A Case Study of a Patient with a Diagnosis of Prostate Cancer

By BANDA, Erika Shayne M. DELA CRUZ, Vergel ENALPE, Annalyn FAGARANG, Keyzl G. FLORES, Rhona FRANCIA, John Mark M.

INTRODUCTION Men are often referred as sex symbols, but the public awareness and the knowledge regarding their organ and Genito-urinary Cancers such as Penile Cancer, Prostate Cancer or Testicular Cancer is not. Prostate cancer , the second leading Cancer in men next to lung cancer develops in the prostate, a gland in the male reproductive system which is located below the bladder, wrapped around the urethra and in front of the rectum. The prostate may appear small and insignificant in the diagram but an unhealthy prostate can result to enlargement, and infection. A troubled prostate can lead to health conditions such as prostatitis, lower urinary tract symptoms and the worst, Cancer. According to Dr. Philip S. Chua of Philippine Daily Inquirer Global, this type of cancer does not cause symptoms early because the malignant tumor usually develops in the outer portion of the prostate, and therefore does not cause blockage of the urethra. Even without symptoms, this form of early stage of the cancer may be detected during a medical examination. This is the reason why a regular checkup, including a digital (finger) rectal prostate examination, once or twice a year is very important among men who are 40 years and older, even those without symptoms, to catch prostate cancer before it spreads. Prostate cancer is considered as one of the most common cancers among males around the globe. It is estimated that prostate cancer kills one man almost every 19 minutes while a new case is detected every two and a half minute. The American Cancer Society estimates that more than 232,000 men in the United States will be diagnosed with prostate cancer this year, and about 30,000, or roughly 13 percent, will die of it. This figure is in addition to the existing 2 million who have already been diagnosed to have it. In the Philippines, it is one of the top five cancers among men, and in 2005 alone, about 4000 new prostatic cancer cases were found. According to the Philippine Cancer Society Inc.s (PCSI) population-based cancer registry, it is reported that one out of eight males develops prostate cancer and it is now the second most common cancer among Filipino males following lung cancer. When you're told you have prostate cancer, it's natural to wonder what may have caused the disease. But no one knows the exact causes of prostate cancer. Doctors seldom know why one man develops prostate cancer and another doesn't. However, research has shown that men with certain risk factors are more likely than others to develop prostate cancer. Studies have

found that Age is the main risk factor for prostate cancer. The chance of getting prostate cancer increases as you get older specifically when you reached 50 years and above. A study conducted in Johns Hopkins University in the United States revealed that another factor is Family history, that if in case your father, brother, or son had prostate cancer, it might increase your risk of getting it. On other studies, Prostate cancer is more common among black men than white or Hispanic/Latino men while it is being considered as less common among Asian/Pacific Islander and American Indian/Alaska Native men. Certain prostate changes like high-grade prostatic intraepithelial neoplasia (PIN) can also increase the risk of developing this type of cancer. Many other possible risk factors are under study. Researchers have studied whether vasectomy( surgery to cut or tie off the tubes that carry sperm out of the testicles) may pose a risk, but most studies have found no increased risk. Also, most studies have shown that the chance of getting prostate cancer is not increased by tobacco or alcohol use, BPH, a sexually transmitted disease, obesity, a lack of exercise, or a diet high in animal fat or meat.

HISTORY The patient was a 52y/o male. He reported having a numerous bouts of prostatitis over a 10 year period which became increasingly severe. PSA levels rose from an initial 3.0 to 5.5 ng/ml. At that point, biopsies revealed malignancy in both lobes, at clinical stage II. The couple was presented with treatment options by the urologist: radiation, radical prostatectomy, or doing nothing. The urologist discussed the potential treatment-related side effects in great details with the patient and his wife of 27 years, who is a former registered nurse. They ultimately chose surgery, which they describe as a couple decision. They related that although the subsequent risk of incontinence and impotence were high, they chose the treatment that they felt had the best odds of cure. The patient recovered from the surgery without complications, although he did report problems with incontinence and impotence. Both he and his wife were disappointed to learn that the final pathology indicated seminal vesicle involvement. Initially the patient was depressed and stated that he wanted no further treatment, although his wife was not ready to give up. When the bone scan was negative, he reconsidered further treatment; opting for external beam RT. he received 30 treatments over the course of 6 week.

