O slideshow foi denunciado.
Seu SlideShare está sendo baixado. ×

Benign prostatic hyperplasia (BPH)

Próximos SlideShares
Carregando em…3

Confira estes a seguir

1 de 156 Anúncio

Mais Conteúdo rRelacionado

Diapositivos para si (20)

Semelhante a Benign prostatic hyperplasia (BPH) (20)


Mais de Arsi University, Asella, Ethiopia (20)

Mais recentes (20)


Benign prostatic hyperplasia (BPH)

  1. 1. PROBLEMS OF THE PROSTATE GLAND Presented by---- Mrs. Usha Rani Kandula, MSc.Nursing, Assistant professor, Department of Adult Health Nursing, College of Health Sciences, Arsi University, Asella, Ethiopia.
  3. 3. ANATOMY OF PROSTATE GLAND -The prostate gland lies in the pelvic cavity in front of the rectum and behind the symphysis pubis, surrounding the first part of the urethra.
  6. 6. PHYSIOLOGY OF PROSTATE GLAND -The prostate gland secretes a thin, milky fluid that makes up about 30% of semen, and gives it its milky appearance. -
  8. 8. DEFINITION -Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland. -It is the most common urologic problem in male adults. -About 50% of all men in their lifetime will develop BPH, almost half of them will have lower urinary tract symptoms.
  13. 13. HORMONAL CHANGES  -Hormonal changes associated with the aging process.
  14. 14. EXCESSIVE ACCUMULATION OF DIHYDROXYTESTOSTERONE  Excessive accumulation of di-hydroxy- testosterone (DHT) (intraprostatic androgen) in the prostate cells causes overgrowth of prostate tissue.
  15. 15. INCREASED PROPORTION OF ESTROGEN  -Increased proportion of estrogen (as compared to testosterone) in the blood.  Men produce both testosterone and small amounts of estrogen.  As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen.  A higher amount of estrogen within the gland increases the activity of substances (e.g., DHT) that promote cell growth.
  17. 17. RISK FACTORS FOR BPH  Aging,  Obesity (in particular increased waist circumference),  Lack of physical activity,  Alcohol consumption,  Erectile dysfunction,  Smoking, and diabetes.  A positive family history
  19. 19. PATHOPHYSIOLOGY OF BPH Due to etiological factors, Accumulation of dihydroxytestosterone (DHT) (intraprostatic androgen) in the prostate cells, stimulate cell growth and an overgrowth of prostate tissue
  20. 20. Con-- This enlargement gradually compresses the urethra, leading to partial or complete obstruction, compression of the urethra, ultimately leads to the development of clinical symptoms.
  22. 22. CLINICAL MANIFESTATIONS OF BPH  -Symptoms associated with lower urinary tract.  -The symptoms gradually worsen as the degree of urethral obstruction increases.
  23. 23. SYMPTOMS CAN BE DIVIDED INTO TWO GROUPS:  Symptoms can be divided into two groups: 1.Irritative symptoms  II. Obstructive symptoms.
  24. 24. I.IRRITATIVE SYMPTOMS  Nocturia, (night time urination)  urinary frequency, (No of times)  urgency, (unable to controle)  dysuria, (difficulty in urination)  bladder pain,
  25. 25.  Incontinence, are associated with inflammation or infection.  Nocturia is often the first symptom that the patient notices.
  26. 26. II.OBSTRUCTIVE SYMPTOMS  These are caused by prostate enlargement include a decrease in the caliber and force of the urinary stream,  Difficulty in initiating voiding, (difficulty in passing of urine)
  27. 27.  Intermittency (stopping and starting stream several times while voiding),  Dribbling at the end of urination. (urine passes drop by drop)  These symptoms are due to urinary retention.
  28. 28. THE AMERICAN UROLOGICAL ASSOCIATION (AUA) SYMPTOM INDEX FOR BPH  It is a widely used tool to assess voiding symptoms associated with obstruction.  This tool not helps for diagnostic purpose,  It helps determine the extent of symptoms only.  6 Higher scores on this tool indicate greater symptom severity.
  30. 30. HISTORY AND PHYSICAL EXAMINATION  The primary methods used to diagnose BPH include a  -History and physical examination.
  31. 31. DIGITAL RECTAL EXAMINATION (DRE)  -The prostate can be palpated by digital rectal examination (DRE) to estimate its  -size,  -symmetry, and  -consistency.
  32. 32. URINALYSIS  A urinalysis with culture is routinely done to identify any infection.  -Bacteria,  -white blood cells (WBCs), or  -microscopic hematuria indicate infection or inflammation.
  33. 33. PROSTATE-SPECIFIC ANTIGEN (PSA)  A prostate-specific antigen (PSA) blood test may be done to rule out prostate cancer.
