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Benign Prostatic Hypertrophy or Hyperplasia

Description

  1. A slow enlargement of the prostate gland occurs, with hypertrophy and hyperplasia of normal tissue.
  2. The enlargement causes narrowing of the urethra and results in partial or complete obstruction.
  3. The cause is unknown, and the disorder usually occurs in men older than 50 years.

Causes

Because the condition occurs in older men, changes in hormone balances have been associated with the cause. Androgens (testosterone) and estrogen appear to contribute to the hyperplastic changes that occur. Other theories, such as those involving diet, heredity, race, and history of chronic inflammation, have been associated with BPH, but no definitive links have been made with these potential contributing factors.


Assessment
  1. Urgency, frequency, and hesitancy
  2. Changes in sizes and force of urinary stream
  3. Retention
  4. Dribbling
  5. Nocturia
  6. Hematuria
  7. Urinary stasis
  8. UTIs
Physical Examination

Inspect and palpate the bladder for distension. A digital rectal exam (DRE) reveals a rubbery enlargement of the prostate, but the degree of enlargement does not consistently correlate with the degree of urinary obstruction. Some men have enlarged prostates that extend out into soft tissue without compressing the urethra. Determine the amount of pain and discomfort that is associated with the DRE.

The International Prostate Symptom Score
  1. Incomplete emptying: Over the past month, how often have you had the sensation of not emptying your bladder completely after you have finished urinating? (Not at all _ 0, less than 1 time in 5 _ 1, less than half the time _ 2, about half the time _ 3, more than half the time _ 4, almost always _ 5)
  2. Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? (Not at all _ 0, less than 1 time in 5 _ 1, less than half the time _ 2, about half the time _ 3, more than half the time _ 4, almost always _ 5)
  3. Intermittency: Over the past month, how often have you stopped and started again several times when urinating? (Not at all _ 0, less than 1 time in 5 _ 1, less than half the time _ 2, about half the time _ 3, more than half the time _ 4, almost always _ 5)
  4. Urgency: Over the past month, how often have you found it difficult to postpone urination? (Not at all _ 0, less than 1 time in 5 _ 1, less than half the time _ 2, about half the time _ 3, more than half the time _ 4, almost always _ 5)

Diagnostic Evaluation
  1. Physical examination, including digital rectal examination (DRE).
  2. Urinalysis and urodynamic studies to determine obstructed flow
  3. Renal function tests, including serum creatinine levels
  4. Complete blood studies, including clotting studies

Primary Nursing Diagnosis
  • Urinary retention (acute or chronic) related to bladder obstruction

Medical Management

The treatment plan depends in the cause, severity of obstruction, and condition of the patient. Treatment measures include:
  • Immediate catheterization if patient cannot void (a urologist may be consulted if an ordinary catheter cannot be inserted). A suprapubic cystostomy is sometimes necessary.
  • “Watchful waiting” to monitor disease progression.
  • Balloon dilation or alpha-1 adrenergic receptor blockers (terazosin) to relax smooth muscle of the bladder neck and prostate
  • Hormonal manipulation with antiandrogen (finasteride [Proscar]) decreases the size of the prostate and improves urinary flow.
  • Saw palmetto is a botanical remedy for mild to moderate BPH.
Surgical Management
  • Transurethral laser resection with ultrasound guidance
  • Transurethral needle ablation (spares urethra, nerves, muscles, and membranes)
  • Microwave thermotheraphy (using transurethral probe) applied to hypertrophied tissue, which then becomes necrotic and sloughs off
Surgical procedures such as prostatectomy can be used to remove the hypertrophied portion of the prostrate gland. Other kinds of surgery include:
  • Transurethral resection of the prostrate (TUR or TURP); urethral endoscopic procedure is most common approach.
  • Suprapubic prostatectomy (perineal incision); incontinence, impotence, or rectal injury may be complications
  • Retropubic prostatectomy (low abdominal incision)

Transurethral resection of the prostrate (TUR or TURP)

Pharmacologic Intervention
  1. Phenoxybenzamine (alpha-adrenergic) 10 mg PO bid, to blocks effects of postganglionic blocker synapses at the smooth muscle and exocrine glands; improvement of urinary flow in 75% of patients
  2. Finasteride (5-alpha reductase) 5 mg PO qd, to shrinks prostate gland and improves inhibitor urine flow
  3. Other Medications: Prazosin, alfuzosin, doxazosin

