Benign Prostatic Hypertrophy

It is also called enlarged prostate. In approximately one half of men 50 years and older, the prostate gland enlarges, extending upward into the bladder and obstructing the outflow of urine by encro

aching on the vesical orifice. One of four men who reaches 80 years of age will require treatment for BPH. Pathophysiology and Etiology:

The process of aging and the presence of circulating androgens are required for the development of BPH. The prostatic tissue forms nodules as enlargement occurs. The normally thin and fibrous outer capsule of the prostate becomes spongy and thick as enlargement progresses. The prostatic urethra becomes compressed and narrowed, requiring the bladder musculature to work harder to empty urine. Effects of prolonged obstruction cause trabeculation of the bladder wall, decreasing its elasticity.

Clinical Manifestations:

In early or gradual prostatic enlargement, there may be no symptoms because the bladder musculature can initially compensate for increased urethral resistance. Obstructive symptoms include: urinary hesitancy diminution in size and force of urinary stream terminal dribbling sensation of incomplete emptying of the bladder urinary retention Irritative voiding symptoms include: Urgency Frequency Nocturia

Diagnostic Evaluation:

Rectal examination would reveal smooth, firm, symmetric enlargement of the prostate Urinalysis to rule out hematuria and infection Serum creatinine and BUN to evaluate renal function

Serum PSA to rule out cancer, but may also be elevated in BPH Optional diagnostic studies for further evaluation include: Urodynamics to measure peak urine flow rate, voiding time and volume, and status of the bladders ability to effectively contract Measurement of post-voidal residual urine by ultrasound or catheterization Cystourethroscopy to inspect urethra and bladder and to evaluate prostatic size

Complications:

acute urinary retention involuntary bladder contractions bladder diverticula cystolithiasis vesicoureteral reflux gross hematuria and UTI

Management:

Patients with mild symptoms are follow-up annually as BPH does not necessarily worsen in all men. Pharmacologic treatment: Alpha-adrenergic blockers to relax the smooth muscle of bladder base and prostate to facilitate voiding Finasteride has an anti-androgen effect on prostatic cells by reversing or preventing hyperplasia Surgery such as transurethral incision of the prostate or open prostatectomy, usually by suprapubic approach Newer approaches include laser surgery, transurethral electrovaporization, transurethral needle ablation, and thermotherapy

Photo credits: www.healthguide.howstuffworks.com Nursing Management:

Provide privacy and time for the patient to void. Assist with catheter introduction Monitor intake and output. Monitor patency of catheter Administer medications as ordered and educate patient about its side and adverse effects. Assess for and teach patient to report hematuria and signs of infection. Explain the possible complications of BPH and to report this at once. Advise patient to avoid drugs that impair voiding such as OTC cold medications containing sympathomimetics like phenylpropanolamine. Encourage compliance to follow-up check ups.

TURP (Transurethral Resection of the Prostate) is the most common procedure used to treat BPH. It can be carried out through endoscopy. The surgical and optical instrument is introduced directly through the urethra to

the prostate, which can then be viewed directly. The gland is removed in small chips with an electrical cutting loop.This procedure, which requires no incision, may be used for glands of varying size and is ideal for patients who have small glands and for those who are considered poor surgical risks.Newer technology uses bipolar electrosurgery and reduces the risk of TUR syndrome (hyponatremia, hypovolemia).TURP usually requires an overnight hospital stay. Urethral strictures are more frequent than with (non-trans-urethral procedures, and repeated procedures may be necessary because the residual prostatic tissue grows back. TURP rarely causes erectile dysfunction, but may trigger retrograde ejaculation because removal of the prostatic tissue at the bladder neck can cause seminal fluid to flow backward into the bladder rather forward through the urethra during ejaculation. Pre-operative Management: 1. Inform the patient about the procedure and the expected postoperative care, including catheter drainage, irrigation and monitoring of hematuria. 2. Discuss the complications of surgery which include: 3. Incontinence or dribbling of urine up to 1 year after surgery and that Kegels exercise will help alleviate this problem 4. Retrograde ejaculation 5. Bowel preparation is given. 6. Optimal cardiac, respiratory and circulatory status should be achieved to decrease risk of complications. 7. Prophylactic antibiotics are ordered. Post-operative Management: 1. Urinary drainage is maintained and observed for signs of hemorrhage. 2. Maintain patency of urethral catheter. 3. Avoid overdistention of bladder, which could lead to hemorrhage. 4. Administer anti-cholinergic medications to reduce bladder spasms. 5. Maintain bed rest for the first 24 hours. 6. Encourage early ambulation, thereafter to prevent embolism, thrombosis and pneumonia. 7. Wound care is provided to prevent infection. 8. Administer pain medications. 9. Promote comfort through proper positioning. 10. Administer stool softeners to prevent straining that can lead to hemorrhage. 11. Reduce anxiety by providing realistic expectations about postoperative discomfort and overall progress.

12. Encourage patient to express fears related to sexual dysfunctions and to discuss with partner. 13. Teach measures to regain urinary control.