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Conditions of prostate


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Conditions of prostate

  1. 1. Prostate: Inflammation, Infection, Hypertrophy, Tumour MS. ALISHA TALWAR
  2. 2. Benign Prostate Hyperplasia
  3. 3. Benign Prostate Hyperplasia  It is a condition progressive enlargement of prostate gland, resulting from an increase in the number of size of epithelial cells and stromal tissue.
  4. 4. Epidemiology/ Incidence
  5. 5. Etiology  Ageing  Excessive accumulation of prostaticandrogen  Family history  Diet increase animal fat and saturated faty acids  Reduced exercise and alcoholconsumption
  6. 6. Etiology  Recent studies have identified smoking (both current and former smoking), heavy alcohol consumption, hypotension, heart disease and diabetes mellitus as risk factors associated with BPH.
  7. 7. Pathophysiology  The cause of BPH is uncertain, but studies suggest that estradiol levels may have a relationship to prostate size among men with testosterone levels above the median.  Recent studies have identified smoking both current and former, heavy alcohol consumption, hypertension, heart disease and diabetes as risk factors of BPH.
  8. 8. Pathophysiology  The hypertrophied lobes of prostate may obstruct the vesical neck or prostatic urethra, causing incomplete emptying of the bladder and urinary retention.  As a result. A gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis)can occur. Urinary tract infections may result from urinary stasis. Urine remaining in the urinary tract serves as a medium for infectve organisms.
  9. 9. Pathophysiology
  10. 10. Clinical Manifestations  Obstructive Reduced force of urine stream Difficulty in initiating voiding Intermittency Dribbling at the end of urination
  11. 11. Clinical Manifestations  Irritative Frequency Urgency Dysuria Bladder pain Nocturia (excessive urination at night) Incontinence
  12. 12. Continue  Inflammation and infection  Decrease volume and force of the urinary stream  Sensation of incomplete emptying
  13. 13. Continue  Generalized symptoms include Fatigue Anorexia Nausea and vomiting Epigastric discomfort
  14. 14. Complications  Acute urinary retention  Urinary tract infections(UTI)  Renal stone (kidneystone)/ Bladder stone  Bladderdamage/ decompensation  Hydronephrosis  Pyelonephritis  Sexual Dysfunction  Urinary incontinence
  15. 15. Assessment and Diagnostic Tools  History- H/o surgical procedure (genitourinary), hematuria, UTIs, DM. Current Medications (anticholinergics-which impair bladder contractions or sympathomimetics-that increase outflow resistance, Use of voiding dairy)  Physical examination- Digital rectal examination to detect enlarged prostate, to evaluate anal sphincter tone, to rule out any neurological problems. Urinary outflow resistance can be estimated, provided the bladder pressure, equivalent exit pressure, and the urinary flow rate are measured simultaneously
  16. 16. Assessment and Diagnostic Tools  Urinanlysis-to rule out UTIs & hematuria  Urine culture and sensitivity  Serum Creatinine-to evaluate LUTS  Prostate Specific Antigen (PSA)-can help to rule out prostatic carcinoma  Transrectal Ultrasound- to rule out enlargement  Uroflowmetry & Urodynamics -to evaluate the flow-rate It is electric recording of urine flow-rate throughout course of micturition.
  17. 17. Assessment and Diagnostic Tools  Post-voidal residual urine- to measure residual urine. It ranges b/w 0.09-2.24 ml.  Pressure flow studies- to distinguish uretheral obstruction and impaired detrusor contractility. >15ml/sec flow rate suggests bladder dysfunction.  Filling Cystometry-Invasive urodynamic procedure to determine bladder capacity & compliance
  18. 18. Assessment and Diagnostic Tools  Cystourethoscopy- to visualise the prostatic urethera and bladder.  Complete blood studies are performed because hemorrhage is a major complication of prostate surgery, all clotting defects must be corrected. A high percentage of patients with BPH have cardiac or respiratory complications, or both because of their age therefore cardiac and respiratory function also assessed.
  19. 19. Medical Management  The main goals of medical management are-  Restore bladder function  Relieve signs and symptoms  Prevent and treat complications
  20. 20. Contd..  The treatment Plan depends on the cause of BPH, the severity of the obstruction, and the patient’s general health conditions.  If the patient is admitted on an emergency basis because he can not void, he is immediately catheterized.
  21. 21. Dietary Management  Decrease amount of intake caffeine and artificial sweetners, limit spicy and acidic foods and alcohol.
