DISCUSSION REPORT:

NURSING CARE FOR ADULT CLIENTS WITH BPH

Arranged to fulfill the task of Medical Surgical Nursing II course

Arranged by

Name : Fuzna Dahlia Mudzakiroh

NIM : I1J020010

Facilitator : Ns. Yunita Sari, P.hD.

NURSING UNDERGRADUATE STUDY PROGRAM

FACULTY OF HEALTH SCIENCES

JENDERAL SOEDIRMAN UNIVERSITY

JUNE 2022
 CHAPTER 1: INTRODUCTION

A. Background

The prostate gland position just below the bladder neck, consists of four zones and four
lobes. It surrounds the urethra and is crossed by a conduit that is a continuation of the vas
deferens. This gland produces chemically and physiologically appropriate secretions suitable to
the need for sperm in transit from the testicles. The Cowper's gland is below the prostate behind
the bulbourethral gland. This gland drains secretions to the urethra during ejaculation and
provides lubrication.

As a man ages, the prostate gland may enlarge and prostate secretion decreases, the
scrotum hangs lower, the testes decrease in weight, atrophy and become softer, and pubic hair
becomes sparser and stiffer. This aging factor increases the risk of a man experiencing a disease,
one of which is Benign Prostatic Hyperplasia (BPH). BPH is a noncancerous enlargement or
hypertrophy of the prostate, and 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. in Wilkins, 2017).

BPH develops over a period of time. Changes in the urinary tract are slow and insidious.
BPH is the result of complex interactions including resistance of the prostatic urethra to
mechanical and spasmodic effects, bladder pressure during urination, detrusor strength, neural
function, and overall physical health. The enlarged prostate lobe can occlude the bladder neck or
urethra, incompletely empty the bladder, and cause urinary retention. As a result, the ureters
(hydronephrosis) and kidneys (hydronephrosis) can gradually expand. Urinary retention can lead
to urinary tract infections because the urine remaining in the urinary tract acts as a vehicle for
infectious microorganisms.

B. Purpose
General Purpose : Understanding the nursing management of patients with Benign
Prostate Hyperplasia
Specific Purpose :
1. Can link causes, pathophysiology, signs and symptoms of BPH
2. Can identify the results of the assessment of cases of clients with BPH
3. Can determine nursing diagnosis in cases of adult clients with BPH
4. Can determine appropriate nursing outcomes in cases of patients with BPH
5. Can determine the appropriate nursing intervention in the case of clients with BPH
 CHAPTER 2: CASE DISCUSSION

A. Case Overview

A man, 68 years old was admitted to the surgical ward. He complained pain during
urinate since one week ago, incomplete urinate, drips and took a long time to urinate. Results of
USG showed prostate enlargement. Patient was diagnosed with BPH. Patient had anxiety before
surgery. TURP was conducted 6 hours ago. Urine catheter was inserted. The patient had
irrigation with NaCl 1000 cc, 60 drops/minute. Nurse measured the fluid balance and observed
the color of the discharge. Patient did not pray because he confused if it was appropriate to pray
when having catheterization.

B. Discussion

Integration of Relevant Theory

a. Difficult terms
- TURP : Transurethral resection of the prostate (TURP), is a surgical procedure
that involves cutting away a section of the prostate. TURP has long been considered
the gold standard for surgical treatment of obstructing BPH. Most patients have
marked improvements in symptoms and urinary flow rates. While in the past many
TURP procedures required a longer hospital stay, many TURP procedures now are
done on an outpatient basis.
- BPH : Benign Prostatic Hyperplasia refers to the nonmalignant growth or
hyperplasia of prostate tissue and is a common cause of lower urinary tract symptoms
in men. Disease prevalence has been shown to increase with advancing age.

b. Case questions
- What is BPH and what are the cause?
Benign prostatic hyperplasia (BPH) refers to non-cancerous growth or hypertrophy of the
prostate, considered as one of the most common diseases in aging men. 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 exact cause is
unknown, but it may be due to age-related changes in androgens. Family history of
prostate problems and testicular abnormalities can increase the risk of BPH. Men who
have their testicles removed at a young age do not develop BPH.

- What is the pathophysiology of BPH?

