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benign enlargement of the prostate gland
In what part of the prostate does BPH develop?
inner part of the prostate
Does BPH predispose a pt to prostate CA?
The etiology of BPH is not completely understood - what is the most likely etiology?
endocrine changes associated with aging
2 endocrine changes occur r/t aging that may contribute to the development of BPH?
1. excessive accumulation of dihydroxytestosterone (androgen)
2. decreased testosterone which leads to a greater proportion of estrogen to testosterone
Severity of the s/s of BPH are more r/t _____ than the size of the enlargement.
location of the enlargement
7 risk factors for BPH?
- 1. family Hx
- 2. obesity- especially large waste
- 3. decreased physical activity
- 4. DM
- 5. age >50
- 6. smoking
- 7. drinking
2 ways alcohol effects the development of BPH?
1. increases fat & --> fat stores estrogen --> increased estrogen
2. acts as a diuretic --> dehydration
How does smoking effect the development of BPH?
constricts smooth muscle (muscle in BVs & urinary system) -->issues with the urinary system & blood flow to the urinary system
Manifestations of BPH are a result of _____ _____.
What usually brings a pt with BPH to the MD office?
altered urination pattern
2 types of s/s that occur in BPH?
obstructive s/s & irritative s/s
4 s/s of BPH that occur r/t obstructive s/s?
- 1. decreased size/force of urinary stream
- 2. hesitancy - difficulty initiating
- 3. intermittency - stopping & starting
- 4. dribbling at the end of urination
irritative s/s of BPH?
- 1. frequency
- 2. retention
- 3. urgency
- 4. dysuria
- 5. nocturia
- 6. incontinence - stress incontinence
- 7. bladder pain
What are the s/s of UTI with BPH?
- 1. WBC, bacteria, hematuria on UA
- 2. other s/s of UTI: burning, fever, etc
complications of BPH?
- 1. acute urinary retention
- 2. UTI
- 3. pyelonephritis
- 4. sepsis
- 5. calculi
- 6. bladder damage r/t calculi or retention
- 7. renal failure r/t hydronephrosis -
Tx for acute urinary retention?
- catheter insertion to drain the bladder -
- surgery may be required
Pathophysiology of UTI r/t BPH?
incomplete bladder emptying --> residual urine --> favorable conditions for bacterial growth
Pathophysiology of renal failure r/t hydronephrosis?
urinary retention --> urine backs up into the kidneys --> distention of pelvis & calyces of the kidney
Dx of BPH?
- 1. H & P
- 2. DRE - digital rectal exam
- 3. UA with C&S
- 4. PSA - prostate specific antigen
- 5. serum creatinine
- 6. postvoid residual
- 7. transrectal ultrasound - TRUS
- 8. uroflowmetry
- 9. cystoscopy
- 10. AUA symptom index
Who conducts DRE & what will results be in BPH?
MD does it
prostate will be enlarged, firm, and symmetrical
Priority consideration during DRE?
may cause vagal response: HR & BP drop --> may pass out or change cardiac rhythm
monitor & educate patient
What is PSA mostly testing for?
What other conditions may cause increased PSA?
BPH & other prostate problems
What will serum creatinine show with BPH?
if kidney had been effected
How is the post-void residual test performed?
What is it testing for?
tests for urinary retention
usually done with a TRUS - transrectal ultrasound
Uses for transrectal ultrasound (TRUS) in BPH?
What test may be done with TRUS?
gives accurate assessment of prostate size & differentiates BPH from prostate cancer
may do a biopsy during the ultrasound
What is measured by uroflowmetry?
How is the test performed?
measures volume of urine expelled from the bladder per second
watch the person pee using radiography
Why is postvoid residual urine volume measured?
to show extent of urine flow obstruction/ urine retention
What is the purpose of cytoscopy?
How is it performed?
When will it be done?
internal visualization of the urethra & bladder
a camera is put up through urethra & into the bladder
will be done if Dx is uncertain & in pt who are scheduled for prostatectomy
3 goals of Tx for BPH?
- 1. restore bladder drainage
- 2. relieve s/s
- 3. prevent or Tx complications of BPH
5 things to educate about with BPH?
- 1. yearly DRE
- 2. adequate fluids
- 3. avoid alcohol, caffeine, & smoking
- 4. nutrition: avoid irritating foods: spicy, acidic, artificial sweeteners
- 5. weight mgmt/loss
- 6. s/s to report
2 things to monitor during post-procedure care for a transrectal ultrasound (TRUS)?
- 1. v/s r/t vagal response
- 2. bleeding & irritation
4 things to monitor post-cytoscopy?
- 1. hematuria
- 2. pain
- 3. v/s for hypovolemia r/t bleeding
- 4. make sure pt can pee
interventions for BPH?
- 1. "watchful waiting" -
- 2. meds
- 3. transurethral microwave therapy
- 4. transurethral needle ablation
- 5. laser prostatectomy
- 6. intraprostatic urethral stents
- 7. transurethral resection of the prostate (TURP)
When is "watchful waiting" Tx used?
4 interventions involved in watchful waiting?
used when no-mild s/s
- 1. dietary changes: decreasing caffeine & artificial sweeteners & limiting spicy/acidic
- 2. avoiding some meds: decongestants & anticholinergics
- 3. restricting evening fluid intake
- 4. timed voiding scedule
2 types of drugs that may be used to Tx BPH?
- 1. 5 alpha-reductase inhibitors
- 2. alpha adrenergic receptor blockers
5 alpha-reductase inhibitor action in BPH?
What are two 5 alpha-reductase inhibitors?
proscar & avodart
blocks enzyme(5 alpha-reductase) that is needed for conversion of testosterone to dihydroxytestosterone --> suppresses androgens --> causes prostate to reduce in size
When is proscar an appropriate Tx for BPH?
moderate to severe s/s
Education with proscar?
- 1. takes about 6 mo to be effective
- 2. if used with ED meds may cause orthostatic hypotension
- 3. women of child-bearing age who may become pregnant or are pregnant should not handle tablets
Adverse effects of 5 alpha reductase inhibitors (proscar & avodart)?
- 1.decreased libido
- 2. decreased volume of ejaculate
- 3. ED
How may 5 alpha-reductase inhibitors (proscar & avodart) affect a man's chances of getting prostate cancer?
decreases PSA levels & lowers the risk of low-grade early-stage prostate cancer
6 alpha-adrenergic blockers that may be used for BPH?
- 1. silodosin/Rapaflo
- 2. alfuzosin/Uroxatral
- 3. doxazosin/Cardura
- 4. prazosin/Minipress
- 5. terazosin/Hytrin
- 6. tamsulosin/Flowmax
Action of alpha-adrenergic blockers in BPH?
What are they effective?
Tx s/s of BPH by promoting smooth muscle relaxation in the prostate --> facilitates urinary flow through the urethra (do not Tx hyperplasia just the s/s)
effective b/c there are many adrenergic receptros in the prostate that are increased when the prostate is enlarged
When will improvement of BPH occur using alpha-adrenergic blockers?
