Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations of disorders of the prostate.
- Describe the diagnostics and laboratory values for disorders of the prostate.
- Apply nursing concepts and plan associated nursing care for patients with disorders of the prostate.
- Evaluate the efficacy of nursing care for the disorders of the prostate.
- Describe the medical therapies that apply to the care of patients with disorders of the prostate.
The prostate gland is a major organ of the male reproductive system and is located just below the urinary bladder and anterior to the rectum (see Figure 20.2). Though it is quite small at only 3 cm long, it is very important for male reproduction. The major function of the prostate gland is the production of fluid that is mixed with sperm for ejaculation as semen (InformedHealth.org, 2016). The muscles of this gland also assist with the mechanical expulsion of semen during ejaculation. The two most common pathological conditions associated with the prostate gland are benign prostatic hyperplasia (BPH) and prostate cancer, both of which are discussed in more detail in this section.
Pathophysiology of BPH
Benign prostatic hyperplasia is quite common, affecting over half of men between the ages of 51 and 60 years and 70% of men older than 60 years (National Institute of Diabetes and Digestive and Kidney Diseases, 2014). This condition is benign and results when the prostate becomes enlarged as a normal side effect of aging. As the prostate gland grows larger, it eventually presses against the urethra, resulting in urinary dysfunction and difficulty with the stream of urine flow.
Pathophysiology of Prostate Cancer
Prostate cancer is the most common type of cancer in males, with about 288,300 new cases diagnosed in 2023 in the United States (American Cancer Society, 2023a). Approximately one of every eight men will be diagnosed with prostate cancer in their lifetime, highlighting its significant prevalence. Though it is a common cancer, most patients diagnosed do not die of the condition, because of the availability of advanced treatment options. The underlying pathophysiology of prostate cancer involves a mutation in the normal prostate cells that results in overproduction of cancerous cells within the gland, known as hypertrophy. A disparity of prostate cancer identification affects more Black men than White men, with earlier manifestation, aggressive disease, and a higher mortality rate (Lillard et al., 2022).
Assessment and Diagnostics
The best way to physically assess the size and shape of the prostate gland is by performing a digital rectal examination (DRE). During this assessment, the provider inserts a gloved, lubricated finger into the rectum to feel the prostate gland and determine if it is enlarged or has any other abnormalities, such as nodules. Enlargement of the prostate gland often indicates BPH, whereas the palpation of a hard nodule on the prostate may indicate prostate cancer. If either of these abnormalities is noted during the DRE, further tests will be ordered to assist in confirming the diagnosis.
Often, the next diagnostic test used after an abnormality is noted during the DRE is the prostate-specific antigen (PSA) test. This blood test checks for the presence of PSA which is a protein made by the prostate gland. If this value is elevated, it can be indicative of either BPH or prostate cancer. Occasionally, the provider may also order a urinalysis at this time to check for additional urinary system problems, including UTI and kidney stones, which often occur because of BPH. Current screening guidelines recommend prostate cancer retesting every two years for men with a PSA level less than 2.5 ng/mL and annual testing for men with a PSA level greater than 2.5 ng/mL.
If prostate cancer is suspected, other diagnostic tests may be ordered to confirm the diagnosis and determine its severity. First, imaging is usually ordered to better visualize the gland. This is typically done with use of a transrectal ultrasound. During this procedure, the provider will insert a small ultrasound probe into the rectum to look at the prostate gland and determine if there are any nodules present that are indicative of cancer. If a nodule is noted at this time, a biopsy specimen is usually taken and sent to the laboratory for further analysis. Once the laboratory confirms the diagnosis of prostate cancer, the patient will often undergo other imaging such as computed tomography scan or magnetic resonance imaging to determine if the cancer has spread beyond the prostate gland or if it remains localized.
