Fawn Mumbulo 2013 Course 580 Sheila Gahan FNP instructor CS is a 66 year old male Vitals BP 14277 P 63 R 20 Temp 358 Ht 510 Wt 175lbs BMI 251 Patient was seen at the EdmestonBurlington Health Center for health maintenance ID: 206543
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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/prostateSlide10Slide11
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