Benign Prostatic Hyperplasia is a benign enlargement of the prostate gland. This occurs in around 50% of 50+ males and in over 90% of 80+ males, with a quarter of men requiring some type of treatment by the age of 80. Benign Prostatic Hyperplasia is known as the most common urologic problem encountered in adult males.
Etiology and Pathophysiology of Benign Prostatic Hyperplasia
In ageing males, an imbalance within the endocrine system (gradual decline in hormones during the andropause phase and/or accumulation of dihydroxytestosterone and/or decrease in testosterone resulting in greater estrogen proportion in the blood) may cause Benign Prostatic Hyperlasia.
Risk Factors for Benign Prostatic Hyperplasia
- ageing
- obesity
- sedentary lifestyle
- alcohol consumption
- smoking
- diabetes
- family history of BPH in first-degree relatives (parent or sibling)
Clinical Manifestations of BPH
Clinical manifestations of Benign Prostatic Hyperplasia are usually gradual in onset, resulting from urinary obstruction by the enlarged prostate. These include:
- urinary stream caliber and force decrease
- difficulty in initiating voiding
- intermittent voiding
- dribbling a few cc’s of urine following complete urination
- increased frequency of urination
- a sense of urination urgency
- dysuria (burning, tingling, or stinging sensation in the urethra and meatus whilst voiding)
- pain in the bladder
- incontinence
- nocturia (waking up multiple times at night to urinate)
(American Urological Association)
Complications of BPH
- UTIs
- residual urine in bladder due to incomplete voiding
- urinary obstruction that requires a catheter
- calculi (stones) in the bladder
- pyelonephritis (kidney/s infection)
- hydronephrosis (swelling of one or both kidneys) leading to renal failure
Benign Prostatic Hyperplasia Diagnosis
- patient history
- physical examination
- digital rectal examination
- urinalysis (with culture)
- serum creatinine
- post-void residual
- transrectal ultrasound
- uroflowmetry
- cystoscopy
- rectal prostate ultrasound
- blood investigations (PSA – prostate-specific antigen; BUN – blood urea nitrogen; creatinine)
Post-Void Residual Bladder
Transrectal Ultrasound (TRUS)
Uroflowmetry
Cystoscopy
BPH Care Aims
- Restore bladder function
- Relieve symptoms
- Prevent and treat BPH complications
NUTRITION: A decreased intake of caffeine, artificial sweeteners, spicy and acidic foods is recommended.
FLUID INTAKE: Individuals with BPH should restrict fluid intake in the evening as this may improve their symptoms.
MEDICATIONS: Ideally individuals with BPH should avoid decongestants and anti-cholinergic drugs.
Benign Prostatic Hyperplasia Treatment
Minimal Invasive Therapies:
Dilation of the urethra (repetitive treatment sessions may be required) and Urethral Stents
Transurethral vaporisation of the prostate
- reduced bleeding complications
- short recovery period
- increased risk for retention
Transurethal Microwave Therapy
Transurethral Needle Ablasion
- burns designated areas of enlarged prostate
- ideal for patients with comorbidities
Drug Therapy:
- Androgen-blocking drugs eg. Finasteride, Dutasteride
- Alpha-Adrenergic Blockers eg. Doxazosin, Terazosin, Alfuzosin, Tamsulosin, Silodosin (urethral-relaxing drugs)
TransUrethral Resection of the Prostate (TURP)
TURP is a surgical procedure in which obstructive prostate tissue is removed through the use of a resectoscope which is inserted via the urethra.
- TURP increases quality of life
- TURP is low risk
- 80-90% excellent outcome due to improvement in symptoms and urinary flow
- TURP is performed under anaesthesia (spinal or general) and requires the patient to be kept for up to 2 days at the hospital.
- A resectoscope is inserted via the urethra and obstructive prostate tissue is removed.
- Following the procedure, a 3-way indwelling catheter is inserted into the bladder for haemostasis purposes as well as to facilitate urine drainage.
- During the first 24 hours following the procedure, the bladder is frequently irrigated so as to prevent obstruction from mucus and blood clots.
- In TURP there is no external surgical incision done, and so, post-op care requires no surgical wound care.
TURP Preoperative Nursing Care
- Educate patient about procedure
- Discuss possible complications
- Inform about incontinence and urine dribbling for up to a year post-surgery, and the role of Kegel exercises in providing assistance with this problem
- Inform patient about retrograde ejaculation (sexual climax reached, but semen enters bladder rather than emerging from penis – not harmful, but may cause infertility)
- Gain informed consent
- Ensure optimum cardiac, respiratory and circulatory status (decreased risk for complications)
- Prophylactic antibiotic treatment is prescribed/initiated
- Medical pre-op investigations are carried out (CBC, U&E, MSU – midstream specimen urine, blood group, cross match)
- ECG and chest x-ray are performed
- Anti-coagulants are stopped as per physician orders
- Administer bowel preparation
- Glycerin suppositories are administered the night prior to surgery
- Patient should be kept NBM for 8 hours pre-op
TURP Postoperative Nursing Care
- Monitor vital signs every 15 minutes in the first hour post-surgery, followed by re-monitoring every 4 hours
- If patient received epidural anaesthesia, monitor epidural site, monitor extremities every hour for the first 12 hours, monitor intake and output, and keep patient on bed-rest as per anaesthetist’s recommendations
- Reassure patient so as to avoid/reduce anxiety
- Observe for signs of haemorrhage
- Maintain urinary drainage
- Maintain urethral catheter patency
- Avoid over-distention of bladder (may lead to haemorrhage)
- Administer pain medication
- Administer anti-cholinergic drugs (drugs that block the action of acetylcholine – reduce bladder spasms)
- Maintain bed-rest for 24 hours post-op
- Promote comfort through appropriate patient positioning
- Administer medication to promote soft-stools so as to avoid straining (which may lead to haemorrhage)
- Encourage ambulation as soon as possible to prevent complications such as embolism, thrombosis and pneumonia
- Encourage patient to talk about sexual dysfunction fears and promote discussion with partner
- Teach methods of urinary control eg. kegel exercises
- Encourage foods and fluids if tolerated (unless contraindicated, oral fluids should be encouraged from day 1)
- Empty urine bag and measure urine output; document on fluid balance chart
- Provide catheter care as necessary; If urine is clear, remove catheter on day 1
- Assist patient when taking a shower on day 1 (patient should be able to self-care on day 2)
- Promote oral care and assist on day 1 if necessary
Precautions
- If body temperature exceeds 38.5 degrees celsius, blood and urine culture, CBC and chest x-ray should be performed, followed by paracetamol administration and assistance in bringing fever down.
- In gross haematuria, IV therapy should be maintained, irrigation rate should be increased, temperature and pulse should be monitored hourly, haemoglobin should be checked, and penile tractions with 1 ltr bag of IV fluid for 20 mins on followed by 20 mins off.
- If catheter is blocked, try to milk catheter according to unit practice; if unsuccessful, irrigate; if unsuccessful, notify surgeon but DO NOT remove catheter (in the 24 hours following TURP, nurses and junior doctors cannot re-catheterise patient).
- In the case of failed TWOC (trial without catheter), re-insert catheter.
- In the case of incontinence post TWOC, encourage use of pads and pants and teach pelvic floor exercises.
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Claire Galea is a mum of three currently in her final year following a Degree in Nursing at the Faculty of Health Sciences, University of Malta, as a mature student.
Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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