Benign Prostatic hyperplasia (BPH)

Introduction
Benign prostatic hyperplasia (BPH) is a very common urological problem seen
locally and it is estimated that approximately 20% of men above t he age of 50
years might require treatment. Patient with BPH present with both obstructive
and irritative symptoms. Obstructive symptoms include hesitancy, poor stream,
post micturition dribbling and retention of urine. Irritative symptoms include
frequency, dysuria, urgency and nocturia. About 50% of our local patients with
BPH will have an enlarged prostate gland. However, the size of the prostate
gland bears no relationship with severity of obstruction.The prostate is a male
gland about the size of a chestnut, which surrounds the urethra (water pipe) just
below the bladder.

Definition
Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate
that can cause urinary symptoms identical to prostate cancer. Similar to prostate
cancer, BPH is common in older men and can cause an elevated PSA (prostate
specific antigen) level. BPH is not cancer and cannot spread to other parts of the
body.
Applied Anatomy

1
Prostate gland is para reproductive organ of the male derives from the outpouching
of the urethra during early embryonic life. It weighs about 15 grams in adults and
is situated deep in the pelvis between the bladder and the external sphincter. It is an
organ, which consists of both glandular epithelium and fibromuscular stroma with
numerous ducts emptying into the prostatic urethra. Alkaline secretion is produced
during sexual stimulation by these glands. Two zones or prostate gland are
recognized on histological examination, the outer or the peripheral zone and the
inner or the central zone.

Incidence
It occurs most often in men over the age of 60. Up to 30 per cent of men in their
70s have BPH that causes them symptoms.

Etiology
The exact etiology of BPH is still poorly understood. Various risk factors have
been implicated such as racial predilection, hypertension, liver cirrhosis and
vasectomy but none had been proven convincingly. Studies and observations
have shown that both increasing age and intact testes are important for BPH to
develop as castration in young age of the development of BPH later in life.
Microscopic BPH starts to develop as early as in the thirties but clinical BPH
usually present after the fifties. Studies of the various populations form different
parts of the world have shown that t he incidence of the disease is
approximately the same amongst the various races.

Pathophsiology
Due to etiological Factors Enlargement of prostate gland

Normally thin skin fibrous outer capsule of prostate become spongy & thick as
enlargement progress

Hypertrophied lobe compress the bladder neck or postatic urethra,causing

Gradual dilation of ureter & kidney (hydrourter& hydronpheosis)

Prolonged urinary retension/obstr\uction cause tract infection.

2
Clinical Manifestation
The clinical manifestations of BPH are
-lower urinary tract symptoms (LUTS) that include -increased frequency of
urination,
-nocturia,
-weak urinary stream.
-Hesitancy: difficulty starting the urine flow, even when the bladder feels full.
-Frequency: a need to urinate often during the day and during the night.
-----------Increased need to urinate in the night is usually a very early symptom.
-Urgency: a need to urinate right away. Some men may experience involuntary
discharge of urine (known as urge incontinence).
-Dribbling of urine after urination. This is known as terminal dribbling.
-Dysuria: a burning sensation or pain during urination.

these symptoms typically appear slowly and progress gradually over a period of
years. However, they are not specific for BPH. Furthermore, the correlation
between symptoms and the presence of prostatic enlargement on rectal
examination or by transrectal ultrasonographic assessment of prostate size is
poor.
This discrepancy probably results from changes in bladder function that occur
with aging and from enlargement of the transitional zone of the prostate that is
not always evident on rectal examination.

Diagnostic Evaluation
-urine will be examined, and may be sent for culture, when it will also be tested
for sensitivity to antibiotics.
-Kidney function will also be examined by a blood test.
It's usual for the doctor to send a blood sample to check the prostate specific
antigen (PSA) level. A raised level of PSA may indicate a risk of the presence
of prostate – this may require biopsies of the prostate to investigate further.
-X-rays, including ultrasound examinations, and blood tests, may be necessary.

Medical management
There are two types of medication for this problem.
1)Alpha-blockers. These medicines help to relax muscle fibres within the
prostate, thereby reducing the obstruction to the urine flow. They do not reduce
the size of the prostate. Examples include terazosin (Hytrin), alfuzosin
(Xatral)and tamsulosin (Flomax MR). Patients occasionally experience side-
effects such as dizziness, headache, drowsiness and retrograde ejaculation.
2)5-alpha-reductase inhibitors such as finasteride (Proscar) inhibit the growth
of the prostate and decrease the size of the gland. These medicines can take
many months to become maximally effective since they rely on physically
shrinking the enlarged prostate.
Research studies have shown that both types of medical treatment are effective
at improving urinary symptoms in men with BPH.
3
Surgical management
An operation on the prostate will involve the removal of parts of the enlarged
tissue.
1) Transurethral resection of the prostate (TURP).
Under either a general or spinal anaesthetic, a telescope is inserted into the
urethra via the penis and advanced to the prostate. A special cutting loop is then
used to remove small chippings of prostate until a wider channel is made
through the prostate through which the urine can pass unimpeded.
2)Transurethral incision (TUI) or bladder neck incision (BNI)
If the prostate is only slightly enlarged, it may be enough to make a little cut in
the prostate, without removing tissue, to reduce the constriction of the urethra.
Are there other more gentle surgical treatments?
Newer treatments for benign prostate hyperplasia already exist and are
continually being developed. These techniques are minimally invasive. Some
need only local anaesthesia and the risk of complications is smaller.
New techniques.
3)Microwave thermotherapy
In this treatment, the prostate tissue is heated to around 45ºC by means of
microwaves. This reduces the size of the prostate by causing cells in the centre
of the prostate to die. This treatment is carried out through the urethra.
4)Electrovaporisation
In this procedure, part of the prostate tissue is removed by evaporation by
means of electrical current. The treatment is performed with an endoscope.
5)Laser resection
Another endoscopic treatment, in which part of the prostate tissue is removed
with laser energy.
Many centres are now reporting excellent results with the holmium Laser
(HoLep).

Complications
There are further complications with this disease.
-Some men experience a sudden onset of inability to pass urine (known as acute
retention).
-Studies have shown that acute retention affects between 1 and 2 per cent of
men with BPH each year. This condition is very painful and demands
immediate medical treatment. The usual treatment in the emergency situation is
insertion of a urinary catheter to drain the bladder and relieve the obstruction.
-Other men find it gradually harder to empty the bladder. As the condition
develops, more and more urine is left in the bladder after urination (known as
chronic retention).
Other complications of BPH include: repeated attacks -cystitis (infection of the
bladder) and the
-development of stones in the bladder.
Prognosis
4
The majority of patients with BPH can expect at least moderate improvement of
their symptoms with a decreased bother score and improved quality of life.
Lower urinary tract symptoms (LUTS), secondary to BPH, may affect sexual
wellbeing including erectile function. Medical therapy for BPH may also effect
sexual function, beneficially and harmfully, so this must be considered on an
individual basis. Some studies suggest that patients with a low risk for
progression may be able to discontinue first-line therapy with alpha-blockers
after several months of therapy. However, the majority of patients will require
ongoing therapy.

5
 Nursing care Plan

S Assessment Nursing Expected Intervention Rationale Evaluatio

1 Subject Impaired urinary After 3 hours 1)Monitor vital signs closely. Observe for 1)Loss of kidney function results in Does the
Data:-The Elimination of nursing hypertension, peripheral/dependent decreased fluid elimination and patient
patient may related to Intervention edema, changes in mentation. Maintain accumulation of toxic wastes may able to
verbalizeddiffi increase The accurate I&O. progress to complete renal shut manage
culty in urethral patient will be down.- the
urinating. occlusion able to manage 2. Encourage oral fluids up to 3000 mL manifestati
Objective the daily, within cardiac tolerance, 2)Increased circulating fluid ons of the
Data:-Patient manifestation if indicated maintain disease
may manifest of the disease. renal perfusion and flushes a.-nocturia
one or more of kidneys ,bladder, and ureters b-dysuriac.
the following:- 3. Encourage patient to void every2-4 hours of sediment and bacteria. C-
(+) nocturia- and when urge is noted. 3)may minimize over distension of inconentence
(+)incontinence- the bladder.- reduces risk of d-
(+) dysuria-(+) 4. Encourage meticulous catheter and ascending infection hesitancy
facial grimaces perineal care. 4)reduces risk of ascending to urinate?
upon urination- infection
(+) edema- pt
may also be
seen with an
indwelling
connected
with the
urobag.

6
S Assessment Nursing Expected Intervention Rationale Evaluation
No Diagnosis Outcome

2 .Subject data:- Mild STO: 1) Monitored vital signs and record 1)Serve as a baseline data
Restless,Anxious anxiety Within 3 hours of accordingly.
Objective Data:- related to nursing 2) Assessed respiratory status. 2) To know if the patient is in respiratory
-vital signs taken as upcoming interventions, the distress
follows:- surgical patient will be 3) Established rapport. 3) To gain trust and cooperation.
BP=140/80mmHg- operation. ( able to identify 4) Assisted patient on comfortable 4) Helps to alleviate feeling of
RR=20cpm- Prostatecto ways to deal with position. anxiety.
PR=61bpm-T=36.5 my) and express anxiety. 5) Acknowledged patient’s verbalization of 5) to assure that anxiety is a
-non-conversant but LTO anxiety. normal feeling
cooperative : Within 8 hours of 6)IVF regulated and checked for potency 6) To avoid circulatory overload.
- Able to do ADL as to bed nursing 7)Anticipated and attended to 7) For patient not to strain self
mobility, feeding. interventions, the needed:
-on NPO diet patient will be 8)Encouraged on the following: 8) To know appropriate nursing
-not in respiratory able to - to verbalize feelings and interventions to be done.
distress appear relaxed discomfort -provide comfort to the body
and report -to take rest and sleep causing relief of anxiety
anxiety is reduced to -to have divers ional activities like -for patient to address and reduced
a manageable level. reading newspaper and conversing with feelings of anxiety
others 
9) Emphasized the importance of 9) For patient to comply with the
therapeutic regimen pharmacological interventions
10) Emphasized the presence of 10) Help alleviate the anxiety of
Significant others the patient
11) Informed on NPO Diet. 11)for patient to understand the
reasons for NPO preoperatively