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BPH_(1)(1)
description
Transcript of BPH_(1)(1)
Possible causes
Excessive accumulation of dihydroxytestosterone
Stimulation by estrogen
Local growth hormone action
• Typically develops in inner part of prostate• Not completely understood• Thought to result from endocrine changes from
aging process• Prostate cancer is most likely to develop in the
outer part of the prostate.
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Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc. 3
Fig. 55-2. Benign prostatic hyperplasia. The enlarged prostate compresses the urethra.
Enlargement of prostate
gland resulting from increase
in number of epithelial cells &
stromal tissue
Most common urologic
problem in males
Enlargement gradually
compresses urethra
Partial or complete
obstruction
Compression leads to clinical
symptoms
No direct relationship between prostate size & obstruction
Location of enlargement determines obstructive symptoms
Possible risk factors
Family history
Obesity
Increased waist circumference
Physical activity level
Alcohol consumption, smoking
Diabetes• For example, it is possible for mild hyperplasia to cause severe
obstruction; likewise, it is possible for extreme hyperplasia to cause few obstructive symptoms.
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Occurs in 50% of men over 50 & 90% of men over 80
Approximately 25% will require treatment by age 80
Does not predispose to development of prostate cancer
Part of the Prostate Effected – Usually the central portion of the prostate.
Most Common Initial Symptoms - Urinary symptoms such as frequency of urination, hesitancy, dribbling, and frequent nighttime urination
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Symptoms categorized into two groups
Obstructive symptoms
Irritative symptoms
Obstructive symptoms
Symptoms due to urinary retention
Decrease in caliber of force of urinary stream
Difficulty in initiating urination
Intermittency
Dribbling at end of voiding
Symptoms are usually gradual in onset
Early symptoms are usually minimal because bladder can compensate.
Worsen as obstruction increases 6
Irritative symptoms
Symptoms associated w/ inflammation or infection
Urinary frequency & urgency
Dysuria
Bladder pain
Nocturia
Incontinence• The American Urological Association (AUA) symptom index
for BPH (see Table 55-1) is a widely used tool to assess voiding symptoms associated with obstruction. Although this tool is not diagnostic, it is useful in determining the extent of symptoms.
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Related to urinary obstruction
UTI & Sepsis
Calculi may develop in bladder because of alkalinization of residual urine
• Complications due to urinary obstruction are relatively uncommon in BPH. Acute urinary retention: complication with sudden, painful inability to urinate. Treatment involves catheter insertion & possible surgery
• Incomplete bladder emptying w/ residual urine provides medium for bacterial growth
• Renal Failure: caused by hydronephrosis• Pyelonephritis• Bladder damage
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History & PE
Digital Rectal Examination
Urinalysis w/ culture
PSA level
Serum creatinine
TRUS scan
Uroflometry• Cystoscopy• Using DRE, the health care provider can estimate the size, symmetry,
and consistency of the prostate gland. In BPH the prostate is symmetrically enlarged, firm, and smooth.
• A urinalysis with culture is routinely done to determine the presence of infection. The presence of bacteria, white blood cells, or microscopic hematuria is an indication of infection or inflammation.
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Goals
Restore bladder drainage
Relieve symptoms
Prevent/treat complications
Watchful waiting
Dietary changes
Timed voiding schedule • Treatment is generally based on the degree to which the symptoms bother the patient or the
presence of complications rather than the size of the prostate. • Treatment for BPH has undergone major changes in recent years. • Alternatives to surgical intervention for some patients now include drug therapy and minimally
invasive procedures. • When there are no symptoms or only mild ones (AUA symptom scores of 0 to 7), a wait-and-see
approach is taken.• Prevalence – Very common after age 40 and the most common cause of male urinary tract
obstruction.• Cause – Increased levels of testosterone that occur normally with increasing age.• Physical Examination – Enlarged, “boggy” prostate on digital rectal examination.• Elevated Lab Values – PSA• Where It Spreads – BPH cannot spread to other areas of the body.• Treatment – Depending on the severity of symptoms, treatment can range from nothing, to
medication to shrink the prostate, to surgery to remove the central part of the prostate to allow better flow of urine.
