Smoking. Smoking increases the risk of acquiring BPH due to anti-estrogenic effect

1. Benign Prostatic
Hyperplasia(BPH)
By:- Lemessa Jira

2. Presentation out lines• Objectives
• ProstateOverview
• Definition of BPH
• Epidemiology
• Etiologies
• Pathophysiology
• Symptomsof BPH
• Diagnosis
• Treatment Options
• Nursing Management
2

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

4. Introduction
4
ProstateOverview

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

12. Etiologies
• Smoking. Smoking increasestherisk of
acquiring BPH dueto anti-estrogenic effect.
12
(Getzenberg, 2014)

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)

22. Diagnosis…
• Cystourethroscopy: To view degree of
prostatic enlargement and bladder-wall changes
(bladder diverticulum).
22
(Silva, 2014)

23. urinary function test(s) consistent with
an enlarged prostate
• Uroflowmetry
–Normal: 10 – 21 mL/sec
–Patient: 7 mL/sec
• Residual UrineVolume
–> 50 mL significant
–Patient: 110 mL
(Abrams, 2013)
23

24. Differential Diagnosis
• Urethral stricture
• Bladder neck contracture
• Carcinomaof theprostate
• Carcinomaof thebladder
• Bladder calculi
• Urinary tract infection and proctatitis
24
(Silva, 2014)

25. Treatment Options
25

26. Therapy
• Watchful waiting and behavioral modification
• Medical Management
– Alphablockers
– 5-alphareductaseinhibitors
– Combination therapy
• Surgical Management
26
(Oelke, 2013)

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)

38. Surgical Management…
• Retropubic
–Midlineabd.
incision
• Perineal
–Incision between
thescrotum and
anus
• Suprapubic
–Abdominal
incision 38(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)

41. • Nursing Management
41

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

47. Evaluation
• Reduced anxiety.
• Reduced level of pain.
• Maintained fluid volumebalance
postoperatively.
• Absenceof complications.
47

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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53. THANK YOU
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