Male Reproductive Problemos Flashcards
Benign Prostatic Hyperplasia (BPH)
Prostate = gland that surrounds neck of bladder & urethra in males; secretes fluid that forms part of seminal fluid
def: Non-inflammatory enlargement of prostate gland resulting from increase in # of epithelial cells and amount of stromal tissue
½ men will experience BPH in their lifetimes and ½ of these men (25% total) will have lower UTI symptoms
Benign prostatic enlargement = prostate growth sufficient to obstruct (block) urethral outlet resulting in lower urinary tract symptoms or UTI
Etiology:
-only partly understood
-thought to result from endocrine changes associated with the aging process
-possible causes are excessive accumulation of dihydrotestosterone (DHT) (the principal intraprostatic androgen), stimulation by estrogen & local growth hormone action
-DHT = is the androgen that goes up as men age and is a driver of growth in the prostate
Pathophysiology:
-enlargement obstructs bladder outlet leading to bothersome LUTS (lower urinary tract symptoms), increased risk of UTI, compromised upper urinary tract function
-bladder initially amplifies strength of detrusor contraction -> initially successful -> eventually overwhelms detrusor ability -> decline in urinary stream, feelings of incomplete bladder emptying
-may have UTI & hematuria (growth of blood vessels which are prone to disruption & bleeding)
-function of the detrusor muscle is to contract during urination to push the urine out of the bladder and into the urethra.
Risk Factors:
-family hx (esp 1st degree relatives)
Aging
Physical inactivity, -obesity (esp. increased abd. girth)
Diabetes
protective factors:
-dietary – high in zinc, butter, and margarine; -individuals who eat lots of fruits & veggies have lower incidence; lycopene in cooked tomatoes, green & yellow vegetables may be protective
-physical activity – protective
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Clinical Manifestations:
-Result from obstruction
-Gradual onset; may not be noticed until enlargement has been present for some time
-Early S/s usually minimal b/c bladder can compensate for small amount of resistance to urine flow. S/s gradually worsen as obstruction increases. Nocturia often the presenting symptom
Symptoms can be categorized into two groups: obstructive and irritative
obstructive;
-difficulty initiating voiding
-intermittency: stopping & starting stream several times while voiding
-Decrease in calibre & force of urinary stream
-hesitancy
-dribbling
irritative:
-associated with inflammation or infection
-Urinary frequency
-urgency
-dysuria, bladder pain,
-nocturia,
-incontinence
BPH and prostate cancer have similar symptoms. Obsrtuctuve and irritative s/s
-obstructive is first
-irritative come after and are progressive, to do with urine being retained
-nocturia with bladder spasms
Complications:
-acute urinary retention
-UTI & potential sepsis
-calculi (alkalinization of residual urine)
-renal failure from hydronephrosis, pyelonephritis or -bladder damage (if treatment for retention delayed)
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Diagnostics -dx
1) History and physical
-DRE – digital rectal exam
-Prostate should be evaluated for size, symmetry and consistency. In BPH, the prostate is symmetrically enlarged, form and smooth.
2) PSA levels
-Prostate specific antigen - a glycoprotein - elevated levels indicate a pathological condition of the prostate, though not necessarily prostate cancer. PSA levels can be slightly elevated in BPH, but more in prostatitis.
-PSA is good for trending impact of tx, not for diagnosing
3) Urinalysis with culture
4) Postvoid residual
-increases tx
5) Ultrasound
-Transrectal ultrasonography (RUS) scan is indicated in patients with elevated PSA and abnormal DRE. Helps differentiate between prostate ca and BPH. Biopsies can be taken during this procedure.
6) Cysto -Urethroscopy
-is done allowing internal visualization of the urethra and bladder if the diagnosis is uncertain AND in patients scheduled for prostatectomy
Collaborative Care: BPH
Goal:
-Restore bladder drainage,
-relieve symptoms
-prevent/ treat complications.
