Benign prostatic hyperplasia (BPH) is a common problem that affects the quality of life in approximately one-third of men older than 50 years. BPH is histologically evident in up to 90% of men by age 85 years. In the United States, as many as 14 million men have symptoms of BPH worldwide, approximately 30 million men have symptoms related to BPH.
BPH refers to the nonmalignant growth or hyperplasia of prostate tissue and is a common cause of lower urinary tract symptoms in men. Cellular accumulation and gland enlargement may result from epithelial and stromal proliferation, impaired preprogrammed cell death (apoptosis), or both. BPH is considered a normal part of the aging process in men and is hormonally dependent on testosterone and dihydrotestosterone (DHT) production.
Benign Prostatic Hyperplasia
The prostate is a walnut-sized gland that forms part of the male reproductive system. It is located anterior to the rectum and just distal to the urinary bladder. It is in continuum with the urinary tract and connects directly with the penile urethra. The traditional theory behind BPH is that, as the prostate enlarges, the surrounding capsule prevents it from radially expanding, potentially resulting in urethral compression.
Non-modifiable and modifiable risk factors also contribute to the development of BPH. These have been shown to include metabolic syndrome, obesity, hypertension, and genetic factors. Metabolic syndrome refers to conditions that include hypertension, glucose intolerance/insulin resistance, and dyslipidemia. Obesity is associated with an increased risk of BPH in observational studies. Proposed mechanisms include increased levels of systemic inflammation and increased levels of estrogen. Genetic predisposition to BPH has been demonstrated in cohort studies, first-degree relatives in one study demonstrated a four-fold increase in the risk of BPH compared to control.
Nursing care planning for clients diagnosed with BPH includes a focused assessment of the medical history in all aspects of symptomatology. Physical examination should include abdominal examination and examination of the external genitalia. The role of the nurse can help address the adherence to lifestyle factors affecting BPH through diet advice, weight loss, and glycemic control. The following are nursing diagnoses associated with the management of BPH.
- Acute/Chronic Urinary Retention
- Risk for Deficient Fluid Volume
BPH Nursing Care Plan
Below are sample nursing care plans for the problems identified above.
Acute/Chronic Urinary Retention
Static obstruction is a direct consequence of prostate enlargement resulting in periurethral compression and bladder outlet obstruction. Obstruction-induced bladder dysfunction contributes significantly to lower urinary tract symptoms (LUTS). the bladder may gradually weaken and lose the ability to empty, leading to increased residual volume and acute or chronic urinary retention.
- Acute/Chronic Urinary Retention
- Mechanical obstruction
- Enlarged prostate
- The inability of the bladder to contract adequately
- Urinary frequency, hesitancy
- Inability to empty the bladder completely
- Incontinence and dribbling of urine
- Bladder distention, residual urine
After implementation of nursing interventions, the client is expected to:
- Void in sufficient amounts with no palpable bladder distention.
- Demonstrate postvoid residuals of less than 50ml, with the absence of dribbling of urine or overflow.
- Demonstrate techniques or behaviors to alleviate/prevent retention.
|Assess the client for incidences of stress incontinence when moving, sneezing, coughing, laughing, or 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.||Observing the client’s urinary stream may be useful in evaluating the degree of obstruction and choice of intervention.|
|Note the presence of pathological conditions and current medication use.||Medical history should include relevant prior and current illnesses, as well as prior surgery and trauma. Current medication, including over-the-counter drugs and phytotherapeutic agents, must be reviewed. Assess for effects of medications such as psychotropics, anesthesia, opiates, sedatives, and antihistamines.|
|Monitor vital signs closely. Observe for hypertension, peripheral or dependent edema, and changes in mentation.||Loss of kidney function results in decreased fluid elimination and accumulation of toxic wastes and may progress to complete renal shutdown.|
|Percuss and palpate the suprapubic area and assess the external genitalia.||A distended bladder can be felt in the suprapubic area. Physical examination should include looking for a palpable bladder or loin pain and assessment for meatal stenosis or phimosis.|
|Encourage the client to void every 2 to 4 hours and when the urge is noted.||Scheduled voiding may minimize urinary retention and overdistention of the bladder.|