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5α-Reductase inhibitors:
Finasteride (Proscar), Dutasteride (Avodart)
↓ size of prostate gland
Takes 3 - 6 months for improvement
SE: ↓Libido, ↓ volume of ejaculation, ED
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α-Adrenergic receptor blockers:
Examples: Tamsulosin (Flomax), Doxazosin (Cardura), Silodosin(Rapaflo)
Promotes smooth muscle relaxation in prostate; facilitates urinary flow
Improvement in 2 - 3 weeks
SE: orthostatic hypotension & dizziness, retrograde ejaculation, nasal congestion
• Although α-adrenergic blockers are more commonly used for treatment of hypertension, these drugs promote smooth muscle relaxation in the prostate. Relaxation of the smooth muscle ultimately facilitates urinary flow through the urethra.
• Currently, the α-adrenergic blockers are the most widely prescribed drug for the patient with BPH who is experiencing moderate symptoms without the presence of other complications.
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Transurethral microwave therapy (TUMT)
Outpatient procedure: Delivers microwaves directly to prostate through a transurethral probe
Heat causes death of tissue & relief of obstruction
Postop urinary retention is common
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Transurethral microwave therapy (cont’d)
Patient sent home w/ catheter 2 - 7 days
Antibiotics, pain medication, & bladder antispasmodic medications given
Not appropriate therapy when rectal problems exist• SE: bladder spasm, hematuria, dysuria, & retention• Postoperative urinary retention is a common complication. Thus
the patient is generally sent home with an indwelling catheter for 2 to 7 days to maintain urinary flow and to facilitate the passing of small clots or necrotic tissue.
• Anticoagulant therapy should be stopped 10 days before treatment.
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Transurethral needle ablation (TUNA)
↑ temperature of prostate tissue for localized necrosis
Low-wave frequency used
Only tissue in contact w/ needle affected
Complications include urinary retention, UTI, and irritative voiding symptoms
Some patients require a catheter• Hematuria up to a week• Only prostate tissue in direct contact with the needle is affected, thus allowing
greater precision in removal of the target tissue. The extent of tissue removed by this process is determined by the amount of tissue contact (needle length), amount of energy delivered, and duration of treatment. • Majority of patients show improvement in symptoms• Outpatient uses local anesthesia & sedation• Lasts 30 minutes w/ little pain & quick recovery
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Laser Prostatectomy
Delivers a laser beam transurethrally to cut or destroy parts of the prostate
Common procedure: visual laser ablation of the prostate (VLAP)
Takes several weeks to reach optimal results • Urinary catheter inserted • A variety of laser procedures use different sources, wavelengths, and delivery
systems. • VLAP uses the laser beam to produce deep coagulation necrosis of the prostate. The
affected prostate tissue gradually sloughs in the urinary stream. Contact laser techniques involve direct contact of the laser with the prostate
tissue. This produces immediate vaporization of the prostate tissue. Photovaporization of the prostate is a newer technique that utilizes a high-
power green laser light to vaporize prostate tissue. Improvements in urine flow and symptoms are almost immediate following the procedure.
• Minimal bleeding during & after procedure• Fast recovery time• Patients may take anticoagulants.• Photovaporization of the prostate 16
Invasive therapy indicated when
Decrease in urine flow sufficient to cause discomfort
Persistent residual urine
Acute urinary retention• Intermittent catheterization can reduce symptoms & bypass
obstruction• The choice of treatment approach depends on the size and
location of prostatic enlargement, as well as on patient factors such as age and surgical risk.
• Invasive treatments are summarized in Table 55-3.
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Transurethral Resection (TURP) Removal of obstructing prostate tissue using resectoscope inserted
through urethra Outcome for 80% to 90% is excellent Relatively low risk Performed under spinal or general anesthesia & requires hospital
stay Bladder irrigated for first 24 hours to prevent mucous & blood
clots Complications include bleeding, clot retention, dilutional
hyponatremia, retrograde ejaculation Patients must stop anticoagulants before surgery TURP has long been considered the “gold standard” surgical
treatment for obstructing BPH. Although this procedure remains the most common operation performed, the number of TURP procedures done in recent years has decreased because of the development of less invasive technologies.
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Copyright © 2011, 2007 by Mosby, Inc., an
affiliate of Elsevier Inc. 19
Fig. 55-3. Transurethral resection of the prostate.
• A resectoscope is
inserted through the
urethra to excise and
cauterize obstructing
prostatic tissue.