Watchful waiting
-depending on age, S/s (not size of prostate)
-Treatment is generally based on the degree to which the symptoms bother the patient or the degree to which complications are present vs the size of the prostate
-those with mild LUTS (basically conservative therapy, noninvasive first like diet exercise, maybe introduce medications)
-dietary changes (decreasing caffeine & artificial sweeteners, limiting spicy or acidic foods)
-avoiding OTC decongestants & anticholinergic medications (prevent bladder contraction)
-restricting evening fluid intake
-timed voiding schedule
Drug Therapy:
-relax prostate muscle/slow prostate growth (reduce size of prostate which takes a long time, takes med compliance)
-combination therapy most effective
DRUG 1: 5α-Reductase inhibitors
ex. finasteride, dutasteride
-slow prostate growth by inhibiting conversion of testosterone into dihydroxytestosterone (DHT) in prostate gland
-6 months to achieve effect
-sexual side effects include decreased libido, volume of ejaculate, and erectile dysfunction
-lower serum PSA levels & may mask presence of prostate cancer
DRUG 2: α1-adrenergic blockers
ex. Terazosin or Tamulosin
-selectively relax smooth muscle of prostate, bladder neck & proximal urethra
-Improvement in symptoms occurs within 2-3 weeks
-Side effects include fatigue, dizziness, postural hypotension, retrograde ejaculation, etc, but they provide symptomatic relief vs actual treatment of hyperplasia.
(faster working for BPH s/s, but drop BP)
other drugs:
-Erectogenic drugs: Cialis has been used in some men for BPH AND ED or ED alone. Has shown effectiveness in reducing symptoms
-herbal agents (e.g. Saw Palmetto) but trials suggest no greater effect than placebo
Invasive Therapy:
(TURP is the best curative tx)
-Transurethral resection of the prostate (TURP): GOLD STANDARD
TURP: removal of prostate surgery using resectoscope inserted through urethra; used to be “gold standard” but now used less b/c of dev’t of less invasive technologies
-Done under spinal or general anesthetic
-HOLD ASA or anticoagulants preop
-Pain and UTI most common preop problems necessitating TURP
-TUIP (transurethral incision of prostate)
–moderate to severe symptoms & small prostates who are poor surgical candidates
-done under local anesthesia & as effective as TURP in symptom relief
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Prostatectomy (if radical, entire prostate gland, seminal vesicles, & part of bladder neck removed)
-surgery of choice for larger prostates
-regrowth occurs over period of 1 – 15 years
-prostate cancer may still develop if total prostate not removed
intermittent or indwelling catheter
-may temporarily relieve symptoms when obstruction is severe, severe LUTS, recurrent UTI, hematuria, bladder stones, or upper urinary tract distress
Minimally invasive therapy:
generally don’t require hospitalization or catheterization; decreased complications
TUMT
-transurethral microwave thermotherapy
-heat causes death of tissue
TUNA
-transurethral needle ablation
-increases temperature & causes localized necrosis
Laser prostatectomy
-visual or U/S guidance
intraprostatic urethral stents if contraindications to surgery or anaesthesia
TURP: Preop Care, Postop Care
TURP: Preop Care
hold ASA
Insert catheter to drain bladder before surgery
-Lidocain- Topical analgesic in a prefilled syringe. Freezes end of urethra. Add to sterile field
-May require coude (curved tip) catheter. curved and metal tipped catheter. So doesn’t bend at the prostate
Antibiotics usually given before invasive procedures
Postop Care:
Main complications:
-Hemorrhage
-Bladder spasms
-Urinary incontinence
-Infection
Manage CBI
-To flush the blood out, stop clotting cascade and obstruct outflow
-rate determined by colour of drainage
-Goal is light pink with no clots
-Small clots are expected for 24-36h, but bright red blood can indicate hemorrhage.