  34. 34. SERUM CREATININE LEVELS  Serum creatinine levels  -may be ordered to rule out renal insufficiency.
  35. 35. TRANSRECTAL ULTRASOUND (TRUS) SCAN  -In patients with an abnormal DRE and elevated PSA, a transrectal ultrasound (TRUS) scan is typically indicated.  This examination allows for accurate assessment of prostate size and is helpful in differentiating BPH from prostate cancer.
  36. 36. BIOPSIES,  Biopsies can be taken during the ultrasound procedure.
  37. 37. UROFLOWMETRY  -Uroflowmetry, a study that measures -the volume of urine expelled from the bladder per second, -is helpful in determining the extent of urethral blockage and thus the type of treatment needed.
  38. 38. POSTVOID RESIDUAL URINE VOLUME  Postvoid residual urine volume is often measured to determine the degree of urine flow obstruction.
  39. 39. CYSTOSCOPY  -Cystoscopy, a procedure allowing internal visualization of the urethra and bladder,  -is performed if the diagnosis is uncertain and in patients scheduled for prostatectomy.
  41. 41. COLLABORATIVE CARE  The goals of collaborative care are to  (1) Restore bladder drainage,  (2) Relieve the patient’s symptoms, and  (3) Prevent or treat the complications of BPH.
  42. 42. MANAGEMENT OF BPH  -Treatment is generally based on the degree to which the symptoms bother the patient or  - The presence of complications, rather than the size of the prostate.
  43. 43. DRUG THERAPY.  Drugs that have been used to treat BPH with variable degrees of success include  -5α-reductase inhibitors and  -α-adrenergic receptor blockers.
  44. 44. 5Α-REDUCTASE INHIBITORS.  These drugs work by reducing the size of the prostate gland.  -Ex: Finasteride (Proscar)  -This drug results in regression of hyperplastic tissue through suppression of androgens (DHT).
  45. 45. CON--  Dutasteride (Avodart) has the same effect on prostatic tissue  -The combination of a 5α-reductase inhibitor (dutasteride) and an α-adrenergic receptor blocker (tamsulosin) is now available in a single oral medication (Jalyn).
  46. 46. Α-ADRENERGIC RECEPTOR BLOCKERS.  -These agents selectively block α1- adrenergic receptors, which are abundant in the prostate and are increased in hyperplastic prostate tissue.  These drugs promote smooth muscle relaxation in the prostate, facilitating urinary flow through the urethra.
  47. 47. CON--  -Several α-adrenergic blockers are currently in use,  Silodosin (rapaflo),  Alfuzosin (uroxatral),  Doxazosin (cardura),  Prazosin (minipress),  Terazosin (hytrin),  Tamsulosin (flomax).
  48. 48. ERECTOGENIC DRUGS.  Tadalafil (Cialis) has been used in men who have symptoms of BPH alone or in combination with erectile dysfunction (ED).
  50. 50. MINIMALLY INVASIVE THERAPY.  -Minimally invasive therapies are becoming more common as an alternative to watchful waiting and invasive treatment.  - They generally do not require hospitalization or catheterization and are associated with few adverse events.  -Many minimally invasive therapies have outcomes comparable to those of invasive techniques.
  52. 52. TRANSURETHRAL MICROWAVE THERMOTHERAPY (TUMT).  Transurethral microwave thermotherapy (TUMT) is an outpatient procedure that involves the delivery of microwaves directly to the prostate through a transurethral probe to raise the temperature of the prostate tissue to about 113° F (45° C).  The heat causes death of tissue, thus relieving the obstruction.  -A rectal temperature probe is used during the procedure to ensure that the temperature is kept below 110° F (43.5° C) to prevent rectal tissue damage.  -The procedure takes about 90 minutes.  -Postoperative urinary retention is a common complication.
  53. 53. CON--  patient is generally sent home with an indwelling catheter for 2 to 7 days to maintain urinary flow and to facilitate the passing of small clots or necrotic tissue.  -Antibiotics, pain medication, and bladder antispasmodic medications are used to treat and prevent post procedure problems.  -The procedure is not appropriate for men with rectal problems.  -Anticoagulant therapy should be stopped 10 days before treatment.  -Mild side effects include occasional problems of bladder spasm, hematuria, dysuria, and retention.
