PROSTATE
DISORDERS
OBJECTIVES
• At the end of the lecture, the students should
be able to:
• Identify the different disorders of the
prostrate gland
• Explain their aetiologies
• Discuss the therapeutic interventions as well
as surgeries
• Discuss the nursing care, as well as client
teaching in the different conditions
Introduction
• Problems affecting male genitals and urinary
system are generally difficult areas for both the
patient and the nurse to deal with because of
the sexual nature of the male anatomy
• It is important to realize that sexuality is a
natural part of each of us as human beings and
should not be avoided when we provide care to
patients
Intro cont’d
• The prostate gland sits at the base of the
bladder and wraps around the upper part of
the male urethra like a doughnut
• The primary purpose of the prostate is to
provide alkaline secretions to semen and to
aid in ejaculation
Intro cont’d
• The prostate does not contain any hormones;
however, men fear that prostate problems
and treatment will cause problems with their
erections or their “nature” (sexual activities)
Prostate gland and Related organs
Urinary Bladder
Sacrum
Symphysis Pubis
Rectum
Seminal Vesicle
Glans Penis
Ejaculatory Duct
PROSTATE GLAND
Urethra Epididymis
Testes
Description of the Prostate Gland
The prostate gland lies in the pelvic cavity just
below the neck of the bladder in front of the
rectum and behind the symphysis pubis,
surrounding the first part of the urethra.
It consists of an outer fibrous covering, a layer
of smooth muscle and glandular substance
composed of columnar epithelial cells.
Description of the Prostate Gland
• The gland secretes a thin, milky fluid that
makes up about 30% of semen, and gives it its
milky appearance.
• It contains a clotting enzyme, which thickens
the semen in the vagina, increasing the
likelihood of semen being retained close to
the cervix.
• During ejaculation, muscles in the prostate
gland contract adding their contents to the
fluid passing through the genital duct.
Prostatitis
Pathophysiology
•Prostatitis- inflammation of the prostate gland,
can occur any time after puberty
•R/F- recurrent urinary tract infections,
epididymitis, BPH, urethritis, prostatic carcinoma,
DM, immunocompromised status, urethral
strictures and bladder neck hypertrophy
•Problem may be chronic or a single acute episode.
The inflammation causes the prostate gland to
swell, resulting in pain, especially when standing
Pathophysiology of prostatitis
cont’d
• It may eventually lead to difficulty in passing urine
as a result of an inward squeezing of the urethra
that causes a mild obstruction
Etiology
• There are three basic types of prostatitis:
• Acute bacterial,
• Chronic bacterial, and
• Nonbacterial- An important theory about non
bacterial prostatitis includes the increased
content of creatinine, urate and white blood cells
due to reflux into the prostatic ducts. These
agents can act as chemical agents leading to an
inflammatory response
Etiology
• Bacterial prostatitis is most common in older
men
• It results in oedema and inflammation of all or
part of the prostate gland
• The bacteria primarily responsible for the
infection are gram-negative organisms such as
Escherichia coli; however, gram-positive and
gonococcal bacteria may also play a part
Etiology
The prostate gland may become infected by the
following:
•Bacteria ascending the urethra. Ascending infection
from the urethra and the chemical damage
secondary to the reflux of urine through the
prostatic and ejaculatory ducts
•Infected urine refluxing from the bladder into the
prostatic ducts
•Bacteria in the blood or lymph supply to the glands
•Surgical instrumentation or other forms of urethral
trauma
Signs and Symptoms
The most common symptoms are the same as
with UTI:
•Complaints of urgency, frequency, hesitancy
and dysuria
Due to the location and role of the prostate
gland, the patient may complain of:
•Low back, perineal and post-ejaculation pain;
•May also complain of fever and chills
