BENIGN PROSTATE HYPERPLESIA.pptx anatomy and physiology

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1. BENIGN PROSTATE HYPERPLESIA (BPH) PREPARED BY NASIYO TABITHA

2. OBJECTIVES Describe the anatomy of the prostate gland Define benign prostate hyperplasia/hypertrophy State the causes of BPH Describe the pathophysiology of BPH Describe the clinical features of BPH Discus the management of BPH

3. Anatomy of the prostate gland

4. Central zone – surrounds the ejaculatory ducts, comprising approximately 25% of normal prostate volume. The ducts of the glands from the central zone are obliquely emptying in the prostatic urethra, thus being rather immune to urine reflux. Transitional zone – located centrally and surrounds the urethra, comprising approximately 5-10% of normal prostate volume. The glands of the transitional zone are those that typically undergo benign hyperplasia (BPH)

5. Peripheral zone – makes up the main body of the gland (approximately 65%) and is located posteriorly. The ducts of the glands from the peripheral zone are vertically emptying in the prostatic urethra; that may explain the tendency of these glands to permit urine reflux. That also explains the high incidence of acute and chronic inflammation found in these compartments, a fact that may be linked to the high incidence of prostate carcinoma at the peripheral zone.

6. The peripheral zone is mainly the area felt against the rectum on DRE, which is of irreplaceable value. FUNCTIONS OF THE PROSTATE Releases a milky substance that combines with seminal fluid and sperm to form semen. It secretes proteolytic enzymes into the semen, which act to break down clotting factors in the ejaculate.

7. Definition of BPH Benign prostate hyperplasia refers to the nonmalignant adenomatous overgrowth of the periurethral prostate gland. or Benign prostatic hyperplasia (BPH) is the enlargement, or hypertrophy, of the prostate gland. The enlargement causes narrowing of the urethra and results in partial or complete obstruction. It describes a proliferative process of the cellular elements of the prostate, an enlarged prostate, or the voiding dysfunction resulting from prostatic enlargement and bladder outlet obstruction.

8. It is much more common with advancing age, although histological evidence of hyperplasia may be evident from much earlier ages (<40 yrs old). 30- 40 years – 8% 50-60 years - 50% 80 – 80% 100 – 100%

9. BENIGN PROSTATE HYPERPLASIA

10. Etiology of BPH The cause is not well understood, but evidence suggests hormonal involvement. BPH is influenced by a wide variety of risk factors in addition to direct hormonal effects of testosterone on prostate tissue. Risk Factors 1. Genetic Factor If a man from one’s immediate family (say for example brother or father) has been diagnosed with benign prostatic hyperplasia, then there’s a greater possibility of the man developing the same symptom.

11. 2. Ageing With ageing, the prostate gland develops a larger size. Hence, the risk of developing an enlarged prostate becomes apparent. This is significant for men raging over the age of 50 years. For men who are above 80 years of age, the vast majority will apparently develop an enlarged prostate gland. 3. The Ethnic Background Enlarged prostate symptoms might be higher in the black people than in the white men. Apparently, the reason behind the increased risk might be because of some genetic differences. Alternatively, the risk might have to do with some metabolic diseases too which is most common in the Latinos, Americans, and Africans.

12. 4. People with Diabetes A man who has diabetes, has an increased risk of developing an enlarged prostate gland or BPH. Type 2 diabetes (with high glucose levels) might increase the progression of benign prostatic hyperplasia. This is due to the elevated insulin levels. 5. A sedentary Lifestyle A sedentary lifestyle or a lack of exercise can also increase the risk of developing an enlarged prostate. This is due to the fact that exercise helps in fighting obesity. It also helps in reducing inflammation and the risk of type 2 diabetes. It also helps insulin resistance and other factors associated with BPH.

13. 7. People with Heart Diseases - The same risks contributing to heart problems also increase the growth of the prostate. These include obesity, high blood pressure, and diabetes.

