INTRODUCTION I.

DEFINITION Benign prostatic hyperplasia is a noncancerous (benign) enlargement of the prostate gland that can make urination difficult. It is also called Benign Prostatic Hypertrophy, but the preferred term used is Benign Prostatic Hyperplasia due to pathologic process. Prostatic changes are caused by hyperplasia not hypertrophy. II.ETIOLOGY: Unknown III. RISK FACTORS 1. Age (above 50 y/o) As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. Estrogen appears to be involved in the induction of androgen receptor into which dihydrotestosterone (DHT), an active factor in BPH, binds with leading to tissue growth. 2. Family History A family history of BPH appears to increase a man's chance of developing the condition. 3. Race (African American) African Americans are at risk to BPH because they are less likely to visit their doctor. 4. Hormonal Factors A. Testosterone Free plasma testosterone enters prostatic cells wherein it is converted into DHT by the action of an enzyme 5-alpha reductase. High levels of 5-alpha reductase are found in nuclear membrane microsomes of prostatic epithelial cells. Prostatic levels of DHT, as well as the androgen receptor, remain high with aging, despite the fact that levels of testosterone decrease. B. Estrogen Estrogen appears to be involved in the induction of androgen receptor into which dihydrotestosterone (DHT) binds with. It also inhibits the rate of cell death thus, allowing increase abnormal cell proliferation. 5. Obesity High levels of fat can alter the production of sex hormones. 6. Diet (high in fat) IV.CLINICAL MANIFESTATIONS 1. Urinary urgency 2. Difficulty urination 3. Weak urinary stream 4. Postvoid dribbling 5. Sensation of incomplete emptying of the bladder 6. Acute urinary retention 7. Increased urinary frequency 8. Pain 9. Hematuria 10. Nocturia V.COMPLICATIONS 1. Urinary stasis 2. Urinary tract infection 3. Hydroureter - dilation of the ureters 4. Hydronephrosis - dilation of the kidneys 5. Acute renal failure 6. Chronic renal failure

VI.DIAGNOSTIC TESTS 1) Digital Rectal Examination Digital rectal examination is used to examine external surface of the prostate. It is performed to assess prostate size, shape, and consistency of the prostate gland. It also differentiates BPH from prostate enlargement caused by adenocarcinoma or infection. It is recommended as part of the regular health checkup every year for every man older than 40 years of age. Normal Findings: No problems such as organ enlargements or growths felt. Abnormal Findings: BPH reveals a symmetrically enlarged prostate with an obliterate central sulcus (large, palpable prostate with a smooth rubbery surface) Prostatic infection(prostitis) is associated with symmetrical enlargement, a boggy consistency and discomfort on palpation Adenocarcinoma of the prostate is associated with asymmetric enlargement, hardened nodules or induration. Nursing Responsibilities: Explain the purpose of the procedure to the patient. Inform patient who will perform the procedure and when will it be done. Explain how the patient can cooperate. Provide privacy and proper draping. Prepare the patient. Inform patient that he needs not to restrict foods and fluids. Encourage the patient to relax. Explain to the patient that he may experience slight discomfort from the examination. Position patient in left side lying position with knees bent toward chest. Not right side lying due to contour of rectum. Latex-free gloves should be available if the patient or clinician is allergic to latex. 2) Urinalysis Urinalysis provides important clinical information about the function of the kidneys. This test evaluates physical characteristics of urine; determine specific gravity and pH; detects and measures protein, glucose and ketone bodies and examines sediments for blood cells, casts & crystals. The amount of creatinine and urea excreted in the urine can be used to calculate the level of kidney function and the glomerular filtration rate (GFR). Normal Findings: Minimal numbers of red and white blood cells; no bacteria; clear urine with no occult blood and no protein. Abnormal Findings: Urinary tract infection may occur with the presence of bacteria, blood, leukocytes, protein, or glucose due to urinary retention may lead to infection. Nursing Responsibilities: Explain the purpose of the procedure to the patient. Inform the patient that the test requires a urine specimen and that no restriction of fluids and foods is necessary. Observe standard precautions when handling urine specimen. Instruct patient how to collect a clean-voided midstream specimen. Instruct patient to wash his hands then clean the genitalia.

