LBM 6 SGD 7 UG

Step 1
Straining: the difficulty of starting miction
with stressing first,somebody have more
power to start miction
Terminal dribbling: there is some urine after
the end of miction
Nocturia: miction at night more than 3-4
times

STEP 2
1.
Why he was complain to the doctor
that he couldnt urinate since this
morning?
2.
Why he had a weak strain whenever
he urinate?
3.
Why the doctor have came with
conclusion that there was straining,
terminal dribbling, frequent, nocturia, and
suprapubic mass?

4.
Why the doctor decided to do
catheterization and RT?
5.
Are there correlation between age and
gender with patients problem?
6.
What are the clinical finding of RT?
7.
DD

STEP 3
1.
Why he was complain to the doctor
that he couldnt urinate since this
morning?
Greater prostate can narrow lane that urinary tract urination will be more
difficult to do. Urine if not immediately removed will accumulate in the
bladder so it will be a breeding nest of bacteria which ended in inflammation
of the prostate.
(http://organisasi.org/gangguan-penyakit-radang-pembesaran-prostatdefinisi-penyebab-ciri-dan-pencegahan-gangguan)

2.
Why he had a weak strain whenever
he urinate?

In accordance with the increased obstruction caused by an enlarged prostate

gland - destrusor held a compensation of muscle thickening in the bladder
wall - to hold a stronger contraction - as difficult urination - so that the client
should be straining if it will release urine - urine out menetets further and
emit weak. (Mansjoer Arif tahun 2000)

3.
Why the doctor have came with
conclusion that there was terminal

dribbling, frequent, nocturia, and

suprapubic mass?
symptoms of enlarged prostate is usually expressed as the urine is not
smooth, urine should straining, incomplete urination (still dripping after
urination), dissatisfaction after urinating as much residual urine in the
bladder. These symptoms indicate a blockage in the urinary tract.
Blockage of the disease caused by an enlarged prostate enlarged prostate
gland pressure against the urethra. Prostate enlargement usually occurs
slowly so that the symptoms of blockage also become worse gradually.
Blockages caused by an enlarged prostate disease to severe urinary tract can
cause the patient can not urinate at all. This is known in medical terms as
"urinary retention". If this happens, the urine will accumulate in the bladder
so that the patient will feel desperate to pee but no urine comes out. The
more water that accumulates the urinary bladder will be enlarged (stretched)
that feel pain in the lower abdomen. Sometimes patients feel a bloated
stomach is actually happening due to bladder pressure is growing.
(http://annurhospital.com/web/index.php?
option=com_content&view=article&id=113&Itemid=127)

Terminal dribbling: Clinical features on prostate hyperplasia symptoms are classified as

two signs of obstruction and irritation. Symptoms of obstruction due to detrusor fails to
contract with a long and strong so result: the emission of micturition weakened,
dissatisfaction after micturition, micturition if you want to wait a long time (hesitancy),
must strain (straining), intermittent urination (intermittency), and time micturition
became elongated and incontinence of urine retained because of overflow.
Symptoms of irritation, discharge occurred because an imperfect or an enlarged
prostate will stimulate the bladder, so often, although not the full contract or be
regarded as hipersenitivitasotot detrusor with signs and symptoms include: frequent
micturition (frequency), awoke to micturition at night (nocturia) , that feeling of
wanting micturition urgency (urgency), and pain during micturition (dysuria).
(Mansjoer,2000)

4.
Why the doctor decided to do
catheterization and RT?
5.
Are there correlation between age and
gender with patients problem?
Cause prostate hyperplasia is not known with certainty, there are some
opinions and facts that show, it comes and complicated process of androgen
and estrogen. Dehidrotestosteron coming and with the help of testosterone

5-reductase enzyme thought to be the main mediator of prostate growth.