Recognizing and Analyzing Cues
Because of the high prevalence of BPH and prostate cancer in older adult males, it is important for nurses to be aware of symptoms that may indicate the patient has either of these conditions. Often, while obtaining the health history, the nurse will use a standardized questionnaire to determine whether the patient is exhibiting symptoms indicative of BPH or prostate cancer. The most used scale is the International Prostate Symptom Score (I-PSS). There are also some key assessment findings that the nurse should look for during a physical assessment, including
- chronic urinary retention and inability to fully empty bladder
- hematuria (blood in urine) – this is a late sign of prostate cancer
- increased urinary frequency
- nocturia (increased urinary frequency during nighttime hours)
- pain during intercourse or ejaculation
- recurrent UTIs and/or kidney stones due to urinary stasis
- urinary hesitancy (difficulty starting urinary stream)
- urinary leaking and incontinence
- urine flow “dribbling” at end of stream
- urine stream that starts and stops intermittently
Link to Learning
The International Prostate Symptom Score (IPSS) is used widely to assess for BPH and severity of symptoms of the lower urinary tract. This calculator provides a quick method for the assessment.
Medical Therapies and Related Care
Though BPH and prostate cancer often cause similar symptoms, treatment goals and options differ between the two conditions. These treatments are discussed in more detail in the following two sections.
Medical Treatment for BPH
Before attempting any invasive procedures to treat BPH, there are some behavioral changes and pharmacological therapies that are offered to the patient. First, patients with BPH are counseled about fluid intake, especially caffeine and alcohol, which have diuretic effects. Patients with BPH should drink enough fluids to maintain adequate hydration but refrain from drinking too much, especially within four hours of bedtime, which can contribute to worsening urinary frequency and retention, and nocturia. A voiding schedule, whereby the patient is instructed to void every two hours, is another helpful intervention to avoid urinary dribbling. In addition to limiting fluid, caffeine, and alcohol intake and trying a voiding schedule, patients with BPH are often prescribed medications to help improve BPH symptoms. Common medication classes prescribed for BPH as well as their mechanisms of action and common adverse effects are listed in Table 20.6.
| Drug Class | Mechanism of Action | Common Adverse Effects |
|---|---|---|
α1-Adrenergic antagonists
|
Relaxation of smooth muscle in the bladder and prostate gland, which allows easier flow of urine |
|
5-α-Reductase inhibitors
|
Decreased production of dihydrotestosterone, which causes reduced growth of prostate gland |
|
Phosphodiesterase-5 inhibitors*
|
Relaxation of smooth muscle in the urinary tract, which can aid effective urine flow |
|
*Note: This class of medications is typically only used to treat ED, but it has been shown to have some effectiveness for treating symptoms associated with BPH. |
||
If behavior modifications and medications are ineffective for treating symptoms associated with BPH, more invasive procedures can be considered. These procedures are described in Table 20.7.
| Procedure | Description |
|---|---|
| Transurethral needle ablation (TUNA) | Low-radiofrequency needles are placed through the urethra and into the excess prostate tissue. Waves are sent through the needles, which kill prostate tissue and decrease the size of the prostate gland. |
| Transurethral microwave thermotherapy (TUMT) | A small microwave antenna is inserted through the urethra toward the prostate, where microwave energy is delivered to destroy excess prostate tissue. |
| Photovaporization of the prostate (PVP) | GreenLight laser is used to vaporize excess prostate tissue. |
| Transurethral resection of the prostate (TURP) | A resectoscope is inserted through the urethra and small parts of prostate tissues are trimmed away (Figure 20.10). These pieces are then flushed out with irrigation fluid at the end of the procedure. This procedure requires an indwelling catheter immediately after surgery and usually a one- to two-day postoperative hospital stay. Some patients require a three-way foley that promotes continuous bladder irrigation, if clinically required. |
| Transurethral incision of the prostate (TUIP) | Small incisions are made in the prostate tissue where it meets the bladder. This allows for improved flow of urine. |
| Prostatic urethral lift (UroLift) | Permanent implants are placed in the urethra where it is obstructed, to hold back the enlarged prostate tissue and improve urine flow through the urethra. |
| Simple prostatectomy | Removal of excess prostate tissue through incisions in the lower abdomen or perineum. This is one of the most invasive treatment options and requires a two- to four-day postoperative hospital stay, with a longer recovery period. |
Medical Treatment for Prostate Cancer
Because prostate cancer grows slowly and often does not affect men until later in life, treatment is not always required. In these situations, the provider may choose a “wait and see” approach. During this time, the patient is monitored at regular intervals with DREs and PSA tests. If symptoms become bothersome or the cancer progresses, further intervention may be warranted.