  55. 55. TRANSURETHRAL NEEDLE ABLATION (TUNA).  Transurethral needle ablation (TUNA) is another procedure that increases the temperature of prostate tissue, thus causing localized necrosis.  TUNA differs from TUMT in that low-wave radiofrequency is used to heat the prostate.  Only prostate tissue in direct contact with the needle is affected, thus allowing greater precision in removal of the target tissue.  -The extent of tissue removed by this process is determined by the amount of tissue contact (needle length), amount of energy delivered, and duration of treatment.  -This procedure is performed in an outpatient unit or physician’s office using local anesthesia and IV or oral sedation.
  56. 56. CON--  The TUNA procedure lasts approximately 30 minutes.  -The patient typically experiences little pain with an early return to regular activities.  -Complications include urinary retention, UTI, and irritative voiding symptoms (e.g., frequency, urgency, dysuria).  -Some patients require a urinary catheter for a short time.  -Patients often have hematuria for up to a week.
  58. 58. LASER PROSTATECTOMY.  -The use of laser therapy through visual or ultrasound guidance is an effective alternative to transurethral resection of the prostate (TURP) in treating BPH.  -The laser beam is delivered trans urethrally through a fiber instrument and is used for cutting, coagulation, and vaporization of prostatic tissue.
  60. 60. VISUAL LASER ABLATION OF THE PROSTATE (VLAP),  One common procedure is visual laser ablation of the prostate (VLAP), which uses the laser beam to produce deep coagulation necrosis.  -The affected prostate tissue gradually sloughs in the urinary stream.  -It takes several weeks before the patient reaches optimal results after this type of laser therapy.  -At the completion of VLAP, a urinary catheter is inserted to allow for drainage.
  62. 62. CONTACT LASER TECHNIQUES  Contact laser techniques involve the direct contact of the laser with the prostate tissue, producing an immediate vaporization of the tissue.  -Blood vessels near the laser tip are immediately cauterized.  -Thus bleeding during the procedure is rare.  -A three way catheter with slow-drip irrigation is placed immediately after the procedure for a short time.
  63. 63. CON--  Typically the catheter is removed within 6 to 8 hours after the procedure.  -Advantages of this procedure over TURP include minimal bleeding both during and after the procedure, faster recovery time, and ability to perform the surgery on patients taking anticoagulants.
  65. 65. PHOTOVAPORIZATION OF THE PROSTATE (PVP)  Photovaporization of the prostate (PVP) uses a high-power green laser light to vaporize prostate tissue.  Improvements in urine flow and symptoms are almost immediate after the procedure.  -Bleeding is minimal, and a catheter is usually inserted for 24 to 48 hours afterward.  - PVP works well for larger prostate glands.
  67. 67. INTERSTITIAL LASER COAGULATION (ILC).  Another approach to laser prostatectomy is interstitial laser coagulation (ILC).  -The prostate is viewed through a cystoscope.  -A laser is used to quickly treat precise areas of the enlarged prostate by placement of interstitial light guides directly into the prostate tissue.
  69. 69. -INTRAPROSTATIC URETHRAL STENTS.  -Symptoms from obstruction in patients who are poor surgical candidates can be relieved with intra prostatic urethral stents.  -The stents are placed directly into the prostatic tissue.  -Complications include chronic pain, infection, and encrustation (tissue hardness).  - The long-term effects are not known.
  71. 71. -INVASIVE THERAPY (SURGERY).  Invasive treatment of symptomatic BPH involves surgery.  The choice of the treatment approach depends on the size and location of the prostatic enlargement and patient factors such as age and surgical risk.  -Invasive therapy is indicated when the decrease in urine flow is sufficient to cause discomfort, persistent residual urine, acute urinary retention because of obstruction with no reversible precipitating cause, or hydro nephrosis.
  72. 72. Con--  - Intermittent catheterization or insertion of an indwelling catheter can temporarily reduce symptoms and bypass the obstruction.  -However, avoid long term catheter use because of the increased risk of infection.
  74. 74. TRANSURETHRAL RESECTION OF THE PROSTATE (TURP)  Transurethral resection of the prostate (TURP) is a surgical procedure involving the removal of prostate tissue using a resecto scope inserted through the urethra. –  TURP has long been considered the gold standard for surgical treatments of obstructing BPH.
