benign prostatic hyperplasia
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be·nign pros·tatic hy·per·pla·si·a (BPH),[MIM*600082]
benign prostatic hyperplasia
benign prostatic hyperplasiaBenign enlargement of the prostate, which is normal after age 50 and secondary to androgen and related hormones; BPH pushes against the urethra, blocking urine flow.
Bladder-outlet obstruction, seen in 50% of men ≥ age 60; excess enlargement may obstruct the urethra, causing urinary retention; 30+% require surgery.
be·nign pros·tat·ic hy·per·pla·si·a(BPH) (bĕ-nīn' pros-tat'ik hī'pĕr-plā'zē-ă)
Benign prostatic hyperplasia (BPH)
Benign Prostatic Hyperplasia (Hypertrophy)
|Mean LOS:||4.4 days|
|Description:||SURGICAL: Transurethral Prostatectomy With CC or Major CC|
|Mean LOS:||5.9 days|
|Description:||MEDICAL: Benign Prostatic Hypertrophy With Major CC|
Benign prostatic hyperplasia (BPH; excessive proliferation of normal cells in normal organs) or hypertrophy (an increase in size of an organ), one of the most common disorders of older men, is a nonmalignant enlargement of the prostate gland. It is the most common cause of obstruction of urine flow in men and results in more than 4.5 million visits to healthcare providers annually in the United States. The degree of enlargement determines whether or not bladder outflow obstruction occurs. As the urethra becomes obstructed, the muscle inside the bladder hypertrophies in an attempt to assist the bladder to force out the urine. BPH may also cause the formation of a bladder diverticulum that remains full of urine when the patient empties the bladder.
As the obstruction progresses, the bladder wall becomes thickened and irritable, and as it hypertrophies, it increases its own contractile force, leading to sensitivity even with small volumes of urine. Ultimately, the bladder gradually weakens and loses the ability to empty completely, leading to increased residual urine volume and urinary retention. With marked bladder distention, overflow incontinence may occur with any increase in intra-abdominal pressure, such as that which occurs with coughing and sneezing. Complications of BPH include urinary stasis, urinary tract infection, renal calculi, overflow incontinence, hypertrophy of the bladder muscle, acute renal failure, hydronephrosis, and even chronic renal failure.
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.
When BPH occurs in men under age 60 and is severe enough to require surgery, chances of a genetic component are high. Autosomal dominant transmission appears likely because a man who has a male relative requiring treatment before age 60 has a 50% lifetime risk of also requiring treatment.
Gender, ethnic/racial, and life span considerations
By the age of 60, 50% of men have some degree of prostate enlargement, which is considered part of the normal aging process. Many of these men do not manifest any clinical symptoms in the early stages of hypertrophic changes. As men become older, the incidence of symptoms increases to more than 75% for those over age 80 and 90% by age 85. Of those men with symptoms, approximately 50% of men are symptomatic to a moderate degree and 25% of those have severe symptoms that require surgical interventions. While there are no clear ethnic/racial patterns of risk for BPH, symptoms of BPH tend to be more severe and progress more quickly in African American men than in other populations, possibly because of higher testosterone levels that lead to an increased rate of prostatic hyperplasia and gland enlargement.
Global health considerations
BPH is a significant and widespread international problem that causes symptoms in at least 30 million men globally.
