Question

BPH Discussion Case Study

S.M. is a 68-year-old man who is being seen at your clinic for routine health maintenance and health promotion. He reports that he has been feeling well and has no specific complaints, except for some trouble “emptying my bladder.” Vital signs (VS) at this visit are 148/88, 82, 16, 96.9° F (36.1° C). He had a CBC and complete metabolic panel (CMP) completed 1 week before his visit, and the results are listed below.

Laboratory Test Results

Sodium 140 mEq/L

Potassium 4.2 mEq/L

Chloride 100 mEq/L

Bicarbonate 26 mEq/L

BUN 19 mg/dL

Creatinine 0.8 mg/dL

Glucose 94 mg/dL

RBC 5.2 million/mm 3

WBC 7400/mm 3

Hgb 15.2 g/dL

Hct 46%

Platelets 348,000/mm 3

Prostate-specific antigen (PSA) 0.23 ng/mL

Urinalysis WNL

What can you tell S.M. about his lab work?

What is the significance of the PSA result?

What other specific examination will S.M. need to have along with the PSA?

While obtaining your nursing history, you record no family history of cancer or other genitourinary (GU) problems. S.M. reports frequency, urgency, and nocturia × 4; he has a weak stream and has to sit to void. These symptoms have been progressive over the past 6 months. He reports he was diagnosed with a large prostate a number of years ago. Last month, he began taking saw palmetto capsules but had to stop taking them because they “made me sick.

Why did S.M. try taking the saw palmetto, and why do you think he stopped taking it?

S.M. is curious why his enlarged prostate would affect his urination. He is concerned that he has prostate cancer. What would you teach him?

The primary care provider (PCP) asked for a postvoiding residual (PVR) urine test. You use a bedside bladder scanner and document that S.M. voided 60 mL and his PVR is 110 mL. You report the PVR to the PCP. What is the significance of his PVR?

Commonly used medications for BPH are 5-alpha reductase inhibitors, such as finasteride (Proscar) and alpha-blocking drugs, such as tamsulosin (Flomax). How do these drugs differ?

The PCP ordered tamsulosin (Flomax) 0.4 mg/day PO. You enter S.M.'s room to teach him about this medication. What side effects will you tell S.M. about? (Select all that apply.)

a. Dizziness

b. Diarrhea

c. Dry mouth

d. Insomnia

e. Heartburn

f. Orthostatic hypotension

The client asks, “Will this condition affect my relationship with my wife?” What should you tell him?

What would you expect S.M. to report if the medication was successful?

S.M. returns in 8 months to report that his symptoms are worse than ever. He has tried several different medications, but medication management failed, and he is told that surgical intervention is necessary.

What surgical options are available to S.M.?

Answer 1

• What can you tell S.M. about his lab work?

I can tell that all of his labs are within normal limits . His blood pressure is slightly elevated , and His PSA indicates that he does not have prostate cancer

• What is the significance of the PSA result?

The PSA test is a blood test used primarily to screen for prostate cancer.The test measures the amount of prostate-specific antigen (PSA) in your blood. PSA is a protein produced by both cancerous and noncancerous tissue in the prostate, a small gland that sits below the bladder in men

• What other specific examination will S.M. need to have along with the PSA?

patient may need to have an abdominal ultra sound : it involves the application of ultra sound in creating the image of the urinary tract which help in its examination. possibly a urodynamic test -this checks the normal functioning of the bladder , urethra and spinchiter.

• While obtaining your nursing history, you record no family history of cancer or other genitourinary (GU) problems. S.M. reports frequency, urgency, and nocturia × 4; he has a weak stream and has to sit to void. These symptoms have been progressive over the past 6 months. He reports he was diagnosed with a large prostate a number of years ago. Last month, he began taking saw palmetto capsules but had to stop taking them because they “made me sick.

Why did S.M. try taking the saw palmetto, and why do you think he stopped taking it?

