BPH LATEST

DMS 2144
BENIGN PROSTATIC

HYPERPLASIA

SITI FATIMAH MD SHARIFF
MNrsg
KUIM

ANATOMY: quick revise

The prostate: The main function of the prostate gland is

• is a gland that forms To secrete an alkaline fluid that
part of the male reproductive system. comprises 70% of the seminal volume.
It is a conduit between the bladder The secretions produce:
and the urethra. • lubrication and nutrition for thesperm.
It is composed of several zones. • liquefaction of the seminal plug.
(Peripheral, central, anterior • neutralize the acidic vaginal
fibro muscular stroma, and transition
zones). environment.
BPH originates in the transition zone,
which surrounds the urethra.

INTRODUCTION
WHAT IS BPH?

• It is an enlarged prostate gland. It is also known as benign prostatic hypertrophy.
It is defined as, “ noncancerous increase in
size of prostate gland which involves
hyperplasia of prostatic stromal and
epithelial cell resulting in formation of large,
fairly discrete nodules in transitional zone
of prostate, which push on and narrow the
urethra resulting in an increase resistance
to flow of urine from the bladder.”

DEFINITION

Benign Prostatic Hyperplasia (BPH) is one of the most common diseases in aging
men. enlargement, or hypertrophy, of the prostate gland enlarges, extending upward
into the bladder and obstructing the outflow of urine.
• • Cause is not well understood, butevidence suggests hormonal involvement.
• • Common in men older than 40 years.
• • Cause lower urinary tract symptoms
• CAUSES OF BPH
• BPH is probably a normal part of the aging
processin men.
• Changes in hormone balance.
• Changes in cell-growth factors.
• Genetics (may also play a role).

PATHOPHYSIOLOGY



EPIDEMIOLOGY / INCIDENCE

• BPH typically occurs in men older than 40 years of age.
• By the time they reach 60 years of age,50% of men have BPH.
• BPH affects as many as 90% of men by 85 years of age.
• •BPH is the second most common cause of surgical intervention in men older

than 60 years of age.

RISK FACTORS OF BPH

• Aging
• Family History
• Ethnic Background
• Diabetes And Heart Disease
• Lifestyle

COMPLICATIONS OF BPH

• Acute urinary retention
• Involuntary bladder contractions
• Bladder diverticula
• Cystolithiasis
• Vesicoureteral reflux
• Hydroureter
• Hydronephrosis
• Gross hematuria
• UTI

Clinical manifestations

DIAGNOSIS OF BPH

• TESTS THAT ARE OFTEN DONE :

• Digital rectal exam. The doctor inserts a finger into
• the rectum to check your prostate for enlargement.
• Urine test and urine culture. Analyzing a sample of
• your urine can help identifying an infection or
• Other conditions that can cause similar symptoms

• TESTS THAT ARE OFTEN DONE :

• A prostate-specific antigen (PSA) test helps check
• for prostate cancer, which can cause the same
• symptoms as BPH.

TESTS THAT ARE USED AS NEEDED

• A blood creatinine test checks how well your kidneys are working.
• Post-void residual urine test (PVR) measures the amount of urine left in

the bladder after urination using ultrasound or a small tube (catheter)
put into the bladder through the urethra
• Pressure flow studies measure pressure in the bladder while urinating .
• Cystometrogram measures the bladder's pressure,
compliance, and capacity during urinary storage. Like
• Uroflowmetry test, which measures how fast the urine flows out of the
bladder.

ASSESSMENT AND DIAGNOSTIC
EVALUATION

• History collection
• Physical examination- including digital
• rectal examination (DRE)
• Urinalysis
• Urine culture
• Prostate specific antigen levels



NON PHARMACOLOGICAL TREATMENT

• Using double-voiding technique when you urinate :
• after urinating, you wait a moment and try again to see if more urine

comes out.
• Doing exercises to train your bladder to hold more urine.

PHARMACOLOGICAL MANAGEMENT

Alpha blockers:
• These medications relax bladder neck muscles and muscle fibers in the prostate,

making urination easier.
5-alpha reductase inhibitors (antiandrogen agents) :
• These medications shrink prostate by preventing hormonal changes that cause

prostate growth.
 Combination drug therapy:
• Doctor might recommend taking an alpha blocker and a 5-alpha reductase inhibitor

at the same time if eithermedication alone isn't effective.
Tadalafil (Cialis):
• Studies suggest this medication, which is often used to treat erectile dysfunction,

can also treat prostate enlargement.

 Α1-ADRENERGIC ANTAGONIST

• Terazosin, Doxazosin, Tamsulosin, Alfuzosin, &Silodosin
Mechanism of Action
• They block the α1(A) and α1(B) receptors in the prostate, causing prostatic

smooth muscle relaxation, which leads to improved urine flow.

• Doxazosin, Terazosin,& Alfuzosin block α1(A) and α1(B) receptors, which
decrease peripheral vascular resistance and lower arterial BP by causing
relaxation of both arterial and venous smooth muscle.

• Tamsulosin & silodosin, are more selective for the α1(A) receptors and have
less effect on BP.

