Case study about Urology - Essay Example

Case Study Case Study BPH (benign prostatic hypertension) and eventually TURP (transurethral pro ctomy) are difficult both physically and psychologically for men. There are many issues in their care as there was in the care of the patient in this case study. This was a 63 year old male who can seeking help for a frequency of urination and inability to empty his bladder. He often feels he has to urinate and can't and it has become more than he can deal with at this point. He is admitted to the hospital and has a TURP. This paper will discuss the condition of BPH and the resulting TURP as well as what these diagnosis and treatment mean to the patient. The impact of any problem with micturation is difficult for most of us but is particularly difficult for men. It affects their quality of life. They often have concern over increased voiding frequency bringing problems such as seep deprivation, psychological embarrassment, and the need to be absent from social occasions. (Jakobsson, 2004). Men often say that they have symptoms such as incontenence and dribbling as well as stress incontinence which cause them a great deal of distress and depression. Many male patients go for long periods of time with the above symptoms without telling anyone because of the embarrassment they feel. (Gilchrist, 2007). It is an increasingly common disease as the number of men that go over the age of 50 increases. Many patients hear from their friends that their symptoms may be prostate cancer and for some that drives them to see a physician but for others, it means denial and attempting not to see a physician. Getting up in the middle of the night frequently will finally send a patient to the physician. By the age of 50, 50% of all men will have BPH in the United States. This is a noncancerous proliferation of the prostate gland tissue. It often swells to the point that it begins to cause problems with normal urination. This happens slowly over a long period of time, on the average, and men learn to live with the symptoms until they become much worse (Gilchrist, 2007). Improved patient outcome, of course, comes with early detection which under the circumstances, we do not often see. Prostate surgery is the second most common surgical intervention in men older than age 60. As they get older, the likelihood of having this surgery gets greater. Statistical values show that having BPH does not seem to increase the possibility of prostate cancer. The prostate which is a chestnut shaped part of the mans reproductive system lies between the bladder and rectum remain small until puberty (Kring, 2003). At that time the male hormone DHT is released and the prostate grows. It is normally double in size in the adult male. It grows again when the adult male hits about the age of 25. Men produce both testosterone and estrogen. The theory is that as men get older and testosterone decreases, estrogen increases and the rise in estrogen prompts the prostate to grow again. No one is really sure why it happens though. If a man is having at least a yearly check up chances are even a silent case will be caught by a digital rectal exam but if not then it is usually caught only when it becomes symptomatic. A urinalysis and PSA should be done when he arrives for his exam. A urinary flow study can be done as well as a rectal ultrasound, cystoscopy, or intravenous pyelogram. Keeping a voiding diary when there is suspect of having BPH helps. The bladder outlet obstruction of BPH has two components: a dynamic component related to the tension of prostatic smooth muscle in the prostate, prostate capsule and bladder neck, and a fixed component related to the bulk of the enlarge prostate impinging upon the urethra (Cunningham, 2009). Two classes of drugs work on both of these components. Those are alpha-adrenergic antagonists and 5-alpha-reductase inhibitors. Finasteride (Proscar), an antiandrogen that selectively blocks 5-alpha reductase and converts testosterone to DHT, is one of those medications (Pinnock, 1998). This drug shrinks the prostate and the tissue around it. It should be used with caution because recent studies show that it may make a cancer grow if it is cancer instead of BPH. It should also not be given to patients who have a liver dysfunction. Another drug that has been shown to work is Avodart which is an alpha reductase inhibitor and acts similar to finasteride. There are various alpha-adrenergic blockers that are prescribed in patients who have BPH. Hytrin, Cardura, and Uroxatral as well as Flomax are often used. They relax smooth muscle including that of the bladder and prostate and therefore improve urinary flow. Many men show improvement with these drugs but some of the side effects