Radiation therapy is usually the first treatment option for patients with prostate cancer that is in an early stage and localized to the prostate gland. The two main types of radiation used for treatment of prostate cancer are external beam radiation therapy (EBRT) and brachytherapy (internal radiation). EBRT involves using radiation beams on the external skin located over the prostate gland. Typically, patients receive this kind of radiation therapy five days a week for several weeks on an outpatient basis. This procedure is quick, painless, and highly effective for curing early-stage prostate cancer. An approach called brachytherapy involves placement of radioactive seeds inside the prostate tissue that are left in place and give off radiation to kill excess prostate tissue over several weeks to months. The amount of radiation emitted by the seeds is low, so there is minimal risk of damage to surrounding healthy tissue with this kind of procedure. With radiation therapy, adverse side effects may include ED, urinary incontinence, fatigue, and radiation proctitis, or inflammation of the rectum lining, which can result in diarrhea and rectal leakage.
Pharmacological interventions, including hormone therapy and chemotherapy, can also be used in the treatment of prostate cancer. Hormone therapy includes the use of luteinizing hormone-releasing hormone agonists and antiandrogens. Luteinizing hormone-releasing hormone agonists work by preventing the production of testosterone, which results in slower cancer cell growth. Antiandrogens, also known as androgen deprivation therapy, prevent the body from being able to use the male sex hormones, and this can also assist in slowing cancer growth. Chemotherapy is a systemic pharmacological treatment option typically reserved for patients with more severe and metastatic prostate cancer. Depending on the severity of the cancer and other specific patient characteristics, surgery may be another treatment option considered for prostate cancer. A radical prostatectomy (removal of the entire prostate gland) or bilateral orchiectomy (removal of both testicles) is performed in some cases.
Nursing Care of the Patient with BPH
The two main priorities of care for patients with BPH are related to improving urinary elimination flow and providing psychosocial support. The nurse should take both aspects of care into consideration when planning intervention for a patient with BPH.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
To assist with the improvement of urinary elimination, the nurse should provide education about lifestyle changes such as limiting fluid and caffeine intake, especially before bedtime, to prevent nocturia and other BPH-associated symptoms. If the patient has been prescribed medications for the treatment of BPH symptoms, the nurse should ensure the patient understands how to take the medications correctly and any adverse effects to monitor for. Additionally, the nurse should emphasize the importance of taking medications as prescribed and reporting their effectiveness to the provider so changes in dosing can be made as necessary.
When caring for a patient with BPH who is scheduled to undergo a more invasive procedure such as a TURP or TUNA, the nurse will ensure the patient understands the nature of the procedure and obtain informed consent. During this process, the nurse confirms that the patient understands the information the provider gave them about the procedure, because the provider ultimately has the legal responsibility associated with procedural education. Postoperatively, the nurse will provide care that is tailored to the specific procedure performed. In most cases, the patient will return to the unit with an indwelling urinary catheter, so one of the main nursing interventions is to complete meticulous catheter care to prevent infection. Occasionally, these patients will also be receiving continuous bladder irrigation (CBI), a procedure in which a three-way urinary catheter is used to constantly irrigate the bladder and allow for adequate urinary drainage (Figure 20.11). The nurse will need to adjust the flow of the bladder irrigation solution to maintain patency and monitor for complications such as severe bleeding. Color of the urine may direct urethral patency; urine that is pink tinged and few to no clots is an ideal response with continuous bladder irrigation.