Nursing Intervention
  1. Encourage fluid intake of up to 2000 to 3000 mL per day unless contraindicated.
  2. Prepare for bladder drainage via urinary catheterization for distention.
  3. Avoid administering medications that case urinary retention, such as anticholinergics, antihistamines, and decongentants.
  4. Administer finasteride (proscar) as prescribes to shrink the prostate gland and improve urine flow.
  5. Prepare the client for surgery as prescribed.
Surgical interventions for Benign Prostatic Hyperplasia
    
    a. Perineal prostatectomy
    b. Retropubic prostatectomy
    c. Suprapubic prostatectomy
    d. Transurethral resection of the prostate

Postoperative Care Following Transurethral Resection of the Prostate

    Continuous Bladder Irrigation (CBI)
  • A three- way (lumen) irrigation is used to decrease bleeding and to keep the bladder free from clots:
  • One lumen for inflating the balloon (30mL)
  • One lumen for installation (inflow)
  • One lumen for outflow
    Interventions
  • Maintain traction on the catheter if applied to prevent bleeding by pulling the catheter taut and tapping it to the abdomen or thigh.
  • Instruct the client to keep the leg straight if traction is applied to the catheter and it is taped to the thigh.
  • Catheter traction is not release without a physician’s order and usually is released after any bright red drainage has diminished.
  • Use normal saline or prescribed solution only to prevent water intoxication.
  • Run the solution at a rate, as prescribed, to keep the urine pink.
  • Run the solution rapidly if bright red drainage or clots are present.
  • Run the solution at about 40 gtt/min when the bright red drainage clears.
  • If the urinary catheter becomes obstructed, turn off the CBI and irrigate the catheter wit 30 to 50 mL of normal saline if prescribed; notify physician if obstruction does not resolve.
  • Monitor for transurethral resection syndrome or severe hyponatremia (water intoxication) caused by the excessive absorption of bladder irrigation during surgery (altered mental status, bradycardia , increase blood pressure, and confusion).
  • Discontinue CBI and Foley catheter as prescribed, usually 24 to 48 hours after surgery.
  • Monitor for continence and urinary retention when the catheter is removed.
  • Inform the client that some burning, frequency, and dribbling may occur following catheter removal.
  • Inform the client that he should be voiding 150 to 200 mL of clear yellow urine every 3 to 4 hours by 3 days after surgery.
  • Inform the client that he may pass small clots and tissue debris for several days.
  • Teach the client to avoid heavy lifting, stressful exercise, driving, Valsalva’s maneuver, and sexual intercourse for 2 to 6 weeks to prevent strain, and to call the physician if bleeding occurs or there is a decreased in urinary stream.
  • Instruct the client to drink 2400 to 3000 mL of fluid each day, preferably before 8PM
  • Instruct the client to avoid alcohol, caffeinated beverages, and spicy foods and avoid overstimulation of the bladder
  • Instruct the client that if the urine becomes bloody, to rest and increase fluid intake, and that if the bleeding does not subside, to notify the physician.

Documentation Guidelines
  • Presence of urinary discomfort, bleeding, frequency, retention, or difficulty initiating flow
  • Presence of bladder distension, discomfort, and incontinence
  • Intake and output; color of urine, presence of clots, quality of urine (clear versus cloudy)
  • Presence of complications: Urinary retention, bleeding, infection
  • Reaction to information regarding sexual function

Discharge and Home Healthcare Guidelines
  • PATIENT TEACHING. Instruct patients about the need to maintain a high fluid intake (at least 2 L/day) to ensure adequate urine output. Teach the patient to monitor urinary output for 4 to 6 weeks after surgery to ensure adequacy in volume of elimination combined with a decrease in volume of retention.
  • MEDICATIONS. Provide instructions about all medications used to relax the smooth muscles of the bladder or to shrink the prostate gland. Provide instructions on the correct dosage, route, action, side effects, and potential drug interactions and when to notify these to the physician.
  • PREVENTION. Instruct the patient to report any difficulties with urination to the physician immediately. Explain that BPH can recur and that he should notify the physician if symptoms of urgency, frequency, difficulty initiating stream, retention, nocturia, or bladder distension recur.
  • POSTOPERATIVE. Encourage the patient to discuss any sexual concerns he or his partner may have after surgery with the appropriate counselors. Reassure the patient that a session can be set up by the nurse or physician whenever one is indicated. Usually, the physician recommends that the patient have no sexual intercourse or masturbation for several weeks after invasive procedures.

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