Transcript Benign Prostatic Hyperplasia (Enlarged Prostate)

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Benign prostatic hyperplasia (BPH) is one of
the most common diseases in aging men. It
can cause bothersome lower urinary tract
symptoms that affect quality of life by
interfering with normal daily activities and
sleep patterns. BPH typically occurs in men
older than 40 years of age. By the time they
reach 60 years of age, 50% of men have BPH.
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The etiology of BPH is only partly understood. Whereas prostate
enlargement is universal in men with functioning testes, it is
arrested bilateral orchiectomy. Although androgens, and
particularly testosterone, are not direct causes of BPH their
presence is critical to the normal growth and development of
the prostate as well as BPH. Within the prostate the
testosterone is converted dihydrotestosterone (DHT) under the
influence of an enzyme called 5a-reductase, DHT is the locally
active form of testosterone that supports prostate growth and
development throughout life, and the prostate remains
sensitive to androgen production throughout life to maintain
both prostate size and function.
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As the man ages and prostate enlargement occurs , 5areductase and DHT levels remains similar to those seen in
younger men, but never evidence has shown that the balance
between two forms of this enzyme may be compromised ,
contributing to prostatic enlargement. Additional factors
associated with BPH include a defect in local substances that
regulate the programmed cellular death (apoptosis) common
to many tissues in the body, including the skin and
gastrointestinal tract .Imbalances of local growth factors,
local inflammation, and genetic factors are also thought to
influence the risk of BPH and the timing of its onset.
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Multiple possible risk for BPH has been studied.
For example dietary factors have been examined
and lycopene in cooked tomatoes, green and
yellow vegetables, and other elements of a
traditional Japanese diet appear to provide some
protection against BPH.
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Obesity (particularly increased abdominal girth) may increase
the risk for BPH.The effect of DM on BPH appears to be
minimal. Physical activity has been shown to exert a
protective effect against prostatic enlargement, possibly
because of its indirect effects on obesity. Smoking has been
hypothesized to exert protective effect on BPH because it
reduces serum testosterone levels , but epidemiologic studies
have shown that it has only slight effect on BPH risk
compared with the well-documented and severe adverse
health risk associated with cigarette use. Heavy alcohol use
and cirrhosis of the liver impede prostate enlargement.
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Frequent use of a-adrenergic agonists commonly found in the
over-the-counter cold medications or diet pills increased the
severity of bothersome LUTS associated with BPH and the
risk for acute urinary retention. Hypertension, heart disease,
diabetes, and a western diet (high in animal fat and protein
and refined carbohydrates, low in fiber) are risk factors for
BPH.
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Histologic evidence of prostate enlargement alone does not
constitute clinically relevant problem. Instead, the clinical
disorders associated with BPH occur when this enlargements
obstructs the urinary outlet, leading to bothersome LUTS, an
increased risk of urinary tract infection , and compromised your
upper urinary tract function. Two processes produce this
obstruction: hyperplasia and hypertrophy. Hyperplasia
originates in the glandular (stomal) cells near the urethra –
transitional zone.On the microscope level, prostatic hyperplasia
is nodular, but the effect on palpation is symmetrically enlarge
gland free from palpable nodes characteristics of prostate
cancer. Obstruction occurs when hyperplasia narrows the lumen
of the segment of the urethra coursing through the prostate.
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Obstruction also occurs when the prostate encroaches to the
bladders neck, reducing its ability to funnel in response to
micturation, and when growth of the so-called median lobe
of the prostate it extends to the prostatic urethra. BPH is also
influenced by the prostatic capsule (connective tissue
covering the gland); inward increasing the size of the prostate
rather than the severity of urethral compression and urinary
obstruction.Hypertropphy of the smooth muscle of the
prostate also contributes to urethral obstruction via both
active and passive forces. Hyperplasia of the prostate is
accompanied by hypertrophy of the smooth muscle of the
gland.
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Smooth muscle hypertrophy exacerbates urinary
obstruction by increasing muscle tone at the
bladder neck and in the proximal (prostatic)
urethra mechanically by adding to the tissue
constricting the urethral lumen.
