Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland that is common in aging men. BPH occurs when the prostate gland grows larger and squeezes the urethra. This causes urinary symptoms like frequent and difficult urination. BPH is usually treated with medications to reduce symptoms but may require surgery if medications do not help or if complications occur. Surgical treatments for BPH include transurethral resection of the prostate (TURP) which removes excess prostate tissue through the urethra using an electrosurgical tool. Pre-operative and post-operative care focuses on managing urinary drainage and symptoms to promote healing.

1. BENIGN PROSTATIC HYPERTROPHY
BPH
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3. INTRODUCTION
• The prostate is a gland about the size of a walnut that is only present in
men.
• Sperm duct and male urethra pass through it.
• It is located below the urinary bladder.
• Also attached are two seminal vesicles that add fluid to the sperm to
form semen.
• The prostate gland produces a liquefying component of semen.
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4. • The prostate, normally grows in the presence of Testosterone.
• Benign prostate hyperplasia typically occurs in men older than 50
years of age.
• By the time they reach 60 years of age, 50% of men have BPH.
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5. • It affects as many as 90% of men by 85 years of age.
• BPH is the second most common cause of surgical intervention in men
older than 60 years of age.
• Out of all the cases done in urology, prostate disease accounts for
70% of urology cases seen each year in Zambia.
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6. GENERAL OBJECTIVE
• At the end of the lecture/discussion, students should
demonstrate knowledge and understanding on the
management of patients with Benign Prostatic Hypertrophy
(BPH).
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7. SPECIFIC OBJECTIVES:
At the end of our lecture /discussion, the Student should be able to:
• Define BPH
• State the Causes of BPH
• Explain the Pathophysiology of BPH
• State the signs and symptoms of BPH
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8. • Outline the medical and surgical management of a patient with
BPH
• Outline the preoperative and post-operative management of a
patient undergoing Prostatectomy
• State the complications of Prostatectomy
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9. DEFINITION
• BPH refers to a non malignant enlargement of the peri
urethra prostate gland
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10. Four Areas of the Prostate
 Transition Zone
 Peripheral Zone
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12. CAUSES
• The causes of BPH are not well understood.
• But it is probably considered to be a normal
part of the aging process in men, caused by
changes in hormone balance and in cell
growth.
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13.  Parts of the prostate may atrophy while others become
large and nodular
 Changes occur mainly in the transitional zone of the
prostate near the inner core that surround the urethra
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14.  Changes in size and shape are associated with increase
androgens, estrogen and decreased testosterone.
 Androgens (male hormones) are believed to play a role in
prostate growth.
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15.  The most important androgen is testosterone, which is
produced in the testes throughout a man's lifetime.
 The prostate converts testosterone to a more powerful
androgen, dihydrotestosterone (DHT) which stimulates
prostate cell growth
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16.  BPH is part of the natural aging process (increase in
androgen receptor)
 Increase in Dihydrotestosterone (DHT)
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17. PREDISPOSING FACTORS
• Increasing age
• Family history of bph
• Inflammation
• Neoplasm
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19. PATHOPHYSIOLOGY
• The mechanism is more of a mechanical than a physiological
problem.
• The enlargement occurs both inside and outside, forming some
nodules.
• It is normally thin and fibrous in the centre but becomes spongy
and thick as the enlargement progresses.
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20. • As the glands enlarge inwards, it reduces the area in which the
sperm duct and urethra pass, thus ,squeezing the tubules to a
much smaller size leading to narrowing of the urethra.
• This narrow opening of the urethra causes the pressure of urine
passing through it to increase leading to an increased pressure in
the bladder as well.
• Thus the male can only empty about half or less of the bladder.
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21. • This eventually leads to frequency of micturition and sometimes loss
of libido because of the restricted passage.
• With progressive compression of the urethra and obstruction, there is
increased risk of secondary infection and development of renal calculi
due to urine stasis
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22. • The bladder becomes distended and there is retrograde flow of
urine which can impair renal function and promote
hydronephrosis.
• In the later stages , the flow of urine may become completely
blocked causing pyelonephritis, uraemia and death..
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26. SIGNS & SYMPTOMS
 Hesitancy-Difficulties to start passing urine.
