BENIGN PROSTATIC HYPERPLASIA (Enlarge Prostaste)

DEFINITION Benign prostatic hyperplasia (BPH) also known as benign prostatic hypertrophy, benign enlargement of the prostate (BEP), and adenofibromyomatous hyperplasia, refers to the increase in size of the prostate. To be accurate, the process is one of hyperplasia rather than hypertrophy, but the nomenclature is often interchangeable, even amongst urologists. It is characterized by hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region of the prostate. When sufficiently large, the nodules compress the urethral canal to cause partial, or sometimes virtually complete, obstruction of the urethra, which interferes the normal flow of urine. It leads to symptoms of urinary hesitancy, frequent urination, dysuria (painful urination), increased risk of urinary tract infections, and urinary retention. Although prostate specific antigen levels may be elevated in these patients because of increased organ volume and inflammation due to urinary tract infections, BPH is not considered to be a premalignant lesion. CAUSES The cause of BPH is not well understood, but testicular androgens have been implicated. Dihydrotestosterone (DHT), a metabolite of testosterone, is a critical mediator of prostatic growth. Estrogens may also play a role in the cause of BPH; BPH generally occurs when men have elevated estrogen levels and when prostate tissue becomes more sensitive to estrogens and less responsive to DHT. RISK FACTORS Man older than 40 years of age Smoking Heavy alcohol consumption Obesity Reduced activity level Hypertension Heart disease Diabetes mellitus Western diet (high in animal fat and protein and refined carbohydrates, low in fiber) CLINICAL MANIFESTATION 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). Generalized symptoms may also be noted, including fatigue, anorexia, nausea, vomiting, and pelvic discomfort.

ASSESSMENT AND DIAGNOSTIC FINDINGS >Digital Rectal Examination (DRE) - This is the palpation of the prostate through the rectum, it may reveal a large, rubbery, and nontender prostate gland. >Urinalysis - This is done to screen the urine for hematuria and UTI. >Prostate-Specific Antigen (PSA) Blood Test - PSA is obtained if the patient has at least a 10-year life expectancy and to rule out cancer as a cause of urinary symptoms. This is a protein produced by the prostate cells, is frequently present at the elevated levels in the blood of men who have prostate cancer. And it is also used to monitor patients for recurrence after treatment. >Ultrasound examination - Ultrasound examination of the testicles, prostate, and kidneys is often performed, again to rule out malignancy and hydronephrosis. Direct visualization can be done with the procedure cystoscopy using a resectoscope. >Cystoscopy - This contains a lens and light system that help the doctor to see the inside of the urethra and the bladder. This allows the examiner to determine the size of the gland and identify the location and the degree of the obstruction.

ANATOMY AND PHYSIOLOGY GENITOURINARY SYSTEM A. Urinary System Kidney a. Cortex (outer layer): glomeruli, proximal and distal tubules b. Medulla (middle layer): about eight renal pyramids formed by collecting ducts and tubules c. Renal pelvis (innermost layer): composed of calyces where papillae move urine into the ureter by peristalsis d. Nephron: functional unit that filters, concentrates, reabsorbs and secretes to produce urine

B.

e. Glomerulus: filters fluid wastes out of the blood (plural: glomeruli) f. Tubules (proximal, Henle's loop, distal): here fluid is made into urine Functions i. fluid and electrolyte balance ii. acid-base balance: HPO4 buffer system, NH3 buffer system iii. to regulate arterial blood pressure: renin, aldosterone iv. to excrete waste products: urea, creatinine production of erythropoietin Ureters a) convey urine from pelvis of the kidneys to the bladder b) consist of smooth muscle, moves by peristalsis Bladder - stores urine Urethra conducts urine from the bladder to the outside. It is longer in males.

Reproductive System - Male 1. Testes: ovoid sex gland, are encased in the scrutomand consist of seminiferous tubules in which spermatozoa form. 2. Epididymis, a hoodlike structure lying on the testes where the spermatozoa are transmitted and it contains a winding duct that leads to the vas deferens. 3. Vas deferens conduct semen from each epididymis to ejaculatory ducts passes to the prostate gland to enter the urethra. 4. Seminal vesicles acts as the reservoir for testicular secretion 5. Prostate gland secretes alkaline seminal fluid which helps protect and transport the sperms 6. Bulbourethral glands secrete lubrication prior to ejaculation 7. Penis is the male organ for copulation PATHOPHYSIOLOGY

Risk Factors Man older than 40 years of age Smoking Heavy alcohol consumption Obesity Reduced activity level Hypertension Heart disease Diabetes mellitus Western diet (high in animal fat and protein and refined carbohydrates, low in fiber)

Enlargement of Prostate

Compressed Urethral Lumen

Obstruction and Resistance Of Urethra Loss of Detrusor Contractile Ability Bladder Pressure during Voiding Increased Irritability and Instability

Urinary Symptoms:
Include urinary stream, hesitancy (needing to wait for the stream to begin), intermittency (when the stream starts and stops intermittently), straining to void, and dribbling (urine dribbles out after urination), urinary frequency, urgency (compelling need to void that cannot be deferred), urgency incontinence, and voiding at night (nocturia).