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BPH may or not lead to lower urinary tract symptoms; if
symptoms occur, they may range from mild to severe. Severity
of symptoms increases with age, and half of men with BPH
report having moderate to severe symptoms. Obstructive and
irritative symptoms may include urinary frequency, urgency,
nocturia, hesitancy in starting urination, decreased and
intermittent force of stream and the sensation of incomplete
bladder emptying, abdominal straining with urination, a
decrease in the volume and force of the urinary stream,
dribbling (urine dribbles out after urination), and complications
of acute urinary retention (more than 60mL of urine remaining
in the bladder after urination), and recurrent UTIs. Ultimately,
chronic urinary retention and large residual volumes can lead to
azotemia (accumulation of nitrogenous waste products) and
renal failure.
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The health history focuses on the urinary tract, previous
surgical procedures, general health issues, family history of
prostate disease, and fitness for possible surgery. A patient
voiding diary is used ro record voiding frequency and urine
volume. A DRE often reveals a large, rubbery, and nontender
prostate gland. A urinalysis to screen for hematuria and UTI is
recommended. A PSA level is obtained if the patient has at
least a 10-year life expectancy and for whom knowledge of
the presence of prostate cancer would change knowledge of
the presence of prostate cancer would change management.
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The AUA symptom Index or international Prostate
symptom score (IPPS) can be used to assess the severity
of symptoms (AUA, 2006).
Other diagnostic test may include urinary flow-rate
recording and the measurement of postvoid residual
(PVR) urine. If invasive therapy is considered,
urodynamic studies, urethrocystoscopy, and ultrasound
may be performed. Cardiac status and respiratory
unction are assessed because a high percentage of
patients with BPH have cardiac or respiratory disorders
because of their age.
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The goals of medical management of BPH are to improve
quality of life, improve urine flow, relieve obstruction,
prevent disease progression, and minimize complications.
Treatment depends on the severity of the obstruction, and
the patient’s condition.
If patient is admitted on an emergency basis because he is
unable to void, he is immediately catheterized. The ordinary
catheter may be too soft and pliable to advance through the
urethra into the bladder. In such cases, a thin wire (stylet) is
introduced (by urologist) into the catheter to prevent the
catheter from collapsing when it encounters resistance. A
metal catheter may be used if obstruction is severe. An
incision into the bladder (a suprapubic cystostomy) may be
needed to provide urinary drainage.
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Pharmacologic treatment for BPH includes use of
alpha-adrenergic blockers and 5-alpha-reductase
inhibitors (AUA,2006). Alpha-adrenergic
blockers, which include alfuzosin (uroxatral),
terazosin (hytrin), doxazosin (Cardura), and
tamsulosin, relax the smooth muscle of the
bladder of the neck and prostate. This improves
urine flow and relieves symptoms of BPH. Side
effects include dizziness, headache,
asthenia/fatigue, postural hypotension, rhinitis,
and sexual dysfunction.
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Another method of treatment includes hormonal
manipulation with antiandrogen agents. The
alpha-alpha-reductase inhibitors, finasteride
(proscar) and dutasteride (Avodart), are used to
prevent the conversion of testosterone to DHT
and decrease prostate size. Side effects include
decreased libido, ejaculatory dysfunction,
erectile dysfunction, gynecomastia (breast
enlargement), and flushing. Combination
therapy (doxazosin and finasteride) has
decreased symptoms and decreased clinical
progression of BPH.
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Use of pythotherapeutic agents and other dietary
supplements (serenoa repens and pygeum africanum are not
recommended, although they are commonly used. They may
function by interfering with the conversion of testosterone to
DHT. In addition, S. repens may directly block the ability of
DHt to stimulate prostate cell growth. These agents should
not be used with finasteride, dutasteride, or estrogencontaining medications.
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Other treatment options include minimaly invasive
procedures and resection of prostate gland.
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Several forms of minimally invasive therapy may be used to
treat BPH. Transurethral microwave heat treatment (TUMT)
involves the application of heat to prostatic tissue highenergy TUMT devices and low-energy devices are available. A
transurethral probe is inserted into the urethra, and
microwaves are directed to the prostate tissue. The targeted
tissue becomes necrotic and sloughs. To minimize damage to
the urethra and decrease the discomfort from the procedure,
some systems have a water-cooling apparatus.
