MEDICAL SURGICAL NURSING

SEMINAR ON

BENIGN PROSTATIC
HYPERPLASIA

SUBMITTED TO: SUBMITTED BY:

MS.ANJALI C GARGI M P

ASST.PROFESSOR 1ST YEAR MSC NURSING

AL-SHIFA COLLEGE OF NURSING AL-SHIFA COLLEGE OF NURSING

SUBMITTED ON: .02.2021

CENTRAL OBJECTIVE

At the end of class group will get adequate knowledge about “BENIGN PROSTATIC
HYPERPLASIA”

SPECIFIC OBJECTIVE

At the end of class group will be able to:

 describe about the benign prostatic hyperplasia.

 list down the risk factors of benign prostatic hyperplasia.
 briefly describe about pathophysiology of benign prostatic hyperplasia.
 discuss the management of benign prostatic hyperplasia.
 describe nursing care of a client with benign prostatic hyperplasia.
 BENIGN PROSTATIC HYPERPLASIA

Subject : MEDICAL SURGICAL NURSING Group :

Topic : BENIGN PROSTATIC HYPERPLASIA Place :

Method of teaching : Lecture-cum-discussion Date :

Teaching AV aid : Time :

Name of student teacher: GARGI M P Duration:

Name of the evaluator : MS.ANJALI C

 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 into the bladder and
obstructing the outflow of urine by encroaching on the vesicle orifice.

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. Of these men, almost half of them will
have bothersome lower urinary tract symptoms.

DEFINITION

It is defined as, “ noncancerous increase in size of prostate gland which involves hyperplasia of
prostatic stromal and epithelial cell 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.”

Non cancerous increase in size of prostate gland which involves hyperplasia of prostatic stromal
and epithelial cell 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
INCIDENCE

50% of men having evidence of BPH by age of 50years.

75% by age of 80 years.

CAUSES AND RISK FACTORS

 Dihydrotestosterone (DHT):
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. DHT can act in an autocrine fashion on the
stromal cells or in paracrine fashion by diffusing into nearby epithelial cells. In both of
these cell types, DHT binds to nuclear androgen receptors and signals the transcription of
growth factors that are mitogenic to the epithelial and stromal cells. DHT is ten times
more potent than testosterone because it dissociates from the androgen receptor more
slowly. The importance of DHT in causing nodular hyperplasia is supported by clinical
observations in which an inhibitor of 5α-reductase such as finasteride is given to men
with this condition. Therapy with a 5α-reductase inhibitor markedly reduces the DHT
content of the prostate and, in turn, reduces prostate volume and BPH symptoms.

 Hormones:
Most experts consider androgens (testosterone and related hormones) to play a
permissive role in the development of BPH. This means that androgens must be present
for BPH to occur, but do not necessarily directly cause the condition. This is supported
by evidence suggesting that castrated boys do not develop BPH when they age. In an
unusual study of 26 eunuchs from the palace of the Qing dynasty still living in Beijing in
1960, the prostate could not be felt in 81% of the studied eunuchs. The average time since
castration was 54 years (range, 41–65 years). On the other hand, some studies suggest
that administering exogenous testosterone is not associated with a significant increase in
the risk of BPH symptoms, so the role of testosterone in prostate cancer and BPH is still
unclear. Further randomized controlled trials with more participants are needed to
quantify any risk of giving exogenous testosterone.
  Diet:

Studies indicate that dietary patterns may affect development of BPH, but further research is
needed to clarify any important relationship. Studies from China suggest that greater protein
intake may be a factor in development of BPH. Men older than 60 in rural areas had very low
rates of clinical BPH, while men living in cities and consuming more animal protein had a higher
incidence. On the other hand, a study in Japanese-American men in Hawaii found a strong
negative association with alcohol intake, but a weak positive association with beef intake. In a
large prospective cohort study in the US (the Health Professionals Follow-up Study),
investigators reported modest associations between BPH (men with strong symptoms of BPH or
surgically confirmed BPH) and total energy and protein, but not fat intake. There is also
epidemiological evidence linking BPH with metabolic syndrome (concurrent obesity, impaired
glucose metabolism and diabetes, high triglyceride levels, high levels of low-density cholesterol,
and hypertension)

