Episode 13, Class 13: Renal and GU Issues, Men's Health

Okay, we're going to look at GU complications and men's health. So the initial part of this, the genital urinary complications will include UTIs and real calculi and various surgeries that can be for both men and women and then we'll get into more of the male specific stuff. So we can have ureadural strictures, prostate cancer, bladder cancer, traumatic surgeries, kidney donations. So lots of things we'll talk about, but let's start with UTI. Most people have probably experienced the UTI, so they have some working knowledge of what that feels like. The urinary tract above the urethra is normally sterile and when it gets an infection, UTIs is the second most common bacterial infection, number one in women. It accounts for about 8 million office visits per year, totaling 1.8 billion dollars. So what happens is there's an alteration in the defense mechanisms that increase the risk of contracting UTI. So there's certain predisposing factors, anything that leads to urinary stasis is going to kid possibly lead to UTI. So if you're in sitting in your bladder, it's just a medium for bacteria to grow. So that's why we always want to empty our bladders completely and don't wait to pee all day. Like a lot of nurses do, you realize it's three o'clock in the afternoon, you haven't pee yet. It's not good. So try to go to the bathroom at regular intervals. Any kind of foreign body, like a Foley, for example, if you have a Foley catheter, your chances of getting UTI increase by 10% per day. There could also be a ureteral stint that's been put in or any other kind of implant in that area is going to be a foreign body that could lead to a risk. Anatomic factors like obesity, harder to clean down there, congenital defects, again, same thing, kind of just structural abnormalities or fistulas. Anything that compromises your immune system, so HIV, diabetes, leukemia, maybe just being a little bit sick, maybe if you just have cold, your immunity is low or you're in times of stress as well. Functional disorders like constipation, other factors, pregnancy, multiple sex partners, especially in women, but can also be in men. Is it more common in men or women? More common in women. In water symptoms, we've got the itching, burning, frequency, urgency, dysphoria, all of those kinds of things. I think everybody is probably fairly familiar with that. So a lower UTI is just from the bladder down and an upper UTI is from the ureters up. So just thinking anatomically what that includes. At upper UTI, you're going to have more systemic symptoms, so fever, chills, flank pain, maybe one sided or two sided, so whichever kidney is affected, possibly both. Sistitis. Whenever you see the word cyst, that means bladder. So cystitis is a urinary tract infection, inflammation of the bladder. Sistoscopy is when they go in there and take a look at the bladder. The cystoscope is the tool that they use to do that, a cystectomy would be removal of the bladder, which is usually going to be done related to bladder cancer, and we'll talk more about that later. So frequency and urgency, burning, avoiding small amounts or the inability to avoid. You can have lower abdominal discomfort and low back pain, that usually means the kidneys are involved. Cloudy, dark, foul smelling urine, hematuria, you've got some blood in the urine. You may or may not see it, but if they do a UA, they'll tell you that there is blood in there. Bladder spasms can be very painful, chills and fevers, nausea and vomiting, that would mean that it has gone systemic. Pile and a frightous is when we have inflammation of the renal pelvis, so that's when the infection has gone up into the kidneys. Neff always means kidneys. Pile low is the renal pelvis. So again, similar symptoms, frequency, urgency, burning, avoiding small amounts or the inability to avoid. Flank pain on the affected side could be one, could be both. Cloudy, bloody foul smelling urine, hematuria, bladder spasms, chills, fevers, nausea, and elevated white blood cells in the urine. So the symptoms are pretty similar. The difference is if it's gone higher up, you're going to have that flank pain, you're going to feel it in your kidneys. First thing you'll probably do at the doctor's office is an H&P, an H&P physical examination, and then they'll do a dipstickier analysis because they just want to do a quick examination to see what's in there. And that'll identify if they have the presence of nitrites, white blood cells, and leukocyte esterase. So an enzyme in bacteria changes nitrates to nitrites. So nitrates would be more expected to see, but in the presence of an infection, they would be changed into nitrites. The problem will be confirmed with the urine culture. So first they can say, yeah, you have nitrites and white blood cells, so you do have a UTI, but then they're going to do a culture to see exactly what's in it and what to what back to what antibiotics the bacteria is going to be susceptible. They may do imaging studies, they could do an intravenous pylogram if they want to see up into the kidneys or an abdominal CT if they suspect that there's an obstruction like a stone is generally what they'd be looking for there. Keep in mind that symptoms may be different in the elderly. They may just have generalized abdominal discomfort. They may have cognitive impairment or behavior changes or they just may have generalized clinical deterioration. So they just kind of start going downhill. Or a elderly person has changes in behaviors or their presentation. UTI is a really quick and easy thing to suspect and rule out. So they are going to start you on antibiotics and they'll be selected on the empiric theory or that means what has generally worked in the past, some clinical judgment. So we'll start you on a basic what it probably is, and that's probably going to be sit pro quite likely. And then they'll get the results of the sensitivity testing in a couple of days and they may find that it's not susceptible to sit pro so they may change the antibiotics or they may keep you on that. A short-term course for an uncomplicated bladder infection would be possibly one to three days. If it's a complicated UTI, that's going to require longer-term treatment seven to fourteen days. So if it's uncomplicated, it's just a normal UTI, only affects the bladder. If it's complicated, there's a co-existing problem. So an obstruction, stones, catheter, diabetes, neurochanges, pregnancy, it's a recurrent infection or a longer lasting infection. So uncomplicated and complicated, pretty simple. Oh, the other thing to mention with elderly is that the body temperature is unreliable in them. So it may not increase in elderly, in fact, if they're over 80, and presence of an infection may, their temperature may decrease. So again, just some other gerontologic considerations, their presentations may be a little bit different. Next we have urinary analgesics. So pyridium is the first one and this is often used in combination with antibiotics. It is OTC and if you know anything about pyridium, the big thing is that it turns your urine reddish orange. So if you think you should tell your patients about that, yes, because that's a little bit disconcerting. And in fact, it can be mistaken for blood, you know, it's not typical to see your blood, your urine being dark orange or red, so that can be a little bit shocking. So make sure that you tell them that and it also could stain their underwear if they have a little bit of leakage, which is going to be common in a UTI. Another one is uricide and this also would be used in combination with antibiotics is just to relieve the symptoms. So these just provide a soothing effect on the urinary tract mucosa. Ursaid can be made with methyl and blue and that's a dye that we'll talk about later and that's, you may also see that used in the OR, but that changes, it's tinted blue, so that's going to change the urine to kind of a blue or a green color. So again, let them know that. It's going to be a little upsetting to start seeing green urine. You're going to think you got some major problem going on. So just let them know that. So teaching with infections, increased fluids, 3,000 ml a day, that's a lot, but push fluids. The more we can flush the stuff out of the bladder and out of the kidneys, it's going to be the better. Proper hygiene, that sounds simple, wiping or cleaning themselves, we all kind of know how to do that, but some people aren't as educated and they may not know. So teaching proper wiping and cleaning techniques is going to be important. On water sits baths, if they have pain down there, they can sit into a basin that has some medicated water in there. Voiding after intercourse is important for both men and women and men, especially with anal intercourse, need to void because E. coli is in the colon and that's going to travel up there and that can lead to an infection. We want to increase acid in the diet. should be maintained. The pH should be at 5.5 so we want our urine pH to be 5.5 so we may need to increase acid and an easy way to do that is to increase vitamin C citrus cranberry and when we say cranberry, cranberry juice we don't mean ocean spray cranberry juice cocktail because if you look at the labels on that and I hope you guys are in the in the habit of looking at labels you will see the first ingredient's water the second one is probably high fructose corn syrup so that's very little if anything to do with cranberries you have to get actual langers cranberry juice it's about four dollars for a tiny bottle and it's so sour you can barely drink it I would mix it with some diet ginger ale or sprites something like that to kind of cut that taste or you could just mix it with water menopausal women may use vaginal estrogen cream that lines