05/12/2013. Philippa Aslet Senior Urology Nurse Specialist Hampshire Hospitals Foundation Trust

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1 Philippa Aslet Senior Urology Nurse Specialist Hampshire Hospitals Foundation Trust Role of the Nurse Specialist Side Effects of Hormone manipulation Effects on Bone Health Catheter Management Nurses play an integral part in the Multiprofessional Team. Improved patient outcomes if CNS involved Prostate now No2 in the number of CNSs. Roles and responsibilities vary hugely across the country. Work as part of the team. Over stretched NHS. Increasing referrals Increasing areas of advanced practice Seeing New and Follow up patients LUTS clinics ED clinics Diagnostic Prostate biopsies Transrectal and Transperineal. 1

2 Patient advocate Point of contact for patient and family Resource for the wider team. Advice, information and support. The most common site of distant metastasis is the bones such as spine, pelvis, femur and ribs. Most common symptom is bone pain. Occurs in % with advanced disease. Easy access when problems arise 2

3 Metastatic at presentation - five-year relative survival is lower at around 30%. Cancer research uk The aim is for Quality as well as increasing Quantity Urinary Symptoms and continence Hot Flushes Gynacomastia Decreased Libido Erectile Dysfunction Lethargy Cognitive decline Mood changes Osteoporosis Weight gain Loss of muscle mass Asses LUTS Pharmacotherapy Conservative measures Manage incontinence Containment devices Refer as appropriate for surgical intervention Catheter should not be the easy option Intermittent catheterisation. Stop smoking Reduce caffeine and alcohol intake Reduce spicy food intake Cool room, fan etc Cotton clothes and sheets 3

4 Cyproterone acetate for up to 6 weeks Antidepressants Acupuncture Complimentary therapies Oil of primrose Sage tea Red clover Occurs in around 50% of patients on antiandrogen Breast bud radiotherapy Tamoxifen Surgery Exclude other causes eg anaemia May improve with time Some exercise can increase energy levels Counselling Refer to secondary care if symptoms unmanagble Regular resistance exercise such as swimming Diet Macmillan dietician Reduced muscle and increase in body fat can affect body image of the patient. Support and information. 4

5 Yearly bone loss, % Fracture risk 05/12/2013 Androgen deprivation (ADT) is associated with Osteoporosis and Bone fragility. DEXA scans at diagnosis and 2 yearly thereafter if found to have osteoporosis (EAU guidelines). Bone Metastases - Osteoblasts and osteoclasts are both pathologically activated in the setting of prostate cancer bone metastases Normal men Postmenopausal women 12 ADT Osteoporosis Osteopenia BMD T-score, SD units 5

6 Pathologic fractures increase risk of death by 29% Risk increase 29% P value Hazard ratio (patients ) Resistance training improves Muscle strength, functional performance and balance. Gentle regular exercise reduces cancer related fatigue especially when delivered as a formal programme Payne H etal 2011 Decreased mortality Increased mortality 14. Saad et al. (2007) Good evidence that health eating and Exercise can delay the rate of disease progression. Delay the time to needing hormone treatment 2 hours exercise reduced the risk of PSA relapse 5 hours exercise a week can reduce the risk of death from Prostate cancer. Smoking Cessation Reduce alcohol intake Healthy BMI Diet sufficient in Vit D and Calcium. If not supplement Ornishd etal J urol, 2005 Thomas R et al Nutri food science 2007 Kenfield S etal J Clin Onc

7 Psychological issues Skeletal related events: Bone pain Pathologic fracture Spinal cord compression Vertebral collapse Hypercalcaemia of malignancy Anaemia Useful for pain relief from bone deposits Reduce and delay skeletal complications No survival benefit Denosumab Human monoclonal antibody. Inhibitory effect on osteoclast mediated bone destruction. More effective than Zolondronic acid to prevent skeletal complications. No survival benefit. Risk factors for spinal cord compression in men with metastatic prostate cancer are extensive Bone metastasis Duration of hormonal therapy Back pain (Bayley et al. 2001; Venkitaraman et al 2007), 7

8 Costly to the Patient Effect on Quality of Life Earlier Mortality Often multiple SREs Costly to the NHS 2000 per SRE (Botteman 2006) Think Prevention Auguste Nelaton French Physician and Surgeon. Born in Paris Invented the Nelaton catheter. Tubing made of vulcanised rubber. Encrustation Bladder spasm Balloon Deflation Pain and Trauma Balloon Cuffing Frederick Foley Developed the rubber balloon catheter in

9 Caused by colonisation of urine by bacteria Proteus, Staph Aureus, Pseudomonas, Klebsiella. Produce Urease-splits urea produces ammonia Bacteria adhere to catheter form biofilm Urine Ph raised- alkaline enviroment Attracts calcium + magnesium ions Crystallization occurs Manipulate urine acidity Bladder washouts Catheter maintenance solutions Specialist catheters Pain Bypassing Blockage May occur due to neurological conditions these may predispose the patient to bladder spasm. Patients with previous urgency and frequency may have irritable bladders. Catheter itself may irritate the bladder. 9

10 Bladder spasm occurs when the bladder mucosa becomes clamped around the catheter and the eyes are occluded. Solutions- Anticholinergics, Change type/size of catheter Use catheter valve. Pain and discomfort Cramping similar to dysmenorrhoea Simple analgesia Too large a catheter-can block paraurethral glands causing urethritis Urethral Pressure ulcers- anchor catheter Erosion and fistulae Malignancy Failure to deflate balloon due to calcification in the channel Solution- only use water to inflate balloon. Manufactured to be deflated only once Damaged inflation channel. Would you cut the inflation channel if it failed to deflate? 10

11 Catheter Valve Intermittent Catheterisation Sheaths Pads Use narrowest gauge catheter possible Change catheter in presence of infection. Look for alternatives to a long term catheter. Fluids and Lemon juice Treat colonised urine Don t increase the size of catheter or balloon if bypassing. Dont t see a catheter as an easy solution Do s Don t 11

12 Klebsiella Proteus Pseudomonas Staph aureus 12