-to stop: Slow down to almost the point of stopping the CBI to check if outflow is still light pink = good to stop CBI
-Remove CBI 2-4 days postop; trial of void 6h after cath removal
Avoid activities that increase abdominal pressure (ie straining)
Dietary interventions / bowel protocol to avoid straining; adequate fluid intake
Urinary dribbling/ incontinence common initially; can improve with Kegel exercises over first 2 months postop
Prostate cancer vs BPH
Prostate cancer vs BPH
BPH – smooth symmetrical, enlarged, on the inner part
Cancer- irregular, hard, nodular, on the outer part
Prostate Cancer
Malignant tumor of the prostate gland
Androgen-dependent adenocarcinoma (overgrowth of cells in a gland)
which means….after the age of 50, most men have a decrease in testosterone, but have an increase in dihydrotestosterone (DTH- a potent form of testosterone)
-Majority of tumours in outer aspect of prostate
-Usually slow growing but progressive if left untreated
-Can metastasize through direct extension, lymph system, or bloodstream
-Direct extension – seminal vesicles, urethral mucosa, bladder wall, & external sphincter
-Lymphatic system – regional lymph nodes
-Bloodstream – pelvic bones, head of femur, lower lumbar spine, liver, lungs
Causes:
1/7 men
10% inherited; 90% sporadic
-Age 50+
Ethnicity
-2x higher in black > white >Asian men
Family history-especially if family member got it at a younger age
Obesity/Diet high in fat, dairy products, red meat and processed meat which has saturated fat
Occupational exposure to cadmium
Genetic link -mutations in luminal and basal cells of the prostate. Also links to BRCA1 and BRCA2 (genetic mutations causing breast cancer)
Prevention:
Green & yellow veggies or lycopene in tomatoes is protective; green tea may prevent & diminish progression
More ejaculations found to lower risk
weight and physical activity
Clinical Manifestations:
-Generally asymptomatic during early stages
-Urinary symptoms may occur (similar to BPH):
dysuria
hesitancy
dribbling
frequency
urgency
hematuria
nocturia
retention
interruption of urinary stream
inability to urinate
-pain in lumbosacral area that radiates to hips or legs when coupled with urinary symptoms may indicate metastasis
Early recognition & treatment important to control growth, prevent metastases (to pelvic lymph nodes, bones, bladder, lungs & liver), & preserve QOL
Advanced prostate cancer:
-weight loss
-fatigue, back aches because spreading tends to be local to the pelvis. Can have fractures in pelvis and lower vertebrea if boney spread
Dx:
-DRE: GOLD STANDARD
-Hard, nodular, asymmetrical
First DRE
Then transrectal US
Then biopsy to confirm
Once dx, bone scan, CT and/or MRI for extent of spread
-don’t test PSA in BC to dx. PSA trends response to tx. Should go down to undetectable levels during tx
PSA – prostate-specific antigen; glycoprotein produced by prostate gland; elevated in prostate cancer, BPH or prostatitis; not specific to cancer but when cancer exists, is useful marker of tumour volume (i.e. higher the PSA, greater the tumour mass)
New test: Prostate Cancer Associated 3 gene specific to prostate cancer cells. If present in the urine, indicates prostate ca. More accurate than PSA.
Staging and Grading:
-Two staging classification systems:
1) Whitmore-Jewett. Stages A-D
2) TNM – tumour node metastases
Both based on size of the tumor and spread. Both are used in Canada.
Grading of the tumor is done using Gleason scale – based on how well-differentiated tumour cells appear on microscopic analysis; poorly differentiated cells are associated with more aggressive forms of cancer (scale of 1-5). Based on type of cells
Collaborative Care:
-Depends on the stage of the cancer and overall health of the patient.
At all stages, there is more than one treatment.
-Age/time left and QOL, side effects, long term implications
Watchful waiting
-Slow growing
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Radical prostatectomy:
-removal of entire prostate, seminal vesicles, part of bladder
-entire prostate removed b/c cancer tends to be in many different locations within the gland
-catheter in place for 1-2 weeks postop
-risk for erectile dysfunction & incontinence
-may be possible to do nerve-sparing procedure to spare nerves responsible for erection
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Hormone therapy:
– block androgen (testosterone) production to reduce tumour growth; may be used as adjunct therapy before surgery or radiation.
