BPH

1. BENIGN PROSTATIC HYPERPLASIA
PRESENTED BY
SHILPA.S
MSC. NURSING FIRST YEAR

2. OVERVIEW
Define Benign Prostatic Hyperplasia.
Etiology and Risk factors.
Pathophysiology of BPH.
Clinical Features of BPH.
Complications of BPH.
Diagnostic Studies of BPH.
Management of BPH including nurses responsibility.
Research Studies related to Benign prostatic
hyperplasia.

3. INTRODUCTION
 Benign prostatic hyperplasia (BPH) is a benign
enlargement of the prostate gland.
 In many patients older than 50 years, the
prostate gland enlarges, extending upward in to
the bladder and obstructing he outflow of urine
by encroaching on the vesicle orifice.

4. Contd….
 This condition is known as benign prostatic hyperplasia
(BPH), the enlargement, or hypertrophy, of the prostate.
 It is the most common urologic problem in male adults.
About 50% of all men in their lifetime will develop BPH.
 Research is not clear about whether having BPH lead to
an increased risk of developing prostate cancer.

6. DEFINITION
 It is defined as, “non-cancerous increase in size of
prostate gland which involves hyperplasia of prostatic
stromal and epithelial cells resulting in formation of
large, fairly discrete nodules in transitional zone of
prostate, which push on and narrow the urethra
resulting in an increase resistance to flow of urine from
the bladder.”

7. DEFINITION
OR
 It is a condition in which there is progressive
enlargement of prostate gland, resulting from an
increase in the number of size of epithelial cells and
stromal tissue.

8. ETIOLOGY AND RISK FACTORS:
• Excessive accumulation of dihydroxytestosterone
(DHT).
It is known as principal intraprostatic
androgen. This can stimulate cell growth and an
overgrowth of prostate tissue.

9. CONTD…..
• Increased proportion of estrogen in blood.
Throughout their lives, men produce both
testosterone and small amounts of estrogen. As men
age, the amount of active testosterone in the blood
decreases, leaving a higher proportion of estrogen. A
higher amount of estrogen within the gland promote
cell growth.

10. CONTD…..
RISK FACTORS

11. CONTD…..

12. CONTD…..

13. PATHOPHYSIOLOGY OF BPH:
• McNeal demonstrated that BPH first develops in the
peri- urethral transitional zone of the prostate.
• BPH affects both glandular epithelium and
connective tissue stroma.

14. • It begins as micro nodules in the transitional zone
which grow and coalesce to form macro nodules
around the inferior margin of the pre- prostatic
urethra, just above the verumontanum.
• Macro nodules in turn compress the surrounding
normal tissue of the peripheral zone postero-
inferiorly, creating a ‘false capsule around the
hyperplastic tissue.

15. • As the transitional zone grows, it produces the
appearance of ‘lobes” on either side of the urethra.
• In due course, these lobes may compress or distort
the pre prostatic and prostatic parts of urethra and
produce symptoms.

18. Effects of BPH: -
• Benign prostatic hyperplasia develops over a
prolonged period: changes in the urinary tract are
slow and insidious.
• BPH is a result of complex interactions involving
resistance in the prostatic urethra to mechanical and
spastic effects, bladder pressure during voiding,
detrusor muscle strength, neurologic functioning, and
general physical health.

19. • 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, gradual dilation of the uterus (hydro
ureter) and kidneys (hydro nephrosis) can occur.
• Urinary retention may result in the urinary tract
serves as a medium for infective organisms.

20. Effect of BPH on urethra:
• The prostatic urethra is lengthened (twice its normal
length).
• The normal posterior curve may be so exaggerated
requires a curved catheter to negotiate it.

21. Effect of BPH on the Urinary Bladder
• If BPH causes BOO, the musculature of the bladder
hypertrophies to overcome the obstruction and
appears trabeculated.
• BPH is associated with increased blood flow and the
resultant veins at the base of the bladder causes
hematuria.

22. CLINICAL MANIFESTATIONS
• Manifestations of BPH are mainly associated with
symptoms of the lower urinary tract.
• The patient’s symptoms are usually gradual in
onset and may not be noticed until prostate
enlargement has been present for some time.

