Benign Prostatic Hyperplasia (BPH)

DICAM, Desiree Joy P. 10/29/2012

Benign Prostatic Hyperplasia (BPH)

This condition is evident when the prostate gland enlarges, extending upward into the bladder and obstructing the outflow of urine by encroaching on the vesical orifice. Evident in 80% of men 80 years of age and older. BPH generally begins in a man's 30s, evolves slowly, and most commonly only causes symptoms after 50. RISK FACTORS Age Smoking Heavy alcohol consumption Hypertension Heart disease DM Increased incidence in African American men than in Caucasian men while Asian men are unlikely to develop BPH. PATHOPHYSIOLOGY:

The cause of BPH is uncertain, but studies suggest that estradiol levels may have a relationship to prostate size among men with testosterone levels above the median.

Risk factors

Hypertrophied lobes of the prostate

Obstruction of the vesical neck or prostathic urethra

UTIs may result from stasis and the urine remaining in the urinary tract serves as a medium for infective organisms

Gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis)

Incomplete emptying of the bladder and urinary retention

CLINICAL MANIFESTATIONS: The obstructive and irritative symptoms associated with BPH include: o Increased frequency of urination o Nocturia o Urgency o Hesitancy in starting urination o Abdominal straining with urination o A decrease in the volume and force of the urinary stream o Interruption of the urinary stream o Dribbling o A sensation that the bladder has not been completely emptied o Acute urinary retention o Recurrent urinary retention Generalized symptoms may also be noted: o Fatigue o Anorexia o Nausea o Vomiting o Epigastric discomfort

ASSESSMENT AND DIAGNOSTIC FINDINGS: 1. Digital Rectal Exam It checks the size and firmness of the prostate. The size of the prostate does not always determine the severity of the symptoms. A man with only a small degree of prostate enlargement may have more severe symptoms than a man with more enlargement. Reveals a large, rubbery and nontender prostate gland 2. Urinalysis and urine culture check for a urinary tract infection that might be the cause of the symptoms. 3. A blood creatinine test checks how well the kidneys are working. 4. A prostate-specific antigen (PSA) test helps check for prostate cancer, which can cause the same symptoms as BPH. This blood test measures a protein produced by the cells of the prostate gland. It is always done and evaluated in conjunction with a DRE.

5. Cystoscopy, also called urethrocystoscopy, is a test performed by a urologist to check for problems in the lower urinary tract, including the urethra and bladder. The doctor can determine the presence of structural problems including enlargement of the prostate, obstruction of the urethra or neck of the bladder, anatomical abnormalities, or bladder stones. The test may also identify bladder cancer, and causes of blood in the urine and infection. 6. Ultrasound is a painless procedure that can give an accurate picture of the size and shape of the prostate gland. Ultrasound may also be used for detecting kidney damage, tumors, and bladder stones. Ultrasound tests of the prostate generally use one of two methods:

Transrectal ultrasonography (TRUS) uses a rectal probe for assessing the prostate. TRUS is significantly more accurate for determining prostate volume. Transabdominal ultrasonography uses a device placed over the abdomen. It can give an accurate measure of postvoid residual urine and can be used to check for kidney damage caused by severe BPH.

7. Uroflowmetry measures the speed of urine flow. To perform this test, the patient urinates into a special toilet equipped with a measuring device. A reduced flow may indicate BPH. However, bladder obstruction can also be caused by other conditions including weak bladder muscles and problems in the urethra. 8. The postvoid residual urine volume (PVR) test measures the amount of urine left after urination. Normally, about 50 mL or less of urine is left; more than 200 mL is a sign of abnormalities. Measurements in between require further tests. The most common method for measuring PVR is with a catheter, a soft tube that is inserted into the urethra within a few minutes of urination. PVR can also be measured using transabdominal or suprapelvic ultrasonography.
MEDICAL MANAGEMENT: 1. Pharmacologic Therapy a. Alpha-adrenergic blockers (e.g., terazosin [Hytrin], doxazosin [Cardura], tamsulosin [Flomax]) relax the smooth muscle of the bladder neck and prostate. b. Alfuzosin (Uroxatral) is an extended-release alpha-adrenergic antagonist that exerts its effects on the prostate, bladder neck, and posterior urethra. The smooth muscle blockade improves urine flow and relieves BPH symptoms c. Because a hormonal component of BPH has been identified, one method of treatment involves hormonal manipulation with antiandrogen agents (e.g., finasteride [Proscar], dutasteride [Avodart]). d. In clinical studies, 5-alpha-reductase inhibitors such as finasteride have been effective in preventing the conversion of tertosterone to dihydrotestosterone (DHT). Decreased levels of DHT lead to decreased glandular cell activity and prostate size. Side effects include gynecomastia, erectile dysfunction, and flushing. 2. Other therapies a. TUIP (transurethral incision of the prostate) may be an option for men with only slightly enlarged prostate to decrease resistance to flow of urine out of the bladder. No tissue is removed. b. Resection of the prostate can be performed with ultrasound guidance. The treated tissue either vaporizes or becomes necrotic and sloughs. The procedure is performed in the outpatient setting and usually results in less postoperative bleeding than in a traditional surgical prostatectomy. c. Transurethral needle ablation uses low-level radiofrequencies to produce localized heat that destroys prostate tissue while sparing the urethra, nerves, muscles, and membranes. The radiofrequencies are delivered by thin needles in the prostate gland through use of catheter. The body then resorbs the dead tissue. d. Microwave thermotherapy involves the application of heat to the prostatic tissue. A transurethral probe is inserted into the urethra, and microwaves are carefully directed to the prostatic tissue. A water-cooling system helps minimize damage to the urethra and decreases the discomfort from the procedure. The tissue becomes necrotic and sloughs.

