Possible causes

Excessive accumulation of dihydroxytestosterone

Stimulation by estrogen

Local growth hormone action

• Typically develops in inner part of prostate• Not completely understood• Thought to result from endocrine changes from

aging process• Prostate cancer is most likely to develop in the

outer part of the prostate.

2

Copyright © 2011, 2007 by Mosby, Inc., an

affiliate of Elsevier Inc. 3

Fig. 55-2. Benign prostatic hyperplasia. The enlarged prostate compresses the urethra.

Enlargement of prostate

gland resulting from increase

in number of epithelial cells &

stromal tissue

Most common urologic

problem in males

Enlargement gradually

compresses urethra

Partial or complete

obstruction

Compression leads to clinical

symptoms

No direct relationship between prostate size & obstruction

Location of enlargement determines obstructive symptoms

Possible risk factors

Family history

Obesity

Increased waist circumference

Physical activity level

Alcohol consumption, smoking

Diabetes• For example, it is possible for mild hyperplasia to cause severe

obstruction; likewise, it is possible for extreme hyperplasia to cause few obstructive symptoms.

4

Occurs in 50% of men over 50 & 90% of men over 80

Approximately 25% will require treatment by age 80

Does not predispose to development of prostate cancer

Part of the Prostate Effected – Usually the central portion of the prostate.

Most Common Initial Symptoms - Urinary symptoms such as frequency of urination, hesitancy, dribbling, and frequent nighttime urination

5

Symptoms categorized into two groups

Obstructive symptoms

Irritative symptoms

Obstructive symptoms

Symptoms due to urinary retention

Decrease in caliber of force of urinary stream

Difficulty in initiating urination

Intermittency

Dribbling at end of voiding

Symptoms are usually gradual in onset

Early symptoms are usually minimal because bladder can compensate.

Worsen as obstruction increases 6

Irritative symptoms

Symptoms associated w/ inflammation or infection

Urinary frequency & urgency

Dysuria

Bladder pain

Nocturia

Incontinence• The American Urological Association (AUA) symptom index

for BPH (see Table 55-1) is a widely used tool to assess voiding symptoms associated with obstruction. Although this tool is not diagnostic, it is useful in determining the extent of symptoms.

7

Related to urinary obstruction

UTI & Sepsis

Calculi may develop in bladder because of alkalinization of residual urine

• Complications due to urinary obstruction are relatively uncommon in BPH. Acute urinary retention: complication with sudden, painful inability to urinate. Treatment involves catheter insertion & possible surgery

• Incomplete bladder emptying w/ residual urine provides medium for bacterial growth

• Renal Failure: caused by hydronephrosis• Pyelonephritis• Bladder damage

8

History & PE

Digital Rectal Examination

Urinalysis w/ culture

PSA level

Serum creatinine

TRUS scan

Uroflometry• Cystoscopy• Using DRE, the health care provider can estimate the size, symmetry,

and consistency of the prostate gland. In BPH the prostate is symmetrically enlarged, firm, and smooth.

• A urinalysis with culture is routinely done to determine the presence of infection. The presence of bacteria, white blood cells, or microscopic hematuria is an indication of infection or inflammation.

9

Goals

Restore bladder drainage

Relieve symptoms

Prevent/treat complications

Watchful waiting

Dietary changes

Timed voiding schedule • Treatment is generally based on the degree to which the symptoms bother the patient or the

presence of complications rather than the size of the prostate. • Treatment for BPH has undergone major changes in recent years. • Alternatives to surgical intervention for some patients now include drug therapy and minimally

invasive procedures. • When there are no symptoms or only mild ones (AUA symptom scores of 0 to 7), a wait-and-see

approach is taken.• Prevalence – Very common after age 40 and the most common cause of male urinary tract

obstruction.• Cause – Increased levels of testosterone that occur normally with increasing age.• Physical Examination – Enlarged, “boggy” prostate on digital rectal examination.• Elevated Lab Values – PSA• Where It Spreads – BPH cannot spread to other areas of the body.• Treatment – Depending on the severity of symptoms, treatment can range from nothing, to

medication to shrink the prostate, to surgery to remove the central part of the prostate to allow better flow of urine.

