Case Study #2

1. Case Study #2 Fawn Mumbulo 2013 Course 580 Sheila Gahan, FNP instructor

2. 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.

3. PMH FH • HTN • Hyperlipidemia • Erectile dysfunction • Constipation • Prostate disorder • Actinic keratosis • Right hip pain • H/O colonoscopy • Corrective lenses • Surgical history: • Vasectomy • Right shoulder arthroscopy • Anterior 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 retired

4. 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 HS • Saw palmetto 80mg two tablets po twice daily • Simvastatin 20mg one tablet po at HS • Omeprazole 40mg capsules one po daily • Metamucil pwd one packet po daily • Immunizations: influenza 1/2013, pneumococcal polysaccharide 10/2012

5. 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 encounter

6. Differential Diagnosis r/t symptoms • Obstruction of urethra • Prostate cancer • Bladder neck contracture • Prostatitis • Inability of sphincter relaxation • Neurologic diagnosis – spinal cord injury, stroke, parkinson, multiple sclerosis • Poorly controlled diabetes • CHF • Pharmacological – diuretics, sympathomimetics, anticholinergics • Bladder carcinoma • Overactive bladder • Bladder calculi • UTI

7. 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 urinating

8. American Urology Association

9. 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 biopsy • Urinary cytology • Post-void residual • Uroflowmetry • Cystoscopy • Urodynamic pressure-flow study • Ultrasound of kidney/prostate

11. 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 • Obesity • Poor exercise • Erectile dysfunction • Age • Familiar history • Heart disease & use of beta-blockers

12. 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 compliance • Changes in prostatic urethral geometry • Lower tract UTI can cause same symptoms

13. 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.

14. 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

15. 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 changes • Surgical procedures

16. 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 ejaculation

17. 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 po • Alpha-blockers are not recommended due to the out come of orthostatic hypotension Well 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 seeds

18. 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)

19. TURP

20. 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 medications • Exercise regularly • Do kegel exercises • Reduce stress

21. 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 yearly • Post void residual checks • Referral to urology when symptoms are not under control or PSA is 10 or above

22. 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 growth

23. 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 death • First 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 patient

24. Open Prostectomy ~250g gland with another lobe yet to be removed

25. 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