Prostate cells are found in the cytoplasm of the receptor for
dehidrotestosteron (DHT). This receptor number will increase with the help of
estrogen. DHT formed would then bind to the receptor to form DHT-receptor
complex. Then enter the cell nucleus and influence RNA to cause protein
synthesis resulting in cell protiferasi. The notion that as the basis for the
impaired balance of androgens and estrogens, with age it is known
that the amount of androgen is reduced resulting in elevated
estrogen retatif. Known estrogen affects prostate inner (middle,
lateral lobe and medial lobes) to the hiperestrinisme, this is the part
that had hyperplasia. (Hardjowidjoto, 2000)

6.
What are the clinical finding of RT?
7.
DD
ENLARGEMENT PROSTAT
BPH
Definition: Benign prostatic hyperplasia (BPH) is a non-cancerous
condition that affects a substantial number of men as they age, in
which the enlarged prostate squeezes or partially blocks the
surrounding urethra the tube that carries the urine from the bladder
out of the body. (ucla.edu)
Etiology: The cause of BPH is not well understood. No definite
information on risk factors exists. For centuries, it has been known that
BPH occurs mainly in older men and that it doesn't develop in men
whose testes were removed before puberty. For this reason, some
researchers believe that factors related to aging and the testes may
spur the development of BPH. Throughout their lives, men produce
both testosterone, an important male hormone, and small amounts of
estrogen, a female hormone. As men age, the amount of active
testosterone in the blood decreases, leaving a higher proportion of
estrogen. Studies done on animals have suggested that BPH may occur
because the higher amount of estrogen within the gland increases the
activity of substances that promote cell growth. Another theory focuses
on dihydrotestosterone (DHT), a substance derived from testosterone
in the prostate, which may help control its growth. Most animals lose
their ability to produce DHT as they age. However, some research has
indicated that even with a drop in the blood's testosterone level, older
men continue to produce and accumulate high levels of DHT in the
prostate. This accumulation of DHT may encourage the growth of cells.
Scientists have also noted that men who do not produce DHT do not

develop BPH. Some researchers suggest that BPH may develop as a

result of "instructions" given to cells early in life. According to this
theory, BPH occurs because cells in one section of the gland follow
these instructions and "reawaken" later in life. These "reawakened"
cells then deliver signals to other cells in the gland, instructing them to
grow or making them more sensitive to hormones that influence
growth. (http://kidney.niddk.nih.gov)
Patogenesis:
Patofisiology: Prostatic enlargement depends on the potent androgen
dihydrotestosterone (DHT). In the prostate gland, type II 5-alpha-reductase
metabolizes circulating testosterone into DHT, which works locally, not
systemically. DHT binds to androgen receptors in the cell nuclei, potentially
resulting in BPH. In vitro studies have shown that large numbers of alpha-1adrenergic receptors are located in the smooth muscle of the stroma and
capsule of the prostate, as well as in the bladder neck. Stimulation of these
receptors causes an increase in smooth-muscle tone, which can worsen LUTS.
Conversely, blockade of these receptors can reversibly relax these muscles,
with subsequent relief of LUTS.

The traditional theory behind BPH is that, as the prostate enlarges, the
surrounding capsule prevents it from radially expanding, potentially
resulting in urethral compression. However, obstruction-induced
bladder dysfunction contributes significantly to LUTS. The bladder wall
becomes thickened, trabeculated, and irritable when it is forced to
hypertrophy and increase its own contractile force. This increased
sensitivity (detrusor overactivity [DO]), even with small volumes of
urine in the bladder, is believed to contribute to urinary frequency and
LUTS. The bladder may gradually weaken and lose the ability to empty
completely, leading to increased residual urine volume and, possibly,
acute or chronic urinary retention.
(http://emedicine.medscape.com)
Clinical Appreance: This can lead to bothersome urinary symptoms that
may include a weak stream, trouble starting and stopping, the frequent
feeling of needing to urinate, greater urgency when the feeling hits, leaking
or dribbling, and the sense that the bladder isnt empty after urination. These
symptoms should not be ignored, particularly since there are many good
treatment options. (ucla.edu)

