1

BENIGN PROSTATIC HYPERPLASIA (BPH)

KMU INSTITUTE OF NURSING SCIENCES HAYATABAD
PESHAWAR

“BENIGN PROSTATIC HYPERPLASIA (BPH)”

By :
Fawad Ahmad Khan
Nida Ali
Waqqas Ahmad
Yasmeen Bibi
Khalida Bibi
Amjad Iqbal
Sitara Rehman
Shabeena Sabir
Sonam Bibi
Nazira Mumtaz
Facilitator: Sir Imran Waheed
3
POST RN BScN ,Year I, Semester I
 Objectives
At the end of this presentation, the participants will be able
to:
 Define BPH.
 Discuss the significance of BPH.
 Review the anatomy and physiology of the prostate
gland.
 Enlist risk factors of BPH.
 Evaluate the etiology
 Analysis critically the pathophysiology of BPH.
 Elaborate the clinical features of BPH.
4
 Objectives

 Describe the Diagnostic Criteria for BPH.

 Explain the medical and surgical management of BPH.
 Formulate the nursing diagnosis and nursing
intervention related to BPH.

5
 Case study

 A 65-years-old male weight 80-kg was presented to the

local hospital. He was experiencing Urinary
Retention with severe pain & burning sensation of lower
urinary tract since last day. The vital signs showed blood
pressure 140/90 mmHg; Temperature 99.6F; Pulse rate
100-beats/minute.

6
 Cont...
Past history:
He was a non-smoker and used to work in an environment
with no exposures to chemicals, fumes, dust and other
environmental or occupational allergens. He had unknown
history of allergy to any drug.
Laboratory tests
Including CBC shows TLC (11500) and in the Urine test
shows that pus cellsis slightly increase .

7
 Cont...

On the basis of his investigation and history the physician

prescribed him one week therapy including
Tab Norfloxacin 400mg BD Cap Tamsulosin 0.4mg HS Tab
Spasrid TDS

After one week the patient visited the doctor again with
chief complaint of Lower Abdominal pain, Abdominal
discomfort.

8
 Cont...
 As condition became worse, the patient referred to an
urologist . After ultrasound an emergency catheterization
was advised. Ultrasound reports showed enlarged prostate of
weight 93 grams. He was primarily diagnosed for BPH.
 On the basis of ultrasound the urologist suggested TURP
and prescribed,
 Tab Levofloxacin 500mg BD ,
 Tab Nimesulide 100 mg BD
 Syp Citralka 2TSF TDS.

9
 Cont...

• The TURP was conducted and he was discharged next day

with tab Levofloxacin 500mg BD, Tab Dicloran 50mg BD
and Syp Citralka . After three days, the catheter was
removed and treatment was continue for 10 days . he was
told to use Syp citralka off and on for burning micturition,
the dissected tumor was analyzed and reports showed no
malignancy.

10
 What is
BPH?
 Benign: Non-cancerous
 Prostatic: Relating to the prostate gland
 Hyperplasia: More cells than normal
 Commonly known as enlarged prostate, BPH
means the prostate gland has grown larger than
normal.
 BPH refers to benign prostatic hyperplasia (increase
in the number of cells) and hypertrophy
(increase in size of cells)(1).
11
 Cont.

 BPH is not usually life-threatening but symptoms can

have a major effect on quality of life.
 Benign prostatic hyperplasia/enlargement can lead to
bladder outlet obstruction (BOO) which can cause
lower urinary tract symptoms (LUTS)(1).

12
Cont.

13
 Epidemiology of BPH

 Globally, benign prostatic hyperplasia affects about 210

million males as reported in 2014 (which is 6% of the
total population).
 The prostate gets larger in most men as they get
older. For a symptom-free man of 46 years, the risk
of developing BPH over the next 30 years is 45%.
 Incidence rates increase from 3 cases per 1000 man-
years at age 45–49 years, to 38 cases per 1000 man-
years by the age of 75–79 years.
 While the prevalence rate is 2.7% for men aged 45–
49, it increases to 24% by the age of 80 years. 14
 Cont...

 The annual years of healthy life lost per 100,000 people

from BPH in Pakistan has increased by 7.3% since
1990, an average of 0.3% a year.
 The health burden of BPH in Pakistan, as measured in
years of healthy life lost per 100,000 men, peak at age 80+.
It harms men at the lowest rate at age 40- 44 (3).

15
 What is Prostate gland
 Male Sex Gland
 Walnut-Shaped Gland
 Weight 7-25 gm
 Lobes two lateral and one median
 The prostate gland lies in the pelvic cavity
 In the front of the rectum and behind the symphysis pubis,
surrounding the first part of the urethra and Distal to
Urinary Bladder.
 Produces Prostate Specific Antigen (PSA)(4)(5).

16
 Cont
…
 It consists of an outer fibrous covering, a layer of smooth
muscle and glandular substance composed of columnar
epithelial cells(4)(5).

