Benign Prostatic Hyperplasia

Introduction
BPH is a non-cancerous enlargement or hypertrophy of the prostate, is one of the most
common diseases in aging men. In many patients older than 50 years, the prostate gland
enlarges, extending upward into the bladder and obstructing the outflow of urine by
encroaching on the vesicle orifice. This condition is known as benign prostatic hyperplasia,
the enlargement or hypertrophy of the prostate. It is the common urologic problem in male
adults. Prostatic hyperplasia does not predispose the individual to the development of prostate
cancer. It can cause bothersome lower urinary tract symptoms that affect quality of life by
interfering with normal daily activities and sleep patterns,
Incidence
It is the most common urologic problem in male adults. BPH typically occurs in men older
than 40 years of age. By the time they reach 60 years, 50% of men have BPH. It affects as
many as 90% of men by 85 years of age. BPH is the second most common cause of surgical
intervention in men older than 60 years. Most of the men in Asia are vegetarian; their low fat,
high fiber diet is weak in dietary phytoestrogens, which act as a chemopreventive agents. In
India very limited studies have been conducted on BPH. It is found to be the most common
pathological condition in men with a reported incidence of 92.97%.
Definition
Benign Prostatic Hyperplasia is an enlargement of the prostate gland resulting from an
increase in the number of epithelial cells and stromal tissue
Lewis
It is defined as non-cancerous increase in size of prostate gland which involves hyperplasia of
prostatic stromal and epithelial cell resulting in formation of large, fairly discrete nodules in
transitional zone of prostate, which push on and narrow the urethra resulting in an increase
resistance to flow of urine from the bladder.
The term benign prostatic enlargement is defined as prostate growth sufficient to
obstruct( block) the urethral outlet, resulting in bothersome lower urinary tract symptoms
(LUTS), urinary tract infection, hematuria or compromised upper urinary tract infection.
Black
Etiology
 Unknown
 Theories
 The amount of testosterone level in the blood decreases as men age, leaving a
higher proportion of estrogen which increases the activity of substances that
promote prostate cell growth
  A male hormone dihydrotestosterone, plays a role in prostate development
and growth. Scientists noted that men do not develop BPH when they do not
produce DHT. Older men continue to produce and accumulates high levels of
DHT in the prostate, even if testosterone production is reduced as they age,
which may encourage continues cell growth in the prostrate.

Risk Factors
 Aging- Prostate gland enlargement rarely causes signs and symptoms in men younger
than age 40. About one third of men experience moderate to severe symptoms by age
60 and about half do so by age 80
 Family history- Having a blood relative such as a father or brother with prostrate
problems means more likely to have problems.
 Ethnic background- Prostate enlargement is less common in Asian men than in white
and black men.
 Diabetes and heart disease- Studies show that diabetes, as well as heart disease and
use of beta blockers, might increase the risk of BPH.
 Lifestyle- Obesity increases the risk of BPH, while exercise can lower the risk
 Smoking
 Heavy alcohol consumption
 Reduced activity level
 Hypertension
 Diet high in animal fat and protein and refined carbohydrates, low in fiber

Pathophysiology
Exposure to risk factors and aging process

Elevated estrogen levels

Prolonged exposure
Increased sensitivity of prostrate to estrogens and less response to dihydrotestosterone(DHT)
( a metabolite of testosterone)

Hypertrophied lobes of the prostrate

Obstruct the bladder neck or urethra

Incomplete emptying of the bladder and urinary retention

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

Urinary retention

Urinary Tract Infections

Clinical Manifestations

 Early symptoms are usually minimal. Symptoms fall into two groups obstructive
symptoms and irritative symptoms.
 Obstructive symptoms caused by prostate enlargement which includes:decrease in
calibre and force of urinary stream, difficulty in initiating voiding,
intermittency(stopping and starting stream several times while voiding), and dribbling
at the end of urination. These symptoms are due to urinary retention.
 Irritative symptoms include: urinary frequency, urgency, dysuria, bladder pain,
nocturia, and incontinence are associated with inflammation or infection.
 Generalized symptoms may also be noted, including fatigue, anorexia, nausea,
vomiting and pelvic discomfort
 Chronic urinary retention and large amount of residual volumes can lead to azotemia.

