Pain (chronic bone) related to metastatic spread of disease
778 Prostate Cancer
OUTCOMES. Pain control; Pain: Disruptive effects; Well-being
CONSERVATIVE. Periodic observation, or "watchful waiting," may be proposed to a patient with early-stage, less-aggressive prostate cancer. With this option, no specific treatment is given, but the progression of the disease is monitored via periodic diagnostic tests.
SURGICAL. Radical prostatectomy has been the recommended treatment option for men with middle-stage disease because of high cure rates. This procedure removes the entire prostate gland, including the prostatic capsule, the seminal vesicles, and a portion of the bladder neck. Two common side effects of prostatectomy are urinary incontinence and impotence. The urinary incontinence usually resolves with time and after performing Kegel exercises, although 10% to 15% of men continue to experience incontinence 6 months after surgery. Impotence occurs in 85% to 90% of patients. All men who undergo radical prostatectomy lack emission and ejaculation because of the removal of the seminal vesicles and transection of the vas deferens. Newer surgical techniques (nerve-sparing prostatectomy) preserves continence in most men, and erectile function in selected cases.
Transurethral resection of the prostate (TURP) may be recommended for men with more advanced disease, especially if it is accompanied by symptoms of bladder outlet obstruction. This procedure is not a curative surgical technique for prostate cancer but does remove excess prostatic tissue that is obstructing the flow of urine through the urethra. The incidence of impotence following TURP is rare, although retrograde ejaculation (passage of seminal fluid back into the bladder) almost always occurs because of the destruction of the internal bladder sphincter during the procedure. Many men equate ejaculation with normal sexual functioning, and to some the loss of the ejaculatory sensation may be confused with the loss of sexual interest or potency. Also, a bilateral orchiectomy may be done to eliminate the source of the androgens since 85% of prostatic cancer is related to androgens.
All patients return from surgery with a large-lumen three-way Foley catheter. The large lumen of the catheter and the large volume in the balloon (30 mL) help splint the urethral anastomosis and maintain hemostasis. Blood-tinged urine is common for several days after surgery, but dark red urine may indicate hemorrhage. If continuous urinary drainage is used, maintain the flow rate to keep the urine light pink to yellow in color and free from clots, but avoid overdistension of the bladder.
Antispasmodics may be ordered for bladder spasms. Anticholinergic and antispasmodic drugs may also be prescribed to help relieve urinary incontinence after the Foley catheter is removed. Because of the close proximity of the rectum and the operative site, trauma to the rectum should be avoided as a means of preventing hemorrhage. Stool softeners and a low-residue diet are usually ordered to limit straining with a bowel movement. Rectal tubes, enemas, and rectal thermometers should not be used.
RADIATION. Both external beam radiotherapy and internal implant (brachytherapy) are used in the treatment of prostate cancer. Radiation therapy is also used in areas of bone metastasis. The goal in extensive disease is palliation: Reduce the size of the prostate gland and relieve bone pain. Brachytherapy involving the permanent (iodine-125 or gold-198) or temporary (iridium-192) placement of radioactive isotopes can be used alone or in combination with external radiation therapy.
Patients who receive permanently placed radioisotopes are hospitalized for as long as the radiation source is considered a danger to persons around them. The principles of time, distance, and shielding need to be implemented. Care needs to be exerted so that the radioisotope does not become dislodged. Dressings and bed linens need to be checked by the radiation therapy department before these items are removed from the patient's room.
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