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University of PangasinanPhinma Education Network
Arellano St., Dagupan City
Prostate Cancer
A Case Study Presented to the Faculty of
U NIVERSITY OF P ANGASINAN PHINMA EDUCATION NETWORK
College of Nursing
In partial fulfillment of the requirements for RLE III
Presented by:
Cerdan, Ariane M.
Cerezo, Haidee M.
Cerezo, Jofelyn I.
Cervantes, Kemberly M.
Cervantes, Mary Grace M.
Delos Santos, Christian G.
Dion, Quennie P.
Dismaya, Ma. Zharina P.
Doctolero, Orlando Jr. B
(Level III )
August S.Y. 2010-2011
Presented to:
Mr. Chris Villamil, RN
Clinical Instructor
Pangasinan Medical Center
Dagupan City, Pangasinan
2nd Floor (OB and Surgical Ward), 3-11 Shift
TABLE OF CONTENTS
I. Acknowledgement
II. Objectives
a. General Objectives
b. Specific Objectives
III. Significance of the Study
a. Field of Nursing Education
b. Field of Nursing Practice
c. Field of Nursing Research
IV. Patient Demographic Data
a. Patient Profile
b. History of Present IIlness
V. Anatomy and Physiology
VI. Disease Presentation of Prostate Cancer
a. Pathophysiology
b. Clinical Manifestations
c. Predisposing Factors
d. Complications
VII. Laboratory Test
VIII. Management of Prostate Cancer
a. Medical Management
b. Surgical Management
c. Nursing Management
IX. Discharge Planning
X. Glossary
XI. Bibliography
2
ACKNOWLEDGEMENT
In the deepest recesses of our hearts we, the student nurses assigned at
Pangasinan Medical Center, would like to express our sincerest joy and gratitude to the
following for the invaluable assistance that they have provided for the success and
completion of this case study. Without them, the accomplishment of this case study will
never be possible.
First and foremost, the Almighty father, for the unconditional love and for the
strength and wisdom He has given unto us to finish this endeavor.
To our clinical instructor, Mr. Chris Villamil, for the guidance and assistance he
imparted to us. We are grateful for his expertise and immense patience whenever we
are in the area and for showing and demonstrating to us on how to implement such
nursing intervention and procedure in order for us to gain knowledge, skills and
confidence that we will be needing in this field. And also we thank him for pushing and
motivating us to do better in our studies.
To the whole staff of Pangasinan Medical Center, especially to the nursing
director and staff nurses of the OB and Surgical Ward, for their warm welcome and for
sharing their time and knowledge whenever we have questions and their experiences in
the clinical area for us to gain insights on what we are supposed to learn in the hospital
setting.
To our patient, Mr. X for the cooperation in answering all of our questions,
despite his health condition so as to obtain the data we needed for this case study. We
also want to thank his relatives for the assistance they extended whenever Mr. X
doesn’t remember some pertinent information we needed.
And finally, to our beloved parents and guardians for their undying and unselfish
love and support to us so that we can continue our studies.
3
I - INTRODUCTION
Prostate cancer is one of the most common malignancy in males. Prostate
cancer is a malignant (cancerous) tumor (growth) that consists of cells from the prostate
gland. Generally, the tumor usually grows slowly and remains confined to the gland for
many years. During this time, the tumor produces little or no symptoms or outward signs
(abnormalities on physical examination). However, all prostate cancers do not behave
similarly. Some aggressive types of prostate cancer grow and spread more rapidly than
others and can cause a significant shortening of life expectancy in men affected by
them. A measure of prostate cancer aggressiveness is the Gleason score which is
calculated by a trained pathologist observing prostate biopsy specimens under the
microscope.
As the cancer advances, however, it can spread beyond the prostate into the
surrounding tissues (local spread). Moreover, the cancer also can metastasize (spread
even farther) throughout other areas of the body, such as the bones, lungs, and liver.
Symptoms and signs, therefore, are more often associated with advanced prostate
cancer.
4
II - OBJECTIVES
A. General Objectives:
Our general objective in formulating this case study is to be able to gain
more knowledge about Prostate Cancer including all related information about
the said condition and to be able to apply the nursing assessment and
intervention regarding the aforesaid malignancy.
B. Specific Objectives:
To be able to be familiarized with the different terminologies associated
with prostate cancer.
To be able to have understanding about the causes and risk factors that
triggers prostate cancer.
To be able to know the different interventions and management regarding
prostate cancer.
To be able to have an understanding on the stages of prostate cancer.
To be able to have knowledge about prevention, curative and rehabilitative
phases of prostate cancer.
To be able to practice the theoretical study presented in this case study.
To serve as research material as future reference.
5
III - SIGNIFICANCE OF THE STUDY
Nursing Education
It is beneficial to the nursing education for this will serve as a study guide and as
teaching materials for classroom discussions, case studies, and other school related
research works on the lifestyle modification of patients with Prostate Cancer. This will
provide a firsthand view on the patient’s problems with regards to the risk of having this
malignancy.
Nursing Practice
It is beneficial to the nursing profession and to its practitioners for this research
works will serve as a reference on what changes that will be done on the patient
diagnosed with Prostate Cancer, and to have a better understanding of the illness. The
problems of the participant will help the nursing institution to be able to help provide
some solutions on how to prevent such problems in the future. This study will serve as
an eye opener for all nurses to know the current situation of this patient, how he is
coping with the situation and how did he come up with this malignancy, so that in the
future, other nurses will have better insights of the condition and can give their hundred
percent care with patients in the same situation.
Nursing Research
The nursing institutions and research shall benefit from this study for it will serve
as a reference for other extensive researches on the extent of knowledge of the
students of UNIVERSITY OF PANGASINAN-PEN regarding Prostate Cancer. This
research work can also be a source of information for other researches to be
accomplished on the future.
6
IV - PATIENT DEMOGRAPHIC DATA
Patient’s Profile
Name: Mr. X
Age: 64 year old
Address: Pangasinan
Birthday: July 12, 1941
Status: Married
Occupation: None
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: August 25, 2010
Time Admitted: 8:40 pm
Attending Physician: Dr. Serrano
Chief Complaint: Generalized body weakness
Initial Diagnosis: Adenocarcinoma- Prostate
Final Diagnosis: Adenomacarcinoma-Prostate
Family History
Wife: Mrs. X
Age: 57
No. of Children: Four
Previous Disease: (-) Diabetis Mellitus
(-) Hypertension
Lifestyle: Chronic smoker. Drinks alcoholic beverages occasionally.