Saw palmetto is an herbal product (classified as a dietary supplement by the Food and Drug Administration [FDA]) that has been used to reduce prostate growth. It has antiandrogenic, anti-inflammatory, and antiproliferative properties. It can cause loss of appetite, nausea, dizziness, constipation, diarrhea, headache, and impotence. The side effects, plus the realization that his symptoms were getting worse, might have caused him to stop taking it.

• S.M. is curious why his enlarged prostate would affect his urination. He is concerned that he has prostate cancer. What would you teach him?

BPH is caused by nodular hyperplasia (increase in the number of cells) and hypertrophy (increase in size of the existing cells) of the prostate gland. As the gland increases in size, the tissues that surround the prostatic urethra compress it, causing the symptoms of urethral obstruction and secondary irritative symptoms.• Frequently, patients’ biggest fear is that they have cancer. Until this fear is alleviated, they will not be ready to learn additional information. You should tell S.M. that his blood test results indicate it is very unlikely he has prostate cancer, and again reinforce the previous teaching about BPH.

• The primary care provider (PCP) asked for a postvoiding residual (PVR) urine test. You use a bedside bladder scanner and document that S.M. voided 60 mL and his PVR is 110 mL. You report the PVR to the PCP. What is the significance of his PVR?

S.M. is not completely emptying his bladder. The normal residual urine ranges from 0 to 15 ml; however, for patients with enlarged prostates 50 ml is acceptable. His volume is unacceptably high.

• Commonly used medications for BPH are 5-alpha reductase inhibitors, such as finasteride (Proscar) and alpha-blocking drugs, such as tamsulosin (Flomax). How do these drugs differ?

They decrease smooth muscle contraction and allow the patient to empty the bladder.

• PCP ordered tamsulosin 0.4 mg/day PO. You enter S.M.’s room to teach him about this medication. What points should you include? [k/ap] The most frequently reported side effects of this medication are dizziness, headache, orthostatic hypotension, and retrograde ejaculation. Other side effects include dry mouth, drowsiness, som-nolence, syncope, palpitations, and constipation. He should contact the offi ce if he experiences these symptoms, and he will be given a trial of another medication.

• Will this condition affect my relationship with my wife?” What should you tell him?

patients are often embarrassed to ask questions about their condition and how it may affect their sexuality. The nurse needs to be aware that phrases such as “relationship with my wife” frequently refer to the ability to have an erection or ejaculate. You need to clarify your patient’s question and offer answers in a professional, clear manner. BPH should not affect S.M.’s ability to have an erection or affect his sexual function; however, medication side effects can sometimes affect sexual function. If he experiences sexual side effects, he should discuss this with his physi-cian for a possible medication change.

• What would you expect S.M. to report if the medication was successful?

Decreased symptoms of frequency, urgency, nocturia, and improved stream. He may also report he can void standing up

• What surgical options are available to S.M.?

Transurethral resection of the prostate (TURP): The physician uses a monopolar instrument to enter the urethra and core the prostate. The area is then cauterized to stop the bleeding. This procedure requires inpatient hospitalization because of the increased chance of bleeding. An indwelling catheter is placed overnight or longer as needed.

Gyrus TURP: A standard TURP is performed with a bipolar Gyrus instrument that both cuts and cauterizes the prostate

.KTP laser: KTP is a type of laser that cores the prostate and cauterizes as the procedure is done, thereby decreasing the chances of bleeding. It can be done with a person taking warfarin (Coumadin), if stopping anticoagulants is an issue. It is an outpatient procedure.

Saline TURP: This is similar to a PTCA in that a balloon is positioned inside the prostate and infl ated to open the urethra and compress the prostatic tissue away from the urethra. This procedure may require an overnight stay.

Transurethral microwave thermotherapy (TUMT): Intense heat is transferred to the prostate through a urethral probe. This procedure is usually an outpatient procedure. Patients may experience an irritative voiding pattern (frequency) for months following the procedure. There is no tissue to examine for pathology after this procedure; thus, if the person has prostate cancer and BPH, the prostate cancer may go undetected.

Transurethral needle ablation (TUNA): A needle is placed into the prostate and prostate tissue is ablated. Again, there is no tissue to examine for pathology after this procedure. It can be done in situations where surgery is needed.