Journal of Gerontological Nursing

Prostate Cancer Elder Alert: LIVING WITH TREATMENT CHOICES AND OUTCOMES

Mary Pickett, PhD, RN; Deborah Watkins Bruner, PhD, RN; Angela Joseph, MSN, CURN; Virginia Burggraf, RN, C, DNS

Abstract

TABLE 1

SUMMARY OF URINARY, BOWEL, AND SEXUAL DYSFUNCTIONS ASSOCIATED WITH TREATMENTS FOR PROSTATE CANCER DOCUMENTED IN TWO STUDIES

TABLE 1

SUMMARY OF URINARY, BOWEL, AND SEXUAL DYSFUNCTIONS ASSOCIATED WITH TREATMENTS FOR PROSTATE CANCER DOCUMENTED IN TWO STUDIES

TABLE 2

BRIEF DESCRIPTIONS OF AVAILABLE PROSTATE CANCER TREATMENT MODALITIES

TABLE 3

AVAILABLE INFORMATION AND SUPPORT RESOURCES FOR PROSTATE CANCER PATIENTS

TABLE 4

MEDICAL MANAGEMENT OF ACUTE ENTERITIS

TABLE 5

NUTRITION TIPS FOR MANAGING DIARRHEA…

This article is Part II of a two-part senes. Part I, "Prostate Cancer Elder Alert: Epidemiology, Screening, and Early Detection" appeared in the January 2000 issue of the Journal of Gerontological Nursing.

Prostate cancer is a significant health concern for American men and their families. Currently, prostate cancer accounts for 29% of newly diagnosed cancer cases in men, and it is estimated 179,300 new prostate cancer diagnoses will be made in 1999 (Landis, Murray, B olden, & Wingo, 1999). Effective therapies with known risks and benefits are available, and clinicians are challenged to provide adequate information to patients and families who must make choices among available prostate cancer treatments. A comprehensive review of the epidemiology, screening, and early detection of prostate cancer (Bruner, Pickett, Joseph, & Burggraf, 2000) provides background for understanding factors associated with prostate cancer among American men.

PURPOSE

The purpose of this article is to review the research and related literature that has a direct impact on patient decision-making and patient outcomes related to prostate cancer therapy options. AU prostate cancer therapies have an impact on patients' quality of life (QOL). Clinical guidelines related to posttreatment assessment, symptom management, and patient resources are reviewed in this article to provide current information for practice implementation.

PATIENT CHOICES ABOUT PROSTATE CANCER TREATMENTS

Both radical prostatectomy and radiation therapy are prostate cancer treatments that offer the possibility of cure (i.e., complete tumor eradication). The research literature provides compelling evidence that QOL among prostate cancer patients can be diminished by functional decline, as well as sexual, urinary, and bowel problems associated with prostate cancer and its treatment (Table 1). Table 1 provides results from two studies related to symptom occurrence reported by patients who received differential treatments (i.e., radiation therapy, radical prostatectomy, watchful waiting) for localized prostate cancer. Patient outcomes related to bowel, urinary, and sexual function posttreatment are reported. Complications resulting from surgical or radiation interventions range from mild to severe and from temporary to permanent. All treatment options have potential risks and benefits, and treatment recommendations usually are based on factors such as age, expected life span, personal preferences, stage and grade of cancer, and general health status. Therefore, decisions about treatment choice have serious and longstanding implications related to survival and QOL for men diagnosed with prostate cancer. Patients and their spouses need comprehensive information about the risks and benefits of each intervention to make informed decisions. Some patients desire to optimize their chances for "total cure" and will accept the possible occurrence of negative "trade-offs" (i.e., urinary, bowel, and sexual dysfunctions) related to surgical and radiation therapies. Other patients opt for a higher risk of cancer recurrence in 5 or 10 years to retain sexual potency and urinary continence.

