Gwendolyn Hooper, PhD, APRN

 urology was the most stressed, the London-based 

 bills itself as the “primary source of occupational information” in the United States. Ben Challacombe, BSc, MBBS, a urologic surgeon at Guy’s and St. Thomas’ Hospital in London, commented on the article in 

“Urologists are fundamentally nice people and this is why I chose it as a career, but this strength is also a weakness when it comes to stress,” Dr. Challacombe wrote. “We just can’t say no to things.”

	The topic of stress and urology again surfaced in a 

 by Karen Nash in February 2017. When asked three randomly chosen urologists to comment on the biggest stressor in their office, their responses included getting through a clinic day, dealing with insurance companies, and handling patients who experience complications.

	These two articles on led me to wonder what the primary stressors in urology nursing might be. To find out, I asked a few colleagues to share their urology nursing stressors with us. Their responses follow.

	“The biggest stressor for me and my staff would be not having the equipment needed to do the job! As everywhere, you learn to do work-arounds. My hospital is small and we only have so many sets of equipment, so you carefully plan and time all the procedures that need to be done for that day.”

	“My stressor is people not showing or coming late for the 1-hour urodynamics study, which makes my schedule run late for the rest of the day.”

	“My greatest stressor is seeing more patients in less time allotted.”

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SUNA President Gwendolyn Hooper, PhD, APRN, asked a few colleagues to share their urology nursing stressors.

Stress is part of life, and urology nurses are no exception

	Depression has long been a problem primarily associated with women, leading to less awareness of it as a concern in men, a point highlighted in a

 addressing postpartum depression in new fathers.

	As clinicians who focus on men’s health, urology providers have an opportunity to assist men with emotional and stressful situations. Most men would not consider an association of their urologic symptoms with a psychological cause. In addition, raising the issue of mental health can result in men receiving the dismissive message of “it’s all in your head,” something no concerned provider wants to convey or suffering patient wants to receive.

	It is important to men that men maintain their masculine image. Attaching a mental condition, which many consider a social stigma, could only add to the difficulties men have in seeking care. Psychologists and other mental health professionals have long sought answers to the questions of why men do not seek help for their physical complaints. Emotions have been found to be a central aspect of this issue.

How postpartum depression can affect new fathers 

	A quick review of the literature reveals that 60% of men with prostate cancer experience psychological distress in some form 

) with 10% to 40% meeting criteria for clinically significant depression 

) found 20% of men age 65 or older with a prostate cancer diagnosis had depression, anxiety disorders, or committed suicide. Men with lower urinary tract and sexual symptoms 

), chronic prostatitis/chronic pelvic pain syndrome

) are only a few urologic problems facing our patients that may have a psychological component.

	Incorporating mental health education and awareness into our patient management can improve the emotional and physical health of our patients. Urology providers and caregivers can serve as the primary venue for positively impacting both the psychological and physical components of men’s health as men trust us with their most intimate and personal issues of life.

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"Urology providers and caregivers can serve as the primary venue for positively impacting both the psychological and physical components of men’s health as men trust us with their most intimate and personal issues of life," writes SUNA President Gwendolyn Hooper, PhD, APRN.

 reporting on results of a survey on the experience of Canadian urologists in integrating abiraterone acetate (ZYTIGA) into the urology practice suggests that other forms of chemotherapy are at least being investigated for office use, barring reimbursement issues. Although many offices are familiar with managing prostate cancer patients with anti-androgens, oral androgen receptor inhibitors such as abiraterone are the next step in treatment for our patients, which makes this a topic of interest to many urology providers, as well as their office staff and support personnel.

	Although the urologist takes the lead in any decision to institute these therapies into the office setting, it is the urology team that most often assists in overcoming the barriers mentioned by some urologists in the survey. Typically, the urology team consists of an assistant, nurse, and advanced practice provider, who are all familiar with the special needs of the prostate cancer patient. As a group, these specialized caregivers are accustomed to engaging, managing, supporting, and educating the patient, as well as his family, in all aspects of prostate cancer care.

Urologists positive about abiraterone integration

	With appropriate education and training, the requirements of monitoring and follow-up presented by the patient receiving oral androgen receptor inhibitor therapy can be met. As those of us in practice know, the needs of the prostate cancer patient also include assistance in the acquisition of medications and insurance pre-authorizations, monitoring for medication tolerance/efficacy, lab tests, and imaging. Beyond these tasks, prostate cancer patients may also require additional support such as assistance in decision-making and, in some cases, palliative care.

	The nurse practitioner, nurse, and other ancillary providers who make up the urology team are an essential and valuable asset in the consideration of adding oral androgen receptor inhibitors into the office setting. In order to achieve safe, positive patient outcomes, collaboration and communication, as well as education and training, are an absolute priority for the urologist and the urology team.

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"The nurse practitioner, nurse, and other ancillary providers who make up the urology team are an essential and valuable asset in the consideration of adding oral androgen receptor inhibitors into the office setting," writes Gwendolyn Hooper, PhD, APRN.

	lnterstitial cystitis/painful bladder syndrome (IC/PBS), also known as painful bladder syndrome, chronic pelvic pain, and bladder pain syndrome, affects over 12 million people in the United States, according to the 

 Suffering from pelvic pain, pain on bladder holding, frequent urination both day and night, the patient with IC/PBS has difficulty locating providers who understand this syndrome, and many of them see several providers before the condition is diagnosed.

	There are two distinct types of IC/PBS: with or without Hunner lesions. These two types differ in both pathophysiology and treatment. The type with Hunner lesions is associated with severe bladder inflammation on biopsy and is the type most likely to respond to anti-inflammatory treatments.

 from Shoskes et al provides additional evidence regarding IC/PBS treatment. Cyclosporine A was first evaluated and found to be effective as an IC/PBS treatment in Finland. It was also found to be effective in other countries, especially for the type with Hunner lesions.

Cyclosporine shows efficacy in refractory IC patients

	Unfortunately, it has significant side effects and risks including unusual infections and increased risk of malignancy. Patients require close monitoring and follow-up, including regular office visits for history, exam, blood work, and following for dose adjustments. Some patients with Hunner lesions find the commitment, and even the serious risks, are justified by their significant symptom improvement (in some cases, complete symptom resolution).

 lists cyclosporine as its fifth-tier option in the treatment of IC/PBS. As described by the AUA on the 

Although urology is classified as a surgical specialty, knowledge of internal medicine, pediatrics, gynecology, and other specialties is required by the urologist because of the wide variety of clinical problems encountered.”

	It may be that urologists need to rely more on their internal medicine instincts to find new ways to treat conditions such as IC/PBS by examining treatments that may be outside the typical urology armamentarium. Let us not forget sildenafil citrate (Viagra) and onabotulinumtoxinA (Botox), two examples of medications not initially discovered or intended for use in urologic patients yet now utilized to improve symptoms and quality of life-and two examples of thinking outside the routine or obligatory box.

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“It may be that urologists need to rely more on their internal medicine instincts to find new ways to treat conditions such as IC/PBS,” writes SUNA President Gwendolyn Hooper, PhD, APRN.