Diagnostic Tests
• The first test performed is digital rectal
examination (DRE) of the prostate
• The prostate gland is examined by a health-
care provider by insertion of a gloved finger
into the rectum
• The examiner may find a warm, irregular,
swollen, painful prostate gland
Diagnostic Tests
• A urine culture generally is positive for
bacteria
• The examiner may also gently massage the
prostate gland and order an expressed
prostate secretion (EPS)
• Test can reveals bacteria and a large number
of white blood cells
• Acute bacterial prostatitis is usually treated
medically with antibiotic therapy
Therapeutic Interventions
• The preferred treatment is trimethoprim and
sulfamethoxazole (Bactrim) for 30 days
Other antibiotics, include:
• Fluoroquinolones (ciprofloxacin, ofloxacin),
may be used for chronic prostatitis
• Other forms of treatment may include anti-
inflammatory agents
Therapeutic Interventions
• Stool softeners, warm sitz baths, prostatic
massage
• Diet changes such as decreasing spicy foods
and alcohol
• In some cases, prostate surgery is necessary
to remove the obstruction
Nursing Process for the Patient with
Prostatitis
ASSESSMENT/DATA COLLECTION
•Begin the assessment by asking patient to
describe signs and symptoms that indicate
evidence of a UTI, such as sudden fever, chills,
complaints of urgency, frequency, hesitancy,
dysuria and nocturia
•In addition, the patient may have complaints of
pain in the lower back, in the perineum, or after
ejaculating
ASSESSMENT cont’d
• Ask the patient if he has ever had a UTI or
prostate infection in the past
• Care must be taken to assess urinary retention
resulting from obstruction
• Obtain a urine culture and assist with
collection of the EPS specimen, if requested,
as part of the patient assessment
Possible Nursing Diagnosis
• Impaired urinary elimination related to
obstruction
• Ineffective health maintenance: knowledge
deficit related to cause, treatment, and
prevention of prostatitis
• Impaired comfort related to swelling and
irritation of the prostate gland
• Anxiety related to sexual concerns
PATIENT EDUCATION
Teach patient the causes, prevention and
treatment e.g
•Risk factors such as the use of indwelling
urinary catheters, poor hygiene or risky sexual
practices
•Excessive intake of bladder irritants such as
alcohol
•Ignoring signs of UTIs and poor compliance
with the antibiotic treatment plan
PATIENT EDUCATION cont’d
• Encourage the patient to wash his hands and
sitz bath equipment before and after each
treatment
• Fluids such as water and cranberry juice
should be encouraged up to 2500 to 3000 mL
per day unless contraindicated
PATIENT EDUCATION cont’d
• Bladder irritants in the form of caffeine
products (e.g., coffee, tea, cola, and
chocolate), citrus juices and alcohol should be
taken in very limited amounts
• Encourage the patient to empty his bladder
every 2 to 3hours even if he does not feel the
urge to urinate
Complications
• Acute prostatitis can lead to urinary retention
• If the prostate is extremely swollen, it prevents
complete bladder emptying
• Most troublesome complication may be a
temporary problem with erections
• Ascending infections, prostatic abscess,
epididymitis and prostatic calculi (stones)
Prevention
Ways to avert prostatitis are:
•Regular and complete emptying of the bladder
to prevent urinary tract infection (UTI)
•Avoiding excess alcohol (more than 2 to 3 oz
per day—alcohol is a bladder irritant)
•Avoiding certain high-risk sexual practices
•Avoiding contamination of the urinary tract
Prostate gland and Related organs
Urinary Bladder
Sacrum
Symphysis Pubis
Rectum
Seminal Vesicle
Glans Penis
Ejaculatory Duct
PROSTATE GLAND
Urethra Epididymis
Testes
Benign Prostatic Hyperplasia
• Enlargement of the prostate gland is a normal
process in older men
• It begins at about age 50 and happens in 75%
of men older than age 70
• Benign prostatic hyperplasia (BPH) is a non-
malignant growth of the prostate that
gradually causes urinary obstruction