Early intervention (i.e., radical prostatectomy, radiation therapy) and expectant management (i.e., watchful waiting) are the primary approaches to localized prostate cancer currently used in clinical practice. There is concern that, although early detection techniques for prostate cancer have improved, deaths from prostate cancer continue to increase. Currently there is no scientific evidence that supports radical prostatectomy over watchful waiting. Evidence related to better survival results and QOL outcomes in men diagnosed with localized prostate cancer who receive radical prostatectomy or watchful waiting currently is being gathered. A randomized controlled study designed to compare the two strategies in a sample of 1,000 men younger than age 75 who are newly diagnosed with prostate cancer is underway (Wilt, Brawer, & PIVOT Executive Committee, 1997). Men in the study are randomized to receive either radical prostatectomy with additional intervention for subsequent disease or recurrence, or surveillance (i.e., watchful waiting) with palliative therapy directed toward symptomatic or metastatic disease progression. An overview of the available prostate cancer interventions and potential negative side effects of treatment is provided below.

THERAPIES FOR PROSTATE CANCER

Prostate cancer treatments currently available include:

* Surgery.

* Radiotherapy.

* Hormone deprivation therapy.

* Chemotherapy.

* Cryoablation.

* Watchful waiting.

All these therapeutic modalities confer associated potential benefits and significant risks, and are described briefly in Table 2. Treatment-associated risks, relative to the survival benefit, require further study because survival is not the only factor that influences treatment choice, and many patients may prefer a therapy that offers a lower survival rate but better QOL (McNeil, Weichselbaum, & Pauker, 1981).

Surgery

Radical prostatectomy, usually selected for clinically localized disease, is the surgical removal of the prostate gland, seminal vesicles, and periprostatic tissue, and usually is preceded by a lymph node dissection to rule out micrometastasis. The bladder neck is resected and anastomosed to the urethra. During a radical prostatectomy, the neurovascular bundles that control erection are transected, often resulting in impotence. A newer surgical procedure, the nerve-sparing prostatectomy, is performed when the lesion is small and potency is a concern (Brendler & Walsh, 1992). Radical prostatectomy has an 18% to 50% risk of urinary incontinence when stress incontinence is included (Green, Treible, & Wallack, 1990; Herr, 1997; McCammon & Schellhammer, 1996; Murphy, Mettlin, Menck, Winchester, & Davidson, 1994; ShraderBogen, Kjellberg, McPherson, & Murray, 1997).

Radiotherapy

Radiotherapy is most effective with clinically localized disease and may be delivered by standard external beam, conformai therapy, or interstitial seed implantation. Standard external beam therapy for prostate cancer usually is scheduled to deliver a total of 65 to 70 Gray (Gy) in divided doses to the prostate, periprostatic tissues, and lymph nodes during 6 to 7 weeks. Conformai radiotherapy uses computed tomography simulation to enhance treatment planning. This allows for more precise localization of the target tissue and better designed blocks that conform to the prostate and spare normal tissue (Beard et al., 1997). Interstitial implant treatment for prostate cancer involves transperineal placement of radioactive seeds. The short half-life of both iodine-125 and palladium- 103 allow for permanent implantation of the radioactive seeds. Interstitial implants may be used in combination with external beam radiotherapy or used alone.

Hormone Therapy

Prostate cancer is androgendependent and, therefore, frequently responds to androgen deprivation therapy. Current methods of androgen deprivation therapy include surgery (i.e., bilateral orchiectomy), anti-androgen therapy (i.e., estrogen and analogues) alone or in combination with a leutinizing hormonereleasing hormone (LH-RH) agonist which blocks adrenal androgens. Initially, androgen deprivation therapy was the treatment reserved for metastatic disease. Therefore, most studies that assessed morbidity and QOL after hormone therapy were concerned with metastatic disease. Few studies have reported the effects of hormonal therapy alone or in combination with surgery or radiotherapy on the quality of life of men living with nonmetastatic disease. However, anti-androgens currently are being used in multiple clinical trials as neo-adjuvant therapy in earlier stages of disease prior to either surgery or radiation therapy in an effort to shrink the prostate, and hopefully the tumor, for better local control.

