Benign Prostatic Hyperplasia

Pathophysiology
There is a slow increase in the number of cells in the prostate gland, generally the
results of aging and the male hormone dihydrotestosterone.
As the size of the prostate gland increases, it begins to compress or squeeze the
urethra shut.
The narrowing of the urethra means the bladder must work harder to expel the
urine.
More effort and a longer time is required to empty the bladder.
Eventually the narrow-ing causes an obstruction and may lead to urinary retention
or eventually distention of the kidney with urine (hydronephrosis).
It is the location of the enlargement, not the amount, that causes the problem.
A small growth in the prostate gland closest to the urethra may cause more
problems with urination than a growth the size of an orange in the outer portion of
the gland

• Obstructive symptoms associated with BPH have not only a static component
(enlarged prostate gland) but also a dynamic component that reflects
increased prostatic stromal and urethral smooth muscle tone.
• Increased tone of this smooth muscle is dependent upon stimulation of a1-
adrenoreceptors by noradrenaline released from adrenergic nerves.
• α1-adrenoreceptors affecting the lower urinary tract are found in prostatic
stroma, bladder detrusor and trigone, urethra, ganglia, and spinal and
supraspinal structures.
• The beneficial effects of α1-adrenoreceptor antagonists on symptoms of BPH
may come from action on receptors in any of these areas.

Clinical Manifestations
• The prostate is large, rubbery, and nontender. Prostatism (obstructive and
irritative symptom complex) is noted.
• Hesitancy in starting urination, increased frequency of urination, nocturia,
urgency, abdominal straining.
• Decrease in volume and force of urinary stream, interruption of urinary stream,
dribbling.
• Sensation of incomplete emptying of the bladder, acute urinary retention (more
than 60 mL), and recurrent UTIs.
• Fatigue, anorexia, nausea and vomiting, and pelvic discomfort are also reported,
and ultimately azotemia and renal failure result with chronic urinary retention and
large residual volumes

Assessment and Diagnostic Methods
• Physical examination, including digital rectal examination (DRE), and health
history.
• Urinalysis to screen for hematuria and UTI.
• Prostate-specific antigen (PSA) level is obtained if the patient has at least a
10-year life expectancy and for whom knowledge of the presence of prostate
cancer would change management.
• Urinary flow-rate recording and the measurement of postvoid residual
(PVR) urine.
• Urodynamic studies, urethrocystoscopy, and ultrasound may be performed.
• Complete blood studies, including clotting studies.

Medical Management
• Immediate catheterization if patient cannot void. A suprapubic cystostomy
is sometimes necessary.
• “Watchful waiting” to monitor disease progression.
Pharmacologic Management
• Alpha-adrenergic blockers (eg, alfuzosin, terazosin), which relax the smooth
muscle of the bladder neck and prostate .This improves urine flow and
relieves symptoms of BPH.
• Hormonal manipulation with antiandrogen agents (5-alpha-reductase
inhibitors) (finasteride [Proscar]) decreases the size of the prostate by
preventing the conversion of testosterone to dihydrotestosterone (DHT).

Surgical Management
• Minimally invasive therapy 1. Transurethral microwave heat treatment (TUMT;
application of heat to prostatic tissue) 2. Transurethral needle ablation (TUNA; via
thin needles placed in prostate gland) 3. Prostatic stents (but only for patients with
urinary retention and in patients who are poor surgical risks)
• Surgical resection
Transurethral resection of the prostate (TURP; benchmark for surgical
treatment(formerly the most common procedure) is done without an incision by
means of endoscopic instrument.)
Transurethral incision of the prostate (TUIP)
Transurethral electro vaporization - (TUVP) or Photo vaporization of the prostate
(PVP) is starting to replace TURP; done thro’ a cystoscope , using a laser to
vaporize diseased prostatic tissue.
• Open prostatectomy - Open prostatectomy is the surgical removal of the prostate
gland. It is done under a general or spinal anesthetic.

Nursing management
THE PATIENT UNDERGOING PROSTATECTOMY
Assessment
• Take a complete history, with emphasis on urinary function and the effect
of the underlying disorder on patient’s lifestyle.
•Note reports of urgency, frequency, nocturia, dysuria, urinary retention,
hematuria, or decreased ability to initiate voiding.
•Note family history of cancer, heart disease, or kidney disease, including
hypertension.