14. Pathophysiology of benign prostate hyperplasia The prostate consists predominantly of three distinct zones A central zone A peripheral zone A transition zone, adjacent to the urethra

15. Pathophysiology cont’d BPH develops almost exclusively in the transition zone, whereas prostate cancer usually develops in the peripheral zone. The growth and development of the prostate is influenced by the male hormone testosterone and its more active metabolite dihydrotestosterone (DHT). Testosterone produced in the testes is converted to dihydrotestosterone (DHT) by t he enzyme 5α- reductase 2 in prostate stromal cells.

16. DHT has direct effects on stromal cells in the prostate, paracrine effects in adjacent prostatic cells, and endocrine effects in the bloodstream, which influences both cellular proliferation and apoptosis (cell death). BPH arises as a result of the loss of homeostasis between cellular proliferation and cell death, resulting in an imbalance favoring cellular proliferation. This results in increased numbers of epithelial and stromal cells in the periurethral area of the prostate

17. Pathophysiology cont’d BPH arises in the periurethral and transition zones of the prostate. Multiple fibroadenomatous nodules develop in the periurethral region of the prostate, probably originating within the periurethral glands rather than in the true fibromuscular prostate (surgical capsule), which is displaced peripherally by progressive growth of the nodules. As the lumen of the prostatic urethra narrows and lengthens, urine outflow is progressively obstructed.

18. Pathophysiology cont’d Increased pressure associated with micturition and bladder distention can progress to hypertrophy of the bladder detrusor, trabeculation, cellule formation, and diverticula. Incomplete bladder emptying causes stasis and predisposes to calculus formation and infection. Prolonged urinary tract obstruction, even if incomplete, can cause hydronephrosis and compromise renal function.

19. Symptoms and Signs of BPH Lower urinary tract symptoms These can be divided into; storage (frequency, nocturia, urgency) and voiding symptoms (poor stream, straining, hesitancy, prolonged micturition) Urinary frequency: Frequent trips to the bathroom to urinate may be an early sign of a developing BPH. Urgency: This is the sudden and immediate urge to urinate. Nocturia: Urinating frequently at night is called nocturia. Frequency, urgency, and nocturia are due to incomplete emptying and rapid refilling of the bladder.

20. Hesitancy: Difficulty starting or maintaining a urine stream Intermittency: A urinary stream that is not continuous. Decreased size and force of the urinary stream cause hesitancy and intermittency. Sensations of incomplete emptying, terminal dribbling, overflow incontinence, or complete urinary retention may ensue.

21. Straining to void. This cause congestion of superficial veins of the prostatic urethra and trigone , which may rupture and cause hematuria. Straining also may acutely cause vasovagal syncope and, over the long term, may cause dilation of hemorrhoidal veins or inguinal hernias.

22. Urinary retention Some patients present with sudden, complete urinary retention, with marked abdominal discomfort and bladder distention. Digital rectal examination On digital rectal examination, the prostate usually is enlarged and non tender, has a rubbery consistency, and in many cases has lost the median furrow.

23. Diagnosis of BPH Digital rectal examination: A DRE often reveals a large, rubbery, and nontender prostate gland. Urinalysis : Color: Yellow, dark brown, dark or bright red (bloody); appearance may be cloudy. pH 7 or greater (suggests infection); bacteria, WBCs, RBCs may be present microscopically. Urine culture: May reveal Staphylococcus aureus , Proteus, Klebsiella , Pseudomonas, or Escherichia coli.

24. Typically, urinalysis and urine culture are done, and serum prostate-specific antigen (PSA) levels are measured. Prostate-specific antigen level Prostate-specific antigen (PSA): Glycoprotein contained in the cytoplasm of prostatic epithelial cells, detected in the blood of adult men. Level is greatly increased in prostatic cancer but can also be elevated in BPH.