the urinary tract and that's controversial there's some ebp about that that you can look up if you're interested in but that is something that sometimes older women may be doing so nurses how do we prevent UTIs we want to get our patients voiding frequently and we want to encourage the fluids when they have a fully we want I went to a seminar once and the lady asked who is the fully for if it's for the nurse for their convenience that is not the right answer as I said a fully increases your chance 10% per day of getting UTI so get the fully out ASAP and that has become a real priority and a lot of charting systems have warning systems in place if it's been more than 24 hours a box of pop-up saying why this patient still has a fully why do they still need it and you would have to document a reason a medical reason why they do need that so get the fully as out as soon as possible if we're going to get a urine specimen for culture and sensitivity when do we need to do that what we need to do a urine specimen for culture before antibiotics are started do we use a septic technique or sterile technique when inserting the catheter yes sterile technique and that's a really good way for UTI to occur if sterile technique is not adhered to once somebody does have a catheter we have to do careful cleaning of that some places will have chloroxidine wipes or something like that that the patient will clean with or the nurse will clean the the catheter with do we ever want a drainage bag to be above the level of the bladder no we don't it always needs to be below it's gravity drainage we also want to make sure that there's no kinks in the line because that's going to cause a backup when you lift a drainage bag above the bladder there can be backflow and there's nothing to stop that there's no valves in there in the in the catheter so it'll just all go right back up in there I know you guys know better than that but sometimes you'll see physical therapy if they have a student especially they may not know all the all the rules and they may hang the urinary bag on the walker on the upper bars of the walker it should always be on the lower bars so that just just look at that so if you see someone walking down the hallway with a bag hanging on their walker make sure that it visually that it is below the big bladder another thing transportors they may be transferring a patient over onto a gurney and they may pick up the urinary bag and just pop it in their lap and say here just kind of you know a lot of that you know that's kind of gross for one thing but it also can lead to backflow so we don't want that and if somebody has pile and a fritus or any kind of infection we should be concerned about renal failure and so we want to monitor their urinary output hourly so it's very important obviously we're talking about GU stuff here the GU system is going to be the focused assessments and the big thing there is urine so urine is life we want to make sure that we're getting adequate urine out and we need to monitor that every hour so any kind of pile and a fritus or kidney infection we're going to be concerned about that next we're going to talk about renal calculi or kidney stones so kidney stones are very tiny but they cause a great deal of pain and people who have had stones and children have said many times many people have said that kidney stones are more painful than childbirth so nephrolothiasis is how you may see it referred to nephigan means kidney lift is a stone and isis is disease or formation so several different causes it can be related to the diet there can be metabolic reasons why why they're having it immobilization and dehydration an obstruction anything that causes urinary stasis especially in alkaline urine a urinary infection prolong urinary catheterization history of stone formation either the person or in their family bph would go along with an obstruction so anything that's keeping the urine in the bladder that's providing an area for stones to form they most commonly occur in men ages 20 to 55 and most commonly more commonly in Caucasians so it can be related to increase protein in the diet that's going to increase uric acid large intakes of oxalate and calcium small amounts of fluid intake so again this is a nurse thing nurses personally drink water okay make sure you're drinking throughout the day drinking and peeing if you haven't pee that means you're not drinking enough so make sure you're doing both all right so a couple of zition of stones we've got four different kinds listed here calcium oxalate struvite which is magnesium and ammonium phosphate cysteine or uric acid they can also be located anywhere and they're going to be named for where they're located so in the renal pelvis you'd call it a renal pelvic stone if it's in the ureter it can be an upper your ureteral stone or lower your ureteral stone in the renal calisheal stones if it's up there by the renal pyramids in the calisheal so they're going to be described as where as to where they are located so again they're they're really tiny they can be like little grains of sand or a little bit bigger any stone that's greater than about four millimeters will not pass through the ureter so there's going to need to be some kind of medical intervention taking place when they're at that big so looking at the pictures I have here of the microscopic views you can see I mean they're very they can be very pointy they're like crystals and they those as those pointy parts roll down through the organs they're going to be tearing the mucosa as they go through and that's going to cause pain and it's also going to cause bleeding so people have hematuria stones could also be in the bladder or even in the urethra a urologist friend of mine was telling me about he got called into the ED one time where a patient had one stuck in his urethra and he basically had to hand milk it out so he was basically squeezing the penis up and down you know up until it came out and it actually just kind of popped out and it was pretty good size and I don't remember how big but obviously pretty good size to obstruct the urethra and that was a very painful experience for that guy so first of all let's talk about calcium oxalate stones so this makes up about 75% of the stones so this is by far the most common one it's greater in men than women and the the urine gets saturated with calcium and oxalate the urine becomes alkaline so pH increases so we want to lower the pH and some things we can do is pair calcium foods with oxalate foods but what are oxalate foods that's probably not anything you've ever heard of it's not one of the food groups oxalate foods are things like tea, almonds, cashews, peanuts, chocolate, cocoa, beans, spinach and rebarb that's not an exhaustive list but that's some of the common ones so if you're eating nuts, if you're eating a lot of almonds, cashews, peanuts chocolate same thing you want to pair those with calcium foods so have some cheese or some milk with that what happens when you do that is they bind together in the intestines and they go through better they don't stick around and clog up at informed stones we also can consume a diet low in sodium because that's going to save fluid the more sodium you eat the more fluid you're going to need increase acidic foods and they have an acid ash diet and an alkaline ash diet and ash is kind of a weird word we think of like fireplace ashes it's not anything to do with that it's just how these kinds of foods break down the kind of the residue that they leave behind we can think of that as ash okay so things that are acid ash would be a lot of grains some bread cereals any whole grains also cheese eggs cranberries prunes plums tomatoes meat some fish and poultry so those are the kinds of things that we want to increase next we have struvite stones and these are magnesium and ammonium phosphate and these are caused by urea splitting bacteria so we just talked a little bit ago in the UTI about how bacteria change things, they change nitrates to nitrates, and they split the area. So this one always is associated with the UTI because of that ureous splitting bacteria. These also form in alkaline urine, so we need to acidify the urine. And these are more common in women than men, three to five times more common. However, these only account for about 10 to 15% of the stones. So it's not that common, but it does also occur in alkaline urine. So again, we want to raise or lower the pH. We're going to lower the pH. We want it more acidic. It's alkaline. So alkaline is bad. We don't want to have alkaline urine. So again, we're going to eat an acid ash diet, so review those foods, limit phosphate foods. Anything that has protein basically is going to give you phosphate. So dairy products, red meats, organ meats, some whole grains. We also need to control the infection. So they're going to need an antibiotic, and it may be long term. So that's going to be more like a complicated UTI because it's related to an obstruction or a stone. So I just want you to take note that in these first two that we've talked about, the calcium and the streway, those account for about 85% of stones. And that means 85% of stones occur in alkaline urine. So do you think alkaline urine is bad? Yes. It's very much more common where stones occur. So then the next two are going to occur in acidic urine. And so we're going to want to raise the pH on these. So cysteine stones are the first one. And they form crystals in acidic urine. So we want to avoid the acid ash diet and consume the alkaline ash diet. So most fruits, except for the ones previously mentioned, cranberries, plums, prunes, also milk, vegetables, rhubarb, trout, and salmon. So I said some fish in the other one. This one specifically mentions trout and salmon. Don't get too hung up on these