7
History of Present Illness
Patient was brought to Pangasinan Medical Centerl, accompanied by his
daughter on April 13, 2010 at 4:11 in the afternoon. He was admitted with chief
complaints of fever, difficulty of breathing and cough. He was on the same condition two
days prior to admission. Upon admission, patient was assessed as febrile with a body
temperature of 38°C, with flushed skin, warm to touch and was positive of having a
productive cough.
Physician’s impression was Coronary Obstructive Pulmonary Disease.
Past History
The patient says that he doesn’t have any childhood disease before, especially those diseases that are related to his current condition.
Family History of Illness He stated that his father and some uncles are hypertensive, but none of his brothers
and sisters has such diseases. And according to him, his 6 siblings don’t have any illness.
Functional Health PatternA. Health Perception and Health Management Pattern
Mr. Xyz claimed that he is a chain smoker since he graduated from high school. And he drinks alcohol occasionally and moderately. But he doesn’t take any illegal drugs. When the time that he’s already experiencing such pain in his abdomen, he thinks that it is because of his regular alcohol intake. So, he decided to minimize drinking alcohol.
B. Nutritional and Metabolic Pattern Patient stated that he loves to eat vegetables especially the green leaf one.
C. Elimination Pattern Patient said that he doesn’t have any difficulty upon urinating also in bowel
elimination. And he also has a regular perspiration.
D. Activity-Exercise Pattern He considered that working in the farm every morning is a form of exercise.
E. Sleep-Rest Pattern Patient verbalized that he has sleep-pattern disturbance due to the
intermittent pain he’s suffering that made him awake and couldn’t go back to sleep. There are times that he could only sleep for about 3 hours. But usually take naps every afternoon after their lunch.
F. Cognitive-Perceptual Pattern
8
Mr. Xyz had been long suffering from mild abdominal pain but still manages to tolerate it. His illness had not yet affected any of his senses and he states that he was perfectly fine before the onset of the disease
G. Self Perception and self concept Pattern Mr. Xyz admits that he worries about his family. Without him working on their
farm would put their financial problems to worsen. He claims that he feels restless and not much of a use while staying in the hospital bed all day.
H. Role Relationship Pattern Mr. Xyz was a “hands on” father according to his wife but since he started to
fell the pain on his abdomen, he cannot perform some of chores that he used to do specially his work to their farm. But his family tries to help him and his oldest son did the job in the farm so that they can still earn money.
I. Coping-Stress Tolerance Pattern The sudden onset of his disease made him irritable to stress. An
uncomfortable experience he claimed. Being in a complete bed rest and all could not help him fix some of their financial burden. But still, the presence of his wife beside him helped him alleviate some of the problems that had been bothering him.
J. Value-belief Pattern Despite of what was happening to him, Mr. Xyz still believe and trust God. He
doesn't even blame god for what is happening to him; in fact, he said that his faith to Him became much stronger this time. He claimed prayers are very important and his family gives him the strength.
Impression:
Mr. Xyz experiences allot of problem which causes him depression, but he seemed positive on facing things. There is nothing left for him to be worried about as long as his family is beside him. His condition gravely affects their family’s income since he is responsible for funding their family, yet his family is very supportive to help in every way they could.
9
IV - DEVELOPMENTAL DATA
Erik Erikson’s Psychosocial Theory of Development
Late Adulthood (55 or 65 to Death): Integrity vs. Despair
This is when we begin to reflect on our lives, accepting it for what it was. If we have done well in previous stages, especially stage seven, we can feel a sense of fulfillment and accept death as an unavoidable reality with dignity. If we haven't done well, we can be filled with regret, despair over the time running out and fear of death.
Sullivan’s Developmental Theory
Adulthood
To establish relationships of love for some other person, in which relationship the other person is as significant, or nearly as significant, as one's self. This really highly developed intimacy with another person is not the principal business of life, but is, perhaps, the principal source of satisfaction in life; and one goes on developing in depth of interest or in scope of interest, or in both depth and scope, from that time until unhappy retrogressive changes in the organism lead to old age
Robert Havighurist’s Developmental Theory
Later maturity (60 and over)
The developmental tasks of later maturity differ in only one fundamental respect from those of
other ages. They involve more of a defensive strategy--of holding on the life rather than of
seizing more of it. In the physical, mental and economic spheres the limitations become
especially evident; the older person must work hard to hold onto what he already has. In the
social sphere there is a fair chance of offsetting the narrowing of certain social contacts and
interests by the broadening of others. In the spiritual sphere there is perhaps no necessary
shrinking of the boundaries, and perhaps there is even a widening of them.
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V- ANATOMY AND PHYSIOLOGY
Anatomy:
The prostate gland is an organ that is located at the base or outlet (neck) of the
urinary bladder. The gland surrounds the first part of the urethra. The urethra is the
passage through which urine drains from the bladder to exit from the penis. One
function of the prostate gland is to help control urination by pressing directly against the
part of the urethra that it surrounds. The main function of the prostate gland is to
produce some of the substances that are found in normal semen, such as minerals and
sugar. Semen is the fluid that transports the sperm to assist with reproduction. A man
can manage quite well, however, without his prostate gland. In a young man, the normal
prostate gland is the size of a walnut (<30g). During normal aging, however, the gland
usually grows larger. This hormone-related enlargement with aging is called benign
prostatic hyperplasia (BPH), but this condition is not associated with prostate cancer.
Both BPH and prostate cancer, however, can cause similar problems in older men. For
11
example, an enlarged prostate gland can squeeze or impinge on the outlet of the
bladder or the urethra, leading to difficulty with urination. The resulting symptoms
commonly include slowing of the urinary stream and urinating more frequently,
particularly at night.
Physiology:
The prostate gland produces a secretion known as prostate fluid that makes up
most of the liquid part of semen, which is discharged from the penis during sexual
orgasm. The prostate gland is composed of both glandular tissue that produces prostate
fluid and muscle tissue that helps in male ejaculation. Prostate fluid also helps to keep
sperm, which is found in semen, healthy and lively, thereby increasing the chances that
fertilization will occur.
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VI - Disease Presentation of Prostate Cancer
Prostate cancer is a form of cancer that develops in the prostate, a gland in the
male reproductive system. Most prostate cancers are slow growing; however, there are
cases of aggressive prostate cancers. The cancer cells may metastasize from the
prostate to other parts of the body, particularly the bones and lymph nodes. Prostate
cancer may cause pain, difficulty in urinating, problems during sexual intercourse, or
erectile dysfunction. Other symptoms can potentially develop during later stages of the
disease.