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Other minimally invasive treatment options include
(transurethral needle ablation by radiofrequency energy and
the UroLume stent. TUNA uses low-level radiofrewuencies
delivered by the thin needles placed in the prostate gland to
produce localized heat that destroys prostate tissue while
sparing other tissues. The body then resorbs the dead tissue.
Prostatics stents are associated with significant
complications; therefore. They are used only for patients with
urinary retention and in patients who are poor surgical risks.
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Surgical resection of the prostate gland is another option
for patients with moderate to severe lower urinary tract
symptoms of BPH and for those with acute urinary
retention or other complications. The specific surgical
approach and the energy source are based on the
surgeon’s experience, the size of the prostate gland, the
presence of other medical disorders, and the patient’s
preference. If surgery is to be performed, all clotting
effects must be corrected and medications for
anticoagulation withheld because bleeding is
complication of prostate surgery.
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Transurethral resection of the prostate (TURP) remains
benchmark for surgical treatment of BPH. It involves the
surgical removal of the inner portion of the prostate through
an endoscope inserted through the urethra; no external skin
incision is made. It 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 a traditional surgical prostatectomy.
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Other surgical options for BPH include transurethral incision
of the prostate (TUIP), transurethral electrovaporization,
laser therapy, and open prostatectomy. TUIP is an outpatient
procedure used to treat smaller prostates. One or two cuts
are made in the prostate and prostate capsule to reduce
constriction of the urethra and decrease resistance to flow
urine out of the bladder, and no tissue is removed. Open
prostatectomy involves the surgical removal of the inner
portion of the prostate via a suprapubic, retropubic, or
perineal approach for large prostate glands. Prostatectomy
may also be performed laparoscopically or by a robotassisted laparoscopy.
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Several tests help to confirm Benign Prostatic Hyperplasia (BPH)
diagnosis:
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Excretory urography may indicate urinary tract obstruction,
hydronephrosis, calculi or tumors, and filling and emptying defects in the
bladder.
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Elevated blood urea nitrogen
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Serum creatinine levels suggest impaired renal function.
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Urinalysis and urine culture
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Cystourethroscopy
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Intravenous pyelography (IVP)
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Transrectal prostatic ultrasound (TRUS)
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A prostate-specific antigen test may be performed to rule out
prostatic cancer.
Nursing diagnosis nursing care plans for Benign Prostatic Hyperplasia
(BPH)
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Urinary retention (acute or chronic) related to bladder
obstruction
Common nursing diagnosis found in patient with Benign
Prostatic Hyperplasia (BPH)
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Acute pain
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Fear/Anxiety [specify level]
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Impaired urinary elimination
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deficient Knowledge regarding condition,prognosis,
treatment, self-care, and discharge needs
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Risk for infection
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Risk for injury
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Sexual dysfunction
·
Urinary retention
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Urinary Retention Care (NIC) Independent Encourage patient
to void every 2–4 hr and when urge is May minimize urinary
retention/over distension of the noted. bladder.
Ask patient about stress incontinence when moving, High
urethral pressure inhibits bladder emptying or can sneezing,
coughing, laughing, lifting objects. inhibit voiding until
abdominal pressure increases enough for urine to be
involuntarily lost.
Observe urinary stream, noting size and force. Useful in
evaluating degree of obstruction and choice of intervention.
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Have patient document time and amount of each
voiding. Urinary retention increases pressure
within the ureters and Note diminished urinary
output.
Recommend sitz bath as indicated. Promotes
muscle relaxation, decreases edema, and may
enhance voiding effort.
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Collaborative Administer medications as indicated: Androgen
inhibitors, e.g., finasteride (Proscar); Reduces the size of the
prostate and decreases symptoms if taken long-term;
however, side effects such as decreased libido and
ejaculatory dysfunction may influence patient’s choice for
long-term use. Alpha-adrenergic antagonists, e.g.,
tamsulosin Studies indicate that these drugs may be as
effective as (Flomax), prazosin (Minipress), terazosin (Hytrin),
Proscar for outflow obstruction and may have fewer side
doxazosin mesylate (Cardura); effects in regard to sexual
function. Antispasmodics, e.g., oxybutynin (Ditropan);
Relieves bladder spasms related to irritation by the catheter.
