Full transcript
0:03this is part two of the genital urinary
0:05disorders lecture beginning with bph
0:08benign prosthetic hypertrophy
0:11so bph is um
0:15an overgrowth of the prostate gland you
0:17can see the anatomy there on the left
0:20uh the the prostate is kind of a donut
0:22shaped gland it encircles
0:25um wraps around the urethra so if it
0:28were to overgrow like is shown on the
0:30bottom left there i have that circled
0:32for you
0:33the danger is you could close off the
0:34urethra
0:36closing off the the bladder outlet and
0:38leading to a lot of urinary retention
0:41[Music]
0:42so that's basically what's going on with
0:44bph
0:45bph is not a risk factor for prostate
0:49cancer important understand two
0:51different pathologies two separate
0:52disease processes
0:54so that's a common misconception but
0:56just because somebody has bph
0:59doesn't mean that it progresses into
1:01prostate cancer it's not an early
1:03indicator of prostate cancer it's two
1:05entirely separate things make sure you
1:07understand that
1:09when it comes to bph there are two
1:12components and it's good to have an
1:14understanding of what these two
1:15components are of bph because it's these
1:18two components that will dictate how bph
1:22is then treated there's a dynamic
1:24component and a structural component the
1:27dynamic component of bph is this
1:29increased tension
1:31of the prosthetic smooth muscle
1:33around the the neck that
1:36causes a constriction of the urethra so
1:40it tenses up and closes off
1:44the urinary output for that reason and
1:46then there's also the structural
1:47component the overgrowth the bulking up
1:50of the prostate gland
1:52that leads to a closing off of the
1:55bladder outlet impinging the urethra
1:57closing off the urinary outflow
1:59so it's these two
2:01um components that lead to the problems
2:03with bph the dynamic component which
2:05would need to be treated in the
2:06structural component which needs to be
2:08treated
2:10when it comes to risk factors and the
2:12manifestations
2:14risk factors the number one risk factor
2:16you can put stars next to this is age
2:19there's a direct correlation between the
2:22incidence of
2:24bph and aging 50 of men over 50 have bph
2:3080 of men over 80 have bph there's a
2:34direct correlation with age so that's
2:36the number one risk factor other risk
2:38factors include smoking heavy alcohol
2:41use hypertension heart disease diabetes
2:44so these all serve as risk factors for
2:46developing bph but the number one is age
2:49as far as manifestations
2:52there are several hallmark signs and
2:54manifestations
2:56of bph
2:58increasing nocturia
3:00avoiding frequently at night and that's
3:02directly related to
3:05the incomplete emptying of the bladder
3:07the fact that there's always some
3:08urinary retention left in there
3:10which means that they're going to have
3:12to void more frequently because there's
3:14always a certain amount of urea the
3:16urine that's left in the bladder at all
3:18times so increased nocturia
3:21hesitancy which means very frequently
3:23the person will tell you
3:25that he'll have to kind of bear down in
3:28valsalva to get the stream started it
3:30doesn't flow naturally there's this
3:32hesitancy when he goes to void he has to
3:34kind of force and bear down to get the
3:35stream started
3:37when the stream does start there's a
3:39reduced force of the stream he'll tell
3:41you it just kind of dribbles
3:42um
3:43there may be an interrupted stream again
3:46because of that increased dynamic
3:47component
3:50where it kind of interrupts the stream
3:52uh pinches it off midstream
3:55so it kind of starts and stops starts
3:57and stops
3:58a sensation of incomplete bladder
4:00emptying and again the reason for this
4:02is there's always going to be some
4:04residual urine left in there
4:06so they're never going to feel like
4:07their bladder is completely empty
4:10straining again forcing to get the
4:12stream started to keep the stream going
4:14so it's not interrupted as they're
4:15voiding
4:17post void dribbling or leaking so after
4:19they've voided
4:21a little bit may continue to leak out
4:23for a while afterwards
4:24it may involve hematuria that is not an
4:27early sign that's a very very very late
4:29sign
4:30recurrent urinary tract infections again
4:32because of the constant
4:34um
4:35chronic urinary retention that this
4:37leads to so that urine just sits around
4:39brewing festering it's going to have an
4:41increased likelihood of leading to
4:43urinary tract infections
4:45and acetamia which is nothing more than
4:48an elevated bun in creatinine increased
4:52nitrogen containing compounds
4:54which may lead to
4:56kidney damage and eventual renal failure
4:59um
5:01so it does need to be treated um so it
5:03doesn't progress to kidney failure for
5:05that reason but azatemia
5:07is a sign of bph and again that's
5:09nothing more than elevated bun and cream
5:12as far as labs and diagnostics you can
5:14put a star as i did next to the first
5:17one the digital rectal exam the dre this
5:20is the gold standard for diagnosis of
5:23bph
5:25where
5:26after typically after the age of 40
5:28because that's again when
5:30incidence begins to increase
5:33the doctor before the patient leaves the
5:35office will ask the patient to
5:37turn around put his elbows on the table
5:40and the doctor will insert a finger into
5:42the rectum and feel the prostate
5:45the gland feels large rubbery non-tender
5:49it's uniform it's not nodular it's
5:54symmetrical there's there's no nodules
5:56that can be felt
5:58it's just enlarged and in firm
6:01that's
