Adult Medical-Surgical Adult Medical-Surgical Nursing Nursing

Reproductive Health Module: Reproductive Health Module: Benign Prostatic HyperplasiaBenign Prostatic Hyperplasia

Benign Prostatic Hyperplasia:Benign Prostatic Hyperplasia:DescriptionDescription

A very common condition in older menA very common condition in older men

Benign hyperplasia (enlargement) is thought Benign hyperplasia (enlargement) is thought to be under hormonal influence to be under hormonal influence (testosterone)(testosterone)

The prostate extends upwards into the The prostate extends upwards into the bladder gradually impeding and obstructing bladder gradually impeding and obstructing urine flowurine flow

Benign Prostatic Hyperplasia: Benign Prostatic Hyperplasia: PathophysiologyPathophysiology

Hyperplasia gradually obstructs urine flow Hyperplasia gradually obstructs urine flow from the bladder → from the bladder → acuteacute retention retention (emergency) or (emergency) or partialpartial retention of urine retention of urine

Results in: Results in: A residual pool of urine in the bladder A residual pool of urine in the bladder

following urination following urination Ureteric reflux → hydro-ureter and Ureteric reflux → hydro-ureter and

hydronephrosis (a cause of renal failure)hydronephrosis (a cause of renal failure) Stasis and infection (UTI): pyelonephritisStasis and infection (UTI): pyelonephritis Reduced bladder tone and continenceReduced bladder tone and continence

Benign Prostatic Hyperplasia: Benign Prostatic Hyperplasia: Clinical ManifestationsClinical Manifestations

Frequency of urinationFrequency of urination NocturiaNocturia UrgencyUrgency HesitancyHesitancy Straining to void → occasional haematuriaStraining to void → occasional haematuria Poor stream and dribbling of urinePoor stream and dribbling of urine Sense that bladder not emptiedSense that bladder not emptied Abdominal/ suprapubic distensionAbdominal/ suprapubic distension

Acute Retention of UrineAcute Retention of Urine

*Patients are often admitted as an *Patients are often admitted as an emergency with total urinary obstructionemergency with total urinary obstruction

Acute Retention of Urine: Acute Retention of Urine: Clinical ManifestationsClinical Manifestations

Acute severe supra-pubic pain and Acute severe supra-pubic pain and distensiondistension

Inability to pass urineInability to pass urine Nausea (maybe vomiting)Nausea (maybe vomiting) Neurogenic shock (related to pain)Neurogenic shock (related to pain) (Pyrexia and rigors if urinary tract infection (Pyrexia and rigors if urinary tract infection

and septicaemia → septic shock)and septicaemia → septic shock)

Benign Prostatic Hyperplasia: Benign Prostatic Hyperplasia: DiagnosisDiagnosis

Rectal digital examination: a large soft Rectal digital examination: a large soft rubbery non-tender prostate palpated rubbery non-tender prostate palpated (distinguish from hard, stone-like (distinguish from hard, stone-like malignant prostate) malignant prostate)

Needle biopsyNeedle biopsy Prostate Specific Antigen (PSA) Prostate Specific Antigen (PSA) Residual urine (and urine culture)Residual urine (and urine culture) Renal function testsRenal function tests Creatinine clearance Creatinine clearance

Benign Prostatic Hyperplasia: Benign Prostatic Hyperplasia: ManagementManagement

Medical/ mechanical management (mild)Medical/ mechanical management (mild)

Emergency treatment (acute urinary Emergency treatment (acute urinary retention) retention)

SurgerySurgery

Benign Prostatic Hyperplasia: Benign Prostatic Hyperplasia: Medical/ Mechanical ManagementMedical/ Mechanical Management

May be used in May be used in mild mild cases or if surgery cases or if surgery contra-indicatedcontra-indicated

Smooth muscle relaxant (Terazosin) Smooth muscle relaxant (Terazosin) affects the bladder neckaffects the bladder neck

Dilatation with a balloonDilatation with a balloon Laser resection under ultrasound controlLaser resection under ultrasound control Permanent urinary catheter (urethral or Permanent urinary catheter (urethral or

supra-pubic) under antibiotic cover. Leg supra-pubic) under antibiotic cover. Leg bag can be usedbag can be used

Acute Urinary Retention: Acute Urinary Retention: Emergency TreatmentEmergency Treatment

Analgesia: Morphine (partly given IV) to Analgesia: Morphine (partly given IV) to relieve pain and avoid shockrelieve pain and avoid shock