17
18
 Function of the prostate gland

 The prostate gland secretes a thin, milky fluid that

makes up about 30% of semen, and gives a milky
appearance.it is slightly alkaline.
 It contains substances essential to the survival and
function of sperm cells. This fluid, mixed with sperm,
becomes semen(5).

19
 The prostate gland change with age.
The male sex hormone testosterone makes the prostate grow in
size.
 Histological:8% of men in their 30s
 10%-20% in 40s
 50-60% in 60s
 80-90% in their 70s and 80s.
 Prostate size increases from:
 25g to 30g for men in 40s
 30g to 40g in 50s
 35g to 45g in 60s(6).
19
 Risk factors of BPH

 Aging is the major risk factor for the development of BPH,

so there are no primary preventions. Early detection is the
best secondary prevention . Early detection can lead to
early treatment, which can prevent complications related to
urinary obstruction. Examination of the prostate annually
for men older than 40 years ensures early detection(7)(8).

21
 Causes of BPH
o The exact cause of BPH is unknown
o Age related changes to bladder anatomy and
function
o Race
o Genetics (heredity)
o The prevailing theory is that hormonal alteration is
responsible. Increase Testicular androgen receptor seems to
be the most common hormone suspected as the cause of
BPH.
o Dihydrotestestrone (DHT) may play a role(8).

22
 Pathophysiology of BPH

 As men age increases, the enzymes aromatase and 5- alpha

reductase increase in activity. Aromatase and 5-alpha
reductase are responsible for converting androgen hormone
into estrogen and dihydrotestesrone respectively. This
metabolism of androgen hormones leads to a decrease in
testosterone but raised levels of DHT and estrogen(9).

23
 Pathophysiology of BPH

• Prostatic enlargement depends on the potent androgen

dihydrotestosterone (DHT).
• DHT binds to androgen receptors in the cell nuclei,
potentially resulting in BPH.
• There are large numbers of alpha-1-adrenergic receptors are
located in the smooth muscle of the stoma and capsule of the
prostate, as well as in the bladder neck(1).

2/3/2020
24
 Cont…
.
• Stimulation of these receptors causes an increase in
smooth-muscle tone, which can worsen LUTS.
• Microscopically, BPH is characterized as a
hyperplasia process.
• The prostate enlarges with age in a hormonally
dependent manner.
• Notably, castrated males ( who are unable to make
testosterone) do not develop BPH(1).

2/3/2020
25
• Obstruction-induced BPH
bladder dysfunction
contributes significantly to
LUTS.
• obstruction leads to smooth-
muscle-cell hypertrophy.
• The bladder wall becomes
thickened and irritable when it is
forced to hypertrophy and increase
its own contractile force(1).

2/3/2020
26
 Signs & Symptoms

LUTS : Lower urinary tract symptoms (LUTS) refer to a group

of medical symptoms, that affect approximately 40% of older
men.
• Voiding (Obstructive) Symptoms
• Storage (Irrigative or filling) Symptoms(3)

28
 Voiding (Obstructive) Symptoms

• Hesitancy (uncertainty)
• Weak Stream
• Straining to Pass Urine
• Prolonged Micturition
• Feeling of incomplete bladder emptying
• Urinary Retention

29
 Storage (Irrigative or filling) Symptoms

• Urgency
• Frequency
• Nocturia
• Urge incontinence

30
 Other Common Symptoms

• Decrease in the urinary stream

• Dribbling or Leaking after Urination
• Pain or Burning Urination
• Feeling of incomplete bladder emptying(8)

31
 Diagnostic tools for BPH
 Medical History
 Physical Exam
 Digital rectal examination (DRE)
 Urinary Output Testing
 Post-voiding residual (PVR) volume testing
 Uroflowmetry : Urinary flow rate <10 mL/s
highly suggestive of outlet obstruction(8)

32
33
 CONT.
• Laboratory Studies:
• Urinalysis
• Prostate Specific Antigen(PSA blood test) (0.2 to 4.0
ng/mL)
• BUN & Creatinine
• Endoscopy of the lower urinary Tract
• International Prostate Symptoms Score (IPSS)
• American Urological Association Symptoms Index
(AUA-SI)(8)

34
 Cont.
Further evaluate with AUA Symptom Score, or International
Prostate Symptom Score (IPSS)—7 questions each on
severity scale of 0-5:
1. Frequency,
2. Nocturia,
3. Weak urinary stream,
4. Hesitancy,
5. Intermittency,
6. Incomplete emptying, and Urgency.
7. If score 0 to 7 mild symptomatic, 8 to 19 moderate
symptomatic and 20 to 35 sever symptomatic.
 Medical management
 If no obstruction and limited discomfort, do not need to
treat!!
 Non-pharmacological Management
 Watchful waiting and annual evaluation
 Lifestyle Modifications
 Avoid fluids prior to bedtime or going out
 Reduce caffeine and alcohol
 Scheduled urination at least once every 3 hours.

