Benign prostatic hyperplasia
Benign prostatic hyperplasia: Excerpt from Professional Guide to Diseases (Eighth Edition)
Although most males older than age 50 have some prostatic enlargement, in benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, the prostate gland enlarges sufficiently to compress the urethra and cause some overt urinary obstruction. Depending on the size of the enlarged prostate, the age and health of the patient, and the extent of obstruction, BPH is treated symptomatically or surgically.
Causes and incidence
Evidence suggests a link between BPH and hormonal activity. As males age, production of androgenic hormones decreases, causing an imbalance in androgen and estrogen levels, and high levels of dihydrotestosterone, the main prostatic intracellular androgen. Other causes include neoplasm, arteriosclerosis, diabetes, inflammation, and metabolic or nutritional disturbances.
Whatever the cause, BPH begins with changes in periurethral glandular tissue. As the prostate enlarges, it may extend into the bladder and obstruct urinary outflow by compressing or distorting the prostatic urethra. BPH may also cause a pouch to form in the bladder that retains urine when the rest of the bladder empties. This retained urine may lead to calculus formation or cystitis.
The likelihood of developing an enlarged prostate increases with age. A small amount of prostate enlargement is present in many males older than age 40 and more than 90% of males older than age 80. It’s estimated that by 2006, 115 million men age 50 and older will develop BPH. Blacks, with an incidence rate of 224.3 cases per 100,000 people, are at the greatest risk, present with more advanced disease, and have a poorer diagnosis. Whites, by comparison, have an incidence of 150.3 cases per 100,000 people while Asians have an incidence of 82.2 cases per 100,000 people.
Signs and symptoms
Clinical features of BPH depend on the extent of prostatic enlargement and the lobes affected. Characteristically, the condition starts with a group of symptoms known as prostatism: reduced urinary stream caliber and force, urinary hesitancy, and difficulty starting micturition (resulting in straining, feeling of incomplete voiding, and an interrupted stream). As the obstruction increases, it causes frequent urination with nocturia, dribbling, urine retention, incontinence, and possibly hematuria. Physical examination indicates a visible midline mass above the symphysis pubis that represents an incompletely emptied bladder; rectal palpation discloses an enlarged prostate. Examination may detect secondary anemia and, possibly, renal insufficiency secondary to obstruction.
As BPH worsens, complete urinary obstruction may follow infection or use of decongestants, tranquilizers, alcohol, antidepressants, or anticholinergics. Complications include infection, renal insufficiency, hemorrhage, and shock.
Diagnosis
Clinical features and a rectal examination are usually sufficient for diagnosis. Other findings help to confirm it:
❑ Excretory urography may indicate urinary tract obstruction, hydronephrosis, calculi or tumors, and filling and emptying defects in the bladder.
❑ Elevated blood urea nitrogen and serum creatinine levels suggest renal dysfunction.
❑ Urinalysis and urine culture show hematuria, pyuria and, when the bacterial count exceeds 100,000/µl, urinary tract infection (UTI).
When symptoms are severe, a cystourethroscopy is definitive, but this test is performed only immediately before surgery to help determine the best procedure. It can show prostate enlargement, bladder wall changes, and a raised bladder.
Treatment
Conservative therapy includes prostate massages, sitz baths, fluid restriction for bladder distention, and antimicrobials for infection. If symptoms are mild, methods for relief may include avoiding alcohol and caffeine, especially after dinner; urinating when the urge is initially felt; avoiding over-the-counter cold and sinus medications that contain decongestants or antihistamines because they can increase BPH symptoms; keeping warm and exercising regularly as cold weather and lack of physical activity may worsen symptoms; performing pelvic strengthening exercises (Kegel exercises); reducing stress because nervousness and tension can lead to more frequent urination. Some males have had success taking extracts of saw palmetto berries, an herb that has been used to ease prostate symptoms. Fat-soluble saw palmetto extract that has been standardized to contain 85% to 95% fatty acids and sterols is more effective. Regular ejaculation may help relieve prostatic congestion.