10

5α-Reductase inhibitors:

Finasteride (Proscar), Dutasteride (Avodart)

↓ size of prostate gland

Takes 3 - 6 months for improvement

SE: ↓Libido, ↓ volume of ejaculation, ED

11

α-Adrenergic receptor blockers:

Examples: Tamsulosin (Flomax), Doxazosin (Cardura), Silodosin(Rapaflo)

Promotes smooth muscle relaxation in prostate; facilitates urinary flow

Improvement in 2 - 3 weeks

SE: orthostatic hypotension & dizziness, retrograde ejaculation, nasal congestion

• Although α-adrenergic blockers are more commonly used for treatment of hypertension, these drugs promote smooth muscle relaxation in the prostate. Relaxation of the smooth muscle ultimately facilitates urinary flow through the urethra.

• Currently, the α-adrenergic blockers are the most widely prescribed drug for the patient with BPH who is experiencing moderate symptoms without the presence of other complications.

12

Transurethral microwave therapy (TUMT)

Outpatient procedure: Delivers microwaves directly to prostate through a transurethral probe

Heat causes death of tissue & relief of obstruction

Postop urinary retention is common

13

Transurethral microwave therapy (cont’d)

Patient sent home w/ catheter 2 - 7 days

Antibiotics, pain medication, & bladder antispasmodic medications given

Not appropriate therapy when rectal problems exist• SE: bladder spasm, hematuria, dysuria, & retention• Postoperative urinary retention is a common complication. Thus

the patient is generally sent home with an indwelling catheter for 2 to 7 days to maintain urinary flow and to facilitate the passing of small clots or necrotic tissue.

• Anticoagulant therapy should be stopped 10 days before treatment.

14

Transurethral needle ablation (TUNA)

↑ temperature of prostate tissue for localized necrosis

Low-wave frequency used

Only tissue in contact w/ needle affected

Complications include urinary retention, UTI, and irritative voiding symptoms

Some patients require a catheter• Hematuria up to a week• Only prostate tissue in direct contact with the needle is affected, thus allowing

greater precision in removal of the target tissue. The extent of tissue removed by this process is determined by the amount of tissue contact (needle length), amount of energy delivered, and duration of treatment. • Majority of patients show improvement in symptoms• Outpatient uses local anesthesia & sedation• Lasts 30 minutes w/ little pain & quick recovery

15

Laser Prostatectomy

Delivers a laser beam transurethrally to cut or destroy parts of the prostate

Common procedure: visual laser ablation of the prostate (VLAP)

Takes several weeks to reach optimal results • Urinary catheter inserted • A variety of laser procedures use different sources, wavelengths, and delivery

systems. • VLAP uses the laser beam to produce deep coagulation necrosis of the prostate. The

affected prostate tissue gradually sloughs in the urinary stream. Contact laser techniques involve direct contact of the laser with the prostate

tissue. This produces immediate vaporization of the prostate tissue. Photovaporization of the prostate is a newer technique that utilizes a high-

power green laser light to vaporize prostate tissue. Improvements in urine flow and symptoms are almost immediate following the procedure.

• Minimal bleeding during & after procedure• Fast recovery time• Patients may take anticoagulants.• Photovaporization of the prostate 16

Invasive therapy indicated when

Decrease in urine flow sufficient to cause discomfort

Persistent residual urine

Acute urinary retention• Intermittent catheterization can reduce symptoms & bypass

obstruction• The choice of treatment approach depends on the size and

location of prostatic enlargement, as well as on patient factors such as age and surgical risk.

• Invasive treatments are summarized in Table 55-3.

17

Transurethral Resection (TURP) Removal of obstructing prostate tissue using resectoscope inserted

through urethra Outcome for 80% to 90% is excellent Relatively low risk Performed under spinal or general anesthesia & requires hospital

stay Bladder irrigated for first 24 hours to prevent mucous & blood

clots Complications include bleeding, clot retention, dilutional

hyponatremia, retrograde ejaculation Patients must stop anticoagulants before surgery TURP has long been considered the “gold standard” surgical

treatment for obstructing BPH. Although this procedure remains the most common operation performed, the number of TURP procedures done in recent years has decreased because of the development of less invasive technologies.

18

Copyright © 2011, 2007 by Mosby, Inc., an

affiliate of Elsevier Inc. 19

Fig. 55-3. Transurethral resection of the prostate.

• A resectoscope is

inserted through the

urethra to excise and

cauterize obstructing

prostatic tissue.

