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Benign prostatic hyperplasia (BPH) is the advanced enlargement of the prostate gland that is brought about by varying degrees of urethral obstruction and restriction of urinary flow. However, some men does not experience any symptoms for years. This condition is common among men 50 years old and above.

bph-nursing-care-plan

Etiology 

The cause of BPH is still unknown.   

Incidence of BPH

  • Age: Most prevalent among men 50 years old and older.
  • Race/ Ethnicity:
    • Black and White population in United States have similar incidence of BPH, but earlier development of symptoms manifest more among Blacks.
    • Blacks in United States was also reported to have higher prevalence of adenomatous hyperplasia as compared to Blacks on the African continent.
    • Native Chinese and Japanese have lower prevalence of BPH as compared to White population.

Detecting BPH

Less Serious Manifestation

  • Frequent urination
  • The stream of urine is slow and weak
    • Result to needing more time to urinate. In fact, they also try to urinate harder which is a natural reaction when a person cannot get much out from their usual effort. Unfortunately, straining would not be helpful because it could also worsen BPH.
  • Having the urgency when the person feel like emptying

Serious Manifestations

  • Presence of blood in the urine.
    • This symptoms is a concrete sign that there is a great need to seek medical attention. This manifestation is not only limited to BPH because it could also indicate kidney cancer or bladder cancer, especially if urinary bleeding has no pain.
  • If the person can barely urinate, or if they feel like their bladder is full for an hour or more and seems like it’s about to burst.
    • This kind of situation underscores medical emergency because the urine needs to come out immediately, for the longer is stays in the bladder, the more likely it may lead to extreme pain, backing up of urine, potential infection, and other serious medical consequences.

Complications

  • Urinary Retention
    • Urinary retention may require a patient to be catheterize in order to drain their urine. He may also undergo surgery, particularly among men who have enlarged prostate to alleviate retention
  • Urinary Tract Infection
    • The risk for infection in the urinary tract is increased due to the inability of the bladder to fully empty. A surgery may be required if urinary tract infection transpire frequently, to remove part of the prostate.
  • Bladder Stones
    • Stones develop in the bladder because of its inability to completely empty the bladder.
  • Bladder Damage
    • The bladder stretches and weakens eventually because of its failure to empty completely, due to this, the bladder’s muscular wall don’t properly contract overtime.
  • Kidney Damage
    • Kidney is affected because of the pressure coming from the bladder due to urinary retention. Aside from this, infection in the bladder may also reach up to the kidney.

Test and Diagnosis 

  1. 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.
  2. Urine culture: May reveal Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas, or Escherichia coli.
  3. Urine cytology: To rule out bladder cancer.
  4. BUN/Cr: Elevated if renal function is compromised.
  5. 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. Note: Research suggests elevated PSA levels with a low percentage of free PSA are more likely associated with prostate cancer than with a benign prostate condition.
  6. WBC: May be more than 11,000/mm3, indicating infection if patient is not immunosuppressed.
  7. Uroflowmetry: Assesses degree of bladder obstruction.
  8. IVP with postvoiding film: Shows delayed emptying of bladder, varying degrees of urinary tract obstruction, and presence of prostatic enlargement, bladder diverticuli, and abnormal thickening of bladder muscle.
  9. Voiding cystourethrography: May be used instead of IVP to visualize bladder and urethra because it uses local dyes.
  10. Cystometrogram: Measures pressure and volume in the bladder to identify bladder dysfunction unrelated to BPH.
  11. Cystourethroscopy: To view degree of prostatic enlargement and bladder-wall changes (bladder diverticulum).
  12. Cystometry: Evaluates detrusor muscle function and tone.
  13. Transrectal prostatic ultrasound: Measures size of prostate and amount of residual urine; locates lesions unrelated to BPH.

Treatment

  • Medications:
    • Alpha blockers – help relax the bladder neck as well as prostatic urethra. Also used for hypertension.
    • Finasteride – halts the conversion of testosterone to dihydrotestosterone with the prostate. This process averts the further growth of BPH.
  • Surgery:
    • Transurethral resection – may be performed if the prostates weighs at least less than 2 oz or 56.7g.
    • Suprapubic prostatectomy – most common surgical treatment for BPH and is very useful when the enlargement remains within the bladder area.
    • Perineal prostatectomy- performed for a large gland in an older patient.
    • Retropubic (extravesical) prostatectomy- allows direct visualization.
    • Transurethral incision of the prostate – performed to males with small prostate gland with bladder obstruction.
    • Transurethral needle ablation- uses heat to destroy prostate tissue while sparing the urethra, muscles, and nerves in the area.

Nursing Priorities

  1. Relieve acute urinary retention.
  2. Promote comfort.
  3. Prevent complications.
  4. Help patient deal with psychosocial concerns.
  5. Provide information about disease process/prognosis and treatment needs.

 Discharge Goals

  1. Voiding pattern normalized.
  2. Pain/discomfort relieved.
  3. Complications prevented/minimized.
  4. Dealing with situation realistically.
  5. Disease process/prognosis and therapeutic regimen understood.
  6. Plan in place to meet needs after discharge.

Nursing Care Plans for Benign Prostatic Hyperplasia (Based on NANDA)

Nursing Diagnosis: Urinary Retention 

May be related to:

  • Mechanical obstruction; enlarged prostate
  • Decompensation of detrusor musculature
  • Inability of bladder to contract adequately

Possibly evidenced by:

  • Frequency, hesitancy, inability to empty bladder completely; incontinence/dribbling
  • Bladder distension, residual urine

Desired Outcomes

  • Void in sufficient amounts with no palpable bladder distension.
  • Demonstrate postvoid residuals of less than 50 mL, with absence of dribbling/overflow.
Nursing InterventionsRationales
Independent

Encourage patient to void every 2–4 hr and when urge is noted.

 

May minimize urinary retention/overdistension of the bladder.

Ask patient about stress incontinence when moving, sneezing, coughing, laughing, lifting objects.High urethral pressure inhibits bladder emptying or can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost.
Observe urinary stream, noting size and force.Useful in evaluating degree of obstruction and choice of intervention.
Have patient document time and amount of each voiding. Note diminished urinary output. Measure specific gravity as indicatedUrinary retention increases pressure within the ureters and kidneys, which may cause renal insufficiency. Any deficit in blood flow to the kidney impairs its ability to filter and concentrate substances.
Percuss and palpate suprapubic area.A distended bladder can be felt in the suprapubic area.
Encourage oral fluids up to 3000 mL daily, within cardiac tolerance, if indicated.Increased circulating fluid maintains renal perfusion and flushes kidneys, bladder, and ureters of “sediment and bacteria.” Note: Initially, fluids may be restricted to prevent bladder distension until adequate urinary flow is reestablished.
Monitor vital signs closely. Observe for hypertension, peripheral/dependent edema, changes in mentation. Weigh daily. Maintain accurate I&O.Loss of kidney function results in decreased fluid elimination and accumulation of toxic wastes; may progress to complete renal shutdown.
Provide/encourage meticulous catheter and perineal care.Reduces risk of ascending infection.
Recommend sitz bath as indicated.Promotes muscle relaxation, decreases edema, and may enhance voiding effort.
Collaborative

Administer medications as indicated:

androgen inhibitors, e.g., finasteride (Proscar);

Reduces the size of the prostate and decreases symptoms if taken long-term; however, side effects such as decreased libido and ejaculatory dysfunction may influence patient’s choice for long-term use.
Alpha-adrenergic antagonists, e.g., tamsulosin (Flomax), prazosin (Minipress), terazosin (Hytrin), doxazosin mesylate (Cardura)Studies indicate that these drugs may be as effective as Proscar for outflow obstruction and may have fewer side effects in regard to sexual function.
Antispasmodics, e.g., oxybutynin (Ditropan)Relieves bladder spasms related to irritation by the catheter.
Rectal suppositories (B & O)Suppositories are absorbed easily through mucosa into bladder tissue to produce muscle relaxation/relieve spasms.
Antibiotics and antibacterials.Given to combat infection. May be used prophylactically.
Catheterize for residual urine and leave indwelling catheter as indicated.Relieves/prevents urinary retention and rules out presence of ureteral stricture. Coudé catheter may be required because the curved tip eases passage of the tube through the prostatic urethra. Note: Bladder decompression should be done with caution to observe for sign of adverse reaction, e.g., hematuria (rupture of blood vessels in the mucosa of the overdistended bladder) and syncope (excessive autonomic stimulation).
Irrigate catheter as indicated.Maintains patency/urinary flow.
Monitor laboratory studies:

BUN, Cr, electrolytes

 

Prostatic enlargement (obstruction) eventually causes dilation of upper urinary tract (ureters and kidneys), potentially impairing kidney function and leading to uremia.

Urinalysis and cultureUrinary stasis potentiates bacterial growth, increasing risk of UTI.
Prepare for/assist with urinary drainage, e.g., cystostomy.May be indicated to drain bladder during acute episode with azotemia or when surgery is contraindicated because of patient’s health status.
Prepare for surgical intervention

Balloon urethroplasty/transurethral dilation of the prostatic urethra

Inflation of a balloon-tipped catheter within the obstructed area stretches the urethra and displaces prostatic tissue, thus improving urinary flow.
Transurethral incision of the prostate (TUIP).A procedure of almost equivalent efficacy to transurethral resection of the prostate (TURP) used for prostates with estimated resected tissue weight of 30 g or less. It may be performed instead of balloon dilation with better outcomes. Procedure can be done in ambulatory or short-stay settings. Note: Open prostate resection procedures (TURP) are typically performed on patients with very large prostate glands.
Transurethral microwave thermotherapy (TUMT).Heating the central portion of the prostate by the insertion of a heating element through the urethra destroys prostate cells. Treatment is usually completed in a one-time procedure carried out in the physician’s office.

Nursing Diagnosis: Acute pain 

May be related to:

  • Mucosal irritation: bladder distension, renal colic
  • Urinary infection
  • Radiation therapy

Possibly evidenced by:

  • Reports of pain (bladder/rectal spasm)
  • Narrowed focus; altered muscle tone, grimacing; distraction behaviors, restlessness
  • Autonomic responses

Desired Outcomes

  • Report pain relieved/controlled.
  • Appear relaxed.
  • Be able to sleep/rest appropriately.
Nursing InterventionsRationales
Independent

Assess pain, noting location, intensity (scale of 0–10), duration.

 

Provides information to aid in determining choice/effectiveness of interventions.

Tape drainage tube to thigh and catheter to the abdomen (if traction not required).Prevents pull on the bladder and erosion of the penile-scrotal junction.
Recommend bedrest as indicated.Bedrest may be needed initially during acute retention phase; however, early ambulation can help restore normal voiding patterns and relieve colicky pain.
Provide comfort measures, e.g., back rub, helping patient assume position of comfort. Suggest use of relaxation/deep-breathing exercises, diversional activities.Promotes relaxation, refocuses attention, and may enhance coping abilities.
Encourage use of sitz baths, warm soaks to perineum.Promotes muscle relaxation.
Collaborative

Insert catheter and attach to straight drainage as indicated.

 

Draining bladder reduces bladder tension and irritability.

Instruct in prostatic massage.Aids in evacuation of ducts of gland to relieve congestion/inflammation. Contraindicated if infection is present.
Administer medications as indicated:

Narcotics, e.g., meperidine (Demerol)

 

Given to relieve severe pain, provide physical and mental relaxation.

Antibacterials, e.g., methenamine hippurate (Hiprex)Reduces bacteria present in urinary tract and those introduced by drainage system.
Antispasmodics and bladder sedatives, e.g., flavoxate (Urispas), oxybutynin (Ditropan).Relieves bladder irritability.

Nursing Diagnosis: Risk for Fluid Volume Deficiency

May be related to:

  • Postobstructive diuresis from rapid drainage of a chronically overdistended bladder
  • Endocrine, electrolyte imbalances (renal dysfunction)

Possibly evidenced by:

  • presence of signs and symptoms establishes an actual diagnosis

Desired Outcomes

  • Maintain adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good capillary refill, and moist mucous membranes.
Nursing InterventionsRationales
Independent

Monitor output carefully. Note outputs of 100–200 mL/hr.

Rapid/sustained diuresis could cause patient’s total fluid volume to become depleted and limits sodium reabsorption in renal tubules.
Encourage increased oral intake based on individual needs.Patient may have restricted oral intake in an attempt to control urinary symptoms, reducing homeostatic reserves and increasing risk of dehydration/hypovolemia.
Monitor BP, pulse. Evaluate capillary refill and oral mucous membranes.Enables early detection of and intervention for systemic hypovolemia.
Promote bedrest with head elevated.Decreases cardiac workload, facilitating circulatory homeostasis.
Collaborative

Monitor electrolyte levels, especially sodium.

 

As fluid is pulled from extracellular spaces, sodium may follow the shift, causing hyponatremia.

Administer IV fluids (hypertonic saline) as needed.Replaces fluid and sodium losses to prevent/correct hypovolemia following outpatient procedures.

Nursing Diagnosis: Fear/ Anxiety

May be related to:

  • Change in health status: possibility of surgical procedure/malignancy
  • Embarrassment/loss of dignity associated with genital exposure before, during, and after treatment; concern about sexual ability.

Possibly evidenced by:

  • Increased tension, apprehension, worry
  • Expressed concerns regarding perceived changes
  • Fear of unspecific consequences

Desired Outcomes

  • Appear relaxed.
  • Verbalize accurate knowledge of the situation.
  • Demonstrate appropriate range of feelings and lessened fear.
  • Report anxiety is reduced to a manageable level.
Nursing InterventionsRationales
Independent

Be available to patient. Establish trusting relationship with patient/SO.

 

Demonstrates concern and willingness to help. Encourages discussion of sensitive subjects.

Provide information about specific procedures and tests and what to expect afterward, e.g., catheter, bloody urine, bladder irritation. Be aware of how much information patient wantsHelps patient understand purpose of what is being done, and reduces concerns associated with the unknown, including fear of cancer. However, overload of information is not helpful and may increase anxiety.
Maintain matter-of-fact attitude in doing procedures/dealing with patient. Protect patient’s privacy.Communicates acceptance and eases patient’s embarrassment.
Encourage patient/SO to verbalize concerns and feelings.Defines the problem, providing opportunity to answer questions, clarify misconceptions, and problem-solve solutions.
Reinforce previous information patient has been given.Allows patient to deal with reality and strengthens trust in caregivers and information presented.

Nursing Diagnosis: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs.

May be related to:

  • Lack of exposure/recall, information misinterpretation
  • Unfamiliarity with information resources
  • Concern about sensitive area

Possibly evidenced by:

  • Questions, request for information; verbalization of the problem
  • Inappropriate behaviors, e.g., apathetic, withdrawn
  • Inaccurate follow-through of instructions, development of preventable complications

Desired Outcomes

  • Knowledge: Disease Process
    • Verbalize understanding of disease process/prognosis and potential complications.
    • Identify relationship of signs/symptoms to the disease process.
  • Knowledge: Treatment Regimen
    • Verbalize understanding of therapeutic needs.
    • Initiate necessary lifestyle/behavior changes.
    • Participate in treatment regimen.
Nursing InterventionsRationales
Independent (Teaching: Disease Process)

Review disease process, patient expectations.

 

 

Provides knowledge base from which patient can make informed therapy choices.

Encourage verbalization of fears/feelings and concerns.Helping patient work through feelings can be vital to rehabilitation.
Give information that the condition is not sexually transmitted.May be an unspoken fear.
Review drug therapy/use of herbal products and diet, e.g., increased fruits, soy beans.Some patients may prefer to treat with complementary therapy because of decreased occurrence/lessened severity of side effects, e.g. impotence.
Recommend avoiding spicy foods, coffee, alcohol, long automobile rides, rapid intake of fluids (particularly alcohol).May cause prostatic irritation with resulting congestion. Sudden increase in urinary flow can cause bladder distension and loss of bladder tone, resulting in episodes of acute urinary retention.
Address sexual concerns, e.g., during acute episodes of prostatitis, intercourse is avoided, but may be helpful in treatment of chronic condition.Sexual activity can increase pain during acute episodes but may serve as massaging agent in presence of chronic disease. Note: Medications such as finasteride (Proscar) are known to interfere with libido and erections. Alternatives include terazosin (Hytrin), doxazosin mesylate (Cardura), and tamsulosin (Flomax), which do not affect testosterone levels.
Provide information about basic sexual anatomy. Encourage questions and promote a dialogue about concerns.Having information about anatomy involved helps patient understand the implications of proposed treatments because they might affect sexual performance.
Review signs/symptoms requiring medical evaluation, e.g., cloudy, odorous urine; diminished urinary output, inability to void; presence of fever/chills.Prompt interventions may prevent more serious complications.
Discuss necessity of notifying other healthcare providers of diagnosis.Reduces risk of inappropriate therapy, e.g., use of decongestants, anticholinergics, and antidepressants, which can increase urinary retention and may precipitate an acute episode.
Reinforce importance of medical follow-up for at least 6 mo to 1 yr, including rectal examination, urinalysis.Recurrence of hypertrophy and/or infection (caused by same or different organisms) is not uncommon and requires changes in therapeutic regimen to prevent serious complications.

References

  • Gillenwater, J., Grayhack, J., Howards, S. & Mitchell, M. (2002). Adult and pediatric urology. Philadelphia, PA: Lippincott Williams & Wilkins. 
  • Lange, P. & Adamec, C. (2011) Prostate cancer for dummies. Hoboken, NJ: John Wiley & Sons.
  • Mayo Clinic Staff. (2015). Benign prostatic hyperplasia. Mayo Clinic. Retrieved September 25, 2015 from http://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/basics/definition/con-20030812.   
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Danica is a Registered Nurse in the Philippines who used to work as an Occupational Health Nurse in a pharmaceutical company. She opted to devote and exemplify her profession through writing. She is an Academic Writer for more than three years. A mother of adorable 5 year old girl and an entrepreneur who started designing and making customized and originally crafted bags.