Benign Prostatic Hyperplasia Nursing Care Management: Study Guide

BPH is one of the most common problems in aging men, and most of your work is recognizing obstruction, relieving retention, and getting the patient safely through surgery if it comes to that.

What is Benign Prostatic Hyperplasia?

Benign prostatic hyperplasia (BPH) is enlargement, or hypertrophy, of the prostate gland. The gland grows upward into the bladder and obstructs urine outflow. Incomplete bladder emptying and urinary retention lead to urinary stasis, which can cause hydronephrosis, hydroureter, and urinary tract infections (UTIs). The cause is not well understood, but the evidence points to hormonal involvement. BPH is common in men older than 40 years and drives lower urinary tract symptoms that wreck sleep and daily function.

Pathophysiology

BPH comes from complex interactions that raise resistance in the prostatic urethra to mechanical and spastic effects. The hypertrophied prostate lobes obstruct the bladder neck or urethra, leaving the bladder incompletely emptied and the patient in retention. Over time the ureters and kidneys dilate.

Statistics and Epidemiology

BPH typically starts in men older than 40 years. By age 60, 50% of men have it, and it affects as many as 90% of men by age 85. It is the second most common cause of surgical intervention in men older than 60 years.

Causes

Testicular androgens are implicated, and risk climbs with elevated estrogen levels and prostate tissue that becomes more sensitive. Smoking, a sedentary lifestyle, and a Western diet (high in animal fat, protein, and refined carbohydrates, low in fiber) all predispose a man to BPH.

Clinical Manifestations

Symptoms range from mild to severe, and some men have none. Watch for urinary frequency (often the earliest sign), sudden urgency, nocturia, a weak and intermittent stream, postvoid dribbling, and abdominal straining to void.

Assessment and Diagnostic Findings

Digital rectal examination (DRE) typically reveals a large, rubbery, nontender prostate gland. Get a urinalysis to screen for hematuria and UTI. A PSA level is obtained if the patient has at least a 10-year life expectancy and knowing about prostate cancer would change management.

Other workup includes:

• Urinalysis. Color yellow, dark brown, dark or bright red (bloody), appearance possibly cloudy. pH 7 or greater suggests infection; bacteria, WBCs, and RBCs may be present microscopically.
• Urine culture. May reveal Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas, or Escherichia coli.
• Urine cytology. Rules out bladder cancer.
• BUN/Cr. Elevated if renal function is compromised.
• Prostate-specific antigen (PSA). Glycoprotein in the cytoplasm of prostatic epithelial cells, detected in the blood of adult men. Greatly increased in prostatic cancer but also elevated in BPH. Elevated PSA with a low percentage of free PSA points more toward cancer than a benign condition.
• WBC. May be more than 11,000/mm3, indicating infection if the patient is not immunosuppressed.
• Uroflowmetry. Assesses degree of bladder obstruction.
• IVP with postvoiding film. Shows delayed bladder emptying, degree of urinary tract obstruction, prostatic enlargement, bladder diverticula, and abnormal thickening of bladder muscle.
• Voiding cystourethrography. May replace IVP to visualize bladder and urethra using local dyes.
• Cystometrogram. Measures bladder pressure and volume to identify dysfunction unrelated to BPH.
• Cystourethroscopy. Views degree of prostatic enlargement and bladder-wall changes (diverticulum).
• Cystometry. Evaluates detrusor muscle function and tone.
• Transrectal prostatic ultrasound. Measures prostate size and residual urine, and locates lesions unrelated to BPH.

Medical Management

Treatment depends on symptom severity, and the goal is quality of life. A patient admitted on an emergency basis because he cannot void is catheterized immediately. A cystostomy (incision into the bladder) may be needed for urinary drainage.

Pharmacologic Management

• Alpha-adrenergic blockers (alfuzosin, terazosin) relax the smooth muscle of the bladder neck and prostate; 5alpha reductase inhibitors are also used.
• Antiandrogen agents (finasteride [Proscar]) shrink the prostate and block conversion of testosterone to dihydrotestosterone (DHT).
• Phytotherapeutic agents and dietary supplements (Serenoa repens [saw palmetto berry], Pygeum africanum [African plum]) are commonly used but not recommended.