25. The PSA level is moderately elevated in 30 to 50% of patients with BPH, depending on prostate size and degree of obstruction, and is elevated in 25 to 92% of patients with prostate cancer, depending on the tumor volume. In patients without cancer, serum PSA levels > 1.5 ng /mL (1.5 mcg/L) usually indicate a prostate volume ≥ 30 mL. If the PSA level is > 4 ng /mL (4 mcg/L), further discussion/shared decision-making regarding other tests or biopsy is recommended.

26. Sometimes uroflowmetry and bladder ultrasonography. Assesses degree of bladder obstruction. (an objective test of urine volume and flow rate) with measurement of post void residual volume by bladder ultrasonography. Flow rate < 15 mL/sec suggests obstruction, and post void residual volume > 100 mL suggests acute retention.

27. Other testing Transrectal biopsy is usually done with ultrasound guidance (to minimize risk of infection) and is usually indicated only if there is suspicion of prostate cancer. Transrectal ultrasonography is an accurate way to measure prostate volume. Contrast imaging studies ( eg , CT, intravenous urography [IVU]) are rarely necessary unless the patient has had a urinary tract infection (UTI) with fever or obstructive symptoms have been severe and prolonged.

28. If an upper tract imaging study is warranted due to pain or elevated serum creatinine level, ultrasonography may be preferred because it avoids radiation and IV contrast exposure. Alternatively, men whose PSA levels warrant testing can undergo multiparametric MRI, which is more sensitive (although less specific) than transrectal biopsy. Cystoscopy may help determine the optimal surgical approach and to rule out other obstructive causes such as strictures.

29. MANAGEMENT Medical Management The goals of medical management of BPH are to improve the quality of life and treatment depends on the severity of symptoms. Catheterization. If a patient is admitted on an emergency basis because he is unable to void, he is immediately catheterized. Cystostomy. An incision into the bladder may be needed to provide urinary drainage.

30. Pharmacologic Management Patients with mild to moderate obstructive symptoms, Alpha-adrenergic blockers ( eg . doxazosin , tamsulosin , alfuzosin , terazosin), which relax the smooth muscle of the bladder neck and prostate may decrease voiding problems. 5alpha reductase inhibitors. Hormonal manipulation with antiandrogen agents ( finasteride [ Proscar ], dutasteride ) decreases the size of the prostate and prevents the conversion of testosterone to dihydrotestosterone (DHT).

31. A combination of both classes of drugs is superior to monotherapy . Possible drug combinations may include; finasteride and doxazosin , dutasteride and tamsulosin , alpha blockers and antimuscurinic For men with concomitant erectile dysfunction, daily tadalafil may help relieve both conditions. One herbal medication effective against BPH is Saw Palmetto.

32. Surgical Management Surgery is done when patients do not respond to drug therapy or develop complications such as recurrent urinary tract infection, urinary calculi, severe bladder dysfunction, or upper tract dilation. Transurethral incision of the prostate(TIUP). This is used to widen the urethra if the prostate gland is small but causes a major blockage. Small cuts in the bladder neck are made where the urethra joins the bladder in the prostate. It widens the urethra and reduces the pressure of the prostate on the urethra, making micturition easier.

33. Transurethral resection of the prostate (TURP) is the standard. It uses electric current or laser light to cut and remove tissue. TURP involves the surgical removal of the inner portion of the prostate with a resectoscope inserted through the urethra. The resectoscope provides light, irrigating fluid and an electrical loop.

34. Transurethral needle ablation (TUNA). TUNA uses low-level radio frequencies delivered by thin needles placed in the prostate gland to produce localized heat that destroys prostate tissue while sparing other tissues. Transurethral microwave heat treatment. It uses microwaves to destroy prostatic tissue. A urologist inserts a catheter through the urethra to the prostate. An antenna then sends the micro waves through the catheter to heat parts of the prostate. A cooling system protects the urinary tract from damage

35. Open prostatectomy. Larger prostates (usually > 75 grams) traditionally require open surgery via a suprapubic or retropubic approach. Holmium laser enucleation of the prostate ( HoLEP ) can be done transurethrally .