things. Just kind of be familiar. There's a chart you can look at that just kind of indicates the more acidic foods and more alkaline foods. So just kind of look at that and most of it pretty much makes sense. So these cysteine stones are very rare, one to two percent. And it is a result of a rare genetic autosomal recessive defect. And for treatment, we want to increase fluids. We want to have potassium citrate to maintain alkaline urine and eat those foods. And then we have uric acid stones. These account for about 5 to 10 percent of stones, greater in men than women, more common in Jews. We want to do potassium citrate again and antibiotics. So these come from an excess amount of protein in the diet, which leads to purines breaking down and leading to gout. So this is going to be similar with gout. And there's a medication that we treat gout with. What is that? Ballopurinol. So you may see that here as well. It's the same exact thing. We've got uric acid crystals. It's just that in gout, they tend to settle in the feet. And with uric acid stones, obviously, there's somewhere in the EU system. So we want to decrease animal products, so red and organ meats, sardines, shellfish, anchovies, asparagus, mushrooms, high fructose corn syrup, lots of evil things. Within that, there's several documentaries and research things you can watch about that, trying to avoid that in your diet. And also alcohol. We want to eat low purine diet and alkaline ash foods, fruit to vegetables, whole grains. And then again, the drug alopurinol and potassium citrate. So stones in the nutshell, calcium and phosphate are less soluble in a more alkaline environment. So calcium oxalate and struvate stones are the ones that you're going to see in alkaline urine. So treat those with acidic foods, know what they are. Uric acid and cysteine are less soluble in a more acidic environment. So cysteine and uric acid stones are going to be those that form in acidic urine. And treat those with alkaline foods, know what they are, as well as the medications that I mentioned. So we always want to know when someone has stones, we want to get those stones out and we want to send them to lab for analysis because we need to know what kind of stones they are because that dictates the treatment. So with reoccalculate, sometimes they'll have a lumbar pain. If it's up in the kidneys, you're going to feel it in the low back. That pain often radiates to the testicles, generally only in men, and to the bladder in the women. You're going to have severe, sharp pain. They may have nausea and vomiting, paler, diaphoresis, and hematuria. Again, those little crystals are rolling down the line and they're cutting things up as they go. So you're going to see blood in the urine. Diagnostics tests are going to do KUB, which is kidney or bladder x-ray, that sometimes will show it. They may have to do an IV pylogram. Your analysis might possibly indicate someone's going on, at least that'll tell if they have alkaline or acidic urine, and that'll help them know what to look for. Cestoscopy, they may be able to go in there with a cystoscope and actually see the stones if they're in the bladder, or they may go all the way up into the real pelvis, and then a CT scan. We'll give them a really good picture. So remember with diagnostics, we're always going to do least invasive first. So your analysis is very easy, KUB, also very easy, then CT scan is more invasive in a way. It's not so much invasive, but you're being exposed to a lot of x-rays, so we don't want to do that. And then cystoscopy, very invasive, going in there and taking a look. So whatever kind of stones or whenever somebody has stones, we need to strain the urine. So we're going to give them a little strainer with a very fine screen, and these stones are going to look like grains of sand when they come out. You're barely going to be able to see them, but we need to strain all urine. So I'm always preaching eyes, and I was right this time. It is very important. It's always very important, but this time, mean it. Make them use the urinal, make them use the hat, we need to strain the urine, we need to get the stones, and if they're going home, same thing, pee in something and dump it through the strainer. We want to increase fluids, 3,000 miles a day, and encourage ambulation because if they have stones that are stuck up high somewhere, that can help them to move. And that is going to be painful. The movement is what hurts when they feel the stones moving, but we've got to get them out, right? They can't stay there. They're caused to pain. They need to get out. So very careful eyes and nose, and then modify the diet based on what kind of stones are found. So if they're not going to pass on their own, we're going to need to go in there and get them. So there's several different things we can do to get them. First is a cystoscopy or ureteroscopy, ureteroscopy. So with that one, they're just going in with a cystoscope, so they go right in through the urethra. There's no incision because they're just going in there with a scope. The pathway already exists, and then they're going to just remove the stones. So they may be able to see them, they may be able to snare them and just pull them right out of there. They also could do shock waves through the cystoscope. So they put in the cystoscope, and that becomes like a conduit to put other tools through it. They can push water through there, they can put a bovee, they can do graspers, they can do ultrasound. So a lot of things they can put in through that conduit. So they could do ultrasonic shock waves right there directly, and now I'll break them up. Another thing they can do is percutaneous nephrolithautomy, so that's where they're going to go through the skin into the kidney and directly move the stones that way. So they'll be going through the back, right into the kidney, and pulling the stones right out through there. It's similar, except more invasive, obviously, because they're having to cut through the skin and through the kidney tissue. Next, there's an extra corporeal shock wave lithotripsi or Eswol. There's no incision. Again, there's no drains. They just have ultrasonic waves that are going to go through the back, or do you read through as I just mentioned, with the cystoscope. Ultrasonic waves are going to break up the stones. If they're going through the back, they're going to lie on a bed of water. This is done in the OR with general anesthesia, and the lie on this bed of water, and then the shock waves go through this bed of water, and they break up the stones, and they make them come out like little grains of sand. It's common that somebody will have a foley after this, which is nice because that makes it very easy. You don't have to argue with them to use the hat or the urinal. We can just empty the foley. You may see the sediment in the foley bag. You'll see little grains of sand in there. That's good. That means they're coming out. Always drain it through the screen, so we can catch those fragments. Then percutaneous lithotripsi, that's where they're going to do ultrasonic waves, but through a small incision in the back, so that'd be them going into the kidney that way. Whatever they're doing with these shock waves, the shock waves are breaking up the stones into little grains of sand, and then we're going to check the urine when it comes out. They may put in your reederal stents to keep the urinal open, and that will help the urine pass because we don't want the stone to obstruct the urine because then that can lead to a lot of problems with the kidney. The kidney can get hydroprosis, it's just going to blow up with urine, so we want to always make sure the urinal is open. So if there is a stone trapped in the urinal, they're going to put a stent up there, and that allows the urine to come through. There's a picture of some different stents. They have little curly cues on each end, and that's to anchor them where they need to be. So one end is going to go in the renal pelvis. the other end is going to go in the bladder and it helps keep the ureter open. Next we're going to get into genital urinary surgeries. So there's lots of reasons for surgery. There could be a renal tumor which may need to be removed. It may also lead to the entire kidney being removed. There was a, again my urologist tells me a lot of stories. It was a man who was visiting from Guam who's here for a wedding and he had hematuria and it was getting to be excessive and so his family talked him in to get it checked out and turns out he had a stage 4 cancer renal tumor. So you know, again always good things checked out as soon as you notice that something's wrong. People tend to wait way too long and then it's very late. Polycystic kidney disease, they would have, they could have bleeding or kidney infections. Their kidneys just kind of full of cysts and so oftentimes that's going to need to be removed. There could be trauma that can come from sex. You could be hit either in the kidneys or the testicles. You could be cut or stabbed if you got a knife into the back. That's going to lead to a genital urinary surgery. There could be elective removal of a kidney. That'd be for a donor, a live donor. You can have urethroplasty. Sometimes people have issues with their urethro something happens. It can have a structure, it can have an obstruction. Sometimes it's on the wrong side of the penis. It could be like on the bottom. They usually will correct that in childhood, but that would be a urethroplasty or an or a keyectomy would be a removal of the testicles. That could be through from cancer to a particular cancer or there was a young man who got hit playing basketball and it swelled up a lot and he came in. He waited several days to come in and it ended up, he had a testicular torsion to