Table

TABLE 1SUMMARY OF URINARY, BOWEL, AND SEXUAL DYSFUNCTIONS ASSOCIATED WITH TREATMENTS FOR PROSTATE CANCER DOCUMENTED IN TWO STUDIES

TABLE 1

SUMMARY OF URINARY, BOWEL, AND SEXUAL DYSFUNCTIONS ASSOCIATED WITH TREATMENTS FOR PROSTATE CANCER DOCUMENTED IN TWO STUDIES

Table

TABLE 1SUMMARY OF URINARY, BOWEL, AND SEXUAL DYSFUNCTIONS ASSOCIATED WITH TREATMENTS FOR PROSTATE CANCER DOCUMENTED IN TWO STUDIES

TABLE 1

SUMMARY OF URINARY, BOWEL, AND SEXUAL DYSFUNCTIONS ASSOCIATED WITH TREATMENTS FOR PROSTATE CANCER DOCUMENTED IN TWO STUDIES

Watchful Waiting

Because of the advanced mean age at diagnosis of prostate cancer (72.3) and the slow growth of this tumor in some elderly men, watchful waiting has been suggested by some individuals as a viable treatment alternative. Watchful waiting can be defined as careful monitoring that usually includes a prostate-specific antigen (PSA) blood test and digital rectal examination every 6 months, plus yearly transrectal ultrasound-guided biopsy of the prostate.

IMPACT OF TREATMENT ON QUALITY QF LIFE

Quality of life versus quantity of life trade-offs are documented in the literature. Sixty- eight percent of a sample of men reported they would trade off at least a 10% chance of greater survival to receive a prostate cancer treatment that offered a better chance of preserving potency (Singer et al., 1991). Study results have demonstrated QOL is an independent prognostic indicator for treatment response, survival, and satisfaction with health care (Cella, Fairclou gh, Bonomi, OC Kim, 1997; Coates, 1993; Wensing et al., 1997).

Cancer therapies used in the treatment of early-stage prostate cancer may have a negative impact on patients' QOL related to a variety of side effects. The American public has access to information about the negative outcomes of prostate cancer treatment via the news media and the Internet. Prostate cancer patients and their family members may have serious concerns about the aftermath of treatment. It is important for patients to have access to available information and support resources so they can make informed decisions (Table 3).

Table

TABLE 2BRIEF DESCRIPTIONS OF AVAILABLE PROSTATE CANCER TREATMENT MODALITIES

TABLE 2

BRIEF DESCRIPTIONS OF AVAILABLE PROSTATE CANCER TREATMENT MODALITIES

Bladder and Bowel Symptoms

Therapies used to treat early-stage prostate cancer may have negative effects on elimination patterns. Radical prostate surgery has up to a 30% risk of urinary incontinence when stress incontinence is included (Green et al., 1990), and 3% to 5% of patients may have rectal injury requiring colostomy (Gibbons, Correa, Brannen, & Weissman, 1989; Middleton, Smith, Melzer, & Hamilton, 1986). Patients who have transurethral resection of the prostate (TURP) performed have a 5.5% risk of urinary incontinence pre-radiation or a 33% risk post-radiation therapy. Approximately 17% of men treated with standard radiation therapy (i.e., 6500 to 7000 Gy) experience acute urinary symptoms such as frequency, dysuria, and hematuria (Hanks, Diamond, Krall, Martz, & Kramer, 1987; Zagars, von Eschenbach, Johnson, & Oswald, 1987). Incontinence rates post-radiotherapy gathered from chart reviews and medical professional ratings range from 0% to 7% (Bagshaw, Cox, & Ray, 1988; Green et al., 1990). Patients' reports of stress incontinence post-radiotherapy have been as high as 11% (Jonler et al., 1994). Patients who receive conformai radiation therapy for early prostate cancer demonstrate 50% less morbidity than patients who receive other types of radiotherapy (Soffen, Hanks, Hunt, & Epstein, 1992). Late urinary morbidity may include a 2.6% to 7.7% risk of symptoms that include cystitis, hematuria, incontinence, and urethral stricture.

Bowel symptoms such as diarrhea, tenesmus, or bleeding have been reported in approximately 24% of men who have been treated with larger volume radical radiotherapy of the prostate (Mameghan, Fisher, Mameghan, Watt, & Tynan, 1990). Reports of negative effects following conformai therapy for prostate cancer document late toxicities in 11% of men who receive this treatment (Soffen et al., 1992). Complications requiring colostomy post-radiotherapy have been reported at a .5% to 2% rate (Perez, WaIz, & Zivnuska, et al., 1980; Zagars et al., 1987). Approximately 60% of patients with these symptoms require medications (Soffen et al., 1992). Late bowel sequelae including diarrhea, proctitis, bleeding, or perforation have been reported ranging widely from 3.3% to 24% (Lawton et al., 1991; Mameghan et al., 1990; Scardino et al., 1986).

