BENIGN PROSTATIC HYPERPLASIA PPT.pptx
- 1. BENIGN PROSTATIC HYPERPLASIA PRESENTED BY SHILPA.S MSC. NURSING FIRST YEAR
- 2. OVERVIEW Define Benign Prostatic Hyperplasia. Etiology and Risk factors. Pathophysiology of BPH. Clinical Features of BPH. Complications of BPH. Diagnostic Studies of BPH. Management of BPH including nurses responsibility. Research Studies related to Benign prostatic hyperplasia.
- 3. INTRODUCTION Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland. In many patients older than 50 years, the prostate gland enlarges, extending upward in to the bladder and obstructing he outflow of urine by encroaching on the vesicle orifice.
- 4. Contd…. This condition is known as benign prostatic hyperplasia (BPH), the enlargement, or hypertrophy, of the prostate. It is the most common urologic problem in male adults. About 50% of all men in their lifetime will develop BPH. Research is not clear about whether having BPH lead to an increased risk of developing prostate cancer.
- 6. DEFINITION It is defined as, “non-cancerous increase in size of prostate gland which involves hyperplasia of prostatic stromal and epithelial cells 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.”
- 7. DEFINITION OR It is a condition in which there is progressive enlargement of prostate gland, resulting from an increase in the number of size of epithelial cells and stromal tissue.
- 8. ETIOLOGY AND RISK FACTORS: • Excessive accumulation of dihydroxytestosterone (DHT). It is known as principal intraprostatic androgen. This can stimulate cell growth and an overgrowth of prostate tissue.
- 9. CONTD….. • Increased proportion of estrogen in blood. Throughout their lives, men produce both testosterone and small amounts of estrogen. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of estrogen. A higher amount of estrogen within the gland promote cell growth.
- 11. CONTD…..
- 12. CONTD…..
- 13. PATHOPHYSIOLOGY OF BPH: • McNeal demonstrated that BPH first develops in the peri- urethral transitional zone of the prostate. • BPH affects both glandular epithelium and connective tissue stroma.
- 14. • It begins as micro nodules in the transitional zone which grow and coalesce to form macro nodules around the inferior margin of the pre- prostatic urethra, just above the verumontanum. • Macro nodules in turn compress the surrounding normal tissue of the peripheral zone postero- inferiorly, creating a ‘false capsule around the hyperplastic tissue.
- 15. • As the transitional zone grows, it produces the appearance of ‘lobes” on either side of the urethra. • In due course, these lobes may compress or distort the pre prostatic and prostatic parts of urethra and produce symptoms.
- 18. Effects of BPH: - • Benign prostatic hyperplasia develops over a prolonged period: changes in the urinary tract are slow and insidious. • BPH is a result of complex interactions involving resistance in the prostatic urethra to mechanical and spastic effects, bladder pressure during voiding, detrusor muscle strength, neurologic functioning, and general physical health.
- 19. • The hypertrophied lobes of the prostate may obstruct the bladder neck or urethra, causing incomplete emptying of the bladder and urinary retention. • As a result, gradual dilation of the uterus (hydro ureter) and kidneys (hydro nephrosis) can occur. • Urinary retention may result in the urinary tract serves as a medium for infective organisms.
- 20. Effect of BPH on urethra: • The prostatic urethra is lengthened (twice its normal length). • The normal posterior curve may be so exaggerated requires a curved catheter to negotiate it.
- 21. Effect of BPH on the Urinary Bladder • If BPH causes BOO, the musculature of the bladder hypertrophies to overcome the obstruction and appears trabeculated. • BPH is associated with increased blood flow and the resultant veins at the base of the bladder causes hematuria.
- 22. CLINICAL MANIFESTATIONS • Manifestations of BPH are mainly associated with symptoms of the lower urinary tract. • The patient’s symptoms are usually gradual in onset and may not be noticed until prostate enlargement has been present for some time.
