What are some causes of altered patterns of urinary elimination?

Hypospadias

Benign Prostatic Hypertrophy/Hyperplasia (BPH)

Cancer of the Prostate Gland

Define: Hypospadias

Define: Epispadias

Hypospadias is a ventral (under surface) opening of the male urethra

Epispadias is an urethral opening on the dorsal(upper) surface of the penis

Misplaced urinary meatus

Chordee

Hooding of foreskin

Altered micturition

10% also have inguinal hernia & undescended testicles

Hypospadias Repair

Pre-Op

performed  w/in 6-12m of birth

outpt sx unless severe

no circumcision

Hypospadias Repair

Post Op

Urethral stent or foley to closed drainage

watch for infection, check urine for sediment/odor

pressure dressing x4days to decr. swelling

urine blood tinged x 1 day

ice to decr. edema, analgesics, no tub baths

prophylactic antibiotic

increase fluids ditropan for bladder spasms

no prone position or hip carrying

decreased circulating testosterone w/ aging causes overgrowth of prostate to maintain function

risk factors include family hx, environment, & diet

bladder outlet obstruction

(3 main effects)

urethral diameter, funneling & detrusor muscle contraction strength

clinical manifestations of BPH

list irritative and obstructive symptoms

Irritative symptoms

frequency q2h of more

nocturia 3Xor more at night

hesitancy

obstructive symptoms

intermittency (start & stop)

decr. caliber and force of stream

terminal dribbling

sensation of decr. emptying

abdominal straining

obstructs flow of urine and can cause:

hydroureter - dilated ureter

hydronephrosis - dilated renal pelvis

incomplete bladder emptying - w/ urinary retention

increased risk of UTI - r/t urinary stasis

calculi - residual urine

hematuria - r/t overstretched bld vessels in bladder

bladder trabeculations & diverticuli - loss of contractility & incr. connective tissue in bladder

renal failure

On palpation of the prostate by DRE, how does the prostate present with BPH?

Is the PSA normal?

In BPH the prostate is symmetrically enlarged, firm, and smooth.

The PSA level may be slightly elevated in BPH.

DRE, u/a to r/o UTI, serum creat & BUN for baseline renal function, baseline hematologic, PSA, cystoscopy, uroflowmetry, transrectal u/s, PVR (post void residual),

s/s irritative and obstructive

PSA normal level 0-4ng/ml

mild elavations occur with BPH, aging, bike rides, and catheters

Elevation, when prostate ca exists, are useful a maker of tumor volume (the greater the number the greater the tumor mass)

watchful waiting - q3-6m see doc

pharmocologic therapy for bothersome symptoms

catheterize for acute urinary retention

avoid OTC decongestants

double void - void 1x wait void again

void in shower

avoid large amnts o fluid w/ meals

drink 1500-2000ml per day to dec. risk of UTI

dec. fluid 3h prior to bedtime

avoid alcohol - it exacerbated urinary retention

Restore bladder emptying

Relieve symptoms

Prevent complications

5-alpha reductase inhibitors

Proscar - Avodart

Alpha 1 adrenergic blockers (HTN med)

Hytrin or Cardura

Flomax

3-6m to take effect

dec size of prostate=inc urinary flow (by blocking enzyme that converts testosterone to DHT(DHT incr size of prostate)

dec hair loss and inc hair growth

dec libido

erectile dysfunction

dec volume ejaculate

pregnant women cannot handle med

Relax smooth muscle of bladder neck and prostate

70% results in 2-3 wks

s/e postural hypotension

take a night before bed & rise slowly

Hytrin & Cardua - 1st dose phenomenon significant dec BP, start dose low then incr.

Flowmax- can start on full dose

TURP

Transurethral Resection of the Prostate

Use of excision and cauterization to remove prostate tissue cystoscopically.  Considered the most effective treatment of BPH. GOLD STANDARD

performed with spinal or general anesthesia

3-way foley with 30ml balloon for CBI (continuous bladder irrigation) for first 24 h to prevent obstruction from mucus and blood clots

d/c aspirin & warfarin several days prior to procedure

complications include bleeding, clots, dilutional hyponatremia ass'd with irrigation

Alpha-reductase inhibitors interfere with testosterone metabolism.