Table

TABLE 3AVAILABLE INFORMATION AND SUPPORT RESOURCES FOR PROSTATE CANCER PATIENTS

TABLE 3

AVAILABLE INFORMATION AND SUPPORT RESOURCES FOR PROSTATE CANCER PATIENTS

Sexual Function

Therapies for prostate cancer have a vital impact on sexual function. Sixty-nine percent of men treated with surgery and 62% of men treated with radiotherapy have reported dissatisfaction with posttreatment sexual function (Schrader-Bogen et al., 1997). Anti-androgenic treatment affects the central mechanisms mediating sexual activity and has an associated risk of impotency at 80% (Rousseau, Dupont, Labrie, & Couture, 1988; Schover, 1993). When radiation is used as the only therapy for prostate cancer, there is an associated risk of impotency of 40% (Banker, 1988; Jonler et al., 1994; Talcott et al., 1996). Hormonal therapy carries a risk of impotency of at least 80% (Rousseau et al, 1988; Schover, 1993). Radical surgery has a 90% to 100% risk of impotence (Green et al., 1990), and nerve-sparing radical prostatectomies may result in up to 79% risk of impotence (Talcott et al., 1996; Walsh, 1987). While TURP may carry a low risk of physiologic erectile dysfunction (ED), the risk of retrograde ejaculation is approximately 90% (Heinrich-Rynning, 1987), which may result in psychological ED. The importance of these QOL issues in patient decision-making cannot be overestimated.

PRETREATMENT AND POSTTREATMENT PATIENT ASSESSMENT

Comprehensive assessment of urinary incontinence, bowel function, and erectile function before patients receive prostate cancer treatment provides essential information that has an impact on posttreatment symptom interventions. The Joseph Continence Assessment Tool QCAT) is a biopsychosocial checklist that can be used by health care providers to identify problems (Joseph, 1992). Physiological aspects of the instrument include assessment of:

* Chronic diseases or disorders.

* Medications.

* Nutrition.

* Fluid intake.

* Elimination (i.e., bowel and bladder).

* Sensory function.

* Skin integrity.

* Exercise and rest patterns.

* Physical function.

* Neurological function.

* Endocrine function.

In addition, the psychosocial aspects of the instrument include:

* Role function.

* Self-concept.

* Interdependence.

* Behavior.

* Feelings.

Patients experiencing urinary or bowel dysfunction are asked to state their goals about future continence. The items included in the JCAT were identified after an exhaustive review of the research literature related to animal and human incontinence (Joseph & Lantz, 1996). Often urinary, bowel, or ED result from several biopsychosocial sources. Therefore, a thorough baseline assessment prior to any prostate cancer treatment maximizes the information base used for planning approaches to posttreatment dysfunction.

The benefit of performing Kegel exercises before prostate cancer surgery or radiation still is under investigation. Nurse researchers have reported the positive effects pretreatment Kegel exercises have on return of urinary continence in men treated for prostate cancer (Sueppel, Kreder, & See, 1998). Because the practice of Kegel exercises by prostate cancer patients currently is not part of standard preoperative care, further study is ongoing. Prescribing Kegel exercises to prostate cancer patients for postsurgical or post-radiation urinary incontinence currendy is recognized by most health care providers as well as health maintenance organizations.

Bladder diaries can help identify the type of incontinence and the times of occurrences (Fantil et al., 1996). Individuals are asked to record all bladder and bowel activities (e.g., urinary voiding, urinary leaks [small or large], reasons for the leaks, bowel evacuation pattern, bowel accidents). This cognitive exercise assists individuals to become aware of patterns of time and activity associated with incontinence. This information can be used in a continence treatment plan based on operant learning theory as described by Burgio (1986).

Currently there is no standard method of urinary incontinence pad testing among urology practitioners. Consequently, urinary incontinence assessment varies among health care providers. Pad testing can assist with treatment interventions by establishing pre-urinary and post-urinary leakage patterns. This type of information can validate treatment interventions or support the need for more aggressive treatment interventions.

Urodynamic testing can be used to identify the specific type of urinary incontinence an individual may be experiencing. Leach and Yun (1992) reported that postprostatectomy urinary incontinence ranged from mild to severe (2% to 87%), with a pattern of stress, urge, or mixed stress and urge incontinence. The wide range in reports of urinary incontinence is caused by problems with self-reporting mechanisms, interpretation, and inconsistent methods of measurement.