23. Contd…
• Early symptoms are often minimal because the
bladder can compensate for a small amount of
resistance to urine flow.
• The symptoms gradually worsen as the degree of
urethral obstruction increases.
• Symptoms can be divided into two groups:
 Irritative symptoms
 Obstructive symptoms

24. Contd…
Irritative Symptoms: -
 Nocturia
 Urinary Frequency
 Urgency
 Dysuria
 Bladder pain and incontinence are associated with
inflammation or infection.

25. Contd…
Obstructive symptoms: -
 These symptoms caused by prostate enlargement
include a decrease in the caliber and force of the
urinary stream
 Difficulty in initiating voiding
 Intermittency
 Dribbling of urine at the end of urination.

26. Contd…
• Chronic urinary retention and large residual volumes
can lead to azotemia (accumulation of nitrogenous
waste products) and kidney failure.
• Generalized symptoms may also be noted including
fatigue, anorexia, nausea, vomiting, and pelvic
discomfort, urethral stricture and neurogenic bladder.

27. COMPLICATIONS:
• Acute urinary retention: - It is manifested by the
sudden and painful inability to urinate. Treatment
include the insertion of a catheter to drain the
bladder.
• Urinary Tract Infection(UTI): - Incomplete bladder
emptying results in residual urine, which provides a
favorable environment for bacterial growth.

28. Contd…
• Bladder Calculi: - Calculi may develop in the bladder
because of alkalization of the residual urine. Bladder
stones are more common in men with BPH, although
the risk of renal calculi is not significantly increased.

29. Contd…
• Renal failure caused by hydronephrosis: - It occurs
due to distention of pelvis and calyces of kidney by
urine that cannot flow through the ureter to the
bladder.
• Pyelonephritis and bladder damage if treatment for
acute urinary retention is delayed.

30. DIAGNOSTIC STUDIES
• History collection and physical examination
• Digital rectal examination: - The prostate can be
palpated by digital rectal examination to estimate its
size, symmetry, and consistency. In BPH, prostate is
symmetrically enlarged, firm, and smooth.

31. • Urine analysis with culture: - A urine analysis with
culture is routinely done to identify any infection.
Bacteria, WBCs, or microscopic haematuria indicate
infection or inflammation.
• Prostate- specific antigen (PSA): - It is done to rule
out prostate cancer. However prostate level may be
slightly elevated in patient with BPH.

32. • Serum- creatinine level: - These levels may be ordered
to rule out renal insufficiency.
• Trans Rectal Ultrasound: - This examination allows for
accurate assessment of prostate size and is helpful in
differentiating BPH from prostate cancer.

33. • Uroflowmetry: - It is the study that measures the
volume of urine expelled from the bladder per second,
is helpful in determining the extent of urethral
blockage and thus the type of treatment needed.
• Post void residual urine volume: - It measured to
determine the degree of urine flow obstruction.

34. • Cystoscopy: - It is a procedure allowing internal
visualization of the urethra and bladder, is performed
if the diagnosis is uncertain and in patients scheduled
for prostatectomy.
• The American Urological Association(AUA) symptom
Index or International Prostate Symptom Score(IPSS)
can be used to assess the severity of symptoms.

35. Other studies include:
• Urodynamic studies.
• Complete Blood studies.
• Cardiac status and Respiratory function are assessed
because a high percentage of patients with BPH have
cardiac or respiratory disorders due to their age.

36. MANAGEMENT OF BPH
The Goals of Collaborative Care are to:
 Restore Bladder Drainage
 Relieve the patient symptoms.
 Prevent or treat the complications of BPH
 Improve the quality of Life.

37. Contd……
Management of BPH is divided into:
 Medical Management
 Surgical Management
 Nursing Management

38. Contd……
Medical Management: -
• The most conservative treatment that may be
recommended for some patients with BPH is referred
to as active surveillance.
• When the patient has no symptoms or only mild ones,
a wait and see approach is taken.

39. Contd……
Medical Management: -
• If the patient begins to have signs or symptoms that
indicate an increase in obstruction, further treatment
is indicated.