  75. 75. Con--  TURP is performed under a spinal or general anesthetic and requires a 1- to 2-day hospital stay.  No external surgical incision is made.  -A resecto scope is inserted through the urethra to excise and cauterize obstructing prostatic tissue .  -A large three-way indwelling catheter with a 30-mL balloon is inserted into the bladder after the procedure to provide hemo stasis and to facilitate urinary drainage.
  76. 76. Con--  The bladder is irrigated, either continuously or intermittently, usually for the first 24 hours to prevent obstruction from mucus and blood clots.  -The outcome for 80% to 90% of patients is excellent, with marked improvements in symptoms and urinary flow rates.
  77. 77. Con--  Quality of life is also improved.  -TURP is a surgical procedure with a relatively low risk.  -Postoperative complications include bleeding, clot retention, and dilutional hyponatremia associated with irrigation.  -Because bleeding is a common complication, patients taking aspirin, warfarin (Coumadin), or other anticoagulants must discontinue these medications several days before surgery.
  79. 79. TRANSURETHRAL INCISION OF THE PROSTATE(TUIP).  -Transurethral incision of the prostate (TUIP) is a surgical procedure done under local anesthesia for men with moderate to severe symptoms.  Several small incisions are made into the prostate gland to expand the urethra, which relieves pressure on the urethra and improves urine flow.
  80. 80. Con--  TUIP is an option for patients with a small or moderately enlarged prostate gland.  - TUIP has similar patient outcomes to TURP in relieving symptoms.
  82. 82. NURSING ASSESSMENT  Subjective and objective data that should be obtained from a patient with BPH.
  83. 83. NURSING DIAGNOSES preoperatively may include,  Acute pain related to bladder distention secondary to enlarged prostate  Risk for infection related to an indwelling catheter, urinary stasis, or environmental pathogens
  84. 84. PLANNING The overall preoperative goals for the patient having invasive procedures are to have  (1) restoration of urinary drainage;  (2) treatment of any UTI; and  (3) understanding of the upcoming procedure, implications for sexual function, and urinary control.
  85. 85. Con-- The overall postoperative goals are to have  (1) no complications,  (2) restoration of urinary control,  (3) complete bladder emptying,  (4) satisfying sexual expression.
  86. 86. NURSING IMPLEMENTATION  HEALTH PROMOTION.  Health promotion focuses on early detection and treatment.  The American Cancer Society, along with the AUA, recommends a yearly medical history and DRE for men over 50 years of age in an effort to detect prostate problems early.
  87. 87.  When symptoms of prostatic hyperplasia are present, further diagnostic screening may be necessary .  -Some men find that the ingestion of alcohol and caffeine tends to increase prostatic symptoms because the diuretic effect increases bladder distention.
  88. 88. Con--  -Advise patients with obstructive symptoms to urinate every 2 to 3 hours and when they first feeling the urge.  -This will minimize urinary stasis and acute urinary retention.  -Fluid intake should be maintained at a normal level to avoid dehydration or fluid overload.
  89. 89. PREOPERATIVE CARE (TURP).  -Urinary drainage must be restored before surgery.  -Prostatic obstruction may result in acute retention or inability to void.
  90. 90.  - A urethral catheter may be needed to restore drainage.  -In many health care settings, 10 mL of sterile 2% lidocaine gel is injected into the urethra before insertion of the catheter.
  91. 91.  - The lidocaine gel not only acts as a lubricant, but also provides local anesthesia and helps open the urethral lumen.  -Aseptic technique is important at all times to avoid introducing bacteria into the bladder.
  92. 92. Con--  Any infection of the urinary tract must be treated before surgery.  -Restoring urinary drainage and encouraging a high fluid intake (2 to 3 L/day unless contraindicated) are also helpful in managing the infection.  -Patients are often concerned about the impact of the impending surgery on sexual function.
  93. 93. POSTOPERATIVE CARE. The main complications after surgery are  Hemorrhage,  Bladder spasms,  Urinary incontinence,  Infection.