Rates of detection of prostate cancers vary widely across the world, with South
and East Asia detecting less frequently than in Europe, and especially the United
States. Prostate cancer tends to develop in men over the age of fifty and although it is
one of the most prevalent types of cancer in men, many never have symptoms, undergo
no therapy, and eventually die of other causes. This is because cancer of the prostate
is, in most cases, slow-growing, symptom-free, and since men with the condition are
older they often die of causes unrelated to the prostate cancer, such as heart/circulatory
disease, pneumonia, other unconnected cancers, or old age. About 2/3 of cases are
slow growing "pussycats", the other third more aggressive, fast developing being known
informally as "tigers".
Many factors, including genetics and diet, have been implicated in the
development of prostate cancer. The presence of prostate cancer may be indicated by
symptoms, physical examination, prostate specific antigen (PSA), or biopsy. There is
controversy about the accuracy of the PSA test and the value of screening. Suspected
prostate cancer is typically confirmed by taking a biopsy of the prostate and examining it
under a microscope. Further tests, such as CT scans and bone scans, may be
performed to determine whether prostate cancer has spread.
Treatment options for prostate cancer with intent to cure are primarily surgery,
radiation therapy, and proton therapy. Other treatments, such as hormonal therapy,
13
chemotherapy, cryosurgery, and high intensity focused ultrasound (HIFU) also exist,
depending on the clinical scenario and desired outcome.
The age and underlying health of the man, the extent of metastasis, appearance
under the microscope, and response of the cancer to initial treatment are important in
determining the outcome of the disease. The decision whether or not to treat localized
prostate cancer (a tumor that is contained within the prostate) with curative intent is a
patient trade-off between the expected beneficial and harmful effects in terms of patient
survival and quality of life.
A. Pathophysiology
Prostate cancer is classified as an adenocarcinoma, or glandular cancer, that
begins when normal semen-secreting prostate gland cells mutate into cancer cells. The
region of prostate gland where the adenocarcinoma is most common is the peripheral
zone. Initially, small clumps of cancer cells remain confined to otherwise normal
prostate glands, a condition known as carcinoma in situ or prostatic intraepithelial
neoplasia (PIN). Although there is no proof that PIN is a cancer precursor, it is closely
associated with cancer. Over time, 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 such as the seminal vesicles or the rectum,
or the tumor cells may develop the ability to travel in the bloodstream and lymphatic
system. Prostate cancer is considered a malignant tumor because it is a mass of cells
that can invade other parts of the body. This invasion of other organs is called
metastasis. Prostate cancer most commonly metastasizes to the bones, lymph nodes,
rectum, and bladder.
The prostate is a zinc accumulating, citrate producing organ. The protein ZIP1 is
responsible for the active transport of zinc into prostate cells. One of zinc's important
14
roles is to change the metabolism of the cell in order to produce citrate, an important
component of semen. The process of zinc accumulation, alteration of metabolism, and
citrate production is energy inefficient, and prostate cells sacrifice enormous amounts of
energy (ATP) in order to accomplish this task. Prostate cancer cells are generally
devoid of zinc. This allows prostate cancer cells to save energy not making citrate, and
utilize the new abundance of energy to grow and spread. The absence of zinc is thought
to occur via a silencing of the gene that produces the transporter protein ZIP1. ZIP1 is
now called a tumor suppressor gene product for the gene SLC39A1. The cause of the
epigenetic silencing is unknown. Strategies which transport zinc into transformed
prostate cells effectively eliminate these cells in animals. Zinc inhibits NF-κB pathways,
is anti-proliferative, and induces apoptosis in abnormal cells. Unfortunately, oral
ingestion of zinc is ineffective since high concentrations of zinc into prostate cells is not
possible without the active transporter, ZIP1.
RUNX2 is a transcription factor that prevents cancer cells from undergoing
apoptosis thereby contributing to the development of prostate cancer.
The PI3k/Akt signaling cascade works with the transforming growth factor
beta/SMAD signaling cascade to ensure prostate cancer cell survival and protection
against apoptosis. X-linked inhibitor of apoptosis (XIAP) is hypothesized to promote
prostate cancer cell survival and growth and is a target of research because if this
inhibitor can be shut down then the apoptosis cascade can carry on its function in
preventing cancer cell proliferation. Macrophage inhibitory cytokine-1 (MIC-1) stimulates
the focal adhesion kinase (FAK) signaling pathway which leads to prostate cancer cell
growth and survival.
The androgen receptor helps prostate cancer cells to survive and is a target for
many anti cancer research studies; so far, inhibiting the androgen receptor has only
proven to be effective in mouse studies.[16] Prostate specific membrane antigen (PSMA)
stimulates the development of prostate cancer by increasing folate levels for the cancer
15
cells to use to survive and grow; PSMA increases available folates for use by
hydrolyzing glutamated folates.
B. Clinical Manifestation
In the early stages, prostate cancer often causes no symptoms for many years.
As a matter of fact, these cancers frequently are first detected by an abnormality on a
blood test (the PSA,) or as a hard nodule (lump) in the prostate gland. Occasionally, the
doctor may first feel a hard nodule during a routine digital (done with the finger) rectal
examination. The prostate gland is located immediately in front of the rectum.
Rarely, in more advanced cases, the cancer may enlarge and press on the
urethra. As a result, the flow of urine diminishes and urination becomes more difficult.
Patients may also experience burning with urination or blood in the urine. As the tumor
continues to grow, it can completely block the flow of urine, resulting in a painfully
obstructed and enlarged urinary bladder. These symptoms by themselves, however, do
not confirm the presence of prostate cancer. Most of these symptoms can occur in men
with non-cancerous (benign) enlargement of the prostate (the most common form of
prostate enlargement). However, the occurrence of these symptoms should prompt an
evaluation by the doctor to rule out cancer and provide appropriate treatment.
Furthermore, in the later stages, prostate cancer can spread locally into the
surrounding tissue or the nearby lymph nodes, called the pelvic nodes. The cancer then
can spread even farther (metastasize) to other areas of the body. Symptoms of
metastatic disease include fatigue, malaise, and weight loss. The doctor during a rectal
examination can sometimes detect local spread into the surrounding tissues. That is,
the physician can feel a hard, fixed (not moveable) tumor extending from and beyond
the gland. Prostate cancer usually metastasizes first to the lower spine or the pelvic
bones (the bones connecting the lower spine to the hips), thereby causing back or
pelvic pain. The cancer can then spread to the liver and lungs. Metastases (areas to
which the cancer has spread) to the liver can cause pain in the abdomen and jaundice
16
(yellow color of the skin) in rare instances. Metastases to the lungs can cause chest
pain and coughing.