40. Contd……
 Drug Therapy: -
Drugs that have been used to treat BPH with
variable degree of success include
• 5α- Reductase Inhibitors
• α- Adrenergic Receptor Blockers.
• Erectogenic Drugs
• Herbal Therapy.

41. Contd…
5α- Reductase Inhibitors.
• These drugs include finasteride, dutasteride,
dutasteride plus, tamsulosin.
• They act by reducing the size of the prostate gland.
• Finasteride blocks the enzyme 5α-reductase which is
necessary for the conversion of testosterone to DHT,
the principle intraprostatic androgen.
• It results in regression of hyperplastic tissue through
suppression of androgens

42. Contd…
Α-Adrenergic receptor blockers.
• These drug include silodosin, alfuzosin, doxazosin,
prazosin, terazosin.
• These agents selectively block α1- adrenergic
receptors, which are abundant in prostate and are
increased in hyperplastic prostate tissue.

43. Contd…
• These drugs promote smooth muscle relaxation of
prostate, facilitating urinary flow through the urethra.
• These drugs offers only symptomatic relief of BPH,
they do not treat hyperplasia.

44. Contd…
Erectogenic Drugs.
• Drugs like tadalafil has been used in men who have
symptoms of BPH alone or in combination with
erectile dysfunction.
Herbal Therapy.
• Herbal extracts like saxifrage, beta- sitosterol have
been used in the management of lower urinary
symptoms associated with BPH.

45. Contd…
• Making dietary changes (decreasing intake of
caffeine, artificial sweeteners, and spicy or acidic
foods).
• Avoiding medications such as decongestants and
anticholinergics.
• Restricting evening fluid intake may improve
symptoms.

46. Contd…
Surgical Management: -
 Minimally Invasive Therapy
 Invasive (Therapy)
Minimally Invasive Therapy: -
• These procedures generally do not require
hospitalization or catheterization and are associated
with few adverse effects.

47. Contd…
i. Transurethral Microwave Thermotherapy (TUMT): -
• It is a non- surgical, minimally invasive therapy that
can be performed under a local anesthetic on an
outpatient basis.
• The treatment involves inserting a special microwave
urinary catheter into the hyperplastic prostatic
urethra.

48. Contd…
• The microwave antenna within the catheter then emits
microwaves to heat and destroy the surrounding
prostatic tissue.
• The procedure can take from 30 minutes to one hour
and is well tolerated by patients.
• Following the procedure, the prostate tissue will be
swollen and irritated.

49. Contd…
• Urologist often place a Foley’s catheter to prevent the
patient from having urinary retention
• After three to five days the Foley’s catheter can be
replaced by a temporary prostatic stent to improve
voiding without exacerbating irritation symptoms.

50. Contd…

51. Contd…
Advantages:
• Outpatient procedure
• Erectile dysfunction, urinary incontinence and
retrograde ejaculation are rare.
Disadvantage:
• Potential for damage to surrounding tissue.
• Urinary catheter needed after procedure.

52. Contd…
ii. Transurethral Needle Ablation (TUNA): -
• It is a technique that uses low energy radio frequency
delivered through two needles to ablate excess
prostate tissue.
• A cystoscope deploys the needles towards the
obstructing prostate tissue is inserted into the urethra
directly through the penis under local anesthetic
before the procedure begins.

53. Contd…
• The energy from the probe heats the abnormal
prostate tissue without damaging the urethral
• It can be done with a local anesthetic on an
outpatient basis.
• It takes about an hour to perform the procedure.
• It takes about 30 days for the ablated prostate tissue
to resorb.

54. Contd…

55. Contd…
Advantages:
• Outpatient procedure.
• Erectile dysfunction, Urinary Incontinence are rare.
• Precise delivery of heat to desired area.
• Very little pain experienced.
Disadvantages:
• Urinary retention common.
• Irritative voiding symptoms
• Hematuria.

56. Contd…
iii.Transurethral Electro vaporization of prostate (TUVP):
• In this method electrosurgical vaporization and
desiccation are used together to destroy prostatic
tissue.
Advantages:
• Minimal risks
• Minimal bleeding and sloughing.
Disadvantages:
• Retrograde ejaculation.
• Intermittent Hematuria.

