A CASE SHARING OF BENIGN PROSTATIC HYPERPLASIA

Presented to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
Of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

Cader, Junaifah
Cailing, Trixie Ann
Campong, Shaima Janna
Carlom, Jerrah
Dacalos, Jewela Maureen
Dapanas, Danielle Love
Dato, Rovic
Dela Cruz, Shaneil,
Dimaampao, Hanifa
Dimaporo, Hanifa

October 20, 2021

 TABLE OF CONTENTS

I. TITLE PAGE …………………………………………………………………………... 1

II. TABLE OF CONTENTS ……………………………………………………………… 2

III. LIST OF TABLES ……………………………………………………………………. 3

IV. LIST OF FIGURES …………………………………………………………………… 4

V. OBJECTIVES …………………………………………………………………………. 5

VI. INTRODUCTION …………………………………………………………………… 6

VII. DEFINITION OF TERMS ………………………………………………………… 8

VIII. PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM ……………….... 11

IX. CONCEPT MAP …………………………………………………………………… 12

X. HEALTH TEACHINGS …………………………………………………………… 16

XI. PROGNOSIS ………………………………………………………………………… 19

XII. REFERENCE ………………………………………………………………………. 21

 LIST OF TABLES

I. PHYSICAL ASSESSMENT……………………………………………………………… 11
 LIST OF FIGURES

I. CONCEPT MAP ………………………………………………………………………….. 12

 Objectives

General Objectives

At the end of the case presentation, the student nurses will be able to comprehend overall

disease process of Benign Prostatic Hyperplasia (BPH) and its management.

Specific Objectives

At the end of the one and a half-hour of case presentation, the student nurses will be able to:

1. To understand the background of BPH;

2. Define the medical terms related to the case;

3. Trace the pathophysiology and etiology of Benign Prostatic Hyperplasia (BPH);

4. Acquire knowledge on the use of medications and its implication;

5. Identify the different clinical manifestations;

6. Learn and apply the appropriate nursing diagnosis, nursing intervention, and health

teachings; and

7. Recognize the prognosis of the disease.

 Introduction

Benign prostatic hyperplasia (BPH) is a noncancerous enlargement or hypertrophy of the

prostate, it is one of the most common diseases in aging men. It can cause bothersome lower

urinary tract symptoms that affect quality of life by interfering with normal daily activities and

sleep patterns (McDougal et al., 2016). BPH typically occurs in men older than 40 years. By the

time they reach 60 years, 50% of men have BPH. It affects as many as 90% of men by 85 years of

age. BPH is the second most common cause of surgical intervention in men older than 60 years.

The prostate is located directly beneath the bladder and in front of the rectum. The urethra

passes through the prostate, so if the prostate becomes enlarged, it can keep urine or semen from

passing through the urethra. (Cleveland Clinic, 2020.)

The main function of the prostate is to produce fluid for the semen, the milky fluid in which

sperm swims. Sperm is produced in the testicles, which also make the main male hormone

testosterone. During puberty, testosterone stimulates the growth and function of the prostate, and

helps with the production of fluid for semen. (Cleveland Clinic, 2020.)

Based on research to date, having BPH does not seem to increase the risk of developing

prostate cancer. However, BPH and prostate cancer have similar symptoms, and a man who has

BPH may have undetected cancer at the same time. (Cleveland Clinic, 2020.)

To help detect prostate cancer in its early stages, the American Urological Association and the

American Cancer Society recommend a prostate screening every year for men ages 55 to 69. They

also recommend that men who are at high risk – such as African-American men and men who have

a family history of prostate cancer – begin screening at age 40. Screening tests for prostate cancer
include a blood test for a substance called prostate-specific antigen (PSA) and the digital rectal

exam (DRE). (Cleveland Clinic, 2020.)