• A large three-way

indwelling catheter

with a 30-mL balloon is

inserted into the

bladder after the

procedure to provide

hemostasis and to

facilitate urinary

drainage.

Medications

Estrogen or Testosterone supplementation

Surgery or previous treatment for BPH

Knowledge of condition

Voluntary fluid restriction

Nocturia

Subjective and objective data that should be obtained from a patient with BPH are presented in Table 55-4.

21

Urinary urgency

Diminution in caliber & force of urinary stream

Hesitancy in initiating voiding

Postvoid dribbling

22

Incontinence

Dysuria

Sensation of incomplete voiding

Anxiety of sexual dysfunction

23

Older adult male

Distended bladder on palpation; smooth, firm, elastic enlargement of prostate on rectal examination

U/A findings, enlargement on ultrasound, residual urine, creatinine levels

24

Pain relief for Acute pain

Management of complications - infection

Goals of patient having invasive procedures

Restoration of urinary damage

Treatment of UTI’s

Understanding of treatment procedures & complications

Restoration of urinary control

Complete bladder emptying

Satisfactory sexual expression

Nursing Implementation Focus: early detection & treatment

Prevention - Yearly physical exam and DRE for men over 50

Educate patients that alcohol, caffeine, and cold & cough meds can increase symptoms

25

Instruct patient w/ obstructive symptoms to urinate every 2 - 3 hours & when first feeling urge

Minimizes urinary stasis

Teach patient need for adequate fluid intake

The patient may believe that if he restricts his fluid intake, symptoms will be less severe, but this only increases the chance of an infection. However, if the patient increases his intake too rapidly, bladder distention can develop as a result of the prostatic obstruction.

26

Preoperative care

Use aseptic technique when using urinary catheter

Administer antibiotics preoperatively

Provide patient opportunity to express concerns over alterations in sexual function

• Inform patient of possible complications of procedures

• In many health care settings, 10 mL of sterile 2% lidocaine gel is injected into the urethra before insertion of the catheter.

27

Postoperative care

Postop bladder irrigation to remove blood clots and ensure drainage or urine

Administer antispasmodics• Teach Kegel exercises• The main complications following surgery are hemorrhage, bladder

spasms, urinary incontinence, and infection. • The plan of care should be adjusted to the type of surgery, the reasons

for surgery, and the patient’s response to surgery. • The bladder is irrigated either manually on an intermittent basis, or

more commonly as continuous bladder irrigation (CBI) with sterile normal saline solution or another prescribed solution.

• Use careful aseptic technique when irrigating the bladder because bacteria can easily be introduced into the urinary tract.

28

Postoperative care

Observe patient for signs of infection

Dietary intervention

Stool softeners to prevent straining

Straining increases intraabdominal pressure, which can lead to bleeding at the operative site. A diet high in fiber facilitates the passage of stool.

29

Discharge instructions on indwelling catheter

Managing incontinence

Drink 2 - 3 L fluids per day

Signs and symptoms of UTI, wound infection

The bladder may take up to 2 months to return to its normal capacity. Instruct the patient to drink at least 2 L of fluid per day and to urinate every 2 to 3 hours to flush the urinary tract.

30

Sexual counseling if erectile dysfunction becomes a problem

Avoiding bladder irritants

Yearly digital rectal examination (DRE)

Preventing constipation

Avoiding heavy lifting• Refraining from driving, intercourse after surgery as

directedMany men experience retrograde ejaculation because of trauma to the internal urethral sphincter. Bladder irritants include caffeine products, citrus juices, and alcohol.

31

A patient with benign prostatic hyperplasia is scheduled for a transurethral resection of the prostate (TURP). The nurse assesses the patient’s knowledge of the procedure and its effects on reproductive function, and determines a need for further teaching when the patient says,

1. “It is possible that I’ll be sterile following this procedure.”2. “It is likely that I will become impotent from this procedure.” 3. “I understand that some retrograde ejaculation may occur.”4. “I will have a catheter for a couple of days to keep my urinary

system open.”

Answer: 2Rationale: Retrograde ejaculation is common with transurethral resection of the prostate because of trauma to the internal urethral sphincter. If retrograde ejaculation occurs, the patient may be sterile after the procedure. The catheter is removed 2 to 4 days after surgery. Erectile dysfunction is unlikely with transurethral resection of the prostate.

Audience Response Question

32