2 to 3 wks
4 AE of alpha-adrenergic drugs?
- 1. orthostatic hypotension
- 2. dizziness
- 3. retrograde ejaculation
- 4. nasal congestion
What is retrograde ejaculation?
ejaculate goes into the urinary bladder instead of out the urethra
Effect on BPH?
some ppl think it helps but it has no effect
What 4 procedures for BPH are considered minimally invasive?
- 1. transurethral microwave thermotherapy
- 2. transurethral needle ablation
- 3. laser prostatectomy
- 4. intraprostatic urethral stents
2 advantages of most of the minimally invasive procedures for BPH?
- do not require hospitalization or catheterization usually
- have few adverse effects
less effective than invasive procedures at improving urine flow
What is transurethral microwave thermotherapy (TUMT)?
use of microwave radiating heat to produce coagulative necrosis tissue death) of the prostate
- 1. outpatient
- 2. ED & retrograde ejaculation are rare
- 1. potential for damage to surrounding tissue r/t heat
- 2. urinary catheer needed post-procedure
- 3. may need retreatment
How is TUMT performed?
How are surrounding tissues protected from heat?
transurethral probe is used to deliver microwaves to prostate while rectal temperature is taken during the procedure to be sure temperature is kept below 110 F to prevent rectal tissue damage
Post-op complication with TUMT?
post-op urinary retention - pt will be sent home with indwelling catheter for 2 to 7 days to maintain urinary flow & facilitate passing of small clots or necrotic tissue
Pre-op teaching for TUMT?
pt should stop anticoagulants 10 days before procedure
4 AE (adverse effects) of TUMT?
- 1. bladder spasm
- 2. hematuria
- 3. dysuria
- 4. retention
Transurethral needle ablation (TUNA)?
low-wave radiofrequency (electricity) used to heat the prostate & cause necrosis
(same as TUMT except use different method to heat the tissue)
4 advantages of TUNA for BPH?
- 1. outpatient
- 2. ED & retrograde ejaculation are rare
- 3. greater precision in removal of the target tissue
- 4. very little pain experienced
4 disadvantages of TUNA?
- 1. urinary retention is common
- 2. irritative voiding s/s
- 3. hamaturia
- 4. may need retreatment
What kind of anesthesia is used for a TUNA procedure?
local anesthesia & IV or oral sedation
How long does the TUNA procedure last?
Pain experienced with TUNA?
very little pain with early return to regular activities
4 AE of TUNA?
Will the pt need a urinary catheter?
- 1. urinary retention
- 2. UTI
- 3. irritative voiding s/s
- 4. hematuria for up to a week
some pt requre urinary cath for a short period
What is laser prostatectomy?
How is the laser guided?
procedure that uses a laser beam to cut or destroy part of the prostate
use visual or ultrasound guidance
How does the laser beam reach the prostate?
through the urethra
3 ways laser is used in laser prostatectomy?
- 1. cutting
- 2. coagulation
- 3. vaporization of prostatic tissue
4 types of laster prosatectomy that may be used?
- 1. visual laser ablation of prostate (VLAP)
- 2. contact laser technique
- 3. photovaporization of prostate (PVP)
- 4. interstitial laser coagulation (ILC)
4 advantages of laser prostatectomy procedures?
- 1. short procedure
- 2. comparable results to TURP - very effective
- 3. minimal bleeding
- 4. rapid s/s improvement
4 disadvantages of laser prostatecotomy procedures
- 1. catheter needed for up to 7 days after procedure r/t edema & urinary retention
- 2. delayed sloughing of tissue
- 3. takes severa weeks to reach optimal effect
- 4. retrograde ejaculation
Visual laser ablation of the prostate (VLAP)?
laser beam produces deep coagulation necrosis of the prostate which gradually sloughs in the urinary stream
2 disadvantages VLAP?
- 1. takes several weeks to reach full effect
- 2. need urinary catheter to allow for drainage post-op
Contact laser techniques?
direct contaxct of the laser to the prostate tissue with immediate vaporization of the prostate tissue
4 advantage s of contact laser techniques for BPH?
- 1. bleeding is rare b/c laser cauterizes blood vessels on contact
- 2. catheter is only needed for a short time post-op: 6 to 8 h
- 3. faster recovery time
- 4. may be done on a pt taking anticoagulants
Photovaporization of the prostate (PVP)?
uses high-power green laser light to vaprozie prostate tissue
3 advantages of photovaporization of the prostate (PVP)?
- 1. bleeding is minimal
- 2. catheter only needed for 24 to 48 h post-op
- 3. effective with larger prostate glands
Interstitial laser coagulation (ILC)?
prostate viewed through a cytoscope & a laser is used to treat precise areas by placement of interstititial light guides directly into the prostate tissue
Intraprostatic urethral stents?
How is it performed?
stents placed directly into the prostatic tissue
self-expandable metallic stent is inserted into the urethra where enlarged area of prostate occurs
3 complications of intraprostatic urethral stents?
- 1. chronic pain
- 2. infection
- 3. encrustation
Why are intraprostatic urethral stents usually ineffective?
tissue will continue to grow --> grows over stents
Transurethral electrovaporization of prostate (TUVP)?
electrosurgical vaporization & desiccation are used together to destroy prostatic tissue
2 advantages of TUVP?
minimal bleeding & sloughing
2 disadvantages of TUVP?
Intraprostatic urethral stents 2 advantages/
safe & effective
2 disadvantages of intraprostatic urethral stents?
- 1. stent may move
- 2. long-term effect is unknown
2 invasive procedures used for BPH?
transurethral resection of the prostate (TURP)
transurethral incision of the prostate (TUIP)
Invasive Tx of symptomatic BPH primarily involves _____ or _____ of the prostate.
resection or ablation- (removal of material from the surface of an object by vaporization, chipping, or other erosive processes)
When is invasive therapy indicated in BPH?
What may be used to temporarily relieve these issues until surgery is done?
- 1. decrease in urine flow sufficient to cause discomfort
- 2. persistent residual urine
- 3. acute urinary retention
- 4. hydronephrosis
intermittent or indwelling catheterization
Why is invasive surgery for BPH perferred to long-term catheterization?
risk for infection in catheterization
What surgical procedure has been considered the "gold standard" in BPH Tx?
TURP- transurethral resection of the prostate
Transurethral resection of the prostate (TURP)?
removal of prostate tissue using a resectoscope inserted through the urethra
How is TURP performed?
- 1. pt will be under spinal or general anesthesia
- 2. resectoscope inserted through urethra to excise & cauterize obstructing prostatic tissue
- 3. lg 3-way indwelling cath with a 30-mL balloon is inserted
- 4. bladder is irrigated continuously or intermittently for 1st 24h approx.
Is there an external surgical incision with TURP?
no - through urethra
4 post-op complications of TURP?
- 1. bleeding
- 2. clot retention
- 3. hypo or hypervolemia r/t irrigation
- 4. dilusional hyponatremia r/t irrigation
Pre-op teaching for pt undergoing TURP?
- 1. discontinue aspirin or warfarin several days before surgery
- 2. sexual functioning may be affected by surgery
- 3. Ejaculate may be decreased or absent r/t retrograde ejaculation
- 4. retrograde ejaculation is not harmful: semen is eliminated during the next urination
TURP pre-op care?
