Question

Scenario: Mr. P. S. is an 70 y/o male patient admitted to the medical unit for urinary retention. He complains of dribbling and feeling on incomplete emptying. He states “I’m in the bathroom trying to go but it just takes some time.” Upon assessment, distended bladder is noted. He is alert and oriented but forgetful. His most recent vital signs are 100/65, HR 95, RR 18, Sp02 98%, and T 99.1 F. Dry mucous membranes and poor skin turgor are noted. Pt is a poor historian and unable to provide any medical history besides a cholecystectomy in 1995.

1. What do you think is the cause of Mr. P. S.’s urinary retention? Explain the health problem. Is it common in a certain population?
2. What are the clinical manifestations of this issue?
3. Are there diagnostic tests? Is the PSA level definitive?
4. Is this an increased risk for prostate cancer?
5. What is “mindful watching”?
6. Can Mr. P. S. simply undergo “mindful watching”? Or does he require more intervention now?
7. What are the treatment options for Mr. P. S.? List at least two medications. Medications should include class, mechanism of action, side effects, adverse effects, nursing considerations, and patient teaching.

The physician orders insertion of Foley catheter. Once inserted, the nurse notes drainage of dark and concentrated urine.

8. Mr. P.S. states he is feeling much better. He asks if he can have the Foley in at all times. What would be your response to this?
9. Why do you think his urine is concentrated? What would be the recommendation for this?
10. Are there surgical options? Explain at least one.
11. What are some of the priority post op assessments? What complications can occur?
12. List at least 5 nursing interventions for this patient. Include rationale for each one.

Answer 1

What do you think is the cause of Mr. P. S.’s urinary retention? Explain the health problem. Is it common in a certain population?

Mr. P. S. is a 70 years old male, and prostate enlargement (hypertrophy) is the most common cause of difficulty in initiating urination and feeling of incomplete emptying of bladder in this age group.

Prostate gland is a part of the male reproductive tract. It produces fluid that combines with sperm to make semen.

At birth, the prostate gland is tiny. When testosterone levels rise during puberty, the prostate grows rapidly, doubling in size by age 20.

Growth slows down for the next two decades and the prostate usually does not cause problems for many years. When a man reaches his 40s, the prostate goes through a second growth spurt. Half of all men have an enlarged prostate by the time they reach age 60, and by age 85, 90% of men have an enlarged prostate.

The prostate surrounds urethra that carries urine from the bladder. Enlarged prostate interferes with the flow of urine out of the bladder and makes it harder to empty bladder. Over time, the problem worsens, and eventually not all the urine can be emptied. The bladder wall also may become thickened, which can result in muscle spasms.

What are the clinical manifestations of this issue?

An enlarged prostate can make it more difficult to urinate, however patients experience symptoms on the basis of degree of enlargement and its pressure effect on urethra (degree of constriction).

Initially patient may be asymptomatic or may have mild symptoms because the bladder muscle is able to compensate for the pressure from the enlarged prostate on the urethra. Symptoms are:

· Difficulty starting to urinate

· Continuing to dribble after urination

· Interrupted or weak stream of urine

· A feeling of incomplete emptying of urine

With time enlargement further increases putting more pressure the urine. Urine retaining in bladder causes irritation. These symptoms include:

· Painful urination

· A frequent need to empty the bladder, especially at night and disturbed sleep

· A feeling of urgency that accompanies the sensation to urinate

· Loss of bladder control (incontinence)

Are there diagnostic tests? Is the PSA level definitive?

Usually patient profile and typical nature of symptoms if diagnostic. However physician may conduct:

· Digital rectal exam to feel the size, shape and consistency of the prostate gland

· Urinalysis

· Ultrasound, to measure the amount of residual urine in bladder

· Cystoscopy, to assess bladder condition

Prostate specific antigen(PSA) is a protein produced by normal, as well as malignant, cells of the prostate gland. The PSA test measures the level of PSA in a man’s blood.

In addition to prostate cancer, a number of benign (not cancerous) conditions can cause a man’s PSA level to rise like prostatitis and benign prostatic hyperplasia (BPH).

There is no specific normal or abnormal level of PSA in the blood, and levels may vary over time in the same man.

The PSA test may give false-positive or false-negative results. A false-positive test result occurs when a man’s PSA level is elevated but no cancer is actually present. A false-positive test result may create anxiety for a man and his family and lead to additional medical procedures, such as a prostate biopsy, that can be harmful. False-negative test results may give a man, his family, and his doctor false assurance that he does not have cancer, when he may in fact have a cancer that requires treatment.

Hence PSA level is not definitive.

Is this an increased risk for prostate cancer?

No, BPH does not increase risk of cancer.

What is “mindful watching”?

If your symptoms are not severe, or very mild and not bothering patient then there is no treatment of any kind is required. Only mindful watching and lifestyle modifications are suggested.

· Yearly exam to monitor symptoms and see if any changes in treatment are required.

· Urinate when you first get the urge. Also, go to the bathroom on a timed schedule, even if you don't feel a need to urinate.

