Benign Prostatic Hyperplasia
(BPH) and Bladder Outlet
Obstruction (BOO)
Swe Zin Naing
2nd Year, [Link]
Adult Health Nursing
Introduction
Prostate
a gland in the male reproductive system
approximately 3 cm high and 4 cm wide
weighing no more than 20 g
about the size of a walnut
located just below the bladder
surrounds the urethra that carries urine and semen out
of the body
partly muscular and glandular tissue
Prostate gland
plays a very important role in male fertility because
• involves in formation and development of sperms
• produces much of the ejaculated liquid, which is
made up of sperms and prostate fluid
• produces prostate specific antigen (PSA)
plays a role in the micturition system because it
• closely linked to the two sphincter muscles that
ensure good urinary retention
Zones of the Prostate
Prostate is divided into 4 zones:
Transition zone
Peripheral zone
Central Zone
Anterior Zone
Verumontanum
Transition zone
at the centre of the prostate
increases in size with age and become largest part of the
prostate
known as a prostate adenoma that almost occurs all men
over 70
prostate tumours in the transition zone are unreachable
during a rectal examination therefore can only be
detected following a biopsy
Peripheral zone
largest zone of the prostate
most of the malignant tumours associated with prostate
(approximately 75%) occur in the peripheral zone
closest zone to the rectum and, therefore, easy for doing
a rectal examination
Central zone
behind the transition zone
surrounds the ejaculatory ducts
very few prostate cancers start in the central zone
Anterior zone
thickened area of tissue
surrounds the apex of the prostate
made of muscle fibres and fibrous connective tissue
does not contain any glands
BPH
also called benign prostatic hypertrophy
enlargement of the prostate gland
characterized by an increase in epithelial and stromal
cell numbers (hyperplasia) in the periurethral area of
the prostate
additional cells cause the prostate gland to swell,
squeezes the urethra and limits the flow of urine
one third of men older than 50 years
up to 90% of men by age 85 years
Etiology
Serum testosterone levels
slowly and significantly decrease in advanced age,
but levels of estrogenic steroids not decreased
equally
Therefore, prostate enlarges because of increased
estrogenic effects
Secretion of intermediate peptide growth factors
Aging (over 50 years of age)
Risk Factors
Age : rare in early 40s or younger, 90% in their 80s
Family history
Diabetes: high insulin levels can trigger prostate growth
Heart disease: same risk for heart problems also
increase prostate growth
Obesity : extra body fat have higher levels of estrogen
that make the prostate grow
Inactivity : sedentary lead to prostate problems
Differential Diagnoses
bladder cancer
bladder stones
bladder trauma
interstitial cystitis
neurogenic bladder
prostatitis
radiation cystitis
urethral strictures in males
UTI in males
Pathophysiology
Prostatic enlargement depends on the potent
androgen dihydrotestosterone (DHT)
Type II 5-alpha-reductase metabolizes circulating
testosterone into DHT
DHT binds to androgen receptors in the cell nuclei,
potentially resulting in BPH
BPH occur when
elevated estrogen levels
prostate tissue becomes more sensitive to estrogens
less responsive to DHT
Over stimulation of alpha-1adrenergic receptors located
within the smooth muscle of the stroma, capsule of the
prostate and in the bladder neck
increase muscle tone
worsening symptoms of obstruction
retention of urine
decreasing the urinary flow rate
Nearly all men will develop histological BPH at 80, but
the degree of enlargement is highly variable
Detrusor overactivity in the bladder
contribute for both urinary frequency and BPH
symptoms even if there is little urine in the bladder
Throughout time
the walls of the bladder become weaker
the organ lose ability to fully empty during urination
Bladder obstruction
results in smooth-muscle-cell hypertrophy
Clinical
Manifestations
Obstructive symptoms Irritative Symptoms
hesitancy in starting urination • frequency
decreased and intermittent force • urgency
of stream • nocturia
decreased in volume of stream • recurrent UTIs
dribbling after urination
abdominal straining with
urination
sensation of incomplete
emptying
Chronic urinary retention and large residual volumes
can lead to azotemia (accumulation of nitrogenous
waste products) and renal failure
Generalized symptoms
fatigue
anorexia
nausea
vomiting
pelvic discomfort
Complications
Complications before Surgery
urinary retention
renal insufficiency
recurrent urinary tract infections
gross haematuria
bladder calculi
renal failure or uremia
Complications after Surgery
Hemorrhage, Secondary hemorrhage a/f discharge
Perforation of the bladder or the prostatic capsule
Sepsis - common even in men with sterile urine and
occurs in over 50% of men with infected urine, prolonged
catheterization or chronic retention
Incontinence if the external sphincter mechanism is
damaged
Retrograde ejaculation and impotence
Complications after Surgery (Cont’d.)
