NSG 202: Benign Prostatic Hypertrophy/Hyperplasia & Prostate Cancer

Location

Effects of Aging on Urinary System

• Aging in men means:

  • Decrease kidney size

  • Increased DHT

  • Change in urinary pattern

  
  

• Results in

  • Tissue hyperplasia

  • Local inflammation

  • Increased stasis

  • Urinary retention/dribbling

Etiology

• Very common &  cause not understood

• Due to hormonal changes Dihydrotestosterone 

        (DHT) & aging

• Develops in the inner part of prostate gland

• Excessive prostate tissue = obstructive s/s

Risk Factors

• Age

  • Only “known” factor

    
    

• Race

  • Black men have higher incidence

  • Asian men have less incidence

    
    

• Genetic connection

  • Variants in some genes

    
    

• Modifiable

  • Obesity

  • Metabolic syndrome

  • Coffee and caffeine intake

  • Sedentary lifestyle

Benign Prostatic Hypertrophy/Hyperplasia (BPH)

• Enlargement of the prostate gland not cancer

• Occurs in 50% of men between 50-60 yrs

• 80% of men > 70 yrs 

• Not correlated to sexual frequency

• Does NOT increase risk of prostate CA

What happens in BPH?

• Increase in DHT

  • Causes hyperplasia

  
  

• Enlargement of the tissue

  • Causes LUTS - Urinary retention/leaking/incontinence

  • UTI and/or bladder stones

  • Residual/statis

Assessment of Urinary System

• Subjective

• Objective

Collaborative Care

• History

  • Determine severity of LUTS

  • International Prostate Symptoms Score (I-PSS)

  
  

• Physical Assessment

  • Elimination pattern

  • Urination specific questions

  • Hesitancy, reduced force, incomplete sensation, straining, dribbling, leaking

  
  

• Blood in urine

  
  

• Inspect & palpate abd

  
  

• Prepare for HCP to do DRE

Testing

• Labs

  • CBC for WBC/RBC

  • BUN/Creatinine

  • PSA

  • Serum acid phosphatase

  • Biopsy

• Urine

  • US

  • C&S

  • Residual

  • Pressure

  • flow test

• Imaging

  • TRUS

  • MRI

  • PSMA PET

  • Bladder US

DRE

Normal vs. Enlarged

• What type of kidney failure is the client with BPH at risk for developing?

• What lab value will give you a hint?

• What type of kidney failure is the client with BPH at risk for developing?

• What lab value will give you a hint?

What type of lab would you want to evaluate prior to a biopsy of the prostate?           

Nonsurgical Management

Drug Therapy: Alpha₁-Adrenergic Antagonists

• Alpha₁-Adrenergic Antagonists

  • alfuzosin (Uroxatral)

  • tamsulosin (Flomax)

  • doxazosin (Cardura) 

  • terazosin (Hytrin)

  • silodosin (Rapaflo) 

  
  

• Relaxes smooth muscle in the bladder neck

• Monitor BP → S/E dizziness, HA, weakness → Flomax/Uroxatral 30 min after meals & same time daily → Can interfere w/other drugs

Drug Therapy: 5 Alpha - Reductase Inhibitors

• 5 Alpha - Reductase Inhibitors

  
  

  • finasteride (Proscar)

  • dutasteride (Avodart)

  • Combo Avodart and Flomax – called Jaylen

  • Combo of Proscar and Cardura

  
  

• Reduces size of prostate to improve urine flow

• Assess BP

• Gynecomastia

• Risk for cancer

• Teratogenic - dermal absorption

• Full glass water

• Don't open capsule

Drug Therapy Continued

• Erectogenic Drugs

  • tadalafil (Cialis)

  
  

• Herbal Therapy

  • saw palmetto 

  
  

• Complementary/Integrative

  • Frequent sexual intercourse

Prostate Artery Embolism

Surgical Management HoLEP

Surgical Management TURP & TUIP

Pre/Post Op Care

• Anxiety

  • r/t fear of ED

  • r/t fear of incontinence

  
  