IV line/ antibiotics in case of shock IV line/ antibiotics in case of shock Immediate catheterisation by an Immediate catheterisation by an

experienced urologist using a silastic firm experienced urologist using a silastic firm catheter to avoid trauma to urethra and catheter to avoid trauma to urethra and maintain patencymaintain patency

Urine is released Urine is released graduallygradually to avoid shock to avoid shock Urine sample for culture Urine sample for culture

Benign Prostatic Hyperplasia: Benign Prostatic Hyperplasia: SurgerySurgery

Surgery is the treatment of preference and Surgery is the treatment of preference and is important in order to avoid:is important in order to avoid:

Renal damage from hydronephrosisRenal damage from hydronephrosis

Pyelonephritis, septicaemia and renal Pyelonephritis, septicaemia and renal damage from urinary stasis and infectiondamage from urinary stasis and infection

Benign Prostatic Hyperplasia: Benign Prostatic Hyperplasia: Surgical Procedures Surgical Procedures

Trans-urethral resection of the prostate Trans-urethral resection of the prostate gland (TURP): cutting via cystoscopegland (TURP): cutting via cystoscope

Supra-pubic resection: via abdominal Supra-pubic resection: via abdominal incision and through the bladderincision and through the bladder

Retro-pubic resection: via abdominal Retro-pubic resection: via abdominal incision behind the bladder (larger gland). incision behind the bladder (larger gland). More prone to infection in retropubic spaceMore prone to infection in retropubic space

All hyperplastic tissue is removed leaving All hyperplastic tissue is removed leaving only the prostate capsule (may re-grow)only the prostate capsule (may re-grow)

Prostatectomy: Prostatectomy: Pre-operative ManagementPre-operative Management

*Patients are mostly elderly. Often operation *Patients are mostly elderly. Often operation performed under spinal anaesthetic. Thorough performed under spinal anaesthetic. Thorough preparation: preparation:

General health assessmentGeneral health assessment Chest physioChest physio Anti-embolism stockingsAnti-embolism stockings Blood coagulation studies (the prostate gland is Blood coagulation studies (the prostate gland is

very vascular)very vascular) CBC (Hb), blood group and cross-matchCBC (Hb), blood group and cross-match Correct any dehydration. Promote nutrition Correct any dehydration. Promote nutrition

Prostatectomy:Prostatectomy:Post-operative ManagementPost-operative Management

ICUICU IVI and blood transfusion as requiredIVI and blood transfusion as required A 3-way Foley catheter is used for continuous A 3-way Foley catheter is used for continuous

irrigation of the bladder with saline to flush irrigation of the bladder with saline to flush away clotsaway clots

IV antibiotics (including Gentamycin to IV antibiotics (including Gentamycin to prevent gram negative shock) (also given prevent gram negative shock) (also given when catheter removed)when catheter removed)

PhysioPhysio Anti-embolism stockings/ leg exercisesAnti-embolism stockings/ leg exercises

Prostatectomy: Prostatectomy: Post-surgical ComplicationsPost-surgical Complications

Haemorrhage: prostate is very vascularHaemorrhage: prostate is very vascular Clot retention: clots post-operatively may Clot retention: clots post-operatively may

block the urinary catheter → obstruction: block the urinary catheter → obstruction: Risks neurogenic shock; also stretches Risks neurogenic shock; also stretches

the prostatic bed → further bleedingthe prostatic bed → further bleeding DVT/ pulmonary embolism: (immobility DVT/ pulmonary embolism: (immobility

and risk of ↑ blood viscosity) and risk of ↑ blood viscosity) Pneumonia Pneumonia Urinary infection → septicaemia (shock) Urinary infection → septicaemia (shock)

Prostate Surgery: Prostate Surgery: Post-op Nursing ResponsibilitiesPost-op Nursing Responsibilities

ICU; IVI and blood transfusion as requiredICU; IVI and blood transfusion as required Careful monitoring of vital signs Careful monitoring of vital signs Accurate intake/ output including irrigationAccurate intake/ output including irrigation Monitor urine colour (for ↑ haemorrhage)Monitor urine colour (for ↑ haemorrhage) Monitor drainage: “milk” clots to encourage Monitor drainage: “milk” clots to encourage

urine flow. Note supra-pubic distension, urine flow. Note supra-pubic distension, pain, restlessness. Bladder washout if pain, restlessness. Bladder washout if required (analgesia important in this case)required (analgesia important in this case)

Encourage ↑ oral fluids. Physio. Antibiotics Encourage ↑ oral fluids. Physio. Antibiotics