Benign Prostatic Hyperplasia (BPH)

By:- Lemessa Jira

Presentation out lines • Objectives • Prostate Overview• Definition of BPH• Epidemiology• Etiologies • Pathophysiology• Symptoms of BPH • Diagnosis• Treatment Options• Nursing Management

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Objectives • At the end of session, the student will be able to• Define BPH• Identify the predominant location in the prostate

where BPH develops and describe how this fact relates to the symptoms and signs of BPH

• List the symptoms BPH• List the important components of the physical exam

of a patient with BPH• List the medical and surgical treatment options for

BPH.

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Introduction

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Prostate Overview

• Walnut sized gland at base of male bladder

• Surrounds the urethra

• Produces semen that transports sperm during ejaculation

• Prostate grows to its

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What is the Prostate

(Heidenreich, 2014)

Prostate…• normal adult size in a man’s early

20s; it begins to grow again during the mid-40s

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(Heidenreich, 2014)

• Enlarged Prostate or Benign Prostatic Hyperplasia (BPH)

• Prostatitis• Prostate Cancer • Each condition affects the prostate differently.

(Sosa, 2014)

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What Can Happen to the Prostate

What is BPH?

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Normal adult size = approximately 1.5 inches in diameter

(Silva, 2014)

Normal vs. Enlarged Prostate

• As the prostate enlarges, pressure can be put on the urethra causing urinary problems (LUTS)

Corona, 2014

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Normal Prostate Enlarged Prostate

(Corona, 2014)

Epidemiology•BPH affects 50% of men over 50yrs•Affects 40-50% of men ages 51-60

•Affects 80%+ men over age 80•Obesity, higher body mass index (BMI) and lack of exercise may increase the risk of BPH

(Sosa, 2014)

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• Cause not completely understood• Elevated estrogen levels. BPH generally

occurs when men have elevated estrogen levels and when prostate tissue becomes more sensitive due to aromatase enzyme.

(Getzenberg, 2014)

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Etiologies

Etiologies

• Smoking. Smoking increases the risk of acquiring BPH due to anti-estrogenic effect.

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(Getzenberg, 2014)

Etiologies…

• Reduced activity level. A sedentary lifestyle could also lead to the development of BPH.

• Western diet. A diet high in animal fat and protein and refined carbohydrates while low in fiber predisposes a man to BPH.

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(Getzenberg, 2014)

• Resistance. BPH is a result of complex interactions involving resistance in the prostatic urethra to mechanical and spastic effects.

(Getzenberg, 2014)

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Pathophysiology

Pathophysiology cont….• Obstruction. The hypertrophied lobes

of the prostate may obstruct the bladder neck or urethra, causing incomplete emptying of the bladder and urinary retention.

• Dilation. Gradual dilation of the ureters and kidneys can occur.

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(Getzenberg, 2014)

• Urinary frequency. Frequent trips to the bathroom to urinate may be an early sign of a developing BPH./ 3-5 times per hrs /

• Urinary urgency. sudden and immediate urge to urinate.

• Nocturia. Urinating frequently at night.

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Symptoms of BPH

(Silva, 2014)

Symptoms…• Weak urinary stream.

Decreased and intermittent force of stream is a sign of BPH.

• Dribbling urine. Urine dribbles out after urination.

• Straining. There is presence of abdominal straining upon urination.

17(Silva, 2014)

• Digital rectal examination (DRE). A DRE often

reveals a large, rubbery,

and nontender prostate gland.

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Diagnosis

(Silva, 2014), (Mottete, 2014)

Diagnosis…• Prostate specific antigen levels. - Elevated PSA levels may indicate an

enlarged prostate.•  normally PSA level is under 4

(ng/mL) in the blood

19(Silva, 2014)

Diagnosis…• BUN/Cr: Elevated if renal function is

compromised. Normal ranges BUN:• adult men: 8 to 20 mg/dL• adult women: 6 to 20 mg/dL• children: 5 to 18 mg/dL

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Diagnosis…• WBC: May be more than 11,000/mm3,• Normal value= 4,500 to 11,000 white blood cells

per microliter (mcL).

• Uroflowmetry: Assesses degree of bladder obstruction.

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(Silva, 2014)

Diagnosis…• Cystourethroscopy: To view degree

of prostatic enlargement and bladder-wall changes (bladder diverticulum).

