Benign Prostatic Hyperplasia BPH Chapter 55 Copyright 2014
Benign Prostatic Hyperplasia (BPH) Chapter 55 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Benign Prostate Hyperplasia § Enlargement of prostate gland resulting from increase in number of epithelial cells and stromal tissue § Most common urologic problem in male adults § About 50% of all men will develop BPH in their lifetime. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 2
Etiology and Pathophysiology § BPH is not completely understood. § Thought to result from hormonal changes from aging process § Excessive accumulation of DHT in the prostate cells that can stimulate overgrowth of prostate tissue § Increased proportion of estrogen over testosterone in blood Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 3
Benign Prostatic Hyperplasia (BPH) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 4
Male Reproductive System Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Etiology and Pathophysiology § Compression of the urethra leads to § Decrease in caliber and force of the urinary stream § Difficulty in initiating voiding § Intermittency of voiding § Dribbling Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 6
Etiology and Pathophysiology § Risk factors for BPH § Aging § Obesity § Especially increased waist circumference § Lack of physical activity § Alcohol consumption § Erectile dysfunction § Smoking § Diabetes Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 7
Case Study Jupiterimages/Photos. com/Thinkstock § W. B. is a 62 -year-old man who presents to the clinic where you work complaining of urinary urgency, frequency, and stopping/starting stream. § Urinalysis positive for UTI. § Digital rectal examination shows smooth, firm prostate. § PSA is 5 ng/m. L. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 8
Case Study Jupiterimages/Photos. com/Thinkstock § A transrectal ultrasound (TRUS) is ordered that indicates enlarged prostate. § W. B. begins to express concerns about having cancer. § Why do you think it’s common for people to fear the “worst”? Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 9
Clinical Manifestations § Symptoms are usually gradual in onset. § Manifestations associated with obstruction of lower urinary tract § Early symptoms are usually minimal because bladder can compensate. § Worsen as obstruction increases Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 10
Clinical Manifestations § Symptoms categorized into two groups: § Obstructive symptoms § Irritative symptoms. § Nocturia often the first symptom noticed. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 11
Clinical Manifestations § Irritative symptoms § Symptoms associated with inflammation or infection § Urinary frequency and urgency § Dysuria § Bladder pain § Nocturia § Incontinence Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 12
Clinical Manifestations § Obstructive symptoms § Symptoms due to urinary retention § Decrease in caliber and force of urinary stream § Difficulty in initiating urination § Intermittency �Starting and stopping stream several times while voiding § Dribbling at end of urinating Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 13
Complications § Related to urinary obstruction § Relatively uncommon in BPH § Acute urinary retention § Complication with sudden, painful inability to urinate § Treatment involves catheter insertion and possible surgery. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 14
Complications § UTI and sepsis § Incomplete bladder emptying with residual urine provides medium for bacterial growth. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 15
Complications § Calculi may develop in bladder because of alkalinization of residual urine. § Renal failure § Caused by hydronephrosis § Pyelonephritis § Bladder damage Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 16
Diagnostic Studies § § § History and PE Digital rectal exam Urinalysis with culture PSA level Serum creatinine Neurologic exam Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 17
Diagnostic Studies § TRUS scan § Uroflometry § Cystoscopy Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 18
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Collaborative Care § Goals § Restore bladder drainage. § Relieve symptoms. § Prevent/treat complications. § Treatment based on § How bothersome symptoms are § Presence of complications Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 20
Collaborative Care § Conservative Therapy § Active surveillance § Lack of presence of symptoms § Mild symptoms (AUA score of 0 -7) § Symptoms may disappear. § Lifestyle changes may result in improvement. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 21
Collaborative Care § Drug Therapy § Offers symptomatic relief of BPH § 5α-Reductase inhibitors § Example: finasteride (Proscar), dutasteride (Avodart), Jalyn (finasteride + tamsulosin) § ↓ Size of prostate gland § Takes 3 to 6 months for improvement § Side effects: decreased libido, decreased volume of ejaculation, ED Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 22