• According to current studies, BPH does not
increase a man’s risk of developing cancer of
the prostate
Etiology
• There is no known cause of BPH other than
normal aging
• Some men think they may have caused the
problem by certain sexual practices; however,
there is no scientific proof at this time
• Some factors that are being investigated in
research studies are high-fat diet, ethnic
background and lifestyle issues
Pathophysiology
• There is a slow increase in the number of cells
in the prostate gland, generally as the results
of aging and the male hormone
dihydrotestosterone
• As the size of the prostate gland increases, it
begins to compress or squeeze the urethra
• The narrowing of the urethra means the
bladder must work harder to expel the urine
Pathophysiology cont’d
• More effort and a longer time is required to
empty the bladder
• Eventually the narrowing causes an
obstruction and may lead to urinary retention
or eventually distension of the kidney with
urine (hydronephrosis)
Pathophysiology cont’d
• It is the location of the enlargement, not the
size that causes the problem
• A small growth in the prostate gland closest to
the urethra may cause more problems with
urination than a growth the size of an orange
in the outer portion of the gland
Signs and Symptoms
• Symptoms of BPH are usually identified in two
ways;
• They are either problems related to obstruction
or problems related to irritation
Symptoms related to obstruction include
• Decrease in the size or force of the urinary
stream
• Difficulty in starting a stream
Signs and Symptoms cont’d
• Dribbling after urination is thought to be
completed
• Urinary retention and a feeling that the
bladder is not empty
• The patient may also experience overflow
incontinence or an interrupted stream,
where the urine stops mid stream and then
starts again
Signs and Symptoms cont’d
Symptoms related to irritation include:
•Nocturia, dysuria and urgency
•A prostatic symptom index score sheet has been
developed
•Health-care providers ask older patients the
questions as a way of assessing the seriousness of
their symptoms and determining treatment
options
PATHOPHYSIOLOGY IN BRIEF
• The prostate gland helps to make and store seminal
fluid. In adult men, a typical prostate is 3 centimeters
long and weighs about 20 grams.
• Because of its location, prostate disease often affect
urination, ejaculation, and rarely defecation
• The prostate contains many small glands which make
20 percent of the fluid constituting semen
• In prostate cancer, the cells of these prostate glands
mutate into cancer cells. The prostate glands require
male hormones, known as androgens, to work
properly
PATHOPHYSIOLOGY IN BRIEF
CONTD
• Androgens are also responsible for secondary sex
characteristics such as facial hair and increased
muscle mass
• Prostate cancer is classified as an adenocarcinoma,
or glandular cancer, that begins when normal semen
screening prostate gland cells mutate into cancer
cells. The adenocarcinoma is most common in the
peripheral zone
• Initially, small clumps of cancer cells remain confined
to otherwise normal prostate glands, a condition
known as carcinoma in situ or prostate intraepithelial
neoplasia (PIN)
PATHOPHYSIOLOGY IN BRIEF
CONTD
• The PIN is a precursor and it is closely associated
with cancer
• Overtime, these cancer cells begin to multiply
and spread to the surrounding prostate tissue
(the stroma) forming a tumor
• Eventually, the tumor may grow large enough to
invade nearby organs (seminal vesicles, or the
rectum, travel in the blood stream and lymphatic
system)
• Prostate cancer most commonly metastasizes to
the bones, lymph nodes, and may invade rectum,
bladder and lower ureters after local progression
Diagnostic Tests
• The first step is a medical history that include
specific questions about the patient’s
symptoms
• A DRE of the prostate is then conducted by
the health-care provider to assess for
enlargement and whether the gland is hard,
lumpy, or “boggy.”