In addition to providing care that addresses physical symptoms, the nurse is also tasked with providing psychosocial support to the patient. Disorders of the male reproductive and urinary systems are highly personal and can have a significant impact on mental health. It is important for nurses to remain empathetic to these feelings and provide care that is nonjudgmental and supportive. These patients may also benefit from referrals to various social support groups, so it is important for the nurse to be knowledgeable about these options and provide referrals to this extra support as needed or requested by the patient.
Evaluation of Nursing Care of the Patient with BPH
As part of patient care, the nurse must evaluate interventions and treatment options. The nurse should make sure to assess and consider all aspects of the patient’s well-being, including psychological and educational needs.
Evaluating Outcomes
After treatment, the best outcome is that patients will report improvement in urinary elimination patterns. If the patient reports that symptoms have not improved, the nurse should be sure to escalate the patient’s concerns to the provider and formulate a new plan of care with different treatment options to attempt to improve elimination patterns. While evaluating patient outcomes, the nurse should also assess the patient’s feelings about their disorder. A major part of caring for patients with BPH involves treating the psychosocial aspect of the illness, so the nurse would hope to see improvements in this area as well. If this is not the case, the nurse can refer the patient to counseling or other supportive services that can assist the patient in coping with their disorder.
Nursing Care of the Patient with Prostate Cancer
The nurse will be one member of an interprofessional health care team that will provide care for the patient with prostate cancer. The nurse plays a vital role on the team by creating a comfortable environment and providing necessary interventions, ensuring the best possible outcome.
Recognizing and Analyzing Cues
During the physical examination of a patient with prostate cancer, the nurse should assess for signs that would indicate the condition is not improving, such as worsening nocturia or an inability to empty the bladder completely. It is also important that the nurse assess the patient’s mental health and coping strategies. Though prostate cancer is typically curable, it can still cause feelings of fear and anxiety. The nurse should allow the patient to express and explore these feelings as needed.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Patients diagnosed with prostate cancer are often faced with many treatment options, so one of the main nursing interventions is to help guide the patient through this decision-making process. The nurse will not make the treatment decision for the patient, but it is important that they assist the patient in fully understanding their treatment options and the associated risks and benefits. With this information, the patient can make a better-informed decision about their health. If the patient chooses to try pharmacological options, the nurse should provide education about the medications, their mechanisms of action, and associated side effects. If the patient plans to undergo surgery, the nurse will ensure the patient understands the procedure and obtain an informed consent. Postoperative care for prostate cancer surgery will likely involve catheter care and interventions for reducing postoperative pain.
Evaluation of Nursing Care of the Patient with Prostate Cancer
As with other conditions, the nurse must evaluate any interventions and treatment options for the patient with prostate cancer. The nurse should be sure to assess all aspects of the patient’s well-being, including psychological and educational needs, throughout all of the patient’s follow-up care.
Evaluating Outcomes
After receiving treatment for prostate cancer, the nurse should assess the patient for optimal outcomes, including improved urinary elimination patterns and the complete eradication of cancer cells. It is also important for the nurse to stress the importance of maintaining follow-up appointments even after receiving cancer treatment, because recurrence may occur, necessitating repetition of the procedure or treatment interventions.
Interdisciplinary Plan of Care
Interprofessional Care of the Patient Receiving Treatment for Prostate Cancer
- Dietitian: formulates nutritional plan, which is especially important for patients receiving cancer treatment because they often lose weight from lack of appetite associated with treatment
- Medical physicist: assists oncologist in creating treatment plan for patients opting to receive radiation therapy
- Nurse: provides holistic care for the patient and is a facilitator of both physical and psychosocial interventions
- Oncologist: determines presence and severity of the cancer and oversees the treatment planning process
- Pharmacist: assists in selecting appropriate pharmacological options and doses for cancer treatment
- Social worker: assists patient with psychosocial and financial aspects of cancer treatment