3. Objectives• At theend of session, thestudent will beableto
• DefineBPH
• Identify thepredominant location in theprostatewhereBPH
developsand describehow thisfact relatesto thesymptomsand
signsof BPH
• List thesymptomsBPH
• List theimportant componentsof thephysical exam of apatient
with BPH
• List themedical and surgical treatment optionsfor BPH.
3
5. • Walnut sized gland at
baseof malebladder
• Surroundstheurethra
• Producessemen that
transportssperm during
ejaculation
• Prostategrowsto its
5
What istheProstate
(Heidenreich, 2014)
6. Prostate…
• normal adult sizein aman’searly 20s; it
beginsto grow again during themid-40s
6
(Heidenreich, 2014)
7. • Enlarged Prostate orBenign Prostatic Hyperplasia
(BPH)
• Prostatitis
• Prostate Cancer
• Eachco nditio n affects the pro state differently.
(Sosa, 2014)
7
What Can Happen to the
Prostate
8. What isBPH?
8
No rmal adult size = appro ximately 1 .5
inches in diameter
(Silva, 2014)
9. Normal vs. Enlarged Prostate
• Astheprostateenlarges,
pressurecan beput on
theurethracausing
urinary problems
(LUTS)
Corona, 2014
9
Normal Prostate Enlarged Prostate
(Corona,
2014)
10. Epidemiology
•BPH affects50% of men over 50yrs
•Affects40-50% of men ages51-60
•Affects80%+ men over age80
•Obesity, higher body mass index (BMI)
and lack of exercise may increase the risk
of BPH
(
Sosa, 2014) 10
11. • Causenot completely understood
• Elevated estrogen levels. BPH generally
occurs when men have elevated estrogen
levels and when prostate tissue becomes more
sensitivedueto aromataseenzyme.
(Getzenberg, 2014)
11
Etiologies
13. Etiologies…
• Reduced activity level. A sedentary lifestyle
could also lead to thedevelopment of BPH.
• Western diet. A diet high in animal fat and
protein and refined carbohydrates while low in
fiber predisposesaman to BPH.
13
(Getzenberg, 2014)
14. • Resistance. BPH is a result of complex
interactions involving resistance in the prostatic
urethrato mechanical and spastic effects.
(Getzenberg, 2014)
14
Pathophysiology
15. Pathophysiology cont….
• Obstruction. The hypertrophied lobes of the
prostate may obstruct the bladder neck or urethra,
causing incomplete emptying of the bladder and
urinary retention.
• Dilation. Gradual dilation of the ureters and
kidneyscan occur.
15
(Getzenberg, 2014)
16. • Urinary frequency. Frequent trips to the
bathroom to urinate may be an early sign of a
developing BPH./ 3-5 timesper hrs/
• Urinary urgency. sudden and immediate
urgeto urinate.
• Nocturia. Urinating frequently at night.
16
Symptoms of BPH
(Silva, 2014)
17. Symptoms…
• Weak urinary stream.
Decreased and intermittent
forceof stream isasign of
BPH.
• Dribbling urine. Urine
dribblesout after urination.
• Straining. Thereispresence
of abdominal straining upon
urination.
17
(Silva, 2014)
18. • Digital rectal examination (DRE). A DRE often
reveals a large, rubbery,
and nontender prostate gland.
18
Diagnosis
(Silva, 2014), (Mottete, 2014)
19. Diagnosis…
• Prostate specific antigen levels.
- Elevated PSA levels may indicate an enlarged
prostate.
• normally PSA level is under 4 (ng/mL) in the
blood
19
(Silva, 2014)
20. Diagnosis…
• BUN/Cr: Elevated if renal function is
compromised.
Normal rangesBUN:
• adult men: 8 to 20 mg/dL
• adult women: 6 to 20 mg/dL
• children: 5 to 18 mg/dL
20
21. Diagnosis…
• WBC: May bemorethan 11,000/mm3,
• Normal value= 4,500 to 11,000 white blood cells per
microliter (mcL).
• Uroflowmetry: Assessesdegreeof bladder
obstruction.
