BENIGN PROSTATIC HYPERPLASIA (BPH)

DEFINITION:
• also known as Benign Prostatic Hypertrophy (however, the process is not
hypertrophy but hyperplasia), Benign Enlargement of the Prostate (BEP), and
adenofibromyomatous hyperplasia
• increase in size of the prostate commonly seen in middle-aged and elderly
men
• 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.2

ETIOLOGY/CAUSE:
• Androgens (testosterone and related hormones)
• Dihydrotestosterone (DHT), a metabolite of testosterone, is a critical
mediator of prostatic growth. DHT is synthesized in the prostate from
circulating testosterone by the action of the enzyme 5α-reductase, type 2.
This enzyme is localized principally in the stromal cells; hence, these cells are
the main site for the synthesis of DHT.2

SIGNS/SYMPTOMS:
Signs:
• Weak urinary stream
• Prolonged emptying of the bladder
• Abdominal straining
• Hesitancy
• Irregular need to urinate
• Incomplete bladder emptying
• Post-urination dribble
• Irritation during urination
• Frequent urination
• Nocturia (need to urinate during the night)
• Urgency
• Incontinence (involuntary leakage of urine)
• Bladder pain
• Dysuria (painful urination)
Storage Symptoms:
• urinary frequency,
• urgency (compelling need to void that cannot be deferred),
• urgency incontinence, and
• voiding at night (nocturia)
Voiding Symptoms:
• weak urinary stream,
• hesitancy (needing to wait for the stream to begin),
• intermittency (when the stream starts and stops intermittently),
• straining to void, and dribbling.2
MANAGEMENT:
Medical
*The treatment plan depends on the cause of BPH, the severity of the obstruction,
and the patient’s condition.
a) Intravenous Rehydration
When the fluid loss is severe or life threatening, IV fluids are used for
replacement.
b) Blood Transfusion
It may be necessary for replacement of RBC to WBC, platelets or blood
proteins.
c) Foley Catheter
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 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.1 This is to
facilitate accurate measurement of urinary output for critically ill clients
whose output need to be monitored hourly.3
d) Lavage
The process of washing out an organ, usually the bladder, bowel,
paranasal sinuses, or stomach for therapeutic purposes.
e) Watchful Waiting
Watchful waiting involves lifestyle changes and an annual examination.
It should be noted that even when choosing watchful waiting, an initial
examination is critical to rule out other disorders.3
f) Pharmacologic Therapy:
• Alpha-Adrenergic Blockers – to relax the smooth muscle of the bladder
neck and prostate
 Terazosin (Hytrin)
 Doxazosin (Cardura)
 Tamsulosin (Flomax)
• Extended-Release Alpha-Adrenergic Antagonist – exerts its effects on
the prostate, bladder neck, and posterior urethra
 Alfuzosin (Uroxatral)
 The smooth muscle blockade improves urine flow and relieves
BPH symptoms.
• Antiandrogen Agents – a method of treatment using hormonal
manipulation
 Finasteride (Proscar)
 Dutasteride (Avodart)
 In clinical studies, 5-alpha-reductase inhibitors such as
finasteride have been effective in preventing the conversion of
testosterone to dihydrotestosterone (DHT).
 ↓DHT → ↓glandular cell activity and prostate size
 Side effects: gynecomastia (breast enlarement), erectile
dysfunction, and flushing.1
Surgical
 Sometimes an incision is made into the bladder (a suprapubic cystotomy)
to provide drainage
 Transurethral resection of the prostate (TURP) – involves surgical
removal of the inner portion of the prostate where BPH develops. It is the
most common surgical procedure for BPH
 Balloon dilation
 Transurethral laser resection
 Transurethral needle ablation
 Microwave thermotherapy 1

Nursing
The patient who's having a prostatectomy needs the following supportive care:
 Preoperatively, make sure he and his family understand the prostate's location
and function, the pathophysiology of BPH, and what to expect after surgery.
 Listen to the patient's concerns about hospitalization, treatment, and urinary
dysfunction. Respond with accurate information to foster his understanding and
reduce his anxiety.
 After surgery, provide continuous bladder irrigation using a three-way indwelling
catheter. Use 0.9% sodium chloride to flush away prostatic debris, irrigate the
surgical areas, and minimize bleeding. Titrate the irrigation flow to the amount
of bleeding; if the amount of blood or number of clots in the urine increases,
increase the flow and check the catheter more frequently. Maintain irrigation
until the urine outflow is slightly pink or clear.
 Monitor your patient's wound drains, dressings, and catheter drainage for
excessive bleeding. Although hematuria is normal, notify the physician if frank
bleeding occurs.
 Assess your patient for pain, including bladder spasms after irrigation.
Belladonna and opium suppositories may help stop the spasms.
 Assess him for local and systemic signs and symptoms of infection. Practice
meticulous aseptic technique for wound and catheter care.
 Teach your patient that he may have urine incontinence after his catheter is
removed, but emphasize that the problem typically is temporary.
 Tell him to drink plenty of fluids. Maintaining adequate urine output keeps
sediment and clots from blocking the urethra.
 As part of the discharge teaching, discuss sexual problems your patient may
have, such as retrograde ejaculation or impotence. Sexual counseling may be
helpful if he develops a problem.
 If he's to be discharged with a catheter, teach him about catheter care and
drainage.
 Tell him to notify his physician at once if he develops signs and symptoms of
infection, such as fever, chills, or redness, swelling, or drainage at his incision
site.
 If he still has prostate tissue, remind him that he could develop BPH again.
Encourage him to obtain follow-up care to assess for development of urethral
strictures. 4

References:
1
2008. Smeltzer, S.C. et. al. Brunner & Suddarth’s Textbook of Medical-Surgical
Nursing, 11th ed. USA: Lippincott Williams & Wilkins.
2
http://en.wikipedia.org/wiki/Benign_prostatic_hyperplasia
3
http://www.scribd.com/doc/5989689/Case-Study-BPH
4
http://findarticles.com/p/articles/mi_qa3689/is_199711/ai_n8780770/