Benign Prostatic Hyperplasia (BPH)

BPH Collaborative Care

Goals: -Restore bladder drainage -Relieve symptoms -Prevent/Treat complications Treatment based on: -How bothersome symptoms are -Presence of complications Conservative Therapy: -Active Surveillance -lack of presence of symptoms -mild symptoms (AUA score of 0-7) -Symptoms may disappear -Lifestyle changes may result in improvement

BPH Diagnostics

History and Physical exam Digital rectal exam Urinalysis with culture PSA level Serum creatinine Neurologic exam TRUS scan Uroflowmetry Cystoscopy

BPH Complications

- Acute urinary retention (Related to obstruction and relatively uncommon in BPH): -complication with sudden, painful inability to urinate -treatment involves catheter insertion and possible surgery -UTI and Sepsis: -incomplete bladder emptying with residual urine provides medium for bacterial growth -Calculi may develop in bladder because of alkalization of residual urine -Renal Failure: caused by hydronephrosis -Pyelonephritis -Bladder damage -Ureteral damage due to repeated TURPs

BPH Collaborative Care: Minimally Invasive therapies

-Transurethral Microwave Therapy (TUMT) -out patient procedure -delivers microwaves directly to prostate through a transurethral probe -heat causes death of tissue and relief of obstruction -post-op urinary retention is common -patient sent home with catheter for 2 to 7 days -antibiotics, pain medication, and bladder antispasmodic medications given -not appropriate therapy when rectal problems exist -side effects: bladder spasm, hematuria, dysuria, and retention -Transurethral Needle Ablation (TUNA) -increase in temperature of prostate tissue for localized necrosis -low-wave frequency used -only tissue to contact with needle affected -majority of patients show improvement in symptoms -outpatient uses local anesthesia and sedation -lasts 30 minutes with little pain and quick recovery -Complications include urinary retention, UTI, and irritative voiding symptoms -some patients require a catheter -hematuria up to a week -Laser Prostatectomy -delivers a laser beam transurethrally to cut or destroy parts of the prostate -common procedure: visual laser ablation of the prostate (VLAP) -takes several weeks to reach optimal results -urinary catheter inserted -contact laser techniques -minimal bleeding during and after procedure -fast recovery time -patients may take anticoagulants -photovaporization of prostate -Intraprostatic Urethral Stents -for patients who are poor surgical candidates -stents are placed directly into prostatic tissue -chronic pain, infection, and encrustation are potential complications

BPH Risk Factors

Aging Obesity (especially increased waist circumference) Lack of physical activity Alcohol consumption Erectile dysfunction Smoking Diabetes

BPH Collaborative Care: Drug Therapy

Drug therapy offers symptomatic relief of BPH -5a-Reductase Inhibitors: -Ex: Finasteride (Proscar), Dutasteride (Avodart), Jalyn (finasteride + tamsulosin) -Decreases size of prostate gland -Takes 3 to 6 months for improvement -Side effects: decreased libido, decreased volume of ejaculation, ED -May lower the risk of prostate cancer -Not recommended in the prevention of prostate cancer due to an increased risk of developing an aggressvie form of prostate cancer -a-Adrenergic receptor blockers: -Ex: tamsulosin (Flomax), doxazosin (Cardura), silodosin (Rapaflo) -Promotes smooth muscle relaxation in prostate, facilitates urinary flow -Improvement in 2 to 3 weeks -Offer symptomatic relief but do not treat hyperplasia -Erectogenic drugs: -Ex: tadalifil (Cialis) effectively reduces symptoms of both BPH and ED -Herbal therapy: -Successfulness varies -Use should be revealed to health care provider

BPH health promotion

Focus: early detection and treatment -yearly physical exam and DRE for men over 50 -teach patients that alcohol, caffeine, citrus juices, and cold and cough meds can increase symptoms -instruct patients with obstructive symptoms to urinate every 2 to 3 hours and when first feeling urge -minimizes urinary stasis and acute urinary retention -teach need for adequate fluid intake -restricting fluids increases chance of infection -instructions after surgery: -care of indwelling catheter -managing incontinence -maintaining adequate fluid intake -observing for signs and symptoms of UTI, wound infection -preventing constipation -avoiding heavy lifting (no more than 10 lbs) -refraining from driving, intercourse after surgery as directed - sexual counseling if ED becomes a problem -avoiding bladder irritants -yearly digital rectal examination (DRE)

BPH Collaborative Care: Invasive Therapy

Invasive therapy indicated when: -decrease in urine flow sufficient to cause discomfort -persistent residual urine -acute urinary retention -hydronephrosis -Transurethral Resection (TURP): -removal of obstructing prostate tissue using resectoscope inserted through urethra -outcome for 80% to 90% is excellent -relatively low risk -performed under spinal or general anesthesia and requires hospital stay -bladder irrigated for first 24 hours to prevent mucous and blood clots -complications include bleeding, clot retention, dilutional hyponatremia, retrograde ejaculation -patients must stop anticoagulants before surgery -Transurethral incision of the prostate (TUIP): -moderate to sever symptoms -for patients with a small or moderately enlarged prostate gland -local anesthesia -several small incisions made into prostate to expand the urethra improves urine flow

BPH Pathophysiology

Though to result from hormonal changes from aging process: -Excessive accumulation of DHT in the prostate cells that can stimulate overgrowth of prostate tissue -Increased proportion of estrogen over testosterone in blood Compression (from enlargement) of the urethra leads to: -Decrease in caliber and force of the urinary stream -Difficulty in initiating voiding -Intermittency of voiding -Dribbling -BPH develops in the inner part of the prostate. -This enlargement gradually compresses the urethra, eventually leading to partial or complete obstruction. -There is no direct relationship between the size of the prostate and the severity of symptoms or degree of obstruction. -The location of the enlargement is the most significant in the development of obstructive symptoms.

BPH Clinical Manifestations

Usually gradual in onset: -manifestations associated with obstruction of lower urinary tract -early symptoms are usually minimal because bladder can compensate -worsen as obstruction increases -Biggest complaint: difficulty initiating urination -Nocturia is often the first symptom noticed Symptoms categorized in two groups: -Irritative: symptoms associated with inflammation or infection -urinary frequency and urgency -dysuria -bladder pain -nocturia -incontinence -Obstructive: symptoms due to urinary retention -decrease in caliber and force of urinary stream -difficulty in initiating urination -intermittency (starting and stopping) -dribbling at end of urination

Benign Prostatic Hyperplasia (BPH)

a benign enlargement of the prostate gland resulting from increase in number of epithelial cells and stream tissue. -most common urologic problem in male adults