- 1. urinary drainage must be restored before surgery
- 2. ABX (prophylactic or if have UTI)
- 3. Find out about pt sexual activities r/t sexual function affected by surgery
- 4. Educate
- 5. dietary: NPO
- 6. make sure consents are signed
- 7. labs: CBC, CMP, creatinine/BUN, clotting function, platelets, UA with C&S
How is urinary drainage restored pre-op TURP?
catheter is inserted: may require a coude (curved tip) catheter or urologist may insert a filiform catheter (rigid enough to pass the obstruction)
What is usually done prior to inserting a coude catheter?
2% lidocaine gel is injected into the urethra before insertion
- 1. lubrication
- 2. local anesthesia
- 3. opens urethral lumen
3 interventions that will be done if a pt has a UTI pre-op TURP?
- 1. ABX
- 2. restoring urinary drainage
- 3. encouraging a high fluid intake of 2 to 3 L/day if not contraindicated
What issues may occur r/t sexual functioning post-op TURP?
- 1. some degree of retrograde ejaculation
- 2. decreased orgasmic sensations
Post-op TURP care?
- 1. bladder irrigated intermittently/manually or via continuous bladder irrigation (CBI) with steril NS
- 2. monitor inflow & outflow of catheter
- 3. Catheter care
- 4. Monitor for hemorrhage, bladder spasms, urinary incontinence, infection, & DVT
- 5. Meds: Tx bladder spasms, ABX
- 6. monitor VS for hypo/hypervolemia s/s
- 7. Teach pt to practice Kegel exercises 10 to 20 times per hour while awake
- 8. diet (high fiber) & stool softeners to prevent straining
- 9. prevent increased abd pressure: straining, sitting or walking for prolonged periods, sneezing, coughing, etc
How is manual bladder irrigation performed?
instill 50mL NS then withdraw with a syringe to remove clots
Nursing consideration when doing manual irrigation of the bladder?
may cause painful bladder spasms
What is the rate of infusion of the TURP irrigation catheter based on?
Ideal urine drainage appearance post-op TURP?
the appearance of the drainage
light pink without clots (blood clots are expected for the first 24 to 36 hours)
What type of catheter is used for a TURP procedure?
3-way 18 to 22 french foley catheter with a 30mL bulb that is used to drain & irrigate the bladder
- large balloon provides hemostasis at the surgery site & irrigating facilitates urinary drainage by preventing obstruction from mucus & blood/blood clots
How long will the bladder by irrigated after a TURP?
about 24 h
What should the nurse's first action be if the outflow of the post-op TURP catheter is less than the inflow?
check the catheter patency for kinks or clots
What should the nurse do after discovering that the post-op TURP catheter is clogged with a clot & patency cannot be reestablished by manual irrigation
must stop CBI (cont irrigation) & call the MD
cannot replace the catheter!
Catheter care post-op TURP?
- 1. aseptic technique to prevent infection
- 2. prevent urethral irritaion & minimize risk of bladder infection by securing the catheter to the leg
- 3. connect to a closed-drainage system & do not diconnect unless it is being removed, changed, or irrigated
- 4. cleanse secretions around meatus with soap & water daily
If a post-TURP pt reports pain/bladder spasms what should the nurse's first action be?
check the catheter for clots & remove by irrigation
S/S of hemorrhage in Post-TURP pt?
- 1. s/s of hypovolemia
- 2. lg amnts of bright red blood in the urine
3 causes of hemorrhage in a post-TURP pt?
- 1. displacement of catheter
- 2. dislodging a lg clot
- 3. increases in abd pressure
Intervention that may be done for post-TURP bleeding?
Complication that may occur r/t to this intervention?
may apply traction on the catheter to provide counterpressure (tamponade) to the bleeding site
local necrosis can occur if pressure is applied for too long
How is necrosis r/t pressure on bleeding post-TURP site prevented?
pressure is relieved on a sceduled basis
Education for pt experiencing bladder spasms post-TURP?
teach pt not to urinate around the catheter because it increases likelihood of spasms
Tx for post-TURP bladder spasms/pain?
- 1. make sure urine is flowing freely from catheter
- 2. meds: belladonna & opium suppositories or other antispasmotics (oxybutynin/Ditropan)
- 3. relaxation techniques
When is the catheter removed post-TURP?
2 to 4 days after surgery
When should the pt urinate after catheter is removed post-TURP?
What will be done if the pt cannot urinate at this time?
within 6 hours
reinsert a catheter for a day or 2 - if problem continues will instruct pt in clean intermittent self-catheterization
Why may urinary incontinence/dribbling occur post-TURP?
sphincter tone is decreased by the surgery
- 1. 10-20 kegel exercises per hour while awake
- 2. practice starting & stopping the stream several times during urination
- 3. use a penile clamp, condom catheter, or incontinence pads/briefs
- 4. may implant an occlusive cuff that acts as an artificial sphincter
How long does it take a pt to regain urinary continence after TURP?
How long may incontinence improve?
may take several weeks or may never be regained
can improve for up to 12 months
What special care must be taken post-TURP if a perineal incision has been made?
- 1. increased risk for infection r/t proximity of anus
- 2. rectal procedures should be avoided: temp, enemas
- 3. insertion of well-lubricated belladonna & opium suppositories is acceptable
Instructions for home care post-TURP?
- 1. caring for indwelling catheter if still in place
- 2. managing urinary incontinence
- 3. maintaining oral fluids b/t 2-3L per day
- 4. observing for s/s of UTI & wound infections
- 5. preventing constipation
- 6. avoiding lifting heavy objects (>10lb)
- 7. refraining from driving or intercourse after surgery
- 8. continue to have yearly DRE unless complete prostate removal has been performed
What is the cause of retrograde ejaculation?
What are some s/s?
trauma to the internal urethral sphincter
- 1. semen is decreased or absent
- 2. urine is cloudy when urinating after orgasm
Why may ED occur in post-TURP pt?
nerves may be cut/damaged during surgery
Nursing consideration for a pt who experiences ED r/t surgery?
anxiety may occur r/t change in sex role, self-esteem, & quality of sexual interaction with his partner
How long may it take post -TURP for complete sexual functioning to return?
up to 1 year
How long does it take the bladder to return to its normal capacity post-TURP?
takes up to 2 months
- 1. drink at least 2L fluid per day
- 2. avoid bladder irritants: caffeine, citrus juices, alcohol, artificial sweeteners
What complication may occur post -TURP/BPH surgeries r/t instrumentation or catheterization?
teaching intermittent clean self-cath or having a urethral dilation
Transurethral resection syndrome?
excess absorption of irrigation fluid --> FVE
S/S of transurethral resection syndrome?
- 1. altered LOC/confusion
- 2. agitation
- 3. decreased HR
- 4. increased RR & BP
- 5. vomiting
- 6. HA
- 7. tremors
If s/s of transurethral resection syndrome occur what is the nurse's action?
report to MD immediately
Transurethral incision of the prostate (TUIP)?
surgical procedure done under local anesthesia that is done for men with small prostates & moderate to severe symptoms that are not a condidate for TURP
is as effective as TURP
3 types of invasive resections used in BPH?