 Diminishing in size and force of the urinary. stream(weak
stream).
 Strain at passing urine. Terminal dribbling (loss of sphincter
tone or reduced pressure).
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27.  Sensation of incomplete emptying.
 Urgency i.e. needs to urgently pass urine, secondary to
pressure.
 Enlarged prostate gland
 Frequency of urination
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28.  Poor urinary stream
 Feeling a burning sensation or pain when
passing urine.
 Recurrent Urinary Tract infections.
 Urinary retention.
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29. MANAGEMENT
INVESTIGATIONS
• Physical exam will reveal enlarged prostate.
• Urine for urinalysis, culture and sensitivity, Estimation of the
residual Urine.
• Digital rectal examination to examine size and consistency of the
prostate. This is done by inserting fingers into the rectum
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30. • Cystoscopy will show enlargement of the lobes (bands
of tissue).
• Blood for Prostate specific antigen (PSA) test- levels
may be high.
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32. • Ultrasound examination of the testicles, prostate, and
kidneys is often performed, again to rule out malignancy
and hydronephrosis
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33. TREATMENT
AIMS OF TREATMENT:
• Relieve urinary symptoms.
• Improve quality of life.
• Reduce the complications of bladder outflow
obstruction
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34. TREATMENT OPTIONS FOR BPH
• Active monitoring or ‘Watchful waiting’.
• Pharmacological treatment.
• Minimally invasive therapies.
• Conventional surgery.
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35. Watchful Waiting
Patients with mild symptoms simply need follow up.
Over 5 years:
30% experience progression of symptoms
50% remain static
20% will improve
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36. PHARMACOLOGICAL TREATMENT
This is based on either:
•Reducing the tone of the prostatic smooth muscle
• Reduction of gland volume
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37. PHARMACOLOGICAL TREATMENT
 Major two types of pharmacological treatment
1. Alpha-1-blocker: relax the bladder neck muscle
fibers in the prostate and provide a larger urethral
opening making urination easier. (prazosin, terazosin)
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38. 2. 5-Alpha reductase inhibitor: Shrink the prostate
by preventing hormonal changes that cause prostate
growth
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39. SURGICAL MANAGEMENT
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40. The choice of a specific surgical procedure is usually
based on the severity of your symptoms and the size
and shape of your prostate gland.
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41. PROSTATECTOMY
Prostatectomy: is the surgical removal of the
prostate gland.
Classification
1. Open prostatectomy
2. Closed prostatectomy
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42. GENERAL INDICATIONS FOR SURGERY IN BPH
• Failure to respond to medical treatment
• Bothersome symptoms
• Complications
• Stones
• Hydronephrosis
• UTI ‘s
• Urinary retention
• Impairment in renal function.
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43. TYPES OF SURGERY BASED ON THE APPROACH
•Transurethral resection of prostate (TURP)
•Suprapubic /Trans-vesicle prostatectomy (TVP)
•Retropubic ( Millin’s) prostatectomy
•Perineal ( Young’s) prostatectomy
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44. 1. TRANSURETHRAL RESECTION OF PROSTATE (TURP)
A long thin instrument called a Resectoscope is passed into the
urethra with a light source and a lens on the end.
 It acts as a Telescope allowing viewing the prostate either directly
or by video monitor.
A controlled electrical current is applied by loop at the end of the
resectoscope.
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45. • After TURP a large three-way catheter is inserted
into the bladder for irrigation
• After inflating balloon is pulled down to rest on
prostatic fossa.
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46. THREE WAY CATHETER
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47.  The loop cuts down the tissue and coagulates bleeding
vessels.
 TURP is very effective procedure in 90% of men
 Continuous Bladder Irrigation (CBI) for 24-48 hours
recommended to prevent clot formation and retention
 Procedure requires no incision and causes less pain.
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48. TRANSURETHRAL RESECTION OF PROSTATE (TURP)
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50. SIDE EFFECTS
 Retrograde ejaculation when the semen passes into the
bladder during an orgasm instead of the penis.
 Urinary incontinence
 Damage to the urethra resulting in stricture.
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51. PRE OP CARE FOR TURP
Informed consent is essential before surgery.
The possibility of bleeding, urinary tract
infection, incontinence, stricture, sexual
dysfunction and retrograde ejaculation must be
explained to the patient.
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52. Patients are instructed not to take aspirin or
nonsteroid anti-inflammatory drug for one week
before surgery because of increased risk of
bleeding.
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53. Enema is done before the evening of surgery if not
contracted indicated.
Keep patient nil per oral from midnight if going for
surgery early in the morning.
@plus general preoperative care@
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54. POST OP CARE FOR TURP
•After TURP, iv fluids are given and
discontinued if clear fluids are taken and
tolerated well.
The patient is rapidly progressed to
regular diet.
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55. Monitor continues bladder irrigation if in
place to prevent clots blocking the
urethra
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56. Monitor intake and output especially the amount
of urine after the irrigation as been stopped as this
will help to determine when to remove the
catheter.
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57. Encourage early ambulation and discourage long
periods of sitting as this predisposes to bleeding
due to increased intra-abdominal pressure.
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58. Check the incision sites for bleeding.
Ensure that the irrigation is running well if in
place.
@plus general post operative care@
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59. 2. SUPRAPUBIC OR TRANSVESICAL PROSTATECTOMY
 A lower abdominal incision is used and the bladder is incised vertically
 Enlarged tissue is enucleated by blunt dissection.
 Both suprapubic and urethral catheters are inserted.
 This approach remains a common surgical treatment for BPH in Africa
INDICATIONS
 Very large prostate
 A large middle or lateral prostatic lobe is present
 Presence of bladder abnormality
 when abdominal surgical exploration is needed
 Severe urethral stricture
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60. SIDE EFFECTS
 Bleeding (Blood loss may be greater than other approaches)
 Retrograde ejaculation.
 Pubic bone inflammation
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62. 3. PERINEAL PROSTATECTOMY
• It involves removal of the gland through an incision made in the
perineum.
• It is used when other approaches are not possible.
• It is useful for obtaining a biopsy.
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63. SIDE EFFECTS
• Post operatively, the wound may become infected because it is near the
rectum.
• Allows hemostasis under direct vision and ideal for very old, risk patients
with large prostate.
• High post incidence of impotence and urinary incontinence.
• Possible damage to the rectum and external sphincter muscles.
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64. 4. RETRO PUBIC PROSTATECTOMY
 Lower abdominal incision is made.
 By passes the bladder and passes behind the pubic bone
 The prostate is dissected from the back of the pubic bone through its
capsule
 A 3 way urethra catheter is inserted for irrigation and the capsule of
the prostate is closed.
INDICATIONS
 Suitable for large glands located high in the pelvis.
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67. Side effects
• Blood loss can be controlled and it is easier to visualize the
surgical site.
• Risk of infection is possible.
• Can not treat associated bladder diseases.
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68. PRE-OPERATIVE CARE
AIMS:
 Maintain adequate renal function through adequate
bladder drainage.
 Reduction or prevention of renal infection.
 Maintenance of adequate nutrition
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69. ADMISSION
 Done several days before surgery in order to adjust to
hospital environment, improve general condition and
carry out investigation
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70. PSYCOLOGICAL CARE
 Patient will be worried about loss of Libido or
inability to perform sexually.
 Explain the following:
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71.  Nature of the surgery and its implications.
 Use a diagram
 Involve the wife if he is married
 Post operative expectation e.g. tubing's for drainage
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72. CATHETERISATION
 The patient has altered urinary elimination related to
narrowing of the urethra, acute or chronic obstruction
related to mechanical obstruction due to enlarged
prostate
 Catheterize if unable to void, determining residual
amounts to relieve distention and restore urinary
drainage.
 Maintain patency of catheter and provide catheter
care.
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73. OBSERVATIONS
 Monitor intake and output to assess renal function
 Observe the colour of the urine.
 Observe for bladder distention
 Observe for the flow of urine
 Observe for dysuria and, signs of infection
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74. PAIN RELIEF
 Pain (Acute) related to the irritation of bladder mucosa, bladder
distension, and renal colic, urinary infection is common.