Diagnosis

 History and physical examination

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 to record voiding frequency and urine volume.
 Digital rectal examination
Palpation reveals a large, rubbery and non tender prostate gland
 Urinalysis with culture
It is routinely done to determine the presence of infection
 Serum creatinine
To rule out renal insufficiency
 Prostate Specific Antigen
It is usually measured to find out prostate cancer. PSA levels may be slightly elevated
in patients with BPH.
 Postvoid residual urine volume
 Postvoid urine volume is often measured to determine the degree of urine flow
obstruction
 Uroflowmetry
It is a study that measures the volume of urine expelled from the bladder per second,
is helpful in determining the extent of urethral blockage and thus the type of treatment
needed.
 Transrectal ultrasound
In patients with an abnormal DRE and elevated PSA, a TRUS scan is done. It allows
for accurate assessment of prostate size and is helpful in differentiating BPH from
prostate cancer. Biopsies can be taken during the procedure
 Cystourethroscopy
It allows internal visualization of the urethra and bladder, is performed if the
diagnosis is uncertain and in patients who are scheduled for prostatectomy
Management
Goals: To restore bladder drainage, relieve the patient’s symptoms, and prevent or treat the
complications of BPH.
 The most conservative initial treatment is referred to as ‘’watchful waiting’’. When
there are no symptoms or only mild ones a wait and see approach is taken.
 Dietary changes (( decreasing intake of caffeine and artificial sweeteners, limiting
spicy or acidic foods), avoiding medications such as decongestants and
anticholinergics and restricting evening fluid intake may result in improvement of
symptoms.

Drug Therapy
 Drugs that have been used to treat BPH with variable degrees of success include 5-α
reductase inhibitors and α-adrenergic receptor blockers.
 Combination therapy using both types of drugs has been shown to be more effective
in reducing symptoms than using one drug alone.
 5-α reductase inhibitors: These drugs work by reducing the size of the prostate gland.
It blocks the enzyme 5-α reductase, which is necessary for the conversion of
testosterone to dihydroxy testosterone, the principal intraprostatic antigen. This drug
results in regression of hyperplastic tissue through suppression of androgens.
Eg: Finasteride and dutasteride.
Side effects include decreased libido, decreased volume of ejaculate, and erectile
dysfunction.
 α-adrenergic receptor blockers: α1 adrenergic receptors are abundant in the prostate
and are increased in hyperplastic prostate tissue. Relaxation of the smooth muscles
ultimately facilitates urinary flow through the urethra.
Eg: Alfuzosin, doxazosin, tamsulosin
Side effects include orthostatic hypotension, dizziness, retrograde ejaculation and
nasal congestion
 Invasive Therapy
It is indicated when there is a decrease in urine flow sufficient to cause discomfort ,
persistent residual urine , acute urinary retention because of obstruction with no
reversible precipitating cause, or hydronephrosis.
Various treatment options include:

Treatment Description
Invasive Use of excision and cauterization to remove prostate tissue
Transurethral resection of the cystoscopically. Considered the most effective treatment of
prostate BPH
Transurethral incision of the Involves making transurethral slits or incisions into
prostate prostatic tissue to relieve obstruction. Effective for men
with relatively little prostatic enlargement
Open prostatectomy Surgery of choice for men with large prostates, involves
external incision with three possible approaches
Minimally Invasive Use of microwave radiating heat to produce coagulative
Transurethral microwave necrosis of the prostate
thermotherapy
Transurethral needle ablation Low wave radiofrequency used to heat the prostate, causing
necrosis
Laser prostatectomy Procedure uses a laser beam to cut or destroy part of the
prostate. Different techniques are available:
Visual laser ablation of prostate(VLAP), contact laser
technique, interstitial laser coagulation(ILC)
Transurethral electro Electrosurgical vaporization and dessication are used
vaporization of prostate together to destroy prostatic tissue
Intra prostatic urethral stents Insertion of self expandable metallic stent into the urethra
where enlarged area of prostate occurs