The prostate gland reduces and the urethra opens.

TURP syndrome is a risk associated w/ TURP procedure. 

escessive absorption, of irrigating fluid from CBI , by the prostate into the vascular space l/t hyponatremia, electrolyte imbalances. vomiting, H/A, & agitation

VLAP

Visual Laser Ablation of the Prostate

A laser beam to produce deep tissue coagulation necrosis of the prostate.  The affected tissue sloughs off into the urinary stream  over several weeks.

Foley after procedure

minimal bleeding

can be performed if patient is on anticoagulants

TUIP

Transurethral incision of the Prostate

transurethral slits or incisions into the prostatic tissue to relieve obstruction, effective for men with little prostate enlargement

considered temporary measure

urinary cath placed after procedure

Nursing Management Post-Op

1 of 4

Risk for urinary retention r/t clots

assess q1-2h for patency & assessing for blood loss

tape cath with traction - pulls tip of balloon against prostate to minimize bleeding

CBI

watch for TURP syndrome

Hydrate 1500-2000nl/day, strict I&O (-CBI from foley #)

urine should be pink/light punch colored & no clots

if bright red inc CBI rate

normal to feel urge to void

cath removed in 72h

Nursing Management Post Op

2 of 4

Risk for altered tissue perfusion (DVT)

Teds to promote venous return

Hydrate 1500-200ml/d to dec thrombus formation & preventing hemoconcentration

Leg exercised, OOB, avoid prolonged sitting (blood pools in legs)

Risk for infection

use aseptic technique

prophylactic antibiotics (Cipro & Levaquin)

assess for s/s infection (fever, ^WBC, ^HR)

teach pt aseptic technique when emptying foley bag

Nursing Managment Post Op

3 of 4

Ongoing Care

impotence small risk, ejaculate retrograde (into bladder)

erectile dysf nrml x1yr p/o, resume intercourse 6-8wk

bladder control improve, pelvic muscle exerc., incont. pads

use stool softener / no straining

no sitting alot, keep hydrated, prevent DVT

f/u w/ dr regrowth and ca can reoccur

Nursing Management Post Op

4 of 4

Pain Management

bladder spasms, distention, and catheter irritation

Assess pain - location and quality

assure cath patency - no clots

analgesics - belladonna & opium suppository

bladder spasms -(can cause bloody discharge at tip of pensi) give stool softener, ditropan (antispasmodic)

minimize cath manipulation, tape to thigh

foley large in diameter causing pt feel urge to void

Increased incidence with increased age

More common & aggressive in AA

high risk if1st degree relative had pros ca

slow growing tumor

more aggressive in younger population

Primary Tumor - adenocarcinoma

male hormone dependent ca

occurs in posterior aspect of the prostate gland on outer portion causing nodular irregularity

Nodules are hard and feel stony

can metastisize beyond the prostatic capsule to the lymph nodes and bone

Often no early symptoms

obstructive symptoms - hesitancy or straining to void

may be discovered on routine DRE

Pain or gross hematuria r/t metastasis

hematuria (bloddy urine)

PSA (Prostate Specific Antigen) is a glycoprotein produced by the prostate.

PSA level <4 is normal

It is not definitive for cancer, however it is used for a screening tool @ 50yrs male/yrly

PSA is a tumor marker released from a prostate tumor

monitors effectiveness of tx for pros. ca

checks for met (^^psa) & reoccurrence of ca

DRE and PSA is recommended at 50yrs

unless AA @ 45 yrs

or ^ risk @ 40yrs

TNM system - staging

Gleason system - grading

TNM stands for

Tumor, Node,Metastasis

TNM is based on size (volume) and tumor spread. 

