydronephrosis
-overflow urinary incontinence, leaks around enlarged prostate
-urinary stasis can lead to UTI
-cause is unknown
-because it is almost always older men general theories are:
-systemic hormonal alteration
-aging is major contributor
-presence of testicular androgen
-BPH does not occur in men who were usually traumatically
castrated before puberty
-men w/BPH have regression if testes are removed

S/S of BPH (LUTS)

-hesitancy of urinary stream
-intermittancy of urinary stream
-reduced force and size of stream
-sensation of incomplete bladder emptying
-post-void dribbling (overflow incontinence)
-bladder distention
-hematuria
-possible evidence of renal insufficiency, including edema, pallor, pruritis
-uniform elastic, non-tender, palpable prostate

Laboratory Assessment of BPH

-urinalysis for glucose, protein, occult blood and pH levels
-culture, to rule out UTI
-CBC: WBCs, RBCs (infection)
-evaluate presence of infection
-assess for anemia
-BUN, serum Cr to evaluate renal fxn (elevated w/renal dz)
-PSA
-if prostatic fluid expressed, sent for examination and cultures

Radiographic Assessments for BPH

-xray of kidneys, ureters, and bladder KUB
-IV urography
Other assesements
-urodynamic studies to evaluate degree of obstruction
-flowmetry: flow rate analysis, assessment of residual urine
-bladder scan: measure residual urine
Treatment
-removal is usually only tx
-drug therapy is on the rise
Drug Therapy
-Proscar/Finastra: shrinks the prostate gland
-lowers level of dihydrotestosterone (DHT) which is major cause of prostate gland
enlargement
-may need to take drug for 6 mos b4 improvement is noticed
-s/e ED and decreased libido
-Alpha-blocking agents: Hytrin, Cardura, Flomax
-prostate gland constricts and reduces occlusion and pressure
-improves urine flow
-Androgens

Complementary/Alternative Therapies
-saw palmetto extract
-lycopene: botanical found in tomatoes

Other measures
-release of prostatic fluid
-prostatic massage
-frequent sexual intercourse or masturbation
-avoid drinking large amounts of fluid in short time
-avoid over-consumption of alcohol, caffeine, diuretics
-avoid anticholinergics, antihistamines

Surgical Mgmt
-Criteria for surgery:
-pt has acute urinary retention
-chronic UTI, secondary to residual urine in bladder
-problems w/hematuria, hydronephrosis
-bladder neck obstructions, nocturia, incontinence, dribbling, etc
-Goals:
-remove obstruction
-Procedures for removing:
-surgeon removes hyperplastic tissue and leaves capsule
-open or closed removal depending on size of gland, location of
enlargement, age/physical condition, whether bladder surgery is needed
-TURP: traditional closed, surgical procedure, commonly performed
-thru urethra
-enlarged portion is resected into small pieces
-safer for clients who are at risk for open b/c no surgical inscision
-hospitalization is shorter
-b/c only small pieces are removed, remaining tissue may continue
to grow and cause obstruction
(p1418-1419)
-Davinci
-computer integrated
-robotic
-allows intraabdominal articulation
-3D binocular vision
-minimal blood loss, less than 100ml (open 600ml)
-less pain, less narcotics
-shorter hospitalization, faster recovery
-potentially continence
-better potency
Post Op
-3 way urinary catheter
-once catheter inserted and into bladder, balloon is inflated and anchored
-catheter is pulled down into prostatic fossa to prevent bleeding
-catheter should not be kinked or loose
-continuous bladder irrigation, to remove blood clots and ensure urine drainage
-irrigated w/sterile NS, rate of infusion is based on color of drainage
-urine drainage s/b light pink w/o clots
-inflow and outflow of irrigation s/b continuously monitored
-if not equal there may be a clot that needs to be flushed
-maintain patency
-when urine catheter is removed, client may experience burning, frequency, dribbling, pass small
clots for several daysincrease fluids up to 2500ml to decrease dysuria and keep flushed
-by time of d/c pt should be voiding 150-200ml q3-4 hours

Complications (potential)
-bleeding
-bladder spasms (painful, can trigger bleeding)
-strict I/O
-Amacar may be prescribed to control bleeding
-analgesics and antispasmodics (Bentil, Anatropin, Oxy., Opium suppositories)
-measure H&H, blood loss

Health Teaching
-teach pt that may be a temporary loss or control of urine (dribbling)
-may have to use Kegel exercises to re-establish control
-procedures should not cause ED, may have functional ED for a short time