6:03diagnostic for
6:04bph
6:06other things that can be done
6:08urinalysis
6:10a cns of the urine
6:12just to look for some of those
6:14complications that may arise because of
6:16bph
6:17a cbc
6:18may show an infection from the urinary
6:21tract infection
6:22um if they're actually having
6:25hematuria it could be a decreased red
6:28blood cell count increased reticulocyte
6:30count those kind of things
6:32bu and creatine to show the kidney
6:34function that azatemia that may result
6:36because of ongoing bph
6:39uh the psa the prostate specific antigen
6:43now this is discussed here
6:45because it is prostate related
6:48but this is a diagnostic study used for
6:50prostate cancer the reason it's talked
6:52about here
6:54is it may be erroneously elevated with
6:56patients who've had bph if a digital
7:00rectal exam has been performed recently
7:02that will cause an erroneous elevation
7:05in the psa
7:06a psa greater than four
7:08indicates a chance of there being
7:11prostate cancer however there is a high
7:13rate of false positives with the psa and
7:16in fact for that reason insurance
7:17companies
7:18very frequently nowadays don't reimburse
7:20for a psa there are other better tests
7:24used to test for
7:26both bph and prostate cancer but the psa
7:30may be used and again
7:34greater than four
7:36indicates possible prostate cancer um
7:39cystoscope um like we talked about in
7:42part one of the lecture where they
7:44actually go in with a cystoscope to view
7:46the interior of the bladder the neck of
7:48the bladder to see the impingement
7:51coming from the prostate
7:54bladder ultrasound can be used to assess
7:57that residual urine if the person has
7:59chronic residual urine uh it may be
8:02becoming it may be because he has uh bph
8:06in that chronic residual urine as a
8:09result of that
8:11um urodynamic pressure flow studies
8:14where they actually measure how fast the
8:15urine is coming out
8:17during urination
8:18um
8:19and again that can help to diagnose any
8:22kind of an outlet obstruction where the
8:23person doesn't have a real forceful
8:25stream it kind of dribbles out it starts
8:27and stops
8:28anything less than 15 milliliters per
8:31second is indicative of bph so that is a
8:34possible diagnostic study
8:36and then trans abdominal ultrasound or
8:38trans rectal ultrasound
8:40also known as a truss
8:42where the transducer is in inserted
8:45rectally to be able to view the prostate
8:47from that direction the surrounding
8:48tissues
8:49the advantage here is if they do suspect
8:52that it's prostate cancer not just bph
8:54they can do a biopsy all at the same
8:56time and like has been mentioned earlier
8:58biopsy is necessary to definitively
9:01diagnose cancer
9:03so the trust may be performed not just
9:05to look at the prostate and the
9:06surrounding tissue itself for any
9:08invasion but if they suspect it may be
9:10cancer
9:11they may do the trust that they get the
9:13biopsy at the same time
9:16potential complications again that
9:18azatemia that elevated bun creatinine
9:22which can lead to possible renal failure
9:24and urosepsis
9:26you know frequent urinary tract
9:27infections that may actually lead to
9:30sepsis where it gets into the
9:31bloodstream and affects the whole body
9:34collaborative management
9:36nursing management
9:38medical management
9:40and then patient teaching things to keep
9:42in mind as far as nursing management
9:45again doing a nursing assessment
9:46assessing for bladder distension
9:48palpating the bladder
9:50to feel if there is some urinary
9:51retention feeling that bladder elevating
9:55above the level of the pubic bone
9:56getting up closer to the umbilicus
10:00you know tenderness with palpation
10:02feeling of pressure with palpation
10:04that could all be indicative that the
10:06person might have some vph um assessing
10:09for any sleep disruptions because that
10:12increased nocturia the patient tells you
10:14i have to get up four times during the
10:15night to avoid
10:16that's not normal so that may be because
10:20of bph
10:22and monitoring the intake and output as
10:24far as medical management
10:26the first one you see there is
10:28non-surgical and what we talk about is
10:29watchful waiting watchful waiting as if
10:32the symptoms are not so severe as to
10:34interfere with the person's normal
10:36lifestyle the symptoms aren't so severe
10:38that they're causing complications
10:41then they may just let it go
10:44as long as no complications are
10:46occurring um
10:48try to
10:49manage it um
10:50[Music]
10:52as well as possible without you know get
10:54doing real um invasive interventions
10:57that's the watchful waiting now when the
10:58person starts to develop some some
11:00complication then he starts to show
11:02some kidney disease resulting when he
11:05starts to get very frequent urinary
11:07tract infections when it's interfering
11:08with his lifestyle you know he can't get
11:10any sleep he's not peeing all night
11:12then um they may treat it more
11:14invasively but that's what watchful
11:16waiting is
11:18um
11:19they may it may involve some
11:21catheterization if he's not able to void
11:23so you might have to teach the client to
11:25catheterize himself and we talked before
11:28in part one of the lecture about how
11:30that would involve clean technique not
11:32sterile technique
11:34pharmacologically
11:35so the first one you see there are five
11:37alpha reductase inhibitors
11:39this is frontline drug therapy this is
11:42finasteride or proscar it's also due to
11:46do stereotype or avidar proscore and
11:48have a dart these are five alpha
11:50reductase inhibitors what these do is
