1. BPH Prostate cancer Hanjong Park, PhD, RN

2. Benign Prostatic Hyperplasia(BPH), 양성전립선 비대증
“Benign enlargement of prostate gland
Most common urologic problem in male adults
50% of all men in their lifetime will develop BPH
BPH is a risk factor for developing prostate cancer”
(Lewis et al., 2014, p. 1308)
(Lewis et al., 2014, p. 1307)

3. BPH: Etiology Hormonal changes associated with aging process
dihydroxytestosterone (DHT) (the principal intraprostatic androgen, 전립선내 초기 안드로겐) ↑ in the prostate cells
increased proportion of estrogen (as compared to testosterone) in the blood
Aging
Obesity (waist circumference ↑)
Smoking
Diabetes
Lack of physical activity
Alcohol consumption ↑
Erectile dysfunction
May have family history of BPH(first-degree relatives)
김금순 외(2012), Lewis et al.(2014)

4. BPH : Clinical manifestations (similar to neurogenic bladder)
Minimal early symptoms  urethral obstruction
Irritative symptoms associated with inflammation:
Nocturia, urinary frequency, urgency, dysuria, bladder pain, incontinence
Obstructive symptoms by prostate enlargement & urinary retention:
Weak urinary stream, difficulty in initiating voiding, intermittency, dribbling at the end of urination
김금순 외(2012), Lewis et al.(2014)

5. BPH : AUA symptom index 소변을 본 뒤에 얼마나 자주 방광을 완전히 비우지 못한 느낌을 받았는가?
소변을 본 뒤에 2시간 안에 다시 소변을 본 적이 얼마나 자주 있었는가?
소변을 볼 때 서너번 다시 소변이 중단되거나 시작되는 것을 얼마나 자주 알게되었나?
Lewis et al.(2014, p. 1309)

6. BPH : diagnostic studies
History
Digital rectal examination(DRE, 지두직장검진법): size, symmetry, firm/smooth
Urinalysis with culture: WBCs, microscopic hematuria
Prostate-specific antigen(PSA, 전립선특이항원): slight elevation, to rule out prostate cancer, normal PSA < 4.0ng/mL
Serum creatinine
Postvoid residual
Transrectal ultrasound(TRUS, 경직장초음파촬영술) scan: accurate check of prostate size, to rule out prostate cancer, + biopsies(maybe)
Uroflowmetry(요속측정법): extent of urethral blockage, checking type of needed tx
Cystoscopy
김금순 외(2012), Lewis et al.(2014)

7. BPH : Collaborative care1
Minimally invasive(최소한의 침습적 시술)
Transurethral Microwave Thermotherapy(TUMT, 경요도 극초단파 열요법)
Transurethral Needle Ablation(TUNA, 경요도 침 절제술)
Transurethral Electrovaporization of Prostate(TUVP, 경요도 전립선 전기기화법)
Intraprostatic Urethral Stents(전립선내 요도 스텐트)
Laser Prostatectomy(레이저 전립선 절제술)
Invasive surgery(침습적 수술)
Transurethral Resection of Prostate(TURP, 경요도 전립선 절제술)
Transurethral incision of prostate(TUIP, 경요도 전립선 절개술)
Open Prostatectomy(개방적 전립선 절제술)
김금순 외(2012), Lewis et al.(2014)

8. BPH : Collaborative care2
Drug therapy
5α-Reductase inhibitors(5α환원효소 억제제: 전립선비대 억제, 효과-3-6 months): finasteride [Proscar]- when scores of AUA symptom index > 20-35, dutasteride[Avodart]
Α-Adrenergic receptor blockers(α교감신경수용체 차단제: 전립선평활근이완, 효과-2-3 weeks): silodosin [Rapaflo], alfuzosin[Uroxatral], doxazosin [Cardura], prazosin [Minipress], terazosin[Hytrin], tamsulosin [Flomax])
5α-Reductase inhibitors+ α-Adrenergic receptor blockers: dutasteride + tamsulosin [Jalyn]
Erectogenic drugs: tadalafil [Cialis]
김금순 외(2012), Lewis et al.(2014)

9. BPH : Nursing diagnosis(read p.1613-1618)
Acute pain related to bladder distention secondary to enlarged prostate
Risk for infection related to an indwelling catheter, urinary stasis, or environmental pathogens
요도폐색과 관련된 절박감, 소변줄기의 변화, 요실금, 요정체 혹은 야뇨로 인한 배뇨장애
수술과 관련된 배뇨장애 위험성
방광자극과 불수의적인 소변 누출에 근거한 괄약근 조절능력 저하와 관련된 긴박성 요실금
수술 후 활동제한에 대한 지식부족과 관련된 치료요법의 비효율적 이행
김금순 외(2012), Lewis et al.(2014)

10. Prostate cancer, 전립선암 “malignant tumor of the prostate gland
Most common cancer among men > 65 years old (1/6 men)
Younger men: more aggressive type of cancer”
(Lewis et al., 2014, p. 1315)

11. Prostate cancer : Etiology
androgen-dependent adenocarcinoma
slow growing(usually)
3 routes: direct extension, lymph system, blood stream(pelvic bones, femur head, lower lumbar spine, liver, lungs)
김금순 외(2012), Lewis et al.(2014)

12. Prostate cancer : Etiology
Risk factors
Known: Age, ethnicity(African American>white>Asian A.), family history
Unknown: Smoking , Vitamin D, E (maybe)
BPH
Obesity
Diet: High fat dairy, high in red and processed meat,
Low intake of vegetables, fruits
Genetic link: Hereditary breast and ovarian cancer(HBOC) syndrome, Mutation in BRCA1 and BRCA2
김금순 외(2012), Lewis et al.(2014)