Diagnosis
Preoperative Nursing Diagnoses
•Anxiety related to inability to void
•Acute pain related to bladder distention
•Deficient knowledge of the problem and treatment protocol
Postoperative Nursing Diagnoses
•Acute pain related to surgical incision, catheter placement, and bladder
spasms
•Deficient knowledge about postoperative care

Potential Complications
•Hemorrhage and shock
•Infection
•Deep vein thrombosis
•Catheter obstruction
•Sexual dysfunction

Preoperative Nursing Interventions
Reducing Anxiety
•Clarify the nature of the surgery and expected postoperative outcomes.
•Provide privacy, and establish a trusting and professional relationship.
•Encourage patient to discuss feelings and concerns.
Relieving Discomfort
•While patient is on bed rest, administer analgesic agents; initiate measures to relieve
anxiety.
•Monitor voiding patterns; watch for bladder distention.
•Insert indwelling catheter if urinary retention is present or if laboratory test results
indicate azotemia.
•Prepare patient for a cystostomy if urinary catheter is not tolerated.

Providing Instruction
•Review with the patient the anatomy of the affected structures and their function
in relation to the urinary and reproductive systems, using diagrams and other
teaching aids if indicated.
•Explain what will take place while the patient is prepared for diagnostic tests and
then for surgery (depending on the type of prostatectomy planned).
•Reinforce information given by the surgeon.
•Explain procedures expected to occur during the immediate perioperative period,
answer questions the patient or family may have, and provide emotional support.
•Provide information about postoperative pain management.

Preparing Patient for Treatment
•Apply graduated compression stockings.
•Administer enema, if ordered.

Postoperative Nursing Interventions
Maintaining Fluid Balance
•Closely monitor urine output and the amount of fluid used for irrigation; maintain
intake/output record.
•Monitor for electrolyte imbalances (eg, hyponatremia), increasing blood pressure, confusion,
and respiratory distress.
Relieving Pain
•Distinguish cause and location of pain, including bladder spasms.
•Give analgesic agents for incisional pain and smooth muscle relaxants for bladder spasm.
•Monitor drainage tubing and irrigate drainage system to correct any obstruction.
•Secure catheter to leg or abdomen.
•Monitor dressings, and adjust to ensure they are not too snug or not too saturated or are
improperly placed.
•Provide stool softener, prune juice, or an enema, if prescribed.

Monitoring and Managing Complications
•Hemorrhage: Observe catheter drainage; note bright red bleeding with increased
viscosity and clots; closely monitor vital signs; administer medications, IV fluids,
and blood component therapy as prescribed; maintain accurate record of intake
and output; and carefully monitor drainage to ensure adequate urine flow and
patency of the drainage system. Provide explanations and reassurance to patient
and family.
•Infection: Use aseptic technique with dressing changes; avoid rectal
thermometers, tubes, and enemas; provide sitz bath and heat lamps to promote
healing after sutures are removed; assess for urinary tract infection (UTI) and
epididymitis; administer antibiotics as prescribed.
•Thrombosis: Assess for deep vein thrombosis and pulmonary embolism; apply
compression stockings. Assist patient to progress from dangling the day of surgery
to ambulating the next morning; encourage patient to walk but not sit for long
periods of time. Monitor the patient receiving heparin for excessive bleeding.

• Obstructed catheter: Observe lower abdomen for bladder distention;
examine drainage bag, dressings, and surgical incision for bleeding; monitor
vital signs to detect hypotension; observe patient for restlessness,
diaphoresis, pallor, any drop in blood pressure, and an increasing pulse
rate. Provide for patent drainage system; perform gentle irrigation as
prescribed to remove blood clots.
•Urinary incontinence: Encourage patient to take steps to prevent
incontinence, improve continence, anticipate leakage, and cope with lack of
complete control.
•Sexual dysfunction: Erectile dysfunction, decreased libido, and fatigue may
be a concern soon or months after surgery. Medications, surgically placed
implants, or negative-pressure devices may help restore function.
Reassurance that libido usually returns and fatigue diminishes after
recuperation may help. Providing privacy, confidentiality, and time to discuss
issues of sexuality is important. Referral to a sex therapist may be indicated

Promoting Home- and Community-Based Care
TEACHING PATIENTS SELF-CARE
•Teach patient and family how to manage drainage system, monitor urinary
output, perform wound care, and use strategies to prevent complications.
•Inform patient about signs and symptoms that should be reported to the
physician (eg, blood in the urine, decreased urine output, fever, change in
wound drainage, or calf tenderness).
•Teach perineal exercises to help regain urinary control.
•As indicated, discuss possible sexual dysfunction (provide a private
environment) and refer for counseling.
•Instruct patient not to perform Valsalva maneuver for 6 to 8 weeks because
it increases venous pressure and may produce hematuria.

• Urge patient to avoid long car trips and strenuous exercise, which increases
tendency to bleed.
•Inform patient that spicy foods, alcohol, and coffee can cause bladder
discomfort.
•Encourage fluids to avoid dehydration and clot formation.
CONTINUING CARE
•Refer for home care as indicated.
•Remind patient that return of bladder control may take time.