Urethral stricture
Bladder neck contracture
Reoperation
General complications
cardiovascular (affect in elderly and frail group of
men)
Water intoxication
Diagnostic
Measure
History taking
Digital rectal examination - can assess prostate size
and shape, evaluate for nodules, and detect areas
suggestive of malignancy
Laboratory studies
• Urinalysis and Urine culture
• Prostate-specific antigen (PSA)
• Electrolytes, blood urea nitrogen (BUN), and creatinine
Ultrasonography
Endoscopy of the lower urinary tract
Urinalysis - assess for the presence of blood,
leukocytes, bacteria, protein, or glucose
Urine culture - useful to exclude infectious causes of
irritative voiding
Prostate-specific antigen (PSA) – BPH are also at
risk for prostate cancer therefore should be screened
Electrolytes, blood urea nitrogen (BUN), and
creatinine - useful screening tools for chronic renal
insufficiency in high postvoid residual (PVR) urine
volumes
Ultrasonography - useful for helping to determine
bladder and prostate size and the degree of
hydronephrosis in patients with urinary retention or
signs of renal insufficiency
Endoscopy of the lower urinary tract
• Indicate scheduled for invasive treatment or a foreign body or malignancy suspected
patient
• Indicate history of STD, prolonged catheterization, or trauma
International Prostate Symptom Score/American
Urological Association Symptom Index (IPSS/AUA-
SI)
Questions on the AUA-SI (incomplete emptying,
frequency, intermittency, urgency, weak stream,
straining and nocturia)
IPSS/AUA-SI with the plus a disease-specific quality
of life (QOL) question
QOL
Quality of Life Due to Delighte Pleased Mostly Mixed Mostly Unhappy Terribl
d Satisfie Dissatisfied e
Urinary Symptoms d
0 1 2 3 4 5 6
If you were to spend
the rest of your life
with your urinary
condition just the way
it is now,
how would you feel
about that?
Watchful Waiting
Therapeutic Management
Medication
Surgery
Watchful Waiting
Best option for men with minimal symptoms
Follow up visits are needed about once a year to
review symptom status
conduct a physical examination
perform a few simple laboratory tests
Lifestyle changes help relieve symptoms or prevent
from worsening
Medication
Alpha-Blockers
5-Alpha-Reductase Inhibitors
Combination Therapy ( Alpha Blocker + 5-Alpha-
Reductase Inhibitors)
Phosphodiesterase-5 Enzyme Inhibitors
Anti cholinergic Agents
Surgery
Open surgery
Retropubic prostatectomy (RPP)
Transvesical prostatectomy (TVP)
Perineal prostatectomy (this has now been abandoned
for the treatment of BPH)
Minimally Invasive Surgical Treatments
Transurethral Resection of the Prostate (TURP)
Transurethral Incision of the Prostate (TUIP)
Transurethral microwave thermotherapy (TUMT)
Transurethral needle ablation (TUNA)
Transurethral Ultrasound-guided Laser Incision of the
Prostate (TULIP)
Prostatic stents
Urolift system
Rezum water vapor therapy
Nursing Management
Pre-operative Nursing Intervention
Explain the patient and family about the operative
procedure and postoperative care such as monitoring
irrigation catheter drainage and haematuria and checking
to blockage of catheter
Discuss the possible complications of surgery which
include incontinence or dribbling of urine after surgery
Obtain written inform consent form from the patient.
Provide support and reassurance to the patient during the
preoperative period
Pre-operative Nursing Intervention (Cont’d.)
Perform routine investigations for BPH surgery
• ECG, CXR, haemogram, urea, creatinine, electrolyte,
RBS, INR, HbsAg, Anti HCV and retro screening
Show the patient to the anesthetist to examine for
appropriate anesthetic procedure
Instruct to take a bath or shower evening before surgery
Provide bowel preparation
Nothing per oral after midnight the day before surgery
(Cont’d.)