- 23. Contd… • Early symptoms are often minimal because the bladder can compensate for a small amount of resistance to urine flow. • The symptoms gradually worsen as the degree of urethral obstruction increases. • Symptoms can be divided into two groups: Irritative symptoms Obstructive symptoms
- 24. Contd… Irritative Symptoms: - Nocturia Urinary Frequency Urgency Dysuria Bladder pain and incontinence are associated with inflammation or infection.
- 25. Contd… Obstructive symptoms: - These symptoms caused by prostate enlargement include a decrease in the caliber and force of the urinary stream Difficulty in initiating voiding Intermittency Dribbling of urine at the end of urination.
- 26. Contd… • Chronic urinary retention and large residual volumes can lead to azotemia (accumulation of nitrogenous waste products) and kidney failure. • Generalized symptoms may also be noted including fatigue, anorexia, nausea, vomiting, and pelvic discomfort, urethral stricture and neurogenic bladder.
- 27. COMPLICATIONS: • Acute urinary retention: - It is manifested by the sudden and painful inability to urinate. Treatment include the insertion of a catheter to drain the bladder. • Urinary Tract Infection(UTI): - Incomplete bladder emptying results in residual urine, which provides a favorable environment for bacterial growth.
- 28. Contd… • Bladder Calculi: - Calculi may develop in the bladder because of alkalization of the residual urine. Bladder stones are more common in men with BPH, although the risk of renal calculi is not significantly increased.
- 29. Contd… • Renal failure caused by hydronephrosis: - It occurs due to distention of pelvis and calyces of kidney by urine that cannot flow through the ureter to the bladder. • Pyelonephritis and bladder damage if treatment for acute urinary retention is delayed.
- 30. DIAGNOSTIC STUDIES • History collection and physical examination • Digital rectal examination: - The prostate can be palpated by digital rectal examination to estimate its size, symmetry, and consistency. In BPH, prostate is symmetrically enlarged, firm, and smooth.
- 31. • Urine analysis with culture: - A urine analysis with culture is routinely done to identify any infection. Bacteria, WBCs, or microscopic haematuria indicate infection or inflammation. • Prostate- specific antigen (PSA): - It is done to rule out prostate cancer. However prostate level may be slightly elevated in patient with BPH.
- 32. • Serum- creatinine level: - These levels may be ordered to rule out renal insufficiency. • Trans Rectal Ultrasound: - This examination allows for accurate assessment of prostate size and is helpful in differentiating BPH from prostate cancer.
- 33. • Uroflowmetry: - It is the study that measures the volume of urine expelled from the bladder per second, is helpful in determining the extent of urethral blockage and thus the type of treatment needed. • Post void residual urine volume: - It measured to determine the degree of urine flow obstruction.
- 34. • Cystoscopy: - It is a procedure allowing internal visualization of the urethra and bladder, is performed if the diagnosis is uncertain and in patients scheduled for prostatectomy. • The American Urological Association(AUA) symptom Index or International Prostate Symptom Score(IPSS) can be used to assess the severity of symptoms.
- 35. Other studies include: • Urodynamic studies. • Complete Blood studies. • Cardiac status and Respiratory function are assessed because a high percentage of patients with BPH have cardiac or respiratory disorders due to their age.
- 36. MANAGEMENT OF BPH The Goals of Collaborative Care are to: Restore Bladder Drainage Relieve the patient symptoms. Prevent or treat the complications of BPH Improve the quality of Life.
- 37. Contd…… Management of BPH is divided into: Medical Management Surgical Management Nursing Management
- 38. Contd…… Medical Management: - • The most conservative treatment that may be recommended for some patients with BPH is referred to as active surveillance. • When the patient has no symptoms or only mild ones, a wait and see approach is taken.
- 39. Contd…… Medical Management: - • If the patient begins to have signs or symptoms that indicate an increase in obstruction, further treatment is indicated.
- 40. Contd…… Drug Therapy: - Drugs that have been used to treat BPH with variable degree of success include • 5α- Reductase Inhibitors • α- Adrenergic Receptor Blockers. • Erectogenic Drugs • Herbal Therapy.
- 41. Contd… 5α- Reductase Inhibitors. • These drugs include finasteride, dutasteride, dutasteride plus, tamsulosin. • They act by reducing the size of the prostate gland. • Finasteride blocks the enzyme 5α-reductase which is necessary for the conversion of testosterone to DHT, the principle intraprostatic androgen. • It results in regression of hyperplastic tissue through suppression of androgens
- 42. Contd… Α-Adrenergic receptor blockers. • These drug include silodosin, alfuzosin, doxazosin, prazosin, terazosin. • These agents selectively block α1- adrenergic receptors, which are abundant in prostate and are increased in hyperplastic prostate tissue.
- 43. Contd… • These drugs promote smooth muscle relaxation of prostate, facilitating urinary flow through the urethra. • These drugs offers only symptomatic relief of BPH, they do not treat hyperplasia.
- 44. Contd… Erectogenic Drugs. • Drugs like tadalafil has been used in men who have symptoms of BPH alone or in combination with erectile dysfunction. Herbal Therapy. • Herbal extracts like saxifrage, beta- sitosterol have been used in the management of lower urinary symptoms associated with BPH.
- 45. Contd… • Making dietary changes (decreasing intake of caffeine, artificial sweeteners, and spicy or acidic foods). • Avoiding medications such as decongestants and anticholinergics. • Restricting evening fluid intake may improve symptoms.
- 46. Contd… Surgical Management: - Minimally Invasive Therapy Invasive (Therapy) Minimally Invasive Therapy: - • These procedures generally do not require hospitalization or catheterization and are associated with few adverse effects.
- 47. Contd… i. Transurethral Microwave Thermotherapy (TUMT): - • It is a non- surgical, minimally invasive therapy that can be performed under a local anesthetic on an outpatient basis. • The treatment involves inserting a special microwave urinary catheter into the hyperplastic prostatic urethra.
- 48. Contd… • The microwave antenna within the catheter then emits microwaves to heat and destroy the surrounding prostatic tissue. • The procedure can take from 30 minutes to one hour and is well tolerated by patients. • Following the procedure, the prostate tissue will be swollen and irritated.
- 49. Contd… • Urologist often place a Foley’s catheter to prevent the patient from having urinary retention • After three to five days the Foley’s catheter can be replaced by a temporary prostatic stent to improve voiding without exacerbating irritation symptoms.
- 50. Contd…
- 51. Contd… Advantages: • Outpatient procedure • Erectile dysfunction, urinary incontinence and retrograde ejaculation are rare. Disadvantage: • Potential for damage to surrounding tissue. • Urinary catheter needed after procedure.
- 52. Contd… ii. Transurethral Needle Ablation (TUNA): - • It is a technique that uses low energy radio frequency delivered through two needles to ablate excess prostate tissue. • A cystoscope deploys the needles towards the obstructing prostate tissue is inserted into the urethra directly through the penis under local anesthetic before the procedure begins.
- 53. Contd… • The energy from the probe heats the abnormal prostate tissue without damaging the urethral • It can be done with a local anesthetic on an outpatient basis. • It takes about an hour to perform the procedure. • It takes about 30 days for the ablated prostate tissue to resorb.
- 54. Contd…
- 55. Contd… Advantages: • Outpatient procedure. • Erectile dysfunction, Urinary Incontinence are rare. • Precise delivery of heat to desired area. • Very little pain experienced. Disadvantages: • Urinary retention common. • Irritative voiding symptoms • Hematuria.
- 56. Contd… iii.Transurethral Electro vaporization of prostate (TUVP): • In this method electrosurgical vaporization and desiccation are used together to destroy prostatic tissue. Advantages: • Minimal risks • Minimal bleeding and sloughing. Disadvantages: • Retrograde ejaculation. • Intermittent Hematuria.
- 57. Contd…
- 58. Contd… iv. Intraprostatic Urethral Stents: - • The procedure is carried out by insertion of self- expandable metallic stent into the urethra when enlarged area of prostate occurs. Advantages: • Safe and effective. • Low risk Disadvantages: • Stent may move • Long term effect is unknown.