36. Nursing Management Nursing management of a patient with BPH includes the following: Nursing Assessment Nursing assessment focuses on the health history of the patient. Health history. The health history focuses on the urinary tract, previous surgical procedures, general health issues, family history of prostate diseases, and fitness for possible surgery. Physical assessment. Physical assessment includes digital rectal examination.

37. Subjective Data: Frequent / urgent need to urinate, especially at night Difficulty urinating or weak urine stream Inability to empty the bladder Dribbling urine after voiding Incontinence

38. Objective Data: Elevated PSA Enlarged prostate on exam or ultrasound Inability to pass catheter through urethra

39. Nursing Diagnosis - Based on the assessment data, the appropriate nursing diagnoses for a patient with BPH are: Urinary retention related to obstruction in the bladder neck or urethra. Acute pain related to bladder distention. Anxiety related to the surgical procedure.

40. Nursing Care Planning Relieve acute urinary retention. Promote comfort. Prevent complications. Help patient deal with psychosocial concerns. Provide information about disease process/prognosis and treatment needs.

41. Nursing Interventions Preoperative and postoperative nursing interventions for a patient with BPH are as follows: Reduce anxiety. The nurse should familiarize the patient with the preoperative and postoperative routines and initiate measures to reduce anxiety. Relieve discomfort. Bed rest and analgesics are prescribed if a patient experiences discomfort. Provide instruction. Before the surgery, the nurse reviews with the patient the anatomy of the affected structures and their function in relation to the urinary and reproductive systems. Maintain fluid balance. Fluid balance should be restored to normal.

42. Evaluation Reduced anxiety. Reduced level of pain. Maintained fluid volume balance postoperatively. Absence of complications.

43. Nursing diagnosis Planning Expected outcomes nursing interventions Rationale evaluation 1 impaired urinary elimination related to blader out let obstruction as evidenced by dribbling of urine. 2 . Risk for infection related to urine retention. 3.Acute pain related to bladder distention as evidenced by the patient reporting. After three hours of nursing intervention the patient will be able to report some relieve Void in sufficient amounts with no palpable bladder distension. Demonstrate post void residuals of less than 50ml, with the absence of dribbling of urine or overflow. Demonstrate techniques or behaviors to alleviate/prevent retention. .Re assure the patient Put the patient in a favorable position Encourage the patient to void after every 2-3 hours and whenever urge is felt Health educate on the importance of medication .to allay anxiety. To provide comfort. To prevent urinary retention and bladder distention To enable the patient adhere to treatment Void in sufficient amounts with no palpable bladder distention. Verbalize understanding of causative factors and appropriate interventions , Demonstrate techniques/behaviors to alleviate/prevent retention.

44. Nursing diagnosis Desired outcome Nursing interventions Rationale Evaluation Encourage fluid intake but limit at night to reduce nocturia .administer prescribed medication Catheterize for residual urine and attach indwelling catheter as indicated Encourage on perianal care .for sufficient hydration and also prevent stasis . To relive pain, 'prevent infections To relieve and prevent urinary retention. To prevent ascending infection

45. Complications of benign prostate hyperplasia Urine retention. Urinary stasis happens as the enlarged prostate blocks the bladder of excretion of urine Urinary tract infections. Due to the retention of urine in the bladder, the environment becomes conducive for opportunistic bacteria to proliferate thereby causing infection. Bladder stones. Because of incomplete excretion of urine waste will continuously accumulate in the bladder thereby forming crystals that may cause injury to the thin bladder walls.

46. Bladder damage. As the bladder can not properly empty, its muscles weaken overtime. This loss in elasticity compromises its structure, making contraction ineffective, thereby making urination difficult. Kidney damage. Increased pressure from urinary stasis and/ or ascending infections from the bladder will reach the kidneys, thereby causing damage overtime.

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