11:52these work on that structural component
11:54of bph they help to debulk and shrink
11:57the actual prostate gland so these work
11:59on the structural component how do they
12:01work they actually interfere with
12:04testosterone so as a result they limit
12:07testosterone they minimize testosterone
12:09these can lead to some side effects
12:11because of the loss of testosterone such
12:13as erectile dysfunction it can lead to
12:16some gynecomastia
12:18loss of virility libido
12:22you know the person doesn't feel
12:24interested in
12:26sexual activity anymore um because of
12:28that loss in
12:30um
12:31testosterone the other thing i'd like
12:33you to keep in mind when it comes to
12:34five alpha reductase inhibitors like
12:36proscar and avadart
12:37is especially if you're a female nurse
12:41you make sure when you're working with
12:43proscar and avidart that you wear gloves
12:46to protect yourself again
12:48because it affects
12:51hormones like testosterone
12:54it can affect not just the female nurse
12:56but especially if the female nurse
12:59happens to be pregnant it can be
13:01teratogenic and affect
13:02the fetus so you make sure you wear
13:04gloves when working with proscar and
13:06avidart the 5 alpha reductase inhibitors
13:09the other category is the alpha
13:12adrenergic blockers your alpha blockers
13:14this is tamsilosin that we've talked
13:16about so many times before
13:18um very frequently it's also doxazosin
13:22terazzosin those are the most common
13:24ones phlomax cardora hytrin they're
13:26technically alpha blockers technically
13:28blood pressure pills but what they do is
13:31these work on that dynamic component
13:33they actually help the prostate to relax
13:36so it's not so tense so it's not
13:38impinging on the bladder outlet of
13:41outflow so that the person can actually
13:43get the urine out
13:44so pharmacologically it's usually a
13:475-alpha reductase inhibitor and an alpha
13:49blocker that's typically how they treat
13:51those now remember like we've talked
13:53about before even back in pharmacology
13:55an alpha blocker is technically a blood
13:57pressure pill
13:59so remember your most common side
14:01effects of your alpha blockers
14:03is the dizziness the postural
14:05hypotension so encourage your patient to
14:08make position changes slowly don't jump
14:10up to your feet
14:11[Music]
14:12it can lead to a lot of orthostatic
14:14hypertension syncope dizziness
14:18those are the most common symptoms so
14:19don't forget that saw palmetto
14:22is an herbal that patients may go
14:25all on their own to target and pick up a
14:27bottle of soft palmetto and try to take
14:30the problem is research hasn't really
14:32shown the effectiveness of soft palmetto
14:34um
14:35you know it's a common you know belief
14:38you know patients you know men over the
14:40age of 50 they should be taking soft
14:41palmetto to protect the prostate gland
14:43so it's very common it's out there all
14:45over the internet
14:47and so patients may begin doing this on
14:48their own
14:50but like we've talked about before
14:53you doing your assessment you need to
14:55know what all the person is taking
14:57that's been prescribed by the doctoral
14:59as well as what he's picking up and
15:00taking on his own because there may be
15:02some interactions with other medicines
15:04that he's on
15:05but saw palmetto
15:08you should just have an awareness of
15:09that that a lot of patients will take
15:10that all on their own
15:13and then the other category there that
15:15you see is anti-muscarinic
15:18this is
15:20an anti-cholinergic
15:23detrill
15:25working on the smooth muscle in the
15:27bladder
15:28to help to reduce
15:29some of that retention the frequency the
15:32urgency
15:33the incontinence
15:35so those are some pharmacological
15:37treatments
15:38as far as thermo therapies there's a
15:41couple here to talk about as well
15:43um the tuna the trans urethral nation
15:45needle
15:47graphic for that um
15:49where a
15:50small catheter is actually inserted
15:53through the urethra up into the area of
15:55the prostate you know where the
15:57resistance is first met because of that
15:59overgrown prostate and then they start
16:02to emit some low radio frequency waves
16:04to help to shrink the prostate similar
16:06to that is the
16:09microwave therapy
16:11where they're actually using microwave
16:13sound waves to create high temperatures
16:16to help to destroy some of that
16:17excessive tissue the overgrowth of the
16:19prostate
16:21so that's showing you microwave therapy
16:24other
16:25therapies to talk about are the
16:26interstitial laser coagulation
16:29where they're using laser to debulk the
16:31prostate very similar to the other two
16:33that i've shown you
16:35and then an evap
16:37extra vaporization of the prostate and
16:40evap where they're using high frequency
16:42electrical current to vaporize
16:45some of the tissue to debulk it that way
16:47so again very similar to what we talked
16:49about post procedure there may be a
16:51stent placed there to help to maintain
16:53the patency of the urethra through the
16:55prostate
16:56um
16:58so they may have a stent placed
16:59afterwards
17:01these are done
17:02under
17:04local anesthesia
17:07they're
17:08pretty non-invasive
17:11you shouldn't really
17:12expect to have complications afterwards
17:15they're not going to need a catheter
17:16afterwards
17:18they're pretty low invasive
17:21and then we get into the surgical
17:22treatments
17:24for patients who aren't a candidate
17:27you know for some of the non-surgical
17:29or if they just want to have the surgery