- 1. suprapubic
- 2. retropubic
- 3. perineal
Prostate cancer is an _____-dependent _____carcinoma that is usually _____ (fast/slow) growing.
3 routes by which prostate cancer may spread?
- 1. direct extension
- 2. lymph system
- 3. bloodstream
If prostate cancer spreads by direct extension areas affected include _____ _____, ______ ____, ______ _____, & ______ ____.
What will later occur?
- seminal vesicles (secrete seminal fluid)
- urethral mucosa
- bladder wall
- external sphincter
will later spread through lymph system
If prostate cancer spreads through the bloodstream where does it commonly spread to?
- 1. bones: pelvic, head of femur, & lower lumbar spine
- 2. liver
- 3. lungs
4 risk factors for prostate cancer?
- 1. age: rise after age 50 then again after age 65
- 2. ethnicity: higher in african americans: more agressive tumors with higher mortality
- 3. family Hx
- 4. diet: high in red meat & high-fat dairy & low in veggies & fruits
What drug may prevent prostate cancer?
Progression of s/s in prostate cancer?
- 1. may be asymptomatic in early stages
- 2. will progress to s/s similar to BPH
- 3. pain in lumbosacral area that readiates down to hips or legs indicates metastasis to bones
Once the prostate tumor metastasizes the priority intervention is r/t ____.
bone cancer causes severe pain especially in the back & legs r/t compression of the SC & destruction of bone
At what age should men be screened for prostate cancer?
What screening is performed?
age 50 to age 75 (after age 75 there is little benefit to screening/Tx)
annual DRE & PSA
Dx of prostate cancer?
- 1. DRE: hard, nodular, & asymmetric
- 2. PSA: elevated
- 3. prostatic acid phosphatase (PAP): elevated r/t bone metastasis
- 4. if DRE or PSA are abnormal -> do PAP & if that is elevated -> will do biopsy for definitive DX
- 5. CT, bone scan, & MRI to see location & extent of spread
- 6. TRUS
If a person is Dx with prostate CA using biopsy what will be the next testing done?
radiography (MRI & CT) to test for metastasis
6 causes of increased PSA?
- 1. aging
- 2. BPH
- 3. recent ejaculation
- 4. chronic prostatitis
- 5. long bike rides
- 6. prostate cancer - will be higher than others usually
What may cause decreases in PSA>?
proscar or avodart
What lab may be used to monitor the success of Tx in prostate CA?
PSA level: should fall if Tx is successful
can also monitor for return of CA
How is prostate biopsy normally done?
use TRUS to visualize prostate & find abnormalities --> biopsy needle inserted into prostate
How is an MRI of prostate performed?
using an endorectal probe
2 ways to stage & grade prostate cancer?
- 1. Whitmore-Jewett
- 2. TNM
Whitmore-Jewett staging classification of prostate cancer stage A, B, C, & D?
Stage A1, A2, B1, B2, C1, C2, D1, D2?
- Stage A: clinically unrecognized
- * A1: <5% of prostatic tissue neoplastic
- *A2: >5% of prostatic tissue neoplastic
- Stage B: clinically intracapsular
- B1: nodule <2cm & surrounded by palpably normal tissue
- B2: nodule >2cm or multiple nodules
- Stage C: clinically extracapsular
- C1: minimal extracapsualr extension
- C2: large tumors involving seminal vesicles, adjacent structures, or both
- Stage D: metastatic disease
- D1: pelvic lymph node metastases
- D2: distant metastases to bone, viscera, or other soft tissue structures
How is the prostate tumor graded?
graded on basis of tumor histology using the Gleason scale that grades from 1 to 5 based on degree of glandular differentiation - the 2 most commonly occurring patterns of cells are graded & grades are added together to get Gleason score of 2-10
grade 1 is most well-differentiated
What is the Gleason scale used for?
to predict how quickly cancer will progress
Location of development of BPH & prostate cancer?
BPH develops on the inside of the prostate & prostate cancer develops on the outside
Tx of prostate cancer?
- 1. "watchful waiting"
- 2. surgery
- 3. radiation & chemo
- 4. drug therapy
2 reasons may take "watchful waiting" approach with prostate cancer?
1. life expectancy <10 years = low risk of dying of the cancer
2. presence of a low-grade, low-stage tumor: monitor progress with DRE & PSA
Stage A prostate cancer Tx?
- 1. watchful waiting with annual PSA & DRE
- 2. radical prostatectomy
- 3. radiation therapy : external beam & brachytherapy
Stage B prostate cancer Tx?
- 1. radical prostatectomy
- 2. radiation therapy
Stage C prostate cancer Tx?
- 1. radical prostatectomy
- 2. radiation therapy
- 3. hormone therapy
- 4. orchiectomy
Stage D prostate cancer Tx?
- 1. hormone therapy
- 2. orchiectomy
- 3. chemotherapy
- 4. radiation therapy to metastatic bone areas
entire prostate gland, seminal vesicles, & part of the bladder neck(ampulla) are removed with lymph node dissection usually done as a separate procedure
In what stage of cancer is radical prostatectomy not considered an option unless it is to relieve s/s associated with an obstruction?
3 surgical approaches for a radical prostatectomy?
Surgeries that may be performed?
- 1. retropubic
- 2. perineal
- 3. laparoscopic
- 1. radical prostatectomy
- 2. cryotherapy
- 3. orchiectomy
- 4. nerve-sparing procedure
Retropubic approach to radical prostatectomy?
low midline abd incision made --> access prostate gland & disect pelvic lymph nodes
Perineal resection approach to radical prostatectomy?
incision made b/t scrotum & anus - cannot remove lymph nodes
Laparoscopic approach to radical prostatectomy?
4 small incisions made in abd & surgeon uses computer & cameras
- 1. less bleeding
- 2. less pain
- 3. faster recovery
Nursing care with a radical prostatectomy?
- similar to TURP care:
- 1. will have same catheter as with TURP
- 2. monitor for infection, bleeding, hypovolemia, DVT, & PE
- 3. monitor incision site
- 4. ABX
How is removal of drainage aided during post-radical prostatectomy?
drains are left in surgical site & usually removed after a couple of days
What is the increased risk associated with perineal approach to radical prostatectomy?
increased risk for infection r/t proximity to anus
careful dressing changes & perineal care after each BM
Length of hospital stay post- radical prostatectomy?
1 to 3 days depending on type of surgery
8 complications that may occur post-radical prostatectomy?
- 1. ED
- 2. urinary incontinence
- 3. infection complications: hemorrhage, DVT/PE, infection
- 4. wound dehiscence
- 5. urinary retention
4 factors that effect whether ED occurs during radical prostatectomy?
- 1. pt age
- 2. preoperative sexual functioning
- 3. whether nerve-sparing surgery was performed
- 4. expertise of the surgeon
How long does it take sexual functioning to return post - radical prostatectomy?
returns gradually over at least 24 months or more
may give meds like viagra
When is this contraindicated?
prostate removed while preserving neurovascular bundles that maintain erectile function that are in close proximity to the prostate
CI for pt with cancer outside of the prostate gland
If nerve sparing prostatectomy is performed will the man retain potency?
if the pt is younger than 50 & has low-stage prostate cancer return of potency is expected but not guaranteed
Cryotherapy for prostate cancer?
surgical technique - destroys cancer cells by freezing the tissue
How is cryotherapy performed?