e. Saw palmetto is a herbal product used to treat the symptoms associated with BPH. The active element comes from the fruit of American dwarf palm tree. Research has shown that the efficacy of saw palmetto is similar to that of medications such as finasteride, and the herbal product may be better tolerated and less expensive. In theory, it functions by interfering with the function of testosterone to DHT. It may also directly block the ability of DHT to stimulate prostate cell growth. It should not be used with finasteride, dutasteride, or medications containing estrogen. f. Watchful waiting, in which patients are monitored periodically for severity of symptoms, physical findings, laboratory tests, and diagnostic urologic tests, is the appropriate treatment for many patients, because the likelihood of progression of the disease of the development of complications is unknown. g. Transurethral resection of the prostate (TURP) is the gold standard to which other surgeries for BPH are compared. This procedure is performed under general or regional anesthesia and takes less than 90 minutes. The surgeon inserts an instrument called a resectoscope into the penis through the urethra. The resectoscope is about 12 inches long and 3/8 of an inch in diameter. It contains a light, valves for controlling irrigating fluid, and an electrical loop to remove the obstructing tissue and seal blood vessels. The surgeon removes the obstructing tissue and the irrigating fluids carry the tissue to the bladder. This debris is removed by irrigation and any remaining debris is eliminated in the urine over time. Patients usually stay in the hospital for about 3 days, during which time a catheter is used to drain urine. Most men are able to return to work within a month. During the recovery period, patients are advised to avoid heavy lifting, driving, or operating machinery; drink plenty of water to flush the bladder; eat a balanced diet; Use a laxative if necessary to prevent constipation and straining during bowel movements. NURSING INTERVENTIONS: Nursing diagnosis Urinary retention (acute or chronic) related to bladder obstruction, Decompensation of detrusor musculature Nursing interventions Review medical history for diagnoses such as prostatic hypertrophy, scarring, recurrent stone formation Ask client about stress incontinence when moving, sneezing, coughing, laughing, or lifting objects. Rationale Evaluations Suggest detrusor muscle Void in sufficient atrophy and/or chronic amounts with no overdistention because of palpable bladder outlet obstruction distention. High urethral pressure Verbalize understanding inhibits bladder emptying or of causative factors and can inhibit voiding until appropriate interventions abdominal pressure Demonstrate increases enough for urine techniques/behaviors to to be involuntarily lost. alleviate/prevent

Monitor vital signs

retention. Voiding pattern normalized.

Observe urinary stream, size and force.

Evaluating degree of obstruction and choice of intervention.

Prepare for and assist with urinary drainage, such as emergency cystostomy. Prepare for procedures, such as the following: laser, transurethral microwave thermotherapy (TUMT), Cortherm, Prostatron, and transurethral needle ablation (TUNA), Urethral stent, Open prostate resection procedures, such as TURP

May be indicated to drain bladder during acute episode

done to quickly create a wide open prostatic fossa, often resulting in immediate restoration of normal urine flow

Patient teaching discharge and home healthcare guidelines for patient with Benign Prostatic Hyperplasia (BPH). Provide instructions about all medications used. Provide instructions on the correct dosage, route, action, side effects, and potential drug interactions and when to notify these to the physician. Provide information about specific procedures and tests and what to expect afterward, such as catheter, bloody urine, and bladder irritation Instruct patients about the need to maintain a high fluid intake, to ensure adequate urine output. Teach the patient to monitor urinary output for 4 to 6 weeks after surgery to ensure adequacy in volume of elimination combined with a decrease in volume of retention. Teach the patient to recognize the signs of UTI. Urge him to immediately report these signs to the physician because infection can worsen the obstruction. o After the catheter is removed, the patient may experience urinary frequency, dribbling and, occasionally, hematuria. Reassure him and family members that he'll gradually regain urinary control o Instruct the patient to follow the prescribed oral antibiotic regimen, and tell him the indications for using gentle laxatives.

Postoperative Patient teaching Provide information about sexual anatomy and function as it relates to prostatic enlargement helps client understand the implications of proposed treatments because they might affect sexual performance. Encourage the patient to discuss any sexual concerns he or his partner may have after surgery with the appropriate counselors. Reassure the patient that a session can be set up by the nurse or physician whenever one is indicated. Usually, the physician recommends that the patient have no sexual intercourse or masturbation for several weeks after invasive procedures. Reinforce prescribed limits on activity. Warn the patient against lifting, performing strenuous exercises, and taking long automobile rides for at least 1 month after surgery because these activities increase bleeding tendency. Also caution him not to have sexual intercourse for at least several weeks after discharge

Prevention Instruct the patient to report any difficulties with urination to the physician immediately. Explain that BPH can recur and that he should notify the physician if symptoms of urgency, frequency, difficulty initiating stream, retention, nocturia, or bladder distension recur.

Urge the patient to seek medical care immediately if he can't void at all, if he passes bloody urine, or if develops a fever. Reinforce importance of medical follow-up for at least 6 months to 1 year, including rectal examination and urinalysis.