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Prepare for surgical intervention, e.g.: Inflation of a balloon-tipped
catheter within the obstructed Balloon urethroplasty/transurethral
dilation of the area stretches the urethra and displaces prostatic
tissue, prostatic urethra; thus improving urinary flow. A procedure of
almost equivalent efficacy to transurethral Transurethral incision of
the prostate (TUIP); resection of the prostate (TURP) used for
prostates with estimated resected tissue weight of 30 g or less. It may
be performed instead of balloon dilation with better outcomes.
Procedure can be done in ambulatory or short-stay settings. Note:
Open prostate resection procedures (TURP) are typically performed
on patients with very large prostate glands. Heating the central
portion of the prostate by the insertion Transurethral microwave
thermotherapy (TUMT). of a heating element through the urethra
destroys prostate cells. Treatment is usually completed in a one-time
procedure carried out in the physician’s office.
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Recommend bedrest as indicated. Bedrest may be needed
initially during acute retention phase; however, early
ambulation can help restore normal voiding patterns and
relieve colicky pain. Provide comfort measures, e.g., back
rub, helping patient Promotes relaxation, refocuses
attention, and may enhance assume position of comfort.
Suggest use of coping abilities. relaxation/deep-breathing
exercises, diversional activities. Encourage use of sitz baths,
warm soaks to perineum. Promotes muscle relaxation.
Collaborative Insert catheter and attach to straight drainage
as indicated. Draining bladder reduces bladder tension and
irritability. Instruct in prostatic massage.
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Aids in evacuation of ducts of gland to relieve
congestion/inflammation. Contraindicated if infection is
present. Administer medications as indicated: Narcotics, e.g.,
meperidine (Demerol); Given to relieve severe pain, provide
physical and mental relaxation. Antibacterials, e.g.,
methenamine hippurate (Hiprex); Reduces bacteria present
in urinary tract and those introduced by drainage system.
Antispasmodics and bladder sedatives, e.g., flavoxate
Relieves bladder irritability. (Urispas), oxybutynin (Ditropan).
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Encourage increased oral intake based on individual needs.
Patient may have restricted oral intake in an attempt to
control urinary symptoms, reducing homeostatic reserves
Monitor BP, pulse. Evaluate capillary refill and oral and
increasing risk of dehydration/hypovolemia. mucous
membranes. Enables early detection of and intervention for
systemic Promote bedrest with head elevated. hypovolemia.
Decreases cardiac workload, facilitating circulatory
Collaborative homeostasis. Monitor electrolyte levels,
especially sodium. As fluid is pulled from extracellular spaces,
sodium may Administer IV fluids (hypertonic saline) as
needed. follow the shift, causing hyponatremia. Replaces
fluid and sodium losses to prevent/correct hypovolemia
following outpatient procedures.
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Anxiety Reduction (NIC) Independent Be available to patient.
Establish trusting relationship with Demonstrates concern and
willingness to help. Encourages patient/SO. discussion of sensitive
subjects. Provide information about specific procedures and tests
Helps patient understand purpose of what is being done, and what to
expect afterward, e.g., catheter, bloody urine, and reduces concerns
associated with the unknown, bladder irritation. Be aware of how
much information including fear of cancer. However, overload of
information patient wants. is not helpful and may increase anxiety.
Maintain matter-of-fact attitude in doing procedures/ Communicates
acceptance and eases patient’s dealing with patient. Protect patient’s
privacy. embarrassment. Encourage patient/SO to verbalize concerns
and feelings. Defines the problem, providing opportunity to answer
questions, clarify misconceptions, and problem-solve solutions.
Reinforce previous information patient has been given. Allows patient
to deal with reality and strengthens trust in caregivers and
information presented.