- 1. transrectal ultrasound probe is inserted to visualize the prostate
- 2. probes containing liquid nitrogen are inserted into prostate & freeze the prostate --> destroys the tissue
How long does cryotherapy surgery last?
What type of anesthesia is used?
takes about 2 h under general or spinal anesthesia
no abd incision is made
When is orchiectomy used for prostate cancer?
What is the purpose of it?
surgical removal of testes
used for stage D advanced prostate cancer for cancer control & rapid relief of bone pain
may also shrink the prostate
AE of orchiectomy?
- loss of testosterone: altered physical appearance
- 1. weight gain
- 2. loss of muscle mass
can affect SE & lead to grief & depression
complications of cryotherapy surgery for prostate cancer?
- has more AE than other surgeries
- 1. damage to the urethra
- 2. urethrorectal fistula (opening b/t urethra & rectum)
- 3. urethrocutaneous fistula (b/t urethra & skin)
- 4. tissue sloughing
- 5. ED/nerve damage
- 6. urinary incontinence
- 7. prostatitis
- 8. hemorrhage
2 means of delivering raidation therapy?
external beam radiation- applied to skin
brachytherapy- place radioactive seed implants into the cancerous area (prostate gland)
How is external beam radiation administered?
few minutes of outpatient Tx for 5 days/week X 4 to 8 wks
When may AE of external beam radiation occur?
What is the main AE?
immediately to years
burns skin wherever it is used
AE of external beam radiation?
- 1. skin: dryness, irritation, redness, pain
- 2. GI: diarrhea, abd cramping, bleeding
- 3. GU: dysuria, frequency, hesitancy, urgency, nocturia
- 4. sexual functioning: ED
- 5. fatigue
- 6. bone marrow suppression: decreased RBC, WBC, & platelets
When do AE of radiation therapy usually resolve?
withing 2 to 3 weeks after completion of therapy
Effectiveness of external beam radiation in pt with prostate cancer?
as effective as prostatectomy in localized prostte cancer
Special considerations for pt receiving brachytherapy r/t radiation exposure?
depending on the implant the pt may have minimal radiation precautions or more:
- 1. limit time spent with pt
- 2. tell pt why you have to limit time with them to decrease anxiety
- 3. use shielding & must wear film badge that indicates cumulative radiation exposure
- 4. urine contains radiation
Advantages of brachytherapy?
can deliver higher doses of radiation directly to tissue while sparing surrounding tissue
How is brachytherapy performed?
Advantages over external beam radiation?
radioactive seeds placed in prostate gland via a needle through a grid template guided by TRUS
one-time outpatient procedure
more convenient than external beam & does't affect adjacent tissues
Brachytherapy is best suited for stage ___ or ____ prostate cancer.
A or B
Most common AE of brachytherapy ?
Other AE that may occur?
development of urinary irritative or obstructive problems
Drug therapy involves _____, _____ & combo of both.
Rationale for the use of hormones for prostate cancer?
prostate cancer is largely depndent on presence of androgens - androgen deprivation therapy (ADT) is used
What is hormone refractory?
First sign that it is occurring?
resistance to ADT therapy that occurs withing a few years of therapy
elevated PSA levels?
What 2 types of drugs are anti-androgen therapy?
HOw are they administered?
1. LHRH agonist & 2. LHRH antagonsists
admin SQ or IM injections & must take indefinitely - Viadur is an implant placed SQ for 1 year
What types of drugs are used in ADT?
- 1. drugs that interfere with androgen production: LHRH agonists (orchiectomy has same effect)
- 2. androgen receptor blockers
4 drugs that are LHRH agonists?
leuprolide, goserelin, triptorelin, buserelin
Action of LHRH agonists?
reduce secretion of LH & FSH --> decreases testosterone production
(LH & FSH are reduced by increasing LHRH release until down-regulation of LHRH receptors occurs at the pituitary)
What is the body's initial reaction to LHRH agonists?
increase in LH, FSH, & testosterone - called a "flare"
5 AE of LHRH agonists?
- 1. hot flashes
- 2. gynecomastia
- 3. decreased libido
- 4. ED
- 5. depression & mood chages
2 LHRH antagonists?
degarelix & abarelix
When is degarelix given for prostate cancer?
How is it given?
advanced prostate cancer
Action of LHRH antagonists?
blocks LH receptors --> immediate testosterone suppression
2 AE of LHRH antagonists?
- 1. pain, swelling, redness at injection site
- 2. elevated liver enzymes
3 androgen receptor blockers?
- 1. bicalutamide
- 2. flutamide
- 3. nilutamide
Action of androgen receptor blockers?
block action of testosterone by competing at receptor sites
admin po daily
AE of androgen receptor blockers?
similar to LHRH agonists
3 actions of diethylstibuestrol (DES)?
- 1. inhibits LH secretion
- 2. decreases testosterone production
- 3. blocks circulating testosterone
AE of estrogen?
- 1. breast enlargement
- 2. CV complications: MI, DVT, cerebrovascular disease
Why may hormone therapy cause more harm than good in men with prostate cancer?
unlikely to be compliant with hormone therapy r/t side effects
When is chemo used for prostate cancer?
used in hormone refractory prostate cancer in late-stage disease usually for palliation
hormone refractory (HRPC) - progresses despite Tx with hormones
What drugs are the standard of care for HRPC?
docetaxel combined with prednisone, estramustine, or mitoxantrone
4 AE of docetaxel?
- 1. N
- 2. alopecia
- 3. reduced L ventricular ejection
- 4. bone marrow suppression
Vaccine for prostate cancer?
When is it given?
provenge - given in advance prostate cancer
stimulates pt system against the cancer
What 3 actions may an LPN do for a pt receiving bladder irrigation?
- 1. monitor catheter drainage for increased blood or clots
- 2. increase flow of irrigating solution to maintain light pink color in outflow
- 3. admin antispasmodics & analgesics prn
What 2 actions may the nursing assistive personnel perform for the pt receiving bladder irrigation?
- 1. clean around catheter daily
- 2. record I & O
7 nursing diagnoses for prostate cancer?
- 1. decisional conflict r/t alternatives in Tx options
- 2. acute pain
- 3. urinary retention
- 4. impaired urinary elimination
- 5. constipation or diarrhea r/t Tx
- 6. sexual dysfunction
- 7. anxiety
When should African American & other men with family Hx of prostate cancer begin to have annual DRE & PSA?
45 years old
4 Education for pt going home after prostate surgery?
- 1. catheter care: clean meatus daily with soap & water; keep bag below bladder; anchored to inner thigh or abd
- 2. adequate fluid intake
- 3. s/s of bladder infection - report bladder spasms, fever, or hematuria
- 4. kegel exercises at every urination & throughout the day
6 common problems experienced by pt with advanced prostate cancer?
- 1. fatigue
- 2. bladder outlet obstruction
- 3. ureteral obstruction
- 4. severe bone pain & fractures
- 5. spinal cord compression
- 6. leg edema: lymphedema, DVT, etc
painful downward curve o the penis during erection
What is a very important aspect of care for palliative Tx of prostate cancer?
book pg 1392 - group of inflammatory & noninflammatory conditions affecting the prostate gland
Mrs. Wake: inflammation of the prostate
4 categories of prostatitis?
