Lesson Plan

Subject: Adult medical surgical nursing

Topic: Benign prostate hyperplasia
Date: 2080/3/27
Place: Chitwan medical college
Time: 2pm
Number of participants: 35-40
Level of participant: BNS 1st year student
Name of supervisor: Sirjana Neupane
Name of student: Pramila Adhikari

General objective
At end of class, BNS 1st year student will be able to explain about benign prostate hyperplasia.
s. Time Specific objective content Method Media evaluation
n
1. 3 mins At the Self-Introduction
beginning of the Topic Introduction
teaching session Objectives

Pre-test
Brainstorming,
Q/A
2min

2.
At the end of the
session, the
participant will be
able to:

3. 2min Introduction of Introduction of BPH Interactive lecture Power What is

BPH and discussion. point BPH
4. 2min Define the BPH Definition of BPH Interactive lecture Power What is the
and discussion point BPH
5. 2min State the Epidemiology of BPH Interactive lecture Power What is the
epidemiology and discussion point epidemiolog
y of BPH.
6. 5min State the risk factor Risk factor of BPH. Interactive lecture Power What is the
of BPH and discussion point risk factor of
BPH.

7. 4min State the cause of Causes of BPH Interactive Power What is the causes of
BPH lecture and point BPH
discussion
8. 5min state the sign and Sign and symptoms Interactive Power What is the sign and
symptom of BPH of BPH. lecture and point symptoms of BPH.
discussion
9. 8min Explain the Pathophysiology of Interactive Power What is the
pathophysiology of BPH. lecture and point pathophysiology of
BPH. discussion. BPH.

10. 3min List the complication of Complication of Interactive Power What is the
BPH. BPH. lecture and point complication of
discussion. BPH.
11. 6min. State the Diagnosis of Interactive Power What is the
diagnostic BPH. lecture and point. diagnosis of BPH.
evaluation of discussion.
BPH
12. 7min State the Medical Interactive Power What is the medical
medical treatment of lecture and point. treatment of BPH.
treatment of BPH. discussion.
BPH.
13 7min State the Surgical Interactive Power What is the surgical
surgical treatment of lecture and point. treatment of BPH.
treatment of BPH. discussion.
BPH.
14. 2min Explain about Nursing Assignment Review What is the nursing
nursing management of management of
management of BPH. BPH.
BPH

16. 5min summary summarization Discussion.

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 adult.

 About 50% of all men in their lifetime will develop BPH.

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

 Research is not clear about whether having leads to an increase risk of developing
prostate cancer.
 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 bladder.”

Incidence
50% of men having evidence of BPH by age of 50 to 60 years.
75% by age of 60 to 69 years.
80% of men over 70 years.

Risk factor and etiology

• 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.
• As a man ages 5a-reductase and DHT levels remain similar to those seen in younger men, but
recent evidence has shown that the balance between two forms of this enzyme may be
compromised, contributing to prostatic enlargement.

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 lower PSA level (PSA 4.0ng and lower)
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.

Diet: saturated fatty acid.

Smoking: it reduces serum testerone effect
Alcohol consumption: develop cirrhosis of liver impede prostate enlargement.
Frequent use of a-adrenergic agonists risk of urinary retention.

Pathophysiology
The cause of BPH is not well understood, but testicular androgens have been implicated.

Dihydrotestosterone (DHT), a metabolite of testosterone, is a critical mediator of prostatic

growth.

Estrogens may also play a role in the cause of BPH; BPH generally occurs when men have
elevated estrogen levels and when prostate tissue becomes more sensitive to estrogens and less
responsive to DHT.

Smoking, heavy alcohol consumption, obesity, reduced activity level, hypertension, heart
disease, diabetes, and a Western diet (high in animal fat and protein and refined carbohydrates,
low in fiber) are risk factors for BPH.

BPH develops over a prolonged period; changes in the urinary tract are slow and insidious. BPH
is a result of complexed interactions involving resistance in the prostatic urethra to mechanical
and spastic effects.
bladder pressure during voiding, detrusor muscle strength, neurologic functioning, and general
physical. The hypertrophied lobes of the prostate may obstruct the bladder neck or urethra,
causing incomplete emptying of the bladder and urinary retention.

As a result, a gradual dilation of the ureters (hydroureter)and kidneys (hydronephrosis) can

occur.

Urinary retention may result in UTIs because urine the remains in the urinary tract serves as a
medium for infective organism.

Symptoms can be divided into two groups:

Irritative symptoms

 Nocturia (first symptoms noticed)

 urinary frequency
 urgency
 dysuria
 bladder pain and incontinence,
 Inflammation or infection.