57. Contd…

58. Contd…
iv. Intraprostatic Urethral Stents: -
• The procedure is carried out by insertion of self-
expandable metallic stent into the urethra when enlarged
area of prostate occurs.
Advantages:
• Safe and effective.
• Low risk
Disadvantages:
• Stent may move
• Long term effect is unknown.

59. Contd…
v. Laser Prostatectomy:
This procedure uses a laser beam to cut or destroy part
of prostate.
All lasers use concentrated light to generate precise and
intense heat.
• Laser surgery removes excess prostate tissue by:
Ablation: The laser melts away excess tissue.
Enucleation: The laser cuts away excess prostate
tissue.

60. Contd…..
• There are different types of prostate laser surgery
such as:
• Photo selective vaporization of the prostate. (PVP): A
laser is used to melt away excess prostate tissue to
enlarge the urinary channel.
• Holmium laser ablation of the prostate: This is similar
to PVP except that a different type of laser is used to
melt away the excess prostate tissue.

61. Contd…..
• Interstitial Laser Coagulation: - The prostate is
viewed through a cystoscope. A laser is used to quickly
treat precise areas of the enlarged prostate by placement
of interstitial light guides directly into the prostate tissue.
• Visual Laser Ablation of Prostate: - It refers to any
transurethral endoscopic operation wherein a free beam
laser is used to produce deep coagulation of the prostatic
transition zone to relieve bladder outlet obstruction due
to BPH.

62. Contd…..

63. Contd…..
Advantages:
• Short procedure
• Comparable result to TURP
• Minimal bleeding
• Fast recovery time.
• Rapid symptom Improvement
• Very effective.

64. Contd…..
Disadvantages:
• Catheter up to 7 days needed after procedure due to
edema and urinary retention.
• Delayed sloughing of tissue
• Retrograde ejaculation.
• Takes several weeks to reach optimal effects

65. INVASIVE THERAPY: -
i. Transurethral Resection of Prostate (TURP): -
• It is performed by visualizing the prostate through the
urethra and removing tissue by electrocautery or
sharp dissection.
• It has been the standard treatment for BPH.

66. • It involves removal of prostatic tissue by optimal
instrument introduced through urethra; used for
glands of varying size.
• Ideal for patients who are poor surgical risks.
• Types:
Monopolar TURP: A Monopolar device utilizing a wire
loop with electric current flowing in one direction can

67. be used to excise tissue via the resectoscope. A
grounding ESU pad and irrigation by a non-conducting
fluid is required to prevent this current from disturbing
surrounding tissues. This fluid (usually glycine) can cause
damage to surrounding tissue after prolonged exposure,
resulting in TUR syndrome, so surgery time is limited.

68. Bipolar TURP: This is a newer technique that uses
bipolar current to remove the tissue. Bipolar TURP
allows saline irrigation and eliminates the need for an
ESU grounding pad thus preventing post-TURP
hyponatremia and reducing other complications.

70. Advantages:
• Avoids abdominal incision.
• Safer for surgical- risk patient.
• Shorter length of hospital stays and recovery periods.
• Lower morbidity rate.
• Causes less pain.
• Can be used as palliative approach with history of
radiation therapy.

71. Disadvantages:
• Requires highly skilled surgeon.
• Recurrent obstruction, urethral trauma and stricture
may develop.
• Delayed bleeding may occur.
Nursing Implications:
• Monitor for hemorrhage.
• Observe for symptoms of urethral stricture (dysuria,
straining, weak urinary stream).

72. ii. Open Surgical Removal: -
Suprapubic approach
• A suprapubic prostatectomy is an open surgical
procedure.
• Removal of prostatic tissue through abdominal
incision; can be used for gland of any size.

73. Advantages:
• Technically simple
• Offers wide area of exploration.
• Permits exploration for cancerous lymph nodes.
• Allows more complete removal of obstructing gland.
• Permits treatment of associated bladder lesions.

74. Disadvantages:
• Requires surgical approach through the bladder.
• Control of hemorrhage is difficult.
• Urine may leak around the suprapubic tube.
• Recovery may be prolonged and uncomfortable.

