Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH)

• BPH is a condition where the prostate gland enlarges, restricting urine flow.
• Half of men experience BPH by age 50; this rises to over 70% for men aged 60-69.
• Etiology and Pathophysiology:
  • Hormonal changes associated with aging contribute.
  • Dihydrotestosterone (DHT) stimulates prostate growth. Elevated DHT can lead to prostate overgrowth.
  • DHT levels increase with age, causing prostate enlargement.
  • Increased proportion of estrogen to testosterone is a possible contributor. Testosterone decreases with age, leaving higher estrogen levels in the prostate. This can increase substances promoting prostate growth.
  • BPH typically originates in the transition zone.
  • Prostate enlargement compresses the urethra, potentially causing obstruction.
  • Severity of obstruction does not correlate directly with prostate size; enlargement location is more significant.
• Risk Factors:
  • Aging, obesity (especially increased waist circumference), lack of physical activity, high red meat/animal fat intake, alcohol use, erectile dysfunction (ED), smoking, diabetes, and family history of BPH in first-degree relatives.
• Clinical Manifestations:
  • Symptoms develop gradually, sometimes unnoticed until significant enlargement.
  • Initial symptoms may be mild due to bladder compensation.
  • Symptoms worsen as urethral obstruction increases.
  • Symptoms classified as irritative or obstructive.
    • Irritative: nocturia, urinary frequency, urgency, dysuria, bladder pain, incontinence; these are related to inflammation or infection.
    • Obstructive: decreased urine stream caliber/force, difficulty starting urination, intermittency (stopping and starting), dribbling.
  • Both groups of symptoms are categorized as lower urinary tract symptoms (LUTS).
  • American Urological Association (AUA) symptom index (AUA-SI) assesses symptom severity. Higher scores indicate more severe symptoms.
• Complications:
  • Acute urinary retention (sudden inability to urinate, needing catheter insertion).
  • Urinary tract infection (UTI) from incomplete bladder emptying. Possible progression to kidney infection (pyelonephritis); sepsis can develop.
  • Bladder stones due to residual urine alkalinization.
  • Renal failure due to hydronephrosis (kidney swelling).
• Diagnostic Studies:
  • Detailed history and physical examination are essential.
  • Digital rectal exam (DRE) estimates prostate size, symmetry, and consistency. In BPH, the prostate is symmetrically enlarged, firm, and smooth.
  • Urinalysis (UA) and urine culture detect infection/inflammation.
  • Prostate-specific antigen (PSA) blood test screens for prostate cancer (slightly elevated in BPH).
  • Serum creatinine assesses renal function. High levels may indicate hydronephrosis, requiring further imaging.
  • Neurologic exam if symptoms resemble neurogenic bladder.
  • Transrectal ultrasound (TRUS) and prostate biopsy may be necessary, especially in cases with high PSA or abnormal DRE.
  • Uroflowmetry measures urine stream data to assess obstruction severity.
  • Post-void residual urine volume measures urine remaining after voiding, indicating obstruction.
  • Cystoscopy assesses interior of the bladder and urethra.
  • Urodynamic/pressure flow studies evaluate bladder function/obstruction if needed.

Treatment Options

• Treatment focuses on alleviating symptoms and preventing complications, not solely prostate size.

• Non-surgical options include active surveillance/watchful waiting (mild symptoms, AUA-SI 0-7). Lifestyle changes (diet changes, drug avoidance, fluid restriction), timed voiding schedules (bladder retraining).

• Drug Therapy:

  • 5α-reductase inhibitors: reduce prostate size, delaying DHT conversion.
    • Finasteride inhibits type 2. Moderate-severe AUA-SI scores. Improved symptoms may take 6 months, require regular use, potential decreased libido and decreased PSA values (double the PSA if on finasteride for at least 6 months), may lower risk of some prostate cancers (not recommended for prevention). Patients need regular PSA monitoring.
    • Dutasteride inhibits both types: similar benefits and risks as finasteride.
  • α-adrenergic receptor blockers: relax prostate smooth muscle, improving urine flow.
    • Tamsulosin, alfuzosin, doxazosin, prazosin, silodosin. Immediate to weeks symptom improvement. Can cause retrograde ejaculation (seminal fluid in the bladder).
    • Combination therapy (5α-reductase inhibitor + α-adrenergic blocker) better than single drug.
  • Erectogenic drug (e.g., tadalafil): may alleviate BPH symptoms. Can be used in conjunction with erectile dysfunction.
  • Herbal Therapy (e.g., saw palmetto): lacks proven benefits.

• Minimally Invasive Therapies:

  • Photoselective Vaporization of the Prostate (PVP): Laser vaporization of prostate tissue; effective for larger prostates, rapid symptom improvement.
  • Laser enucleation of the prostate (HoLEP/ThuLEP): precise laser vaporization; better coagulation properties compared to TURP.
  • Prostatic Urethral Lift (PUL): permanent implants to open urethra, minimal tissue ablation.
  • Transurethral Microwave Thermotherapy (TUMT): uses microwaves to heat prostate tissue.
  • Transurethral Needle Ablation (TUNA): uses radiofrequency to heat tissue.
  • Transurethral Vaporization of the Prostate (TUVP): electrosurgical modification of TURP, minimizes TUR syndrome risk.
  • Water vapor thermal therapy: uses heated water vapor, new.

• Surgical Therapy (invasive):

  • Transurethral Incision of the Prostate (TUIP): small incisions to relieve obstruction.
  • Transurethral Resection of the Prostate (TURP): removal of obstructing tissue using a resectoscope. Gold standard for obstructing BPH; careful irrigation to prevent blood clots.
  • Simple Prostatectomy: larger prostates or complex cases.

Nursing Management (Pre/Post-Operative)

• Assessment of patients with BPH (pre-operative) is important per Table 59.4.
• Pre-operative goals: restore urine drainage, treat/resolve any UTI, patient understanding of procedure, sexual function implications, urinary control.
• Postoperative nursing care outlined per eNursing Care Plan 59.1 (available online).
• Important to monitor for complications like acute urinary retention, infections, bladder complications, and/or post-procedure recovery issues.

Questions covering the diagnosis, symptoms, and management of BPH. It includes the role of AUA-SI, treatment options such as 5α-reductase inhibitors, and potential complications like UTIs and elevated creatinine levels. Also covers diagnostic studies and digital rectal exam findings related to BPH.