may be more than they want to deal with. Some of those are low blood pressure, headache, fatigue, and dizziness. Closely monitoring this patient's blood pressure is extremely important. Antiandrogens and gonadotropin-releasing hormone agonists also have been used. GNRH agonists may be somewhat more effective on BPH and LUTS but sometimes the resulting androgen deficiency caused does work. It appears in the United States from most studies that many patients are first managed with watchful waiting, then alpha-adrenergic antagonists proceeding to other therapies. In Europe studies show that alpha-adrenergic antagonists are used most often (Cunningham, 2009). Let us take a moment to look more closely at some of these drugs as they will be a part of any of these patients care plan for some time. There are five long acting alph-1-antagonists, terazoxin, soxazosin, tamsulosin, alfuzosin, and silodosin which have been approved by the Food and Drug Administration. Prazosin is a short acting drug which is sometimes used but the others are preferred. These drugs act against the dynamic component of the bladder outlet obstruction. The side effects were orthostatic hypotension and dizziness. Terazosin and doxazosin generally need to be taken at bedtime and should be titrated over several weeks. Tamsulosin, Aalfuzosin, and silodosin have less effect on blood pressure Chapple, 2004). There are some procedures that are effective if drugs will not work. There is a TUMT which is transurethral microwave thermotherapy which may reduce symptoms such as frequency, urgency, straining, and intermittent urine flow. In this case the hyperplastic prostate tissue is destroyed by using a microwave antenna that is placed through a catheter to the prostate (Helgason & Adolfsson, 1996). Transurethal needle ablation (TUNA) works on the same principle as TUMT but used low frequency radio waves instead Transurethral resection of the prostate (TURP) is what our patient ended up having. It is the most common of the surgical treatments for BPH and is used when all other methods have not been successful. The enlarged prostate tissue is removed by a specialized endoscope called a resectoscope which is inserted through the urethra with in the prostate gland. A wire loop is used to cut off the excess prostate tissue. Laser surgery has been used some recently in which 30 to 60 second burst of energy are beam at the prostate tissue and the tissue vaporizes. This causes less blood loss and recovery time is much improved. The case study patient had TURP. TURP is done through a resectoscope loaded with a diathermy loop which is advanced into the bladder. Strips of prostatic tissue are resected with the loop and dropped into the bladder. This is done under direct visualization and continued until the prostate is resected and the capsule is exposed. At the end of the procedure, the prostate chips are evacuated from the bladder and hemostasis is achieved with electrocautery. The patient is left with an open prostatic fossa and bound by the denuded surgical capsule. A new epithelial surface will cover the area in about 6 to 8 weeks (Cunningham, 2009). Until that epithelial surface regrows the patient is subject to rebleeding. A TURP can be done under a general block or under anesthesia according to the needs of the patient. The procedure takes 60 to 90 minutes to do and will require that the patient stay in the hospital for approximately 24 hours after the procedure due to the possibility of bleeding. In fact, the patient usually does have some bleeding post operatively so this is something that needs to be included on the patients teaching plan. The TURP has been being used for some time and is considered a safe procedure. Most partients that have this procedure have great improvement in symptoms right away. Complications are actually common to the procedure according to most studies. The Veterans Administration did one large study which included 280 men. The main results of that study showed that surgery decreased the residual volume in the bladder and that there was a maximal urinary flow. However, it also showed that the primary outcome of treatment failure was death, repeated or intractable urinary retention, and residual urinary volume, development of bladder calculus, new and persistent incontinence, and doubling of the serum creatinine. There were actually no deaths related directly to the TURP but there were 9% that had complications within 30 days that led to their death. Sexual dysfunction is also a frequent side effect of the surgery. The case study patient had symptoms for quite some time similar to what happens in the usual client according to the research. In talking with him he had all of the symptoms that most men had