Collaborative Care § Drug Therapy § 5α-Reductase inhibitors § May lower the risk of prostate cancer § Not recommended in the prevention of prostate cancer due to an increased risk of developing an aggressive form of prostate cancer Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 23
Collaborative Care § α-Adrenergic receptor blockers § Examples: tamsulosin (Flomax), doxazosin (Cardura), silodosin (Rapaflo) § Promotes smooth muscle relaxation in prostate, facilitates urinary flow § Improvement in 2 to 3 weeks § Offer symptomatic relief but do not treat hyperplasia Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 24
Collaborative Care § Erectogenic Drugs § Tadalifil (Cialis) effectively reduces symptoms of both BPH and ED. § Herbal Therapy § Successfulness varies. § Use should be revealed to health care provider. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 25
Case Study Jupiterimages/Photos. com/Thinkstock § W. B. just began dating again after a recent divorce. § If you are uncomfortable talking with him about his concerns about his sexual performance ability after treatment, what should you say or do? Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 26
Collaborative Care § Minimally Invasive Therapies § Invasive (Surgery) Therapy Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 27
Collaborative Care § Minimally Invasive Therapies § Becoming more common § Destroy prostatic tissue § Lasers § Radiowaves § Ultrasound § Microwaves § Electrical current Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 28
Collaborative Care Minimally Invasive § Transurethral Microwave Therapy (TUMT) § Outpatient procedure § Delivers microwaves directly to prostate through a transurethral probe § Heat causes death of tissue and relief of obstruction. § Postop urinary retention is common. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 29
Collaborative Care Minimally Invasive § Transurethral Microwave Therapy (TUMT) § Patient sent home with catheter for 2 to 7 days. § Antibiotics, pain medication, and bladder antispasmodic medications given Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 30
Collaborative Care Minimally Invasive § Transurethral Microwave Therapy (TUMT) § Not appropriate therapy when rectal problems exist § Side effects: bladder spasm, hematuria, dysuria, and retention Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 31
Collaborative Care Minimally Invasive § Transurethral Needle Ablation (TUNA) § ↑ Temperature of prostate tissue for localized necrosis § Low-wave frequency used § Only tissue in contact with needle affected Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 32
Collaborative Care Minimally Invasive § Transurethral Needle Ablation (TUNA) § Majority of patients show improvement in symptoms. § Outpatient uses local anesthesia and sedation. § Lasts 30 minutes with little pain and quick recovery Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 33
Collaborative Care Minimally Invasive Therapy § Transurethral Needle Ablation (TUNA) § Complications include urinary retention, UTI, and irritative voiding symptoms. § Some patients require a catheter. § Hematuria up to a week Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 34
Collaborative Care Minimally Invasive Therapy § 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 35
Collaborative Care Minimally Invasive Therapy § Laser Prostatectomy § Contact laser techniques § Minimal bleeding during and after procedure § Fast recovery time § Patients may take anticoagulants. § Photovaporization of prostate Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 36
Collaborative Care Minimally Invasive Therapy § Intraprostatic Urethral Stents § For patients who are poor surgical candidates § Stents are placed directly into prostatic tissue. § Chronic pain, infection, and encrustation are potential complications. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 37
Collaborative Care Invasive Therapy § Invasive therapy indicated when § Decrease in urine flow sufficient to cause discomfort § Persistent residual urine § Acute urinary retention § Hydronephrosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 38
Collaborative Care Invasive Therapy § 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 and requires hospital stay Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 39
Transurethral Resection of Prostate Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 40
Collaborative Care Invasive Therapy § Transurethral Resection (TURP) § Bladder irrigated for first 24 hours to prevent mucous and blood clots § Complications include bleeding, clot retention, dilutional hyponatremia, retrograde ejaculation. § Patients must stop anticoagulants before surgery. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 41
Collaborative Care Invasive Therapy § Transurethral incision of the prostate (TUIP) § Moderate to severe symptoms § For patients with a small or moderately enlarged prostate gland § Local anesthesia § Several small incisions made into prostate to expand the urethra improves urine flow. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 42