Because of difficulties managing urinary leakage and bowel urgency, he retired at the age 54, much earlier than he had originally anticipated. They down-sized to a smaller, more manageable home. They attempted several methods of dealing with the erectile dysfunction, including a vacuum device, urethral prostaglandin suppositories and sildenafil, without success. They state that we can live with it, referring to the changes in their sexual relationship. the couple states that they are closer now than even before. Four years after the completion of treatment, the patients PSA remains at 0.1ng/ml: however, he is plagued with worry that the disease will return.

PATHOPHYSIOLOGY
Risk Factors= Idiopathic, Age (50 above), Ethinicity (Less Asians, More on AfricanAmericans), History, Occupational Exposure(Pesticide), Infection (STI) Bacteria (E.coli/Klebsiella) Colonization of Urinary Tract Infection of the Prostate PROSTATIS mutation of genes/cells growth of tumor in the prostate obstruction in the bladder neck/urethra difficulty in urination urinary retention hesitancy in urination metastasis in bladder

interruption in urethra metastasis in bones DRIBBLING URINATION hematuria

sexual dysfunction

UTI irritable bladder dysfunction painful ejaculation blood in semen

suprapubic pain weakness

frequency of urination nocturia hip pain

backache weight loss

perineal discomfort rectal discomfort

ANATOMY & PHYSIOLOGY PROSTATE GLAND The prostate, from Greek prostates, literally "one who stands before", "protector", "guardian" is a compound tubule-alveolar exocrine gland of the male reproductive system in most mammals.

FUNCTION: The function of the prostate is to secrete a slightly alkaline fluid, milky or white in appearance, that usually constitutes 2030% of the volume of the semen along with spermatozoa and seminal vesicle fluid. The alkalinity of semen helps neutralize the acidity of the vaginal tract, prolonging the lifespan of sperm. The alkalinization of semen is primarily accomplished through secretion from the seminal vesicles. The prostatic fluid is expelled in the first ejaculate fractions, together with most of the spermatozoa. In comparison with the few spermatozoa expelled together with mainly seminal vesicular fluid, those expelled in prostatic fluid have better motility, longer survival and better protection of the genetic material (DNA). The prostate also contains some smooth muscles that help expel semen during ejaculation. SECRETIONS: Prostatic secretions vary among species. They are generally composed of simple sugars and are often slightly alkaline. In human prostatic secretions, the protein content is less than 1% and includes proteolytic enzymes, prostatic acid phosphatase, and prostatespecific antigen. The secretions also contain zinc with a concentration 500 1,000 times the concentration in blood. REGULATION: To work properly, the prostate needs male hormones (androgens), which are responsible for male sex characteristics. The main male hormone is testosterone, which is produced mainly by the testicles. Some male hormones are produced in small amounts by the adrenal glands. However, it is dihydrotestosterone that regulates the prostate. STRUCTURE: A healthy human prostate is classically said to be slightly larger than a walnut. In actuality, it is approximately the size of a kiwifruit. The mean weight of the "normal" prostate in adult males is about 11 grams, usually ranging between 7 and 16 grams. It surrounds the urethra just below the urinary bladder and can be felt during a rectal exam. It is the only exocrine organ located in the midline in humans and similar animals. The secretory epithelium is mainly pseudostratified, comprising tall columnar cells and basal cells which are supported by a fibroelastic stroma containing randomly orientated smooth muscle bundles. The epithelium is highly variable and areas of low cuboidal or squamous epithelium are also present, with transitional epithelium in the distal regions of the longer ducts. Within

the prostate, the urethra coming from the bladder is called the prostatic urethra and merges with the two ejaculatory ducts. The prostate does not have a capsule, rather an integral fibromuscular band surrounds it. It is sheathed in the muscles of the pelvic floor, which contract during the ejaculatory process. The prostate can be divided in two ways: by zone, or by lobe. DIVISION OF PROSTATE: A. Zones The "zone" classification is more often used in pathology. The idea of "zones" was first proposed by McNeal in 1968. McNeal found that the relatively homogeneous cut surface of an adult prostate in no way resembled "lobes" and thus led to the description of "zones."[14] The prostate gland has four distinct glandular regions, two of which arise from different segments of the prostatic urethra: Name Fraction of gland Description

Peripheral zone (PZ)

Up to 70% in young men

The sub-capsular portion of the posterior aspect of the prostate gland that surrounds the distal urethra. It is from this portion of the gland that ~7080% of prostatic cancers originate.