Discontinue blood thinning medications
• seven days prior to surgery
Administer prophylactic antibiotics as prescribed to
reduce the risk of infection
Clean or shave the area of penis, scrotum, and
surrounding area to reduce the risk of infection
Remove denture if present
Inform about Kegel’s exercise that help to relieve
urinary incontinence and retrograde ejaculation
(Cont’d.)
Monitor for vital signs closely in order to aware of
signs and symptoms of shock
Inform the patient and family about urine colour
normally change from reddish to pink within 24 hours
Adjust the rate of irrigation fluid depend on the colour
of irrigation output
Monitor the assessment of urine and blood loss every
hour especially on the first 24 hours after surgery
Maintain bed rest for the first 24 hours
(Cont’d.)
Irrigation procedure
• Use normal saline solution
• Assess for the proper placement
• Place the height of irrigation bags that can be
between 2 to 3 feet above the bladder
• Monitor the fluid intake and output
Assess for patient’s mental status because it is the
first sign of water intoxication due to fluid irrigation
Post-operative Nursing Intervention (Cont’d.)
Palpate the bladder to know the catheter is patent or not
and something is obstructing flow of the fluid
Note the signs of the TUR syndrome (hypertension, full
and bounding pulses, confusion, agitation, temporary
blindness)
Note the client’s reaction (incontinence or dribbling)
regarding the removal of the catheter
Administer anti-cholinergic medications as prescribed to
reduce bladder spasms
Post-operative Nursing Intervention (Cont’d.)
Administer pain medications as prescribe
Encourage early ambulation to prevent embolism,
thrombosis and pneumonia
Promote comfort through proper positioning
Administer stool softeners to prevent straining that
can lead to hemorrhage
Reduce anxiety by providing realistic expectations
about postoperative discomfort and overall progress
Health Education and Discharge Plan
Do you
know?
Inform the patient that burning sensation, urinary
frequency, urgency and difficulty passing urine do not
immediately resolve after relief of obstruction, these may
be settle down over a few weeks
Inform the patient that occurring the bleeding is normal
during post operative 9-14 days due to the scab on the
wound come away
Instruct to report to the health care provider, if the patient
experience difficulty passing urine
Instruct to take rest for a few days after discharge from the
Instruct to
avoid strenuous activity, heavy lifting and long
periods of sitting for 6 to 8 weeks
avoid straining at stool
avoid long walks and sports until healed or as
directed by the health care provider
eat high fiber diet and drink plenty of fluid to avoid
constipation
drink plenty of fluid that can also reduce the risk of
UTI and can clear any blood from the urine
Advise the patient to avoid the consumption of
alcohol, caffeine, and spicy foods that over stimulate
the bladder
Advise the patient to urinate every 2 to 3 hours and
when first feeling to urge
Reinforce carefully personal hygiene to minimize the
risk of infection
Encourage the patient to take prescription antibiotics
at regular times of day
Instruct the patient to take regular follow up care
Contacts with health care provider if the patient suffer any of
the following symptoms
increase amount of blood in urine
inability to pass urine
develop a fever
develop confusion
agitation
experience visual disturbances
nausea and vomiting
excessive tiredness
urine smells strong or unpleasant or appears cloudy
burning or pain when passing urine
bladder discomfort or spasms, and pain
Lifestyle changes that can prevent enlarged prostate are
Focus on eating more fruits and vegetables
Eat healthful, low-fat foods
Choose plant protein over animal protein
Avoid foods that are harmful to prostate health
Cut caffeine intake
Cut back on spicy and salty foods
Achieve and maintain a healthy weight
Exercise regularly
Manage stress
Avoid smoking
Limit alcohol
Avoid use of OTC antihistamines and decongestants
Do not hold urine
Keep diabetes under control
Stay warm
Focus on eating more fruits and vegetables
• Fruits and vegetables contain high levels of inflammation-fighting substances such as
antioxidants, vitamins, minerals, and fiber
Eat healthful, low-fat foods
• low in red meat and overall fat
• monounsaturated, omega-3 those found in avocados, nuts, cold water fatty fish, and olive
oil
Choose plant protein over animal protein
• Plant protein (Soy isoflavones)
Avoid foods that are harmful to prostate health
• red meat, calcium, dairy products, and foods high in
sugar
Cut caffeine intake
• Coffee, colas, some energy drinks, tea, and chocolate
can irritate the prostate and worsen BPH symptoms
Cut back on spicy and salty foods
• can make BPH symptoms worse
Achieve and maintain a healthy weight
• excess weight around the waist and hips is especially
associated with a greater risk of BPH
Exercise regularly
• regular exercise program can also help prevent
obesity, a risk factor for BPH
Manage stress
• deep breathing, exercise, and good nutrition may
alleviate the symptoms
Avoid smoking
Limit alcohol
Avoid use of OTC antihistamines and decongestants
Do not hold urine
• delaying urination can worsen BPH symptoms and
even result in urinary tract infections
• when first feeling to urge, urinate immediately
Keep diabetes under control
Stay warm
• cold weather an increase in activity in the
sympathetic nervous system which results in an
increase in smooth muscle tone in the prostate and
possible worsening of BPH symptoms
BOO
BOO is a blockage at the base of the
bladder.
