benign prostatic hyperplasia

hyperplasia

 [hi″per-pla´zhah]

abnormal increase in volume of a tissue or organ caused by the formation and growth of new normal cells. See also hypertrophy and proliferation. adj., adj hyperplas´tic.

benign prostatic hyperplasia benign prostatic hypertrophy.

cutaneous lymphoid hyperplasia a group of benign cutaneous disorders characterized by accumulations of large numbers of lymphocytes and histiocytes in the skin, which may occur as a reaction to insect bites, allergy hyposensitization injections, light, trauma, or a tattoo pigment or may be of unknown etiology.

focal nodular hyperplasia (FNH) a benign, usually asymptomatic tumor of the liver, occurring chiefly in women; it is a firm, nodular, highly vascular mass resembling cirrhosis, usually with a stellate fibrous core containing numerous small bile ducts, and having vessels lined by Kupffer cells.

nodular hyperplasia of the prostate benign prostatic hypertrophy.

be·nign pros·tatic hy·per·pla·si·a (BPH),

[MIM*600082]

progressive enlargement of the prostate due to hyperplasia of both glandular and stromal components, typically beginning in the fifth decade and sometimes causing obstructive or irritative symptoms, or both; does not evolve into cancer.

benign prostatic hyperplasia

n.

A nonmalignant enlargement of the prostate gland commonly occurring in men after the age of 50, and sometimes leading to compression of the urethra and obstruction of the flow of urine.

benign prostatic hyperplasia (BPH)

a histological diagnosis associated with nonmalignant, noninflammatory enlargement of the prostate, most common among men over 50 years of age. BPH diagnosis can only be made after biopsy or resection; otherwise the diagnosis is benign prostatic enlargement. BPH is usually progressive and may lead to urethral obstruction and to interference with urine flow, urinary frequency, nocturia, dysuria, and urinary tract infections. Treatment may include medication, localized application of heat, balloon dilation, laser vaporization, and microwave hyperthermia. Surgical resection of the enlarged prostate is sometimes necessary. Also called benign prostatic hypertrophy, prostatic hypertrophy. Compare prostatitis. See also prostatectomy.

benign prostatic hyperplasia

Benign 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.
 
Clinical findings
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)

Progressive enlargement of the prostate due to hyperplasia of both glandular and stromal components, typically beginning in the fifth decade andsometimes causing obstructive or irritativesymptoms or both; does not evolve into cancer.

Benign prostatic hyperplasia (BPH)

A noncancerous condition of the prostate that causes overgrowth of the prostate tissue, thus enlarging the prostate and obstructing urination.

Mentioned in: Prostate Biopsy, Prostate Cancer

Benign Prostatic Hyperplasia (Hypertrophy)

DRG Category:	713
Mean LOS:	4.4 days
Description:	SURGICAL: Transurethral Prostatectomy With CC or Major CC
DRG Category:	725
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.

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.

Genetic considerations

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.

Assessment

History

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)

Physical examination

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.

Psychosocial

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.

Diagnostic highlights

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

Diagnosis

Urinary retention (acute or chronic) related to bladder obstruction

Outcomes

Urinary continence; Urinary elimination; Infection status; Knowledge: Disease process, medication, treatment regimen; Symptom control behavior

Interventions

Urinary retention care; Bladder irrigation; Fluid management; Fluid monitoring; Urinary catheterization; Urinary elimination management; Tube care: Urinary

Planning and implementation

Collaborative

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.

Pharmacologic highlights

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

Independent

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.

Documentation guidelines

• 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

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 provide this information 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 distention recur. A diet low in fat and high in protein and vegetables may reduce the risk of the disorder. Regular alcohol consumption within recommended limits of drinking (no more than two standard drinks per day) is associated with a reduced risk of symptomatic BPH.

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, physicians recommend that patients have no sexual intercourse or masturbation for several weeks after invasive procedures.

benign prostatic hyperplasia (bi·nīnˑ pr·staˑ·tik hī·per·plāˑ·zh),

n condition marked by enlargement of the prostate gland that exerts pressure on the urethra thereby obstructing the flow of urine.

Benign prostatic hyperplasia.

prostatic

pertaining to or emanating from the prostate.

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prostatic abscess

occurs in dogs, often as a complication of benign prostatic hypertrophy and squamous metaplasia. Clinical signs are variable, sometimes resembling those of acute prostatitis with fever and systemic illness, or they can be similar to those of chronic prostatitis with straining, dysuria and hematuria.

benign prostatic hyperplasia

a diffuse glandular and stromal hyperplasia and hypertrophy of the prostate is commonly seen in dogs from middle age, increasing in frequency and degree with advancing age. Clinical effects are minimal or absent in the majority of dogs, but occasionally dysuria and constipation result. Infection can be a complication, causing an acute or chronic prostatitis.

prostatic calculi

occur uncommonly in dogs. May originate in the urinary tract, becoming lodged in the prostate, or form within prostatic tissue.

prostatic cyst

may occur in association with benign prostatic hyperplasia or as a separate entity, developing from vestiges of müllerian ducts.

prostatic fluid

secretion of the prostate; the third, sperm-free, fraction in a dog semen collection.

prostatic inflammation

see prostatitis.

prostatic massage

firm digital pressure and massage of the prostate, applied per rectum, may be performed to increase the amount of cellular material and secretions collected in a urine or prostatic wash sample.

prostatic neoplasms

adenocarcinomas occur infrequently in older dogs, invading locally and metastasizing to sublumbar lymph nodes and lumbar vertebrae.

prostatic wash

placement of a urinary catheter in the prostatic urethra and a flush followed by aspiration of fluid is used to obtain samples for culture and cytology in the diagnosis of prostatic disease.