  94. 94. Con--  -After surgery the patient will have a standard catheter or a triple-lumen catheter.  -Bladder irrigation is typically done to remove clotted blood from the bladder and ensure drainage of urine.
  95. 95.  -The bladder is irrigated either manually on an intermittent basis or more commonly as continuous bladder irrigation (CBI) with sterile normal saline solution or another prescribed solution.
  96. 96. Con--  -If the bladder is manually irrigated (if ordered), instill 50 mL of irrigating solution and then withdraw with a syringe to remove clots that may be in the bladder and catheter.  -Painful bladder spasms often occur as a result of manual irrigation.
  97. 97. Con--  With CBI, irrigating solution is continuously infused and drained from the bladder.  -The rate of infusion is based on the color of drainage.  -Ideally the urine drainage should be light pink without clots.  -Continuously monitor the inflow and outflow of the irrigant.
  98. 98.  -If outflow is less than inflow, assess the catheter patency for kinks or clots.  -If the outflow is blocked and patency cannot be reestablished by manual irrigation, stop the CBI and notify the physician.
  99. 99. Con--  -Use careful aseptic technique when irrigating the bladder because bacteria can easily be introduced into the urinary tract.  -To prevent urethral irritation and minimize the risk of bladder infection, secure the catheter to the leg with tape or a catheter strap.  -The catheter should be connected to a closed-drainage system.
  100. 100.  -Do not disconnect unless it is being removed, changed, or irrigated.  -Proper care of the catheter is important.  On a daily basis, cleanse the secretions that accumulate around the meatus with soap and water.
  101. 101. NURSING ASSESSMENT  Blood clots are expected after prostate surgery for the first 24 to 36 hours.  However, large amounts of bright red blood in the urine can indicate hemorrhage.  -Postoperative hemorrhage may occur from displacement of the catheter, dislodgment of a large clot, or increases in abdominal pressure.
  102. 102.  -Release or displacement of the catheter dislodges the balloon that provides counter pressure on the operative site.
  103. 103. Con--  - Traction on the catheter may be applied to provide counter pressure (tamponade) on the bleeding site in the prostate, thereby decreasing bleeding.  -Such traction can result in local necrosis if pressure is applied for too long.
  104. 104. Con--  Therefore pressure should be relieved on a scheduled basis by qualified personnel.
  105. 105.  -Activities that increase abdominal pressure, such as sitting or walking for prolonged periods and straining to have a bowel movement , should be avoided in the postoperative recovery period.
  106. 106. Con--  Bladder spasms are a distressing complication for the patient after transurethral procedures.  -They 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.
  107. 107.  -Instruct the patient not to urinate around the catheter because this increases the likelihood of spasm.
  108. 108. Con--  - If bladder spasms develop, check the catheter for clots.  -If present, remove the clots by irrigation so that urine can flow freely.  -Belladonna and opium suppositories or other antispasmodics (e.g., oxybutynin [Ditropan]), along with relaxation techniques, are used to relieve the pain and decrease spasm.
  109. 109.  -The catheter is often removed 2 to 4 days after surgery.  - The patient should urinate within 6 hours after catheter removal.  -If he cannot, reinsert a catheter for a day or two.
  110. 110. Con--  - If the problem continues, instruct the patient to perform clean intermittent self- catheterization.  -Sphincter tone may be poor immediately after catheter removal, resulting in urinary incontinence or dribbling.
  111. 111.  -This is a common but distressing situation for the patient.  -Sphincter tone can be strengthened by having the patient practice Kegel exercises (pelvic floor muscle technique) 10 to 20 times per hour while awake
  112. 112. Con--  Encourage the patient to practice starting and stopping the stream several times during urination.  -This facilitates learning the pelvic floor exercises.  -It usually takes several weeks to achieve urinary continence.  -In some instances, control of urine may never be fully regained.