• Medications

  • Review meds to be stopped prior to sx per HCP

  
  

• Catheter

  • If needed they may see small clots or tissue

  • If home w/ catheter - teach care

Foley Irrigation

• Continuous 

• Closed Intermittent & 

• Open Catheter

Nursing Diagnosis for BPH

• Acute pain r/t bladder distention

• Risk for infection r/t indwelling catheter, urinary stasis

• Acute pain r/t inflamed tissues secondary to sx 

• Urinary retention r/t blockage from enlarged prostate

• Urinary incontinence r/t over distention of bladder

• Disturbed sleep pattern r/t nocturia

• Risk for infection r/t residual urine

• Knowledge deficit r/t management of BPH

The nurse notes bright red urinary drainage from a client who had a TURP with continuous bladder irrigation yesterday. What is the appropriate initial nursing action?

1. Calculate intake and output

2. Monitor Hgb/Hct

3. Increase the rate of the bladder irrigation

4. Document findings in the EHR

• A client has a continuous bladder irrigation after surgery yesterday.  The amount of bladder irrigating solution that has infused over the past 12 hours is 1100 mL’s.  The amount of fluid in the urinary drainage bag is 1950 mL’s. 

• The nurse records that the client had how many mL’s urinary output in the past 12 hours?

Prostate Cancer

Prostate Cancer Pathophysiology

• This cancer loves hormones!

• Androgen dependent adenocarcinoma 

• Tumors on outer area of prostate

• Slow growing

• Mets has predictable pattern

Prostate Cancer Risk Factors

• Age

  
  

• First degree relative

  
  

• African American

  
  

• Diet

Prostate Cancer Clinical Manifestations

• Asymptomatic in early stages

  • Eventually may experience s/s similar to BPH

  
  

• Urination issues

  • Gross hematuria late sign

  
  

• Pain

  • Pelvis, hips, spine & ribs

  
  

• Swollen lymph nodes

  
  

• Unexpected weight loss (advanced stages)

Important History

• Age

  
  

• Ethnicity

  
  

• Family history

  
  

• Nutritional habits

  
  

• Urinary issues

  
  

• Medications

  
  

• Changes in sexuality

  
  

• STI's

  
  

• Pain

  
  

• Last DRE

  
  

• Last PSA

Labs & Dx Studies for Prostate CA

• Initially:

  • PSA – Normal <50 yrs is 2.5 ng/mL

                 - suspicious if >4.0 ng/mL

  • DRE 

  • Biopsy – TRUS

  • Prostate specific biomarkers

   

• Once diagnosed:

  • Lymph node biopsy 

  • CT abd and pelvis and lymph nodes

  • MRI

  • Radionuclide bone scan

  • Liver function study

  • Serum acid phosphatase

  • Serum alkaline phosphatase

Plan of Care Status Post Diagnosis

• Based on extent of disease & pt physical condition

  
  

• Active surveillance in early stage

  • Consider pt overall health

  • Consider s/e of treatment r/t age of patient

  • Consider estimated life expectancy

  • Can be done for up to 10 years before tx starts

  
  

• Follow up imperative

  • Get regular DRE and PSA

  • Consider palliative tx to control spread or relieve distressing s/s

  
  

• Biopsy

  • Staging

  
  

• TURP

  • Staging done and potential removal of tumor

  
  

• Consider:

  • Tx with consideration for age, ED and incontinence potential.

  • Radiation therapy

  • Hormone therapy

  • Chemo

Metastasis of Prostate CA to Pelvis and Lumbar Spine

Non-surgical Radiation Therapy: External Beam Radiation Therapy (EBRT)

• 3D-CRT

  3-dimensional conformal radiation therapy

  Targets cancer

  Reduced damage to nearby organs & tissue

• IMRT

  • Intensity modulated radiation therapy

  • Most common

  • Very high doses to the prostate

• SBRT

  • Stereotactic body radiation therapy

  • Large doses to prostate over a few days

  • Takes less time than IMRT but has more s/e

Non-surgical Radiation Therapy EBRT Side Effects

• Erectile Dysfunction

  • Causes ED in many men well after the tx is done

  
  

