Benign pro-static hyperplasia (BPH)@nursesoutlook

INTRODUCTION

Benign prostatic hyperplasia (BPH) is not simply a case of too many prostate cells. Prostate growth involves hormones, occurs in different types of tissue (e.g., muscular, glandular), and affects men differently. As a result of these differences, treatment varies in each case. There is no cure for BPH and once prostate growth starts, it often continues, unless medical therapy is started.  The prostate grows in two different ways. In one type of growth, cells multiply around the urethra and squeeze it, much like you can squeeze a straw. The second type of growth is middle-lobe prostate growth in which cells grow into the urethra and the bladder outlet area.This type of growth typically requires surgery.
The likelihood of developing an enlarged prostate increases with age.
BPH is so common that it has been said all men will have an enlarged prostate if they live long enough.
A small amount of prostate enlargement is present in many men over age 40 and more than 90% of men over age 80.

• age

• herediatry

• effect of chronic inflammation

• socio economic status

• race

DEFINITON

Benign prostatic hyperplasia (BPH) also known as benign prostatic hypertrophy (technically a misnomer), benign enlargement of the prostate (BEP), and adenofibromyomatous hyperplasia, refers to the increase in size of the prostate.

CAUSESThe cause of benign prostatic hyperplasia is unknown. It is possible that the condition is associated with hormonal changes that occur as men age. The testes produce the hormone testosterone, which is converted to dihydro-testosterone (DHT) and estradiol (estrogen) in certain tissues. High levels of dihydrotestosterone, a testosterone derivative involved in prostate growth, may accumulate and cause hyperplasia. How and why levels of DHT increase remains a subject of research
EPIDEMIOLOGY
The prostate gets larger in most men as they get older, and, overall, 45% of men over the age of 46 can expect to suffer from the symptoms of BPH if they survive 30 years. Incidence rates increase from 3 cases per 1000 man-years at age 45–49 years, to 38 cases per 1000 man-years by the age of 75–79 years. Whereas the prevalence rate is 2.7% for men aged 45–49, it increases to 24% by the age of 80 year .For some men, the symptoms may be severe enough to require treatment.

PATHOPHYSIOLOGY Benign Prostatic Hyperplasia is an abnormal increase in number of normal cells in the prostate, rather than an increase in cell size. Thus although the disease wan known as  benign prosthetic hyperplasia is more accurate name. With ageing, peri urethral glands undergo hyperplasia . gradually they grow and compress surrounding normal pro static tissue, pushing it towards the gland periphery, forming a false or surgical capsule. Many theories have been postulated concerning the pathophysiology. For BPH to occur  5α dihydroxytestesterone ( DHT) must be present and client must be ageing. DHT , the main prostatic androgen produced when testosterone is acted on by 5α – reductase. Is more potent androgen within the prostate than testosterone itself. DHT , not testosterone , produces growth of prostatic tissue.  The thory is that with BPH , increased level of DHT combined with increased  5α – reductase activity leads to hyperplasia of prostate tissue .  Aging on the other hand lowers testosterone levels In relation to estrogen level. Increased estrogen level increase the longevity of prostatic cells. So cell death decreases . this leads to more cell being available to be acted on by the DHT.   Which leads to further hyperplasia

CLINICAL MANIFESTATION

1. Lack of force of urinary stream

1. Weak and dribbling stream

1. Unable to empty the his bladder

1. Blood in urine ( hematuria )

1. Complete urinary obstruction

DIAGNOSTIC EVALUATION 

Physical examination

Blood studies

X= ray

prostate specific antigen ( PSA ) test

trans rectal ultrasound

digital rectal examination

MANAGEMENT
Testosterone-ablating agents decrease the amount of circulating testosterone level, leading to suppression of prostatic tissue growth. Estrogen inhibit prostatic growth by suppressing release of leuteinizing hormone – releasing agent, leading to decrease in testosterone . 