- 1. acute bacterial prostatitis
- 2. chronic bacterial prostatitis
- 3. chronic prostatitis/chronic pelvic pain syndrome
- 4. asymptomatic inflammatory prostatitis
Cause of acute & chronic bacterial prostatitis?
3 ways this may occur?
organisms reaches prostate gland by these routes:
- 1. ascends from urethra
- 2. descends from bladder
- 3. via bloodstream or lymph
Difference b/t chronic & acute bacterial prostatitis?
chronic involves recurring episodes of infection
Chronic prostatitis/chronic pelvic pain syndrome?
When may it occur?
syndrome of prostate & urinary pain in the absence of an obvious infectious process
may occur after having a virus or with STI's
2 lab results with Chronic prostatitis/chronic pelvic pain syndrome?
culture shows no causative organisms
may have leukocytes in prostatic secretions
Asymptomatic inflammatory prostatitis?
pt has no s/s but has inflammatory process in the prostate: leukocytes are present in seminal fluid but cause is unclear
6 S/S of acute bacterial prostatitis?
- 1. flu-like s/s: fever, chills, back pain
- 2. perineal pain
- 3. acute urinary s/s: similar to BPH s/s
- 4. cloudy urine
- 5. acute urinary retention r/t prostate swelling
- 6. DRE: swollen, very tender, & firm
3 Complications that may occur with acute bacterial prostatitis?
- 1. epididymitis & cystitis
- 2. sexual functioning affected: postejaculation pain, libido probs, & ED
- 3. prostatic abscess (uncommon)
S/S of chronic bacterial prostatitis & chronic pelvic pain syndrome?
- similar s/s to acute bacterial prostatitis but milder - obstructive s/s are uncommon
- DRE: enlarged, firm, & slightly tender
The 2 types of chronic prostatitis predispose pt to what problem?
What medical condition may mimic the s/s of prostatitis?
UTI - but acute cystitis is not common in men
5 Dx of prostatitis?
- 1. UA with C&S: usually has WBC & bacteria
- 2. blood: WBC & cultures for infection
- 3. PSA to rule out prostate cancer: may be elevated r/t prostatitis
- 4. microscopic eval & culture of expressed prostate secretion
- 5. transabdominal ultrasound or MRI to rule out an abscess on the prostate
How is prostate secretion expressed?
use pre-massage & post-massage test: void into a specimen cup just before & just after prostate is massaged
When is prostate massage contraindicated?
when there is an acute bacterial prostatitis b/c it is very painful and cause spread of infection
9 Tx of prostatitis?
- 1. ABX
- 2. pain mgmt: antiinflammatory meds, opioids
- 3. physical therapy
- 4. warm baths
- 5. alpha-adrenergic blockers to relax muscles
- 6. bladder drainage with suprapubid catheter if urinary retention develops
- 7. repetitive prostatic massage (except acute bacterial)
- 8. ejaculation to drain prostate
- 9. adequate fluids to prevent UTI & prevent dehydration r/t fever & infection
5 ABX that are commonly used for prosatitis?
- 1. bactrim
- 2. cipro
- 3. floxin
- 4. doxycycline
- 5. tetracycline (doxycycline & tetracycline given if pt has mult. sex partners)
How are ABX admin in acute & chronic bacterial prostatitis?
Acute: po for up to 4 weeks OR if high fever etc. will be hospitalized with IV ABX
Chronic: po for 4 to 12 weeks - may have lifetime therapy if pt is immunocompromised
When will pain from prostatitis begin to resolve?
when the infection is treated
2 alpha-adrenergic blockers that may be used for prostatiits?
tamsulosin/Flomax & alfuzosin/Uroxatral
Why is suprapubic catheterization used in a pt with acute urinary retention r/t acute prostatitis?
catheterization through an inflamed urethra in acute prostatitis is contraindicated
Intervention for preventing infection or further infection of the prostate?
adequate fluid intake
- urethral meatus on ventral/underside of the penis
- b/t glans & scrotum
Is surgery necessary for hypospadias?
not unless associated with chordee or if it prevents intercourse or normal urination
may also be done for cosmetic reasons
complex birth defect usually associated with other genitourinary tract defects: urethral meatus on dorsal/top of penis
Does epispadias require surgery?
corrective surgery will be done to place the urethra in a normal position - usually in early childhood
3 What problems can be prevented by circumcision?
- 1. phimosis
- 2. paraphimosis
- 3. cancer of the penis
foreskin becomes tight around the head of the penis -> retraction becomes difficult
Cause of phimosis?
edema or inflammation of the foreskin usually r/t poor hygiene that allows bacterial & yeast organisms to become trapped under the foreskin
can also be caused by external beam radiation r/t tissue damage & adhesions
unable to pull forskin back from a retracted position
Cause of paraphimosis?
may occur if forskin is pulled back (when bathing, inserting catheter, or intercourse) & not placed back in the forward position
3 Tx for paraphimosis?
- 1. ABX
- 2. warm soaks
- 3. circumcision or dorsal slit may be needed
Prevention of paraphimosis?
careful cleaning & replacement of forskin over glans
Complication of paraphimosis?
ulcer can develop if the foreskin remains contracted
painful erection lasting longer than 5 h
- obstruction of the venous outflow in the penis:
- 1. thrombosis of the corpora cavernasal veins
- 2. leukemia
- 3. sickle cell anemia
- 4. DM
- 5. degernative lesions of the spine
- 6. neoplasms of the brain or spinal cord
- 7. vasoactive meds injecting into the corpora cavernosa & meds
3 Meds that may cause priapism?
- 1. sildenafil
- 2. cocaine
- 3. trazodone
4 Tx of priapism?
- 1. sedatives
- 2. injection of smooth muscle relaxants into penis
- 3. aspiration & irrigation of corpora cavernosa with a lg-bore needle
- 4. surgical creation of a shunt to drain
3 Complications of priapism?
- 1. penile tissue necrosis r/t lack of blood flow
- 2. hydronephrosis from bladder distention
- 3. after episode of priapism pt may be unable to achieve normal erection
curved or crooked penis caused by plaque formation in one of the corpora cavernosa of the penis (plaque prevents adequate blood flow into the spongy tissue --> curvature)
S/S of Peyronie's disease?
palpable, nontender, hard plaque usually found on posterior surface of penis
Causes of Peyronie's disease?
- 1. usually r/t trauma to penil shaft
- 2. can occur spontaneously
3 Problems that occur with Peyronie's disease?
- 1. painful erections
- 2. ED
- 3. embarrassment
Tx for Peyronie's disease?
surgery may be needed
2 risk factors for cancer of the penis?
How may cancer of the penis appear?
may appear as a superficial ulceration or pimple-like nodule (could be mistaken for venereal wart)
What type of malignancies are majority of penis cancers?
well-differentiated squamous cell carcinomas
Tx of cancer of the penis?
- 1. surgery:laser removal of the growth (early stages); radical resection of penis (if cancer has spread)
- 2. radiation
- 3. chemo
3 most common skin conditions of the scrotum?