Generally, men with suspected BPH have a history of frequent urination, urinary urgency, nocturia, straining to urinate, weak stream, and an incomplete emptying of the bladder. Distinguish between these obstructive symptoms and irritative symptoms such as dysuria, frequency, and urgency, which may indicate an infection or inflammatory process. A “voiding diary” can also be obtained to determine the frequency and nature of the complaints. The International Prostate Symptom Score (IPSS) has been adopted worldwide and provides information regarding symptoms and response to treatment (Box 1). Each question allows the patient to choose one of six answers on a scale of 0 to 5 indicating the increasing degree of symptoms; the total score ranges from 0 (mildly symptomatic) to 35 (severely symptomatic). The eighth question, known as the Bother score, refers to quality of life.The International Prostate Symptom Score
- 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)
- 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)
- 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)
- 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)
- Weak stream: Over the past month, how often have you had a weak urinary stream? (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)
- Straining: Over the past month, how often have you had to push or strain to begin urination? (Never = 0, once = 1, twice = 2, three times = 3, 4 times or more = 4, 5 times or more = 5)
- Nocturia: Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? (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)
- How would you feel if you were to spend the rest of your life with your urinary condition just the way it is now? (Delighted = 0, pleased = 1, mostly satisfied = 2, mixed = 3, mostly dissatisfied = 4, unhappy = 5, terrible = 6)
Inspect and palpate the bladder for distention. A digital rectal examination (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 patient who is experiencing BPH may voice concerns related to sexual functioning after treatment. The patient’s degree of anxiety as well as his ability to cope with the potential alterations in sexual function (a possible cessation of intercourse for several weeks, possibility of sterility or retrograde ejaculation) should also be determined to provide appropriate follow-up care.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Urinalysis and culture||Minimal numbers of red and white blood cells; no bacteria; clear urine with no occult blood and no protein||Urinary tract infection may occur with the presence of bacteria, blood, leukocytes, protein, or glucose||Urinary retention may lead to infection; voiding may be irritating|
|Uroflowmetry||Males ages 46–65 have more than 200 mL of urine at a flow rate of 21 mL/sec||Flow rate is decreased||Prostate inflammation leads to a narrowed urethral channel and obstruction of urine outflow|
|Prostate-specific antigen (PSA)||Normal: < 4 ng/mL||May be slightly elevated||PSA testing may reduce the likelihood of dying from prostate cancer. Patients should be alerted that PSA testing poses the risk of treatment of prostate cancer that would not have caused ill effects if left undetected.|
Other Tests: Serum creatinine and blood urea nitrogen (BUN), electrolytes, postvoid residual volume (PRV), diagnostic ultrasound, cystourethroscopy, abdominal or renal ultrasound, transrenal ultrasound (TRUS). Note that while BPH does not cause prostate cancer, men at risk for BPH are also at risk for prostate cancer. Screening for prostate cancer remains controversial (see diagnostic highlights above).
Primary nursing diagnosis
DiagnosisUrinary retention (acute or chronic) related to bladder obstruction
OutcomesUrinary continence; Urinary elimination; Infection status; Knowledge: Disease process, medication, treatment regimen; Symptom control behavior
InterventionsUrinary retention care; Bladder irrigation; Fluid management; Fluid monitoring; Urinary catheterization; Urinary elimination management; Tube care: Urinary
Planning and implementation
medical.Men with mild or moderate symptoms but without complications, and who are not bothered by their symptoms, may be monitored by “watchful waiting.” Most experts suggest that in this situation, the risks of medical treatment may outweigh the benefits, although most experts recommend annual examinations in case their condition changes.
surgical.Those patients with the most severe cases, in which there is total urinary obstruction, chronic urinary retention, and recurrent urinary tract infection, usually require surgery. Transurethral resection of the prostate (TURP) is the most common surgical intervention. The procedure is performed by inserting a resectoscope through the urethra. Hypertrophic tissue is cut away, thereby relieving pressure on the urethra. Prostatectomy can be performed, in which the portion of the prostate gland causing the obstruction is removed.
The relatively newer surgical procedure called transurethral incision of the prostate (TUIP) involves making an incision in the portion of the prostate attached to the bladder. The procedure is performed with local anesthesia and has a lower complication rate than TURP. The gland is split, reducing pressure on the urethra. TUIP is more helpful in men with smaller prostate glands that cause obstruction and for men who are unlikely to tolerate a TURP. Other minimally invasive treatments for BPH rely on heat to cause destruction of the prostate gland. The heat is delivered in a controlled fashion through a urinary catheter or a transrectal route, has the potential to reduce the complications associated with TURP, and has a lower anesthetic risk for the patient. Minimally invasive procedures include heat from laser energy, microwaves, radiofrequency energy, high-intensity ultrasound waves, and high-voltage electrical energy. Several minimally invasive therapies are continuously being tested and refined to increase efficacy and safety.