Gleason grades by combining scores:

differentiation of cells 1-5

patterns of cells 1-5

grade 5-7 40% chance of mets

grade 8-10 75% chance of mets

1 well differentiated, 5 poorly diff.  1 is better than 5

Direct Invasion - urethra, bladder

Lymphatics - regional pelvic nodes

Blood - bone, liver, lungs

Radiation Therapy

Hormone Therapy

Chemotherapy

radiation can eradicate rapidly growing tumor cells

not permanent lasts approx 6 wks

can cause cystitis, proctitis (inflammed prostate gland), enteritis (inflammed rectal area)

addn'l s/e diarrhea, burning urination

check fluids and electro.

pyridium for urinary analgesia and antispasmodic

Hormone Therapy for Prostate Ca

suppression of adrogenic stimulation to the prostate

by decreasing testosterone levels, does not cure disease, only controls disease

Estrogen - DES  - can cause clots

form of androgen deprivation therapy s/e cardio related - MI, DVT,CVD

Antitestosterone drugs

Lupron (leuprolide)-inhibits release of androgens SQ/d or IM/m

Zoladex(goserelin)-control tumor growth sq/m

Androgen receptor blocker -

Eulixin (flutamide) oral

given w/ Luron & Zoladex, dec tumor, dec met pain, inc sense of well being

impotence

dec libido

gynecomastia

hot flashes

Nausea

Vomiting

3 Types of Radiation Therapy

for the Treatment of Prostate Cancer

External Beam Radiation -destroys tumor cells & shrinks tumor

IMRT - Intensity Modulated Radiation Therapy - similar to external beam-more accurate,dec damage to surrounding tissue

Bachytherapy - internal radiactive seeds placed in the prostate, emits radiation 3-6 months

1st few weeks cannot be near children or pregnant women

Diagnostic Studies Cancer of the Prostate

PSA

DRE

TRUS (transrectal u/s) - & needle bx if indicated

Biopsy - thru rectum or perineum

Mets studies -

Serum acid phosphtase - released by prostate, ^ w/ mets

serum alkaline phosphatase -  w/ bone mets

pelvic lymphadenectomy - open or laparascopic to take sample of area to stage

skeletal x rays

bone scan

Alpha-adrenergic blockers prevent the activation of alpha receptors.

They relax the smooth muscle in the urethra and bladder neck and open the urethral lumen.

Surgical management

Cancer of the Prostate

obstructive symptoms = surgery

Radical Prostatectomy

(in conjunction w/ radiation tx)

suprapubic retropubic

perineal

laparoscopic

Orchiectomy

Radical Prostatectomy

Suprapubic

Suprapubic -

thru bladder

urethral anastamosis

p/o suprapubic catheter

complications include - UTI, bladder spasms, bleeding

Radical Prostatectomy

Retropubic

Retropubic  - thru lower abdomen

no bladder surgery

large, high prostate location

lymph node dissection

gives adequate control of bleeding

foley w/ no traction b/c of anastamosis

Radical Prostatectomy

Perineal

Perineal

 - if prostate lower in pelvis

increased chance of injury to nerves = impotence

increased chance of rectal injury

use Penrose drainage

**risk of fecal contamination

foley w/ no traction b/c anastamosis

Radical Prostatectomy

Laparascopic

Laparascopic

4-5 small incisions

remove prostate capsule

obtain lymph node samples

Orchiectomy

surgical removal of testicles

impotence

emotional impact

Nursing Management

Cancer of the Prostate

Goals

Goals:

prevent post-op complications

re-establish acceptable patterns of urinary elimination

sexual function/erectile function may/may not be affected

Nursing Management

Cancer of the Prostate

Foley

Wound

Pain

Nutrition/Elimination

Monitor Foley-no traction,7-12 day duration,waiting for adequate healing at anastamosis site,monitor output-blood, adequate drainage,patent of clots & obstr., irrigate w/ sterile technique

Wound Care - Penrose drain, assess for healing/infec, chng dressing frequently in perineal area, sitz baths

Pain Management -air doughnut, pain med, gel cushion

Nutrition/Elimination-adeq fluid intake, good diet, stool softener

Cancer of the Prostate

Nursing Management

Long Term COnsiderations

Incontinence - approx 12m, use Kegel exerc.,

sudafed ^ bladder tone, artificial urinary sphincter

Erectile dysfunction - Viagra, penile implant (may not work if nerve damage present)

Chronic Pain - significant need, Radiation Tx, pharm methods

Terminal Illness

- Gland enlarges under influence of testosterone

- Enlarged gland creates physical obstruction of urethra

-Alpha-adrenergic receptors are activated in smooth mouscle in the urethra and neck of bladder

-Smooth muscle contracts to narrow the lumen in the urethra