• Primary tests include urinalysis and blood test
Diagnostic Tests cont’d
• BUN (blood urea nitrogen), serum creatinine and
prostate specific antigen (PSA) levels may be
elevated
• Secondary tests include urodynamic flow
studies which may show a decreased urine flow
rate
• Transrectal ultrasound of the prostate and
cystoscopy may reflect structural abnormalities
Therapeutic Interventions
• If the patient has no symptoms or only mild
ones, the most current medical approach is
“watchful waiting”
• The healthcare provider watches for any
increase in symptoms or signs that the urethra
is becoming obstructed
Interventions cont’d
• Treatment of symptoms may include use of a
catheter (indwelling or intermittent)
• Oral fluids
• Antibiotics for UTI
• Conservative medical treatment includes the
use of medication to either relax the smooth
muscles of the prostate and bladder neck or
block the male hormone to prevent or shrink
tissue growth
Interventions cont’d
Alpha-adrenergic antagonists are medications that
relax the smooth muscles, such as
•Tamsulosin (Flomax), terazosin (Hytrin), and
doxazosin (Cardura)
•These medications are also used to treat high
blood pressure
•The most commonly used medications to block
the action of the male hormone in the prostate
gland are finasteride (Proscar) and dutasteride
(Avodart)
Interventions cont’d
• All these medications must be taken on a
long-term, continuous basis to achieve results
• Conservative measures are used initially
unless there are recurring infections, repeated
gross haematuria, bladder or kidney damage,
evidence of cancer, or unsatisfactory lifestyle
changes
Interventions cont’d
Nonsurgical invasive treatments, some of which
are experimental, are available in some areas of
the country in addition to surgical options
•These include the transurethral microwave
antenna (TUMA), which involves heat applied
directly to the gland, and may inhibit growth
and the prostatic balloon, which dilates the
urethra by stretching or compressing urethral
tissue
•Prostatic stents may be used to open the
passageway for urine to flow more freely
Surgical Treatment
1. TRANSURETHRAL RESECTION OF THE PROSTATE
•During the past 50 years, transurethral
resection of the prostate (TURP) has been the
surgical treatment used most often to relieve
obstruction caused by an enlarged prostate
•Several other transurethral options also exist
Surgical Treatment
2. Transurethral Incision of the Prostate (TUIP)
•It uses surgical incisions into the gland to
relieve obstruction
3. Transurethral Ultrasound-guided Laser-
Induced Prostatectomy (TULIP) uses laser to
relieve obstruction
•For TURP, the patient is anesthetized and the
surgery is performed using an instrument called
a resectoscope
Surgical Treatment Cont’d
• The resectoscope is inserted into the urethra
and the prostate gland is “chipped” away a
piece at a time
• Special surgical instruments are now being
used that “vaporize” or “microwave” the
pieces and cut down on the amount of
bleeding during surgery
Surgical Treatment Cont’d
• During routine TURP, the “chips” are flushed
out using an irrigating solution and are sent to
the laboratory to be analyzed for possible
evidence of cancer
• The prostate gland is not completely removed
but peeled away like the rind of an orange
Surgical Treatment Cont’d
• The prostatic tissue that is left can grows back
and can cause obstruction again at a later
time
• Patients need to be reminded to continue
having yearly prostate examinations
• As the tissue is removed during TURP,
bleeding occurs
• A Foley catheter is left in place with 30 to 60
mL of sterile water inflating the balloon
Surgical Treatment Cont’d
• The balloon is overfilled and may be secured
tightly to the leg or abdomen to tamponade
(compress) the prostate area and stop bleeding
• Irrigation solution generally flows continuously;
manual irrigation may be done for the first 24hrs
to help maintain catheter patency by removing
clots and chips
• The nurse removes the Foley catheter after the
danger of haemorrhage has passed
Intervention cont’d
• You may need to save “serial urines” after the
Foley catheter has been removed
• To do this, each time the patient urinates,
save some of the urine in a transparent cup,
line up the cups in order (usually on a shelf in
the bathroom)
• This shows whether the urine is becoming
progressively less bloody and clearer with
each void
Complications
• Complications associated with prostate
surgery depend on the type and extent of the
procedure performed
• The main medical complications include clot
formation, bladder spasms, and infection
• Less common complications may be urinary
