Case Study #2 - PowerPoint Presentation

Slide1

Case Study #2

Fawn Mumbulo 2013

Course 580

Sheila Gahan, FNP instructorSlide2

C.S. is a 66 year old male

Vitals:

BP 142/77, P 63, R 20, Temp 35.8, Ht 5’10”, Wt 175lbs. BMI 25.1

Patient was seen at the Edmeston/Burlington Health Center for health maintenance.

CC:

Difficulty with urination. Follow up after starting Saw palmetto.

HPI:

Urinary frequency, urgency, nocturia, and one incidence of incontinence. These symptoms have been gradually getting worse over the past year. Continues to be a nuisance and an every day experience. The symptoms are so aggravating that patient has reframed from going places & if he does then he does not drink any liquids. Associations are “the more I drink, the more I have to urinate.” Alleviations are none at this time. Aggravation has to deal with water pill & amount that patient drinks.Slide3

PMH FH

HTN

Hyperlipidemia

Erectile dysfunction

Constipation

Prostate disorderActinic keratosisRight hip painH/O colonoscopyCorrective lensesSurgical history:VasectomyRight shoulder arthroscopyAnterior cervical fusion x 2

Mother – deceased, diabetes, HTN, Arthritis

Father – deceased, HTN, heart disease

Sister – breast CA, heart disease, HTN

Brother – HTN, high cholesterol

Social history:

Never smoked or used smokeless tobacco

Drinks 0.6oz of alcohol wkly

Currently retiredSlide4

Medication list

Aspirin 81mg one tablet po daily

Colace 100mg three times daily po

Hydrochlorothiazide 12.5mg one tablet po daily

Multivitamin one tablet po daily

Niacin 500mg CR capsule take 1000mg po at HSSaw palmetto 80mg two tablets po twice dailySimvastatin 20mg one tablet po at HSOmeprazole 40mg capsules one po dailyMetamucil pwd one packet po dailyImmunizations: influenza 1/2013, pneumococcal polysaccharide 10/2012Slide5

ROS

Constitutional:

appears well groomed for appropriate age, denies fever, chills or weakness

Respiratory:

Denies wheezing, dyspnea, cough, hemoptysis, pleurisy, TB, or asthma

Cardiovascular: Denies cardiac history, denies palpitations, tachycardia, heart murmur, irregular rhythm, chest pain, discomfort, exertional dyspnea, cyanosis, phlebitis, or skin color changes. Denies history of rheumatic fever, cold extremities, edema or heart medications

Neurological:

Denies dizziness, sleeping disturbances, denies twitching, convulsions, loss of consciousness or memory loss

GU:

Reports frequency, polyuria, noctoria, urgency, reduced forced stream, hesitancy, dribbling, incontinence. Denies burning/pain on urination, hematuria, infections, stones, or pain. Recalls urine is clear/yellow. Denies hernias, discharge, sores, or pain on testes or penis. Denies doing self-exam’s. Reports no sexual intercourse due to erectile dysfunction.

Psychological:

Denies history of psychiatric diseases or disorders. Denies nervousness, tension, mood changes, including depression or anxiety, or hallucinations

.

Labs:

9/7/2012 PSA

0.63 (norm <= 4ng/ml); No U/A or C&S obtained at

this encounterSlide6

Differential Diagnosis r/t symptoms

Obstruction of urethra

Prostate cancer

Bladder neck contracture

Prostatitis

Inability of sphincter relaxationNeurologic diagnosis – spinal cord injury, stroke, parkinson, multiple sclerosisPoorly controlled diabetesCHFPharmacological – diuretics, sympathomimetics, anticholinergicsBladder carcinoma

Overactive bladder

Bladder calculi

UTISlide7

Incidence Prevalence

There is no clear identifying characteristics to determine incidence.