Trade name	Generic name	Action	Dosage	Route	Frequency
Inj.Taxim	Cefotaxim	Antibiotics	1gm	IV	Twice in a day
Inj. Tramadol	tramadol	Analgesics	100mg	IM	6 hourly
Inj. Campose		sedative			Necessary

  

The major goal of collaborative management is to
·        Restore the bladder drainage
·        Relieve the patient symptoms
·        Prevent or treat the complication of BHP
The preliminary treatment of BPH  is now referred as to “ watchful waiting” . The numerous treatment options for BPH can be categorized as
Ø  Pharmacological therapy
Ø  Nonsurgical invasive options
Ø  Surgical  invasive options

Pharmacological teherapyTestosterone –ablating agents . :-
Testosterone-sparing agent :-A 5 –α reductase inhibitor that blocks dihydrotestosterone without suppressing  circulating testosterone. Decrease prostatic tissue without affecting potency or libido
Alpha- adrenergic blocking agent:-
There is abundant automatic innervation of the bladder neck and prostatic smooth muscle. Prostatic obstruction is due in part to the neurogenic tone of the bladder neck and prostatic smooth muscle. These agents block the alpha receptors , improving urination by decreasing outlet obstruction




Nonsurgical invasive options
Intermittent catheterization or an indwelling catheter can temporarily  be used to reduce symptoms and bypass the obstruction. Long term catheter should be avoided due to risk of infection.Prostatic Balloon dilation, which is used balloon device to dilate the urethra by stretching , fracturing or compressing the gland to enlarge the passage and allow for  free flow of urine. After the dilation the balloon is removed and check for  increase in diameter of urethra . if the procedure is successful the indwelling catheter is left for the first 24 hours for monitor the urine output and hematuria .
Microwave therapy  i
o   Transurethreal prob  ( 107.6⁰-111⁰ F) obstruction is relived through inflammatory reaction
o   Transrectal probe      (below 110⁰F) prevent rectal tissue damage

Surgical  invasive options
Surgery is most common means of relieving urinary obstruction caused by BPH. The main indications for surgery is
§  Decrease urine flow
§  Persistent residual urine
§  Acute rinary retention
Laser Ablation :-
A  transurethral , ultrasound guided , laser indused prostectomy (TULIP) os a specially designed laser used to decrease the obstructive tissue.
A second approach is visual laser ablation of prostate (VLAP),which  uses a standard cystoscope and allow direct visualization
Transurethral Resection of the Prostate
Transurethral Resection of the Prostate  is most common route for partial removal of the prostate. No external surgical incision is made because a resectoscope is passed through the urethra to excise and cauterize prostatic tissue. A large ( no;18 to no:22 ) three way indwelling catheter with a 30 ml balloon containing 30- 60 ml of sterile water is usually inserted into the bladder after the procedure to provide homeostasis and facilitate urinary drainage. The bladder irrigated continuously or intermittently to prevent obstruction due to blood clot and mucus threads.
Transurethral   Incision of the Prostate
It is done when an extremely large mass of tissue obstructs the urethra.This technique removes the gland completely. The prostate is approached through low midline abdominal incision that cuts through the bladder to the anterior aspect of the protate. Suprapubic catheter is required to prevent pressure in the suture site. And place an indwelling catherter with 30 ml balloon is placed in bladder via urethre to prevent strictures . the bladder irrigate continuously.
Retro pubic Resection :-The retropubic Resection is used to remove a massive gland located high in the pelvic area. A low midline abdominal incision is made tint to the prostate gland . after the surgery place an indwelling catherter with 30 ml balloon is placed in bladder via urethre. A surgical drain may be left at the site of the abdominal incision to remove drain.
Perineal Resection :This approach is rare occasions to remove large mas located in the pelvic area or for cancer of the prostate. The incision is made between the scrotum and anus . the bowel is prepared with enemas , antibiotics and low residual diet . after the surgery an indwelling catheter with 30 ml balloon is left in urethra and also provide a surgical drain in the site of incision.
COMPLICATION OF  BPH
Retrograde ejaculation - If during surgery the muscle that is involved in ejaculation may be cut, semen may travel backward into the bladder during an orgasm, instead of traveling out of the body through the urethra.
Blood clots.Excessive bleeding