 Assess for pain using a pain scale every 2 to 4 hours.
 Maintain traction on the urethral catheter
 Give the drug as indicated (antispasmodic)
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75. FLUID AND NUTRITION
 Any Nutritional deficiencies should be corrected to
enable the patient withstand surgery as most of them
are elderly with a weak immunity.
 Give up to 3000 ml of fluid a day.
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76. SPECIFIC PRE-OP NURSING CARE
 Inform the patient about the three-way Foley’s
catheter and its purpose
 Inform patient that urine will be red or pink for
several days and give reasons
 Inform patient about possible pain due to bladder
spasms and presence of large catheter and that pain
will be relieved
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77. BLADDER CARE
 Monitor the urine output and characteristics of output.
 Maintain bladder irrigation as prescribed in the first 24hrs to
prevent clots from obstructing catheter
 Maintain patency of in dwelling urinary catheter by
irrigating to prevent clots from obstructing catheter
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78.  Encourage high intake of fluids2.5-3litres/day to promote flow
of urine
 The size of the catheter is gradually reduced e.g. from size 24-
20-18 to prevent incontinence and exercise the internal
sphincter muscle.
 After catheter removed, continue to monitor for signs of
retention
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79. SPECIFIC POST OP CARE
 Monitor urine output &characteristic
 Maintain constant bladder irrigation
 Maintain patency of indwelling catheter
 After catheter removal monitor signs of retention
(distended bladder, fevers, chills, pain on urination)
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80.  Monitor patient for pain and relieve pain
 Monitor vital signs to rule out fluid volume
excess, deficit, hypotension, infection etc
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81. BLADDER IRRIGATION
•Bladder irrigation is a procedure in which sterile fluid is
used to prevent clot retention by continuously irrigating
the bladder via a three-way catheter (Gilbert and Gobbi,
1989)
•To prevent blood clot formation, allow free flow of urine
and maintain IDC patency, by continuously irrigating the
bladder with Normal Saline
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82. RATE OF IRRIGATION
• The rate of administration of irrigation fluid is dependent on
the colour of the drainage from the catheter.
• If it is heavily bloodstained (claret-coloured) the irrigation
should be run quickly, as the likelihood of clot formation is
increased due to the presence of a large amount of blood.
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83. • If the drainage is lightly blood stained (rose-coloured) the
irrigation can be allowed to run at a slower rate.
• Irrigation is normally discontinued when the urine has been only
lightly bloodstained for 24-48 hours.
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84. IRRIGATION CONT…..
• Occasionally a clot can lodge itself within the catheter tip, bringing on the
symptoms of acute urinary retention.
• If this should occur the irrigation should be ceased immediately to prevent
further discomfort for the patient.
• The clot may be dislodged by either squeezing the catheter tubing or ‘milking’ it
with rubber-covered milking tongs (Lowthian, 1991).
• This causes pressure within the catheter lumen, which in turn expels the clot.
• If this is unsuccessful a bladder washout will need to be performed.
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85. EXPECTED OUTCOMES OF BI
The urinary catheter remains patent and urine is able to drain freely via
the indwelling catheter (IDC)
• The patients comfort is maintained
• Clot formation within the bladder or IDC is prevented or minimised
• The patient’s risk of Urinary Tract Infection is minimised, through use
of aseptic technique when connecting bladder irrigation to IDC
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86. INFORMATION EDUCATION COMMUNICATION
• OUTLINE 5 POINTS
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87. POSSIBLE COMPLICATIONS
 Bleeding (clot formation and catheter obstruction)
 Electrolyte imbalance
 Incontinence
 Impotence (no or retrograde ejaculation)
 Urethra stricture
 Cloudy urine
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88. REFERENCES
1. Chang, M. et al (2006) Pathophysiology Applied to Nursing
Practice 2nd edition, Mosby, Sydney
2. Gulanick, M. and Myers, J.L (2007) Nursing Care Plans, Nursing
Diagnosis and Intervention. 6th edition, Mosby publishers,
Chicago
3. William N.S. et al (2008) Bailey and Love’s Short Practice of
Surgery, 25th edition. Hoddler Anold Publishers, London
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