Men aged 31-40 – 8%

Men aged 51-60 – 40-50%

Men over 80 years of age – 80%

Age dependent disease that begins at age 50 & by age 85 –95% of men have difficulty urinatingSlide8

American Urology AssociationSlide9

Diagnosis Refining Dx

Evident by a digital rectal exam (prostate should be walnut size)

PSA level less than 10

U/A would show pyuria stones, infection & pH changes with a positive culture

BUN/CR should be done

Referral to urology: Confirmation is by obtaining a biopsyUrinary cytologyPost-void residualUroflowmetry

Cystoscopy

Urodynamic pressure-flow study

Ultrasound of kidney/prostateSlide10
Slide11

Etiology Risk factors

No basic etiology for an enlarged prostate

Research has shown that testosterone or a by product of testosterone may be the cause of enlarged prostate

Theory is that the ratio of testosterone & estrogen as men age cause the prostate to grow

Medications such as OTC cold & allergy drugs can drastically worsen BPH

ObesityPoor exerciseErectile dysfunctionAgeFamiliar history

Heart disease & use of beta-blockersSlide12

Pathophysiology

Glandular enlargement d/t chronic inflammation

Hyperplastic process of the transitional zone & periurethral tissues

Prostatic capsule results in compressive forces on the prostatic urethra

Increased prostatic smooth muscle tone

Decreased prostatic complianceChanges in prostatic urethral geometryLower tract UTI can cause same symptomsSlide13

Prostate Lobes/Zones: used by pathologists

PZ (posterior/lateral lobes)

 70% of the prostate gland in young men. Surrounds the distal urethra. More than 70% of prostatic cancers originate.

CZ (partially median/lateral lobe) 25% of a normal prostate gland. Surrounds the ejaculatory ducts. More than 25% of all prostate cancers originate.

TZ (partially anterior/lateral lobe – isthmus) 5% of the prostate volume. Rarely associated with carcinoma. Surrounds the proximal urethra. Responsible for BPH.

Anterior fibromuscular zone (Stroma – lateral lobe) 5% of the prostate weight. Holds glandular components, composed of fibrous muscular tissue.Slide14

BPH

Benign prostatic hyperplasia is an increase in number of stroma & epithelial cell linings within the prostate that increase in size

The urethra may become compressed & narrowed which causes the presenting symptoms Slide15

Medical Therapies

Typically are used to treat bladder obstruction which in turn reduces prostate volume & relaxation of the smooth muscle in the prostate

Treatment depends on age, overall health, & severity of symptoms

Treatment options consist of pharmacological drugs such as alpha-adrenergic antagonists (reduces the smooth muscle tone, improving urination flow)

Alternative medications

Lifestyle changesSurgical proceduresSlide16

Alpha-adrenergic drugs

Non-selective

Selective

Terazosin (Hytrin)

1-10mg po

Doxazosin (Cardura)1-8mg po

Produce fewer side effects

More expensive

Tamsulosin (Flomax)

0.4mg po

Alfuzosin (Uroxatral)

10mg po

Side effects include:

dizziness, headache, fatigue, postural hypotension, nasal congestion, edema, & retrograde ejaculationSlide17

5-alpha-reductase inhibitors Alternative drugs

Reduces prostatic volume

These drugs reduce PSA by ½, so the PSA results should be doubled for purposes of screening for prostate cancer

Finasteride (Proscar)

5mg po

Dutasteride (Avodart)0.5mg poAlpha-blockers are not recommended due to the out come of orthostatic hypotensionWell tolerated drugs, small risk of libido reduction & erectile dysfunction

Vit

D receptor agonist

Appears to help with management of lower UTI related to BPH

Saw palmetto (Serenoa repens)

Appears to block 5-alpha-reductase

Pygeum or African plum extract (Pygeum africanum)

Decreases nocturia, improves urine flow

Grass pollen (Secale cereale)

Improves nocturia, the amt of urine left in bladder, decreases the size of the prostate

The main ingredient in some of these drugs is Beta-sitosterol which lowers cholesterol, improves urinary flow, & decrease amts of urine left in the bladder

60-130mg daily

Found in pumpkin seedsSlide18

Procedure/Surgical Options

RF Therapy/Laser Prostatectomy

Resection/Incision/Needle

Heat to produce coagulation necrosis with needles in the lateral lobes

Transurethral microwave thermotherapy (TUMT)

Produces coagulation necrosis by coil, complications include – prolonged urinary retention & irritative voiding symptoms

Transurethral holmium laser ablation of the prostate (HoLAP)

Tissue vaporization

Transurethral holmium laser enucleation of the prostate (HOLEP)

Tissue is pushed into bladder & removed using a evacuator

Holmium laser resection of the prostate (HoLRP)