BPH is characterized by the proliferation of benign interstitial and glandular elements.
Dihydrotestosterone (DHT), an androgen derived from testosterone, is the main hormonal
stimulus for proliferation. DHT is synthesized in the prostate from circulating
testosterone by the action of enzymes. DHT binds to nuclear androgen receptors that
regulate the expression of genes that support the growth and survival of prostate
epithelium and stromal cells. Testosterone can also bind to androgen receptors and
stimulate growth, but DHT is 10 times more potent. BPH most commonly affects the
periurethral zone of the prostate and produces nodules that compress the prostatic urethra.
On microscopic examination, nodules show different proportions of stroma and glands.
Hyperplastic glands are lined by two layers of cells. The outer layer, which consists of an
inner columnar layer and flat basal cells.

- Why is the patient diagnosed with BPH?

In this case, there are the following data which strengthens that the patient is a patient
with BPH:
a) Patient had complaints of pain when urinating since one week ago, incomplete
urination, dripping and long urination.
b) Results of USG showed prostate enlargement. From the ultrasound results, the
diagnosis of BPH was obtained, BPH itself is a condition in which the prostate
gland is enlarged.

- How can the patient experience incomplete urination?

If the prostate is enlarged, it will expand to the top of the bladder so that on the inside it
will narrow the prostatic urethra and block the flow of urine. This condition can increase
intravesical pressure. To compensate for the resistance of the prostatic urethra, the
detrusor and bladder muscles contract more forcefully to pump urine out. detrusor muscle
fails to contract strongly or for long enough to fail to maintain intravesical pressure until
voiding ends and flow becomes intermittent.

- What is the risk factor of BPH?

Risk factors for BPH include:
a) Aging. Prostate gland enlargement rarely causes signs and symptoms in men
younger than age 40. About one-third of men experience moderate to severe
symptoms by age 60, and about half do so by age 80.
b) Family history. Having a blood relative, such as a father or a brother, with prostate
problems means you're more likely to have problems.
c) Diabetes and heart disease. Studies show that diabetes, as well as heart disease
and use of beta-blockers, might increase the risk of BPH.
d) Lifestyle. Obesity increases the risk of BPH, while exercise can lower your risk.

- What are the clinical manifestations of BPH?

BPH may or may not lead to lower urinary tract symptoms; if symptoms occur, they may
range from mild to severe. Severity of symptoms increases with age, and half of men
with BPH report having moderate to severe symptoms. Obstructive and irritative
symptoms may include urinary frequency, urgency, nocturia, hesitancy in starting
urination, decreased and intermittent force of stream and the sensation of incomplete
bladder emptying, abdominal straining with urination, a decrease in the volume and force
of the urinary stream, dribbling (urine dribbles out after urination), and complications of
acute urinary retention and recurrent UTIs. Normally, residual urine amounts to no more
than 50 mL in the middle-aged adult and less than 50 to 100 mL in the older adult (Weber
& Kelley, 2014). Ultimately, 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. Other disorders that produce similar symptoms include urethral
stricture, prostate cancer, neurogenic bladder, and urinary bladder stones.

- Is it appropriate to pray while undergoing catheterization?

This requires the cooperation of health workers to support the spiritual activities of the
client. When the patient is about to carry out his obligations, the catheter bag is emptied
first. Nurses can provide education about tayammum and pray by sitting and how to
pluralize the prayer if the client does not understand.
 - How is the management of BPH?
a) Surgery. Recommended procedures include transurethral incision of the prostate,
transurethral resection of the prostate, in addition to newer techniques such as laser
vaporization and holmium laser enucleation, which have largely replaced open
prostatectomy.
b) TURP/TUIP. Transurethral resection surgery focuses on debulking the prostate to
produce an adequate channel for urine to flow. This is achieved through diathermy to
produce a high-frequency current that allows the cutting of tissue. By resecting all
obstructing prostatic tissue, an adequate channel can be created to allow urine to flow.
c) Catheterization. Catheterization uses a tube called a catheter in the bladder to drain
urine. Catheters can be placed through the urethra or via a small puncture in the
bladder above the pubic bone.
Nursing Management
a. Nursing Assessment
Subjective and objective data that obtained from Mr. A is:
Subjective Data Objective data