13. Prostate cancer : Clinical manifestations (similar to BPH)
Usually asymptomatic in the early stage  urethral obstruction
BPH like symptoms: dysuria, hesitancy, dribbling, frequency, urgency, hematuria, nocturia, retention, interruption of urinary stream, inability to urinate
Symptoms associated with metastasis:
Severe pain when bone metastasis(common site)
pain in the back and legs(요통, 좌골신경통) due to spinal cord compression & bone destruction
김금순 외(2012), Lewis et al.(2014)

14. Classification for staging Prosate cancer
Lewis et al.(2014, p. 1317)
Stage I to IV (A to D)
(2015, November 1). New Hope for Prostate Cancer Detection. Retrieved from

15. Prostate cancer : diagnostic studies
History
Digital rectal examination(DRE, 지두직장검진법): 비대칭적, 돌처럼 단단함
Prostate-specific antigen(PSA, 전립선특이항원): for early detection & monitoring treatment effects, normal PSA < 4.0ng/mL
Prostatic acid phosphatase(PAP, 혈청 산성인산효소): normal < 2.5ng/mL
Serum alkaline phosphatase for advanced prostate cancer(e.g, bone metastasis)
Transrectal ultrasound(TRUS, 경직장초음파촬영술) scan with biopsy: biopsy confirms the diagnosis
Bone scan checking spread of prostate cancer
CT, MRI using endorectal probe
김금순 외(2012), Lewis et al.(2014)

16. Prostate cancer : Collaborative care1
Watchful waiting(보존적 요법)
DRE & PSA follow up
기대수명이 10년 이하
유의한 공존질병 있을시
낮은 등급, 병기의 종양시
Surgery therapy (침습적 수술)
Radical prostatectomy(근치적 전립선 절제술)
Nerve-sparing procedure(신경보존술)
Cryosurgery(전립선 동결수술)
김금순 외(2012), Lewis et al.(2014)

17. Prostate cancer: Collaborative care2
Lewis et al.(2014, p. 1319)
Radiation therapy(방사선 요법)
External Beam Radiation(체외빔 방사선)
Stage A, B, C에서 6-8주 동안 주 5일 치료,
치료시간: 몇 분/1회
진행된 암인 경우 근접치료와 병행
Brachytherapy(근접치료)
Stage A, B에 적합
고용량 방사성 종자(radioactive seed)를
전립선 안에 심는 시술로
방광과 직장 조직 보존

18. Prostate cancer : Collaborative care2
Drug therapy
Therapy
Mechanism of action
Side effects
LH-RH agonists(촉진제)
leuprolide (Lupron, Lupron Depot, Eligard, Viadur)
goserelin (Zoladex)
triptorelin (Trelstar)
buserelin (Suprefact)
Reduce secretion of LH and FSH
Decrease testosterone production
SC or IM injection
Hot flahes, gynecomastia, decreased libido, erectile dysfunction
Depression & mood change
LH-RH Antagonist(길항제)
degarelix
Blocks LH receptors
Immediate testosterone suppression
SC injection
Pain, redness, swelling at injection site, elevated liver enzymes
LH-RH(luteinzing hormone releasing hormone)황체형성 호르몬 분비호르몬
김금순 외(2012), Lewis et al.(2014, table 55-7 , p. 1319)

19. Prostate cancer : Collaborative care2
Drug therapy
Therapy
Mechanism of action
Side effects
Androgen receptor blockers
Bicalutamide(Casodex)
Flutamide(Eulexin)
Nilutamide(Nilandron)
Enzalutamide(Xtandi)
Block action of testosterone by competing with receptor sites
Oral medication
Loss of libido, erectile dysfunction, hot flashes
Breast pain and gynecomastia may occur
Estrogen
Diethylstibestrol(Des)
LH 분비 억제, 테스토스테론 생산 감소, 순환 테스토스테론 차단
김금순 외(2012), Lewis et al.(2014, table 55-7 , p. 1319)

20. Prostate cancer : Collaborative care2
Drug therapy
항암화학요법: 호르몬 불응성 전립선암(hormone-refractory prostatic cancer, HRPC)환자에게 제한적 적용
docetaxel(Taxotere), cabazitaxel (Jevtana), paclitaxel (Abraxane), mitoxantrone (Novantrone), vinblastine (Velban), cyclophosphamide (Cytoxan), and estramustine (Emcyt).
vaccine (sipuleucel-T [Provenge] which stimulates the patient’s system against the cancer and may prolong survival.
김금순 외(2012), Lewis et al.(2014)

21. Prostate cancer : Nursing diagnosis(read p.1613-1618)
다양한 대안적인 치료의 선택과 관련된 의사결정 갈등
수술, 전립선 비대, 뼈 전이, 방광경련과 관련된 급성 통증
방광경부 괄약근 손상과 관련된 요 배설장애
요도폐색, 방광 긴장력 감소와 관련된 요정체
질병과정의 불확실한 결과와 관련된 불안 또는 죽음에 대한 공포
치료적 중재와 관련된 변비 또는 설사
김금순 외(2012), Lewis et al.(2014)

22. References 김금순 외(2012). 성인간호학 II, 7판. 수문사
Lewis, Sharon L.; Dirksen, Shannon Ruff; Heitkemper, Margaret M.; Bucher, Linda (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier Health Sciences. Kindle Edition.