where the testicles was twisted around in there and so the blood supply had been cut off and there was no choice but to remove it. It was dead at that point, so that's an or keyectomy. So lots of different reasons, lots of different types of genital urinary surgery and so that includes all the way from the urethro to the kidneys. Kidney transplants are fairly common but there's never enough donors so there's some information here, there's a video you can watch an article you can read about transplant chain. This was a few years ago but at the time it was the largest transplant chain and what that means is that you want to give a kidney to your sister but you're not the right blood type or the tissue type but you're still willing to donate so they'll let you donate to someone else and then they'll match your sister with someone else. So you're basically giving a kidney to your sister but you're doing it through someone else so you're giving one to someone else and then someone else and someone else and someone else they are the match for your sister. So if anyone wants to be what they call an altruistic donor meaning you just want to donate a live kidney it will be used and I hope everybody is an organ donor because there are never enough organs to go around. So take a look at that article about that, about the 60 person transplant chain. So refractomy, let's start with that. So that is removing a kidney and it can be for any of the reasons that we mentioned previously there. Pre-op care, it's going to be your typical surgery prep. They're going to want to make sure that they have normal electrolyte balance and adequate fluid intake beforehand up until their NPO. So they'll be checking a lot of labs. Pre-op teaching, they're going to be getting a flank incision, they're going to probably be sideline, hyper extended. If they do it laparoscopically, they're able to get the kidneys out. Kidneys are pretty small, they're smaller than you think. They're make a fist and that's about the size of your kidney. So they can get that out through a fairly small hole with the laparoscopic surgery. They may want to open it up and if they do they may end up removing the 12th rib so they can have better access there. There's a lot more kidney stuff in the self-learning module chapter so you can take a look at that. You've focused assessment for any kind of kidney surgery is obviously going to be urine, urine output. If we're doing a kidney transplantation, so we've just removed a kidney from someone else through that sideline position. If you are the recipient, they do not remove the old kidney. There's really no reason to. It's already shriveled up. It's going to continue to shrivel up more once they kind of take away the blood supply because they're going to take away the blood supply and connect that to the transplanted kidney. So they're going to take the Iliac external and internal Iliac artery and vein and reconnect them to the new kidney. So the new kidney ends up being kind of lower than your other ones are, more closer to the bladder. So for the recipient, before the incision, they're going to have a urinary catheter placed into the bladder and they're going to instill an antibiotic solution. This is going to distant the bladder and decrease the risk of infection and they'll have a crescent shaped incision to open it up to allow for visualization and they need to attach all of those blood vessels and things so they need to have a good canvas upon which to work, if you will. Rapid re-vascularization is critical. So once they get that kidney out, they need to reconnect it to the blood supply as soon as possible. So the artery, the donor's artery is anastomose to the recipients internal external Iliac artery. The vein is anastomose to the external Iliac vein and when those are complete, they release the clamps. Blood flows reestablished, they check for any leaks anywhere around there. The blood flow starts going through the kidney and the kidney just starts working. So the blood starts getting filtered right away and urine will begin to be made. They may give a diuretic to speed that process up to get the urine out. There will be some blood in the urine for a while obviously because they've done a lot of vessel work there and this is a rather complex surgery. It's going to take about three to four hours. Postop, urine output is going to be very closely monitored. Again, urine is life. Remember any large rapid weight changes we want to think fluids. It's not because they ate a big dinner or skipped meal. It's going to be a fluid problem when they gain or lose weight rapidly. So we want to measure urine output every one to two hours, probably every one hour, immediately after surgery, looking also at the color, the consistency, the clarity. The urine output is going to be replaced with fluids milliliter by milliliter every hour. So as we take urine out, we say they got 366 mls out this hour. You're going to put 366 mls back the next hour. That may be kind of a high number, probably. No, I think of it. But you get the idea. We never want to irrigate or clamp a catheter. Any kind of GU surgery be very careful with the catheters that are existing. You don't want to mess with them. Normally we want 0.5 milliliters per kilogram per hour in urine output and then again, we're going to do daily weights because we want to watch out for weight shifts. Before the donor, post-op care is going to be similar to any laparoscopic surgery, especially laparoscopic nephrectomy, closely monitor the renal function and hematocrit so they'll be doing labs. They're going to be looking at the fluids and electrolyte balances and once all of that is stable, the person can go home. Their other kidney will compensate for it and they will be fine. For the recipient, it's a little more complicated. Maintaining fluid electrolyte balance is going to be your top priority. They should have large volumes of urine soon after the transplanted kidney is reconnected. The new kidneys are going to have the ability to filter their BUN. The old kidney did not. Obviously they're getting this kidney because their old kidney was bad, right? It's going to start working and things are going to start really being flushed out. They're going to be getting a lot of fluids during the operation. They put some directly into the bladder but they're putting a lot in the veins. We just really want to restore the kidney function, so we want to get things flushed out and just make sure that that's all working very well. They're going to have a lot of urine output initially. There is always a chance of rejection and it can be hyperacute. This is an antibody mediated rejection that's going to occur minutes to hours after transplantation or chronic rejection and that occurs over several months or years and is irreversible. Either way the patient is going to be treated with immunosuppressants. Think about all the things that goes along with that. Their immunity is now suppressed forever. They're going to be on these immunosuppressants for life because we're trying to trick the body into not rejecting this foreign body that's just been put into it. They depress the immune response. Most commonly that's going to happen within the first month if it's going to happen, then they can also get the other infections that every post-op person is at risk for. So pneumonia, wound infection, the IV line, the drain, so lots of risk for infection and again especially because they are immunosuppressed. So infection is a big risk. Some general GU post-op care. Some abdominal distension is going to be normal. Any kind of abdominal surgery is quite brutal. They're going to be stretched, pulled, they're going to have hands in the back. there, there's going to be rings, clamps, retractors, blades, all kinds of stuff in the abdominal cavity. So there's no wonder that there's going to be so much pain and swelling. So we're going to have some distension. That's going to be normal. We do want to also monitor balsams, even though this is a GU case, we need to pay attention to GI. Just like we would with any surgery, really, we want to make sure that the gut is starting to work. But this one in particular, because we found our hands in there, literally. It should return within 24 to 48 hours. They're going to need to be on a clear liquid diet at first, and then the advances tolerate. They'll advance faster than a typical GI surgery would, because we didn't actually cut into the GI surgery. In this case, anyway, with the kidney, there's going to be some surgeries we'll talk about in a minute, where they will have. But as long as they haven't interrupted the GI tract, their diet can advance rather quickly. As always, monitor for obstruction and paralytic ilias. We want to ask about, if they're passing gas and monitor balsams. So GI assessment is going to go right along with the GU assessment. And then respiratory, again, just like everybody else, we want to make sure they have adequate ventilation, that they're deep breathing, coughing, using incentive spirometer, turning every two hours when they're not ambulating, but ambulate as much as possible. Another reason for some GU surgeries is bladder cancer. And smokers are at least three times as likely to get bladder cancer as non-smokers. And that's according to the American Cancer Society. I've been told that you will get bladder cancer faster than you get lung cancer if you're a smoker. And the people that are vaping, they're going to get all kinds of cancers all over everywhere because the poisons are aerosolized, so they're much smaller, and so they can get right into the cells in all different levels. So just mark my words in a few years. We're going to have epidemics of all kinds of different cancers in those people. The study by the National Institute of