- He complained pain during urinate - Results of USG showed prostate

since one week ago enlargement
- Incomplete urinate - Patient diagnosed with BPH
- Drips and took a long time to - TURP was conducted
urinate - Urine catheter was inserted
- Patient had anxiety before surgery - The patient had irrigation with
NaCl 1000 cc, 60 drops/minute

b. Nursing Diagnosis
Nursing diagnosis that can be appeared base on Mr. A cases may include:
Pre-operation
1) Anxiety related to situational crisis, lack of exposure to information
2) Urinary retention related to increased urethral pressure
Post-operation
1) Acute pain
2) Risk of bleeding related to surgery
3) Risk of infection related to invasive procedure effect
c. Planning
The overall preoperative goals for the patient having invasive procedures are to have (1)
restoration of urinary drainage; (2) resolution of any UTI; and (3) understanding of the
upcoming procedure, implications for sexual function, and urinary control.
The overall postoperative goals are to have (1) no complications, (2) restoration of
urinary control, (3) complete bladder emptying, and (4) satisfying sexual expression.
d. Nursing Implementation
 Preoperative Care
1) Antibiotics are usually given before any invasive genitourinary (GU) procedure.
2) Any infection of the urinary tract must be treated before surgery.
3) Restoring urinary drainage and encouraging a high fluid intake (2 to 3 L/day
unless contraindicated) are helpful in managing the infection.
4) A urethral catheter, such as a coudé (curved-tip) catheter, may be needed to
restore bladder drainage.
5) Provide an opportunity for the patient and his partner to express their concerns.
Tell the patient that his ejaculate volume may be decreased or absent after the
procedure.

Postoperative Care
1) After surgery, the patient will have a standard catheter or a triple lumen catheter.
2) Bladder irrigation is typically done to remove clotted blood from the bladder and
ensure drainage of urine. The bladder is irrigated either manually on an
intermittent basis or more often, as continuous bladder irrigation (CBI) with
sterile normal saline solution or another prescribed solution.
3) Activities that increase abdominal pressure should be avoided in the recovery
period. These include sitting or walking for prolonged periods and straining to
have a bowel movement (Valsalva maneuver).
4) Teach the patient how to use a penile clamp, a condom catheter, or incontinence
pads or briefs to avoid embarrassment from dribbling. In severe cases, an
occlusive cuff that serves as an artificial sphincter can be surgically implanted to
restore continence.
5) Observe the patient for signs of infection. If an external wound is present (e.g.,
from an open, laparoscopic, or robotic-assisted prostatectomy), assess the area for
redness, heat, swelling, and purulent drainage.
6) Dietary intervention and stool softeners are important to prevent the patient from
straining while having bowel movements. Straining increases the intra abdominal
pressure, which can lead to bleeding at the operative site. A diet high in fiber
promotes the passage of stool.
e. Evaluation
The expected outcomes are that the patient with BPH who has surgery will
● Report acceptable pain control
● Report improved urinary function with no pain or incontinence
 CHAPTER III: CONCLUSION AND SUGGESTIONS

A. Conclusions
BPH is a non-cancerous growth or hypertrophy of prostate disease that is common in
older men. Not yet found the exact cause of the emergence of this disease, but some sources say
that changes in androgens trigger the emergence of this disease. In addition, family history of
prostate problems and testicular abnormalities can put a person at a higher risk of BPH.
Symptoms of this disease can be mild or even severe. Generalized symptoms may also
be noted, including fatigue, anorexia, nausea, vomiting, and pelvic discomfort. Other disorders
that produce similar symptoms include urethral stricture, prostate cancer, neurogenic bladder,
and urinary bladder stones. Whereas obstructive and irritative symptoms may include urinary
frequency, urgency, nocturia, hesitancy in starting urination, etc.
Nursing management in BPH patients needs to be considered properly and correctly so
that what is given is in line with what is needed. A nurse must consider both preoperative and
postoperative nursing care plans, not just one.

B. Suggestions
In the case of Mr. A as a client with BPH, nurses should not only provide clinical or
medical support but also in other matters. For example, facilitating clients in spiritual matters. In
that case, Mr. A still hesitated to pray because of the catheter that was attached to his body.
Therefore, the education that nurses provide is not only limited to how to keep the catheter clean
but also how when the client wants to carry out his obligations when he has a catheter attached.
 REFERENCES

Harding, M.M., Kwong, J., Roberts, D., Hagler, D. & Reinisch, C. 2019, Lewis’s Medical-
Surgical Nursing E-Book: Assessment and Management of Clinical Problems, Single
Volume, Elsevier Health Sciences, viewed 16 May 2022.

Ng, M. & Baradhi, K.M. 2021, “Benign Prostatic Hyperplasia,” NCBI Bookshelf, viewed
<https://www.ncbi.nlm.nih.gov/books/NBK558920/>.

Wilkins, L.W.& 2017, Brunner’s Textbook of Medical-Surgical Nursing 14th Edition + Study
Guide Package, 14th edn, Julie K. Stegman, viewed 16 May 2022.