 Degeneration:

Benign prostatic hyperplasia is an age-related disease. Misrepair-accumulation aging

theory suggests that development of benign prostatic hyperplasia is a consequence of
fibrosis and weakening of the muscular tissue in the prostate. The muscular tissue is
important in the functionality of the prostate, and provides the force for excreting the
fluid produced by prostatic glands. However, repeated contractions and dilations of
myofibers will unavoidably cause injuries and broken myofibers. Myofibers have a low
potential for regeneration; therefore, collagen fibers need to be used to replace the broken
myofibers. Such misrepairs make the muscular tissue weak in functioning, and the fluid
secreted by glands cannot be excreted completely. Then, the accumulation of fluid in
glands increases the resistance of muscular tissue during the movements of contractions
and dilations, and more and more myofibers will be broken and replaced by collagen
fibers.
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 more likely to have problems.

 Ethnic background: Prostate enlargement is less common in Asian men than in white and
black 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 your risk.

CLINICAL MANIFESTATIONS

 Lower urinary tract symptoms:

BPH is the most common cause of lower urinary tract symptoms (LUTS), which
are divided into storage, voiding, and symptoms which occur after urination.
Storage symptoms include the need to urinate frequently, waking at night to
urinate, urgency (compelling need to void that cannot be deferred), involuntary
urination, including involuntary urination at night, or urge incontinence (urine
leak following a strong sudden need to urinate). Voiding symptoms include
urinary hesitancy (a delay between trying to urinate and the flow actually
beginning), intermittency (not continuous), involuntary interruption of voiding,
weak urinary stream, straining to void, a sensation of incomplete emptying, and
uncontrollable leaking after the end of urination. These symptoms may be
accompanied by bladder pain or pain while urinating, called dysuria.
  Bladder outlet obstruction:
Bladder outlet obstruction (BOO) can be caused by BPH. Symptoms are
abdominal pain, a continuous feeling of a full bladder, frequent urination, acute
urinary retention (inability to urinate), pain during urination (dysuria), problems
starting urination (urinary hesitancy), slow urine flow, starting and stopping
(urinary intermittency), and nocturia.

Pathophysiology:
As men age, the enzymes aromatase and 5-alpha reductase increase in activity. These
enzymes are responsible for converting androgen hormones into estrogen and
dihydrotestosterone, respectively. This metabolism of androgen hormones leads to a
decrease in testosterone but increased levels of DHT and estrogen.

Both the glandular epithelial cells and the stromal cells (including muscular fibers)
undergo hyperplasia in BPH. Most sources agree that of the two tissues, stromal
hyperplasia predominates, but the exact ratio of the two is unclear.

Anatomically the median and lateral lobes are usually enlarged, due to their highly
glandular composition. The anterior lobe has little in the way of glandular tissue and is
seldom enlarged. (Carcinoma of the prostate typically occurs in the posterior lobe – hence
the ability to discern an irregular outline per rectal examination). The earliest microscopic
signs of BPH usually begin between the age of 30 and 50 years old in the PUG, which is
posterior to the proximal urethra. In BPH, the majority of growth occurs in the transition
zone (TZ) of the prostate. In addition to these two classic areas, the peripheral zone (PZ)
is also involved to a lesser extent. Prostatic cancer typically occurs in the PZ. However,
BPH nodules, usually from the TZ are often biopsied anyway to rule out cancer in the
TZ. BPH can be a progressive growth that in rare instances leads to exceptional
enlargement. In some males, the prostate enlargement exceeds 200 to 500 grams. This
condition has been defined as giant prostatic hyperplasia (GPH).
Assessment and Diagnostic Methods:

 History collection

 Physical examination- including digital rectal examination(DRE) , 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 • Ultrasound • Complete blood studies,
including clotting studies.

