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