According to global healthcare company GlaxoSmithKline Philippines, 24 percent of Filipino

men aged 50-59 years old suffer from at least moderate symptoms of Benign Prostatic Hyperplasia

(BPH). (Manila Standard, 2018)

The most important risk factor of prostate cancer in Filipinos was increasing age. The

increasing number of males who were 55 years. of age and older was the main reason for the

significant increase expected. Unlike other cancers, the evidence of association between.

Unhealthy lifestyles was not yet clear. In contrast, studies showed in Asian Americans that alcohol

and possibly cigarettes are related to a lower risk for clinical BPH. (Firaza P et.al, 2017)

In parallel to BPH, also BPE, LUTS and abnormal urodynamic patterns increase with age. In

a prevalence study based on 2,096 men living in Austria, it was calculated that currently

approximately 350,000 men older than 40 years living in Austria (total population 8.7 million)

have moderate to severe LUTS. Due to demographic changes, this figure will rise substantially to

approximately 500,000 in the next 2 decades, emphasizing also its socioeconomic relevance.

(Madersbacher S.et. Al., 2019).

Despite its high prevalence and socioeconomic impact, the pathophysiology of BPH is only

incompletely understood. It is, for example, still largely unknown why some men develop a 40-g

prostate and others a 200-g prostate. The pathomechanisms leading to LUTS are much more

complex than just BPH/BPE and involve several urodynamic patterns (e.g., detrusor over

activity/underactivity), changes within the urothelium and bladder ultrastructure, receptor status

of the anticholinergic system, pelvic ischemia and many more. (Madersbacher S. et. Al.,2019).
 The most common presenting complication of BPH that requires hospitalization is acute

urinary retention, which greatly affects patients’ quality of life and is an important health issue.

Many of the other complications of BPH/BOO are in part due to complications of chronic urinary

retention; these include recurrent urinary tract infections (UTIs), formation of bladder calculi,

hematuria, and damage to bladder wall and kidneys. (Speakman et al., 2014.)
 DEFINITION OF TERMS

Alpha Blocker. A substance that relaxes muscle tissue in blood vessels and in the prostate
gland, which improves the flow of urine and blood.

5 Alpha Reductase Inhibitor. A substance that blocks an enzyme needed by the body to make
dihydrotestosterone (a male sex hormone made from testosterone).

Benign Prostatic Hyperplasia. A noncancerous enlargement or hypertrophy of the prostate, it is

one of the most common diseases in aging men.

Cystoscopy. It is a procedure that lets the healthcare provider view the urinary tract, particularly
the bladder, the urethra, and the openings to the ureters.

Cystourethroscopy. It is a procedure that allows your provider to visually examine the inside of
your bladder and urethra.

Dihydrotestosterone. A hormone with powerful androgenic actions, causes the body to mature
during puberty and is responsible for many of the physical characteristics associated with adult
males.

Digital Rectal Examination (DRE). A test that examines a person's lower rectum, pelvis, and
lower belly.

Lower Urinary Tract Symptoms (LUTS). A group of clinical symptoms involving the bladder,
urinary sphincter, urethra and, in men, the prostate.

Prostate Abscess. A collections of pus that develop as the result of acute bacterial prostatitis.

Prostate cancer. A form of cancer that begins in the gland cells of the prostate, which is found
only in males.

Transrectal Ultrasonography (TRUS). An ultrasound probe is inserted into the rectum to

check the prostate.

Transurethral Incision of the Prostate (TUIP). An instrument is inserted through the urethra
and one or two small cuts are made in the bladder neck and prostate. This relieves pressure and
improves urine flow.
Transurethral Needle Ablation of the Prostate (TUNA). a technique that uses low energy
radio frequency delivered through two needles to ablate excess prostate tissue.

Transurethral Resection of the Prostate (TURP). Surgery to remove parts of the prostate
gland through the penis with no incisions are needed.

Urinary Tract Infection (UTI). It is an infection of the urinary system

Urinary Incontinence. It is the unintentional passing of urine.