C. Predisposing Factors
The cause of prostate cancer is unknown, but the cancer is not thought to be
related to benign prostatic hyperplasia (BPH). The risk (predisposing) factors for
prostate cancer include advancing age, genetics (heredity), hormonal influences, and
such environmental factors as toxins, chemicals, and industrial products.
AGE. The chances of developing prostate cancer increase with age. Thus,
prostate cancer under age 40 is extremely rare, while it is common in men older
than 80 years of age. As a matter of fact, some studies have suggested that
among men over 80 years of age, 50%-80% of them may have prostate cancer!
More than 80% of prostate cancers are diagnosed in men older than 65 years of
age.
RACE. African-American men are 1.6 times more likely than white men to
develop prostate cancer. They are also 2.4 times more likely to die from their
disease as compared to white men of a similar age. These differences in
diagnosis and death rates are, however, more likely to reflect a difference in
factors such as environmental exposure, diet, lifestyle, and health-seeking
behavior rather than any racial susceptibility to prostate cancer. Recent studies
indicate that this disparity is progressively decreasing with chances of complete
cure in men undergoing treatment for organ-confined prostate cancer (cancer
that is limited to within the prostate without spread outside the confines of the
prostate gland), irrespective of race.
GENETICS. Heredity plays a role in the risk of developing a prostate cancer.
Prostate cancer is more common among family members of individuals with
prostate cancer. This risk may be two to three times greater than the risk for men
17
without a family history of the disease. Earlier age at diagnosis (<60 years) in a
first-degree relative (father or brother) and disease affecting more than one
relative also increases the risk for developing prostate cancer.
DIETARY FACTOR. Because a Western lifestyle is associated with prostate
cancer, so dietary factors have been intensively studied. Results have been
inconsistent and inconclusive, however.
Fats. Some studies have found an association between high fat-intake and
prostate cancer. In particular, high consumption of red meat and high-fat dairy
products has been linked to increased risk for prostate cancer. In contrast, the
omega-3 fats in fish may be protective.
Vegetables and Fruits. A diet rich in vegetables, fruits, and legumes appears to
protect against prostate cancer. However, it is not clear whether this is due to
the nutrients contained in these foods, or the fact that these foods are low in fat.
No specific vegetable or fruit has been proven to decrease risk. Lycopene, which
is found in tomatoes, has been a target of research interest, but the evidence for
its protective benefit is still inconclusive.
Vitamins and Minerals. Major clinical studies have found that vitamin and
mineral supplements (vitamin E, vitamin C, vitamin D, and selenium) do not
prevent prostate cancer. Nutritious foods that are part of a healthy diet are the
best sources for vitamins and minerals. A high intake of calcium has been linked
to an increased risk of prostate cancer in some studies.
HORMONE. Testosterone, the male hormone produced by the testicles, directly
stimulates the growth of both normal prostate tissue and prostate cancer cells.
Not surprisingly, therefore, this hormone is thought to be involved in the
development and growth of prostate cancer. The important implication of the role
18
of this hormone is that decreasing the level of testosterone should be (and
usually is) effective in inhibiting the growth of prostate cancer.
SEXUALLY TRANSMITTED INFECTIONS. Recent evidence has suggested that
sexually transmitted infections are risk factors for developing prostate cancer.
Men with a history of sexually transmitted infections have a 1.4 times greater
chance of developing prostate cancer as compared men without this history.
OTHERS. Although still unproven, environmental factors, such as cigarette
smoking and diets that are high in saturated fat, seem to increase the risk of
prostate cancer. There is also a suggestion that obesity leads to an increased
risk of having more aggressive, larger prostate cancer, which results in a poorer
outcome after treatment. Additional substances or toxins in the environment or
from industrial sources might also promote the development of prostate cancer,
but these have not yet been clearly identified. Geographical influences also
seem to play a role in the development of prostate cancer with men living in the
Scandinavian and North American countries being at a higher risk for the disease
as compared to those residing in Asian countries. Of note, there is no proven
relationship between the frequency of sexual activity and the chances of
developing prostate cancer.
Having a risk factor doesn't mean that a man will develop prostate cancer. It will
only increase the chance of having one.
D. Complication
The main complications of prostate cancer are incontinence and erectile
dysfunction. Other complications include the usual risks of any surgery, such as blood
clots, heart problems, infection, and bleeding.
Urinary Incontinence. Urinary incontinence is a common complication. When the
urinary catheter is first removed following surgery, nearly all patients lack control of
19
urinary function and will leak urine for at least a few days and sometimes for months.
Normal urinary function usually returns within about 18 months. A percentage of men
will continue to have small amounts of leakage with heavier exertion or possibly sexual
activity.
Erectile Dysfunction. Erectile dysfunction can be a result of prostate cancer or its
treatment, including surgery, radiation or hormone treatments. Medications, vacuum
devices that assist in achieving erection and surgery are available to treat erectile
dysfunction. Erectile dysfunction after radical prostatectomy is caused by nerves that
were damaged or removed during the surgery. Virtually all men will have problems with
erectile dysfunction after surgery. It can take up to one to two years to recover erectile
function after surgery. Because seminal glands are removed along with the prostate
gland during surgery, men who regain sexual function will not produce semen during
orgasm (dry ejaculation).
With the use of effective nerve-sparing techniques, men who were sexually
active before surgery and are involved in an ongoing relationship seem to have a better
chance of returned sexual function. Drugs such as sildenafil (Viagra) may help some
men regain erectile function. Use of these drugs three times a week accompanied by
sexual stimulation is now commonly recommended. Other treatments for erectile
dysfunction (alprostadil injections, vaccum devices, penile implants) may also be
options.
20
VII - LABORATORY RESULTS
SPECIMEN DATA REPORT
TEST RESULT FLAG LIMIT REFERENCE RANGE
LIMIT 1 RESULT
WBC 16.4 G/L H [ ]* 5.0 – 10.0 G/L
LYM 1.8 RM 11.0% L
[ * ] 0.6 – 4.1 20.0 – 40.0 %L
Normal
MID 1.1 R2 6.5%M [* ] 0.0 – 5.3 0.0 -7.0 %M Normal
GRAIN 13.5 R3 82.5% G
H [ ]* 2.0 – 7.8 50.0 – 70.0%G
RBC 6.38 T/L H [ ]* 4.04 – 6.13 T/L
HGB 185 G/L HH [ ]* 120. – 180. G/L
HCT .580 L/L H [ ]* .370 - .540 L/L
MCV 90.9 FL [ * ]
80.0 – 97.0 FL26.0 -32.0 pg310. – 360. g/L11.5 – 14.5 %
Normal
PLT 242 G/L [ * ] 150. – 400.G/L Normal
21
URINALYSIS
CHARACTERISTICS RESULT INTERPRETATION6
Color Dark yellow
Yellow color can be caused by recent use of laxatives or
consumption of B complex vitamins or carotene. It is considered as
concentrated urine.