Many symptoms of BPH stem from obstruction of the urethra and

gradual loss of bladder function, which results in incomplete emptying
of the bladder. The symptoms of BPH vary, but the most common ones
involve changes or problems with urination, such as a hesitant,
interrupted, weak stream, urgency and leaking or dribbling, more
frequent urination, especially at night. The size of the prostate does

not always determine how severe the obstruction or the symptoms will
be. Some men with greatly enlarged glands have little obstruction and
few symptoms while others, whose glands are less enlarged, have
more blockage and greater problems. Sometimes a man may not know
he has any obstruction until he suddenly finds himself unable to
urinate at all. This condition, called acute urinary retention, may be
triggered by taking over-the-counter cold or allergy medicines. Such
medicines contain a decongestant drug, known as a sympathomimetic.
A potential side effect of this drug may prevent the bladder opening
from relaxing and allowing urine to empty. When partial obstruction is
present, urinary retention also can be brought on by alcohol, cold
temperatures,
or
a
long
period
of
immobility.
(http://kidney.niddk.nih.gov)
Diagnose: You may first notice symptoms of BPH yourself, or your
doctor may find that your prostate is enlarged during a routine
checkup. When BPH is suspected, you may be referred to a urologist, a
doctor who specializes in problems of the urinary tract and the male
reproductive system. Several tests help the doctor identify the problem
and decide whether surgery is needed. The tests vary from patient to
patient, but the following are the most common.
Digital Rectal Examination (DRE)
This examination is usually the first test done. The doctor inserts a
gloved finger into the rectum and feels the part of the prostate next to
the rectum. This examination gives the doctor a general idea of the
size and condition of the gland.
Prostate-Specific Antigen (PSA) Blood Test
To rule out cancer as a cause of urinary symptoms, your doctor may
recommend a PSA blood test. PSA, a protein produced by prostate
cells, is frequently present at elevated levels in the blood of men who
have prostate cancer. The U.S. Food and Drug Administration (FDA) has
approved a PSA test for use in conjunction with a digital rectal
examination to help detect prostate cancer in men who are age 50 or
older and for monitoring men with prostate cancer after treatment.
However, much remains unknown about the interpretation of PSA
levels, the test's ability to discriminate cancer from benign prostate
conditions, and the best course of action following a finding of elevated
PSA.
Rectal Ultrasound and Prostate Biopsy
If there is a suspicion of prostate cancer, your doctor may recommend
a test with rectal ultrasound. In this procedure, a probe inserted in the
rectum directs sound waves at the prostate. The echo patterns of the

sound waves form an image of the prostate gland on a display screen.

To determine whether an abnormal-looking area is indeed a tumor, the
doctor can use the probe and the ultrasound images to guide a biopsy
needle to the suspected tumor. The needle collects a few pieces of
prostate tissue for examination with a microscope.
Urine Flow Study
Your doctor may ask you to urinate into a special device that measures
how quickly the urine is flowing. A reduced flow often suggests BPH.
Cystoscopy
In this examination, the doctor inserts a small tube through the
opening of the urethra in the penis. This procedure is done after a
solution numbs the inside of the penis so all sensation is lost. The tube,
called a cystoscope, contains a lens and a light system that help the
doctor see the inside of the urethra and the bladder. This test allows
the doctor to determine the size of the gland and identify the location
and degree of the obstruction. (http://kidney.niddk.nih.gov)
The diagnosis of benign prostatic hyperplasia (BPH) can often be
suggested on the basis of the history alone. Special attention to the
following features is essential to making the correct diagnosis:
Onset and duration of symptoms
General health issues (including sexual history)
Fitness for any possible surgical interventions
Severity of symptoms and how they are affecting quality of life
Medications
Previously attempted treatments
Symptoms often attributed to BPH can be caused by other disease
processes, and a history and physical examination are essential in
ruling out other etiologies of (lower urinary tract symptoms (LUTS) (see
Diagnostic Considerations).
When the prostate enlarges, it may act like a "clamp on a hose,"
constricting the flow of urine. Nerves within the prostate and bladder
may also play a role in causing the following common symptoms:
Urinary frequency - The need to urinate frequently during the day or
night (nocturia), usually voiding only small amounts of urine with each
episode
Urinary urgency - The sudden, urgent need to urinate, owing to the
sensation of imminent loss of urine without control
Hesitancy - Difficulty initiating the urinary stream; interrupted, weak
stream
Incomplete bladder emptying - The feeling of persistent residual
urine, regardless of the frequency of urination