Urinary Retention. It is a condition where your bladder doesn't empty all the way or at all when
you urinate

Urethral Stent. are small tubes inserted into the ureter to treat or prevent a blockage that
prevents the flow of urine from the kidney to the bladder.
 PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM
Areas examined Subjective Objective Problems identified
Genito urinary • Fear of • Nocturia, • Anxiety/fear
system embarrassment/loss incontinence • Urinary
of dignity with • Facial retention
genital exposure grimaces • Acute pain r/t
before, during, and upon bladder
after. urination distension as
• Diminished evidence by
urine volume urinary
incontinence
• Risk for
infection within
urinary tract
• Urge urinary
incontinence r/t
of obstruction of
the urethra

Reproductive • Uncomfortable • Bladder • Impaired

system urinary symptoms urinary tract urinary
• Bladder, urinary or kidney elimination r/t
tract or kidney problems obstruction in
problems • DRE result the bladder or
(Enlargement urethra
of prostate)
• Ultrasound
• Cystoscopy

Hematologic • A normal
System PSA level is
considered to
be 4.0
nanograms
per milliliter
(ng/mL) of
blood.
 Benign Prostatic
Hyperplasia (BPH)

NON-MODIFIABLE RISK FACTORS: MODIFIABLE RISK FACTORS:

• Age: (Middle age & Elderly) • -Smoking

• Gender: (Male) • -Excessive Alcohol Consumption
• Race: (African-American Men) • -Obesity
• Genetics • -Reduced Activity Level
• -Hypertension
• -Heart Disease
• -Diabetes
• -Western Diet (high in animal fat, a protein
and refined carbohydrates, low in fiber)

Cellular Proliferation reveals a large, rubbery,

(Stromal, Epithelial) and nontender prostate
gland.
-Transrectal Prostatic Digital Rectal Exam
Ultrasound (DRE)
-Digital Rectal Exam
Laparoscopic Radical Enlargement of Prostate (DRE)
Prostatectomy -Cystourethroscopy/
Narrowing of
cystoscopy
Prostatic specific antigen the urethra
Alpha-adrenergic blockers
(eg, Xantral and alfusozin) Prostatic Hyperplasia

Saw Palmetto

Fear related to
(DYNAMIC)
(STATIC) embarrassment/loss of
Additional tension/pressure
Prostate encroaching dignity associated with
of P smooth muscle to genital exposure before,
upon prostatic urethra
bladder neck during and after treatment
 Transurethral resection of Narrow Lumen Pressure in bladder
the prostate (TURP) Constricted Urethra neck and to rectum

Urinalysis
Blood test
Bladder Outlet Obstruction PSA
WBC
(11,000/mm3)
Urine culture
Staphylococcus
aureus Proteus
Klebsiella
Pseudomonas
Escherichia coli

Chronic condition

Bladder wall thickening due to muscle Transurethral resection of

Suprapubic Prostatectomy, detrusor the prostate (TURP)
Perineal Prostatectomy, and (Hypertrophy)
Retropubic Prostatectomy

Injury to tissue

High pressure in the bladder

Decrease Output urine

Incomplete emptying the bladder Diminished urine Urinary frequency - Lower abdominal pain
Increase residual urine volume Inability to fully empty - Pain during urination
Rapid filling of urine Fatigue the bladder - Frequent urination
Difficulty starting to urinate Nausea Recurrent UTI's -Difficulty urinating or
Nocturia Swelling due to fluid Abdominal straining interrupted urine flow
Straining to urinate retention with urination - Blood in the urine
Needing to urinate urgently and/or
frequently
Weak dribble or stream of urine.
Urinary incontinence
 5-alpha- Catheterization Alpha-
Urinary
reductase adrenergic
retention
inhibitors (eg, blockers (eg, Catheterization Cystostomy
finasteride and alfuzosin and
dutasteride) terazosin)

Alpha- Kidney Damage Alpha- Bladder Stone

Urinary retention r/t adrenergic Urinary Tract adrenergic
obstruction in the blockers (eg, Infection blockers (eg,
bladder. alfuzosin and alfuzosin and
terazosin) terazosin)