- 1. fungal infections
- 2. dermatitis
- 3. parasitic infections: scabies, lice
acute, painful inflammatory process
3 common causes of epididymitis?
- 1. infection (STI or other)
- 2. trauma
- 3. urinary reflux down the vas deferens
Most common cause of epididymitis in men <35?
sexual transmission of gonorrhea or chlamydial infection
use of ABX in both partners
Tx of epidiymitis?
- 1. no sex during acute phase
- 2. use a condom if have sex
- 3. bed rest with elevation of the scrotum: ambulation puts scrotum in dependent position & increases pain
- 4. ice packs
- 5. analgesics
When does tenderness subside with epididymitis? Swelling?
tenderness usually within 1 week but swelling may last for weeks or months
acute inflammation of the testis
S/S of orchitis?
1. testis is painful, tender, & swollen
What may bring on an episode of orchitis?
generally occurs after bacterial or viral infection: mumps, pneumonia, tuberculosis, or syphilis
may also occur as an AE of epididymitis, prostatectomy, trauma, infectious mononucleosis, influenza, catheterization, or complicated UTI
Complication of mumps orchitis?
can cause infertility
childhood vaccination against mumps
Tx of orchitis?
- 1. ABX - if organism known
- 2. same Tx with epididymitis: bed rest, elevate scrotum, ice packs, pain meds
congenital prob: undescended testes bilaterally or unilaterally
2 Complications of cryptorchidism?
- 1. infertility if not surgically corrected by age 2
- 2. increased risk for testicular cancer if not corrected before puberty
Tx for cryptorchidism?
surgery is done to locate & suture testis or testes to the scrotum
nontender, fluid-filled mass r/t interfenrence with lymphatic dranage of the scrotum & swelling of the tunica vaginalis that surrounds the testis
Dx of hydrocele?
transillumination - can see mass by shining a flashlight through the scrotum
Tx of hydrocele?
no Tx needed unless swelling very lg & uncomfortable - will aspirate or surgically drain
firm, sperm-containing, painless cyst of the epididymis that may be visible with transillumination
Tx of spermatocele?
important for pt to see MD if he feels any scrotal lumps b/c they are indistinguishable from cancer
dilation of the veins that drain the testes
S/S of a varicocele?
scrotum feels wormlike when palpated - usually located on left side of scrotum r/t retrograde blood flow from the left renal vein
Tx of varicocele?
surgery if pt is infertile
2 types of surgeries used to repainr a varicocele?
- 1. injection of a sclerosing agent
- 2. surgical ligation of the spermatic vein
twisting of spermatic cord that supplies blood to the testes & epididymis - ***EMERGENCY***
tESTICULAR TORSION IS MOST COMMONLY SEEN IN MALES YOUNGER THAN AGE ____.
S/S of testicular torsion?
- 1. severe scrotal pain, tenderness, & swelling
- 2. pain does not usually subside with rest
- 3. NV
- 4. cremasteric reflex is absent
How may testicular torsion be differentiated from other male repro conditions?
no urinary s/s, fever, or WBC/ bacteria in the urine
light stroking of inner thign in downward direction causes contraction of the cremaster muscle that pulls up the scrotum & testis on the side stroked
Dx of testicular torsion?
nuclear scan of the testes or dopplar ultrasound to assess blood flow - decreased or absent blood flow confirms the Dx
Tx of testicular torsion?
unless resolves spontaneously must have surgery to untwist the cord immediately to restore BF
Complication of testicular torsion?
if blood supply is not restored within 4 to 5 h ischemia to testis will occur -> necrosis & possible need for testicular removal & infertility
Testicular cancer is the most common type of cancer in young men b/t ___ & ___ years of age.
Occurs more commonly in which testicle?
15 to 34
Risk factors for testicular cancer?
- 1. age 15 to 34
- 2. white
- 3. cryptorchidism
- 4. family Hx
- 5. orchitis
- 6. HIV
- 7 maternal exposure to DES
- 8. testicular cancer in the other testicle
2 types of germ cell cancers that occur in testicles?
seminoma & nonseminomas
Seminoma germ cell cancers?
most common & least aggressive
Nonseminoma testicualar cancer?
rare but very aggressive
2 types of non-germ cell tumors that arise fom other testicular tissue?
Leydig cell & Sertoli cell tumors
5 S/S of testicular cancer?
- 1. slow or rapid onset depending on type of tumor
- 2. painless lump in scrotum
- 3.. scrotal swelling & feeling of heaviness
- 4. dull ache or heavy sensation in lower abd, perianal area, or scrotum
- 5. acute pain may be initial s/s
S/S of testicualar cancer metastasis?
- 1. back pain
- 2. cough
- 3. hemptysis
- 4. dyspnea
- 5. dysphagia
- 6. alterations in vision or mental status
- 7. papilledema (swelling of optic disc caused by increased intracranial pressure)
- 8. seizures
Dx of testicular cancer?
- 1. palpation of scrotal contents
- 2. ultrasound
- 3. blood/CBC: tested for tumor markers, anemia, & liver function
- 4. CXR
- 5. CT scan of abd & pelvis to detect metastasis
What does testicular cancer mass feel like?
firm, does not transilluminate (differentiates it from other masses)
What 3 tumor markers are associated with testicular cancer?
- 1. alpha-fetoprotein AFP
- 2. lactate dehydrogenase LDH
- 3. human chorionic gonadotropin hCG
Tx of testicular cancer?
- 1. surgery: orchiectomy or radical orchiectomy
- 2. retroperitoneal lymph node dissection & removal may also be done
Postorchiectomy Tx ?
surveillance, radiation therapy, or chemo
Primary route for testicular cancer metastisis?
retroperitoneal lymph nodes
Complications of testicular cancer?
Mostly relate to toxicity from Tx: infertility & ejaculatory dysfunction
need careful follow-up & regular phys exams, CXR, CT scans, & hCG/AFP levels to detect relapse and secondary malignancies r/t chem or radiation
Intervention for prevention of testicular cancer?
testicular self-exam starting at puberty done every month
should perform frequently at first until familiar with the procedure
How is a testicualar self-exam performed?
- 1. Use both hands to feel each testis. Roll b/t thumb & first 3 fingers covering entire surface. Palpate each one separately.
- 2. ID the structures: testes, epididymis, & spermatic cord
testes feel round & smooth like a hard-boiled egg - differentiate from epididymis b/c it is not as smooth; locate spermatic cord: usually firm & smooth & gos up toward the groin
3. Check for lumps, irregularities, pain, or a dragging sensation
When is the best time to do a testicular self exam?
during a shower or bath b/c testes hang lower in scrotum
should choose a consistent day of the month that is easy to remember
What should pt do if he finds that one of his testicles is bigger than the other during testicular self-exam?
this is normal
Major complication r/t testicular cancer?
What Tx may cause infertility?
infertility or impaired fertility
may be caused by chemo with cisplatin and/or pelvic irradiation
spermatogenesis can return, but should suggest pt cryopreserve sperm before Tx
bilateral surgical ligation or resection of the vas deferens performed for purpose of sterilization
How long does vasectomy take to perform?