Photoselective vaporization of the prostate (PVP)

Transurethral vaporization of the prostate (TUVP)

Transurethral resection of the prostate (TURP)

Hallmark “Gold Standard”

Complications:

TURP syndrome – in 2% of patients, vision disturbances, changes in mental status, wide complex tachycardia, glycine is used to irrigate (does not prevent hyponatremia, limits hemolysis)

Can causes incontinence

Erectile dysfunction

Transurethral incision of the prostate (TUIP)

Transurethral needle ablation (TUNA)Slide19

TURPSlide20

Lifestyle Changes

Urinate when the urge is first felt

Go to the bathroom when time allows, even if you do not have to urinate

Avoid alcohol/caffeine, especially at night & 2 hours before bed

Spread out fluid intake throughout the day & avoid drinking large amts at once

Avoid cold/sinus medicationsExercise regularlyDo kegel exercisesReduce stress Slide21

Follow up care

Patient was started on Flomax 0.4mg one capsule at bedtime

Watchful & Wait

Monitor symptoms every 3-12 months

Yearly digital rectal exam

PSA yearlyPost void residual checksReferral to urology when symptoms are not under control or PSA is 10 or aboveSlide22

Correlation to Prostatitis:

BPH

Prostate Cancer

Prostatic inflammation is involved in pathogenesis/progression of BPH

Develops in the transitional zone & central zone

Chronic disease, with early initiation & slow progression

Hormone & age dependent

Hypothesized that BPH is an immune-medicated inflammatory disease

Related to lower urinary tract symptoms

Pathogens: bacterial, urine reflux with chemical inflammation, dietary factors, hormones, autoimmune response, & combination of above

Viruses: human papilloma virus, herpes simplex virus type 2, cytomegalovirus, STD’s

Gram-negative pathogens: E-coli

Prostatic inflammation is involved in pathogenesis/progression of Prostate Cancer

Develops in the peripheral zone

Chronic disease, with early initiation & slow progression

Hormone & age dependent

Chronic inflammation is considered a risk factor for many organ cancers

Obesity & metabolic syndrome’s are associated with low grade chronic inflammation that may affect tumor growthSlide23

Urinary Retention

Is intermittent self catheterization still considered treatment?

Associated with BPH

Characterized by sudden, painful inability to urinate

Distressing

Can lead to ill health deathFirst line treatment is prescribing Alpha-1 Blocker without catheter.

Prolonged cath associated with increased risk of infection

Prolonged hospitalizations

Research has shown that urethral cath in an emergency followed by a treatment without a cath is the standard practice worldwide & by prescribing an Alpha-1 Blocker prior treatment without a cath doubles the chance of success for the patientSlide24

Open Prostectomy

~250g gland with another lobe yet to be removedSlide25

References

De Nunzio, C., Kramer, G., Marberger, M., Montironi, R., Nelson, W., Schroder, F., Sciarra, A., & Tubaro, A. (2011). The controversial relationship between benign prostatic hyperplasia and prostate cancer: The role of inflammation.

European Urology 60

, 106-117. doi: 10.1016/j.eururo.2011.03.055. Retrieved from http://www.sciencedirect.com

Domino, F. (2013).

The 5-minute clinical consult, 21 ed., Philadelphia, PA: Lippincott Williams & Wilkins, a Wolters Kluwer

Lepor, H. (2005).

Pathophysiology of benign prostatic hyperplasia in the aging male population, 7

(4), S3-S12. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477609

University of Maryland Medical Center. (2011).

Benign prostatic hyperplasia.

Retrieved from http://www.umm.edu/altmed/articles/benign-prostatic-000018.htm

Urology Care Foundation. (2011).

Management of benign prostatic hyperplasia (BPH).

Retrieved from http://www.urologyhealth.org/urology/index.cfm?article=144

Urologymatch.com (2009).

II. Basic principles: Benign prostatic hyperplasia (BPH) and its treatment.

Retrieved from http://www.urologymatch.com/book/export/html/88

BJUI. (2011). Treatment for acute urinary retention due to BPH varies among countries.

Urology Journal BJUI.

Retrieved from http://www.news-medical.net/news/20111128/Treatment-for-acute-urinary-retention- due-to-BPH-varies-among-countries.aspx