Transparency Slightly turbid
Reaction 6.0 Normal
Specific Gravity 1.020 Normal
Albumin Traces
Small amounts of protein are more significant in dilute or unconcentrated urine.
The morning dipstick detects the albumin and it disappears later
during the course of the day as you drink more liquids, the diluted urine escapes detection by the
dipstick.
Sugar Negative Normal
MICROSCOPIC
CHARACTERISTICS RESULT INTERPRETATION
Epithelial cells: Few
Pus cells: 1 – 3
Erythrocytes: 0 -2
Amorph. Urates: Few Many times amorphous urates forms as a result of the
refrigeration process of urine when it is being process
Others: Pus cast – 0 - 2
22
BLOOD TYPE: A, RBS = 199mgs/dL
VIII - MANAGEMENT OF PROSTATE CANCER
Treatment for prostate cancer may involve active surveillance (monitoring for
tumor progress or symptoms), surgery (i.e. radical prostatectomy), radiation therapy
including brachytherapy (prostate brachytherapy) and external beam radiation therapy,
High-intensity focused ultrasound (HIFU), chemotherapy, oral chemotherapeutic drugs
(Temozolomide/TMZ), positron emission tomography, cryosurgery, hormonal therapy,
or some combination.
Which option is best depends on the stage of the disease, the Gleason score,
and the PSA level. Other important factors are the man's age, his general health, and
his feelings about potential treatments and their possible side-effects. Because all
treatments can have significant side-effects, such as erectile dysfunction and urinary
incontinence, treatment discussions often focus on balancing the goals of therapy with
the risks of lifestyle alterations. Prostate cancer patients are strongly recommended to
work closely with their urologist and use a combination of the treatment options when
managing their prostate cancer.
The selection of treatment options may be a complex decision involving many
factors. For example, radical prostatectomy after primary radiation failure is a very
technically challenging surgery and may not be an option. This may enter into the
treatment decision.
If the cancer has spread beyond the prostate, treatment options significantly
change, so most doctors that treat prostate cancer use a variety of nomograms to
predict the probability of spread. Treatment by watchful waiting/active surveillance,
HIFU, external beam radiation therapy, brachytherapy, cryosurgery, and surgery are, in
general, offered to men whose cancer remains within the prostate. Hormonal therapy
and chemotherapy are often reserved for disease that has spread beyond the prostate.
23
However, there are exceptions: radiation therapy may be used for some advanced
tumors, and hormonal therapy is used for some early stage tumors. Cryotherapy (the
process of freezing the tumor), hormonal therapy, and chemotherapy may also be
offered if initial treatment fails and the cancer progresses.
A. Medical Management
Active surveillance
Active surveillance refers to observation and regular monitoring without invasive
treatment. Active surveillance is often used when an early stage, slow-growing prostate
cancer is suspected. However, watchful waiting may also be suggested when the risks
of surgery, radiation therapy, or hormonal therapy outweigh the possible benefits. Other
treatments can be started if symptoms develop, or if there are signs that the cancer
growth is accelerating (e.g., rapidly-rising PSA, increase in Gleason score on repeat
biopsy, etc.). Approximately one-third of men that choose active surveillance for early
stage tumors eventually have signs of tumor progression, and they may need to begin
treatment within three years. Men that choose active surveillance avoid the risks of
surgery, radiation, and other treatments. The risk of disease progression and metastasis
(spread of the cancer) may be increased, but this increase risk appears to be small if
the program of surveillance is followed closely, generally including serial PSA
assessments and repeat prostate biopsies every 1–2 years depending on the PSA
trends.
or younger men, a trial of active surveillance may not mean avoiding treatment
altogether, but may reasonably allow a delay of a few years or more, during which time
the quality of life impact of active treatment can be avoided. Published data to date
suggest that carefully selected men will not miss a window for cure with this approach.
Additional health problems that develop with advancing age during the observation
period can also make it harder to undergo surgery and radiation therapy.
24
Hormonal therapy
Hormonal therapy uses medications or surgery to block prostate cancer cells
from getting dihydrotestosterone (DHT), a hormone produced in the prostate and
required for the growth and spread of most prostate cancer cells. Blocking DHT often
causes prostate cancer to stop growing and even shrink. However, hormonal therapy
rarely cures prostate cancer because cancers that initially respond to hormonal therapy
typically become resistant after one to two years. Hormonal therapy is, therefore,
usually used when cancer has spread from the prostate. It may also be given to certain
men undergoing radiation therapy or surgery to help prevent return of their cancer.[4]
Hormonal therapy for prostate cancer targets the pathways the body uses to
produce DHT. A feedback loop involving the testicles, the hypothalamus, and the
pituitary, adrenal, and prostate glands controls the blood levels of DHT. First, low blood
levels of DHT stimulate the hypothalamus to produce gonadotropin-releasing hormone
(GnRH). GnRH then stimulates the pituitary gland to produce luteinizing hormone (LH),
and LH stimulates the testicles to produce testosterone. Finally, testosterone from the
testicles and dehydroepiandrosterone from the adrenal glands stimulate the prostate to
produce more DHT. Hormonal therapy can decrease levels of DHT by interrupting this
pathway at any point. There are several forms of hormonal therapy:
Orchiectomy , also called "castration," is surgery to remove the testicles.
Because the testicles make most of the body's testosterone, after orchiectomy
testosterone levels drop. Now the prostate not only lacks the testosterone
stimulus to produce DHT but also does not have enough testosterone to
transform into DHT. Orchiectomy is considered the gold standard of treatment.[5]
Antiandrogens are medications such as flutamide, bicalutamide, nilutamide, and
cyproterone acetate that directly block the actions of testosterone and DHT within
prostate cancer cells.
25
Medications that block the production of adrenal androgens such as DHEA
include ketoconazole and aminoglutethimide. Because the adrenal glands make
only about 5% of the body's androgens, these medications are, in general, used
only in combination with other methods that can block the 95% of androgens
made by the testicles. These combined methods are called total androgen
blockade (TAB). TAB can also be achieved using antiandrogens.
GnRH action can be interrupted in one of two ways. GnRH antagonists such as
abarelix and degarelix suppress the production of LH directly by acting on the
anterior pituitary. GnRH agonists such as leuprolide and goserelin acetate
suppress LH through the process of downregulation after an initial stimulation
effect which can cause initial tumor flare. Abarelix and degarelix are examples of
GnRH antagonists, whereas the GnRH agonists include leuprolide, goserelin,
triptorelin, and buserelin. Initially, GnRH agonists increase the production of LH.