Prostate Cancer
-most common invasive cancer of men
-95% are adenocarcinoma that arise from epithelial cells of prostate, usually located in posterior
lobe or outer portion of gland
-one of slowest growing, metastasizes in a predictable pattern
-common sites: lymph nodes, bone marrow, bones of pelvis, sacrum, lumbar spine, lungs, liver,
adrenal glands
-intact hypothalamic-pituitary-testicular pathway must be present
-men castrated b4 puberty at little risk
-increasing age increases risk
-family hx
-hx of sexually transmitted dz
-viruses: herpes II, cytomegalovirus (CMV), heavy metal exposure
-occurs rarely b4 age 39
-1/6 b/w ages of 60-79

S/S of Prostate Cancer

-bladder neck obstruction -difficulty initiating urination
-recurrent bladder infections -urinary retention
-most common: gross, painless hematuria -bone pain in surrounding areas, more advanced stage
-physical exam and prostate cancer screening -increased incidence in AA
-DRE and PSA beginning at age 50 -1st degree relative= risk: should begin screening
earlier
-PSA is produced slowly by prostate -stony, hard, palpable indurations suspect malignancy
(DRE)
-normal PSA is <4ng/mL
-higher in men w/BPH, prostatitis
-should never be used as a screening test w/o a DRE
-PSA is not specifically dx of prostate cancer
-25% of clients w/cancer have PSA levels of <4ng/mL
-runs higher in older adults, AA
Other Dx
-ultrasonography w/biopsy
-needle core/aspiration biopsy
-complications: hematuria, clots, fever, perineal pain
-after dx is made, radiographic and blood studies
-CT of pelvis and abd
-MRI to assess status of pelvic lymph nodes
-bone scan to detect metastatic dz
-liver studies to indicate metastasis
-about 90% of clients w/bone metastasis have elevated serum alkaline phostpatase
Tx
-older adults, clients who are asymptomatic may choose to just observe
-avg time from dx to start of tx 7-10years
-active tx options:
-surgery
-radiation
-drugs
-management depends on extent of dz and physical condition
-b/c some are resistant to radiation, surgery is standard
-radical prostatectomy is performed
-may have ED after surgery, directly related to pudendal nerve damage
-possibility of urinary incontinence
-can be performed perineal, suprapubic, retropubic
-entire gland and capsule removed, cuff at bladder neck, seminal vesicles, regional lymph nodes,
remaining urethra is attached to bladder neck
-drug therapy after surgery: abx, analgesics, IV PCA, laxative, stool softeners
-indwelling catheter
-Bentil to reduce bladder spasms
-Kegel exercises after surgery
-bilateral orchiectomy: palliative surgery, advanced cancer, not curative, removes both testes,
intent is to arrest cancer spread by removing testosterone source

Complications
-urinary incontinence (internal and external sphincters lie close to prostate)
-ED-damage to pudendal nerves

Non-surgical Mgmt
-adjunct to surgery
-radiation therapy
-hormonal or chemotherapy
-prostate cancer is hormone dependent, extensive tumors, usually managed by androgen
deprivation, estrogens, gonadotropin releasing hormones
-chemo: systemic, cytotoxic not as effective as main tx; used when no response from hormonal
-may prolong survival but do not cure dz
-targeted therapy: antibodies, antisense drugs

Teaching
-if pt goes home w/catheter may have for up to 2-3wks
-teach catheter care
-walk short distances after surgery
-lift no more than 15 lbs for up to 6 wks
-remain in upright position
-no vigorous exercise for 12 wks then gradually introduced
-opiods for pain, tx constipation

ED
-inability to maintain or achieve erection for sexual intercourse
-2 classes: organic and functional
-organic
-gradual deterioration of fxn
-diminishing firmness
-decrease of frequencies of erections
-inflammation of prostate, urethra, seminal vesicles
 -surgical procedures (prostatectomy)
-pelvic fractures
-lumbosacral injuries
-vascular dz, HTN
-chronic neurological conditions (parkinsons, MS)
-endocrine d/o, DM, thyroid
-smoking and alcohol consumption
-drugs
-poor overall health
-functional/psychological
-normal, nocturnal and morning erections
-every time a man goes into REM sleep, erection occurs
-preceded by high stress

Diagnostic
-hormone testing used for client w/poor libido, small testicles, sparse beard growth
-serum testosterone, gonadotropins
-duplex Doppler, ultrasonographyarterial and venous blood flow
-noctile penile tumescence test: done in sleep lab, measures nighttime erections
-if nocturnal erections, functional ED

Management
-sexual therapy
-drug therapy: relaxation of smooth muscles so blood flow is increased
-viagra, levitra-sexual stimulation is needed w/in 30-60minutes to
promote erection
-cialis-erection can be stimulated over longer period
-headaches, facial flushing, profound HoTN
-intracorporal injections: vasoconstrictive agent
-intraurethral applications: creams
-prostheses