Health found that 50 percent of all cases of bladder cancer are found in smokers. Former smokers are twice as likely to develop cancer as those who have never smoked current smokers are four times more likely. And a recently published analysis of 89 studies underscores these findings, and that was from 2018. So if we have bladder cancer, guess what, we're going to lose the bladder, and that's going to change your life. So occasionally there is a bladder tumor that they are able to resect and maintain the bladder as is, however, that just depends on how quickly it's been caught. So let's talk about removing the bladder, and that's going to lead to urinary diversions. So that's what we're going to talk about first. So urinary diversions, reasons for doing that, is going to be from bladder cancer or other pelvic malignancies, so any kind of tumor that goes into the bladder, birth defects, trauma, strictures, neurogenic bladder, which means that the bladder just kind of stops relaxing and contracting. It just kind of stops working neurologically. It's dead. There could be a chronic infection or intractable cystitis. That means that the bladder is just chronically infected and we can't stop it. So these may also be used as a last resort for incontinence. You're going to have cutaneous urinary diversions, iliocondoid, cutaneous ureterostomy, a vesic constomy, nephrostomy. We're going to talk about all of those, and then we can have continent urinary diversions, which would be the Indiana pouch, cockpouch, main pouch, some different pouches. We'll talk about that a little bit. And then there used to be something called ureterosigmoidostomy, and I crossed that out here on the slide because they're not using that anymore. I want you to just take some time and think about why, and we'll talk about that in class. Let's see what your ideas are for that. So first of all, we're going to talk about cutaneous urinary diversions. So cutaneous means it's coming through the skin. So the first one is an iliocondoid. And a conduit is something, a channel for something to go through in this case urine. So iliol, where do you think that comes from, is the ilium. So they take a piece of the ilium and they make a conduit. So they take a piece of the ilium, it's still connected to the blood supply and the nerves, and it's going to be, it's going to have the ureters hooked into it, and then they make an ostomy. So it's just like the other ostomies that we talked about in GI, they make an ostomy out of the ilium, and the ureters are feeding through that. And so it's going to be constantly putting out urine. So they need to wear a bag. So this is an inconsolate device, so they need to wear a bag because that's going to be constantly making urine, so they have to have a bag on that. The next one is a cutaneous ureter ostomy. This would mean that the ureters are actually coming out through the skin, one or both of them is coming out through the abdominal wall. And that's going to be a very tiny stoma because the ureter is very tiny. This is not commonly done in adults. This is something that they may do as children, and it's usually temporary. So you don't normally see this in adults. They could also have a ureter o ureter ostomy, which means one ureter feeds into the other, and then that one comes out through the skin, or they can have two. They can have both coming out through the skin. So again, not so common in adults. So that's the ostomy, we've got the bladder, sorry, the bladder is sutured to the abdominal wall, and then there's an opening, a stoma through the abdominal wall, right directly from the bladder. So the stoma is made from the bladder tissue, and then it's just leaking out right there. So again, inconsolate and needing a bag. And then the last one here is enough rostomy, and that means it's a tube coming right out of the nephro, the kidney. So there's a catheter going into the renal pelvis, and there's a tube coming out the back. So that's a nephrostomy tube. Again, also inconsolate. You can't control your kidneys output. So all of these are going to require a bag on them. And then we have the continent diversions, urinary diversions. So anything that says pouch, I'm just going to talk about it as similar, okay? Port names, Indiana, Coc, Maine, Florida. They have, it just depends on slight variations, but for our purposes, it doesn't matter. It's a pouch that becomes made out of the intestinal tissue. So they take pieces of the intestine, and they kind of ball it up and split open, and then sew it together, and they form a little pocket, a little pouch there. And then from the pouch, they have a stoma that comes out through the abdominal wall. And this is continent, they put a one-way valve in there. So it does not drain all the time. They have to put a catheter in about every four hours to drain the urine that fills up in there. So that's a good thing that these are continent. They don't have to wear the bag all of the time. Those problems with this, they can get pouchitis, they can get infection in the pouch. The drainage is also going to be mucusy, because the intestines make mucus. So it'll be common to see mucus in there, not to worry about that. In male patients, the cockpouch can be modified by attaching one end of the pouch to the urethra, as long as they have a working urethra, and then they can have more normal voiding. The female urethra is too short for this modification. Then there's the urethra sigmoid ostomy, and that is where the urethras are going into the sigmoid colon, allowing the urine flow to come out of the rectum. So again, we'll talk about why that's not such a good idea, but you can start thinking about it. So when we're talking about stomas, there's a few things we need to remember about stomas. The ostomy RN should pre-evaluate the patient and mark the best spot for an ostomy to avoid leaks to make pouching easier, so it should be above a big belly, not below it, avoid the fat rolls, any bumps, have the patient move, sit, stand, et cetera, so we want to see how it's going to affect their pouch if they have a bag attached to that. So make sure we're putting it in the right space. With urethlames, we want to empty them when they're a third full, because it gets heavy, and that's going to pull and that leads to leaking. They also are going to have a spigot, so it's going to be different than the colostomy bags, or really ostomy, where they have the velcro closure or the clamp, where it just kind of dumps out. This will have a spigot, so you can more gracefully empty the urine that way. Urant pH should be about five and a half or six, the more alkaline the urine, the worse it is for skin, so a higher pH is more detrimental to the skin. And so with the pouches and the ostomies, there's going to be a little bit of urine leaking onto the skin, right, because it's not going to be a perfect seal around that ostomy. So we want to protect patient's skin. There's a stoma paste that we use for colostomies or early ostomies. This is not for ure ostomies, because the urine will melt it, so that paste will not work for these. If we need to do a urine sample from an ostomy, how would we do that? So we would not take it out of the bag. We never take samples out of a bag or a hat or a urinal, or a fully, it's always infected, right? It's always colonized as soon as it is out of the body. So we want to clean the stoma with beta dine, get a sterile 14 French catheter, and put it in there. if they have a reservoir, like one of the pouches, then it should come out immediately. If they don't, you're gonna just have to wait. Your urine is always being made, just milliliter by milliliter, but you're gonna have to stick that catheter in there and wait, so just kind of chat. Make some small talk until the urine comes out. So normally our stoma similar to the GI stomas, we want it to be symmetrical. It'll protrude about one and a half centimeters. We want it to be beefy red and no skin break down around it. There are some complications of stomas similar to the GI ones. Another kind of diversion they can make is orthotopic bladder or neoblatter. So orthotopic, that means it's in the normal anatomic position. It's also made from the intestines, so it's similar, it's a pouch, but in this case they're gonna have the output via the urethra. So the patient is, that means that there's been no bladder neck or urethra involvement in the cancer. Remember they've taken this out because of bladder cancer most likely. But the bladder neck, the sphincture, the urethra are not involved. So they make this new pouch, this orthotopic bladder, and it's still, the urine can come out through the urethra. If they're male, they're able to do an AUS, which is an artificial urinary sphincter. Sometimes they can do that in men. And that's something where they have a cuff that they can inflate. So they'll put a little button in the scotum and the man can pump that or push on it and it'll inflate the cuff. And that inflation closes off, it acts as a sphincter. So then the urine is not draining. And then when you need to go, they push another button or squeeze it or whatever they do. However it's set up, they squeeze it, it releases the air that's in there. And it opens up the artificial sphincter and lets the urine flow. So they open it up to let the urine flow, then they pump it back up to close it to grip it basically to shut that off. So to do an orthotopic bladder and also really any of the pouches that are made out of the intestines, the patient should have no history of IBS or colon cancer or Crohn's or anything like that because if they have a problem with the intestine, what's to say it's not going to pop up in this new bladder or this pouch that we've just made. We've just done this $50,000 surgery and the patient's going through all this