• Elimination issues

  • Urine frequency

  • Diarrhea

  • Acute radiation cystitis

  
  

• Avoid caffeine

  • Drink plenty of fluids

  
  

• Radiation proctitis

  • Irritation of the rectum

  • Causes cramping and diarrhea and rectal leaking

  • Usually resolves following tx but rare cases it is permanent

  • Avoid spicy foods, fatty foods, caffeine and dairy products

Brachytherapy

• Implantation of radioactive seeds

  
  

• One time outpatient tx

  
  

• Side effects

  • Urinary issues

  • ED issues

  • Fatigue

  • Radiation proctitis

Drug Therapy

• Androgen deprivation therapy (ADT) (two types)

  • Androgen synthesis inhibitors

  • Androgen receptor blockers

• Luteinizing hormone-releasing hormone (LHRH) agonist or antiandrogens 

• Chemotherapy

Drug Therapy: Androgen Receptor Blockers

• Example: flutamide (Eulexin), nilutamide (Nilandron), bicalutamide (Casodex)

  
  

  • Block the action of testosterone by competing with circulating androgens at receptor sites

  • Can be combined with LH-RH agonists

  • Side effects: loss of libido, erectile dysfunction, hot flashes, breast pain, and gynecomastia

Radiopharmaceuticals

• To tx prostate cx that has spread

  
  

• Must have previously been tx with hormone therapy & chemo

  
  

• Intravenously in specific cycles

  
  

• Side Effects

  • Low RBC

  • Low platelets

  • Low WBC

  • Kidney damage

Drug Therapy Luteinizing hormone-releasing hormone agonist (LHRH agonist)

• Examples: 

  • leuprolide (Lupron) 

  • goserelin (Zoladex)

  • histrelin (Supprelin)

  • triptorelin (Trelstar)

  
  
  

  • Injections

  • Decreases testosterone production

  • For advanced prostate cancer

  • Goal: palliation

Drug Therapy Gonadotropin-releasing Hormone Antagonist

• Examples: 

  • degarelix (Firmagon) is injection 

  • relugolix (Orgovyx) is oral

  
  
  

  • Suppresses the testes' ability to produce androgens

  • For advanced prostate cancer

Drug Therapy Androgen Receptor Blockers

• Examples:

  • flutamide (Eulexin)

  • bicalutamide (Casodex)

  • nilutamide (Nilandron)

  
  
  

  • Block the body’s ability to use available androgens

  • May be used in combo with LHRH agonists for maximum effect

  • For metastatic disease and surgical or chemical castration with Degarelix/Relugolix

  • Liver toxicity danger

Chemo

• Systemic

• For patients with mets or if other therapies have not worked

• Done to slow the growth not to cure the cancer

• For quality-of-life purposes

Minimally Invasive Surgery Laparoscopic Radical Prostatectomy (LRP)

• Done with robotic assistance

• Most common procedure

• Removal of prostate gland, surrounding tissues and seminal vesicles

Radical Prostatectomy 

• Type is decided related to desired outcome and stage of the cancer

• Removal of entire prostate, prostatic capsule, the cuff at bladder neck, seminal vesicles and regional lymph nodes

• Post Op

  • Catheter in place 1-2 weeks

  • PCA for pain control

  • Monitor for PE and/or DVT

  • No strain with BM

  • 1 & O's

  • Monitor for infection - keep urinary meatus clean

  • No rectal meds or enemas

  
  

• Teach

  • Catheter care at home

  • Follow up visits imperative

Invasive: Radical Prostatectomy

Nursing Diagnosis

• Impaired Urinary Elimination 

• Anxiety/Fear

• Acute Pain / Chronic Pain

• Risk for sexual dysfunction

• Dysfunctional grieving or anticipatory grieving

The nurse is caring for a patient after a radical perineal prostatectomy for advanced cancer of the prostate.  What is a priority nsg dx for this patient?

 

1. Risk for infection

2. Sexual dysfunction

3. Total urinary incontinence

4. Risk for situational low self-esteem