17:31performed because
17:33their symptoms are just interfering with
17:35their life too greatly they may decide
17:37to jump right to surgery
17:39if they're younger and they don't want
17:40to allow it to progress
17:43to give it the opportunity to progress
17:45into complications they may just elect
17:46to go ahead and have the surgery
17:48so the most common surgery done here the
17:51gold standard is the terp the
17:52transurethral resection of the prostate
17:55where they go in with a cystoscope that
17:57actually has a receptoscope
17:59attached to it and basically they just
18:03drill away that excess tissue with the
18:06prostate
18:08they resect it they they just kind of
18:10basically drill right through there
18:12scrape it away um
18:15so preoperatively um
18:18you're going to talk to your patient
18:20ease his anxiety answer his questions
18:23discuss the concerns obviously you have
18:25to get a consent for this this is
18:27invasive
18:29operatively wise like you have in your
18:31notes again they use the receptoscope to
18:33actually cut away some of that excess of
18:35tissue they can cauterize it
18:37to stop any bleeding
18:41and then post-operatively
18:43um afterwards
18:45there's going to be a three-way catheter
18:47what we call a murphy drip catheter a
18:48continuous bladder irrigation from going
18:51in there and resecting the prostate
18:53scraping away cutting it away um there's
18:55going to be some bleeding obviously you
18:57don't want that blood to be sitting in
18:58the in the bladder just sitting around
19:01having the chance to agglutinate and
19:02clot and then those blood clots could
19:05clog the urinary outflow and then you've
19:06got some acute urinary retention and
19:08obstruction which could lead to
19:10hydronephrosis
19:11and kidney damage so you want to
19:14minimize the the formation of those
19:15clots so the person will have a
19:17continuous bladder irrigation this
19:19three-way catheter where there's a large
19:21large large bag of normal saline that
19:24continuously drips through the catheter
19:26going up into the bladder to keep it
19:29irrigated and it comes out through the
19:31third port into the drainage tube
19:34so you're watching that outflow
19:35constantly immediately after surgery it
19:38is going to be hematuria it's going to
19:40be red that should slowly start to clear
19:42up and get
19:43less red and more pink and then after a
19:46couple days the pink should go away and
19:48it should just return to looking amber
19:50colored um as always
19:53it should always progress in that way if
19:55it ever goes backwards that's when
19:57you're getting concerned if it was pink
19:59this morning and now it's red this
20:00afternoon that's unnatural that's not
20:03normal i would be concerned and call the
20:05doctor about that if it's been yellow
20:07and now it's pink it's working its way
20:09backwards that's what i'm concerned
20:10about so those are what you would you
20:13know have as un unexpected findings and
20:16what would prompt you to call the doctor
20:18and get a little bit more concerned
20:20as far as complications of that
20:24after the terp in the continuous bladder
20:25irrigation some things to watch for
20:28could be hyponatremia because of the
20:30dilution
20:32from that continuous bladder irrigation
20:33so you're watching for the signs and
20:34symptoms that we've talked about earlier
20:36this semester with hyponatremia
20:38restlessness diaphoresis
20:41power
20:42um you're going to watch the blood
20:43pressure
20:45you're going to watch that catheter for
20:46any obstruction like i mentioned earlier
20:49if they there is an obstruction
20:52and you're noticing that the urinary
20:54output is decreasing you know that
20:56should be pretty steady they're getting
20:57this continuous irrigation it should
20:59remain pretty steady so if that ever
21:00decreases it could be an early sign that
21:03there's an obstruction
21:04um you're going to want to first nursing
21:07process assess to make sure there's
21:09nothing wrong with the catheter itself
21:11to make sure that it's hanging freely
21:12it's not you know kinked up anywhere
21:14nothing like that
21:15and then if you establish that the
21:17catheter is in fact patent then your
21:19next intervention is you could irrigate
21:21it
21:22again no pressure bulb syringe
21:24only with normal saline just easily
21:27instill some normal normal saline don't
21:29ever withdraw afterwards you don't want
21:31that negative pressure that can cause
21:32some damage so just instill the normal
21:34saline with the bulb syringe very gently
21:36kink off the catheter reattach it to the
21:38drainage device and open it up and just
21:41let it drain again
21:43never never never big capital letters
21:45change the rate of the continuous
21:46bladder irrigation that is not within
21:49your scope of practice the doctor will
21:51dictate um
21:53how fast that murphy drip runs um so you
21:55never change that
21:58and then once the catheter is removed
22:01the person may have
22:02some irritation some burning um on
22:05urination again they've just gone in
22:07there and scraped and cut and everything
22:09it's gonna be a little irritated when
22:10urine comes in contact with it so don't
22:12be surprised if they have some burning
22:13initially
22:15excuse me that eventually will go away
22:17increased frequency some dribbling
22:20because again those muscles are not as
22:22strong as what they used to be because
22:24of going in there and resecting and
22:26cutting and all that kind of stuff they
22:28may have less control over the urination