15 to 30 minutes
Pt education with vasectomy?
- 1. permanent
- 2. need alternative contraception until semen exam revels no sperm: usually requires at least 10 ejaculations or 6 wks for no sperm
- 3. sperm cells are still produced but are absorbed by the body
3 complications of vasectomy?
- 1. post-op hematoma & swelling of scrotum can occur
- 2. psychological: ED or more sexually active r/t feeling castrated
Nursing intervention r/t psych issues with vasectomy?
Discuss procedure & outcome with pt & determine pt attitude toward it
inability to attain or maintain an erect penis that allows satisfactory sexual performance
Risk factors for ED?
- 1. increasing age
- 2. substance abuse (usually in younger men)
- 3. medical conditions
- 4. physical inactivity
- 5. anything that decreases blood flow
Causes of ED?
- 1. most common cause is vascular disease
- 2. DM
- 3. AE from meds or surgery
- 4. trauma: spinal cord injuries, etc
- 5. chroniic illness
- 6. decreased gonadal hormone secretion
- 7. stress
- 8. relationship probs
- 9. depression
ED may be3 a significant s/s of undiagnosed ___ _____.
Gradual onset of ED is usually ____, and a sudden onset of ED is usually _____ in etiology.
Complications of ED?
- 1. distress & altered self-concept
- 2. anger
- 3. depression
Dx of ED?
- 1. H&P: focus on secondary sex char
- 2. questionnaries
- 3. DRE
- 4. BP & palpation of femoral arteries & peripheral pulses
- 5. serum glucose & lipid profile to rule out DM
- 6. hormone levels: for testosterone, prolactin, LH, & thyroid
- 7. blood chemistries: PSA, CBC
- 8. nocturnal penile tumescence & rigidity testing
- 9. vascular studies: penile areteriography, blood flow study & duplex dopploer ultrasound studies to assess penile blood flow
How may we differentiate b/t phys & psych causes of ED & also track progress of ED Tx?
How is the test performed?
nocturnal penile tumescence & rigidtiy testing
noninvasive method - continuous measurement of penile circumference & axial rigidity during sleep
Can ED Tx restore ejaculation or tactile sensations?
2 factors that increase satisfaction in results of ED Tx?
- 1. both partners are involved
- 2. realistic expectations of the Tx
It is important to determine what before ED Tx is initiated?
if ED is reversible
Tx for ED?
- 1. HRT if hypogonadism is prob
- 2. counseling for psych probs
- 3. oral drug therapy
- 4. devices & implants
- 5. sexual counceling before & after Tx: recommended for man and partner
3 erectogenic meds that may given as oral drug therapy for ED?
- 1. viagra
- 2. cialis
- 3. levitra
Action of erectogenic drugs?
smooth muscle relaxation & increased blood flow into the corpus cavernosum
should be taken orally about 1h prior to sex no more than once per day
AE of erectogenic drugs?
- 1. HA
- 2. dyspepsia
- 3. flushing
- 4. nasal congestion
- 5. blurred or blue-green visual disturbances
- 6. sudden hearing loss
Drug interaction with erectogenic drugs?
potentiates hypotensive effects of nitrates
Vacuum Constriction devices (VCD)?
suction devices applied to flaccid penis -> produce erection by pulling blood up into corporeal bodies
penile ring or constrictive band placed around base of penis to retain venous blood
vasoactive drugs admin onto or into penis that enhance lood flow into the penile arteries
How may intraurethra devices be administered?
- 1. topically as a gel
- 2. injection into penis
- 3. pellet inserted into the urethra using a MUSE device
Current vasoactive drugs that may be used via intraurethral devices?
- 1. papaverine - topical gel
- 2. caverject - topical gel, transurethral pellet, or injection
- 3. vasomax
implants of semirigid or inflatable penile prostheses - highly invasive with potential complications
3 Complications that may occur with penile implants?
- 1. mechanical failure
- 2. infection
- 3. erosions
Interventions for psych issues r/t ED?
- 1. reassure pt that confidentiality will be maintained
- 2. counseling & therapy
- 3. be caring & provide them with answers (will be highly motivated & expect immediate solutions)
gradual decline in androgen secretion that occurs in most men as they age - can start as early as age 40
3 S/S of andropause/
- 1. loss of libido
- 2. fatigue
- 3. ED
2 long-term effects of andropause?
- 1. osteoprosis
- 2. decreased muscle mass & strength
Dx of andropause?
- 1. H&P
- 2. serum total testosterone - normal = 280 to 1100
Tx for andropause?
When is Tx initiated?
testosterone replacement therapy
when testosterone is <250
Complications of testosterone replacement therapy (TRT)?
- 1. lowered HDL
- 2. increased Hct
- 3. worsening sleep apnea
Contraindications for TRT?
pt with BPH or prostate cancer
will have DRE & PSA before TRT begins
Admin of TRT?
- 1. IM injection (depo-testosterone & delatest)
- 2. transdermal: patches & gels: androderm, testim
AE of IM TRT?
create a cyclic rise & fall in serum teststerone levels -> mood swings with these flutuations
AE of transdermal TRT?
may apply triamcinolone cream (amcort, kenalog) to skin before application of the patch to decrease irritation
inability to achieve conception X 1 year of frequent unprotected intercourse
3 Causes of infertility?
- 1. disorders of hypothalamic-pituitary system
- 2. disorders of the testes
- 3. abnormalities of the ejaculatory system
Physical causes of infertility are divided into what 3 categories?
Which is the most common?
pretesticular, testicular, & post-testicular
endocrine causes - 3% of cases
7 Examples of testicular causes of infertility?
- varicocele (most common cause)
- 2. infection
- 3. congential anomalies
- 4. meds
- 5. radiation
- 6. substance abuse
- 7. environmental hazards
3 Infections that can cause testicular infertility?
- 1. mumps
- 2. STDs
- 3. bacterial infections
3 Posttesticular causes of infertility?
- 1. obstruction
- 2. infection
- 3. result of surgical procedure
Starting point in Dx of infertility? Factors included?
- starting point is Hx:
- 1. age
- 2. occupation
- 3. past injury, surgery, or infections to the genital tract
- 4. lifestyle
- 5. sexual practices
- 6. frequency of intercourse
- 7. emotional factors: stress & desire for children
- 8. use of drugs
Lifestyle issues that can cause infertility?
- 1. hot tubs
- 2. weight training
- 3. wearing tight undergarments
Drugs that may be involved in infertility?
- 1. chemo drugs
- 2. anabolic steroids - testosterone
- 3. sulfasalazine/Azulfidine
- 4. cimetidine/Tagamet
- 5. recreational drugs: can reduce sperm count
First test in an infertility study?
semen analysis: sperm concentration, motility, and morphology
- 1. plasma testosterone
- 2. serum LH & FSH
- 3. test for sperm penetration abilities
Nursing interventions r/t infertility?
- 1. be concerned & tactful
- 2. be sensitive to gender identity
- 3. refer to marriage counceling prn (can strain marriage)
Tx of infertility?
- 1. meds
- 2. lifestyle changes: avoid scrotal heat, substance abuse, & high stress
- 3. in vitro fertilization
- 4. corrective surgery