BENIGN PROSTATIC HYPERPLASIA

What is it?

Almos 50% of men will have signs of BPH by age 50; 70% by ages 60 to 69

enlargement of prostate gland leading to disruption of urine outflow from bladder to urethra

Lower Urinary Tract Symptoms (LUTS)

Difficulty starting a urine stream

Decreased/weakened flow of urine

Urinary frequency

Etiology and Pathophysiology

BPH is not completely understood

Hormonal changes from aging process may contribute

Excessive accumulation of DHT (dihhdroxytestosterone) in prostate cells that can stimulate overgrowth of prostate tissue

Increased proportion of estrogen over testosterone in the blood

Develops in the inner part of the prostate: “transition zone”

As enlarges, leads to the compression of the urethra resulting in partial or complete obstruction leading to manifestations

No direct relationship between size of prostate and severity of obstruction or symptoms; locations is significant

Risk factors

Aging

Obesity— increase waist circumference

Lack of physical activity

Alcohol use

Erectile dysfunction

Smoking

Diabetes

Family history—first degree relative

Diagnostic Studies

History and PE

Digital rectal exam (DRE)

Size, symmetry, and consistency

Urinanalysis, urine culture, and sensitivities

Prostate specific antigen (PSA) level

Serum creatinine

Renal ultrasound

Postvoid residual ( by ultrasound)

Transrectal ultrasound

Biopsy

MRI of pelvis

Targeted biopsy

Uroflowmetry

Cystoscopy

Urodynamic/pressure flow studies

Nursing Assessment

Functional health patterns

Objective Data

Nursing diagnoses

Preoperative goals

Cognitive-perceptual: dysuria, sensation of incomplete voiding, bladder discomfort

Sexuality-reproductive: anxiety about sexual dysfunction

Elimination: urinary urgency, diminution in caliber and force of stream, hesitancy in initiating voiding, postvoid dribbling, urinary retention, urinary incontinence

Sleep-rest: noctouria

General: older adult male

Urinary: distended bladder on palpation, smooth, firm, elastic enlargment of prostate on rectal examination

Possible diagnostic findings: enlargement on ultrasound, obstruction on cystoscopy, urine residual, urinanalysis, increased creatinine levels

Acute pain

Risk for infection

Impaired urinary system function

Restoration of urinary drainage

Resolutions of UTI

Understanding of

Upcoming procedure

Implications for sexual functioning

Urinary control

Clinical Picture

Manifestations occur gradually

Early: bladder may initially compensate for small amounts of resistance to urine flow

Symptoms worsen as URETHRAL obstruction increases

Lower urinary tract symptoms (LUTS)

Irritating Symptoms

Obstructive Symptoms

Inflammation or infection

Nocturia—often first

Urinary frequency

Urgency

Dysuria

Bladder pain

Incontinence

Caused by prostate enlargement— decrease diameter of urethra

Decrease in caliber and force of urinary stream

Difficulty initiating a stream

Intermittency

Starting and stopping stream several times while voiding

Dribbling at the end of urination

Complications of BPH

UTI

If Severe

Renal failure

Incomplete bladder emptying/residual urine allows for bacterial growth

Pyelonephritis

Sepsis

Bladder calculi

Caused by hydronephrosis

Bladder damage

Treatment Goals

Goals

Restore bladder drainage

Relieve symptoms

Prevent/treat complications

Treatment based on

How bothersome are the symptoms

Presence of complications

Options: surveillance, drug therapy, and minimally invasive procedures

conservative therapy

Active surveillance—watchful waiting

Mild symptoms (AUA score of 0-7)

Lifestyle changes

Decrease bladder irritants

Restrict evening fluid intake

Timed voiding schedule—bladder retraining

Get annual PSA and DRE

Medical Treatment

Conservative

Two main drug therapy groups

5a-Reductase Inhibitors

a-Adrenergic receptor blockers

Blocks enzyme necessary for conversion of testosterone to DHT

Decrease size of prostate gland

More effective for larger prostates with bothersome symptoms

Finasteride (Proscar): see drug alert

Dutasteride (Avodart)