Nursing Assessment § Medications § Estrogen or testosterone supplementation § Surgery or previous treatment for BPH § Knowledge of condition § Voluntary fluid restriction § Nocturia Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 43
Nursing Assessment § Urinary urgency § Diminution in caliber and force of urinary stream § Hesitancy in initiating voiding § Postvoid dribbling Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 44
Nursing Assessment § § Incontinence Dysuria Sensation of incomplete voiding Anxiety of sexual dysfunction Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 45
Nursing Assessment § Older adult male § Distended bladder on palpation; smooth, firm, elastic enlargement of prostate on rectal examination § Urinalysis findings, enlargement on ultrasound, residual urine, creatinine levels Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 46
Nursing Diagnoses § Acute pain § Risk for infection Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 47
Planning § Goals for patient having invasive procedures § Restoration of urinary damage § Treatment of UTI § Understanding of § Upcoming procedure § Implications for sexual functioning § Urinary control Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 48
Planning § Goals for postoperative care § No complications § Restoration of urinary control § Complete bladder emptying § Satisfactory sexual expression Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 49
Case Study Jupiterimages/Photos. com/Thinkstock § What information might be most helpful for W. B. at this point in his nursing care? Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 50
Nursing Implementation Health Promotion § Focus: early detection and treatment § Yearly physical exam and DRE for men over 50 § Teach patients that alcohol, caffeine, and cold and cough meds can increase symptoms. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 51
Nursing Implementation Health Promotion § Instruct patient with obstructive symptoms to urinate every 2 to 3 hours and when first feeling urge. § Minimizes urinary stasis and acute urinary retention § Teach need for adequate fluid intake. § Restricting fluids increases chance of infection. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 52
Nursing Implementation § Preoperative care for TURP § Restore urinary drainage § Coude – curved-tip catheter § Filiform – rigid catheter § Aseptic technique very important in preventing infection § Administer antibiotics § Treat UTIs Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 53
Nursing Implementation § Preoperative care for TURP § Provide patient opportunity to express concerns over alterations in sexual function. § Inform patient of possible complications of procedures. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 54
Nursing Implementation § Postoperative care for TURP § Assess for complications § Hemorrhage § Bladder spasms § Urinary incontinence § Infection Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 55
Nursing Implementation § Postoperative care for TURP § Postoperative bladder irrigation to remove blood clots and ensure drainage or urine § Administer antispasmodics. § Teach Kegel exercises. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 56
Nursing Implementation § Postoperative care for TURP § Observe patient for signs of infection. § Dietary intervention § Stool softeners to prevent straining Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 57
Nursing Implementation Ambulatory and Home Care § Instructions after prostate surgery § Care of indwelling catheter § Managing incontinence § Maintaining adequate fluid intake § Observing for signs and symptoms of UTI, wound infection Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 58
Nursing Implementation Ambulatory and Home Care § Instructions after prostate surgery § Preventing constipation § Avoiding heavy lifting § Not more than 10 lb or 4. 5 kg § Refraining from driving, intercourse after surgery as directed Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 59
Nursing Implementation § Sexual counseling if erectile dysfunction becomes a problem § Avoiding bladder irritants § Yearly digital rectal examination (DRE) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 60
Evaluation § Expected outcomes after BPH surgery § Report satisfactory pain control. § Report improved urinary function with no pain or incontinence. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 61
Case Study Audience Response Question Jupiterimages/Photos. com/Thinkstock W. B. is scheduled for a TURP. When you assesses his knowledge of the procedure and its effects, you realize he needs further teaching when he says, a. “It is possible that I’ll be sterile following this procedure. ” b. “It is likely that I will become impotent from this procedure. ” c. “I understand that some retrograde ejaculation may occur. ” d. “I will have a catheter for a couple of days to keep my urinary system open. ” Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 62
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