75. Nursing Implications:
• Monitor for indications of hemorrhage and shock.
• Provide meticulous aseptic care to the area around
supra pubic tube.
Perineal Approach
• Removal of gland through an incision in the perineum;
preferred approach for patients who are obese.

76. Advantages:
• Offers direct anatomic approach.
• Permits gravity drainage.
• Low mortality rate.
• Low incidence of shock.
• Ideal for patients with large prostate who are very old,
frail, and poor surgical risks.
• Allows hemostasis under direct vision.

77. Disadvantages:
• Higher postoperative incidence of impotence and
urinary incontinence.
• Restricted operative field.
• Greater potential for contamination and infection of
incision.
• Possible damage of rectum and external sphincter.

78. Nursing Implications:
• Avoid using rectal tubes or thermometers and enemas
after perineal surgery.
• Use drainage pads to absorb excess urinary drainage.
• Provide foam rubber ring for patient comfort in sitting.

79. Nursing Implications:
• Avoid using rectal tubes or thermometers and enemas
after perineal surgery.
• Use drainage pads to absorb excess urinary drainage.
• Provide foam rubber ring for patient comfort in sitting.

80. Retro pubic Approach
• It involves low bladder incision; bladder is not entered.
Advantages:
• Avoids incision into the bladder.
• Permits surgeon to see and control bleeding.
• Shorter recovery period.
• Less bladder sphincter damage.
• Suitable for removal of large glands.

81. Disadvantages:
• Cannot treat associated bladder disease.
• Increased incidence of hemorrhage from prostatic
venous plexus; osteitis pubis.
Nursing Implications:
• Monitor hemorrhage
• Anticipate post urinary leakage for several days after
removing the catheter.

82. iii.Transurethral Incision: -
• It is a urethral approach; 1-2 cuts are made in the
prostate and prostate capsule to reduce pressure on
the urethra and to reduce urethral constriction.
• Once the anesthetic is working, physician will insert a
resectoscope into the tip of your penis and extend it
to the prostate area.

83. • The resectoscope has a lens or camera, a cutting
device, and valves to release fluid to wash the surgery
area. Using the resectoscope, physician makes one or
two incisions on the inner surface of the prostate.

84. Advantages:
• Results comparable to TURP.
• Low incidence of erectile dysfunction and retrograde
ejaculation.
• No bladder neck contracture.
Disadvantages:
• Require highly skilled surgeon.
• Recurrent obstruction and urethral trauma.
• Delayed bleeding.

85. Nursing Implications:
• Monitor hemorrhage
iv. Laparoscopic Radical Prostatectomy: -
• In this approach, 4- 6 small incisions are made in the
abdomen; Laparoscopic instruments inserted through
the incisions are used to dissect the prostate

86. Advantages.
• Minimally invasive technique.
• Short convalescence.
• Reduce infection risk.
• Less scarring.
• Decreased blood loss to 400ml.
• Short indwelling catheter duration.
• Shorter length of hospital stay.

87. Disadvantages.
• Technically demanding.
• Long surgical time (4-5 hours)
• Lack of tactile sensation available with open
prostatectomy.
Nursing Implications.
• Observe for symptoms of urethral stricture, straining,
weak urinary stream.
• Monitor for hemorrhage and shock.

88. • Monitor for changes in bowel function.
• Use drainage pads to absorb excess urinary drainage.
• Anticipate urinary leakage around the wound for
several days after the catheter is removed.

89. Nursing Management: -
Nursing Diagnosis:
Pre- operative Nursing Diagnosis
• Anxiety about surgery and its outcome.
• Acute pain related to bladder distention.
• Deficient knowledge about factors related to the
disorder and treatment protocol.

90. Post-operative Nursing Diagnosis
• Risk for imbalanced fluid volume.
• Acute pain related to the surgical incision, catheter
placement, and bladder spasms.
• Deficient Knowledge about postoperative care

91. Preoperative Nursing Interventions: -
• Reducing Anxiety:
• The nurses must establish communication with the
patient to assess his understanding of the diagnosis
and of the planned surgical procedure.
• Patient is encouraged to verbalize his feelings and his
current feelings.
• The nurse familiarize the patient with the pre and
postoperative routines and initiates measures to
reduce anxiety.