21
(Silva, 2014)
27. Watchful Waiting and Behavioral
Modification
• is the preferred management technique in
patientswith mild symptoms
• 1/3 improveon own.
27
(Oelke, 2013)
28. Watchful Waiting and Behavioral
Modification….
Decrease caffeine, alcohol )diuretic effect(
Avoid taking large amounts of fluid over a short period
of time
Void whenever the urge is present, every 2-3 hours
Maintain normal fluid intake, do not restrict fluid
28
(Oelke, 2013)
29. Watchful Waiting and Behavioral
Modification….
Avoid bladder irritants to include artificial
sweeteners, carbonated beverages
Limit nighttimefluid consumption
BPH symptomscan bevariable, intermittent
29
(Oelke, 2013)
30. Medical Managment
• Catheterization: if the patient is admitted to
an emergency basis because he is unable to
void, heisimmediately catheterized.
30
31. • Nutritional supplements
– Saw Palmetto
• Alphablockers
– Doxazosin (Cardura)=Initial dose1mg
po/d for 1or 2wks
maxim dose1 to
8mg po/d
– Terazosin (Hytrin)= Initial dose: 1 mg
orally onceaday at bedtime, Maintenance
dose: 1 to 5 mg orally onceaday.
Maximum dose: 20 mg per day. 4 to 6 weeks
( Margie, 2014) 31
Medical Management
32. Medical Management…
– Tamsulosin (Flomax)=initial doseo.4mg
po/d, maxim dose0.8mg po/d for 6-12 months
– Alfuzosin (Uroxatral) = 10 mg orally oncea
day immediately after thesamemeal each day
for 2 to 3wks
Sideeffects: postural hypotension, dizziness,
fatigue
32
( Morgia, 2014)
33. Medical Management…
• 5-alphareductaseinhibitors
– Finasteride (Proscar)=5mg po/d for
3months, Dutasteride (Avodart)= 0.5 mg
orally onceaday for 6 - 12 months
– Less effective for relief of BPH
symptoms than alpha blockers
33( Morgia, 2014)
34. Combination Therapy
• Concomitant use of alpha blockers and 5-alpha
reductaseinhibitors
– Should be reserved for patients who are at
significant risk of progression and adverse
outcome
• Patient wantsto avoid surgery
• Significant cost associated with dual medications
(Morgia, 2014)
34
35. Surgical Management
• Transurethral needle ablation (TUNA). A
combined visual and surgical instrument
(cystoscope) is inserted and guides a pair of
tiny needles into the prostate tissue that is
pressing on theurethra.
35
(LEE, 2012)
36. Surgical Management…
• TUNA useslow-level radio frequencies to
producelocalized heat that destroysprostate
tissuewhilesparing other tissues.
36
(LEE, 2012)
37. Surgical Management…
• Open prostatectomy. Open prostatectomy
involves the surgical removal of the inner
portion of the prostate via a suprapubic,
retropubic, or perineal approach for large
prostateglands.
37
(LEE, 2012)
39. Surgical Management…
• Patients who have developed complications of
BPH (i.e urinary retention, renal insufficiency,
recurrent UTI and obstructed urinary flow )
arebest treated surgically.
39
(LEE, 2012)
40. Complicationsof BPH
• Urinary retention
• UTI
• Sepsissecondary to UTI
• Residual urine
• Calculi
• Renal failure
• Hematuria
40
(Speakman, 2014)
42. Nursing Assessment
Isbaseon health history
• Health history. The health history focuses on
the urinary tract, previous surgical procedures,
general health issues, family history of
prostate diseases, and fitness for possible
surgery.
• Physical assessment. Physical assessment
includesdigital rectal examination.
42
43. Nursing Diagnosis
• Based on the assessment data, the appropriate
nursing diagnosesfor apatient with BPH are:
• Urinary retention related to obstruction in the
bladder neck or urethra.
• Acute painrelated to bladder distention.
• Anxiety related to thesurgical procedure.
43
44. Thegoalsfor apatient with BPH include:
• Relieveacuteurinary retention.
• Promotecomfort.