BENIGN PROSTATIC HYPERPLASIA

BPH develops over a prolonged period; changes in the urinary tract are slow and insidious. It is a result of complex interactions involving resistance in the prostatic urethra to mechanical and spastic effects, bladder pressure during voiding, loss of detrusor muscle strength, neurologic functioning, and general physical health. As the hyperplastic process increases the volume of the prostate, the urethral lumen is compressed, causing outlet obstruction. An enlarged median lobe may cause relatively more severe symptoms than lateral lobe hyperplasia of similar magnitude because it can act as a valve at which increased bladder pressure may actually cause further obstruction. Intravesical extension of the lateral lobes may act in a similar fashion. At the same time, a dynamic component involving the stromal prostatic tissue and bladder is present, which is often more significant in causing urinary symptoms than simple mechanical obstruction from an enlarged prostate. The precise interaction of these two mechanisms, mechanical and dynamic, is not well understood. When a bladder is trying to empty through a blocked outlet from an obstructing prostate gland, the increased workload produces several changes to the bladder muscle. Initial changes

include increased instability and irritability, which progress to decompensation with permanent loss of detrusor contractile ability. In patients with BPH, the intravesical pressure required to open the bladder neck is increased. The bladder is initially able to produce a higher transitory voiding pressure when required, but loses muscle tone over time. Evidence also indicates that obstruction causes partial denervation of the bladder smooth muscle, which results in further bladder irritability and involuntary detrusor contractions. Fortunately, most of these hyperactive symptoms resolve over time with removal of the prostatic obstruction or with a response to appropriate medications. The detrusor becomes less able to maintain a constant voiding pressure over time, which leads to early termination of voiding, intermittency of the urinary stream, and higher residual urine volume. This is accompanied by a loss of bladder compliance. Overall bladder mass increases because of detrusor muscle hypertrophy, but collagen deposition is also increased, which eventually contributes to decompensation, urinary retention, and permanent loss of detrusor contractile ability. A fact that has been known for many years is that prostate size alone is not a reliable or accurate predictor of the presence or degree of urinary outlet obstruction. COMPLICATIONS BPH can be a progressive disease, especially if left untreated. Incomplete voiding results in stasis of bacteria in the bladder residue and an increased risk of urinary tract infection. Urinary bladder stones are formed from the crystallization of salts in the residual urine. Urinary retention, termed acute or chronic, is another form of progression. Acute urinary retention is the inability to void more than 60 ml of urine that remains in the bladder after urination, while in chronic urinary retention the residual urinary volume gradually increases, and the bladder distends. The hypertrophied lobes of the prostate may obstruct the bladder neck or urethra, causing incomplete emptying of the bladder and urinary retention. As a result, a gradual dilatation of the ureters (hydroureter) and kidneys (hydronephrosis) can occur. Urinary retention may result in UTIs because urine that remains in the urinary tract serves as a medium for infective organisms. Some patients that suffer from chronic urinary retention may eventually progress to renal failure, a condition termed obstructive uropathy and even azotemia (accumulation of nitrogenous waste products). MEDICAL MANAGEMENT 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 symptoms, the cause of disease, the severity of the obstruction, and the patients condition. If admitted to emergency basis because of unable to void a catheter is inserted. 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 the urologist) into the catheter to prevent it from collapsing when it encounters resistance. PHARMACOLOGIC THERAPY The two main medications for management of BPH are alpha blockers and 5-reductase inhibitors. Alpha-Adrenergic Blockers, which includes alfuzosin (Uroxatral), terazosin (Hytrin), doxazosin (Cardura), and tamsulosin, this relax the smooth muscle of the bladder 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. The 5-reductase inhibitors finasteride (Proscar) and dutasteride (Avodart), are used to prevent the conversion of the testosterone to dihydrotestosterone (DHT) and decrease the prostate size. Side effects include decreased libido, ejaculatory dysfunction, erectile dysfunction, gynecomastia (breast enlargement), and flushing. Combination therapy (doxazosin and fenasteride) has decreased symptoms and reduced clinical progression of the BPH. Antimuscarinics such as tolterodine may also be used, especially in combination with alpha blockers. They act by decreasing acetylcholine effects on the smooth muscle of the bladder, thus helping control symptoms of an overactive bladder. Use of phytotherapeutic agents and other dietary supplements (Serenoa repens [saw palmetto berry] and Pygeum africanum [African pulm]) are not recommended, although they are commonly used. They may function by interfering with the conversion of the testosterone to DHT. In addition, S. repens may directly block the ability of the DHT to stimulate prostate cell growth.