92. • Relieving Discomfort:
• Bed rest is prescribed
• Analgesic agents are administered
• Nurse should monitor his voiding patterns, watches for
bladder distention, and assist with catheterisation if
indicated.

93. • Providing Education:
• Before surgery, the nurse reviews with the patient the
anatomy of the affected structures and their function
in relation to the urinary and reproductive systems,
using diagrams and other educational aids if indicated.

94. • Preparing the Patient:
• Anti- embolism stockings are applied before the
surgery.
• An enema is usually administered before the surgery.
Postoperative nursing Interventions: -
• Maintaining Fluid balance:
• An intake and output recording, including the amount
of fluid used for irrigation, must be maintained.

95. • The patient is monitored for electrolyte imbalance,
increasing blood pressure, confusion and respiratory
distress.
• The urine output and the 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.

96. • Relieving pain:
• Administer medications like ibuprofen to patient
• Complete bed rest on initial days.
Other care includes:
• Administer antibiotics before the invasive procedure.
• After surgery, bladder irrigation is typically done to
remove blood clot from bladder and ensure drainage of
urine.

97. • Promote activities that increase abdominal pressure,
such as sitting to have a bowel movement, should be
avoided in the postoperative recovery period.
• Observe the patient for signs of postoperative
infection.
• Dietary intervention and stool softeners are important
in post op period to prevent the patient from straining
while have bowel movements.

98. RESEARCH STUDIES

99. Research study: A STUDY TO ASSESS THE KNOWLEDGE AND
QUALITY OF LIFE OF PATIENTS WITH BPH
Abstract: Benign Prostatic Hyperplasia (BPH) refers to increased size of
prostate gland. In India, the incidence of BPH 92.97%. BPH tends to change
from benign to malignant. If the client is having BPH, he is at high risk for
Prostate Cancer. A descriptive survey approach was used with the purpose
of assessing the knowledge and quality of life among patients with BPH. The
objectives of the study were to assess knowledge, quality of life and to find
relationship between knowledge and quality of life. Total 71 subjects were
studied and the results showed that most 44 (62%) of the subjects has
average knowledge on BPH. About 44 (62%) of subjects had good quality of
life and 27(38%) had poor quality of life.

100. Research study: Benign Prostatic Hyperplasia and the Risk of Prostate
Cancer and Bladder Cancer
A Meta-Analysis of Observational Studies
Abstract: Benign prostatic hyperplasia (BPH) has been suggested to be a
risk factor for certain urologic cancers, but the current evidence is
inconsistent.
The aim of this study was to investigate the association between BPH and
urologic cancers.
We included case-control studies or cohort studies, which evaluated the
association between BPH and urologic cancers (including prostate cancer,
bladder cancer, kidney cancer, testicular cancer, or penile cancer).

101. Overall effect estimates were calculated using the Der Simonian–Laird
method for a random-effects model. Summary effect-size was calculated as
risk ratio (RR), together with the 95% confidence interval (CI).
This systematic review included 16 case-control studies and 10 cohort
studies evaluating the association of BPH and prostate or bladder cancer;
we did not identify any study about other urologic cancers. Meta-analyses
demonstrated that BPH was associated with an increased incidence of
prostate cancer (case-control study: RR = 3.93, 95% CI = 2.18–7.08;
cohort-study: RR = 1.41, 95% CI = 1.00–1.99) and bladder cancer (case-
control study: RR = 2.50, 95% CI = 1.63–3.84; cohort-study: RR = 1.58,
95% CI = 1.28–1.95). Subgroup analysis by ethnicity suggested that the
association between BPH and prostate cancer was much stronger in Asians
(RR = 6.09, 95% CI = 2.96–12.54) than in Caucasians (RR = 1.54, 95% CI
= 1.19–2.01). Egger's tests indicated low risk of publication bias (prostate
cancer: P = 0.11; bladder cancer: P = 0.95).

102. BPH is associated with an increased risk of prostate cancer and bladder
cancer. The risk of prostate cancer is particularly high in Asian BPH patients.
Given the limitations of included studies, additional prospective studies with
strict design are needed to confirm our findings

103. THANK YOU