including getting up at night and never feeling like he emptied his bladder. He was embarrassed to talk about the problem for a long time so by the time he went to the physician, his symptoms were well progressed. He did try the wait and see approach but his symptoms seemed to get worse fast and he found himself having to stay home a lot because of them. His physician placed him on medication and this seemed to help for awhile but now he is in crisis with pain and difficulty voiding. He has TURP and is discharged. He remains without symptoms several months later. In conclusion urinary tract issues alone are embarrassing for men, often driving them to have a great change in the quality of their lives. Once a patient decides he can no longer live with his symptoms is when he often comes for follow up and by that time medication and sometimes surgery is the only answer. If they came earlier, it might not come to the surgical stage. The surgery has been around a long time but there are still many complications related to it and therefore medication would be a better choice if caught earlier. Reference Chapple, C. Pharmacological therapy of benign prostatic hyperplasia/lower urinary tract Symptoms; an overview for the practicing clinician. BJU Int. 94;738. Cunningham, G. Kadmon, D. (2009). Medical treatment of benign prostatic hyperplasia. UpToDate. Available at www.uptodate.com Cunningham, G. Kadman, D. (2009). Surgical and other invasive therapies of benign Prostate hyperplasia. UpToDate. Availabe at www.uptodate.com Gilchrist, K. (2007). When your patient has BPH. RN: 3(1). 38-39. Gilchrist, G. Benign prostatic hyperplasia: Is it a precursor to prostate cancer The Nurse Practitioner. 29(6); 30-37. Helgason, AR, Adolfsson, J. & Dickman P., (1996). Sexual desire, reaction, orgasm and Ejaculatory functions and their importance to elderly Swedish men. Age Ageing. 6; 106-118. Jakobsson, L., Loven, R., Lars, H., (2004). Micturition problems in relation to quality of life in men with prostate cancer benign prostatic hyperplasia; comparison with men from the general population. Cancer Nursing. 27(3). 218-229. Kring, D. (2003). Benign prostatic hyperplasia. Nursing. 33 (5). 44-45. Pinnock, C., O'Brien, B, Marshall, V. Older men's concerns about their urological health a qualitative study. Aust NZJ Public Health. 1998: 22: 368-373. Weeks, B. Ficorelli, C. (2005). The ABC's of BPH. Nursing. 35(10). 68-69. Appendix I Patient presented complaining of increased frequency of urination and feeling as though he cannot empty his bladder completely. After voiding, he often feels as though he needs to urinate again. He denies a urethral discharge. He has been having problems for some time and has been on medication from his doctor but today it got much worse and he is unable to get comfortable. He has mild hypertension and takes a thiazide diuretic. His only other medication is ampicillin, prescribed for two urinary tract infections during the past year. His urinary track infections over this last year have not been severe enough to admit him to the hospital and it is noted the his urine is negative for red blood cells, white blood cells and is clear but concentrated. Al foley catheter has been placed for relief and bladder residual was 200cc. Clinical examination DCB, a 60 year old male complains of a six month history of difficulty to void. His blood pressure is 130/84 mm Hg and his pulse rate is 80 bpm; he is afebrile Findings from examination of the heart and lungs are normal and the abdomen reveals no masses From the evidence above, a preliminary diagnosis of benign prostatic hypertrophy (BPH) was made and do to the discomfort the patient is feeling, the plan is to admit to the hospital, work up, and surgery in the morning. His initial order include surgical permit, IV fluids, NPO, blood and urine for preop work up, EKG. Surgical Intervention The patient was taken to surgery for a TURP the next day. Nursing Plan of Care Plan Reason When Assure patients comfort Patient admitted because of pain and discomfort, assure that the patient is medicated for comfort and rest As soon as patient is on floor and initial assessment is done Prepare patient for surgery Patient will need to sign surgical permit. All labs and h&p on the chart. Family and pt will need to know when surgery is scheduled and what to expect both pre and post op Assure that all medications etc that are ordered pre op are available. Before surgery Check for bleeding, check urine often. Assure patient and family Post op teaching and observation Post op Reduce pain as needed Observe and treat pain as needed Prepare for discharge Assure patient understands possible bleeding. Assure understands medications and treatments and has follow up Read More