Obstructive symptoms caused by prostate enlargement include a decrease in the

caliber and force of the urinary stream,

 Difficulty in initiating voiding,

 Intermittency (stop- ping and starting stream several times while voiding),
 Dribbling at the end of urination.
 Urinary retention.
Complications
 Acute urinary retention
 Involuntary bladder contractions
 Bladder diverticula
 Cystolithiasis
 Vesicoureteral reflux Hydroureter
 Hydronephrosis
 Gross hematuria
 UTI

Diagnostic Studies

History taking
includes specific questions about daytime voiding frequency, nocturia, urgency, urinary
incontinence, the force of the urine stream, perception of bladder emptying, and prior
episodes of acute urinary retention.

Physical examination
The prostate can be palpated by digital rectal examination (DRE) to estimate its size,
symmetry, and consistency. In BPH, the prostate is symmetrically enlarged, firm, and
smooth.
BPH reveals a symmetrically enlarged prostate with an obliterated central sulcus.
Prostatic infection (prostatitis) is associated with symmetric enlargement, a boggy
consistency, and discomfort on palpation. Adenocarcinoma of the prostate is associated
with asymmetric enlargement, hardened nodules, or induration.

Prostate-specific antigen (PSA)

Blood test may be done to rule out prostate cancer. However, PSA levels may be slightly
elevated in patients with BPH.
Cystoscopy
A procedure allowing internal visualization of the urethra and bladder, is performed if the
diagnosis is uncertain and in patients scheduled for prostatectomy.
Uroflowmetry
A study that measures the volume of urine expelled from the bladder per second, Results
are usually given in milliliters per second (mL/sec). This test is used to evaluate the
impact that benign prostatic hyperplasia (BPH) has on urine flow or to monitor the effect
of treatment. typically, urine flow runs from 10 ml to 21 ml per second. A slow or low
flow rate may mean there is an obstruction at the bladder neck or in the urethra, an
enlarged prostate, or a weak bladder.

Ultrasonography (bladder scan)

Residual urine is determined after the urine flow either by catheterization or by
ultrasonography.
This examination allows for accurate assessment of prostate size and is helpful in
differentiating BPH from prostate cancer.
Other test
Serum creatinine
may be ordered to rule out renal insufficiency. Because symptoms of BPH are similar to
those of a neurogenic bladder, a neurologic examination may also be performed. In
patients with an abnormal DRE and elevated PSA,

Postvoid residual urine volume

Measurement of the PVR determines the quantity of urine remaining in the bladder
shortly after a voluntary void; this measurement can be obtained using a portable
dedicated bladder scanner, a formal bladder ultrasound examination, or by directly
measuring the urine volume via urinary catheterization.
Normal residual urine in bladder: <50ml
Obstruction of the bladder residual urine volume:>200ml

Urinalysis with culture

Is routinely done to identify any infection. Bacteria, white blood cells (WBCs), or
microscopic hematuria indicate infection or inflammation.
Kidney function test
Urea nitrogen and blood urea nitrogen and creatinine level monitored
Complications
 Acute urinary retention
 Involuntary bladder contractions
 Bladder diverticula
 Cystolithiasis
 Vesicoureteral reflux Hydroureter
 Hydronephrosis
 Gross hematuria
 UTI

The goal of Management of BPH

To restore bladder drainage

Relieve the patient's symptoms
Prevent and treat complications

Management of BPH

Conservative management
Behavioral modification
Medical management
Surgical management
Nursing management

Conservative Management
Watchful waiting: Patient with mild symptoms or moderate -to- severe symptoms who
are not bothered by their symptoms and are not manifesting secondary signs of
complications of BPH should be managed with watchful waiting.
They have no treatment but get regular checkups and wait to see whether or not the
condition gets worse.
 Behavioral Modification
Decrease caffeine, alcohol (diuretic effect)
Avoid taking large amounts of fluid over a short period of time
Maintain normal fluid intake, do not restrict fluid
Void whenever the urge is present, every 2-3 hours
Avoid bladder irritants to include dairy product, artificial sweetenrs, and carbonated
beverages.
Limit nighttime fluid consumption.

Treatment (medical treatment) of benign prostate hyperplasia

Drug Therapy.

Drugs that have been used to treat BPH with variable degrees of success include 5a-
reductase inhibitors and a-adrenergic receptor blockers. Combination therapy using both
types of these drugs has been shown to be more effective in reducing symptoms than
using one drug alone.

5a-Reductase Inhibitors.

These drugs work by reducing the size of the prostate gland.