• A large three-way
indwelling catheter
with a 30-mL balloon is
inserted into the
bladder after the
procedure to provide
hemostasis and to
facilitate urinary
drainage.
Medications
Estrogen or Testosterone supplementation
Surgery or previous treatment for BPH
Knowledge of condition
Voluntary fluid restriction
Nocturia
Subjective and objective data that should be obtained from a patient with BPH are presented in Table 55-4.
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Urinary urgency
Diminution in caliber & force of urinary stream
Hesitancy in initiating voiding
Postvoid dribbling
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Incontinence
Dysuria
Sensation of incomplete voiding
Anxiety of sexual dysfunction
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Older adult male
Distended bladder on palpation; smooth, firm, elastic enlargement of prostate on rectal examination
U/A findings, enlargement on ultrasound, residual urine, creatinine levels
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Pain relief for Acute pain
Management of complications - infection
Goals of patient having invasive procedures
Restoration of urinary damage
Treatment of UTI’s
Understanding of treatment procedures & complications
Restoration of urinary control
Complete bladder emptying
Satisfactory sexual expression
Nursing Implementation Focus: early detection & treatment
Prevention - Yearly physical exam and DRE for men over 50
Educate patients that alcohol, caffeine, and cold & cough meds can increase symptoms
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Instruct patient w/ obstructive symptoms to urinate every 2 - 3 hours & when first feeling urge
Minimizes urinary stasis
Teach patient need for adequate fluid intake
The patient may believe that if he restricts his fluid intake, symptoms will be less severe, but this only increases the chance of an infection. However, if the patient increases his intake too rapidly, bladder distention can develop as a result of the prostatic obstruction.
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Preoperative care
Use aseptic technique when using urinary catheter
Administer antibiotics preoperatively
Provide patient opportunity to express concerns over alterations in sexual function
• Inform patient of possible complications of procedures
• In many health care settings, 10 mL of sterile 2% lidocaine gel is injected into the urethra before insertion of the catheter.
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Postoperative care
Postop bladder irrigation to remove blood clots and ensure drainage or urine
Administer antispasmodics• Teach Kegel exercises• The main complications following surgery are hemorrhage, bladder
spasms, urinary incontinence, and infection. • The plan of care should be adjusted to the type of surgery, the reasons
for surgery, and the patient’s response to surgery. • The bladder is irrigated either manually on an intermittent basis, or
more commonly as continuous bladder irrigation (CBI) with sterile normal saline solution or another prescribed solution.
• Use careful aseptic technique when irrigating the bladder because bacteria can easily be introduced into the urinary tract.
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Postoperative care
Observe patient for signs of infection
Dietary intervention
Stool softeners to prevent straining
Straining increases intraabdominal pressure, which can lead to bleeding at the operative site. A diet high in fiber facilitates the passage of stool.
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Discharge instructions on indwelling catheter
Managing incontinence
Drink 2 - 3 L fluids per day
Signs and symptoms of UTI, wound infection
The bladder may take up to 2 months to return to its normal capacity. Instruct the patient to drink at least 2 L of fluid per day and to urinate every 2 to 3 hours to flush the urinary tract.
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Sexual counseling if erectile dysfunction becomes a problem
Avoiding bladder irritants
Yearly digital rectal examination (DRE)
Preventing constipation
Avoiding heavy lifting• Refraining from driving, intercourse after surgery as
directedMany men experience retrograde ejaculation because of trauma to the internal urethral sphincter. Bladder irritants include caffeine products, citrus juices, and alcohol.
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A patient with benign prostatic hyperplasia is scheduled for a transurethral resection of the prostate (TURP). The nurse assesses the patient’s knowledge of the procedure and its effects on reproductive function, and determines a need for further teaching when the patient says,
1. “It is possible that I’ll be sterile following this procedure.”2. “It is likely that I will become impotent from this procedure.” 3. “I understand that some retrograde ejaculation may occur.”4. “I will have a catheter for a couple of days to keep my urinary
system open.”
Answer: 2Rationale: Retrograde ejaculation is common with transurethral resection of the prostate because of trauma to the internal urethral sphincter. If retrograde ejaculation occurs, the patient may be sterile after the procedure. The catheter is removed 2 to 4 days after surgery. Erectile dysfunction is unlikely with transurethral resection of the prostate.
Audience Response Question
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