• Prevent complications.
• Help patient deal with psychosocial concerns.
• Provideinformation about disease
process/prognosisand treatment needs.
44
Nursing Care Planning &Goals
45. Nursing Interventions
• Nursing Interventions
• Preoperativeand postoperativenursing
interventionsfor apatient with BPH areasfollows:
• Reduce anxiety. Thenurseshould familiarizethe
patient with thepreoperativeand postoperative
routinesand initiatemeasuresto reduceanxiety.
• Relieve discomfort. Bed rest and analgesicsare
prescribed if apatient experiencesdiscomfort.
45
46. Nursing interventions…
• Provide instruction. Beforethesurgery, the
nursereviewswith thepatient theanatomy of
theaffected structuresand their function in
relation to theurinary and reproductive
systems.
• Maintain fluid balance. Fluid balanceshould
berestored to normal.
46
48. Take-Home Messages
• Aging Population= More BPH
• Not all Male LUTS=BPH
• Not all BPH=LUTS
• Consider Combination Therapy
• Quality of life issues
48
49. References
1. Heidenreich A, Bastian PJ, Bellmunt J, Bolla M, Joniau S, van der Kwast T, et al. EAU
guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with
curative intent—update 2013. European urology. 2014;65(1):124-37.
2. Hambrock T, Hoeks C, Hulsbergen-van de Kaa C, Scheenen T, Fütterer J, Bouwense S, et
al. Prospective assessment of prostate cancer aggressiveness using 3-T diffusion-
weighted magnetic resonance imaging–guided biopsies versus a systematic 10-core
transrectal ultrasound prostate biopsy cohort. European urology. 2012;61(1):177-84.
3. Sosa MS, Bragado P, Aguirre-Ghiso JA. Mechanisms of disseminated cancer cell
dormancy: an awakening field. Nature Reviews Cancer. 2014;14(9):611-22.
4. Silva J, Silva CM, Cruz F. Current medical treatment of lower urinary tract
symptoms/BPH: do we have a standard? Current opinion in urology. 2014;24(1):21-8.
49
50. Reference…
5. Corona G, Vignozzi L, Rastrelli G, Lotti F, Cipriani S, Maggi M. Benign prostatic
hyperplasia: a new metabolic disease of the aging male and its correlation with
sexual dysfunctions. International journal of endocrinology. 2014;2014.
6. Getzenberg RH, Kulkarni P. Etiology and pathogenesis. Male Lower Urinary Tract
Symptoms and Benign Prostatic Hyperplasia. 2014:218.
7. Mottet N, Bastian P, Bellmunt J, Van den Bergh R, Bolla M, Van Casteren N, et al.
Guidelines on prostate cancer. Eur Urol. 2014;65(1):124-37.
8. Abrams P, Chapple C, Khoury S, Roehrborn C, De la Rosette J. Evaluation and
treatment of lower urinary tract symptoms in older men. The Journal of urology.
2013;189(1):S93-S101.
50
51. Reference…
9. Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, et al. EAU
guidelines on the treatment and follow-up of non-neurogenic male lower urinary
tract symptoms including benign prostatic obstruction. European urology.
2013;64(1):118-40.
10. Morgia G, Russo GI, Voce S, Palmieri F, Gentile M, Giannantoni A, et al. Serenoa
repens, lycopene and selenium versus tamsulosin for the treatment of LUTS/BPH.
An Italian multicenter double-blinded randomized study between single or
combination therapy (PROCOMB trial). The Prostate. 2014;74(15):1471-80.
11. Lee NG, Xue H, Lerner LB. Trends and attitudes in surgical management of benign
prostatic hyperplasia. The Canadian journal of urology. 2012;19(2):6170-5.
51
52. Reference…
12. Speakman MJ, Cheng X. Management of the complications of BPH/BOO. Indian
Journal of Urology. 2014;30(2):208.
13. Jain P, Neveu B, Fradet Y, Pouliot F. Moderated Posters 8: Prostate (Cancer/BPH)
July 1, 2014, 0730-0915. CUAJ. 2014;8:5-6Suppl3.
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