 Instruct patient to begin urinating in the toilet, then stop and continue to urinate into the sterile cup without touching the inside of cup. When obtaining a specimen from an indwelling urinary catheter it may necessary to clamp tubing below the collection port to collect a specimen in the tubing. Then use an alcohol pad to clean the port. Next, using sterile needle and syringe, aspirate 4 ml specimen from the port and transfer it into a sterile specimen cup.

3) Renal function tests (blood urea nitrogen{BUN} and creatinine levels) Renal function tests are used as an estimate of the glomerular filtration rate and renal function, performed to determine if there is renal impairment from prostatic back-pressure and to evaluate renal reserve Normal Findings: Creatinine level: 0.6 to 1.2 mg/dL (50 to 110 mmol/L) BUN level: 7 to 18 mg/dL : Patient > 60 y/o: 8 to 20 mg/dL BUN/Creatinine ratio: 10:1 to 20:1 Abnormal Findings: >20:1 with normal/decrease creatinine occurs in the following conditions: Heart failure, salt depletion, dehydration Catabolic states with tissue breakdown GI hemorrhage Impaired renal function >20:1 with elevated creatinine occurs in the following conditions: Obstruction of urinary tract Prerenal azotemia <10:1 with decrease BUN occurs in the following condition: Acute tubular necrosis Decrease urea synthesis SIADH <10:1 with increased creatinine occurs in the following conditions: Muscular patients who develop renal failure Rhabdomyolysis(release muscle creatinine) Nursing Responsibilities: Explain the purpose of the procedure to the patient. Prepare the patient. Tell the patient that the test requires a blood sample. Explain how the patient can cooperate. Inform patient who will perform the procedure and when will it be done. Explain to the patient that she may experience slight discomfort from the tourniquet and needle puncture. Apply direct pressure to the venipuncture site. Inform the patient that he need not restrict food and fluids. Not to eat meat or protein intake. 4) Prostate-Specific Antigen(PSA) Test Differential Diagnosis only Prostate-specific antigen test is used to screen for prostatic cancer over 50 years every year. PSA is a specific antigen produced by the cells of the prostate capsule (membrane covering the prostate) and periurethral glands. Levels are raised in men with noncancerous (benign) enlargement of the prostate and considerably higher in men with prostate cancer. Normal Findings: 0-4 ng/ml Abnormal Findings: 4-8 ng/ml may represent benign prostatic hyperplasia or possible cancer of the prostate. >8 ng/ml highly suggestive of prostatic cancer

Nursing Responsibilities: Explain the purpose of the procedure to the patient. Tell the patient that the test requires a blood sample. Inform patient that he needs not to restrict foods and fluids. Inform patient who will perform the procedure and when will it be done. Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture. Apply direct pressure to the venipuncture site. 5) Cystourethroscopy Cystourethroscopy allows direct visualization of the tissue of the lower urinary tract (urethra, bladder and ureters). It is a test that combines two endoscopic techniques, one of the instruments used in this test is the cystoscope, which has a fiber-optic light source, a magnification system, a right angled telescopic lens, and an angled beak for smooth passage into the bladder. The other instrument, the urethroscope, is similar, but has a straight-ahead lens and is used for examination of the bladder neck and the urethra. Normal Findings: The urethra, bladder and urethral orifices appear normal in shape, size and position. The case mucosa lining the lower urinary tract should appear smooth and shiny, with no evidence of erythema, cyst or other abnormalities. The bladder should be free from obstructions, tumors and calculi. Abnormal Findings: Enlarged prostate Urethral stricture Calculi Tumors Diverticula Nursing Responsibilities Before: Make sure that the patient or responsible family member has signed an informed consent. Explain the purpose of the procedure to the patient. Unless a general anesthetic has been ordered, inform the patient that he needs not to restrict foods and fluids. If a general anesthetic will be administered, instruct the patient to fast for 8 hours before the test. Tell the patient who will perform the test, where it will take place, and it takes about 2030 minutes. Inform the patient that he may fell discomfort after the procedure, including a slight burning when he urinates. During: Provide patients privacy Place patient in lithotomy position during the procedure. Drape patient properly. Inform patient that desire to void is felt as cystourethroscope is inserted. After: Monitor vital signs and urine output. Instructed patient to have bed rest until VS are stable to prevent orthostatic hypotension. Pink tinged urine is normal 24-48 hours after the procedure due to irritation of mucous membrane during the insertion of cystourethroscope. Observe for urinary retention, sign of infection and excessive hematuria. Encourage increase fluid intake to prevent ascending UTI. 6) Intravenous Pyelography Intravenous pyelography is a radiological procedure requires I.V. administration of contrast medium and allows visualization of the renal parenchyma, calyces, and pelvis as well as the ureters and bladders.