Patients who experience bowel dysfunction resulting from prostate cancer treatment usually have a sigmoidoscopic procedure to visualize the rectal mucosa.

NURSING MANAGEMENT

Bladder Symptoms

The urinary bladder performs in a coordinated fashion with the external sphincter to allow the bladder to store urine and empty when signaled by the brain (Barrett & Wein, 1987). Men who receive prostate cancer treatments can experience interruption in this voluntary mechanism that causes the system to malfunction. Postprostatectomy men usually notice urinary incontinence during the day with a pattern of dryness at night. Involuntary loss of urine may be due to a weak external urinary sphincter that causes stress incontinence, or due to erroneous sensory bladder stimuli that produces urge incontinence (Goluboff, Chang, Olsson, & Kaplan, 1995).

Urinary incontinence is common after radical prostatectomy. Presti, Schmidt, Narayan, Carroll, and Tanagho (1990) explored the pathophysiologic cause of urinary incontinence after radical prostatectomy. The results of this retrospective study demonstrated both the tubular smooth muscle of the distal urethra and the striated muscle of the external sphincter support urinary continence. The ability of the bladder neck and the external sphincter to function appropriately was in jeopardy when the functional urethral length was less than 2.5 cm in length.

It is imperative to identify the specific type of urinary incontinence problem before interventions are initiated. Research has demonstrated identification of the specific incontinence problem will directly affect patient outcomes (Goluboff et al., 1995). Stress incontinence, urge incontinence, or mixed stress and urge incontinence usually result from an incompetent bladder neck or urethra, detrusor instability, or an areflexic bladder.

Stress incontinence results from the inability of the bladder neck, urethra, and external sphincter to contain urine until the cerebral centers send a signal to empty the bladder. Stress incontinence has been treated effectively with behavioral therapies. A behavioral program (Meaglia, Joseph, Chang, & Schimdt, 1990) designed for patients diagnosed with stress incontinence resulted in a 56.6% improvement in urinary continence. This behavioral program included the following components:

Table

TABLE 4MEDICAL MANAGEMENT OF ACUTE ENTERITIS

TABLE 4

MEDICAL MANAGEMENT OF ACUTE ENTERITIS

* Fluid spacing.

* Bowel regulation.

* Medication adjustments.

* Timed voiding.

Key features of successful behavioral programs to improve urinary continence include:

* Decreased use of incontinence pads or devices.

* Strengthening the pubococcygeal muscle (Pickett, Cooley, Patterson, & McCorkle, 1996).

* Motivational strategies to encourage daily practice of pelvic floor muscles (Burgio, Stutzman, & Engel, 1989).

Verbal instruction and biofeedback are the methods used to assist with pelvic floor muscle re-education. Biofeedback, with or without behavioral interventions, can be helpful in improving symptoms. However, success is dependent on the intensity of the program, patient motivation, severity of the problem, and the skill of the provider (Fantil et al., 1996).

Urge incontinence, leakage of urine due to detrusor instability or a noncompliant bladder, may result from an obstructive prostate prior to the prostatectomy. Treatment of urge incontinence with anticholingerics has proven to be effective. However, many patients dislike the side effects of dry mouth and constipation. New antimuscarinic agents currently are available, and fewer side effects have been reported (Abrams, Freeman, Anderstrom, & Mattiasson, 1998). Biofeedback may assist patients who experience urge incontinence. Patients can learn to inhibit bladder contractions by quickly contracting and relaxing the pelvic musculature in a flutter fashion.

Overflow incontinence is a direct result of a bladder that has been denervated. This condition may result from surgical complications, myogenic failure due to long-term obstruction, or uncontrolled diabetes causing peripheral neuropathy with loss of sensory or motor function. Dillioglugil et al. (1997) identified risk factors for developing incontinence postprostatectomy including age, and more significantly, the presence of comorbid conditions. The best treatment for this condition is clean, intermittent catheterization. When the Valsalva maneuver is performed to void, concomitant inguinal and rectal hernias usually develop.

