Description/Etiology

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Benign Prostatic
Hyperplasia
Description/Etiology
Benign prostatic hyperplasia (BPH; also called benign prostatic hypertrophy) is a nonmalignant condition in which
excessive smooth muscle and epithelial cell proliferation results in an enlarged prostate gland that constricts or
deforms the lower urinary tract and causes difficulty with urination. BPH occurs primarily in older men, affecting 50%
of men by age 60 and 90% of men by age 85. BPH is rare in men under the age of 40.
Although the etiology of BPH is not fully understood, animal studies suggest age-related sex hormone
imbalances involving testosterone, estrogen, and dihydrotestosterone (DHT) may cause excessive growth of
prostatic tissues, causing the gland to enlarge and compress the urethra and even protrude into the bladder neck,
resulting in urinary outlet irritation, obstruction, and urinary retention. The hypothesized etiologies of BPH
suggest prostate cell growth due to reactivation of genes in the prostate cells and a role of impaired catechol-omethyl transferase gene activity.
Complications of BPH include bladder stones, prostatitis, hematuria, urinary retention, and renal failure. BPH is
diagnosed based on patient history and a variety of tests, including digital rectal examination (DRE), prostate-specific
antigen (PSA) blood test, transrectal ultrasound (TRUS), and prostate biopsy. BPH must be differentiated from
prostate cancer (CaP), urinary tract infection (UTI), prostatitis, urethral stricture, overactive bladder, neurogenic
bladder, bladder cancer, poorly controlled diabetes, and neurologic conditions that produce neurogenic bladder and
bladder symptoms (e.g., Parkinson’s disease, diabetic autonomic neuropathy, multiple sclerosis, spinal cord injury).
ICD-9
600.90
Treatment options for BPH include surgery and use of pharmacologic agents, such as non-selective or selective
alpha-adrenergic blockers, to help relax the smooth muscle tissue of the prostate and bladder neck, improving urinary
flow; 5-alpha reductase inhibitors to reduce prostate size; stool softeners for constipation; analgesics for pain; muscle
relaxants to reduce pelvic muscle spasms; and antibiotics for infection. Surgical procedures to remove part or all of
the prostate gland include transurethral resection of the prostate (TURP) and suprapubic or retropubic prostatectomy.
Minimally invasive surgical procedures include holmium laser ablation of the prostate, transurethral vaporization
of the prostate, interstitial laser coagulopathy, high-frequency focused ultrasound, transurethral needle ablation,
transurethral microwave thermoplasty, transurethral balloon dilatation therapy, transurethral ethanol ablation, and
water-induced thermoplasty. (For more information, see Quick Lesson About…Prostatectomy, Benign Prostatic
Hyperplasia.) The overall prognosis is fairly good, as treatment improves symptoms in 70–80% of cases.
Facts and Figures
Authors
Gilberto Cabrera, MD
Tanja Schub, BS
Reviewers
Eliza Schub, RN, BSN
Cinahl Information Systems
Glendale, California
Rosalyn Robinson, RN, DNP,
APNP, FNP-BC
Cinahl Information Systems
Glendale, California
Nursing Executive Practice Council
Glendale Adventist Medical Center
Glendale, California
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems
BPH is the most common cause of urinary tract obstruction in men over the age of 50, affecting ~ 14 million men in
the United States and ~ 30 million men worldwide. Evidence for racial predisposition is not supported. Up to 33% of
men with BPH have coexisting CaP.
Risk Factors
Risk factors for BPH include advanced age, intact testes, and family history of BPH. Abdominal obesity and
consumption of a diet high in fat and red meat are possible risk factors. The risk for complications increases
proportionally with the amount of prostatic enlargement.
Signs and Symptoms/Clinical Presentation
Obstructive symptoms include urinary hesitancy or retention, decreased force and caliber of the urine stream,
sensation of incomplete bladder emptying, straining to urinate, and post-void dribbling. Irritative symptoms include
increased urinary urgency, frequency, and nocturia.