|Educate the client to monitor and document their voiding time and urinary output at home.||Urinary 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.|
|Encourage oral fluids up to 3,000L/day daily, if not contraindicated.||Increased circulating fluid maintains renal perfusion and flushes kidneys, bladder, and ureters of sediment and bacteria. Note: Fluids may be restricted to prevent bladder distention if a severe obstruction is present or until the adequate urinary flow is reestablished.|
|Encourage the client to perform meticulous catheter and perineal care.||Proper perineal hygiene reduces the risk of ascending infection. Urinary tract infection may also occur due to incomplete bladder emptying resulting in incomplete bladder emptying and stagnant urine.|
|Encourage the client to increase intake of foods low in fat and high in protein.||Data from the Prostate Cancer Prevention Trial revealed that a diet low in fat and fed meat and high in protein and vegetables may reduce the risk of symptomatic BPH.|
|Monitor laboratory studies, such as BUN, creatinine, and electrolytes.||Prostatic enlargement with obstruction eventually causes dilation of the upper urinary tract, ureters, and kidneys, potentially impairing kidney function and leading to uremia.|
|Review the client’s prostate-specific antigen (PSA) result.||PSA testing can be considered for men who have at least a 10-year life expectancy and desire screening, after an appropriate discussion of its risks and limited benefits. PSA may be used to estimate the size of the prostate.|
|Administer medications, as prescribed.||Medications have long been used as first-line therapy for clients with mild to moderate symptoms. 5-a-reductase inhibitors reduce the size of the prostate and decrease symptoms if taken long-term; alpha-adrenergic antagonists block the effects of postganglionic synapses that affect smooth muscle and exocrine glands and reduce adverse urinary tract symptoms; antispasmodics/antimuscarinics reduces smooth muscle tone and improve symptoms in those with an overactive bladder.|
|Catheterize for residual urine and attach indwelling catheter, as indicated.||An indwelling catheter relieves and prevents urinary retention and rules out the presence of ureteral stricture. A Coude catheter may be required because the curved tip eases the passage of the tube around the enlarged prostate.|
|Assist in obtaining specimens for urinalysis and culture.||Urinary stasis potentiates bacterial growth, increasing the risk of urinary tract infection. A urine culture may be useful to exclude infectious causes or irritative voiding. It is usually performed if the initial urinalysis findings indicate an abnormality.|
|Prepare for procedures such as the following:|
|Transurethral resection surgery focuses on debulking the prostate to produce an adequate channel for urine to flow.|
||Previously, open prostatectomy allowed adenoma to be removed or enucleated off its capsule. This can now be achieved with laser enucleation, referred to as HoLEP. Meta-analysis shows improved Qmax (flow rate), reduction in post-void residual, and IPSS compared to TURP.|
||Most minimally invasive therapies rely on heat to destroy prostatic tissue. this heat is delivered in a limited and controlled fashion, in the hope of avoiding the complications associated with TURP. Heat may be delivered in the form of laser energy, microwaves, radiofrequency energy. high-intensity ultrasound waves, and high-voltage electrical energy.|
|Prepare and assist for other procedures, such as photoselective vaporization, also called laser ablation.||The procedure is done to quickly create a wide-open prostatic fossa, often resulting in immediate restoration of normal urine flow. The procedure can be performed on an outpatient basis or in short-stay settings.|
Risk for Deficient Fluid Volume
Chronic retention is commonly referred to as either high or low-pressure retention. High-pressure chronic retention commonly occurs in bladder outflow obstruction as a result of high detrusor pressures required to overcome the obstruction. The persistence of this high pressure causes reflux and subsequent hydronephrosis. Over time this can result in an insidious deterioration in renal function. Following catheterization, the client may undergo post-obstructive diuresis characterized by increased urine output in the following 24 to 72 hours.
- Risk for Deficient Fluid Volume
- Post-obstructive diuresis from rapid drainage of a chronically overdistended bladder
- Endocrine, electrolyte imbalances, such as in renal dysfunction
- (Not applicable; the presence of signs and symptoms establishes an actual diagnosis)
After implementation of nursing interventions, the client is expected to:
- Maintain adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good capillary refill, and moist mucous membranes.
- Identify individual risk factors and appropriate interventions.
- Demonstrate lifestyle changes or behaviors to prevent the development of fluid volume deficit.
|Monitor intake and output carefully.||Note the output of 100 to 200 ml/hr. Rapid or sustained diuresis could cause the client’s total fluid volume to become depleted and limits sodium reabsorption in renal tubules.|
|Monitor the BP and pulse rate.||Hypovolemia may cause a decrease in cardiac output, leading to hypotension caused by a decreased preload. The body compensates with the increased sympathetic tone resulting in increased heart rate.|
|Evaluate capillary refill and oral mucous membranes.||This enables early detection of and intervention for systemic hypovolemia. Markers of reduced perfusion include deranged physical findings such as delayed capillary refill time and dry mucous membranes.|
|Encourage increased oral intake based on individual needs.||The client may have restricted oral intake in an attempt to control urinary symptoms, reducing homeostasis reserves and increasing the risk of dehydration and hypovolemia.|
|Promote decreased intake of alcoholic beverages and moderate consumption of caffeine.||The intake of high levels of alcohol reduces plasma testosterone concentration, with decreased production and increased metabolism; thus the alcohol intake influences the androgen balance. Caffeine stimulates the adrenergic nervous system (smooth muscles of the prostate) and may worsen BPH symptoms.|
|Encourage the client to eat foods low in cholesterol and unsaturated fatty acids.||High consumption of unsaturated fatty acids may contribute to lipid peroxidation of the cell membrane and of the components and fluidity of cell membranes, which may affect 5z-reductase activity. Cholesterol has been associated with both BPH and prostate cancer. Reducing consumption of these foods can benefit BPH clients by reducing inflammatory triggers.|
|Promote bed rest with the head elevated.||Keeping the head elevated while lying down decreases cardiac workload, facilitating circulatory homeostasis.|
|Monitor electrolyte levels, especially sodium.||As fluid is pulled from extracellular spaces, sodium may follow the shift, causing hyponatremia.|
|Educate the client about zinc and vitamin D supplementation.||Zinc supplementation resulted in a reduction of prostate size as well as symptoms of BPH. This may be attributed to blockade of 5-alpha-reductase and/or inhibition of prolactin, resulting in decreased uptake of testosterone by the prostate. An increased intake of vitamin D from diet and supplements has shown a correlation with a decrease in BPH prevalence. vitamin D attaches to its receptors in the prostate and bladder and inhibits prostate growth, lowers excessive contractility, and reduces inflammation.|
|Administer intravenous fluids- hypertonic saline as needed.||IV fluids replace fluid and sodium losses to prevent or correct hypovolemia following outpatient procedures.|
Men diagnosed with BPH commonly have lower urinary tract symptoms (LUTS), including frequency, urgency, and hesitancy, which cause significant distress. Recent evidence has shown a bidirectional relationship between LUTS and mental health. Results of the study show a higher prevalence of anxiety in younger individuals (18-64 years) with BPH as compared to older individuals (65+ years).
- Change in health status
- Possibility of surgical procedure or malignancy
- Embarrassment; loss of dignity associated with genital exposure before, during, and after treatment
- Concern about sexual ability
- Increased tension, apprehension, and worries
- Expressed concerns regarding perceived changes
- Fear of unspecific consequences
After implementation of nursing interventions, the client is expected to
- Appear relaxed.
- Verbalize accurate knowledge of the situation.
- Demonstrate the appropriate range of feelings and lessened fears.
- Report anxiety is reduced to a manageable level.
|Assess the client’s perception of the threat represented by the situation.||A study conducted in Singapore revealed that there was a high prevalence of anxiety (10.3%) and depression (21.6%) among clients diagnosed with BPH. Studies have demonstrated a diverse array of adverse impacts on personal and public health, including mental health as well as health-related quality of life.|
|Assess the client’s level of anxiety.||The Hospital Anxiety and Depression Scale (HADS) is a self-administered questionnaire specifically designed for screening anxiety and depressive symptoms. An observational study reported a higher level of anxiety with 35.9% of men with LUTS who met the criteria for clinical anxiety (HADS-A).|
|Assess verbal and nonverbal cues of anxiety.||Nurses should carefully observe and interpret the anxiety of clients as reflected in nonverbal negative behaviors as well as any anxiety that is expressed verbally.|
|Be available to the client. Establish a trusting relationship with the client and their family members.||This demonstrates concern and willingness to help. When the client trusts the nurse, this encourages discussion of sensitive subjects.|
|Encourage the client and the family members to verbalize concerns and feelings.||Verbalization helps define the problem, providing an opportunity to answer questions, clarify misconceptions, and problem-solve solutions. While the client may be ashamed to talk about this delicate subject, the nurse should encourage the client to express his concerns and fears by establishing safe and professional forms of communication.|
|Provide information about specific procedures and tests and what to expect afterward.||Providing information helps the client understand the purpose of what is being done and reduces concerns associated with the unknown, including the fear of cancer. Inform them of what to expect after tests and procedures such as a catheter, bloody urine, and bladder irritation. However, be aware of how much information the client wants. Overload of information is not helpful and may increase anxiety.|
|Maintain a matter-of-fact attitude in doing procedures and dealing with the client. Protect the client’s privacy.||This communicates acceptance and eases the client’s embarrassment.|
|Educate the client about coping strategies to reduce anxiety.||The client should be taught coping strategies for reducing and resisting the emotional stress created by events or situations that cause anxiety. Methods used by nurses to assist clients to cope with anxiety include practices such as progressive relaxation exercises, slow and deep breathing, distraction, active imagination, music therapy, hypnosis, biofeedback, and aromatherapy.|
|Provide a calm and comfortable environment.||The client’s room should be quiet, well-ventilated, and clean with a suitable temperature to ensure their comfort.|
|Reinforce previous information the client has been given.||This allows the client to deal with reality and strengthens trust in caregivers and the information presented.|
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