Normal Findings: The kidneys, ureters, and bladder show no gross evidence of soft or hard tissue lesions. Prompt visualization of the contrast medium in the kidneys demonstrates bilateral renal parenchyma and pelviccalyceal system of normal conformity. The ureters and bladder show no mucosal abnormalities and minimal residual volume.

Abnormal Findings: Renal or ureteral calculi Abnormal size, shape or structure of the kidneys, ureters and bladder Pyelonephrosis Hydronephrosis Space occupying lesion

Nursing Responsibilities: Before: Obtain informed consent. Explain the purpose of the procedure to the patient. Assess the patient for allergies to iodinated dye or shellfish. Keep patient NPO for 6-8 hours before the test. Tell him who will perform the test and where it will take place. Inform patient that he may experience a transient burning sensation and metallic taste when contrast is injected. During: Provide patients privacy Place patient in supine position on the X-ray table during the procedure. Drape patient properly. After: Monitor vital signs. Encourage patient to increase fluid intake to prevent urinary tract infection and excrete the dye. Burning sensation on voiding may be experienced. Evaluate patient for delayed reaction to the dye. This usually occurs 2-6 hours after the test. Treat antihistamine or steroids, as ordered. VII.MEDICAL MANAGEMENT 1) Watchful waiting Watchful waiting is the appropriate treatment for many patients because the likelihood of progression of the disease or the development of complications is unknown. Patients are monitored periodically for severity of symptoms, physical findings, laboratory tests, and diagnostic urologic tests. 2) Medications A. 5-Alpha reductase inhibitors such as finasteride (Proscar) and dutasteride (Avodart) prevent the conversion of testosterone to the hormone dihydrotestosterone (DHT). It inhibits enzyme 5alpha reductase to convert into DHT. With decreased levels of DHT, suppression of glandular cell activity and decreases in prostate size has been demonstrated. Side effects of these medications include gynecomastia (breast enlargement), erectile dysfunction, and flushing. In many cases, a treatment period of 6-month is necessary to see if the therapy is going to work. These drugs are taken orally, once a day. Finasteride is available in tablet form and dutasteride is available as soft gelatin capsules. Patients should see their physician regularly to monitor side effects and adjust the dosage, if necessary. B. Alpha-adrenergic receptor blockers (eg, terazosin [Hytrin]) relax the smooth muscle of the bladder neck and prostate. These agents help to reduce obstructive symptoms in many patients.

VIII.SURGICAL MANAGEMENT 1) Prostatectomy a) Transurethral Resection of Prostate(TURP) Transurethral resection of prostate is a closed method of treatment without incision made and the hyperplastic prostate tissue is removed/excise through resectoscope which is inserted through the urethra. The gland is removed in small chips with an electrical cutting loop. Continuous bladder irrigation or cystoclysis is done postoperative to irrigate the bladder and remove blood clots. b) Suprapubic (transvesical) Prostatectomy Suprapubic (transvesical) prostatectomy is a surgical approach that involves a lower abdominal incision. Open method treatment in which hyperplastic tissue is enucleated through the anterior walls of the abdomen and bladder. It may be operation of choice when the prostate is too large to be resected transurethrally, a large, pecundulated middle prostatic lobe or lateral lobes are present, a bladder abnormality needs correction, and an abdominal surgical exploration is necessary. Continuous bladder irrigation or cystoclysis is done postoperative to irrigate the bladder and remove blood clots. c) Retropubic (extravesical) Prostatectomy Retropubic (extravesical) prostatectomy is an open method treatment where a low abdominal incision is made between the pubic arch and the bladder. The surgeon approaches the prostate a low abdominal incision without entry into the bladder. This is the operation of choice when the prostate is very large and severe urethral stricture is present. Continuous bladder irrigation or cystoclysis is done postoperative to irrigate the bladder and remove blood clots. d) Perineal Prostatectomy Perineal prostatectomy is an open method of treatment involving an incision between the anus and the scrotum. Postoperaively, the wound may easily become contaminated because the incision is near the rectum. This operation is rarely used for treating BPH because great potential for erectile dysfunction. Nursing Responsibilities: Secure consent. Explain the purpose of the procedure to the patient. Inform patient who will perform the procedure and when will it be done. Observe proper draping. Let the patient verbalize his feelings. Provide patients privacy. Position the patient appropriately. Observe proper hygiene before and after the procedure. Monitor vital signs and urine output. 2) Balloon Dilatation of the Prostate Balloon dilatation of the prostatic urethra, or balloon urethroplasty, is a therapeutic procedure intended to manage symptoms associated with benign prostatic hypertrophy. Under fluoroscopic guidance, a flexible balloon catheter is placed in the urethra at the level of the prostate above the external sphincter. The balloon is then inflated for a short period of time to distend the prostatic urethra. This widening process is intended to relieve obstruction of the urethra caused by the enlarged prostate and alleviate the symptoms of benign prostatic hypertrophy (e.g., urinary retention, urgency, hesitancy, nocturia, and dysuria). Nursing Responsibilities: Secure consent. Explain the purpose of the procedure to the patient. Observe proper draping. Let the patient verbalize his feelings. Take vital signs. Provide patients privacy Position the patient appropriately