- 59. Contd… v. Laser Prostatectomy: This procedure uses a laser beam to cut or destroy part of prostate. All lasers use concentrated light to generate precise and intense heat. • Laser surgery removes excess prostate tissue by: Ablation: The laser melts away excess tissue. Enucleation: The laser cuts away excess prostate tissue.
- 60. Contd….. • There are different types of prostate laser surgery such as: • Photo selective vaporization of the prostate. (PVP): A laser is used to melt away excess prostate tissue to enlarge the urinary channel. • Holmium laser ablation of the prostate: This is similar to PVP except that a different type of laser is used to melt away the excess prostate tissue.
- 61. Contd….. • Interstitial Laser Coagulation: - The prostate is viewed through a cystoscope. A laser is used to quickly treat precise areas of the enlarged prostate by placement of interstitial light guides directly into the prostate tissue. • Visual Laser Ablation of Prostate: - It refers to any transurethral endoscopic operation wherein a free beam laser is used to produce deep coagulation of the prostatic transition zone to relieve bladder outlet obstruction due to BPH.
- 62. Contd…..
- 63. Contd….. Advantages: • Short procedure • Comparable result to TURP • Minimal bleeding • Fast recovery time. • Rapid symptom Improvement • Very effective.
- 64. Contd….. Disadvantages: • Catheter up to 7 days needed after procedure due to edema and urinary retention. • Delayed sloughing of tissue • Retrograde ejaculation. • Takes several weeks to reach optimal effects
- 65. INVASIVE THERAPY: - i. Transurethral Resection of Prostate (TURP): - • It is performed by visualizing the prostate through the urethra and removing tissue by electrocautery or sharp dissection. • It has been the standard treatment for BPH.
- 66. • It involves removal of prostatic tissue by optimal instrument introduced through urethra; used for glands of varying size. • Ideal for patients who are poor surgical risks. • Types: Monopolar TURP: A Monopolar device utilizing a wire loop with electric current flowing in one direction can
- 67. be used to excise tissue via the resectoscope. A grounding ESU pad and irrigation by a non-conducting fluid is required to prevent this current from disturbing surrounding tissues. This fluid (usually glycine) can cause damage to surrounding tissue after prolonged exposure, resulting in TUR syndrome, so surgery time is limited.
- 68. Bipolar TURP: This is a newer technique that uses bipolar current to remove the tissue. Bipolar TURP allows saline irrigation and eliminates the need for an ESU grounding pad thus preventing post-TURP hyponatremia and reducing other complications.
- 70. Advantages: • Avoids abdominal incision. • Safer for surgical- risk patient. • Shorter length of hospital stays and recovery periods. • Lower morbidity rate. • Causes less pain. • Can be used as palliative approach with history of radiation therapy.
- 71. Disadvantages: • Requires highly skilled surgeon. • Recurrent obstruction, urethral trauma and stricture may develop. • Delayed bleeding may occur. Nursing Implications: • Monitor for hemorrhage. • Observe for symptoms of urethral stricture (dysuria, straining, weak urinary stream).
- 72. ii. Open Surgical Removal: - Suprapubic approach • A suprapubic prostatectomy is an open surgical procedure. • Removal of prostatic tissue through abdominal incision; can be used for gland of any size.
- 73. Advantages: • Technically simple • Offers wide area of exploration. • Permits exploration for cancerous lymph nodes. • Allows more complete removal of obstructing gland. • Permits treatment of associated bladder lesions.
- 74. Disadvantages: • Requires surgical approach through the bladder. • Control of hemorrhage is difficult. • Urine may leak around the suprapubic tube. • Recovery may be prolonged and uncomfortable.
- 75. Nursing Implications: • Monitor for indications of hemorrhage and shock. • Provide meticulous aseptic care to the area around supra pubic tube. Perineal Approach • Removal of gland through an incision in the perineum; preferred approach for patients who are obese.
