BPH is enlargement of the prostate that constricts the urethra, causing urinary symptoms.
Incidence
50 years-50% of men.
70 years -75%
More than 80 years-90%
More common among black men.
Causes
Exact cause unknown. Hormonal alteration is responsible exposure to radiation testosterone androgen.
Pathophysiology
Cause - uncertain, but evidence suggests hormonal cause.
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Hyperplasia of the supporting stromal tissue and glandular elements in the prostate. [The prostatic tissue forms nodules as enlargement occurs. The normally thin and fibrous outer capsule of the prostate because spongy and thick as enlargement progresses.]
Prostatic urethra becomes compressed and narrowed.
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Obstruction to flow of urine.
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A gradual dilatation of the ureters (hydroureter) and kidneys (hydronephrosis)
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Incomplete emptying and urinary retention.
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Urinary tract infection
Clinical manifestations
1. In early or gradual prostatic enlargement, there may be no symptoms.
2. Obstructive symptoms - hesitancy, diminition in size and force of urinary stream, terminal dribbling, sensation of incomplete emptying of the bladder, urinary retention.
3. Irritating voiding symptoms urgency, frequency, nocturia.
Diagnostic Evaluation
1. Rectal examination - smooth, firm, symmetric enlargement of the prostate can be
2. Urine analysis to rule out haematuria and infection.
3. Serum creatinine and BUN to evaluate renal function.
4. Serum PSA (Prostate specific antigen) to rule out cancer, but may also be elevated in BPH.
5. Measurement of post void residual urine; by ultrasound or catheterization [Residual urine > 100 above high].
6. Cystourethroscopy - to inspect urethra and bladder and evaluate prostatic size.
7. Biopsy of prostate confirms the diagnosis.
Medical Management
1. Pharmacologic management
a. Alpha- Adrenergic blockers such as doxazosin (Cordura), Tamsulosin (Flomax), Tetrazosin (Hytrin) relax smooth muscle of bladder base and prostate to facilitate voiding.
b. Finasteride (Prosdar) antiandrogen effect on prostatic cells, reverses or prevents hyperplasia
2. Non-surgical invasive management
a. Heat-localized application of heat reduces the size of the prostate tissue.
Temp. <113° F (45° c)
hypothermia
Temp. 113° F- thermo therapy.
[To achieve temp. 109.4° F/greater is intra cavitary placement in urethra of a radiating microwave antenna that emits heat Murine flow rate, in post void residual urine capacity and in frequency of nocturia.
b. Laser surgery (laser ablation - A transurethral u/s guided, laser-induced prostatectomy (TULIP).
C. Insertion of intraurethral stents and coils - [placement of stents (stainless steel or coils (Titanium) in prostatic urethra. Holds back the walls of prostate allows unobstructive flow of urine. Stents get completely covered with epithelium risk of encrustation and infection].
d. Transurethral electrovapourization.
e. Transurethral needle ablation
Surgical invasive management
1. Transurethral resection of prostate (TURP). [Resectoscope inserted through urethra.
2. Hot-loop resectoscope with movable loop of urine cuts tissue with high frequency current.
3. Cold-punch resectoscope punches out tissue, piece by piece with a circular knife blade.
4. Bleeding controlled by cauterization irrigating fluid passed in and out debris falls back into bladder and washed out.
Isotonic irrigation fluid is used H₂O, never used because during surgery. Client absorbs 900ml. Irrigating fluid thro' tissues and veins at operative site. H2O precipitate haemolysis and acute renal failure?
5. Prostatectomy
- Retropubic - low abdominal Incision facilitates approach to prostrate without entering bladder,
- Perineal - incision perineum anus & scrotum Suprapubic incision made into the bladder.
6. Transurethral excision of prostrate. (TULP)
Complication
1. Acute urinary retention, involuntary bladder contraction, bladder diverticula, cystolithiasis.
2. Vesicoureteral reflux, hydroureter, hydronephrosis.
3. Gross haematuria, UTI.
Postop complications
Haemorrhage, infection and thrombosis and catheter obstruction.
Nursing Management
1. The nurse familiarizes the patient with the hospital environment.
2. Privacy is provided and a trusting and professional relationship is developed.
3. Verbalization of concerns is encouraged.
4. Provide information about the condition, diagnostic tests, surgery (nature of incision), drainage expectations type of anaesthesia and immediate preoperative period.
5. Monitor patient's voiding patterns, observe for bladder distention and assists with catheterization for retention. An indwelling catheter is introduced if the patient has continuing urinary retention.
6. Antiembolism stockings are applied before the operation and are particularly important if the patient is placed in a lithotomy position during surgery.
Post operative Interventions
1. Maintain oral fluids 2000-3000 ml/day.
2. Post Op haemorrhage may occur due to displacement of catheter or from increase in abdominal pressure. Traction on catheter provide counter-pressure on bleeding site in prostate, decreasing bleeding. Pressure to be released on schedule basis.
3. After surgery, the bladder is continuously irrigated with sterile Ns to remove clotted blood from the bladder and ensure drainage of urine. (Blood clots are normal in 24-36 hrs. post operatively)
4. Following perineal prostectomy, careful aseptic techniques is practiced during dressing, to prevent infection. Dressings are held in place by a double-tailed T- binder bandage (or a padded athletic supporter). Avoid rectal temperature, rectal tubes and enemas. After perineal sutures are removed the perineum is cleansed. A heat lamp may be directed to the perineal area to promote healing. [the scrotum is protected with a towel while the heat lamp is in use] sitz baths are also used to encourage healing.
5. Observe for bladder distention [a distinct rounded swelling above the pelvis]
6. Check the drainage bag, dressings and incision site for evidence of bleeding. Note color of urine; change in color from pink to amber indicates lessened bleeding.
7. Monitor the BP, pulse and respiration and compare with the preoperative vital signs to assess for hypotension. Observe the Pt for restlessness; cold, sweating, skin, pallor, fall in Bp and an increasing pulse rate.
8. For the First 24 hrs, the patient is kept on bed rest.
9. When the patient i ambulatory. He is encouraged to walk but not to sit for prolonged periods, since this intra possibility of discomfort and bleeding. abdominal pressure and increases the
10. The bowel movements are kept soft to prevent straining. If an enema is prescribed, it is administered with caution to avoid possible rectal perforation.
11. Exercises are helpful for regaining urinary control [Tense the perineal muscles by pressing the buttocks together; hold this position, relax. This exercise done 10-20 times each hr. can be performed while sitting or standing.]
Try to shut off the urinary stream after starting to void; wait a few seconds and then continue to void] Perinea! exercises are continued until full urinary control is gained.
12. Advise the patient to avoid lifting heavy weight. He should avoid long automobile rides, a strenuous exercise, which increase the tendency to bleed. Avoidance of certain foods (spicy) alcohol and coffee as they may cause discomfort.
13. Sexual activity may be resumed in 6-8 weeks.
14. Advise follow up visits after treatment because urethral stricture may occ and regrowth of prostate is possible after TURP.