and then two months later they end up with Crohn's and their bladder. So they have to make sure that they have a good, clean, working intestinal system. We also want to make sure that they have at least a year or two of life expectancy or more, but we're not going to do this for somebody in hospice. Okay, they're just going to get a foley or a super pubic or something like that. This is not something that would be done for a short term. This is a long term solution and there's a better picture of the one of the topic bladder there you can take a look at. So one thing to know with urine, again, alkaline urine is bad. Drinking more water is going to be the best treatment. So for any kind of GU thing, drink water, that's going to be important to do. Alcaline urine leads to infection and how does it do that? Well, a number of ways, a number one, it leads to stones and then the stones are going to cause an infection and it's going to lead to urinary stasis. I mean, I'm sorry, an obstruction. Stones lead to obstruction, which leads to stasis, which leads to infection. Infection then leads to sepsis and sepsis can lead to death. Can somebody die from a UTI? Yes, just like I just said, okay? So alkaline urine is bad. (upbeat music) Moving into men's cells, we're going to talk about benign prostate, hyperplasia, BPH, testicular cancer and prostate cancer. So BPH is enlargement of the prostate gland and it results from the increase in the number of epithelial cells and stromal tissue. So the cause is not fully understood. It's likely thought to be endocrine changes associated with aging. Possibly the accumulation of dihydroxy testosterone, which is the principal inter-prostatic androgen. So it is the most common urologic problem in males greater than 50. I was lucky, I got it at 40. It does not predispose you to development of prostate cancer. The symptoms are categorized into two groups obstructive and irritative. So obstructive is meaning, there's an obstruction, something's in the way. So it leads to a decrease in the force of the stream, difficulty in starting, intermitency, and dribbling at the end. Irritative symptoms are more like inflammation or infection, frequency, urgency, dysuria, and incontinence. So the anatomy of the prostate, it is a walnut-sized gland that surrounds the male urethra. And BPH occurs in the inner portion. So there's excess growth in the inner portion which squeezes the urethra. This differs from prostate cancer and that prostate cancer occurs in the outer area. So it grows outwardly. So the urethra gets obstructed or squeezed, which leads to cause difficulty urinating. Urinary retention can occur and that can lead to infection. So several different symptoms here. So residual urine feeling like you're not completely emptying. The weak urine stream, sometimes it's like a dripping faucet, urgently having to urinate. Frequent urination at night, a lot of forces needed to kind of push it out and then also loss of libido. So some complications urinary obstruction, acute urinary retention, which can lead to UTI, stones, sepsis. So incomplete bladder emptying provides a medium for bacterial growth. So whenever you're not completely emptying, your bladder bacteria has a chance to grow and that puts you at risk for infection. The American Urologic Association AUA has a symptom index and that gives you a score that helps decide on treatment. So when a man comes in with this, with complaints of BPH, the urologist will give him this quiz kind of thing and it talks about how many times at night you get up to pee if you have difficulty starting, stopping, dribbling, frequency, all of the things I just mentioned. And then based on how he answers, they're gonna get a score and that's gonna decide on treatment. So do they need to do surgery? Can they manage it with meds, if meds, which kind? So that's how they're gonna figure out how to treat him. So some other complications, calculate can develop because the alkalization of residual urine, renal failure can happen because of hydronephrosis. So the distinction of the renal pelvis can happen because the prostate is so tight, the urine's not able to get out of the kidneys. Also bladder damage can occur. So we really just wanna get the urinal obviously, right? So diagnostics, we're gonna do a history and physical exam, a DRE digital rectal exam, urinalysis with culture and a PSA prostate specific antigen 'cause that'll help rule out anything else that might be going on. They'll do a serum creatinine and bun, which is gonna tell if there's any kidney issues. And then a cystoscopy is probably the most invasive and that would reveal enlargement of the gland and obstruction of urine flow. So that's where they're gonna take a cystoscope, put it in through the urethra and take a look at the interlobes of the prostate. So they're gonna do UA and they might find bacteria, white blood cells, red blood cells, microscopic hematuria can occur and that would mean that there's infection which would be prostateitis. So they wanna rule out as well, out, rule out out as well. The bun and creatinine that can rule out renal insufficiency in severe cases, they just wanna make sure that the kidney's not failing. So some nursing interventions, we're gonna administer antibiotics if it's an infection. Medication teaching, we're gonna get into the meds in a minute but there's a few things to know about those. Encourage fluids, so we wanna increase fluids again two to three thousand millimeters a day and encourage frequent voiding. So tell them to not store it up, but if you feel you gotta pee a little bit, go ahead and go. I've gotten into the habit of fine about to leave somewhere. I'm always just gonna go to the bathroom first because as I get in the car and sit there for a few minutes, I gotta go or when I'm out at a restaurant or a mall or something like that. So if I see a bathroom, I'm just gonna use it just to get it out. So frequent voids is gonna be important. So I'm nursing diagnoses, acute pain, risk for infection, fear about what's gonna happen. The first thing when somebody has something wrong with their prostate, the first thing they're gonna think about is prostate cancer. So they need to be told right away that BPH does not lead to prostate cancer. They're unrelated. There could be an effective therapeutic regimen management if they're not taking their medications correctly. Urge and continents is a thing and hemorrhage if there's massive bleeding in there. So let's talk about the medications. The first one is the five alpha reductase inhibitors and these are the steroids. Not steroids, steroids 'cause that's what the medications names end with. They do shrink the inflammation. So, I'm gonna go ahead and take a look at them. We have finasteride, dutasteride, et cetera. They decrease the size of the prostate gland. Takes about three to six months to feel improvement. And how it does that is it suppresses the androgens. So it decreases the hormones that are available for the prostate, which relates to it shrinking up. And these are only about 50% effective. Side effects, they have decreased libido, decreased volume of ejaculation, and erectile dysfunction, and hair growth. And you may recognize finasteride by its other brand name is Propecia. So when this medication first started going into studies probably 20 years ago or so, men that were taking it found that they started to grow their hair back. And the evil pharmaceutical companies being what they are realized that they could make billions of dollars more in marketing it in a vanity drug as a hair growth medication. So it's the exact same medication, finasteride. It's a bit of a lower dose when they take it as Propecia than Proscar. And that's how they can get their hair back. An important note is that pregnant women should not handle this medication. So sometimes when you get the pull the card out of the pixels, you know, with the 10 pills, I've seen it where each one of them has a stick around it. This is a caution and do not handle it pregnant. So that's a little scary, I think. Just make you wonder what exactly is going on in there. But because of the suppressing of the androgens, I can mess up a pregnant woman's hormones. So that's why. The next we have the alpha adjunergic receptor blockers. And the examples of this would be Tamsulocin, Doxazocin. So these are the zoosens. And these promote smooth muscle relaxation in the prostate and it facilitates urinary flow. You'll see improvement in this in a couple of weeks. These are the most commonly prescribed medications for moderate symptoms. And according to a Harvard study, they're about 70% effective. They provide symptom relief, but they don't actually treat hyperplasia. And side effects there, orthostatic hypotension. These, they relax smooth muscle. And what are the blood vessels? Smooth muscles. So it expands the blood vessels leading to hypotension and orthostatic hypotension. You know, that can be dangerous for falls. So that and dizziness. I was on this for a time. And every time I stood up, I was just dizzy. Because my BP's kind of low anyway. So that was not something good to be on. And then retrograde ejaculation, which is also no fun. That's where it goes. It backs up and backs up into the bladder rather than coming out. And it does not feel good. Then we have low dose to dalafil, and that's siallus. So that was previously marketed as the weekend sex pill, like Vagra, the weekend Vagra, more or less. It had a longer half life. This is a smaller dose. And it's the chemical part of it is kind of complicated here. Don't worry about it too much. But CGMP increases the flow of blood to the penis. But PDE5 breaks down CGMP. So siallus targets that PDE5, which then means that there's more CGMP in the bladder and prostate to increase blood flow. So the