- 76. Advantages: • Offers direct anatomic approach. • Permits gravity drainage. • Low mortality rate. • Low incidence of shock. • Ideal for patients with large prostate who are very old, frail, and poor surgical risks. • Allows hemostasis under direct vision.
- 77. Disadvantages: • Higher postoperative incidence of impotence and urinary incontinence. • Restricted operative field. • Greater potential for contamination and infection of incision. • Possible damage of rectum and external sphincter.
- 78. Nursing Implications: • Avoid using rectal tubes or thermometers and enemas after perineal surgery. • Use drainage pads to absorb excess urinary drainage. • Provide foam rubber ring for patient comfort in sitting.
- 79. Nursing Implications: • Avoid using rectal tubes or thermometers and enemas after perineal surgery. • Use drainage pads to absorb excess urinary drainage. • Provide foam rubber ring for patient comfort in sitting.
- 80. Retro pubic Approach • It involves low bladder incision; bladder is not entered. Advantages: • Avoids incision into the bladder. • Permits surgeon to see and control bleeding. • Shorter recovery period. • Less bladder sphincter damage. • Suitable for removal of large glands.
- 81. Disadvantages: • Cannot treat associated bladder disease. • Increased incidence of hemorrhage from prostatic venous plexus; osteitis pubis. Nursing Implications: • Monitor hemorrhage • Anticipate post urinary leakage for several days after removing the catheter.
- 82. iii.Transurethral Incision: - • It is a urethral approach; 1-2 cuts are made in the prostate and prostate capsule to reduce pressure on the urethra and to reduce urethral constriction. • Once the anesthetic is working, physician will insert a resectoscope into the tip of your penis and extend it to the prostate area.
- 83. • The resectoscope has a lens or camera, a cutting device, and valves to release fluid to wash the surgery area. Using the resectoscope, physician makes one or two incisions on the inner surface of the prostate.
- 84. Advantages: • Results comparable to TURP. • Low incidence of erectile dysfunction and retrograde ejaculation. • No bladder neck contracture. Disadvantages: • Require highly skilled surgeon. • Recurrent obstruction and urethral trauma. • Delayed bleeding.
- 85. Nursing Implications: • Monitor hemorrhage iv. Laparoscopic Radical Prostatectomy: - • In this approach, 4- 6 small incisions are made in the abdomen; Laparoscopic instruments inserted through the incisions are used to dissect the prostate
- 86. Advantages. • Minimally invasive technique. • Short convalescence. • Reduce infection risk. • Less scarring. • Decreased blood loss to 400ml. • Short indwelling catheter duration. • Shorter length of hospital stay.
- 87. Disadvantages. • Technically demanding. • Long surgical time (4-5 hours) • Lack of tactile sensation available with open prostatectomy. Nursing Implications. • Observe for symptoms of urethral stricture, straining, weak urinary stream. • Monitor for hemorrhage and shock.
- 88. • Monitor for changes in bowel function. • Use drainage pads to absorb excess urinary drainage. • Anticipate urinary leakage around the wound for several days after the catheter is removed.
- 89. Nursing Management: - Nursing Diagnosis: Pre- operative Nursing Diagnosis • Anxiety about surgery and its outcome. • Acute pain related to bladder distention. • Deficient knowledge about factors related to the disorder and treatment protocol.
- 90. Post-operative Nursing Diagnosis • Risk for imbalanced fluid volume. • Acute pain related to the surgical incision, catheter placement, and bladder spasms. • Deficient Knowledge about postoperative care
- 91. Preoperative Nursing Interventions: - • Reducing Anxiety: • The nurses must establish communication with the patient to assess his understanding of the diagnosis and of the planned surgical procedure. • Patient is encouraged to verbalize his feelings and his current feelings. • The nurse familiarize the patient with the pre and postoperative routines and initiates measures to reduce anxiety.
- 92. • Relieving Discomfort: • Bed rest is prescribed • Analgesic agents are administered • Nurse should monitor his voiding patterns, watches for bladder distention, and assist with catheterisation if indicated.