This zone surrounds the ejaculatory ducts. The central zone accounts for roughly 2.5% of Central zone Approximately prostate cancers although these cancers tend to (CZ) 25% normally be more aggressive and more likely to invade the seminal vesicles. ~1020% of prostate cancers originate in this zone. The transition zone surrounds the proximal urethra and is the region of the 5% at puberty prostate gland that grows throughout life and is responsible for the disease of benign prostatic enlargement. Approximately This zone is usually devoid of glandular components, and composed only, as its name

Transition zone (TZ)

Anterior fibro-

muscular zone (or stroma)

5%

suggests, ofmuscle and fibrous tissue.

B. LOBES The "lobe" classification is more often used in anatomy. Anterior lobe (or isthmus) Posterior lobe Lateral lobes roughly corresponds to part of transitional zone roughly corresponds to peripheral zone spans all zones

Median lobe (or middle lobe) roughly corresponds to part of central zone

NURSING PHYSICAL ASSESSMENT RELATED TREATMENTS NURSING CARE PLAN RECOMMENDATIONS REFERENCES 1. Ma Rachel Roxas Yapchionco, Prostate Cancer Awareness http://www.thepoc.net/thepoc-features/health-and-wellness/health-and-fitnessfeatures/8153-prostate-cancer-awareness-month-mens-health.html Philippine Online
Chronicles. June 28, 2010

2. Dr. Phillip Chua, Prostatic Cancer http://globalnation.inquirer.net/cebudailynews/opinion/view/20080107110897/Prostatic_cancer Philippine Daily Inquirer: Lifestyle (Heart to Heart Talk). 3. National Cancer Institute. What you need to know about prostate cancer. http://www.cancer.gov/cancertopics/wyntk/prostate/page7. November 20, 2011 4. Risk Factors of Prostate Cancer. http://www.cancer.gov/cancertopics/wyntk/prostate/page4 National Cancer Institute. November 20, 2011 5. Jenny F. Manongdo, 1 of 8 Filipino men get prostate cancer. http://www.mb.com.ph/node/247804/1-8-filipino-men-get-pro Manila Bulettin Publishing Corporation. March 15, 2010. 6. John Hopkins Medicine, Health Alerts. http://www.johnshopkinshealthalerts.com/alerts_index/prostate_disord ers/25-1.html. March 10, 2009.
7. Wikipedia. http://en.wikipedia.org/wiki/Prostate . Retrieved February 21, 2012 8. 8. Tsukise, A.. "Complex carbohydrates in the secretory epithelium of the goat prostate" http://www.springerlink.com/content/j7p435385n140463/. Dated November 26, 2009. Retrieved February 21, 2012. 9. Instant Anatomy. http://www.instantanatomy.net/abdomen/vessels/vprostaticplexus.html Zones and Lobes of Prostate. Dated November 23, 2007. Retrieved February 21, 2012. 10.Wexner Medical Center. Anatomy of Prostate Gland http://medicalcenter.osu.edu/patientcare/healthcare_services/prostate_health /anatomy_prostate_gland/Pages/index.aspx August 2011. Dated August 2011. Retrieved February 21, 2012. 11.J. Trax, PSA Rising. http://www.psa-rising.com/prostatecancer/prostate.htm Issued December 26, 2008. Retrieved February 22, 2012.

12. Smeltzer C.S et. al. (2010) Brunner & Suddarths Textbook of MedicalSurgical Nursing. Volume 2 (12th Edition). Page 1516-1523. Published by Lippincott-Raven Publishers, Philadelpia PA. 13. Langhorne M.E et.al (2007) Textbook of Oncology Nursing. Fifth Edition. Page 164-171. Published by Elsevier Pte Ltd, Winsland House I, Sinapore.