36
 Cont.
 Alpha-1-adrenergic antagonists: Relax smooth muscle in
the bladder neck, prostate capsule, and prostatic urethra,
provide Immediate relief! Examples
 Terazosin, Doxazosin
 Initiate at bedtime (hypotension)

37
Cont.

Tamsulosin, Alfuzosin
 Major Side Effects
o HYPOTENSION!
o Ejaculatory Dysfunction (particularly
Tamsulosin)

38
 Cont.

 5-alpha-reductase inhibitors
• Reduces the size of the prostate gland
• Prevents conversion
testosterone→ dihydrotestosterone(DHT)
• Need to use for 6 to 12 months before prostate size is
sufficiently reduced to improve symptoms As
discontinuation may lead to symptom relapse.

39
Cont.

 Examples
o Finasteride (initiated and maintained at 5
mg once daily)
o Dutasteride
 Side Effects
o Sexual dysfunction
o Decrease PSA(4)(9)

40
Cont.

 Anticholinergic
o monotherapy for patients with predominately
irritated symptoms related to overactive
bladder
o Frequency, urgency, incontinence
 Examples
o Oxybutynin, Tolterodine
 Side Effects
o Dry mouth, blurred vision,
tachycardia, constipation(4).
41
 Cont.
 Combination therapy
o Severe symptoms without maximal response to
maximal monotherapy
o Alpha 1 and anticholinergic
o Alpha 1 and reductase inhibitor.

42
 COMPLICATION

 Urinary retention
 Renal insufficiency
 Recurrent UTI
 Gross hematuria
 Bladder calculi
 Renal failure or Uremia(5)

43
 Surgical management

• Transurethral resection of the prostate (TURP): The

criterion standard for relieving BOO secondary to BPH.

• Open prostatectomy: Reserved for patients with very large

prostates (>100 g), patients with bladder stones, and
patients who cannot be positioned for transurethral
surgery.
• Laser treatment - Used to cut or destroy prostate
tissue(4)(8).

44
Cont.
 Transurethral microwave therapy (TUMT) - Generates
heat that causes cell death in the prostate, leading to
prostatic contraction and volume reduction(4)(8).

45
46
 Nursing Management

 Nursing Diagnose: Altered Urinary Elimination

Pattern i.e. Urinary Retention r/t mechanical
obstruction of prostate enlargement as evidence by
inability to empty the bladder and bladder
distension.
 Goal:
o Improved pattern of urinary elimination
o Urination by a considerable amount.
o Shows post-voiding residual of less than 50 ml(8).

47
 Cont.

 Intervention:
1. Encourage clients to urinate every 2 to 4 hours.
Rational : Minimizing excessive retention of urine in the
bladder.
2. Observation of the flow of urine. Rational :
Useful for evaluating obstruction(4)(8).

48
Cont.

3. Supervise and record time, the number of each voiding.

Note any changes in urine specific gravity. Rational: Urinary
retention increases the pressure in the upper urinary tract that
can affect the kidneys.
4. Encourage drinking water to 3000 ml / day. Rational : The
increased flow of fluid to maintain renal perfusion and
kidney cleanness, bladder from bacterial growth(4)(8).

49
Cont.

5. Perform catheterization and perianal care.

Rational : Reduce the risk of ascending infection.
6. Collaboration of anti-spasmodic drugs, rectal
suppositories, antibiotics.
Rational: Eliminating bladder spasm, while
antibiotics to fight infection.

50
 Reference

1.Porth M.C & Heymann H.G (2015). Essentials of Pathophysiology: Concepts of

Altered Health States (4th E.d). Ch: 39, Disorders of the Male Genitourinary System.
Wolters Kluwer. Page # 993-999
2. MacDonald, Roderick; Wilt, Timothy J.; Howe, R. William (2014).
3.Huma A, Zubair A. Overview of Benign and Malignant Prostatic Disease in
Pakistan, Asian Pac J Cancer Prev.2013;14(5):3005-10
4. Brunner & Suddarth (2010). Textbook of Medical Surgical Nursing (12th
e.d). Lippincott. Page # 1494-1508
5. ROSS AND WILSON(2014).Textbook anatomy and physiology of nursing 4th
edition
6.Khattak S., Kamal A., & Khattak AM. (2004). Surgical Treatment of Benign
Prostatic Hyperplasia: Outcome of Transvesical Prostatectomy. Biomedical
New Journal. Jul.- Dec,2004; vol.20
51
 Cont.
7.Guyton C.A, Hall E.J (2006). Textbook of Medical Physiology. (11th
E.d). Unit 10 Reproductive Function. Elsevier Saunders. Page # 1007-
1011
8.Luck,s man textbook medical and surgical of nursing (2005,4th edition)
9.Wasserman, Neil F. (1 September 2006). "Benign Prostatic
Hyperplasia: A Review and Ultrasound Classification". Radiologic
Clinics of North America. 44 (5): 689–710

52
53