Finasteride and finasteride:

are used to prevent the conversion of testosterone to DHD and decrease prostate size. is
an appropriate treatment option for individuals who have a moderate to severe symptom.
Size effects include decrease libido, ejaculatory dysfunction, erectile dysfunction,
gynecomastia, and flushing.
 Adrenergic Receptor Blockers.
Adrenergic receptor block. are another drug treatment option for BPH.
A-adrenergic blockers these drugs promote smooth muscle relaxation in the prostate,
facilitating urinary flow through the urethra.
These agents demonstrate a 50% to 60% efficacy in improvement of symptoms, which
occurs within 2 to 3 weeks.
Several a-adrenergic blockers are currently in use, including silodosin, alfuzosin,
doxazosin, prazosin, terazosin, and tamsulosin. symptomatic relief of BPH, they do not
treat hyperplasia.

Erectogenic Drugs.

Tadalafil has been used in men who have symptoms of BPH alone or in combination with
erectile dysfunction (ED). The drug has shown to be effective in reducing symptoms for
both these conditions (see 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.
Antibiotics, pain medication, and bladder antispasmodic medications are used tolerate
and prevent post procedure problems.

2. Transurethral Needle Ablation.

Transurethral needle ablation (TUNA) is another procedure that increases the
temperature of prostate tissue, thus causing localized necrosis.

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.

4. Photo vaporization
(PVP) uses a high-power green 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.

5. 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.

6. 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.
 (B). 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.

1.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.
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.

Postoperative complications include bleeding, clot retention, and dilutional hyponatremia

associated with irrigation.
 2.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.

Nursing management of the medical client

Assessment
• Obtain history of voiding symptoms, including onset, frequency of day and nighttime
urination, presence of of decreased force of stream. urgency, dysuria, sensation
incomplete bladder emptying, and 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 postvoid residual,
if indicated.

Diagnosis
Readiness for Enhanced Self-Care related to desire to learn more about BPH,
manifestations, and medical treatments.
Intervention
• Provide teaching about BPH
• Men often have only a vague understanding of what an enlarged prostate is much less
where the gland lies.
• Many men fear they have prostate cancer or that BPH is a precursor of prostate cancer.
• Beliefs about treatment affecting their sexual functioning are also a concern.
• Show the client and significant other a picture of the reproductive organs and prostate,
and explain the effects of enlargement on urine excretion.
 Encourage Fluids.
• Many clients limit their fluid intake to combat the manifestations of BPH.
• Explain that concentrated urine acts as an irritant to the bladder. Caffeine and alcohol
also can exacerbate bothersome LUTS, and their intake should be reduced or avoided.
• Clients increase their risk of UTI with limited fluid intake. the client should maintain an
intake of 30 ml/kg/day or ½ ounce per pound of body weight.
Explain Medications.
• If medications are being used to treat BPH, men need a thorough explanation of how the
medications work, their side effects, and precautions.
• Warn the client to increase dosage only under the physician's orders because more
medication may not help manifestations and may cause serious cardiovascular problems.
• Encourage clients to be patient because the effects of medication on the prostate may take
time.

SAFETY
Clients ALERT are counseled to inform all health care providers of their BPH because
multiple medications (including antimuscarinics, certain antidepressants, antipsychotics,
and calcium channel blockers) may adversely affect bladder function and increase the
risk for acute urinary retention.

Diagnosis
Impaired Urinary Elimination related to increasing urethral occlusion.
Interventions
Catheterize.
• When the client has urinary difficulties, such as obstruction, urinary retention, or
diminished renal function, some form of catheterization may be necessary.
• Never force a urinary catheter. If it cannot be inserted with gentle pressure, notify the
urologist, who may need special instruments to get the catheter past the obstruction.
 Monitor Urine Output.
• If an indwelling catheter is placed for acute retention, observe the client for hourly urine
output (should be at least 0.5 ml/kg/hour), hematuria, and shock caused by post
obstructive diuresis.
• Hematuria can occur because of the sudden release of pressure on the blood vessels
supplying the bladder or mild trauma resulting from catheterization.
• Treat Post obstructive diuresis means increased urine output caused by Sterile in inability
of the renal tubules to absorb water and electrolytes after prolonged urinary obstruction.
• It is usually self-limiting but can cause sodium depletion in some clients, which leads to
vascular collapse and death if not detected and treated.

Nursing Management of the Surgical Client

Preoperative Care
• Assess the client's ability to empty his bladder. The bladder should be percussed for
distention. If the client can not void, a urethral catheter may have to be placed.
• Clients taking any drug or supplement with anticoagulant effects must discontinue these
substances before surgery.
• The nurse should carefully review all prescription drugs, over-the-counter medicines, and
herbal agents for anticoagulant properties.
• Preoperative assessment should also include attention to expectations about the
procedure, such as anticipated changes in voiding and sexual function.
• You are often able to lessen the client's fear and anxiety during the nursing history by
reinforcing preoperative teaching provided by the urologist and by ensuring that the client
understands the anticipated outcomes of the procedure.
• Respond to the concerns of the client and significant others with empathic listening,
accurate information, and ongoing support.
• Informed consent requires that the man understand short term risks (e.g., possible sexual
dysfunction, retrograde ejaculation; and infertility) long-term benefits (e.g., relief of
urinary manifestations and promotion of optimal renal function). It is important for the
client to receive honest answers to questions concerning sexuality and reproduction.
 Postoperative Care
Assessment
• Immediately after surgery, your major task is to observe the vital signs and maintenance
of urinary drainage.
• Indwelling catheters are used to facilitate urinary drainage after many types of prostate
procedures.
• Document the urine color, including the presence of blood clots, each time urine output is
recorded.
Diagnosis,
• Risk for Injury related to presence of urinary catheters, hematuria, irrigation, or
suprapubic drains.
Interventions
Maintain Irrigation.
• Closed bladder irrigation decreases the development of obstruction. If obstruction is
suspected, manual (hand) irrigation may be necessary.
• After prostatectomy for BPH, at least 60 ml of irrigant must be used, with some force, to
dislodge and evacuate.
• Blood clots and other debris. If there is resistance to the introduction of irrigating fluid
into the catheter or if there is no return of irrigating fluid, do not force the fluid. Instead,
notify the surgeon immediately.
• Never remove a catheter that is occluded instead, determine a plan for re-catheterization
in close consultation with the physician.
• Keep the penis and meatal area clean by washing them with soap and water at least twice
a day.
• Antibacterial ointments were formerly used, but they are no more effective than cleansing
with a perineal cleanser or soap and water. Antibacterial soaps or antiseptics may dry out
skin.
Monitor for Bleeding
• Some hematuria is usual for several days after surgery however, frank bleeding, arterial
or venous, may occur during the first day after surgery.
Prevent Catheter Dislodgment.
• The client may be confused immediately after surgery or may forget that he has a catheter
and accidentally pull out the catheter.
• Show him how to get in and out of the bed or chair without pulling on the catheter.
• Remind the client that he has a tube in his bladder through his penis or abdomen
(whichever it is), and instruct him not to touch it.
• A displaced or removed urinary catheter after prostatic sur gery is painful and disrupts
recovery. Securing the catheter with a Velcro catheter strap (holder) is strongly
recommended. If the client does pull the catheter out, notify the surgeon immediately.
Prevent Infection.
• Observe the client carefully for local or systemic indications of infection.
• Handle catheters, drainage apparatus, and urine collection carefully to avoid introducing
microorganisms into the urinary tract.
• Maintain a closed urinary drainage system unless manual irrigation is absolutely required.
Encourage increased fluid intake, ambulation, and deep-breathing exercises.
• Wound drains are usually removed earlier than suprapubic catheters. Keep skin around
the drain and catheter sites clean, dry, and protected. Observe for redness, edema, or
infection.
.
Monitor for Retention.
• The catheter is associated with a risk for urinary retention because of changes in detrusor
contractility, transient obstruction resulting from urethral edema or local discomfort, or
urethral blockage caused by clots or other debris.

Manage Temporary Incontinence.

• Advise the client that storage LUTS such as daytime voiding frequency, urgency,
leakage, and dysuria are anticipated and will persist until complete healing occurs.
• Keep reminding him that these problems are temporary but may take some time to
resolve.
• Pelvic muscle exercises may help to reduce this problem. Additional surgery is
occasionally required for persistent incontinence.
References
1. Brunner and Suddarth’s(2014) .text book of medical-surgical Nursing.13 h edition. Page
no 1147-1150
2. Davidson’s .principle and practice of Medicine.22th edition .
3. Lewis’s.Medical surgical Nursing(2013).New delhi .Elsevier. 1 st edition. Vol 2. Page no
1624-1628
4. Mandal, G.n Medical surgical nursing.5 th edition. Makalu Publication House. Page no
257-260
5. Sharma. comprehensive textbook of medical surgical nursing 3rd edition, Samiksha
publication pvt.ltd.Page.no 153-156
6. https://www.ncbi.nlm.nih.gov/books/NBK538230
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4137581
8. https://rnspeak.com/fever-hyperthermia-nursing-care-plan