Table

TABLE 5NUTRITION TIPS FOR MANAGING DIARRHEA

TABLE 5

NUTRITION TIPS FOR MANAGING DIARRHEA

Integration of continence techniques into patients' lifestyles is imperative for successful outcomes. Knowledge about phases of urinary continence recovery provides patients with a pathway to master long-term success (Joseph & Chang, 1989). Individuals need to be motivated to perform the continence program strategies for the rest of their lives (Jackson, Emerson, Johnston, Wilson, & Morales, 1996). Treatment of bladder symptoms is dependent on patients' ability to learn and the goals they hope to achieve related to urinary leakage.

Bowel Symptoms

New developments in radiation therapy for localized prostate cancer have decreased the incidence and severity of complications to the rectum that result in irritation (i.e., proctitis), blood loss, and diarrhea. For example, three-dimensional conformai radiation uses information from computer simulations of the exact location of the prostate gland to increase the precision of the radiation beam, resulting in fewer side effects from therapy. These symptoms usually are temporary and can be managed during the course of treatment.

Radiation-induced proctitis (i.e., inflammation of the rectum) may result in:

* Mucoid rectal discharge.

* Rectal pain.

* Rectal bleeding.

Three percent of prostate cancer patients undergoing brachytherapy develop rectal ulcerations causing pain and bleeding with bowel movements (Whittington, 1997). Patients who experience mild rectal bleeding are treated with stool softeners, steroid enemas, and anti-inflammatory drugs. One case report noted the positive effect of sucralfate enemas on radiation-induced rectal bleeding that had been unresponsive to steroid enemas (Stockdale & Biswas, 1997). Rectal ulceration can be successfully treated with laser surgery (Whittington, 1997).

Acute radiation enteritis results from the cytotoxic effect of radiation therapy on rapidly proliferating epithelial cells, resulting in diarrhea, abdominal cramping, and rectal urgency. Chemotherapeutic agents also affect the lining of the intestinal tract. However, diarrhea can be managed effectively in most prostate cancer patients. Medical approaches and dietary recommendations for patients coping with diarrhea and abdominal cramping are found in Tables 4 and 5. Rectal urgency is a symptom that interferes with patients' daily routines and involvement in social activities. Traveling even short distances away from home is a problem for patients with rectal urgency because of the heightened concern about quick access to a bathroom. The acute sensation of wanting to have a bowel movement, even when the rectum is empty, can be treated successfully with "bulking agents" such as Metamucil® (Procter & Gamble, Cincinnati, Ohio).

Sexual Function

The American Urologie Association Clinical Guidelines Panel on ED offers recommendations based on posttreatment outcomes data from men with organic (versus psychological) ED (NIH Consensus Development Panel on Impotence, 1993). The panel reviewed published outcomes for five treatment alternatives including:

* Vacuum constriction devices.

* Intracavernous vasoactive injections.

* Penile prosthesis implants.

* Venous and arterial surgery.

* Oral drug therapy with yohimbine.

The panel concluded that only the first three alternatives had acceptable outcomes in terms of return to intercourse, patient satisfaction, and partner satisfaction (Montague et al., 1996). Yet, all three of these alternatives have significant drawbacks.

Vacuum devices are the least invasive and least expensive techniques for achieving erections (Lewis, 1993). A hollow tube is placed around the flaccid penis and suction is applied to create negative pressure, allowing blood to fill the corpora cavernosa. When an erection is achieved, an elastic constriction band is placed around the base of the penis to preserve the rigidity of the penis to allow for sexual penetration. The constriction band may be left in place for up to 30 minutes. The vacuum device may be used daily. However, undesirable side effects such as retrograde ejaculation, decreased sensation, and penile injury with ecchymosis can occur. Some men report the vacuum device is difficult and time consuming to use to achieve an erection (Bruner & Iwamoto, 1996).

Vasoactive agents such as alprostadil (prostaglandin E1) cause temporary vasodilation and vasocongestion within the spongy tissue of the penis by reducing the resistance of the arteriolar and cavernosal smooth muscle tissue, resulting in penile erection (Williams, 1989). Administration of this medication is a task difficult for many men because it has to be injected directly into the shaft of the penis. Erection usually develops within 8 to 10 minutes and can last for 30 to 90 minutes. Local side effects include penile pain, bruising, and priapism (i.e., prolonged erections). Orgasm and ejaculation are not adversely affected by these side effects. Systemic effects may include syncope, flushing, and hypotension. Contraindications for these vasoactive drugs include unstable cardiac disease, sickle cell disease, hypotension, transient ischemic attacks, or significant penile venous incompetence. Because scar tissue can form along the shaft of the penis, patients are instructed to restrict the use of these agents to no more than twice a week (Bruner & Iwamoto, 1996).

