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

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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

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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,

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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

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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

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(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

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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

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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.

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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

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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

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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.

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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.

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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.

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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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