Management:

 Lifestyle modifications:
Lifestyle alterations to address the symptoms of BPH include
physical activity, decreasing fluid intake before bedtime, moderating
the consumption of alcohol and caffeine-containing products and
following a timed voiding schedule. Patients can also attempt to
avoid products and medications with anticholinergic properties that
may exacerbate urinary retention symptoms of BPH, including
antihistamines, decongestants, opioids, and tricyclic antidepressants;
however, changes in medications should be done with input from a
medical professional.
 Voiding positions:
Voiding position when urinating may influence urodynamic
parameters (urinary flow rate, voiding time, and post-void residual
volume).A meta-analysis found no differences between the standing
and sitting positions for healthy males, but that, for elderly males
with lower urinary tract symptoms, voiding in the sitting position:

 Decreased the post void residual volume

 Increased the maximum urinary flow, comparable with
pharmacological intervention
 Decreased voiding time
 MEDICAL MANAGEMENT

The treatment plan depends on the cause, severity of obstruction, and condition of the patient.
Treatment measures include the following:

 Immediate catheterization if patient cannot void (an urologist may be consulted if an

ordinary catheter cannot be inserted).
 A suprapubic cystostomy is sometimes necessary
 Watchful waiting” to monitor disease progression

Pharmacologic Management:

 Alpha blockers. These medications relax bladder neck muscles and muscle fibers
in the prostate, making urination easier. Alpha blockers — which include,
I. Alfuzosin (Uroxatral)
II. Doxazosin (Cardura)
III. Tamsulosin (Flomax)
IV. Silodosin (Rapaflo)
 Alpha reductase inhibitors: These medications shrink prostate by preventing
hormonal changes that cause prostate growth. These medications — which
include:
a) Finasteride (Proscar)
b) Dutasteride (Avodart)
 Combination drug therapy: Doctor might recommend taking an alpha blocker and
a 5-alpha reductase inhibitor at the same time if either medication alone isn't
effective.
 Tadalafil (Cialis): Studies suggest this medication, which is often used to treat
erectile dysfunction, can also treat prostate enlargement. However, this
medication is not routinely used for BPH and is generally prescribed only to men
who also experience erectile dysfunction.
SURGICAL MANAGEMENT

Minimally Invasive Therapy

Minimally invasive therapies are becoming more common as an alternative to watchful waiting
and invasive treatment. They generally do not require hospitalization or catheterization.

Transurethral Microwave Thermotherapy:

 Transurethral microwave thermotherapy (TUMT) is an outpatient procedure that involves

the delivery of microwaves directly to the prostate through a transurethral probe to raise
the temperature of the prostate tissue to about 113° F (45° C). The heat causes death of
tissue, thus relieving the obstruction.
 A rectal temperature probe is used during the procedure to ensure that the temperature is
kept below 110° F (43.5° C) to prevent rectal tissue damage.
 The procedure takes about 90 minutes. Postoperative urinary retention is a common
complication.
 Thus the patient is generally sent home with an indwelling catheter for 2 to 7 days to
maintain urinary flow and to facilitate the passing of small clots or necrotic tissue.
  Antibiotics, pain medication, and bladder antispasmodic medications are used tolerate
and prevent post procedure problems.
 The procedure is not appropriate for men with rectal problems.
 Anticoagulant therapy should be stopped 10 days before treatment.
 Mild side effects include occasional problems of bladder spasm, hematuria, dysuria, and
retention.

Transurethral Needle Ablation:

 Transurethral needle ablation (TUNA) is another procedure that increases the temperature
of prostate tissue, thus causing localized necrosis.
  TUNA differs from TUMT in that low-wave radiofrequency is used to heat the prostate.
 Only prostate tissue in direct contact with the needle is affected, thus allowing greater
precision in removal of the target tissue.
 The extent of tissue removed by this process is determined by the amount of tissue
contact (needle length), amount of energy delivered, and duration of treatment.
 This procedure is performed in an outpatient unit or physician’s office using local
anesthesia and IV or oral sedation.
 The TUNA procedure lasts approximately 30 minutes.
 The patient typically experiences little pain with an early return to regular activities.
 Complications include urinary retention, UTI, and irritative voiding symptoms (e.g.,
frequency, urgency, dysuria).
 Some patients require a urinary catheter for a short time.
 Patients often have hematuria for up to a week.