  113. 113.  -Continence can improve for up to 12 months.  -If continence has not been achieved by that time, refer the patient to a continence clinic.  -A variety of methods, including biofeedback, have been used to achieve positive results.
  114. 114. Con--  You can also instruct the patient to use a penile clamp, a condom catheter, or incontinence pads or briefs to avoid embarrassment from dribbling.  - In severe cases, an occlusive cuff that serves as an artificial sphincter can be surgically implanted to restore continence.
  115. 115.  -Assist the patient in finding ways to manage the problem that allow him to continue socializing and interacting with others.
  116. 116. Con--  Observe the patient for signs of postoperative infection.  -If an external wound is present (from an open prostatectomy), assess the area for redness, heat, swelling, and purulent drainage.
  117. 117.  -Special care must be taken if a perineal incision is present because of the proximity of the anus.  -Avoid rectal procedures, such as taking rectal temperatures and administering enemas.
  118. 118. Con--  -The insertion of well-lubricated belladonna and opium suppositories is acceptable.  -Dietary intervention and stool softeners are important in the postoperative period to prevent the patient from straining while having bowel movements.
  119. 119.  -Straining increases the intra abdominal pressure, which can lead to bleeding at the operative site.  -A diet high in fiber facilitates the passage of stool.
  120. 120. EVALUATION  The expected outcomes are that the patient with BPH who has  surgery will--  • Report satisfactory pain control  • Report improved urinary function with no pain or incontinence
  121. 121. AMBULATORY AND HOME CARE.  Discharge planning and home care issues are important aspects of care after prostate surgery.  Instructions include  (1) caring for an indwelling catheter (if one is left in place);  (2) managing urinary incontinence;  (3) maintaining adequate oral fluid intake;
  122. 122. Con--  (4) observing for signs and symptoms of urinary tract and wound infection;  (5) preventing constipation;  (6) avoiding heavy lifting (more than 10 lb [4.5 kg]); and  (7) refraining from driving or intercourse after surgery as directed by the physician.
  124. 124.  Left to right: 2 Bard-Parker knife handles #4;  1 Bard-Parker knife handle #3, long;  2 Mayo dissecting scissors, curved and straight;  2 Metzenbaum dissecting scissors, 7 inch and extra long;  2 Snowden- Pencer scissors, straight and curved;  1 Jorgenson dissecting scissors;
  125. 125.  Left to right: 2 Adson tissue forceps (1 × 2), front view and side view;  2 Ferris Smith tissue forceps (1 × 2), front view and side view;  2 Russian tissue forceps, front view and side view; 2 thumb tissue forceps with teeth (1 × 2), long, front view and side view;  2 DeBakey vascular Autraugrip tissue forceps, long, front view and side view;  2 DeBakey vascular Autraugrip tissue forceps, extra long, front view and side view.
  126. 126.  Hemoclip-applying forceps, 2 medium, 2 large.
  127. 127.  1 Gil-Vernet retractor;  2 Goelet retractors, front view and side view;  2 Gelpi retractors.
  128. 128.  2 Greenwald suture guides, 24Fr and 28Fr;  3 Deaver retractors: narrow, side view; medium, front view; and wide, side view;  2 Harrington splanchnic retractors, small and large, side view.
  129. 129.  Top: 2 Balfour abdominal retractor fenestrated blades, large.  Left to right: 1 Balfour abdominal retractor frame; 2 Balfour abdominal retractor fenestrated blades, small;  2 Balfour abdominal retractor center blades, large and small;  2 Richardson retractors, medium and large;  3 Ochsner malleable retractors, narrow (side view), medium, and large.
  131. 131. -
  132. 132.  Left to right: Paper drape clip; -Halsted hemostatic forceps, straight; -Mayo dissecting scissors, -straight; Crile hemostatic forceps, -straight; paper drape clip.
  133. 133.  Resectoscopes: 30-degree telescope; obturator; inner sheath; outer sheath; working element. Top to bottom: 1 red port cap; 1 gray nipple; stopcock; 2 metal tubing connectors; bridge; and 2 peg clamps.
  134. 134.  Top, left to right: Plastic tubing; spoon.  Bottom, left to right: inner sheath; obturator; outer sheath; light cord; van Buren urethral male sounds, 30Fr to 22Fr.
  135. 135.  Left to right: A, cutting electrode with pointed end and tip;  B, coagulating electrode with ball end and tip;  C, cutting electrode with round wire and tip.
  136. 136. THANKING YOU