  22. 22. Pharmacological Management  Alfa-adrenergic blockers such as doxazosin, tamsulosin (relaxes smooth muscles of bladder neck and prostate to facilitate voiding).  5-alfa reductase inhibitors such as finasteride and dutasteride (exert anti-androgen effect on prostatic cells and can reverse or prevent hyperplasia).  Aromatase Inhibitors  Symptomatic Management
  23. 23. Surgical Management  Several approaches or methods depends on size of gland, severity of obstruction, age, health of client & prostatic disease.  Surgery is primary intervention for BPH.  During surgery prostate gland is left intact and adenomatous soft tissue is removed by one of four surgical routes.  Transuretheral, Suprapubic, Retropubic, Perineal
  24. 24. Contd…  2 newer approaches balloon dilatation of prostate under endoscopy and TUIP.  Indications-  Acute urinary retention  Recurrent infection  Recurrent hematuria  Azotemia
  25. 25. Closed Surgical Procedures  TURP (Transurethral resection of the prostate)  TUIP (Transurethral incision of the prostate)  TUMT (Transurethral Microwave therapy)  TUNA (Transurethral Needle ablation)
  26. 26. Open Surgical Procedures  Suprapubic Prostatectomy  Perineal Prostatectomy  Retropubic Prostatectomy
  27. 27. Others • Newer treatments include balloon urethroplasty, laser therapy, and intraurethral stents • Other minimally invasive surgical techniques include: ◗ Transurethral needle ablation to burn away well-defined regions of the prostate, thereby improving urine flow with less risk
  28. 28. TURP  Removal of prostate tissue using a resectoscope is inserted through the tip of penis and into the tube that carries urine from bladder (urethra) under spinal or general anaesthesia.
  29. 29. TUIP  A combined visual and surgical instrument (resectoscope) is inserted through the tip of penis into the tube that carries urine from bladder (urethra). The prostate surrounds the urethra. The surgeon cuts one or two small grooves in the area where the prostate and the bladder are connected (bladder neck) to open the urinary channel and allow urine to pass through more easily.
  30. 30. TUMT  A small microwave antenna is inserted through the tip of penis into the tube that carries urine from bladder (urethra)
  31. 31. TUNA  Radiofrequency ablation, is a minimally invasive treatment option used to treat benign prostatic hyperplasia. During the procedure, radiofrequency needles are placed through the urethra into the area of the prostate that is pressing on the urethra.
  32. 32. Suprapubic Prostatectomy  Suprapubic Prostatectomy is one method of removing the enlarged gland through an abdominal incision . An incision is made into the bladder and the prostate gland is removed from above.
  33. 33. Perineal prostatectomy  Perineal prostatectomy involves removing the gland through an incision in the perineum. (This method is practical when other methods or approaches are not possible.
  34. 34. Retropubic prostatectomy  Retropubic prostatectomy is a another technique, is more common than suprapubic approach. Incision made on low abdominal between prostate gland and pubic arch and the bladder without entering the bladder.
  35. 35. Cancer of Prostate
  36. 36. Cancer of Prostate  Abnormal proliferation of cells of prostate.  Most common carcinoma in men over 65 years.  Etiology is UNKNOWN. Increased risk if family history, influences of dietary intake, S. testosterone levels are under investigation.
  37. 37. Clinical Manifestation  May be asymptomatic at early stage.  Symptoms due to obstruction of urinary flow:  Hesitancy & straining on voiding  Frequency  Nocturia  Diminution in size & force of urinary stream.
  38. 38. Clinical Manifestation  Symptoms due to metastasis:  Pain in lumbosacral area radiating to hips & down legs.  Perineal & rectal discomfort.
  39. 39. Clinical Manifestation  Anemia, weight loss, weakness, nausea, oliguria, hematuria  Lower extremities edema occurs when pelvic node metastasis compromise venous return.
  40. 40. Investigations  Digital rectal examination (Hard nodule may be felt)  Needle biopsy for Histological study  Trans-rectal USG  PSA (4-10 ng/ml-suspect and > 10 ng/ml indicate cancer)
  41. 41. Medical Management  Periodic PSA determination & examination for evidence of metastasis  Symptomatic management  Analgesics & Narcotics to relieve pain  TURP to relieve obstruction  Suprapubic cystostomy
  42. 42. Surgical Management  Radical Prostatectomy- entire prostate gland, capsule, seminal vesicle and pelvic lymph nodes are removed.  Cryosurgery of prostate freezes prostatic tissue killing tumor cells without removing gland.
  43. 43. Radiation  External beam radiation- focused on prostate.  Interstitial radiation (Brachytherapy)  Complications- Radiation cystitis (frequency, urgency, nocturia), Uretheral stricture, Radiation enteritis (diarrhoea, anorexia, nausea), Radiation Prostatitis (diarrhoea, rectal bleeding), Impotence.
