BPH

BPH (BENIGN PROSTATIC HYPERPLASIA)

INTRODUCTION

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 vesical orifice.  It is a common disorder of the aging male. The prostate is very small at birth but grows at puberty to adult size at age 20years.

      

DEFINITION

BPH is defined as an aged related nonmalignant enlargement of the prostate gland.

CAUSES

The cause is uncertain, but evidence suggests that hormones (Testicular androgen has been implicated) has been implicated. Dihydrotestosterone (DHT), a metabolic of testosterone, is a critical mediator of prostatic growth. Estrogen may also play a role in the cause of BPH. BPH generally occurs when men have elevated estrogen levels and when prostate tissue become more sensitive to estrogen and less responsible to DHT).

RISK FACTORS

Risk factors for prostate gland enlargement include:

·         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 prostate problems means you're more likely to have problems.

·         Ethnic background. Prostate enlargement is less common in Asian men than in white and black men. Black men might experience symptoms at a younger age than white 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.

·         Western diet. Diet high in animal fat, protein, refine carbohydrate, and diet low in fibres.

PATHOPHYSIOLOGY

The prostate gland is located beneath the bladder. The tube that transports urine from the bladder out of the penis (urethra) passes through the centre of the prostate. When the prostate enlarges, it begins to block urine flow.

The two necessary preconditions for BPH are of 50 years or greater and the presence of testes. Men who are castrated before puberty do not develop BPH. The androgen that mediate the prostatic growth is dihydrotestosterone (DHT) which is formed in the prostate from the testosterone. Although androgen levels decrease in ageing men, the ageing prostate appears to become more sensitive to available DHT. Estrogen produces in small quantity in men appears to sensitise the prostate gland to the effect of DHT. Increase estrogen levels associated with ageing or relative increase related to testosterone levels may contribute to prostatic hyperplasia.

BPH begins as small nodules in the periurethral glands, which are the inner layers in the prostate gland. The prostate enlarges through formation and growth of nodules (hyperplasia) and enlargement of glandular cells (hypertrophy). These changes occur over a long period of time.

The hypertrophy results in the obstruction of the vesical neck or prostatic urethra, causing incomplete emptying of the bladder and urinary retention. As a result, a gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis) can occur. Urinary stasis can also lead to urinary tract infections because dome urine remains in the urinary tract can serve as a medium for the growth of infectious organism.

CLINICAL MANIFESTATION

The severity of symptoms in people who have prostate gland enlargement varies, but symptoms tend to gradually worsen over time. Common signs and symptoms of BPH include:

·         Urinary frequency, urgency.

·         Increased frequency of urination at night (nocturia)

·         Hesitancy in starting urine

·         Decreased and intermittent force of stream.

·         Dribbling at the end of urination

·         Abnormal straining while urinating

·         Sensation of incomplete bladder emptying.

·         Urinary tract infection

·         Inability to urinate

·         Blood in the urine

General symptoms may also be noted including fatigue, anorexia, nausea, vomiting and pelvic discomfort.

ASSESSMENT AND DIAGNOSTIC FINDINGS

·         Urine test. Analysing a sample of the urine can help rule out an infection or other conditions that can cause similar symptoms.

·         Blood test. The results can indicate kidney problems.

·         Prostate-specific antigen (PSA) blood test. PSA is a substance produced in the prostate. PSA levels increase when there is an enlarged prostate. However, elevated PSA levels can also be due to recent procedures, infection, surgery or prostate cancer.

·         Neurological exam. This brief evaluation of the mental functioning and nervous system, can help identify causes of urinary problems other than enlarged prostate.

·         Postvoid residual volume test. This test measures whether bladder can be emptied completely. The test can be done using ultrasound or by inserting a catheter into the bladder after urination to measure how much urine is left in bladder.

·         24-hour voiding diary. Recording the frequency and amount of urine might be especially helpful if more than one-third of your daily urinary output occurs at night.

·         Transrectal ultrasound. An ultrasound probe is inserted into the rectum to measure and evaluate the prostate.

·         Prostate biopsy. Transrectal ultrasound guides needles used to take tissue samples (biopsies) of the prostate. Examining the tissue can help diagnose or rule out prostate cancer.

·         Urodynamic and pressure flow studies. A catheter is threaded through the urethra into the bladder. Water or, less commonly, air is slowly injected into the bladder. This helps to measure bladder pressure and determine how well the bladder muscles are working.

·         Cystoscopy. A lighted, flexible cystoscope is inserted into the urethra, allowing to see inside the urethra and bladder. local anaesthesia may be given before this test.

·         Intravenous pyelogram or CT urogram. A tracer is injected into a vein. X-rays or CT scans are then taken of the kidneys, bladder and the tubes that connect the kidneys and the bladder (ureters). These tests can help detect urinary tract stones, tumors or blockages above the bladder.

PREVENTION

Men at risk are advised:

i.                    Eat healthful, low fat foods: research shows that men who consume a diet low in red meat (which is high in saturated fat) and overall fat (such as The Prostate Diet) are less likely to develop benign prostatic hyperplasia.

ii.                  Achieve and maintain a healthy weight: Numeral studies has shown a link between overweight and having a high risk of BPH

iii.                Exercise regularly: a recent review of 14 studies that evaluated the impact of exercise on BPH found strong evidence that exercise helps prevent the development of BPH.

iv.                Live a prostate friendly lifestyle: smoking and irregular sleep patterns can affect the health of the prostate gland.

v.                  Maintain hormone balance

vi.                Cut caffeine intake

vii.              Keep diabetes under control

MEDICAL MANAGEMENT

The goals of medical management of BPH are to improve the quality of life, improve urine flow, relieve obstruction, prevent disease progression an minimize complication.