Straining - The need strain or push (Valsalva maneuver) to initiate

and maintain urination in order to more fully evacuate the bladder
Decreased force of stream - The subjective loss of force of the
urinary stream over time
Dribbling - The loss of small amounts of urine due to a poor urinary
stream
(http://emedicine.medscape.com)
Treatment: No single prostate treatment is best for everyone. Much
depends on the symptoms and individual preferences. For minor symptoms,
certain lifestyle changes can help, including simple changes to limit
beverages consumed at night; lower alcohol and caffeine consumption;
reduce intake of diuretics, antihistamines and decongestants; and maintain
an active lifestyle. Medications can be very effective. These include drugs
that take aim at BPH symptoms so-called alpha blockers that relax the
bladder muscle to help improve urine flow (terazosin, or Hytrin; doxazosin, or
Cardura; tamsulosin, or Flomax; and alfuzosin, or Uroxatral); and those that
attack the problem directly by shrinking the prostate and slowing its rate of
growth, known as 5-alpha-reductase inhibitors (finasteride, or Proscar; and
dutasteride, or Avodart). While some patients experience side effects, they
are usually mild, occur immediately, and are reversible once the patient stops
taking the drug. For men with moderate symptoms who are looking for more
natural alternatives to BPH medications either because the drugs side
effects are intolerable or because they simply dont like the idea of being on
medication options such as herbal prostate treatments have become
more widespread. An estimated one-third of men with BPH have tried these
supplements, the most common of which are saw palmetto, pygeum
africanum, and beta-sitosterol. When used appropriately, herbal medicines
tend to have few side effects, and many men with mild symptoms have found
that they provide relief, either alone or in conjunction with FDA-approved
drugs. However, in the United States supplements do not undergo the same
rigorous testing and regulation as medications; as a result, the evidence on
their efficacy is less certain, and the contents of each product can vary
widely. Transurethral resection of the prostate (TURP) has long been the
mainstay of enlarged prostate surgery, but less invasive alternatives are
now available, with the potential for equal results. With TURP, the
obstructing portion of the enlarged prostate tissue is removed. Although
effective, TURP requires hospitalization and catheterization for 48 hours or
more and comes with risks associated with anesthesia; bleeding during and
after the operation; and, in rare cases, fluid absorption that can be lifethreatening. One alternative that has emerged is laser enlarged prostate
surgery. Like TURP, the so-called GreenLight PVP Laser Therapy aims to
create a channel in the urethra through which men can urinate more freely
but the surgery is considerably less invasive. Instead of cutting tissue out, the
newer technique creates the channel by vaporizing the tissue using laser

energy. Thus far, almost every study has shown that when done by
experienced urologists, the laser enlarged prostate surgery produces
results that are equal to those with TURP, but without the severe side effects
and risks. It is an outpatient procedure with minimal to no bleeding, no risk of
fluid absorption, and catheterization only overnight, if at all. An even less
invasive option, thermotherapy delivers microwave energy through a
catheter inserted into the bladder in an effort to shrink the inside of the
prostate. The office-based outpatient procedure takes an hour or less and
requires only mild sedation. The downside to the thermotherapy is that it
takes 6-8 weeks for the impact of the treatment to be realized, and although
the risks are relatively minimal, the results are not comparable to those of
TURP or laser surgery. (ucla.edu)

Complication: Complications related to bladder outlet obstruction

(BOO) secondary to BPH include the following:
Urinary retention
Renal insufficiency
Recurrent urinary tract infections
Gross hematuria
Bladder calculi
Renal failure or uremia (rare in current practice)
(http://emedicine.medscape.com)

CA PROSTAT
Local symptoms
In the pre-PSA era, patients with prostate cancer commonly presented
with local symptoms. Urinary retention developed in 20-25% of these
patients, back or leg pain developed in 20-40%, and hematuria
developed in 10-15%. Currently, with PSA screening, patients report
urinary frequency (38%), decreased urine stream (23%), urinary
urgency (10%), and hematuria (1.4%). However, none of these
symptoms is unique to prostate cancer; each can arise from various
other ailments. Forty-seven percent of patients are asymptomatic.
Metastatic symptoms
Metastatic symptoms include weight loss and loss of appetite; bone
pain, with or without pathologic fracture (because prostate cancer,
when metastatic, has a strong predilection for bone); and lower
extremity pain and edema due to obstruction of venous and lymphatic
tributaries by nodal metastasis. Uremic symptoms can occur from
ureteral obstruction caused by local prostate growth or retroperitoneal
adenopathy secondary to nodal metastasis.
(http://emedicine.medscape.com)