Urge urinary Acute pain r/t bladder

-Encouraged regular intake
of cranberry juice.
-Encouraged fluid intake.
-Place the patient in an
upright position to
facilitate successful
voiding.
-Encourage the patient to
void at least every 4 hours.
-Allow the patient to listen
to the sound of running
water, or dip hands in
warm water/pour lukewarm
water over perineum.
incontinence r/t
obstruction of the
-Promote access to toilet
facilities, and instruct patient
to make scheduled trips to the
bathroom.
-Educate the patient about the
effects of extreme alcohol and
caffeine intake.
-Aid the patient with
developing a bladder training
program that includes voiding
at scheduled intervals,
gradually increasing the time
between voiding.
distension as
Risk for infection
evidence by urinary
within urinary
urethra incontinence
tract
Independent:
-Apply a heating pad to the -Encouraged fluid intake.
suprapubic area or lower -Placed the patient in an upright position to
back. facilitate successful voiding.
-Encouraged the patient to -Allow the patient to listen to the sound of
increased oral fluid intake running water, or dip hands in warm water/pour
-Encouraged the client to lukewarm water over perineum.
void frequently. Dependent:
-Administer antibacterial -Keep indwelling catheter patent; maintain
agents as indicated drainage tubing kink-free.
-Open up about your awareness of the patient’s fear.
-Discuss the situation with the patient and help
differentiate between real and imagined threats to well-
being.
-Tell patient that fear is a normal and appropriate response
to circumstances in which pain, danger, or loss of control is
anticipated or felt.
-Be with the patient to promote safety especially during
frightening procedures or treatment.
-Maintain a relaxed and accepting demeanor while
communicating with the patient.
 LEGEND:

RISK FACTORS MEDICAL MANAGEMENT NURSING DIAGNOSIS

PATHOPHYSIOLOGY PHARMACOLOGICAL
MANAGEMENT NURSING INTERVENTIONS

CLINICAL MANIFESTATION SURGICAL MANAGEMENT

ASSESSMENT AND
DIAGNOSTIC FINDINGS COMPLICATION
 HEALTH TEACHING

Before:
Educate the patient with the help of diagrams, you should highlight which structures are being
affected, and what their job is in the urinary and reproductive system.
Give the patient an overview of how the surgery works, and what he can expect after it is done.
Mainly that he will have a urinary catheter inserted, and possibly also an irrigation system.
Reassure the patient that the post-operative pain will be addressed through analgesia and
supportive measures.
Encourage the patient to verbalise any concerns that he might have and answer accordingly.
Reassure the patient that once he is fully recovered, he will be able to function normally and go
on with his daily life.
The patient may be hospitalised before the surgery, so you should take note of his voiding
patterns, bladder distention, urinary retention.
Pay close attention to your patient’s blood pressure and kidney function as they might fluctuate
after inserting the catheter.

During:
Make sure that the patient is ready for surgery from the medical perspective. Your patient should
be starved for at least 6 hours before the surgery, and make sure that he is kept hydrated through
adequate IVI infusions.

Make sure that the patient has the following:

- Identification Bracelet
- Allergy Bracelet (if applicable)
- Changed into a hospital gown and removed his underwear
- Removed all jewellery/ foreign teeth/ hearing aid/ contact-lenses/ glasses/ make-up
Before going down to the Operating room, the patient’s file should have:
- All medical notes and treatment charts
- A signed consent form
- Pre-operative medical assessment
- An ECG done in the last 2weeks
- Blood results, and Blood type from the past 3 days (often found online)
After:
When the patient complains of pain, ask him to identify which part of his body is painful. Pain in
the flank area can be from kidney problems or radiating from bladder spasms, while pain in the
penis is likely from the catheter.
Pay close attention to the drainage tubing and irrigate the system as prescribed to relieve any
obstruction.
Advise the patient not to sit for long periods as this increases the intra-abdominal pressure, and
can worsen the pain.
Make sure to chart the patient’s intake and output frequently, and record any discrepancies. You
should also look out for high blood pressure, confusion, respiratory distress, or electrolyte
imbalance as they are all symptoms of fluid imbalance.
 GENERAL HEALTH TEACHINGS

Lifestyle factors
Limit fluids in the evening, empty your bladder before going to bed, and don’t take water
pills (diuretics) that are active at night. Not smoking can also help ease BPH symptoms.