  44. 44. Hormonal therapy (Palliative)  Aim is to deprive tumor cells & its by-product.  Bilateral orchidectomy (removal of testes)  Luteinizing hormone releasing hormone analogues  Antiandrogen drugs  Complications- hot flushes, N/V, gynaecomastica, sexual dysfunction.
  45. 45. Nursing Management  The goals of nursing management Restoration of urinary drainage Treatment of urinary tract infections Understanding the procedure
  46. 46. Nursing Diagnosis • Impaired urinary elimination related to obstruction of urethra • Risk for infection related to surgical incision, urinary catheter • Anxiety related to urinary incontinence, difficulty voiding.
  47. 47. Pre-operative Interventions  Avoid alcohol and caffeine  Advise to urinate every 2-3 hours  Normal fluid intake should be maintain and avoid over fluid intake and volume over land.  Antibiotics before any Invasive procedure
  48. 48. Post-Operative Care  Assess the patient’s conditions.  Main complications is hemorrhage, bladder spasm, urinary Incontinence and infections.  Bladder irrigation  Catheter care  Avoid activities that increase abdominal pressure.
  49. 49. Post-Operative Care  ToRelive bladder spasms use Anti spasmodics  After removing catheter, patient should urinate within 6 hours.  Patient should practice pelvic floor exercise ( kegel exercise)  Encourage to practice straining and stoping the stream during urination.
  50. 50. Post-Operative Care  Dietary advice or management including fiber and easily digestibale food  Adminster stool softners, avoid heavy alcohol intake, weighting, and sexual intercourse.
  51. 51. Prostatitis
  52. 52. Prostatitis  An inflammation of the prostate gland.  Prostatitis is most common prostate problem in men under the age of 50.  It is classified as- Bacterial Prostatitis Non-bacterial Prostatitis
  53. 53. Bacterial Prostatitis  There are 4 types of bacterial prostatitis  Type I- acute bacterial caused by GI or sexually transmitted bacteria  Type II- chronic bacterial caused by GI (gram negative ) organisms  Type III- chronic pelvic pain syndrome  Type IV- asymptomatic inflammatory prostatitis
  54. 54. Pathophysiology & Etiology  Acute bacterial invasion of prostate from reflux of infected urine into ejaculatory & prostatic duct or secondary to urethritis or rectal examination when bacteria are present. It is often caused by gram negative bacteria- pseudomonas, gram positive cocci- streptococcus, staphylococcus.
  55. 55. Contd…  Chronic bacterial prostatitis: Ascending infection from urethera. Due to gram negative bacteria- E.Coli, proteus, klebsiella, pneumonia & pseudomonas aeruginosa.  Non-bacterial prostatitis: May be complication of urethritis.
  56. 56. Clinical Management  Sudden chills & fever with body aches with acute prostatitis.  More subtle symptoms with chronic prostatitis.  Bladder irritability, frequency, dysuria, nocturia, urgency, hematuria  Pain in perineum, rectum, lower back and lower abdomen & penile head.  Pain after ejaculation, symptoms of uretheral obstruction.
  57. 57. Investigations  Culture & Sensitivity test for urine  Rectal examination- tender, painful swollen prostate, warm to touch in acute cases.  Elevated leucocytes (leucocytosis)
  58. 58. Management  Antimicrobial therapy- 10-14 days  Suprapubic cystostomy. Avoid uretheral catherization  Antipyretics
  59. 59. Chronic bacterial prostatitis  Antimicrobial- 4 weeks (Ciprofloxacin, Norfloxacin, Sulfonamides)  Oral antispasmodic agents to relieve urinary frequency, urgency.
  60. 60. Non bacterial prostatitis  Antimicrobial 2 weeks (Doxycycline, Erythromycin)  Symptomatic relief  Anti-cholinergics to relieve spasms  Anti-inflammatory  Hot sitz bath
  61. 61. Nursing Considerations  History of previous LUTS/STDs  Recent voiding patterns  Genital examination-uretheral discharge  Rectal examination except acute bacterial prostatitis  Urine culture & sensitivity
  62. 62. Nursing Diagnosis & Interventions  Ineffective thermoregulation related to infection/ Hyperthermia related to infection  Monitor vitals  Cooling measures  Hydration status  Oral/Parenteral fluids  Antipyretics as prescribed.
  63. 63. Nursing Diagnosis & Interventions  Pain & discomfort related to inflammation  Bed rest  Warm sitz bath to relieve pain & promote muscular relaxation of pelvic floor  Stool softeners, high fibers diet to prevent constipation  Anti-inflammatory & Analgesics as prescribed