Urine flow rates can be improved with alpha1-adrenergic blockers, which relieve bladder outlet obstruction by preventing contractions of the prostatic capsule and bladder neck. Finasteride lowers levels of hormones produced by the prostate, reduces the size of the prostate gland, increases urine flow rate, and decreases symptoms of BPH. It may take 3 to 6 months before a significant improvement in symptoms occurs. Potential adverse effects related to finasteride include decreased sex drive and impotence.
Surgery is the only effective therapy to relieve acute urine retention, hydronephrosis, severe hematuria, recurrent UTIs, and other intolerable symptoms. A transurethral resection may be performed if the prostate weighs less than 2 oz (56.7 g). In this procedure, a resectoscope removes tissue with a wire loop and electric current. In high-risk patients, continuous drainage with an indwelling urinary catheter alleviates urine retention. Transurethral needle ablation may be used to heat and destroy prostate tissue by radiofrequency; this helps spare surrounding tissue.
The following procedures involve open surgical removal:
❑ suprapubic (transvesical) resection: most common and useful when prostatic enlargement remains within the bladder
❑ retropubic (extravesical) resection: allows direct visualization; potency and continence are usually maintained.
Balloon dilatation of the prostate is still being investigated. Balloon dilatation or balloon urethroplasty involves passing a flexible balloon catheter through the urethra at the level of the prostate while being guided by fluoroscope. The balloon is inflated for a short time to distend the prostatic urethra.
Special considerations
Prepare the patient for diagnostic tests and surgery, as appropriate.
❑ Monitor and record the patient’s vital signs, intake and output, and daily weight. Watch closely for signs of postobstructive diuresis (such as increased urine output and hypotension), which may lead to serious dehydration, lowered blood volume, shock, electrolyte loss, and anuria.
❑ Administer antibiotics, as ordered, for UTI, urethral instrumentation, and cystoscopy.
❑ If urine retention is present, insert an indwelling urinary catheter (although this is usually difficult in a patient with BPH). If the catheter can’t be passed transurethrally, assist with suprapubic cystostomy (under local anesthetic). Watch for rapid bladder decompression.
After prostatic surgery:
❑ Maintain patient comfort, and watch for and prevent postoperative complications. Observe for immediate dangers of prostatic bleeding (shock and hemorrhage). Check the catheter often (every 15 minutes for the first 2 to 3 hours) for patency and urine color; check dressings for bleeding.
❑ Postoperatively, many urologists insert a three-way catheter and establish continuous bladder irrigation. Keep the catheter open at a rate sufficient to maintain returns that are clear and light pink. Watch for fluid overload from absorption of the irrigating fluid into systemic circulation. If a regular catheter is used, observe it closely. If drainage stops because of clots, irrigate the catheter, as ordered, usually with 80 to 100 ml of normal saline solution, while maintaining strict sterile technique.
Alert Watch for septic shock, the most serious complication of prostatic surgery. Immediately report severe chills, sudden fever, tachycardia, hypotension, or other signs of shock. Start rapid infusion of antibiotics I.V. as ordered. Watch for pulmonary embolus, heart failure, and renal shutdown. Monitor vital signs, central venous pressure, and arterial pressure continuously. The patient may need intensive supportive care in the intensive care unit.
❑ Administer anticholinergics, as ordered, to relieve painful bladder spasms that often occur after transurethral resection.
❑ Take patient comfort measures after an open procedure: provide suppositories (except after perineal prostatectomy), analgesic medication to control incisional pain, and frequent dressing changes.
❑ Continue infusing I.V. fluids until the patient can drink sufficient fluids (2 to 3 L/day) to maintain adequate hydration.
❑ Administer stool softeners and laxatives, as ordered, to prevent straining. Don’t check for fecal impaction because a rectal examination may precipitate bleeding.
❑ After the catheter is removed, the patient may experience frequency, dribbling, and occasional hematuria. Reassure him that he’ll gradually regain urinary control.
❑ Reinforce prescribed limits on activity. Warn the patient against lifting, strenuous exercise, and long automobile rides because these increase bleeding tendency. Also caution the patient to restrict sexual activity for at least several weeks after discharge from the hospital.
❑ Instruct the patient to follow the prescribed oral antibiotic drug regimen, and tell him the indications for using gentle laxatives. Urge him to seek medical care immediately if he can’t void, if he passes bloody urine, or if he develops a fever.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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