Surgical Management

Options run from minimally invasive procedures to resection of the gland:

• Transurethral microwave heat treatment. Applies heat to prostatic tissue.
• Transurethral needle ablation (TUNA). Uses low-level radio frequencies through thin needles to destroy prostate tissue while sparing surrounding tissue.
• Transurethral resection of the prostate (TURP). Removes the inner portion of the prostate through an endoscope inserted via the urethra.
• Open prostatectomy. Removes the inner portion through a suprapubic, retropubic, or perineal approach for large glands.

Nursing Management

Nursing Assessment

Take a health history focused on the urinary tract, previous surgical procedures, general health, family history of prostate disease, and fitness for possible surgery. Physical assessment includes the DRE.

Nursing Diagnosis

• Urinary retention related to obstruction in the bladder neck or urethra.
• Acute pain related to bladder distention.
• Anxiety related to the surgical procedure.

Nursing Care Planning & Goals

Relieve acute urinary retention, promote comfort, prevent complications, help the patient deal with psychosocial concerns, and provide information about the disease process, prognosis, and treatment.

Nursing Interventions

• Reduce anxiety. Familiarize the patient with preoperative and postoperative routines.
• Relieve discomfort. Give bed rest and analgesics as prescribed.
• Provide instruction. Before surgery, review the anatomy and function of the affected structures in the urinary and reproductive systems.
• Maintain fluid balance. Restore fluid balance to normal.

Evaluation

Reduced anxiety, reduced pain, maintained fluid volume balance postoperatively, and absence of complications.

Discharge and Home Care Guidelines

Give written and oral instructions to monitor urinary output and prevent complications. Teach exercises to regain urinary control. Have the patient avoid the Valsalva maneuver (straining, heavy lifting), avoid bladder irritants (spicy foods, alcohol, coffee), and drink enough fluids.

Documentation Guidelines

Document degree of impairment, the patient's description and acceptable level of pain, prior medication use, level of anxiety with precipitating and aggravating factors, the patient's feelings and ability to recognize and express them, the treatment and teaching plans, response to interventions and teaching, progress toward desired outcomes, modifications to the plan of care, and referrals made.

Practice Quiz: Benign Prostatic Hyperplasia

A five-question quiz on this study guide.

1. Enlargement of the prostate gland, BPH, is usually associated with:

A. Dysuria. B. Dilation of the ureters. C. Hydronephrosis. D. All of the above.

2. The incidence of BPH among men older than 60 years of age is:

A. 35% B. 50% C. 65% D. 80%

3. The following are surgical procedures used in BPH except:

A. Prostatectomy. B. TURP. C. TUNA. D. Circumcision.

4. A result of the digital rectal examination in a patient with BPH includes what findings?

A. Enlarged, tender prostate. B. Large, rubbery prostate. C. Small, nontender prostate. D. Pus-covered prostate.

5. What is the surgical removal of the inner portion of the prostate through an endoscope inserted through the urethra?

A. Open prostatectomy. B. TUNA. C. DRE. D. TURP.

Answers and Rationale

1. Answer: D. All of the above. Dysuria, dilation of the ureters, and hydronephrosis are all associated with BPH.

2. Answer: B. 50%. 50% of men who reach age 60 develop BPH. It is not 35%, 65%, or 80%.

3. Answer: D. Circumcision. Circumcision is not used in BPH. Prostatectomy, TURP, and TUNA can be.

4. Answer: B. Large, rubbery prostate. BPH manifests a large, nontender, rubbery prostate on DRE. The prostate is not tender, small, or covered in pus.

5. Answer: D. TURP. TURP removes the inner portion of the prostate through an endoscope inserted via the urethra. Open prostatectomy uses a suprapubic, retropubic, or perineal approach for large glands; TUNA uses low-level radio frequencies through thin needles; DRE is manual palpation of the prostate via the rectum.