 Observe proper hygiene before and after the procedure. 3) Transurethral Incision of the Prostate (TUIP) Transurethral incision of the prostate may be recommended to treat a prostate that is not greatly enlarged. The surgeon makes one or more cuts in the bladder neck where the urethra joins the bladder, extending into the prostate. This reduces the prostate's pressure on the urethra and makes urination easier.

4) Transurethral ultrasound-guided laser incision of the prostate (TULIP) It is a new minimally invasive procedure that is similar to TUIP, except that the cuts are made with a laser. It is associated with minimal blood loss, no irrigation is necessary. 5) Prostatic Stent Prostatic stents are used most often for patients with significant medical problems that prohibit medication or surgery. It is designed to relieve urinary obstruction in men and improve the ability to urinate. It is a tiny, springlike device inserted into the urethra. When expanded, it pushes back the surrounding tissue and widens the urethra. They can be placed in less than 15 minutes under regional anesthesia and bleeding during and after is minimal. Nursing Responsibilities: Explain the purpose of the procedure to the patient. Inform patient who will perform the procedure and when will it be done. Observe proper draping. Let the patient verbalize his feelings. Provide patients privacy. Position the patient appropriately. Observe proper hygiene before and after the procedure. Monitor vital signs and urine output. IX.ALTERNATIVE TREATMENTS 1) Nutrition Eat whole, fresh, unrefined, and unprocessed foods. Include fruits, vegetables, whole grains, soy, beans, seeds, nuts, olive oil, and cold-water fish (salmon, tuna, sardines, halibut, and mackerel). Avoid refined sugar and flour, dairy products, refined foods, fried foods, junk foods, hydrogenated oils, alcohol (particularly beer), and caffeine. 2) Supplements Supplements are intended to provide nutritional support. Because a supplement or a recommended dose may not be appropriate for all persons, a physician (i.e., a licensed naturopathic physician or holistic MD) should be consulted before using any product. Recommended doses follow: Amino acids The combination of glycine, alinine, and glutamic acid (200 mg of each daily) reduces urinary urgency, urinary frequency, and delayed micturition (initiation of flow). Beta-sitosterol 120 mg daily in 3 divided doses may help reduce symptoms. Betasitosterol also lowers cholesterol (a higher dose of 500 mg 3 times daily is required), which is important since high cholesterol levels can cause prostatic hyperplasia.

3) Herbal remedies Herbal medicines usually do not have side effects when used appropriately and at suggested doses. Occasionally, an herb at the prescribed dose causes stomach upset or headache. This may reflect the purity of the preparation or added ingredients, such as synthetic binders or fillers. For this reason, it is recommended that only high-quality products be used. As with all medications, more is not better and overdosing can lead to serious illness and death.

These herbs may be used to treat BPH: Saw palmetto (Serenoa repens) Inhibits the conversion of testosterone to DHT in the prostate, has an antiestrogenic effect, and helps improve all symptoms of BPH. Recommended dosage is 320 mg of extract (standardized to contain approximately 85% fatty acids and sterols) daily. Pygeum (Pygeum africanum) Reduces BPH symptoms. Recommended dosage is 100200 mg of extract (standardized to 14% triterpenes) 2 times daily.