-Selection or combination of – bilateral orchiectomy, estrogens, gonadotropin-releasing hormone analogs, & anti-androgens
-Hormonal side effects:
-effectively Counteracts DHT but has female characteristic side effects -hot flashes, muscle atrophy, loss of libido
-Long term risk factors such as cardiovascular disease, risk for CVA
Radiation:
– poor surgical risk, > 70 years
-Common side-effects may include:
Nausea, vomiting, fatigue, hair loss
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Cryosurgery:
– destroys cancer cells by freezing tissue (liquid nitrogen to freeze)
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Chemo:
– limited to treatment for those with hormone-resistant cancer in late-stage disease. Not a standard tx for prostate cancer
-Common side-effects may include:
Nausea, vomiting, fatigue, hair loss
Testicular Cancer
Relatively rare
5 year survival rate of 96%
common in:
-males ages 15-29 years
-in Rt testicle
-undistended testes
-fam hx of test cancer
-synthetic estrogen that prevents miscarriages- risk factor for test cancer
Predisposing factors: HIV, orchitis (inflam of testicle), maternal exposure to diethylstilbestrol, testicular ca in contralateral testis
Clinical Manifestations:
-Similar to breast cancer
-painless, non-tender, firm, lump in scrotum
-scrotum swelling, feeling of heaviness
-Slow or rapid onset depending on type of tumor
Dx:
-Palpation of firm mas
-Ultrasound
-Serum alpha-fetoprotein, LDH, and hCG; CBC/ LFT’s
-CXR and/ or CT abdo/pelvis to detect metastases
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Collaborative Care:
-Early recognition: TSE (see Table 57-9) from the age of 15 yrs
-Fertility and sperm banking should be discussed preop. Tx can affect both erections and fertility
Surgery:
-Orchiectomy or radical orchiectomy (removal of affected testis, spermatic cord, and regional lymph nodes)
Postop Care:
-Surveillance
-Chemotherapy/ radiation
97% remission rates with early recognition
Treatment-related toxicity significant
Vasectomy
def: Bilateral surgical ligation of the vas deferens for the purpose of sterilization
15-30 minutes in duration
Outpatient procedure under local anaesthesia
Usually irreversible
Does NOT affect production of hormones nor ejaculation
Not “reliable” until 6 month postop; alternate forms of contraception should be used until verification occurs
After surgery, ejaculation is tested for presence of sperm
abnormal dx
PSA between 0-4 is a normal range. A 3.4 is a little high, but within normal range.
blood is more dilute than normal because he is not eliminating enough fluid as usual from the urinary tract.
possible answers
-inform him that erectile problems are uncommon following a TURP, but that some retrograde ejaculation may occur.
- Risk for bleeding as evidenced by treatment regimen (presence of urinary catheter)
^ Correct! Although all the nursing diagnoses may be appropriate for R.W., you must prioritize assessment of urinary drainage because postoperative hemorrhage may occur from displacement of the catheter, dislodgement of a large clot, or increases in abdominal pressure. Release or displacement of the catheter dislodges the balloon that provides counterpressure on the operative site. Remember your ABCs of prioritization!
R.W. returns from surgery with IV fluids running and a triple-lumen urinary catheter connected to continuous bladder irrigation (CBI) with sterile normal saline. The catheter tubing that exits R.W. has light red drainage with a few small clots, and the irrigation is ordered to be kept at a rate to keep the urine light pink. Two hours after his return to the unit, R.W. asks you to check his catheter for leaks because his bed feels wet. You find the linen under his hips saturated with pink-tinged urine.
The most likely cause of R.W.’s problem is:
clots in the catheter. (correct)
hyperperistalsis and abdominal pressure.
traction on the catheter.
temperature of irrigant.
A - Bladder spasms occur as a result of irritation of the bladder mucosa from the insertion of the resectoscope, presence of a catheter, or clots leading to obstruction of the catheter. If bladder spasms develop, check the catheter for clots.
The continuous bladder irrigation is stopped the second postoperative day, and R.W.’s catheter is discontinued the next morning in preparation for discharge. You recognize that discharge may be somewhat delayed if R.W. experiences
reddish voided urine.
dribbling of urine after voiding.
an inability to void within 6 hours. (correct)
bladder pain and burning on urination
C - Correct! After the catheter is removed, the patient should void within 6 hours, and if he cannot, a catheter is reinserted for a day or two. The patient may be discharged home with an indwelling catheter but will need education on its care before discharge. Blood in the urine is expected and should subside with rest and more fluids. Postoperative dribbling or incontinence is not uncommon, as is some bladder pain and burning on urination.
You plan teaching for R.W. in preparation for his discharge. Select the appropriate instructions that should be included in his discharge teaching. There are 6 correct responses.
(Y) Avoid heavy lifting, driving, and sexual activity until approved by the health care provider.
(Y) Avoid or limit intake of bladder irritants such as caffeine, citrus juices, and alcohol.
(Y) Drink at least 2 L of fluid per day and urinate q2-3hr to flush the urinary tract.
(Y) If dribbling or incontinence occurs, use the previously taught Kegel exercises 10 to 20 times/hr.
(N) You may return to work after a 6-week recovery period at home with restricted activity.
(Y) Report any fever, increased redness of your urine, or increased pain to your health care provider.
(N)Since your prostate gland was removed, you do not have to have annual prostatic examinations.
(N) Use daily enemas and stool softeners to avoid straining to have a bowel movement.
(N) Shower and apply a clean dressing over your incision daily.
(Y) You should eat a diet high in fibre to prevent constipation.