22:30afterwards so it's not uncommon for them
22:33to have some dribbling and some
22:34incontinence afterwards obviously what
22:37you would do for that is encourage them
22:38to do some kegel exercises to try to
22:40regain some of that urinary control
22:42afterwards
22:46potential complications after having a
22:48terp
22:50again it could be bleeding and
22:51hemorrhage so again you're watching the
22:53um the output in that continuous bladder
22:55irrigation to see what it looks like
22:57you're watching the h you're watching
22:59for systemic symptoms that maybe they're
23:00hemorrhaging things that we've talked
23:02about before
23:03another complication is the catheter
23:05itself could become obstructed
23:08with clots so you're watching for all
23:10those symptoms we talked about earlier
23:12with hydronephrosis
23:15you know with the nausea the vomiting
23:17the tachycardia
23:19the hypertension
23:21the flank pain
23:22those kind of symptoms to indicate maybe
23:24there is in fact an obstruction um
23:26that's causing some hydrogen phroses the
23:28hyponatremia
23:30is a potential complication that i
23:31mentioned just a couple minutes ago
23:33because of that bladder irrigation so
23:34you're watching for those signs and
23:36symptoms if the person develops signs
23:38and symptoms maybe he's becoming
23:40hyponatremic
23:42you want to i would go ahead and
23:44encourage you slow down the drip call
23:46the doctor
23:48and report that and get new orders um
23:50you don't want to stop the drip entirely
23:52because you don't want him to develop
23:54any clots or anything in the meantime
23:56he could get an infection afterwards he
23:58could develop incontinence um
24:01and
24:02it could also lead to retrograde
24:05ejaculation during sex in the future
24:08afterwards um so those are potential
24:10complications as far as patient teaching
24:12i already mentioned the importance of
24:13teaching kegel exercises to try to
24:16strengthen up those pelvic floor muscles
24:18to help him to be able to regain urinary
24:20control as much as possible
24:22he may be discharged with a catheter um
24:25until his first follow-up theorologist
24:28so you would have to teach him foley
24:29care how to clean the catheter uh keep
24:32it flowing um complications of the
24:35catheter you know to let them know you
24:37know
24:38what to watch for if it would become
24:40obstructed or anything so you have to
24:42teach him foley care
24:44medication regimen you know as far as
24:46taking your alpha blocker taking your 5
24:48alpha reductase inhibitor
24:50make sure that you've got your
24:51antispasmodic if you start to experience
24:54pain and spasms all those kind of things
24:57avoid drinking large amounts of fluids
24:59yes i want you to drink fluids i want
25:00you to keep your urinary system flushed
25:02out
25:03obviously
25:04we want to keep your urine diluted
25:07but i don't want you to drink
25:09gulp large amounts of fluid over a short
25:11period of time that could cause a lot of
25:13pressure um
25:15in your bladder and lead to some
25:16problems avoid alcohol avoid caffeine
25:19encourage them to avoid as soon as they
25:21feel the urge to void rather than trying
25:24to hold on to it at least initially um
25:28again they may experience some
25:29difficulty with urinary control so over
25:31time with those kegel exercises you can
25:33have them slowly increase uh the length
25:36of time between their voids but
25:38initially encourage them to avoid as
25:39soon as you feel it in their
25:42and then last you see avoid
25:43antihistamines avoid decongestants
25:46remember these antihistamines have
25:48anticholinergic properties decongestants
25:51have some pathomimetic properties you're
25:53trying to avoid the effects of the
25:54sympathetic nervous system which if you
25:56remember causes urinary retention we're
25:58trying to avoid that so encourage them
26:01to avoid some of those over-the-counter
26:03medicines that have been discussed
26:04earlier as well
26:07next is
26:08oh next is prostate cancer
26:12the second most common cancer among men
26:15second only to skin cancer that we'll
26:17talk about later this semester this is
26:19the second leading cause of death
26:22of cancer in men followed only by lung
26:24cancer that we'll talk about later this
26:25semester
26:27um as far as the pathology the
26:29pathophysiology
26:30um in big bold letters you can see
26:32they're androgens there's a direct
26:34correlation from excess androgen excess
26:37testosterone
26:39leading to an overgrowth a mutation in
26:42the cells of the prostate leading to
26:45prostate cancer so these are almost all
26:48androgen sensitive androgen related
26:51as far as risk factors
26:53over the age of 65 is a risk factor for
26:56prostate cancer
26:57african-american men are at an increased
27:00risk of prostate cancer
27:02high androgens testosterone therapy
27:05testosterone replacement
27:07certain dietary factors
27:09like a diet that's high in red meats
27:13low fiber
27:14those actually increase the likelihood
27:16of developing prostate cancer men who've
27:19had a vasectomy in the past or an
27:20increased risk of developing prostate
27:22cancer
27:23and with most cancers as with most
27:25cancers a familial history
27:28having somebody in the immediate family
27:30a male in the immediate family who had
27:32prostate cancer increases the risk of
27:34developing prostate cancer
27:39as far as labs and diagnostics so
27:42there's the psa again that i mentioned
27:44earlier the prostate specific antigen
27:47this
27:49is a cancer-related antigen it's
27:51released by the prostate cells when