Three types of surgically implanted penile prostheses are available:

* Malleable (i.e., semi-rigid).

* Semi-inflatable.

* Fully inflatable.

All these prostheses produce erections suitable for sexual penetration; however, there are associated risks of erosion or infection that may require removal of the implants (Bruner & Iwamoto, 1996). Patient self-care guidelines that describe how to use either the semi-inflatable or fully inflatable prostheses have been published (Bruner & Iwamoto, 1996).

The risks and difficulties associated with these alternatives have given rise to unprecedented patient popularity for the recently FDAapproved medication Viagra® (Pfizer, New York, New York), for the treatment of ED after prostate cancer therapy. Viagra appears to be an effective oral agent used for the treatment of ED. It works by enhancing smooth muscle relaxation and inflow of blood in the corpus cavernosum. This occurs in conjunction with sexual stimulation. Viagra has demonstrated significant improvement in ED patients with various histories and concomitant disease states, including radical prostatectomy. Results of one longitudinal study indicated that Viagra improved penile erections in 88% of patients (V. Mascoli, personal communication, June 8, 1999). Clinical trials of Viagra in radical prostatectomy patients has demonstrated improved erections in 43% of patients who received Viagra, compared to 15% of patients who received a placebo (Boolell et al., 1996, Goldstein, Feldman, Deckers, Babayan, & Krane, 1984). To date, the effectiveness of Viagra has not been evaluated in a sample of prostate cancer patients treated with radiotherapy.

GERONTOLOGICAL NURSING IMPLICATIONS

Nurses who provide primary health care for men who are age 40 and older have a responsibility to review current guidelines for prostate cancer screening and to provide the appropriate screening tests as part of annual health examinations (American Cancer Society, 1997). However, when a diagnosis of prostate cancer is made, nurses' responsibility should shift to providing information about available treatment options and symptom management. The hallmark of comprehensive cancer care is to provide psychosocial support to patients and families to decrease fears associated with cancer diagnosis. Human sexuality, continence, and potency are topics that may be difficult for men to discuss. It may be helpful to refer patients and their partners to practitioners who have the knowledge and skills to provide the necessary informational and emotional support regarding changes in potency and continence. There is a growing cadre of nurses who have expertise in urinary continence and human sexuality and can offer strategies to cope with problems that result from prostate cancer and its treatment.

Prostate cancer patients of all ages need time to process new information, to think through the menu of available treatment options, and to receive acceptance and support related to decisions they select. Gerontological nurses can assist prostate cancer patients in this process by providing resources, clarifying information, and conveying an attitude of acceptance and support.

Important topics for nursing research include clinical trials to determine the survival benefit and cost effectiveness of screening and to evaluate prostate cancer therapy outcomes. Descriptive studies have documented the impact of prostate cancer therapy on patients' QOL. However, there is a paucity of data related to intervention trials designed to improve QOL in men treated for prostate cancer. Incontinence training, use of Viagra postprostatectomy, and efficacy of diarrhea management strategies are all research areas of concern for nurses who provide follow-up care for men after prostate cancer therapy.

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TABLE 1

SUMMARY OF URINARY, BOWEL, AND SEXUAL DYSFUNCTIONS ASSOCIATED WITH TREATMENTS FOR PROSTATE CANCER DOCUMENTED IN TWO STUDIES

TABLE 1

SUMMARY OF URINARY, BOWEL, AND SEXUAL DYSFUNCTIONS ASSOCIATED WITH TREATMENTS FOR PROSTATE CANCER DOCUMENTED IN TWO STUDIES

TABLE 2

BRIEF DESCRIPTIONS OF AVAILABLE PROSTATE CANCER TREATMENT MODALITIES

TABLE 3

AVAILABLE INFORMATION AND SUPPORT RESOURCES FOR PROSTATE CANCER PATIENTS

TABLE 4

MEDICAL MANAGEMENT OF ACUTE ENTERITIS

TABLE 5

NUTRITION TIPS FOR MANAGING DIARRHEA

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