Sildenafil citrate popularly known as Viagra shows some symptomatic relief, suggesting a possible common etiology with erectile dysfunction.

SURGICAL TREATMENT MINIMALLY INVASIVE THERAPIES Transurethral microwave heat treatment (TUMT) involves the application of heat to prostatic tissue. A transurethral probe is inserted into the urethra, and microwaves are directed to the prostate tissue. The targeted tissue becomes necrotic and sloughs. Transurethral needle ablation (TUNA) is another minimally invasive treatment option that uses radiofrequency energy and the UroLume stent. TUNA uses low level radiofrequencies delivered by 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. SURGICAL RESECTION 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. Transurethral resection of the prostate (TURP) remains the 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. The treated tissue either vaporizes or becomes necrotic and sloughs. Transurethral incision of the prostate (TUIP) is also 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 of urine out of the bladder, and no tissue is removed.

Open prostatectomy involves the surgical removal of the inner portion of the prostate via suprapubic, retropubic, or perineal (rare) approach for large prostate glands. NURSING MANAGEMENT (PERIOPERATIVE NURSING) PREOPERATIVE PHASE The nurse must instruct the patient to visit the physician, as ordered before the surgery for: Complete physical exam To make sure medical problems, such as diabetes, high blood pressure, and heart or lung problems, are being treated well If the patient is a smoker, smoking should stop several weeks before the surgery. The nurse familiarizes the patient with preoperative and postoperative routines and initiates measures to reduce anxiety. The day before procedure, deep breathing and coughing exercises should be taught to the patient. If the patient experiences discomfort before surgery, bed rest is prescribed, analgesic agents are administered and measures are initiated to relieve anxiety. Preoperative medication administration and an NPO status should be carried out as ordered by the physician. Preoperative preparations such as bowel preparation like enema and use of laxatives and preparations like removal of nail polish, dentures, and cosmetics should be done. Antiembolism stockings are applied before surgery and particularly important to prevent deep vein thrombosis (DVT) if the patient is placed in lithotomy position during surgery. The consent should be checked if signed by the patient not more than 24 hours before the procedure and determine if the it was explained by the physician.

INTRAOPERATIVE PHASE The responsibilities of the nurse depend on the role during the procedure whether the nurse is a scrub nurse, assist, or circulating nurse. The most important responsibility of a nurse during the procedure is to maintain surgical asepsis which would help prevent harming the patient.

POSTOPERATIVE PHASE After surgery, the patient will have a Foley catheter in the bladder to remove urine. The urine will look bloody at first. It will clear with time. A bladder irrigation solution may be attached to the catheter to continuously flush the catheter. This helps keep it from getting clogged with blood. Clot obstruction is suspected if the patient complains of bladder spasm and anuria. The bleeding will gradually decrease, and the catheter will be removed within 1 to 3 days. Facilitate urinary elimination. The urine output and amount of fluid used for irrigation must be closely monitored to determine whether irrigation fluid is being retained and to ensure an adequate urine output. Assess for bowel sounds and flatulence to determine if bowel functioning returned to normal. Monitor intake and output. Daily weighs is also essential. Postoperative medication should be administered as ordered. The patient is assisted to sit and dangle his legs on the side of the bed on the day after surgery and next is assisted to ambulate.

The patient may need to wear special compression stockings and use a breathing device to keep your lungs clear as ordered by the physician. When discharged from the hospital, patients are advised to: Avoid alcoholic beverages. Avoid sexual activities for a few weeks. Avoid driving a car for a week or more. Keep domestic activities to a minimum. Avoid weight lifting or strenuous exercise. Check their temperature and report any fever to the physician. Practice good hygiene, especially of the hands and penis. Drink plenty of liquids.

First Asia Institute of Technology and Humanities

College of Nursing

Case Study of Benign Prostatic Hyperplasia

Submitted to: Mr. Bryan Kim Pascua, RN, MAN Clinical Instructor Batangas Regional Hospital Submitted by: Princess Kaye S. Morales BSN-4B