27:53there are cancers mutations involved it
27:56gets released in the bloodstream and you
27:58can pick that up on a routine
28:00blood test you know draw draw blood from
28:02their arm and you can detect an elevated
28:04psa
28:05that may be indicative that they have
28:07some prostate cancer releasing that psa
28:10into the bloodstream and you can detect
28:12that like i already mentioned earlier
28:13greater than four is indicative
28:16of cancer not always there's a high rate
28:18of false positives like i said if the
28:21person actually diagnostically has a
28:23digital rectal exam ordered and a psa
28:27like i mentioned earlier that dre will
28:29cause a false positive in the psa so
28:32make sure you draw the psa before you do
28:35the digital rectal exam or you will get
28:37erroneous results
28:40like you can see there any time that the
28:42psa is greater than 10
28:45that indicates the person needs a biopsy
28:49there's again a biopsy is required for
28:52diagnosis of any cancer
28:54but greater than 10
28:56indicates usually that the cancer is no
28:58longer organ confined and chances are at
29:01this point it's already invaded nearby
29:04tissue so again for that reason they may
29:06do like i mentioned earlier the trust
29:08the trans-rectal ultrasound to be able
29:10to look at the prostate gland itself to
29:12be able to do the biopsy and to look at
29:15the surrounding tissue at the same time
29:17and see if there is in fact any invasion
29:19into that nearby tissue
29:21um
29:23so there's the psa already talked about
29:26the trust this gives them the
29:27opportunity to
29:29examine the nearby tissue the
29:30surrounding tissue and do the biopsy all
29:32at the same time
29:33the digital rectal exam now findings on
29:36this
29:37is
29:38whenever you do the digital rectal exam
29:41filling the prostate it may be tender
29:44very hard very irregular very nodular
29:46it's not smooth it's not rubbery
29:50and so those are all indicative of
29:52prostate cancer now
29:55bph
29:56that we talked about earlier just
29:58pathophysiology it's an overgrowth of
30:00the prostate gland it occurs throughout
30:03the prostate tissue which is why it
30:05leads to impingement of the urinary
30:08outflow prostate cancer tends to form
30:12beginning on the outer surface of the
30:14prostate gland and work its way
30:18interiorly
30:20towards the middle and so
30:22that urinary outflow
30:25obstruction is a very late sign the
30:27hematuria is a very late sign um because
30:30it has to have worked its way the whole
30:32way through the prostate gland before
30:34you get those symptoms and i'll talk
30:35about symptoms in a minute
30:37so prostate cancer usually forms on the
30:39outer surface of the gland so when
30:41you're feeling it with a digital rectal
30:42exam you'll be able to feel
30:44that the irregularities the asymmetry
30:47the nodules the tenderness those kind of
30:49things will be palpated because that
30:51prostate cancer forms on the outer
30:52surface of the clams
30:55um
30:58it's not on the slide there but
31:00after a diagnosis has been made you can
31:02see they may do ct scans to follow up
31:06some lymph node biopsy
31:08to check for any metastasis where the
31:11prostate cancer may have spread to other
31:13places in the body it may involve an mri
31:16it can involve
31:18a nuke med study a radionuclide study
31:21where the client is given a radioactive
31:24isotope and they wait for it to absorb
31:27and then put them under the scanner and
31:28look for those hot spots so all those
31:31things that we talked about earlier and
31:32again that can be very useful to detect
31:34for any metastasis where else
31:36um did this radioactive isotope that
31:40should you know be absorbed into the
31:41prostate gland um where else did it tend
31:43to absorb at did it absorb in the bone
31:45that absorbs the lymph nodes where else
31:47is it to show some possible metastasis
31:50um
31:54i already talked about that
31:55okay as far as manifestations like you
31:58can see in red letters and starred this
32:00is typically asymptomatic
32:03again the person usually doesn't know
32:05that he has prostate cancer because the
32:06symptoms
32:08that you see listed there the urinary
32:10obstruction the painful ejaculation
32:13the erectile dysfunction the hematuria
32:16these are later signs by the time that
32:18that cancer has worked its way through
32:20the entirety of the prostate gland so
32:22these are actually later signs usually
32:24it's asymptomatic the person doesn't
32:26even know
32:29as far as
32:30management again there's the watchful
32:33waiting um
32:36where they may just let it rot it out
32:38let it go you know think about this even
32:40if you have a person who's got prostate
32:42cancer it's been confirmed with a biopsy
32:44he definitely has prostate cancer but
32:46he's 90 years old when we talk about
32:49some of these surgical treatments you
32:51know do we really want to put this 90
32:53year old through a very very invasive
32:55surgical procedure
32:56at that stage of life or would it be
32:57better just to do watchful waiting and
33:00just just let it go as long as it
33:02doesn't progress too quickly and result
33:04in you know
33:05complications that would really affect
33:07his overall health they may determine
33:09they may decide just to do watchful
33:10waiting so that is a possible
33:14treatment option
33:15they may do a bilateral orchiectomy
33:18medical root word or key is testes
33:20ectomy removal of they can remove the
33:22testes to
33:24reduce the testosterone production
33:26remember prostate cancer is largely