Nursing Management
Preoperative goals:
 restoration of urinary drainage
 Treatment of any urinary tract infection
 Understanding of the upcoming procedure, implications for sexual
functioning, and urinary control
Postoperative Goals:
 No complications
 Restoration of urinary control
 Complete bladder emptying
 satisfying sexual expression
Nursing Diagnoses
1. Acute pain related to bladder irritability, irrigations, and distention; presence of
catheter; and surgical trauma as evidenced by reports of pain
 Intervention
 Monitor pain intensity, quality and duration
 Teach patient regarding non pharmacologic techniques before pain occurs
or increases, and along with other pain relief measures
 Explore with the patient factors that relieve or worsen pain
 Teach the patient and family members the action and side effects of pain
relieving agents
2. Urge urinary incontinence related to bladder irritation and poor sphincter control
as evidenced by involuntary leakage of urine
 Identify factors that contribute to incontinence episodes to plan appropriate
interventions
 Instruct patient to respond immediately to urge to void to prevent
involuntary leakage
 Explain aetiology of problem and rationale for actions to help patient plan
appropriate interventions
 Limit ingestion of bladder irritants (colas, coffee, tea and chocolate) to
decrease urinary urgency
 Limit fluids for 2-3 hour before bedtime to avoid night time urgency
3. Ineffective therapeutic regimen management related to lack of knowledge
regarding need for follow up care and activity restriction postoperatively as
evidenced by questioning or inaccurate comments about postoperative activity
 Formulate a maintenance plan for post-discharge follow up
 Coordinate referrals relevant to linkages among health care providers
 Assist patient or family or significant others in planning for supportive
environment necessary to provide for patients posthospital care
4. Anxiety related to bladder distention
Pre operative care
 Urinary drainage must be restored before surgery
 Prostatic obstruction may result in acute retention or inability to void
 A urethral catheter such as Coude (curved tip) catheter may be needed to
restore drainage
 Any infection of the urinary tract must be treated before surgery
 All type of prostatic surgery generally result in some degree of retrograde
ejaculation. The patient should be informed that the ejaculate may be
decreased in amount or totally absent
Post operative care
 The main complications following surgery are hemorrhage, bladder spasms,
urinary incontinence, and infection
 After surgery the patient will have a standard catheter or a triple lumen
catheter. Bladder irrigation is typically done to remove clotted blood from the
bladder and ensure drainage of urine
 Blood clots are expected in the first 24- 36 hours. However large amounts of
bright red blood in the urine can indicate hemorrhage
 Activities that increase abdominal pressure such as sitting or walking for
prolonged periods and straining to have a bowel movement should be avoided
in the post operative recovery period.
 Bladder spasms are a distressing complication for the patient after
transurethral procedures. They occur as a result of irritation of the bladder
mucosa from the insertion of the resectoscope, presence of catheter or clots
leading to obstruction of the catheter. Belladona and opium suppositories or
other antispasmodics (oxybutynin) along with relaxation techniques are used
to relieve pain and decrease spasm.
 Sphincter tone may be poor immediately after catheter removal resulting in
urinary incontinence or dribbling. Sphincter tone can be strengthened by
having the patient practice Kegel exercises (pelvic floor muscle technique) 10-
20 times per hour while awake.
 The patient should be observed for signs of postoperative infection. If an
external wound is present the area should be observe for redness, heat,
swelling and purulent drainage.
 Dietary intervention and stool softeners are important in the postoperative
period to prevent the patient from straining while having bowel movements.
 The patient should be instructed to drink at least 2L of fluid per day and
urinate every 2 to 3 hours to flush the urinary tract

Conclusion
BPH is a part of ageing. It is common for the prostate gland to become
enlarges as a man ages. The prostate gland surrounds the urethra. As the
prostate gets bigger, it may squeeze or partly block the urethra, which causes
problems with urinating. BPH is benign it is not a cancer. About half of all
men between ages 51 and 60 have BPH. Upto 90% of men over age 80 have it.
The patient should be advised to have an yearly digital rectal examination of
he had any procedure other than complete removal of the prostate.

Bibliography
1. Brunner and Suddarth,” Textbook of medical surgical nursing”, South asian
edition; Wolters Kluwer publications
Page no: 1219-1221
2. Chintamani, “Lewis’s medical surgical nursing”; south asian edition; Elsevier
publications
Page no: 1377- 1383
3. Stuart H Ralson, ”Davidson’s principles and practice of medicine”, 23rd
edition; Elsevier publication.
Pgno: 437- 438
4. Joyce M Black, “Medical- Surgical nursing”: 8th edition,vol 1, Elsevier
publications
Page no:873-886

SEMINAR ON
 BENIGN PROSTATIC

HYPERPLASIA

Submitted to Submitted by
Dr. Liny Joseph Anju Rachel Jose
Asst. Professor 1st year Msc Nursing
Govt college of nursing, Kottayam Govt college of nursing, Kottayam