muscle is relaxed and the urine's able to flow freely. And this leads to improvement in about a month. We don't want to take this with nitrates or alpha blockers can cause dangerous drops in blood pressure. So after we've tried all the medications and he's still not getting good symptom relief, then they might move towards surgery. And TURP is the big one here. Transurethral resection of the prostate. So they remove the prosthetic tissue through the urethra. So again, they put a cystoscope in there. And then again, that's a conduit. So they can put a lot of tools in there. They'll put a loop bove in there. And they just kind of slide it across the inside. I'll show you a video in class. And it just slides around the inside and hollows out the prostate, basically. So it is destroying the urethra that passes through that part. But as it scars up the area that they burned and cut, as that scars that basically forms a new urethra. More or less, the outcome is excellent for 80 to 90% of men. It has very low risks. It can be performed under spinal or general. Requires an overnight hospital stay. And then the man will have bladder irrigation for the first 24 hours. So they call that CBI Continuous Bladder Irrigation. And that's to prevent mucus and blood clots clogging it up. So we'll talk about that more in class. But it's some large bags of saline. And they're going to run into the bladder and then out of. So it's a three-way catheter. That'll be a lot easier to talk about when I can draw it. But the point is to keep the clots from forming. So just to kind of keep the blood flowing freely, because there will be some blood in there. We want to chart the color of the drainage in there. It's going to be kind of dark red at first, because it's a lot of blood that's going to be coming out. But we want it to lighten up. It should be kind of light pink within 24 hours. It's nice when they have a urine-colored chart of some sort to where when the nurses assess it, they can say, it's number three, pink, number four red, whatever. Because rather than that, if they don't have something like that, then they're going to say, it's like cherry-cooled, or it's like pink lemonade, or rosé. And that's kind of subjective and not really that helpful. It's better to have concrete numbers on what the color is. So some complications of a turb, they can have a lot of bleeding. So we do expect bleeding, but like I said, we want that to clear up within a day. They could retain a clot. So if you've got the CBI running and the man starts complaining of bladder distension and feeling like he's really got to go, you want to check that line and see if there's a clot in there. And if there is, then you can use a piston syringe and kind of force it kind of piston it in and out and force that clot through. And then you'll see the clot come out, and then all kinds of water will come out. The important thing here is to monitor the true urine, because everything that comes out in that bag is not urine. Most of it, the greater portion of it, is the saline that's going in. So there's a 3,000 ml bag of saline going into the bladder, and then your fully drainage bag at the bottom coming out. So you subtract what went in from what comes out, and the difference from that's going to be the urine. They can also get dilutional hyponotremia, because if they're putting in, if they're using water for irrigation, that's going to mess up your sodium balance. That could be bad. And then a long term effect of the turp would be retrograde ejaculation all the time, and that would be unfortunate. So our goal is clear urine in about two days. They may also be given antispasmodics, which would be B&O supositories, that's Belodona and Opium. So it's a supository, it goes right in there to the area that's being affected. And also teaching kegolic exercises will help them to get a little bit of better control more quickly. So after surgery, after the turp, we're going to observe the patient for signs of infection. Dietary intervention, we need to decrease caffeine products. Why? Because caffeine is a diuretic. And they're already having issues with urinary retention. So this is something that we should do for anybody with BPH, really, is decrease caffeine, tell you what's I did that that made a world of difference. But after surgery, they need school softeners to prevent straining. Again, the surgery's kind of in that area. So anything that's going to cause pressure there is not going to be good. We don't want them to sit for prolonged periods of time because same thing, the pressure on the perinium avoid heavy lifting and avoid rectal temperatures. Then we're going to keep taking a look at their labs for the first couple of days, looking at their H&H because of the bleeding that we do expect to the beginning of surgery. Next is testicular cancer. And this is the most common cancer in men ages 15 to 40. So you may see different numbers, different places. It might say 15 to 35 or 18 to 40 or something like that. But basically, it's a young man's disease. And I don't know about you guys, but a lot of men or not young men are not educated about it. This is something that should really be a priority in junior high or high school. But of course, those boys are not going to be mature enough to hear this information without giggling. But when it's found, it's highly treatable and curable. Sometimes they remove the testicle. Other times, they may be able to actually just remove the tumor. And they can save the testicle in preserved men's fertility. But because boys are not taught to do the self checks, like women, everyone knows to do the breast checks. And I'm sure teenage girls start figuring that out as well. But teenage boys are never told this or if they are, they don't take it seriously. And then they end up with prostate cancer. My neurologist said he works at the marine base. And he said that about 1/3 of his practices were removing testicles from these guys. So that's the age group. You know, he's got the young 18 to 25 range. So if they had found him sooner, they may have been able to save them. So some risk factors, undescended testicles were younger, positive family history, cancer of one testicle, and being Caucasian. I had a former student who had his dad had a testicular cancer. I'm not sure if that's what he died of, but I know he was dead. and then John, the student had it. one testicle when he was about 18 and then he was almost out of the window, he was getting his checks, he was doing his checks and then getting clinical exams every year and he was just out of the window, he was about 35 and he ended up getting it in his other one. So he's had to have both testicles removed. The manifestations will have a painless lump or mass in the test season so that's why it's important to to feel them and get to know them just like with women's breasts, get to know the bumps and lumps and you know what's normal and what's not normal so that when something changes you can recognize that. There's also a 70% greater chance of developing testicular cancer if you're a regular marijuana user and 95% of patients with testicular cancer are alive after five years. So it's got really good survival rates. So early diagnosis is very important in your monthly testicular self-exam or TSE and an annual clinical testicular exam. The treatment is basically going to be an orchidectomy so that's removing the testicle. They may do a retroperitoneal lymph node dissection which is where they're going to take out the lymph nodes in that area and this could be done open or laparoscopically and then follow it up by radiation or chemotherapy. They also can put in prosthetics if somebody has a testicle removed but they still want it to look and feel normal, they can put in a little silicone prosthetics and they're weighted similarly. And then next we have prostate cancer. So you'll see different numbers, different you know books or statistics but you might see that it's one in five, six, seven men will be diagnosed with prostate cancer so somewhere around there it's pretty common. About one in 38 men will die from it. Average age diagnosis is 66 so this is the most common cancer in men aside from skin cancer and the second leading cause of cancer death in men next to lung cancer. Most cases develop in men that are over 65 and many men die with prostate cancer not from it. It is generally a slow growing cancer and so consequently the treatment of choice when in it with initial diagnosis is what they call watchful waiting so they're just going to keep coming back and having the exams because they don't want to rush to take it out necessarily. So it is an androgen dependent, add no carcinoma and as I said it is slow growing. So when prostate cancer spreads it can be spread by three routes direct extension through the lymphatic system or through the bloodstream. So direct extension that's going to go to the seminal vesicles the urethra the bladder and the external sphincter. Cancer later can spread through the lymphatic system to the regional lymph nodes and that way or through the blood it can really go anywhere. The veins from the prostate seem to be the motor spread towards the pelvic area so the pelvic bones the head of the femur the lower lumbar spine and then also the liver and lungs. So when somebody has pain in the lumbar lumbosacral area that radiates down to the hips of the legs coupled with urinary symptoms that may indicate that they have prostate cancer and it is metastasized. If someone has been diagnosed with prostate cancer in the past even if they've had surgery even if they've had the prostatectomy and then they end up having these pelvic low back symptoms there's a good chance that it's metastasized there. So a high fat diet is associated with increased risks just like with a lot