Laser Prostatectomy:

 The use of laser therapy through visual or ultrasound guidance is an effective alternative
to transurethral resection of the prostate (TURP) in treating BPH.
 The laser beam is delivered transurethrally through a fiber instrument and is used for
cutting, coagulation, and vaporization of prostatic tissue.
 There are a variety of laser procedures using different sources, wavelengths, and delivery
systems.

Photovaporization :

 Photovaporization(PVP) uses a high-powergreen laser light to vaporize prostate tissue.

 Improvements in urine flow and symptoms are almost immediate after the procedure.
 Bleeding is minimal, and a catheter is usually inserted for 24 to 48 hours afterward.
 PVP works well for larger prostate glands.
Interstitial laser coagulation (ILC):

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.

Intraprostatic Urethral Stents:

Symptoms from obstruction in patients who are poor surgical candidates can be relieved with
intraprostatic urethral stents. The stents are placed directly into the prostatic tissue.
Complications include chronic pain, infection, and encrustation

Invasive Therapy (Surgery)

Invasive treatment of symptomatic BPH involves surgery. The choice of the treatment approach
depends on the size and location of the prostatic enlargement and patient factors such as age and
surgical risk.

Transurethral Resection of the Prostate:

Transurethral resection of the prostate (TURP) is a surgical procedure involving the removal of
prostate tissue using a resectoscope inserted through the urethra.

TURP has long been considered the gold standard for surgical treatments of obstructing BPH.
Although this procedure remains the most common operation performed, the number of TURP
procedures done in recent years has declined due to the development of less invasive
technologies.
TURP is performed under a spinal or general anesthetic and requires a 1- to 2-day hospital stay.
No external surgical incision is made. A resectoscope is inserted through the urethra to excise
and cauterize obstructing prostatic tissue.

A large three-way indwelling catheter with a 30-mL balloon is inserted into the bladder after the
procedure to provide hemostasis and to facilitate urinary drainage. The bladder is irrigated, either
continuously or intermittently, usually for the first 24 hours to prevent obstruction from mucus
and blood clots.

The outcome for 80% to 90% of patients is excellent, with marked improvements in symptoms
and urinary flow rates. • Postoperative complications include bleeding, clot retention, and
dilutional hyponatremia associated with irrigation.

Transurethral Incision of the Prostate:

Transurethral incision of the prostate (TUIP) is a surgical procedure done under local anesthesia
for men with moderate to severe symptoms. Several small incisions are made into the prostate
gland to expand the urethra, which relieves pressure on the urethra and improves urine flow.

TUIP is an option for patients with a small or moderately enlarged prostate gland. TUIP has
similar patient outcomes to TURP in relieving symptoms.
Nursing Assessment

 Obtain history of voiding symptoms, including onset, frequency of day and nighttime
urination, presence of urgency, dysuria, sensation of incomplete bladder emptying, and
decreased force of stream. Determine impact on quality of life.
 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.

Patient Education and Health Maintenance

 Explain to patient not undergoing treatment the symptoms of complications of BPH

urinary retention, cystitis, and increase in irritative voiding symptoms. Encourage
reporting these problems.
 Advise patients with BPH to avoid certain drugs that may impair voiding, particularly
OTC cold medicines containing sympathomimetics such as phenylpropanolamine.
 Advise patient that irritative voiding symptoms do not immediately resolve after relief of
obstruction; symptoms diminish over time.
 Tell patient postoperatively to avoid sexual intercourse, straining at stool, heavy lifting,
and long periods of sitting for 6 to 8 weeks after surgery, until prostatic fossa is healed.
 Advise follow-up visits after treatment because urethral stricture may occur and regrowth
of prostate is possible after TURP. • Be aware of herbal or natural• products marketed for
prostate health.

Complications

 Acute urinary retention.

 Involuntary bladder contractions
 Bladder diverticula
 Cystolithiasis
 Vesicoureteral reflux
 Hydroureter
 Hydronephrosis
 Gross hematuria
 UTI