- 93. • Providing Education: • Before surgery, the nurse reviews with the patient the anatomy of the affected structures and their function in relation to the urinary and reproductive systems, using diagrams and other educational aids if indicated.
- 94. • Preparing the Patient: • Anti- embolism stockings are applied before the surgery. • An enema is usually administered before the surgery. Postoperative nursing Interventions: - • Maintaining Fluid balance: • An intake and output recording, including the amount of fluid used for irrigation, must be maintained.
- 95. • The patient is monitored for electrolyte imbalance, increasing blood pressure, confusion and respiratory distress. • The urine output and the amount of fluid used for irrigation must be closely monitored to determine whether irrigation fluid is being retained and to ensure an adequate urine output.
- 96. • Relieving pain: • Administer medications like ibuprofen to patient • Complete bed rest on initial days. Other care includes: • Administer antibiotics before the invasive procedure. • After surgery, bladder irrigation is typically done to remove blood clot from bladder and ensure drainage of urine.
- 97. • Promote activities that increase abdominal pressure, such as sitting to have a bowel movement, should be avoided in the postoperative recovery period. • Observe the patient for signs of postoperative infection. • Dietary intervention and stool softeners are important in post op period to prevent the patient from straining while have bowel movements.
- 98. RESEARCH STUDIES
- 99. Research study: A STUDY TO ASSESS THE KNOWLEDGE AND QUALITY OF LIFE OF PATIENTS WITH BPH Abstract: Benign Prostatic Hyperplasia (BPH) refers to increased size of prostate gland. In India, the incidence of BPH 92.97%. BPH tends to change from benign to malignant. If the client is having BPH, he is at high risk for Prostate Cancer. A descriptive survey approach was used with the purpose of assessing the knowledge and quality of life among patients with BPH. The objectives of the study were to assess knowledge, quality of life and to find relationship between knowledge and quality of life. Total 71 subjects were studied and the results showed that most 44 (62%) of the subjects has average knowledge on BPH. About 44 (62%) of subjects had good quality of life and 27(38%) had poor quality of life.
- 100. Research study: Benign Prostatic Hyperplasia and the Risk of Prostate Cancer and Bladder Cancer A Meta-Analysis of Observational Studies Abstract: Benign prostatic hyperplasia (BPH) has been suggested to be a risk factor for certain urologic cancers, but the current evidence is inconsistent. The aim of this study was to investigate the association between BPH and urologic cancers. We included case-control studies or cohort studies, which evaluated the association between BPH and urologic cancers (including prostate cancer, bladder cancer, kidney cancer, testicular cancer, or penile cancer).
- 101. Overall effect estimates were calculated using the Der Simonian–Laird method for a random-effects model. Summary effect-size was calculated as risk ratio (RR), together with the 95% confidence interval (CI). This systematic review included 16 case-control studies and 10 cohort studies evaluating the association of BPH and prostate or bladder cancer; we did not identify any study about other urologic cancers. Meta-analyses demonstrated that BPH was associated with an increased incidence of prostate cancer (case-control study: RR = 3.93, 95% CI = 2.18–7.08; cohort-study: RR = 1.41, 95% CI = 1.00–1.99) and bladder cancer (case- control study: RR = 2.50, 95% CI = 1.63–3.84; cohort-study: RR = 1.58, 95% CI = 1.28–1.95). Subgroup analysis by ethnicity suggested that the association between BPH and prostate cancer was much stronger in Asians (RR = 6.09, 95% CI = 2.96–12.54) than in Caucasians (RR = 1.54, 95% CI = 1.19–2.01). Egger's tests indicated low risk of publication bias (prostate cancer: P = 0.11; bladder cancer: P = 0.95).
- 102. BPH is associated with an increased risk of prostate cancer and bladder cancer. The risk of prostate cancer is particularly high in Asian BPH patients. Given the limitations of included studies, additional prospective studies with strict design are needed to confirm our findings
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