Assessment
44 Patient History
•• Ask the patient about history of urinary dysfunction and family history of BPH
44 Physical Findings of Particular Interest
June 8, 2012
•• DRE may reveal smooth, firm, elastic enlargement of the prostate
•• Physical examination may reveal bladder distention and neurological dysfunction (e.g., sensory and/or motor)
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general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
44 Laboratory Tests That May Be Ordered
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PSA levels may be elevated in BPH and CaP
Serum chemistry studies may reveal ↑ serum blood urea nitrogen and creatinine levels
UA and urine culture to evaluate for UTI, prostatitis, hematuria, and pyuria
Histopathologic testing of biopsied prostate tissue is negative for malignancy in BPH
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••
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Pressure flow studies and flow rate test to assess for urinary flow abnormalities
TRUS to assess prostate size; abdominal ultrasound to assess for hydronephrosis or increased post-void residual
Cystoscopy to assess for renal obstruction
Chest X-ray and EKG to evaluate pre- and postoperative pulmonary and cardiac status
44 Other Diagnostic Tests
Treatment Goals
44 Provide Supportive Care During Treatment and Monitor for Complications
•• Assess all physiologic systems and review laboratory/diagnostic study results for abnormalities; assess for pain, voiding dysfunction, infection, and constipation
–– Administer antibiotics for infection, nonselective alpha-adrenergic blockers (e.g., doxazosin, terazosin), selective alpha-adrenergic blockers (e.g.,
terazosin, tamsulosin) to help relax the bladder, 5-alpha reductase inhibitors (e.g., finasteride, dutasteride) to reduce size of enlarged prostate, stool
softeners and laxatives for constipation and to reduce straining, muscle relaxants to reduce pelvic muscle spasms, and analgesics (e.g., ibuprofen,
aspirin) for pain
–– Insert an indwelling urinary catheter if ordered for urinary retention/obstruction and ensure meticulous hygiene; monitor catheter patency and urine
collection, and avoid rapid bladder decompression
•• Follow facility pre- and postsurgical protocols if patient becomes a surgical candidate; reinforce pre- and postsurgical education and verify completion of
facility informed consent documents; monitor closely for complications following surgical intervention (e.g., septic shock, renal failure, heart failure)
–– Monitor vital signs, intake and output, nutritional and respiratory status, response to treatment, and for medication side effects; ensure bed rest and
adherence to a fluid restrictive diet, and provide sitz baths for comfort, as ordered
44 Educate and Provide Emotional Support
•• Assess patient’s anxiety level and coping ability; express empathy, and educate about BPH, potential complications, and treatment risks and benefits
Food for Thought
44 Although sexual function is initially affected in some cases after surgery for BPH, it generally returns fully with time. Retrograde ejaculation (i.e., semen
entering the bladder instead of exiting through the urethra during ejaculation), which can cause sterility, occurs rarely
44 Some men with BPH use alternative treatments (e.g., herbs such as saw palmetto, African plum tree, rye, stinging nettle root), although their effectiveness
has not been proven
44 Alpha-1 and alpha-2 receptors, the targets of alpha-adrenergic blockers, are found in a variety of tissues other than prostate tissue, including platelets;
in a recent study of the effects of the alpha-adrenergic blockers doxazosin, terazosin, alfuzosin, and tamsulosin on endothelial function and coagulation
parameters in 89 patients with BPH, the researchers found that these drugs may decrease cardiovascular risk by reducing platelet aggregation and protecting
endothelial function (Alan et al., 2011)
Red Flags
44 Avoid checking for fecal impaction, as a rectal examination may precipitate bleeding
44 Some alpha-adrenergic blockers (e.g., alfuzosin, doxazosin, terazosin) produce a vasodilatory effect that has been associated with increased risk of
developing vascular adverse events (e.g., presyncope, syncope)
What Do I Need to Tell the Patient/Patient’s Family?
44 Advise the patient to increase water intake to flush the bladder, avoid straining during bowel movements, eat a nutritious diet but avoid spicy foods, avoid
alcoholic or caffeinated drinks, avoid heavy lifting, and avoid driving or operating heavy machinery
44 Emphasize the importance of continued medical surveillance, including PSA screening
44 Educate to seek immediate medical attention for new or recurrent urinary symptoms, surgical complications, or medication side effects
44 Recommend finding additional information from the National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) at
www.kidney.niddk.nih.gov
References
•• Alan, C., Kirilmaz, B., Koçoğlu, H., Ersay, A. R., Ertung, Y., & Eren, A. E. (2011). Comparison of effects of alpha receptor blockers on endothelial functions and coagulation parameters in patients with benign prostatic hyperplasia.
Urology, 77(6), 1439-1443.
•• Deters, L. A., Costabile, R. A., Leveillee, R. J., Moore, C. R., & Patel, V. R. (2011). Benign prostatic hypertrophy. Medscape Reference. Retrieved May 8, 2012, from http://emedicine.medscape.com/article/437359-overview
•• DynaMed. (2012, March 20). Benign prostatic hypertrophy (BPH). Ipswich, MA: EBSCO Publishing. Retrieved May 8, 2012, from
http://search.ebscohost.com/login.aspx?direct=true&db=dme&AN=116944&site=dynamed-live&scope=site
•• Evans, J. D., Pace, K., & Evans, E. W. (2011). Natural therapies used by adult men for the treatment of erectile dysfunction, benign prostatic hyperplasia, and for augmenting exercise performance. Journal of Pharmacy Practice, 24(3), 323-331.
•• Longstroth, D. (2012). Prostatic hyperplasia, benign (BPH). In F. J. Domino (Ed.), The 5-minute clinical consult 2012 (20th ed., pp. 1068-1069). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
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