33:28testosterone related androgen related
33:32so they may just remove the testes to
33:34get rid of some of that testosterone
33:37hormonal therapy this is one that we
33:39actually mentioned back in pharmacology
33:42if you remember our potassium sparing
33:44diuretics like spironolactone aldactone
33:47that may be prescribed because remember
33:50with your potassium sparing diuretics
33:52like spironolactone dactyl that also
33:54blocks androgen so it can
33:57reduce testosterone levels
34:00so don't be surprised if your patient
34:04is on a potassium sparing diuretic like
34:06aldactone um when he doesn't really need
34:10a diuretic he may be taking that to
34:12block the testosterone in his body
34:15uh the next one you see in your notes is
34:17a laparoscopic
34:18radical prostatectomy
34:20where they're actually making a puncture
34:23going through the abdominal wall
34:24laparoscopically and removing prostate
34:27tissue
34:28that way the person is going to return
34:30with just some puncture sites monitor
34:32those puncture sites obviously you're
34:34watching for things like hemorrhage
34:36infection
34:38those kind of things a little bit less
34:39invasive than an open procedure
34:43so less chance of complications a little
34:45bit safer
34:46which leads to the very next one an open
34:49radical prostatectomy
34:51um
34:52where they're actually making an
34:55incision through the abdomen or the
34:57perineum and removing the prostate that
35:00way
35:01so let's talk about those two type you
35:04see
35:05in your notes there on the slide
35:07[Music]
35:09the
35:10transparent neural or retropubic that's
35:12considered a nerve
35:14sparing
35:16[Music]
35:17procedure
35:18there's an abdominal incision that's
35:20made the entire prostate along with the
35:22prostatic neck the seminal vesicles
35:24radical means everything they're taking
35:26everything out around there
35:28everything that's connected to the
35:30bladder neck they get rid of it
35:32it may cause some rectal dysfunction
35:35temporarily
35:36it's nerve sparing so it should not
35:39they're hoping not to result in
35:41long-term erectile dysfunction but there
35:43may be some initially
35:45again because of you know irritation
35:48inflammation all that kind of stuff
35:49while they're in there
35:51as opposed to the perineal approach
35:54where they're going in through the
35:55perineum
35:56making a perineal incision and typically
36:00that does result in impotence erectile
36:02dysfunction as a result
36:04also because of
36:07geography just where it's located going
36:09in through the perineum
36:11there's a lot of bacteria in that area
36:13so there's also a high incidence a high
36:15risk of them getting an infection in
36:17that area you know it's hard to keep
36:19that area clean because of bowel
36:21movements and everything
36:23[Music]
36:24so the perineal approach
36:26usually results in
36:29impotence rectal dysfunction and very
36:31very high risk of infection so you have
36:32to watch for those things
36:34um
36:36post-operative care obviously you're
36:38watching the surgical site you're
36:39managing their pain you're treating them
36:41for bladder spasms
36:43which can manifest as that colicky pain
36:47a feeling of urgency to void all of a
36:49sudden because the bladder is going
36:50under spasm trying to force the urine
36:52out so they get that that sudden urgency
36:54to void a feeling of pressure a feeling
36:56of fullness
36:57um so they can be prescribed a couple
36:59different categories of drugs here the
37:00first you see is anti-spasmodics that we
37:03mentioned earlier
37:04ditcher pain eurospas
37:06getting them something for the spasms
37:08and then they could also be ordered
37:11belladonna and opium suppositories bno
37:13suppositories um which is an opioid to
37:16try to relax um the urinary system as a
37:20suppository
37:22so they may get either or
37:24the patient is going to be prescribed a
37:26stool softener afterwards
37:29so that he doesn't have to strain you
37:31don't want anything to increase the
37:33inter-abdominal pressure that after
37:34they've been in the abdominal region
37:36doing surgery so he'll get stool
37:37softeners avoid any straining any heavy
37:39lifting avoid any you know vasava
37:41maneuver
37:43um you're going to watch
37:45for any edema in the the penis in the
37:48scrotum
37:51they usually actually wear something
37:53very similar to like a chalk strap to
37:54keep it supported keep it elevated when
37:57they're laying in bed you know roll up a
37:58towel and place under their scrotum to
38:01kind of keep it elevated to minimize
38:02some of that
38:03edema
38:05they're going to have a catheter after
38:08having a prostatectomy
38:10and again it usually stays in place
38:11until the first follow-up visit with the
38:14urologist so you'll have to teach them
38:15catheter care
38:16all that kind of stuff and because
38:19they've been in there working on the
38:20prostate
38:22the person may at least temporarily use
38:25some urine control so teaching them
38:27kegel exercises would be important as
38:29well
38:31other therapies that you see listed
38:33there is radiation therapy using
38:35radiation
38:36um to try to kill off the prostate gland
38:39that way that can be delivered to a
38:41external beam or brachytherapy also
38:44known as internal beam external beam is
38:46basically they're blasting the patient
38:48with radiation from outside of his body
38:50they're blasting him with the radiation
38:52to kill off the prostate tissue that way
38:55um
38:57the the biggest thing here
39:00to think about is skin integrity it can
39:02cause a lot of burns