However, because the constant supply of the medication does not match the
body's natural production rhythm, production of both LH and GnRH decreases
after a few weeks.
A very recent Trial I study (N=21) found that abiraterone acetate caused dramatic
reduction in PSA levels and tumor sizes in aggressive end-stage prostate cancer
for 70% of patients. This is prostate cancer that resists all other treatments (e.g.,
castration, other hormones, etc.). Officially the impacts on life-span are not yet
known because subjects have not been taking the drug very long. Larger Trial III
Clinical Studies are in the works. If successful an approved treatment is hoped
for around 2011.
The most successful hormonal treatments are orchiectomy and GnRH agonists.
Despite their higher cost, GnRH agonists are often chosen over orchiectomy for
cosmetic and emotional reasons. Eventually, total androgen blockade may prove to be
better than orchiectomy or GnRH agonists used alone.
26
Each treatment has disadvantages that limit its use in certain circumstances.
Although orchiectomy is a low-risk surgery, the psychological impact of removing the
testicles can be significant, and sterility is certain. The loss of testosterone can cause
hot flashes, weight gain, loss of libido, enlargement of the breasts (gynecomastia),
impotence, testicular atrophy, penile atrophy, and osteoporosis. GnRH agonists
eventually cause the same side effects as orchiectomy but may cause worse symptoms
at the beginning of treatment. When GnRH agonists are first used, testosterone surges
can lead to increased bone pain from metastatic cancer, so antiandrogens or abarelix is
often added to blunt these side effects. Estrogens are not commonly used because they
increase the risk for cardiovascular disease and blood clots. In general, the
antiandrogens do not cause impotence, and usually cause less loss of bone and muscle
mass. Ketoconazole can cause liver damage with prolonged use, and
aminoglutethimide can cause skin rashes.
Radiation therapy
Radiation therapy, also known as radiotherapy, is often used to treat all stages of
prostate cancer. It is also often used after surgery if the surgery was not successful at
curing the cancer. Radiotherapy uses ionizing radiation to kill prostate cancer cells.
When absorbed in tissue, Ionizing radiation such as gamma and x-rays damage the
DNA in cancer cells, which increases the probability of apoptosis (cell death). Normal
cells are able to repair radiation damage, while cancer cells are not. Radiation therapy
exploits this fact to treat cancer. Two different kinds of radiation therapy are used in
prostate cancer treatment: external beam radiation therapy and brachytherapy
(specifically prostate brachytherapy).
External beam radiation therapy
External beam radiation therapy uses a linear accelerator to produce high-energy
x-rays that are directed in a beam towards the prostate. A technique called Intensity
Modulated Radiation Therapy (IMRT) may be used to adjust the radiation beam to
27
conform with the shape of the tumor, allowing higher doses to be given to the prostate
and seminal vesicles with less damage to the bladder and rectum. External beam
radiation therapy is generally given over several weeks, with daily visits to a radiation
therapy center. New types of radiation therapy such as IMRT have fewer side effects
than traditional treatment. Doctors are also studying proton therapy for prostate cancer,
which uses protons rather than X-rays to kill the cancer cells. They are also studying
types of stereotactic body radiotherapy (SBRT) to treat prostate cancer.
Brachytherapy
Permanent implant brachytherapy is a popular treatment choice for patients with
low to intermediate risk features, can be performed on an outpatient basis, and is
associated with good 10-year outcomes with relatively low morbidity . It involves the
placement of about 100 small "seeds" containing radioactive material (such as iodine-
125 orpalladium-103) with a needle through the skin of the perineum directly into the
tumor while under spinal or general anesthetic. These seeds emit lower-energy X-rays
which are only able to travel a short distance. Although the seeds eventually become
inert, they remain in the prostate permanently. The risk of exposure to others from men
with implanted seeds is generally accepted to be insignificant. However, men are
encouraged to talk to their doctors about any special temporary precautions around
small children and pregnant women. Brachytherapy for prostate cancer is administered
using "seeds," small radioactive pellets or ribbons implanted directly into the tumor.
Alternative therapies
As an alternative to active surveillance or definitive treatments, other therapies
are also under investigation for the management of prostate cancer. PSA has been
shown to be lowered in men with apparent localized prostate cancer using a vegan diet
(fish allowed), regular exercise, and stress reduction. These results have so far proven
durable after two-years' treatment. However, this study did not compare the vegan diet
28
to either active surveillance or definitive treatment, and thus cannot comment on the
comparative efficacy of the vegan diet in treating prostate cancer.
Many other single agents have been shown to reduce PSA, slow PSA doubling
times, or have similar effects on secondary markers in men with localized cancer in
short term trials, such as pomegranate juice or genistein, an isoflavone found in various
legumes.
The potential of using multiple such agents in concert, let alone combining them
with lifestyle changes, has not yet been studied. A more thorough review of natural
approaches to prostate cancer has been published.
Neutrons have been shown to be superior to X-rays in a the treatment of
prostatic cancer. The rationale is that tumours containing hypoxic cells (cells with
enough oxygen concentration to be viable, yet not enough to be X-ray-radiosensitive)
and cells deficient in oxygen are resistant to killing by X-rays. Thus, the lower Oxygen
Enhancement Ratio (OER) of neutrons confers an advantage. Also, neutrons have a
higher relative biological effectiveness (RBE) for slow-growing tumours than X-rays,
allowing for an advantage in tumour cell killing.
Neither selenium nor vitamin E have been found to be effective for prostate
cancer.
B. Surgical Management
Surgical removal of the prostate, or prostatectomy, is a common treatment either
for early stage prostate cancer or for cancer that has failed to respond to radiation
therapy. The most common type is radical retropubic prostatectomy, when the surgeon
removes the prostate through an abdominal incision. Another type is radical perineal
prostatectomy, when the surgeon removes the prostate through an incision in the
perineum, the skin between the scrotum and anus. Radical prostatectomy can also be
29
performed laparoscopically, through a series of small (1 cm) incisions in the abdomen,
with or without the assistance of a surgical robot.
Radical prostatectomy
Radical prostatectomy is effective for tumors that have not spread beyond the
prostate; cure rates depend on risk factors such as PSA level and Gleason grade.
However, it may cause nerve damage that may significantly alter the quality of life of the
prostate cancer survivor.