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Recommend avoiding spicy foods, coffee, alcohol, long May
cause prostatic irritation with resulting congestion.
automobile rides, rapid intake of fluids (particularly Sudden
increase in urinary flow can cause bladder alcohol). distension
and loss of bladder tone, resulting in episodes of acute
urinary retention. Address sexual concerns, e.g., during acute
episodes of Sexual activity can increase pain during acute
episodes but prostatitis, intercourse is avoided, but may be
helpful in may serve as massaging agent in presence of
chronic treatment of chronic condition. disease. Note:
Medications such as finasteride (Proscar) are known to
interfere with libido and erections. Alternatives include
terazosin (Hytrin), doxazosin mesylate (Cardura), and
tamsulosin (Flomax), which do not affect testosterone levels.
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Disease Process (NIC) Independent Provide information
about basic sexual anatomy. Having information about
anatomy involved helps patient Encourage questions and
promote a dialogue about understand the implications of
proposed treatments concerns. because they might affect
sexual performance. Review signs/symptoms requiring
medical evaluation, e.g., Prompt interventions may prevent
more serious cloudy, odorous urine; diminished urinary
output, inability complications. to void; presence of
fever/chills.
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Discuss necessity of notifying other healthcare providers
of Reduces risk of inappropriate therapy, e.g., use of
diagnosis. decongestants, anticholinergics, and
antidepressants, which can increase urinary retention
and may precipitate an acute episode. Reinforce
importance of medical follow-up for at least 6
Recurrence of hypertrophy and/or infection (caused by
mo to 1 yr, including rectal examination, urinalysis. same
or different organisms) is not uncommon and requires
changes in therapeutic regimen to prevent serious
complications. POTENTIAL CONSIDERATIONS
following acute hospitalization (dependent on patient’s
age, physical condition/presence of complications,
personal resources, and life responsibilities) Urinary
Retention [acute/chronic]—urethral obstruction,
decompensation of detrusor musculature, loss of
bladder tone. Infection, risk for—urinary stasis, invasive
procedure (periodic catheterization).
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Common nursing diagnosis found in patient with
Benign Prostatic Hyperplasia (BPH); Acute
pain, Fear, Anxiety, Impaired urinary
elimination, deficient Knowledge, Risk for
infection, Risk for injury, Sexual dysfunction,
Urinary retention
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Relieve acute urinary retention.
Promote comfort.
Provide information about disease process, prognosis, and
treatment needs.
Prevent complications.
Help client deal with psychosocial concerns.
Sample Nursing care plans for Benign Prostatic Hyperplasia
(BPH) with nursing diagnosis Urinary retention (acute or
chronic)
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Patient usually needs assistance with management of
therapy and catheter. 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
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Instruct patients about the need to maintain a high fluid
intake, to ensure adequate urine output.
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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.
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
Instruct the patient to follow the prescribed oral antibiotic
regimen, and tell him the indications for using gentle
laxatives.
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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.
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Encourage the patient to discuss any sexual concerns he
or his partner may have after surgery with the appropriate
counselors.
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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.
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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
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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.
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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.
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Reinforce importance of medical follow-up for at least 6
months to 1 year, including rectal examination and
urinalysis.
Prepare the patient for diagnostic tests and surgery as
appropriate.
Obtain a urine culture if UTI is suspected.
Administer antibiotics as ordered for UTI, urethral
procedures that involve instruments, and cystoscopy.
If urine retention occurs, insert an indwelling catheter.
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Monitor and record the patient’s vital signs, intake,
output, and daily weight.
Watch closely for signs of postobstructive diuresis such
as increased urine output and hypotension, which may
lead to serious dehydration, lowered blood volume,
shock, electrolyte loses, and anuria.
Instruct the patient to follow prescribed oral antibiotics
regimen and tell him the indications for using gentle
laxatives.
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Urge the patient to seek medical care immediately if he can’t
void, if he passes bloody urine, or if he develops a fever.
Advise the patient that it may take several months of medical
therapy before symptoms improve.
Urge him to seek medical care immediately if he can’t void, if
he passes bloody urine, or if he develops fever.
Submitted by: Chester Glee Zolina
Frances Mariel Ann Espinosa