incontinence, haemorrhage, and erectile
dysfunction
Retrograde Ejaculation
• Is a common side effect of prostate surgery
• When any of the prostate gland is removed,
there is a decrease in the amount of semen
produced and a part of the ejaculatory ducts
may be removed
• The result is that less semen is pushed outside
the body, and instead it “falls back” into the
bladder
• This causes no harm; the semen is simply passed
during the next urination
Erection, Ejaculation and
Orgasm
• It is important to understand that erection,
ejaculation, and orgasm are all separate actions
• Erection means the penis becomes hard
• Ejaculation is the release of semen and orgasm
is felt as pulsations along the urethra
• Unless additional problems are present, patient
continues to have erections and orgasmic
sensations but decreased or no ejaculation
RADICAL PROSTATECTOMY
• When the prostate gland is very large, is
causing obstruction, or is cancerous, a radical
prostatectomy is performed to remove the
entire prostate gland
Open Prostatectomy
• Several approaches may be taken during
traditional radical surgery
Approach cont’d
• In the Suprapubic Approach, an incision is
made through the lower abdomen into the
bladder
• The gland is removed, and the urethra is
reattached to the bladder
• The Retropubic Approach is similar except
there is no incision into the bladder
Perineal Prostectomy
• A perineal prostectomy involves making an
incision between the scrotum and anus and
removing the gland
• This procedure is rarely done because of the
increased risk of contamination of the incision
(close to the rectum), and risk of urinary
incontinence, erectile dysfunction, or injury to
the rectum
Necessary Care
• An open prostatectomy means a longer
hospital stay compared with other BPH
surgeries
• A suprapubic catheter and care for an
abdominal incision increase the length of stay
and the risk for complications
• Follow-up home care for wound dressing
changes and catheter care is an important
aspect of nursing interventions for these
patients
Minimally Invasive Prostatectomy
• Newer techniques use laparoscopy and even
tiny robot arms to perform radical
prostatectomy through five small “porthole”
incisions in the abdomen
• The surgeon makes all the decisions about the
surgery, while guiding the robotic arms
Minimally Invasive Prostatectomy
cont’d
• The robotic arms allow more precision and
maneuverability, especially in small areas
• Robotic surgery is less invasive, studies are
showing better results with less post-
operative bleeding and incontinence and
shorter hospital stays
Nursing Process for the Patient with
BPH and TURP
ASSESSMENT/DATA COLLECTION
•Begin by asking the patient if he has ever had
treatment or surgery for prostate trouble
•Assess amount and type of fluid intake per day
and whether the patient has noticed any of the
symptoms of BPH
•Monitor output, and, if he is not catheterized,
assure that urine retention is being managed
appropriately
Possible Nursing Diagnosis
• Risk for injury (bleeding) related to surgical
intervention
• Acute pain related to bladder spasms,
obstruction, or surgical process
• Urge urinary incontinence related to poor
sphincter control
• Ineffective therapeutic regimen management
related to lack of knowledge of postoperative
restrictions and care
• Anxiety related to concerns over loss of sexual
functioning following prostate surgery
Benign Prostatic Hyperplasia
(BPH) Summary
• S&S Related to Obstruction: Decrease in
size/force of stream, difficulty in starting stream,
dribbling, interrupted stream, urinary retention,
overflow incontinence
• S&S Related to Irritation: Nocturia, dysuria,
urgency
• Diagnostic Tests: Primary: Urinalysis, BUN,
serum creatinine, prostate-specific antigen (PSA)
• Secondary: Urodynamic flow studies, transrectal
ultrasound, cystoscopy
Therapeutic Interventions
• Conservative: Alpha-blockers, testosterone
blockers
• Nonsurgical: Transurethral microwave antenna
(TUMA), prostatic balloon, prostatic stents
• Transurethral: Transurethral incision of the
prostate (TUIP), transurethral ultrasound-guided
• laser-induced prostatectomy (TULIP),
transurethral resection of the prostate (TURP)
• Radical Prostatectomy: Suprapubic, retropubic,
perineal, laparoscopic, or robotic resection
Complications
• Ascending or localized infection, Injury to
surrounding tissues during surgery, Impaired
sexual function related to tissue injury
• NSG Diagnosis: Impaired urinary elimination
related to obstruction
• Ineffective health maintenance: knowledge
deficit related to causes, treatment, and
prevention of BPH
• Pain (acute or chronic) related to urine
retention, bladder spasms, surgery