Benign Prostatic Hypertrophy

Walnut sized gland below bladder
Part muscle, part gland
Secretes seminal fluid
Normally 20gms, surrounds the urethra
Divided in 3 zones; peripheral, transitional and central

Enlargement of the prostate gland
Hypertrophy: increase in size of cells
Hyperplasia: increase in the number of cells
Increase in number of stromal and epithelial cells in inner prostate
Can double or triple in size

Rarely occurs in men <40 years
50% of men >50 years are affected
80% of men >80 years are affected
25% of men will need surgery by 80

Cellular overgrowth blocks urethra
No relationship between size of prostate and degree of obstruction
Obstruction can be partial or complete
Complete obstruction requires medical treatment immediately

Hydronephrosis - stretching of the renal pelvis
Hydroureter - stretching of ureter wall "Fishhooking" of ureter
Thickening of bladder wall
Urinary tract infections
Renal damage leading to kidney failure

Usually begin gradually and advance as obstruction becomes worse
Two classes of symptoms:
Classic voiding symptoms
Irritative symptoms

Decreased force and caliber of stream
Difficulty initiating urination
Intermittency
Dribbling at end of urination
Incomplete bladder emptying because of obstruction

Urinary frequency
Urgency
Dysuria
Bladder pain
Nocturia
Incontinence

History and physical exam
Digital rectal exam (DRE)(Men over forty)
Urinalysis
Prostate specific antigen - may or may not be elevated
Transrectal ultrasound (TRUS)
Uroflometry

Based on severity of American Urological Assoc. Symptom Index (AUA symptom index score)
See attached table
-Mild: 0-7
-Moderate: 8-19
-Severe: 2-35
Helps determine appropriate treatment

Mild BPH:
Watchful waiting
Self-care behavior modifications such as: avoiding alcohol, spicy foods, caffeine, decongestants, liquids late at night and making sure to void regularly (timed)

Moderate BPH - between 12-26 on AUA
Medical interventions:
May require intermittent or indwelling catheterization
Medications:
Alpha blockers
5-alpha-Reductase inhibitors

Alpha blockers work by promoting smooth muscle relaxation
Facilitates urinary flow through urethra
50-70% efficiency
-Tamsulosin (Flomax)
-Doxazosin (Cardura)
-Terazosin (Hytrin)

Decreases size of prostate by blocking hormone(s) - needed for prostate tissue growth
40-50% effective, takes 3-6 months
Finasteride (Proscar)
Dutasteride (Duagen)
See attached

Herb can decrease S&S of BPH
Compare with effect of Proscar
Few SE
Not regulated
Not standardized

TUMT (Transurethral microwave thermotherapy)-
*Reduce urinary frequency, urgency, straining, intermittent urine flow
TUNA (Transurethral needle ablation)
*also reduces urine outflow problems

Indicated when medical therapy ineffective and:
*Decreased urine flow causing pain
*Persistent urinary retention
*Hydronephrosis - stretching of the renal pelvis as a result of obstruction to urinary outflow
Usually TURP

Instrument inserted through resectoscope to remove the prostate gland

General Anesthesia
Resectoscope through penis
Narrowed area of urethra is cut
Pieces of tissue are flushed out of the bladder after surgery
NO INCISION

Laser Surgery
*Same approach as TURP
*Compared to Turp=decreased blood flow and quicker recovery
Open Prostatectomy (Prostate Cancer)
*suprapubic
*retropubic

Restore urinary drainage (foley in place)
Pre-operative antibiotics
Encourage fluids
Client education re: post-op complications

Bleeding and clots (foley catheter with irrigation running)
Bladder spasms (increase irrigation)
Urinary incontinence
Infection (urine-cloudy)
Bloody urine is normal after a TURP - watch for hemorrhage

Client will have foley or 3-way foley
Continuous bladder irrigation (CBI)
*monitor output, notify MD if output is less then amount of irrigation solution
*monitor for hemorrhage - drainage will be blood tinged or have clots, not frank blood
*Should be closed system, maintain sterility

Common, but distressing
Sphincter tone is poor after surgery
Teach kegal exercises
Improvement may take place over weeks to months

Common after surgery
Distressing symptom - result from irritation of bladder mucosa
Medications:
*Belladonna
*Opium suppositories (NO other rectal medications or procedures!)
*Oxybutin (Ditropan) - spasms

Monitor for infection:
External wound - with open prostatectomy
Urinary tract infection - greater risk due to indwelling urinary catheter
Ensure adequate fluid intake 2-3 liters per day if not contraindicated

Used when drug therapy is ineffective and client is not a surgical candidate:
*Balloon urethroplasty
*Prostatic urethral stents

Teach client not to lift >5lbs
Avoid prolonged periods of travel
No rectal procedures, avoid straining
Surgeon needs to approve:
-Resumption of sexual activity
-Driving
-Stair climbing

Retrograde ejaculation due to sphincter trauma is common and reversible
Possibility of erectile dysfunction
May experience decreased self-esteem or loss of client's sex role
May need sexual counseling and offering of treatment options

Post-op assessment
True urinary output
Monitor 3-way irrigation infusion
Monitor for clots, hemorrhage
Monitor for s/s infection
Assess wound drainage
Interpret test results
Educate client and partner re: home catheter care
Psychosocial needs