postsurgical.Postsurgical care involves supportive care and maintenance of the indwelling catheter to ensure patency and adequacy of irrigation. Belladonna and opium suppositories may relieve bladder spasms. Stool softeners are used to prevent straining during defecation after surgery. Ongoing monitoring of the drainage from the catheter determines the color, consistency, and amount of urine flow. The urine should be clear yellow or slightly pink in color. If the patient develops frank hematuria or an abrupt change in urinary output, the surgeon should be notified immediately. The most critical complications that can occur are septic or hemorrhagic shock.
nonsurgical.In patients who are not candidates for surgery, a permanent indwelling catheter is inserted. If the catheter cannot be placed in the urethra because of obstruction, the patient may need a suprapubic cystostomy. Conservative therapy also includes prostatic massage, warm sitz baths, and a short-term fluid restriction to prevent bladder distention. Regular ejaculation may help decrease congestion of the prostate gland.
|Medication or Drug Class||Dosage||Description||Rationale|
|Phenoxybenzamine||10 mg PO bid||Alpha-adrenergic blocker||Blocks effects of postganglionic synapses at the smooth muscle and exocrine glands; improvement of urinary flow in 75% of patients|
|Finasteride||5 mg PO qd||5-alpha reductase inhibitor||Shrinks prostate gland and improves urine flow|
Other Drugs: Prazosin, alfuzosin, doxazosin, terazosin, silodosin, tamsulosin, dutasteride
Patients with severe alterations in urinary elimination may require a catheter to assist with emptying the bladder. Never force a urinary catheter into the urethra. If there is resistance during insertion, stop the catheterization procedure and notify the physician. Monitor the patient for bleeding and discomfort during insertion. In addition, assess the patient for signs of shock from postobstruction diuresis after catheter insertion. Ensure adequate fluid balance. Encourage the patient to drink at least 2 L of fluid per day to prevent stasis and infection from a decreased intake. Encourage the patient to avoid the following medications, which may worsen the symptoms: anticholinergics, decongestants (over-the-counter and prescribed), tranquilizers, alcohol, and antidepressants.
Evaluate the patient’s and partner’s feelings about the risk for sexual dysfunction. Retrograde ejaculation or sterility may occur after surgery. Explain alternative sexual practices and answer the patient’s questions. Some patients would prefer to talk to a person of the same gender when discussing sexual matters. Provide supportive care of the patient and significant others and make referrals for sexual counseling if appropriate.
Evidence-Based Practice and Health Policy
Schenk, J.M., Calip, G.S., Tangen, C.M., Goodman, P., Parsons, J.K., Thompson, I.M., & Kristal, A.R. (2012). Indications for and use of nonsteroidal anti-inflammatory drugs and the risks of incident, symptomatic benign prostatic hyperplasia: Results from the prostate cancer prevention trial. American Journal of Epidemiology, 176(2), 156–163.
- Identifying men with elevated risk for BPH assists in targeted screening and early diagnosis.
- Among a sample of 4,735 men enrolled in a prostate cancer prevention trial, aspirin and non-aspirin NSAID use was associated with an increased likelihood of developing BPH (HR 1.18, p = 0.08 and HR 1.25, p = 0.07, respectively).
- However, when the reason for NSAID use was accounted for, the underlying conditions explained some of the increase in risk. Men suffering from arthritis were 1.77 times more likely (p < 0.0001) to develop BPH compared with men without arthritis, men suffering from chronic musculoskeletal pain were 1.57 times more likely (p = 0.006) to develop BPH compared with men without chronic musculoskeletal pain, and men suffering from chronic headaches were 1.4 times more likely (p = 0.008) to develop BPH than men without chronic headaches.
- Presence of urinary discomfort, bleeding, frequency, retention, or difficulty initiating flow
- Presence of bladder distention, 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