of a lot of the GI cancers high fat high meat. There's also an exposure to certain chemicals that can increase the risk and it's important to note again history of BPH is not a risk factor. So it's usually asymptomatic in the early stages and eventually the mental experience symptoms similar to BPH. So the painful urination frequent urination at night, blood in the urine, sexual dysfunction, pelvic pain, hesitancy, dribbling all of that stuff. So the symptoms are very similar. So that's why when somebody first comes in reporting of those symptoms the first thing we want to do is rule out prostate cancer because that obviously is the more serious of the two. So the symptoms are similar. The two primary screening tools they can do a PSA and a DRE. So the PSA is the prostate specific antigen. It's a blood test and it should be zero to four. Anything greater than four should be biopsy. However this is becoming even less and less reliable because they're realizing that other things can elevate it. BPH, prostateitis can elevate it greatly. I can vouch for that. It can also be raised by other things like high PTH. Oh, that's the pap, sorry, come back to that. So it can be elevated by, the PSA can be elevated. There are two primary screening tools, the PSA and the DRE and then they may also do the PAP, prosthetic acid phosphatase. So the PSA first prostate specific antigen that should be zero to four. This is a blood test and anything greater than four should be biopsy. However, it's becoming less and less reliable. They're realizing because BPH or prosthetitis can also elevate it. And I'll tell you a couple stories about my experience with that. So the prosthetic pathology is what it indicates. So it's not necessarily cancer. However, when a tumor has been verified through a biopsy, then it's used as a tumor marker. So that means they're going to treat your cancer and they'll check your PSA and then as it goes up or down, that can tell you if the pathology is getting better or worse. So it monitors the success of the treatment, whatever treatment they're doing. The other diagnostic is the DRE, digital rectal exam, and that's just like it sounds. And they can feel hard, nodular and asymmetric prostate. So with BPH, when they do that, the prostate is described as soft or boggy. So it's kind of larger and swollen, but it's bouncy and soft. And so it becomes hard nodular when it's cancer. And then PAP, prosthetic acid phosphatase, this can also indicate prostate cancer. However, it's also not that reliable. It can be elevated by other things, like a high level of PTH, Pegee's disease, which is a bone recycling problem, leads to your bones getting brittle, certain medications, and sickle cell disease. So neither a PSA or a DRE is a definitive diagnostic test. They need to do a biopsy. And so this is where people can get on what they call the PSA Mary go round. And that's where they get a high PSA score, kind of panics, been out for a few days. They go through the process of getting a biopsy, which is not fun. And then they say it's fine. It's elevated by something else. So then they relax and they go on about life. And then a couple of years later, they get another test with their blood work and it ends up being high again. Well, they're not going to just ignore it and say, well, it was fine last time. It's probably fine this time, or maybe they will, but they shouldn't. So if they don't say that, they're going to say, yeah, let's biopsy it again. So then they biopsy again. It finds that it's fine. And so then they're just on this cycle. And it can be very frustrating. And it toys with your emotions. It makes you very nervous and upset. My brother is currently going through that right now. So once they do a biopsy and they confirm it, they use the Whitmore duet scale and the tumor node metastasis or TNM system. And that stages the prostate cancer. They're also going to grade the tumor using the Gleason scale. So tumors are graded from one to five and score one. They're well differentiated. The cells are very different. And then five, they're undifferentiated. And there's a little picture of chart there that you can look at to understand that and make sure you look through that and maybe talk about it in your study groups. So they do the biopsy and then commonly they do active surveillance or watchful waiting. And that's where they're just going to have you come back in in the year or six months and they'll do another test on it. They can also do radiation therapy. Two different ways of doing this brachytherapy is where they actually implant radioactive seeds into the prostate. And these can be radioactive gold or some other kind of metal. And they inject them through the perinium with a long needle. So they load the seed up into this little needle shooter kind of thing. Stick the needle in directly into the prostate and then they release the seed. And they'll do that dozens of time, several dozen seeds all at once. So that's going to be several dozen needle pokes in your perinium. So that's not fun. And then they just let off radiation. So caution with that. You don't want to hold babies or small pets in your lap because your crotch is radioactive. And then teletherapy is what we think of as typical cancer radiation. That's where you're on the table when they shoot the beam of radiation torches. So that causes the prosthetic epithelium cells to die. And they're going to have to go for six to eight weeks, probably five days a week. And they're just on the table for like 15 minutes and they just shoot radiation at your groin. And then there's hormonal therapy, which is where they can do androgen blocking agents or they can even do an orchidectomy where they remove the testicles, which will remove the antigens. And then there is surgical therapy. So that would mean removing the prostate. So radical prosthetectomy is the first thing. When we see radical, that just means everything. So everything in the area. So the entire prostate gland, the seminal vesicles, and part of the bladder neck are going to be removed. They'll do a retroperennial lymph node dissection, and that's to take out the lymph nodes in the area, and they'll check them and see if they are positive for cancer or not. If not, they're all good. If they are, that means then there's risk of having spread through the lymphatic system. So radical prosthetectomy is the most effective strategy for long-term survival. And it is the preferred treatment for men that are less than 70 and have relatively good health, and cancer is confined to the prostate. The patient is going to be catheterized for a week to two with a leg bag, because they've taken out the prostate. They can't really separate it from the urethro, so they've probably taken out part of the urethra and then attached it back together. So they're going to not want urine to go directly through that for a while, so they're going to have to have a fully for a while. Major complications would be erectile dysfunction and incontinence, because there's a lot of important nerves in that area that control those things. And so there wouldn't be surprising to to nick those or cut those. Using the Da Vinci robot has greatly helped this, and most men that are younger are going to opt for that option, because it's microsurgery. They can be a lot more precise and careful, and not get those nerves that are so important. So with the radical prosthetectomy, there are three different approaches. They can go retro pubic, perennial, and super pubic. There's pictures of that in the slide, pretty self-explanatory. One goes through the bladder, and the other goes around it. So the top one, the retro pubic, goes around the anterior prostate capsule, and the bottom one, the super pubic, goes through the anterior bladder wall. So complications of radical prosthetectomy, hemorrhage is always a risk, urinary retention could happen initially afterwards, that should resolve. And then infection, there's a high risk for infection due to the incision location, especially if they do the perennial incision. So bowel movements can get up into the wound there. So very careful cleaning after each bowel movement is going to be important, and careful dressing changes as well. They also could have wound dehycens, VTE, pulmonary embolite, all the basics that we've talked about at nauseam here. What we can do to prevent wound dehycens is have them not sit for long periods of time. So they should be up walking around or lying down if they sit, that puts pressure in that area, and that's going to lead to a risk of dehycens. So the nerve sparing procedure, that's the divinciano saying spares the nerve responsible for erection. This is only if cancer is confined to the prostate. There's never a guarantee that potency will be maintained. The drug treatment, belladonna and opium suppositories, the B&O suppositories, that's a narcotic analgesic and anti-spasmotic agent. So we want to monitor preside effects, same as any narcotic, and B&O suppositories also contain atropine. So think about what we want to monitor for that. You can tell them they'll probably have dry mouth, but the more important thing would be dysrhythmias. I have a familial risk, my grandfather, father, and brother all have prostate cancer. So I know that puts me at risk. And I've known a lot of men who have suffered from prostate cancer, three of my friends, dads have died from it. So every November, I sport a ridiculous mustache of some sort and raise money through the November foundation. And my link is there to my fundraising website if you want to share that with anybody. And I encourage you guys to do that too. And not just for men, you can be a mow bro or a mowsis. So the women can raise money for it as well. So just go to www.movember.com if you want more information about that.