39:04on the skin so you really want to
39:06protect the skin monitor the skin do a
39:08good assessment of the skin
39:10it can get very burned it can cause some
39:12rectal dysfunction
39:14some cystitis
39:16some inflammation of the bladder
39:18and some proctitis
39:22as a result the other one is
39:24brachytherapy
39:26where they actually insert some
39:28radioactive seeds into the patient right
39:31around his prostate gland and they
39:33implant those right there and then let
39:35them emit the radiation directly onto
39:39the the prostate gland to kill it off
39:41that way so the person's going to walk
39:43around with this radiation these
39:45radioactive seeds implanted in his body
39:47for that reason we do have some
39:49precautions to be aware of he will be
39:51slightly radioactive so for that reason
39:54he should limit his exposure to other
39:57people to less than 15 minutes a day he
40:00should try to maintain as much distance
40:02a minimum of six feet away from anybody
40:04else who he is visiting with and coming
40:06in contact with he should have no
40:08contact while he has the brachytherapy
40:11with pregnant ladies he should have no
40:13contact with kids because we want to
40:16protect them from any radiation
40:19he should ultimately have his own
40:21bathroom that he's using
40:23so he could quarantine himself lock
40:25himself in the basement
40:27where he has his own basement and the
40:28rest of the family i'm sorry his own
40:30bathroom and the rest of the family is
40:32using the bathroom upstairs um
40:35he should be you know double flushing he
40:37should be washing his clothes and
40:39running an empty cycle in between his
40:41and the rest of the families
40:44if he does have to share a bathroom
40:46upstairs in the home with the rest of
40:48the family again make sure that he at
40:50least double flushes afterwards to try
40:53to get as much of the leftover radiation
40:56out of that toilet before somebody else
40:57goes and sits on that same toilet he
40:59should not ever be going out of public
41:02and using public restrooms
41:05it should be his own ultimately his own
41:07his own bathroom
41:09chemotherapy we're going to talk about
41:13cancer
41:14later this semester
41:16but radiation therapy primarily is used
41:18to treat the primary tumor and
41:20chemotherapy is primarily used to treat
41:23any metastasis any distant tumors so he
41:27may be getting chemotherapy
41:29to treat or to prevent any spread of the
41:32cancer to other sites in the body
41:34uh graphics there's an example of the
41:37suprapubic prostatectomy
41:39where they're actually making an
41:41abdominal incision and going in and
41:42removing the prostate that way
41:45there's the perineal prostatectomy again
41:48chances are the person as a result is
41:51going to experience erectile dysfunction
41:54as a result because the nerves being
41:56damaged and there's a high incidence of
41:58infection because of where it's located
42:01so you're really monitoring for that as
42:02well
42:03here's a picture showing you that
42:04continuous bladder irrigation the murphy
42:06drip that i talked about you can see
42:08that large
42:09bag of saline only normal saline that's
42:12constantly dripping down into his
42:15bladder keeping it irrigated keeping it
42:17full keeping it diluted so he doesn't
42:19develop blood clots and then coming out
42:21through that third port
42:23where it's collecting in the drainage
42:24bag and you're constantly watching that
42:27again initially red to pink to amber and
42:30you're watching that you're watching the
42:32outflow it should be a continuous you
42:34know pretty steady outflow because of
42:35the continuous irrigation so if it ever
42:39slows down if it ever stops you need to
42:41assess to see what is keeping it from
42:43coming out he probably has an
42:45obstruction somewhere
42:46like i mentioned earlier big capital
42:48levers never letters never change the
42:50rate of the irrigation that is not your
42:52scope of practice that's the doctor's
42:54job to do
42:56monitor for signs of hyponatremia
42:58so you're watching for all of those
43:00things
43:01as far as potential complications
43:04hemorrhage it could be bleeding it could
43:05be infection he could develop a dvt
43:09because of bed rest and immobility
43:11it could be catheter obstruction talked
43:13about that earlier he could have some
43:15urinary leakage after the catheter has
43:17been removed
43:19and so again
43:20caution him about that warn him about
43:22that teach him about that teach him some
43:23kegel exercises to try to minimize some
43:25of that as much as possible encourage
43:27him to empty his bladder as soon as he
43:29gets the urge to go so he's not getting
43:31residual which could lead to some
43:33urinary leakage and like i mentioned
43:35earlier it could result even permanently
43:38with some sexual dysfunction um
43:41so that may be
43:42something to talk to the patient about
43:44um and that may help to dictate believe
43:47it or not on the person's
43:50decision
43:51for treatment you know he may decide not
43:53to have a prostatectomy because he
43:55doesn't want to run the risk of having
43:57erectile dysfunction afterwards and then
43:59instead he may just decide to do that
44:01watchful waiting instead
44:04if he wants to maintain his sex life so
44:06those are all potential complications um
44:09so this second part of the lecture
44:11talked about the bph and the prostate
44:13cancer
44:14symptoms treatments complications um if
44:17you have any questions problems issues
44:18as always please let me know
44:22and thank you very much