· Avoid alcohol and caffeine, especially after dinner.

· Preventing or treating constipation

· DO NOT drink a lot of fluid all at once. Spread out fluids during the day. Avoid drinking fluids within 2 hours of bedtime.

· Try NOT to take over-the-counter cold and sinus medicines that contain decongestants or antihistamines. These drugs can increase BPH symptoms.

· Keep warm and exercise regularly. Cold weather and lack of physical activity may worsen symptoms.

· Reduce stress. Nervousness and tension can lead to more frequent urination.

Can Mr. P. S. simply undergo “mindful watching”? Or does he require more intervention now?

· No. Mr. P.S. is elderly, having distended bladder and elevated temperature. Elevated temperature may be because of urinary infection secondary to retention.

What are the treatment options for Mr. P. S.? List at least two medications.

Medications should include class, mechanism of action, side effects, adverse effects, nursing considerations, and patient teaching.

1. Drugs

Class :alpha-blockers like tamsulosin (Flomax), alfuzosin (UroXatral), doxazosin (Cardura) and terazosin (Hytrin).

Mechanism: generally used for treatment of hypertension They help to relax the muscles at the base of the bladder and increase a man's ability to urinate. Approximately 70% of men see improvement in their symptoms within a few days to a few weeks after beginning one of these medications.

Side effects: alpha-blockers can cause dizziness, fatigue and excessively low blood pressure.

2. Drug

Class : testosterone blockers, include finasteride (Proscar) and dutasteride (Avodart).

Mechanism: block testosterone can shrink the size of the prostate and increase the flow of urine

Side effects: can take three to six months to show improvement, and that it can cause impotence, decreased sexual drive, problems with ejaculation

The physician orders insertion of Foley catheter. Once inserted, the nurse notes drainage of dark and concentrated urine. Mr. P.S. states he is feeling much better. He asks if he can have the Foley in at all times. What would be your response to this?

On insertion of indwelling Foley’s catheter a dark colour is noted due to removing retained urine. Due to emptying of bladder patient is feeling better. But it is not definitive treatment and cannot be left in place due to its associated complications, inconvenience of having an external device and the maintenance of sexual activity.

Why do you think his urine is concentrated? What would be the recommendation for this?

Urine may be concentrated due to retention. Encourage patient to take plenty of water, but DO NOT drink a lot of fluid all at once. Spread out fluids during the day. Avoid drinking fluids within 2 hours of bedtime.

Are there surgical options? Explain at least one.

Surgery offers the best chance for improving symptoms but also carries the greatest risk of complications. There are several types of surgical procedures:

Transurethral resection of the prostate (TURP)— This is the most commonly performed procedure. The surgeon inserts a telescope and an electrical loop through the urethra to the enlarged prostate. The electrical loop burns away the extra prostate tissue to open the urethral passage. The operation takes approximately 90 minutes. It involves either general or spinal anaesthesia and an overnight hospital stay. The most common side effect is retrograde ejaculation, in which semen flows into the bladder rather than out the end of the penis, and results in "dry" orgasms.

Others are-

· Transurethral incision of the prostate (TUIP)

· Transurethral microwave thermotherapy (TUMT)

· Transurethral needle ablation of the prostate (TUNA)

· Transurethral ultrasound-guided laser-induced prostatectomy (TULIP)

· Simple prostectomy

What are some of the priority post op assessments? What complications can occur?

List at least 5 nursing interventions for this patient. Include rationale for each one.

Postoperative assessment

1. Urine output

2. Colour of urine

3. Patency of catheter

4. Pain

5. Intravenous fluid administration and intake output chart

Complications after surgery may include

· Problems urinating

· Urinary incontinence

· Bleeding

· Infection

· Scar tissue

· Sexual dysfunction

· Recurring problems such as urinary retention and utis

· Recurrence of condition

Nursing interventions and rationale

· After benign prostatic hyperplasia surgery, the prostate or tissues around it may bleed. Blood or blood clots may appear in urine. Some bleeding is normal and should clear up within several days. Patient need to be monitored for colour of urine and its clearance. Monitoring of fluid intake and output.

· Observe for patency and drainage of urine post-operative in foley’s catheter and urine drained hourly, 4 hourly and 24 hourly. Retention may happen due to blockage of catheter from a clot. Catheter irrigation may be done if required.

· Blood clots from benign prostatic hyperplasia surgery can pass into the bloodstream and lodge in other parts of the body—most often the legs. Men should contact a health care provider right away if they experience swelling or discomfort in their legs.

· Use of a Foley catheter after benign prostatic hyperplasia surgery may increase the risk of a UTI. Anaesthesia during surgery may cause urinary retention and also increase the risk of a UTI. For this maintain a closed drainage system and prophylactic antibiotics are prescribed.

· Post operatively after removal of catheter men may initially have painful urination or difficulty urinating, urinary frequency, urgency, incontinence, or retention. These problems will gradually lessen and, after a couple of months, urination will be easier and less frequent.