It reduces or stops the flow of urine into
the urethra.
Etiology
Men- young (1) urethral stricture
(2) stone
- old (1) BPH
(2) prostatic cancer
Women- (1) cystocele
(2) urethral stricture
(3) Fowler’s syndrome (idiopathic urinary retention)
Both- neurological disease
BPH
Most common benign tumor in men
By the age of 5o years, 50% will be
affected
Atage of 80 years, more than 90% will
be affected
50% only will be symptomatic
Etiology of BPH
Endocrine
Age related
Genetic
Racial
Zones of the Prostate
Prostate is divided into 4 zones:
Transition zone
Peripheral zone
Central Zone
Anterior Zone
Verumontanum
Pathophysiology
Prostatic enlargement depends on the potent
androgen dihydrotestosterone (DHT)
Type II 5-alpha-reductase metabolizes circulating
testosterone into DHT
DHT binds to androgen receptors in the cell nuclei,
potentially resulting in BPH
BPH occur when
elevated estrogen levels
prostate tissue becomes more sensitive to estrogens
less responsive to DHT
Over stimulation of alpha-1adrenergic receptors located
within the smooth muscle of the stroma, capsule of the
prostate and in the bladder neck
increase muscle tone
worsening symptoms of obstruction
retention of urine
decreasing the urinary flow rate
Nearly all men will develop histological BPH at 80, but
the degree of enlargement is highly variable
Detrusor overactivity in the bladder
contribute for both urinary frequency and BPH
symptoms even if there is little urine in the bladder
Throughout time
the walls of the bladder become weaker
the organ lose ability to fully empty during urination
Bladder obstruction
results in smooth-muscle-cell hypertrophy
Clinical
Manifestations
LUTS
Hematuria
Urine retention
Uremia
Obstructive symptoms Irritative Symptoms
hesitancy in starting urination • frequency
decreased and intermittent force • urgency
of stream • nocturia
decreased in volume of stream • recurrent UTIs
dribbling after urination
abdominal straining with
urination
sensation of incomplete
emptying
Chronic urinary retention and large residual volumes
can lead to azotemia (accumulation of nitrogenous
waste products) and renal failure
Generalized symptoms
fatigue
anorexia
nausea
vomiting
pelvic discomfort
Other common causes of BOO include:
Pelvictumors (cervix, prostate, uterus,
rectum)
Narrowing of the tube that carries urine
out of the body from the bladder
(urethra), due to scar tissue or certain
birth defects
Less common causes include:
• Cystocele (when the bladder falls into
the vagina)
• Foreign objects
• Urethral or pelvic muscle spasms
• Inguinal hernia
The symptoms of BOO may vary, but can include:
• Abdominal pain
• Continuous feeling of a full bladder
• Frequent urination
• Pain during urination (dysuria)
• Problems starting urination (urinary hesitancy)
• Slow, uneven urine flow, at times being unable to urinate
• Straining to urinate
• Urinary tract infection
• Waking up at night to urinate (nocturia)
Exams and Tests
History taking and physical exam
Tests may include:
• Blood chemistries to look for signs of kidney damage
• Cystoscopy and retrograde urethrogram (x-ray) to look for narrowing
of the urethra
• Tests to determine how fast urine flows out of the body
(uroflowmetry)
• Tests to see how much the urine flow is blocked and
how well the bladder contracts (urodynamic testing)
• Ultrasound to locate the blockage of urine and find out
how well the bladder empties
• Urinalysis to look for blood or signs of infection in the
urine
• Urine culture to check for an infection