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(Silva, 2014)

urinary function test(s) consistent with an enlarged

prostate• Uroflowmetry

–Normal: 10 – 21 mL/sec–Patient: 7 mL/sec

• Residual Urine Volume–> 50 mL significant–Patient: 110 mL (Abrams, 2013)

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Differential Diagnosis• Urethral stricture• Bladder neck contracture• Carcinoma of the prostate• Carcinoma of the bladder• Bladder calculi• Urinary tract infection and proctatitis

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(Silva, 2014)

Treatment Options

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Therapy• Watchful waiting and behavioral

modification• Medical Management

– Alpha blockers– 5-alpha reductase inhibitors– Combination therapy

• Surgical Management26

(Oelke, 2013)

Watchful Waiting and Behavioral Modification

• is the preferred management technique in patients with mild symptoms

• 1/3 improve on own.

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(Oelke, 2013)

Watchful Waiting and Behavioral Modification….

Decrease caffeine, alcohol )diuretic effect(

Avoid taking large amounts of fluid over a short period

of time

Void whenever the urge is present, every 2-3 hours

Maintain normal fluid intake, do not restrict fluid

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(Oelke, 2013)

Watchful Waiting and Behavioral Modification….

Avoid bladder irritants to include artificial sweeteners, carbonated beverages

Limit nighttime fluid consumptionBPH symptoms can be variable,

intermittent

29(Oelke, 2013)

Medical Managment

• Catheterization: if the patient is admitted to an emergency basis because he is unable to void, he is immediately catheterized.

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•Nutritional supplements– Saw Palmetto

•Alpha blockers– Doxazosin (Cardura)=Initial dose 1mg po/d for 1or 2wks maxim dose 1 to 8mg po/d – Terazosin (Hytrin)= Initial dose: 1 mg orally once a day at bedtime, Maintenance dose: 1 to 5 mg orally once a day. Maximum dose: 20 mg per day. 4 to 6

weeks ( Margie, 2014) 31

Medical Management

Medical Management…– Tamsulosin (Flomax)=initial dose o.4mg po/d, maxim dose 0.8mg po/d for 6-12

months – Alfuzosin (Uroxatral) = 10 mg orally once

a day immediately after the same meal each day for 2 to 3wks

Side effects: postural hypotension, dizziness, fatigue

32( Morgia, 2014)

Medical Management…• 5-alpha reductase inhibitors

– Finasteride (Proscar)=5mg po/d for 3months, Dutasteride (Avodart)= 0.5 mg orally once a day for 6 - 12 months

– Less effective for relief of BPH symptoms than alpha blockers

33( Morgia, 2014)

Combination Therapy• Concomitant use of alpha blockers and 5-

alpha reductase inhibitors– Should be reserved for patients who are

at significant risk of progression and adverse outcome• Patient wants to avoid surgery• Significant cost associated with dual medications

(Morgia, 2014)

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Surgical Management• Transurethral needle ablation

(TUNA). A combined visual and surgical instrument (cystoscope) is inserted and guides a pair of tiny needles into the prostate tissue that is pressing on the urethra.

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(LEE, 2012)

Surgical Management…• TUNA uses low-level radio

frequencies to produce localized heat that destroys prostate tissue while sparing other tissues.

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(LEE, 2012)

Surgical Management…• Open prostatectomy. Open

prostatectomy involves the surgical removal of the inner portion of the prostate via a suprapubic, retropubic, or perineal approach for large prostate glands.

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(LEE, 2012)

Surgical Management…• Retropubic

– Midline abd. incision

• Perineal– Incision between

the scrotum and anus

• Suprapubic– Abdominal

incision38(LEE, 2012)

Surgical Management…• Patients who have developed

complications of BPH (i.e urinary retention, renal insufficiency, recurrent UTI and obstructed urinary flow ) are best treated surgically.

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(LEE, 2012)

Complications of BPH• Urinary retention• UTI• Sepsis secondary to UTI• Residual urine• Calculi• Renal failure• Hematuria

40(Speakman, 2014)

• Nursing Management

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Nursing AssessmentIs base on health history• Health history. The health history

focuses on the urinary tract, previous surgical procedures, general health issues, family history of prostate diseases, and fitness for possible surgery.

• Physical assessment. Physical assessment includes digital rectal examination.