Radical prostatectomy has traditionally been used alone when the cancer is
localized to the prostate. In the event of positive margins or locally advanced disease
found on pathology, adjuvant radiation therapy may offer improved survival. Surgery
may also be offered when a cancer is not responding to radiation therapy. However,
because radiation therapy causes tissue changes, prostatectomy after radiation has
higher risks of complications.
Laparoscopic radical prostatectomy, LRP, is a new way to approach the prostate
surgically with intent to cure. Contrasted with the open surgical form of prostate cancer
surgery, laparoscopic radical prostatectomy requires a smaller incision. Relying on
modern technology, such as miniaturization, fiber optics, and the like, laparoscopic
radical prostatectomy is a minimally invasive prostate cancer treatment but is technically
demanding and seldom done in the USA.
Some believe that in the hands of an experienced surgeon, robotic-assisted
laparoscopic prostatectomy (RALP) may reduce positive surgical margins when
compared to radical retropubic prostatectomy (RRP) among patients with prostate
cancer according to a retrospective study. The relative risk reduction was 57.7%. For
patients at similar risk to those in this study (35.5% of patients had positive surgical
margins following RRP), this leads to an absolute risk reduction of 20.5%. 4.9 patients
must be treated for one to benefit (number needed to treat = 4.9). Other recent studies
have shown RALP to result in a significantly higher rate of positive margins.[11] Other
30
studies showed no difference of robotic to open surgery. A recent French study
comparing standard laparoscopic to robotic to open prostatectomy showed no
difference in margin status or biochemical recurrence at 5 years. The relative merits of
RALP and potential benefit versus open radical prostatectomy is currently an area of
intense research and debate in urology. The only proven and accepted advantage to
RALP is less intraoperative blood loss. Other suggested advantages beyond this lack
definitive data and have not been widely accepted by the broader urological community.
Transurethral resection of the prostate
Transurethral resection of the prostate, commonly called a "TURP," is a surgical
procedure performed when the tube from the bladder to the penis (urethra) is blocked
by prostate enlargement. In general, TURP is for benign disease and is not meant as
definitive treatment for prostate cancer. During a TURP, a small instrument
(cystoscope) is placed into the penis and the blocking prostate is cut away.
Orchiectomy
In metastatic disease, where cancer has spread beyond the prostate, removal of
the testicles (called orchiectomy) may be done to decrease testosterone levels and
control cancer growth.
Cryosurgery
Cryosurgery is another method of treating prostate cancer in which the prostate
gland is exposed to freezing temperatures. It is less invasive than radical prostatectomy,
and general anesthesia is less commonly used. Under ultrasound guidance, a method
invented by Dr. Gary Onik, metal rods are inserted through the skin of the perineum into
the prostate. Highly-purified argon gas is used to cool the rods, freezing the surrounding
tissue at −186 °C (−302 °F). As the water within the prostate cells freezes, the cells die.
The urethra is protected from freezing by a catheter filled with warm liquid. In general,
31
cryosurgery causes fewer problems with urinary control than other treatments, but
impotence occurs up to ninety percent of the time. When used as the initial treatment for
prostate cancer and in the hands of an experienced cryosurgeon, cryosurgery has a 10-
year biochemical disease-free rate superior to all other treatments including radical
prostatectomy and any form of radiation. Cryosurgery has also been demonstrated to
be superior to radical prostatectomy for recurrent cancer following radiation therapy.
Brachytherapy
Brachytherapy for prostate cancer involves the surgical placement of radioactive
'seeds' or implants directly into the cancerous portions of the prostate, where the
radiation kills the surrounding cancerous cells. It is therefore usually classified as a
radiation treatment, rather than as a surgical treatment, because the actual treatment of
the disease is by radiation, not surgery.
C. NURSING MANAGEMENT
The nurse plays a key role in identifying potential candidates for pulmonary
rehabilitation and in facilitation and reinforcing the material learned in the rehabilitation
program. However, the nurse can be instrumental in teaching the patient and family as
well as facilitating specific services for the patient (eg. respiratory therapy education,
physical therapy for exercise and breathing retraining, occupational therapy for
conserving energy during activities of daily living, and nutritional counseling). In
addition, numerous education materials are available to assist the nurse in teaching
patients with COPD. Potential resources include the American Lung Association, the
American Association of Cardiovascular and Pulmonary Rehabilitation, the American
Thoracio Society, and American College of Chest Physicians, and the American
Association of Respiratory Therapy.
32
PATIENT EDUCATION
Patient education is a major component of pulmonary rehabilitation and includes
a broad variety of topics. Depending on the length and setting of the program, topics
may include normal anatomy and physiology of the lung, pathophysiology and changes
with COPD, medications and home oxygen therapy, nutrition cessation, sexuality and
COPD, coping with chronic disease. Communicating with the health care team and
planning for the future (advance directive, living wills, informed decision making about
health care alternatives).
Breathing Exercises. The breathing pattern of most people with COPD is shallow,
rapid, and inefficient; the more severe the disease, the more inefficient the breathing
pattern. With practice, this type of upper chest breathing can be changed to
diaphragmatic breathing, which reduces the respiratory rate, increases alveolar
ventilation, and sometimes helps expel as much air as possible during expiration.
Pursed lip breathing helps to slow expiration, prevents collapse of small airways, and
helps the patient to control the rate and depth or respiration. It also promotes relaxation,
enabling the patient to gain control or dyspnea and reduce feelings of panic.
Inspiratory Muscle Training. Once the patient masters diaphragmatic breathing, a
program of inspiratory muscle training may be prescribed to help strengthen the
muscles used in breathing. This program requires that the patient breathe against
resistance for 10 to 15 minutes every day. As the resistance is gradually increased, the
muscles become better conditioned. Conditioning of the respiratory muscles takes time,
and the patient is instructed to continue practicing at home (Larson, Covey, Wirtz et al.,
1999; NIH 2001)
Activity Pacing. A patient with COPD has decreased exercise tolerance during specific
periods of the day. This is especially true on arising in the morning, because bronchial
secretions collect in the lungs during the night while the person is lying down. The
33
patient may have difficulty bathing or dressing. Activities requiring the arms to be
supported above the level of the thorax may produce fatigue or respiratory distress but
may be tolerated better after the patient has been up and moving around for an hour or
more. Working with the nurse, the patient can reduce these limitations by planning self-
care activities and determining the best time for bathing, dressing and daily activities.
Self-Care Activities. As gas exchange, airway clearance, and the breathing pattern
improve, the patient is encouraged to assume increasing participation in self-care
activities. The patient is taught to coordinate diaphragmatic breathing with activities
such as walking, bathing, bending, or climbing stairs. The patient should bathe, dress,
and take short walks, resting as needed to avoid fatigue and excessive dyspnea. Fluids
should always be readily available, and the patient should begin to drink fluids without
having to be reminded. If postural drainage is to be done at home, the nurse instructs
and supervises the patient before discharge or in the outpatient setting.
