Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH)

• Risk factors include being 40 years or older, a family history of BPH, obesity, heart disease, type 2 diabetes, lack of physical exercise, and erectile dysfunction.
• Symptoms of BPH include changes in urination, frequency, urgency, nocturia, and incontinence.
• Long-term effects stemming from BPH include bladder damage, kidney damage, and stones.
• Diagnosing BPH involves a urine flow test, postvoid residual volume test, 24-hour voiding diary, prostate-specific antigen (PSA) test, and renal labs.
• Management for BPH involves incontinence care, exercise, adequate sleep, decreased stress, good nutrition, surgery, and medications.
• Surgical interventions for BPH include transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and laser photoselective vaporization of the prostate (PVP).
• Post-operative care includes a diligent bowel regimen, encouraging fluids, indwelling catheter use, and continuous irrigation.
• Medications for BPH include Dutasteride, Tamsulosin, and Tadalafil.
• Dutasteride is an antiandrogen that can take months to decrease prostate size, decreasing libido and causing gynecomastia; it has a long half-life (5 weeks).

Tamsulosin and Tadalafil

• Tamsulosin is an alpha-adrenergic blocker that relaxes smooth muscle that can take 2 weeks to see effects, adverse effects dizziness, hypotension, headache, and nausea.
• Tadalafil is a smooth muscle relaxer; adverse effects are hypotension and headache, use with NTG needs to be done carefully.

Renal Stones

• Also known as renal calculi, nephrolithiasis, or urolithiasis.
• Calcium oxalate stones are often caused by dehydration, high sodium/oxalate/protein intake, and immobility.
• Calcium phosphate stones are often caused by dehydration, high sodium/protein intake, and hyperparathyroidism.
• Uric acid stones can be caused by high purine intake and/or gout.
• Struvite stones are associated with UTIs, while cystine stones are related to genetics.
• Symptoms of renal stones include blood in urine, pain with urination, flank pain, abdominal pain, and pain radiating down the leg.
• Diagnosis involves labs for blood, albumin, or calcium in urine, as well as a CT scan or ultrasound.
• Management includes pain control, hydration, nutrition, straining urine, lithotripsy, and percutaneous nephrolithotomy.
• Diet recommendations include avoiding leafy greens, nuts, chocolate, strawberries, dried fruit, and sweet potatoes (oxalates), organ meat, gravy, red wine, sardines, and shellfish (purine); calcium intake should be at 1200mg/day.
• Post-op care includes straining urine, 3-4 L daily fluid intake, pain control, and monitoring changes in blood in urine.
• Medications include pain control- NSAIDs or opioids, oxybutynin chloride, tamsulosin, and allopurinol.
• Oxybutynin chloride adverse effects are dry mouth, constipation, nausea, dizziness/drowsiness, tachycardia, and dry eyes; avoid ETOH.
• Allopurinol inhibits uric acid production and is helpful for uric acid stones; caution with heart failure, renal failure, bone marrow depression.

Acute Kidney Injury (AKI)

• Prerenal causes: shock, heart failure, renal artery stenosis, sepsis, respiratory failure.
• Intrarenal causes: nephrotoxins, acute tubular necrosis (ATN), nephritis.
• Postrenal causes: obstruction (stones or stricture), cervical cancer, bladder atony, BPH.
• All causes lead to decreased oxygenation/perfusion and/or direct damage to renal tissue.
• Phases include onset (hours to days, normal UO), oliguric (>10-14 days, oliguria, increased BUN/Creatinine and electrolytes).
• Patients in the diuretic phase have increased UO, but it is not concentrated appropriately and labs are usually still abnormal.
• Patients in the recovery phase, can take up to 1 year for full recovery and will sometimes sustain permanent damage.
• Normal lab values include a Glomerular Filtration Rate (GFR) of > 90 mL/min/1.73m², serum creatinine of 0.8-1.2 mg/dL, Blood Urea Nitrogen (BUN) of 7-20 mg/dL, Na+ of 135-145 mEq/L, K+ of 3.5-5.0 mmol/L, and PO₄ of 3.0-4.5 mg/dL.
• Symptoms include low or no urine output, hyperkalemia, anemia, hyperphosphatemia, GI upset, mental status changes, and bleeding.
• Management involves fluid management, hemodialysis, electrolyte correction, VS monitoring, diligent I/O, and diet.
• Oliguric patients should limit salt, fluids, potassium, and phosphorous; diuretic patients may still limit salt, potassium, and phosphorous.
• Medications used are Erythropoietin stimulating agents, Epoetin alpha, Darbepoetin, Methoxy polyethylene glycol-epoetin beta, Furosemide, Spironolactone, and Hydrochlorothiazide.

Chronic Kidney Disease (CKD)

• CKD may be permanent dysfunction from AKI or may be slow onset due to vascular damage or nephrotoxic medications.
• Risk factors: diabetes, hypertension, hyperlipidemia, heart failure, SLE, sickle cell anemia, cirrhosis.
• Stages of CKD are based on GFR and lab values.
• Stage 1 is GFR > 90, with normal labs.
• Stage 2 is GFR 60-89, indicating renal insufficiency.
• Stage 3 has a GFR of 30-59, with BUN and creatinine elevated, edema, headaches, nausea, fatigue, and lower UO.
• Stage 4 has a GFR of 15-30, with elevated BUN and creatinine, anemia, potential dialysis, hypertension, and nausea/vomiting.
• Stage 5 has a GFR < 15 and definitely requires dialysis, indicating End-Stage Renal Disease (ESRD).
• Symptoms include lethargy, mental status changes, hyperkalemia, changes in phosphorous and sodium levels, pruritis, edema, and hypertension.
• Management includes hemodialysis, peritoneal dialysis, diet restrictions, fluid management, medications, symptom management, and electrolyte management.
• Medications include erythropoietin alfa, lactulose, ACEIs, ARBs, and diuretics.
• Hemodialysis involves weights before and after HD for comparison, holding medications until after HD is complete, monitoring for bleeding, and maintaining updated I/O.
• Peritoneal dialysis involves a Tenckhoff catheter, fluid warmer; it is considered more gentle than HD, and still requires VS, electrolyte, and fluid status monitoring.
• Peritoneal dialysis exchange requires sterile access, draining indwelling fluid, filling with new fluid, dwelling for a prescribed length of time.
• Four to six exchanges per day are typical either through continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis.