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  • Description/EtiologyBenign prostatic hyperplasia (BPH) is a nonmalignant condition in which excessive smooth muscle and epithelial cell proliferation results in an enlarged prostate gland that constricts or deforms the lower urinary tract and causes difficulty with urination. BPH occurs primarily in older men, affecting 50% of men over the age of 60 and 80% of men over the age of 70. BPH is rare in men under the age of 40.

    Although the etiology of BPH is not fully understood, animal studies suggest age-related sex hormone imbalances involving testosterone, estrogen, and dihydrotestosterone (DHT) may cause enlargement of prostatic tissues, causing the gland to compress the urethra and even protrude into the bladder neck, resulting in urinary outlet irritation, obstruction, and urinary retention. Hypothesized etiologies suggest prostate cell growth due to reactivation of genes in the prostate cells and a role of impaired catechol-o-methyl transferase gene activity.

    Complications of BPH include bladder stones, prostatitis, hematuria, urinary retention, and renal failure. BPH is diagnosed based on patient history and a variety of tests, including digital rectal examination (DRE), prostate-specific antigen (PSA) blood test, ultrasound, and prostate biopsy. BPH must be differentiated from prostate cancer (CaP), urinary tract infection (UTI), prostatitis, urethral stricture, overactive bladder, neurogenic bladder, bladder cancer, poorly controlled diabetes, and neurologic conditions that produce neurogenic bladder and bladder symptoms (e.g., Parkinsons disease, diabetic autonomic neuropathy, multiple sclerosis, spinal cord injury).

    Treatment options for BPH include surgery and use of pharmacologic agents such as non-selective or selective alpha-adrenergic blockers, to help relax the smooth muscle tissue of the prostate and bladder neck, improving urinary flow; 5-alpha reductase inhibitors to reduce prostate size; stool softeners for constipation; analgesics for pain; muscle relaxants to reduce pelvic muscle spasms; and antibiotics for infection. Surgical procedures include transurethral resection of the prostate (TURP) and suprapubic or retropubic prostatectomy. Minimally invasive surgical procedures include holmium laser ablation of the prostate, transurethral vaporization of the prostate, interstitial laser coagulopathy, high-frequency focused ultrasound, transurethral needle ablation, transurethral microwave thermoplasty, transurethral balloon dilatation therapy, transurethral ethanol ablation, and water-induced thermoplasty. (For more information, see Quick Lesson AboutProstatectomy, Benign Prostatic Hypertrophy.) The overall prognosis is fairly good, as treatment stabilizes symptoms in 7080% of cases.

    Facts and FiguresBPH is the most common cause of urinary tract obstruction in older men, affecting ~ 14 million men in the United States and 30 million men worldwide. Evidence for racial predisposition is not supported. In the U.S. in 2000, BPH accounted for $1.1 billion in health care costs, 4.4 million physician visits, 117,000 emergency department visits, and 105,000 hospitalizations. Up to 33% of men with BPH have CaP, and 83% of CaP cases develop in men who also have BPH.

    Risk FactorsRisk factors include advanced age, intact testes, and family history of BPH. Abdominal obesity is a possible risk factor. The risk for complications increases proportionally with the amount of enlargement.

    Signs and Symptoms/Clinical PresentationObstructive symptoms include urinary hesitancy or retention, decreased force and caliber of the urine stream, sensation of incomplete bladder emptying, straining to urinate, and post-void dribbling. Irritating symptoms include urinary urgency, frequency, and nocturia.

    AssessmentPatient History 4

    Ask the patient about history of urinary dysfunction and family history of BPH Physical Findings of Particular Interest 4

    DRE may reveal smooth, firm, elastic enlargement of the prostate Physical examination may reveal bladder distention and neurological dysfunction (e.g., sensory and/or motor)September 10, 2010


    AuthorsGilberto Cabrera, MD

    Tanja Schub, BS

    ReviewersSara Grose, MSN, RN, PHN, CNL, CLE

    Medical Writer

    Cinahl Information Systems

    Glendale, California

    Eliza Schub, BSN, RNCinahl Information Systems

    Glendale, California

    Nursing Practice CouncilGlendale Adventist Medical Center

    Glendale, California

    EditorDiane Pravikoff, RN, PhD, FAAN

    Cinahl Information Systems

    Benign Prostatic Hyperplasia


    Published by Cinahl Information Systems. Copyright2010, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

  • Laboratory Tests That May Be Ordered 4PSA levels may be elevated in BPH and CaP Serum chemistry studies may reveal serum blood urea nitrogen (BUN) and creatinine levelsUA and urine culture to evaluate for UTI, prostatitis, hematuria, and pyuria Histopathologic testing of biopsied prostate tissue is negative for malignancy in BPH

    Other Diagnostic Tests 4Pressure flow studies and flow rate test to assess for urinary flow abnormalities Transrectal ultrasound to assess prostate size; abdominal ultrasound to assess for hydronephrosis or increased post-void residual Cystoscopy to assess for renal obstruction Chest X-ray and EKG to evaluate pre- and postoperative pulmonary and cardiac status

    Treatment GoalsProvide Supportive Care During Treatment and Monitor for Complications 4

    Assess all physiologic systems and review laboratory/diagnostic study results for abnormalities; assess for pain, voiding dysfunction, infection, and constipation

    Administer antibiotics for infection, nonselective alpha-adrenergic blockers (e.g., doxazosin, terazosin), selective alpha-adrenergic blockers (e.g., terazosin, tamsulosin) to help relax the bladder, 5-alpha reductase inhibitors (e.g., finasteride, dutasteride) to reduce size of enlarged prostate, stool softeners and laxatives for constipation and to reduce straining, muscle relaxants to reduce pelvic muscle spasms, and analgesics (e.g., ibuprofen, aspirin) for pain Insert an indwelling urinary catheter if ordered for urinary retention/obstruction and ensure meticulous hygiene; monitor catheter patency and urine collection, and avoid rapid bladder decompression

    Follow facility pre- and postsurgical protocols if patient becomes a surgical candidate; reinforce pre- and postsurgical education and ensure completion of facility informed consent documents

    Monitor closely for complications following surgical intervention (e.g., septic shock, renal failure, heart failure) Monitor vital signs, intake and output, nutritional and respiratory status, response to treatment, and for medication side effects; ensure bed rest and adherence to a fluid restrictive diet, and provide sitz baths for comfort, as ordered

    Educate and Provide Emotional Support 4Assess patients anxiety level and coping ability; express empathy, and educate about BPH, potential complications, and treatment risks and benefits

    Food for ThoughtAlthough sexual function is initially affected in some cases after surgery for BPH, it generally returns fully with time. Retrograde ejaculation (i.e., 4semen entering the bladder instead of exiting through the urethra during ejaculation), which can cause sterility, occurs rarely Some men with BPH use alternative treatments (e.g., herbs such as saw palmetto, African plum tree, rye), although their effectiveness has not 4been provenBotulinum A toxin injections effectively reduce BPH symptoms and may be considered for patients who are poor surgical candidates or who 4experience continued symptoms in spite of the conventional pharmacologic regimen Improvement in medical management of BPH has resulted in an average 1015-year delay in the need for surgery, but has not eliminated it entirely 4

    Red FlagsAvoid checking for fecal impaction, as a rectal examination may precipitate bleeding 4Some alpha-adrenergic blockers (e.g., alfuzosin, doxazosin, terazosin) produce a vasodilatory effect that has been associated with increased risk for 4developing vascular adverse events (e.g., presyncope, syncope)

    What Do I Need to Tell the Patient/Patients Family?Advise the patient to increase water intake to flush the bladder, avoid straining during bowel movements, eat a nutritious diet but avoid spicy foods, 4avoid alcoholic or caffeinated drinks, avoid heavy lifting, and avoid driving or operating heavy machineryEmphasize the importance of continued medical surveillance, including PSA screening 4Educate to seek immediate medical attention for new or recurrent urinary symptoms, surgical complications, or medication side effects 4Recommend finding additional information from the National Kidney and Urologic Diseases Clearinghouse (NKUDIC) at 4 www.kidney.niddk.nih.gov

    ReferencesAuffenberg, G. B., Helfand, B. T., & McVary, K. T. (2009). Established medical therapy for benign prostatic hyperplasia. Urologic Clinics of North America, 36(4), 443-459.Bushman, W. (2009). Etiology, epidemiology, and natural history of benign prostatic hyperplasia. Urologic Clinics of North America, 36(4), 403-415.Longstroth, D., & Cyr, P. R. (2010). Prostatic hyperplasia, benign (BPH). In F. J. Domino (Ed.), The 5-minute clinical consult 2011 (19th ed., pp. 1068-1069). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.Rosenberg, M. T., Miner, M. M., Riley, P. A., & Staskin, D. R. (2010). STEP: Simplified Treatment of the Enlarged Prostate. International Journal of Clinical Practice, 64(4), 488-496.Thorner, D. A., & Weiss, J. P. (2009). Benign prostatic hyperplasia: Symptoms, symptom scores, and outcome measures. Urologic Clinics of North America, 36(4), 417-429.