Dietary factors
Stay away from or reduce the amount of alcohol, coffee, and other fluids. This is
especially important after dinner. A higher risk for BPH has been linked to a diet high in zinc,
butter, and margarine. Men who eat lots of fruits are thought to have a lower risk for BPH.

Don't use medicines that worsen symptoms

Decongestants and antihistamines can slow urine flow in some men with BPH. Some
antidepressants and diuretics can also make symptoms worse. Talk with your healthcare provider
if you are taking any of these medicines.

Kegel exercises
Repeated tightening and releasing the pelvic muscles are called Kegel exercises. These
can help prevent leaking urine. Practice these exercises while urinating to train the specific
muscle. To do Kegels, contract the muscle until the flow of urine decreases or stops. Then
release the muscle.
 PROGNOSIS

Deterioration in LUTS (lower urinary tract symptoms)/increasingly problematic voiding

symptoms is the most common indicator of disease progression. In addition to this, patients may
present with complications, including acute retention, infections, or haematuria.

Observational studies have demonstrated that when left without treatment, clinical
progression of BPH increased over a 48-month period, with 31% of the cohort requiring
presentation at 48 months and 5% developing acute retention in the 48-month period.

The risk of acute urinary retention also increased with age, in the Olmsted County study,
the incidence of retention in men increased over ten-fold, from 3/1000 (40-49yrs) to 34.7/1000
(70-79yrs). Left untreated, BPH, therefore, has a significant risk of progression and presentation.
Indeed, up to 42% of men who presented with retention in 1 study, went on to have surgery. Men
with significantly enlarged prostates (>30ml) have also been shown to be at an increased risk of
disease progression.
 REFERENCES

Hinkle J. & Cheever K, Brunner & Suddarth's Medical Surgical Nursing Volume II, 2018

p. 1762

Cleveland Clinic (2020, 10 March). Benign Prostatic Enlargement/Hyperplasia (BPE/BPH)

https://my.clevelandclinic.org/health/diseases/9100-benign-prostatic-enlargement-bph

Manila Standard Lifestyle and Gabbie Parlade (2018, 02 July). In the name of prostate health:
GSK pioneers World BPH Day

https://www.manilastandard.net/mobile/article/269479

Karger (2019, August). Pathophysiology of Benign Prostatic Hyperplasia and Benign Prostatic
Enlargement: A Mini-Review

https://www.karger.com/Article/Fulltext/496289

Deters LA. Benign prostatic hypertrophy. Emedicine website. http://emedicine.medscape.com

External link. Updated March 28, 2014. Accessed July 29, 2014

Mayo Clinic (2020, 07 Nov). Benign Prostatic Hyperplasia (BPH)

https://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/symptoms-
causes/syc-20370087

NCBI (2021, 11 Aug). Benign Prostatic Hyperplasia

https://www.ncbi.nlm.nih.gov/books/NBK558920/

Medscape (2021, 19 Feb). What is the patient education for benign prostatic hyperplasia (BPH)?

https://www.medscape.com/answers/437359-90391/what-is-the-patient-education-for-
benign-prostatic-hyperplasia-
bph?fbclid=IwAR3fqfnz1tZiW5QoKIjFsC8EFtzyXV5GHZ1XkC46wpBn0C-
nYKjquoAOIUg

University of Rochester Medical Center (2020). Benign Prostatic Hyperplasia (BPH)

https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=85&Content
ID=P01470