Physical Conditioning. Physical conditioning techniques include breathing exercises
and general exercises intended to conserve energy and increase pulmonary ventilation.
There is a close relationship between physical fitness and respiratory fitness. Graded
exercises and physical conditioning programs using treadmills, stationary bicycles, and
measure level walks can improve symptoms and increase work capacity and exercise
tolerance. Any physical activity that can be done regularly is helpful. Lightweight
portable oxygen systems are available for ambulatory patients who require oxygen
therapy during physical activity.
Oxygen Therapy. Oxygen supplied to the home comes in compressed gas, liquid, or
concentrator systems. Portable oxygen systems allow the patient to exercise, work, and
travel. To help the patient adhere to the oxygen prescription, the nurse explains the
proper flow rate and required number of hours for oxygen use as well as the dangers of
arbitrary changes in flow rates or duration or therapy. The nurse cautions the patient
that smoking with or near oxygen is extremely dangerous. The nurse also reassures the
34
patient that oxygen is not "addictive" and explains the need for regular evaluations of
blood oxygenation by pulse oximetry or arterial blood gas analysis.
Nutritional Therapy. Nutritional assessment and counseling are important aspects in
the rehabilitation process for the patient with COPD. Approximately 25% of patients with
COPD are undernourished (NIH, 2001; Ferreira, Brooks, Lacasse& Goldstein, 2001). A
thorough assessment of caloric needs and counseling about meal planning and
supplementation are part of the rehabilitation process.
Coping Measures. Any factor that interferes with normal breathing quite naturally
induces anxiety, depression, and changes in behavior. Many patients find the slightest
exertion exhausting. Constant shortness of breath and fatigue may make the patient
irritable and apprehensive to the point of panic. Restricted activity (and reversal of
family roles due to loss of employment), the frustration of having to work to breathe, and
the realization that the disease is prolonged and unrelenting may cause the patient to
react with anger, depression, and demanding behavior. Sexual function may be
compromised, which also diminishes behavior. Sexual function may be compromised,
which also diminishes self-esteem. In addition, the nurse needs to provide education
and support to the spouse/significant other and family because the caregiver role in
end-stage COPD can be difficult.
35
X - DISCHARGE PLANNING
A. MEDICATION
1. Advice the patient to continue the medication as ordered by the physician.
2. Inform the patient’s guardian on the right dose and the right time in taking the
medication.
3. Explain in layman’s term the actions of the drugs the patient taking.
Medication:
Cefuroxime
Salbutamol
Hydrocortisone
B. EXERCISE
1. Instruct the patient to do deep breathing exercise regularly for lung expansion.
C.TREATMENT
1. Let the patient in a daily routine bath for proper hygiene unless contraindicated.
2. Provide a safe and clean environment
3. Promote water therapy
D. HEALTH TEACHING
Advise the guardian of the patient to:
1. Emphasize the importance of hand washing to prevent the spread of microbes.
2. Use disposable tissue to wipe any secretion, use once and throw them immediately
and properly.
36
3. Encourage the patient to have adequate and sufficient intake of fluids to at least 8-10
glasses a day for internal hydration.
4. Avoid exposing patient to smoky places.
5. Never take medications that are not prescribed by the physician.
E. OPD
1. If there are onset signs and symptoms of the illness, consult the physician
immediately.
2. Have a regular check-up.
F. DIET
1. Feed with head elevated.
2. Maintain adequate high calorie diet such as chicken, soup, fish.
3. Increase food intake high in protein, carbohydrates and minerals. Because they
provide energy, build and repair tissue which is also important in growth and
development.
4. Increase intake of vitamins especially Vitamin C to boost up immune system.
5. Raw juices such as apple, citrus, pineapple.
6. Well balance diet of natural food with emphasis on fresh fruits and vegetables.
37
XI - GLOSSARY
Angiosgenesis- is a physiological process involving the growth of new blood vessels from pre-existing vessels.[1] Though there has been some debate over terminology, vasculogenesis is the term used for spontaneous blood-vessel formation, and intussusception is the term for new blood vessel formation by splitting off existing ones.[
Apoptosis-is the process of programmed cell death (PCD) that may occur in multicellular organisms. Biochemical events lead to characteristic cell changes (morphology) and death
Bladder-Any pouch or other flexible enclosure that can hold liquids or gases but usually refers to the hollow organ in the lower abdomen that stores urine
Colliculusseminalis/verumontanum-An elevation, or crest, in the wall of the urethra where the seminal ducts enter it.
Cryotherapy- medical treatment that involves cooling the body, especially by applying ice packs.
Dennonvillier’s fascia-The part of the pelvic fascia that separates the prostate and the vesiculae septum from the rectum. It consists of a single fibromuscular structure with several layers that are fused together and covering the posterior aspect of the prostate and surrounding the seminal vesicles.
Dolichoetatic aortic arch- Terminal dribbling- when described as a urinary symptom, refers to the dribbling of urine at the end of the stream. When combined with other urinary symptoms it can be a sign of prostate cancer.
Hyperplasia-which is the formation of new muscle cells.
Hypertrophy-is the increase of the size of muscle cells.
Resection-Excision of a portion or all of an organ or other structure.
Resectoscope-is a hysteroscope with a built in wire loop (or other shape device) that uses high-frequency electrical current to cut or coagulate tissue. It was developed for surgery of the bladder and the male prostate over fifty years ago to allow surgery inside an organ without having to make an incision.
Retrogade ejaculation-sometimes referred to as a "dry orgasm." Retrograde ejaculation is not life threatening but is one cause of male infertility. Men often notice during masturbation that they do have an orgasm but there is no semen production.[1] Another underlying cause for this phenomenon may be ejaculatory duct obstruction.
Stoma-The supportive framework of an organ (or gland or other structure), usually composed of connective tissue. The stroma is distinct from the parenchyma, which consists of the key functional elements of that organ. The stroma of the thyroid gland is the connective tissue that supports the lobules and follicles of the thyroid gland.
38
XII- BIBLIOGRAPHY
http://ezinearticles.com/?Ericksons-Theory-of-Human-Development&id=20117
http://herkules.oulu.fi/isbn9514265068/html/x149.html
http://www.montereybayurology.com/urocond/bphinfo.html
http://www.prostate-cancer.com/prostate-cancer-treatment-overview/overview-turp.html
http://nongae.gsnu.ac.kr/~bkkim/won/won_117.html
www. yahoo.com
www.google.com
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