DOXAZOSINCARDURA®, CARDURA XL®, CADEX®) TAMSULOSIN (FLOMAX®)

S/E: dizziness, headache, diarrheal, S/E: anemia, nausea & vomiting,
• low blood pressure weakness,
• Dizziness, a lack of energy, nasal congestion, • headachehas a caution about “floppy iris
• headache, drowsiness and orthostatic • syndrome”, a condition in which the iris
• hypotension.
• Tachycardia, vertigo, and sexual dysfunction. billows in
• Inhibition of ejaculation and retrograde • response to intraoperative surgery.
• ejaculation. • Preparations: 0.4mg Cap.
Preparations: TAB. (1,2,4&8 mg) • Dosing:
• TAB. SR (4&8 mg). • The dose may be increased after 2-4

weeks if the
• response is not adequate.

 5-Α REDUCTASE INHIBITORS

• Finasteride & Dutasteride

Mechanism of Action
• They inhibit the enzyme 5-α rductase, which is responsible for converting testosterone to

the more active dihydrotestosterone (DHT).
• DHT is an androgen that stimulates prostate growth. By reducing it, the prostate shrinks

and urine flow improves.

S/E:
• impotence, decreased libido, confusion, decreased, ED, gynecomastia & oligospermia).
• They have teratogenicity potential:
• Causing birth defects involving genitalia in a male fetus.

FENASTERIDE (PROSCAR®) DUTASTERIDE (AVODART®)

• Preparations: 1.5 mg TAB. . • Preparation: 0.5mg liquid-filled
• Dosing: capsule.
• For 6-12 months to notice a benefit.

Surgical management



Minimally Invasive Therapy

Minimally invasive therapies are becoming more common as an alternative to watchful
waiting and invasive treatment. They generally do not require hospitalization or
catheterization.



• The procedure is not appropriate for men with rectal problems.
• Anticoagulant therapy should be stopped 10 days before treatment. Mild side
effects include occasional problems of bladder spasm, hematuria, dysuria, and
retention.
• A rectal temperature probe is used during the procedure to ensure that the

temperature is kept below 110° F (43.5°C) to prevent rectal tissue damage
• The procedure takes about 90 minutes.
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.
• Antibiotics, pain medication, and bladder antispasmodic medications are used
tolerate and prevent post procedure problems.



This procedure is performed in an outpatient using local anesthesia and IV or
oral sedation. The TUNA procedure lasts approximately 30 minutes. The patient
typically experiences little pain with an early return to regular activities.
Complications include urinary retention, UTI, and irritative voiding symptoms
(e.g., frequency, urgency, dysuria).
Some patients require a urinary catheter for a short time.
Patients often have hematuria for up to a week.



• The use of laser therapy through visual or ultrasound guidance is an effective
alternative to transurethral resection of the prostate (TURP) in treating BPH.

• The laser beam is delivered transurethral through a fiber instrument and is
used for cutting, coagulation, and vaporization of prostatic tissue.

• There are a variety of laser procedures using different sources, wavelengths,
and delivery systems.







Invasive Therapy
(Surgery)

• Invasive treatment of symptomatic BPH involves surgery.
• The choice of the treatment approach depends on the size and

location of the prostatic enlargement and patient factors such as age
and surgical risk



Transurethral Resection of the Prostate.

Transurethral resection of the
• prostate (TURP) is a surgical
• procedure involving the removal of
• prostate tissue using a resect scope
• inserted through the urethra.

TURP

• TURP procedure remains the most common operation performed, but the
number of TURP procedures done in recent years has declined due to the
development of less invasive technologies.

• TURP is performed under a spinal or general anesthetic and requires a 1 to 2-
day hospital stay.

• No external surgical incision is made. A resectoscope is inserted through the
urethra to excise and cauterize obstructing prostatic tissue.

• 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.
• The bladder is irrigated, either continuously or intermittently, usually for the

first 24 hours to prevent obstruction from mucus and blood clots

• The outcome for 80% to 90% of patients is excellent, with marked
improvements in symptoms and urinary flow rates.
Postoperative complications include

• bleeding, clot retention, and dilutional hyponatremia associated with irrigation.



NURSING ASSESSMENT

• • Obtain history of voiding symptoms, including onset, frequency of day and
night time urination, presence of urgency, dysuria, sensation of incomplete
bladder emptying, and decreased force of stream- Determine impact on
quality of life.

• • Perform rectal (palpate size, shape, and consistency) and abdominal
examination to detect distended bladder, degree of prostatic enlargement.

• • Perform simple urodynamic measures uroflowmetry and measurement of
post void residual, if indicated.

Discharge and Home Care Guidelines

The patient and the family require instructions about how to promote recovery.
Instructions.
The nurse provides written and oral instructions about the need to monitor urinary output and
strategies to prevent complications.
Urinary control.
The nurse should teach the patient exercises to regain urinary control.
Avoid Valsalva maneuver.
The patient should avoid activities that produce Valsalva maneuver like straining and heavy
lifting.
Avoid bladder discomfort.
The patient should be taught to avoid spicy foods, alcohol, and coffee.
Increase fluids.
The nurse should instruct the patient to drink enough fluids.

Patient Education and Health Maintenance

Explain to patient not undergoing treatment the symptoms of
complications of BPH: urinary retention, cystitis, and increase in
irritative voiding symptoms.

-Encourage reporting these problems
Advise patients with BPH to avoid
• certain drugs that may impair voiding, particularly OTC cold

medicines containing sympatho mimetics such as
phenylpropanolamine.

Tell patient postoperatively to avoid
• sexual intercourse,
• straining at stool,
• heavy lifting
• long periods of sitting for 6 to 8 weeks after surgery, until prostatic fossa is

healed.
Advise follow-up visits after treatment
• because urethral stricture may occur and regrowth of prostate is possible after

TURP.
Be aware of herbal or natural
• products marketed for prostate health.