The treatment plan depends on the cause of BPH, the severity of the obstruction, and the patient’s condition. The medical management of BPH includes:

CATHETERIZATION

This is the passage of a tube known as a catheter into the urinary bladder to drain it and to relieve stress. If the patient is admitted on an emergency basis because he cannot 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 called a stylet is introduced (by a urologist) into the catheter to prevent the catheter from collapsing when it encounters resistance. In severe cases, metal catheters with a pronounced prostatic curve may be used. Sometimes an incision is made into the bladder (a suprapubic cystostomy) to provide drainage.

PHARMACOLOGICAL THERAPY

Pharmacological management of BPH includes the following:

i.                    α-blockers such as doxazosin, terazosin and tamsulosin improve symptoms and bladder outflow rates in 60–90% of patients, but may cause unacceptable hypotension.

ii.                  Finasteride is a 5 alpha reductase inhibitor which inhibits the conversion of testosterone to dihydrotestosterone. It is also useful, but generally less effective for symptoms than α-blockers. It seems to be more effective in those with very large prostates and its effects may improve with time.

SURGICAL TREATMENT.

i.  Transurethral resection of the prostate (TURP) has been the standard treatment. The procedure involves removal of prostatic tissue using electrocautery via a resectoscope from within the prostatic urethra, under general or spinal anaethesia. Post-operatively patients require a three-way catheter and continuous bladder irrigation to reduce the risk of clot retention until haematuria is mild.

ii.Although prostatectomy to remove the hyperplastic prostatic tissue is frequently performed, other treatment options are available. These include and Transurethral Incision of the Prostate (TUIP), or open prostatectomy, balloon dilation, alpha-blockers, 5-alpha-reductase inhibitors, transurethral laser resection, transurethral needle ablation, and microwave thermotherapy.

NURSING MANAGEMENT

Nursing care for patients with benign prostatic hyperplasia includes preparation for surgery (if possible) administration of medications for pain, and relieving urinary retention.

NURSING PROCESS

ASSESSMENT

i.        History taking: history of voiding symptoms, including onset, frequency of the day and night urination, presence of urgency, dysuria, sensation of incomplete bladder emptying, and decreased force of stream.

ii.      Physical examination: Perform rectal (palpate size, shape, and consistency) and abdominal examination to detect distended bladder, degree of prostatic enlargement. Perform simple urodynamic measures uroflowmetry and measurement of postvoid residual, if indicated.

NURSING DIAGNOSIS

·         Acute pain related to prostatic bed enlargement evident by patient verbalization.

·          impaired urinary elimination related to the constriction of the urethra evidence by dribbling, decrease urine output.

·         Risk for urinary tract infection related to stasis of urine secondary to obstruction.

GOAL

·         Patient will verbalize less pain within 2-3 hours of Nursing intervention.

·         Patient will return to normal voiding pattern within 24 to 48 hours of Nursing intervention.

·         Patient will no exhibit signs and symptoms od urinary tract infection throughout the period of hospitalization.

NURSING INTERVENTIONS

i.        Provide privacy for the patient and allow enough time for voiding.

ii.      Palpate/percuss suprapubic area to check for bladder distention.

iii.    Encourage to increase oral fluid intake up to 2-4L of water as tolerated.

iv.    Assist with the catheter insertion as indicated.

v.      Monitor vital signs and input and output.

vi.    Maintain patency of the catheter.

vii.    Administer medications as ordered and provide health teaching on how to check for the side-effects.

§  Alpha-adrenergic blockers – orthostatic hypotension, syncope, blurred vision, impotence, rebound hypertension if discontinued suddenly

§  Finasteride (Proscar) – impotence, hepatic dysfunction, interference with PSA testing

viii.Maintain the 3-port catheter postop. One port is for irrigation, another is for drainage, and the third to inflate a balloon that holds the catheter in position.

ix.    Monitor intake and output.

x.      Monitor vital signs for changes.

xi.    Monitor postoperative patient’s bladder irrigation

xii.  Monitor the amount of fluid instilled and the amount of fluid returned and subtract the amount of fluid instilled from the amount returned to determine the actual urine output.

xiii.Document color of urinary output postoperatively; the greatest risk of hemorrhage is the first day after the operation.

xiv.Monitor for bladder spasms which may indicate blocked catheter drainage postoperatively.

xv.  Teach patient to Avoid caffeine, alcohol, decongestants, anticholinergics which may increase symptoms of BPH.

xvi.Proper home care of urinary catheter.

xvii.                      Monitor for signs of urinary tract infection.

OUTCOME

·         Patient verbalize less pain within 2hours of Nursing intervention.

·         Patient regain a normal urinary elimination pattern within 24 – 48 hours of Nursing intervention.

·         Patient did not exhibit the signs and symptoms of urinary tract infection within the period of hospitalization.

COMPLICATIONS

Bladder decompensation due to chronically increased residual volumes (urine retained after voiding), the bladder may become less contractile, lowering flow rates further. Obstruction may lead to dilated ureters and kidney (hydroureter, and hydronephrosis). Other Complications of enlarged prostate can include:

·         Urinary tract infection

·         Urinary stones

·         Kidney damage

·         Bleeding in the urinary tract.
  
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