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Nursing Diagnosis• Based on the assessment data, the

appropriate nursing diagnoses for a patient with BPH are:

• Urinary retention related to obstruction in the bladder neck or urethra.

• Acute pain related to bladder distention.• Anxiety related to the surgical procedure.

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The goals for a patient with BPH include:• Relieve acute urinary retention.• Promote comfort.• Prevent complications.• Help patient deal with psychosocial

concerns.• Provide information about disease

process/prognosis and treatment needs.

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Nursing Care Planning & Goals

Nursing Interventions• Nursing Interventions• Preoperative and postoperative nursing

interventions for a patient with BPH are as follows:

• Reduce anxiety. The nurse should familiarize the patient with the preoperative and postoperative routines and initiate measures to reduce anxiety.

• Relieve discomfort. Bed rest and analgesics are prescribed if a patient experiences discomfort.

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Nursing interventions…• Provide instruction. Before the

surgery, the nurse reviews with the patient the anatomy of the affected structures and their function in relation to the urinary and reproductive systems.

• Maintain fluid balance. Fluid balance should be restored to normal.

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Evaluation

• Reduced anxiety.• Reduced level of pain.• Maintained fluid volume balance

postoperatively.• Absence of complications.

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Take-Home Messages

• Aging Population= More BPH• Not all Male LUTS=BPH• Not all BPH=LUTS• Consider Combination Therapy• Quality of life issues

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References1. Heidenreich A, Bastian PJ, Bellmunt J, Bolla M, Joniau S, van der Kwast T, et al. EAU

guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with

curative intent—update 2013. European urology. 2014;65(1):124-37.

2. Hambrock T, Hoeks C, Hulsbergen-van de Kaa C, Scheenen T, Fütterer J, Bouwense S, et

al. Prospective assessment of prostate cancer aggressiveness using 3-T diffusion-

weighted magnetic resonance imaging–guided biopsies versus a systematic 10-core

transrectal ultrasound prostate biopsy cohort. European urology. 2012;61(1):177-84.

3. Sosa MS, Bragado P, Aguirre-Ghiso JA. Mechanisms of disseminated cancer cell

dormancy: an awakening field. Nature Reviews Cancer. 2014;14(9):611-22.

4. Silva J, Silva CM, Cruz F. Current medical treatment of lower urinary tract symptoms/BPH:

do we have a standard? Current opinion in urology. 2014;24(1):21-8.

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Reference…

5. Corona G, Vignozzi L, Rastrelli G, Lotti F, Cipriani S, Maggi M. Benign prostatic

hyperplasia: a new metabolic disease of the aging male and its correlation with

sexual dysfunctions. International journal of endocrinology. 2014;2014.

6. Getzenberg RH, Kulkarni P. Etiology and pathogenesis. Male Lower Urinary Tract

Symptoms and Benign Prostatic Hyperplasia. 2014:218.

7. Mottet N, Bastian P, Bellmunt J, Van den Bergh R, Bolla M, Van Casteren N, et al.

Guidelines on prostate cancer. Eur Urol. 2014;65(1):124-37.

8. Abrams P, Chapple C, Khoury S, Roehrborn C, De la Rosette J. Evaluation and

treatment of lower urinary tract symptoms in older men. The Journal of urology.

2013;189(1):S93-S101.

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Reference…

9. Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, et al. EAU

guidelines on the treatment and follow-up of non-neurogenic male lower urinary

tract symptoms including benign prostatic obstruction. European urology.

2013;64(1):118-40.

10. Morgia G, Russo GI, Voce S, Palmieri F, Gentile M, Giannantoni A, et al. Serenoa

repens, lycopene and selenium versus tamsulosin for the treatment of LUTS/BPH.

An Italian multicenter double blinded randomized study between single or ‐combination therapy (PROCOMB trial). The Prostate. 2014;74(15):1471-80.

11. Lee NG, Xue H, Lerner LB. Trends and attitudes in surgical management of benign

prostatic hyperplasia. The Canadian journal of urology. 2012;19(2):6170-5.

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Reference…

12. Speakman MJ, Cheng X. Management of the complications of BPH/BOO. Indian

Journal of Urology. 2014;30(2):208.

13. Jain P, Neveu B, Fradet Y, Pouliot F. Moderated Posters 8: Prostate (Cancer/BPH)

July 1, 2014, 0730-0915. CUAJ. 2014;8:5-6Suppl3.

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THANK YOU

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