Jalyn (finasteride plus tamsulosin)

May lower risk of prostate cancer; not preventive

More effective when used in combination

One erectogenic drug—helps to treat BPH and ED

Tadafil (Cialis)

Promote smooth muscle relaxation and facilitate urinary flow through urethra

DO NOT DECREASE SIZE OF PROSTATE

Alfuzosin (Uroxatral)

Doxazosin (Cardura)

Prazosin (Minipress)

Terazosin (Hytrin)

Tamsulosin (Flomax)

Silodosin (Rapaflo)

Side effect: retrograde ejaculation (semen backs into bladder)

Herbal Therapy (saw palmetto)

Research does not support beneficial effects

Tell HCP about use of herbal therapy

Minimally Invasive Therapy

Transurethral Microwave Therapy (TUMT)

Transurethral Needle Ablation (TUNA)

Transurethral Vaporization of the Prostate (TUVP)

Outpatient procedure; hold anticoagulants for 10 days before procedure; ~90 minutes

Delivers heat via microwaves directly to prostate. Through a transurethral probe

Heat (113 F or 45 C) causes death of tissue and relief of obstruction

Rectal temperature monitored to prevent rectal tissue damage

Heat delivered from low-wave radio frequency via needle to prostatic tissue leads to localized necrosis

Only tissue in contact with needle affected

Outpatient procedure; ~30 minutes

Local anesthesia and IV or oral sedation

Very little pain

Electrosurgical modification of TURP

Vaporization and desiccation destroy obstructive prostatic tissue

Various energy delivery mediums can be used

Results, side effects, and long term outcomes are the same as TURP

Uses bipolar energy deliver surface

Energy current not passed through body to grounding surface

Saline used for irrigation results in decreased risk for TUR syndrome

Invasive (Surgery) Therapy

Transurethral resection (TURP)

Low risk but caregivers must watch for

TUR or TURP syndrome

Nausea, vomiting, confusion, bradycardia, HTN

Results from hyponatremia due to longer operative times and prolonged intraoperative bladder irrigation with iso-osmolar fluid; now use bipolar resectoscope and saline to reduced risk

Bleeding and clot retention—other possible postoperative complications

Invasive treatment of BPH involves surgery

Factors for choice of treatment depend on:

Size and location of prostatic enlargement

Age and surgical risk

Indications

Decreased urine flow causes discomfort

Persistent residual urine

Acute urinary retention

Hydronephrosis

Transurethral resection of the Prostate (TURP)

Considered “gold standard” for obstructing BPH; previously required hospitalization but may be done as an outpatient procedure

Surgical removal of prostate tissue through urethra using a resectoscope

Postprocedure: 3-way indwelling catheter with 30 mL balloon inserted for hemostasis and to facilitate urinary drainage

Continuous or intermittent irrigation for first 24 hours if large amount of hematuria with clots

Excellent outcome for most; decreased symptoms, increased urine flow

Preoperative Care for TURP

Treat and manage UTI

Administer antibiotics

Encourages high fluid intake; 2-3 L/day (unless contraindicated)

Restore urinary drainage

Coude—curved-tip catheter

Filiform—rigid catheter

Use aseptic technique to prevent infection

Provide patient and partner the opportunity to express concerns about sexual function

Inform patient of possible complications of procedures

Decreased or absent ejaculate volume

Retrograde ejaculation

Postoperative care for TURP

Assess for complications

Postoperative bladder irrigation

Manual, intermittent irrigation

Continuous bladder irrigation (CBI)

Hemorrhage

Bladder spasms

Urinary incontinence

Infection

Instill and withdraw 50 mL irrigation solution; have cause bladder spasms

Remove blood clots and ensure drainage of urine

Infusion rate based on color of urine; ideally light pink without clots

Assess patency, monitor intake and output; if blocked, stop CBI and notify HCP