Benign prostatic hyperplasia (BPH): Nursing process (ADPIE)

Martin Lewis is a 68-year-old client who presented to his community health clinic complaining of recurring trips to the bathroom, a frequent urge to urinate, and a weak urine stream that dribbles.

His family physician completed an assessment of his symptoms including a digital rectal exam.

A diagnosis of benign prostatic hyperplasia or BPH is suspected.

The physician ordered several laboratory tests including a basic metabolic panel, prostate specific antigen, and urinalysis to help confirm the diagnosis.

After completing these tests, Martin returns to the clinic two weeks later for a follow-up appointment.

Benign prostatic hyperplasia, or BPH, is a condition where noncancerous cells in the prostate gland increase in number, enlarging the prostate.

This condition is common in men over 50 and is often considered a normal part of aging.

By the age of 60 around 50% of men develop BPH, and over 90% have it by the age of 85.

Other risk factors for developing BPH include obesity, sedentary lifestyle, and family history of BPH.

The exact cause of BPH is not well understood, but current understanding is that environmental and genetic factors play a role along with the influence of the sex hormones tesosterone, dihydrotestosterone, or DHT, and estrogen.

Whatever the cause, the hyperplastic growth of prostatic smooth muscle and epithelial tissue enlarges the prostate which then compresses the urethra, obstructing the flow of urine.

BPH can be asymptomatic, but when symptoms are present, they include lower urinary tract symptoms, such as urinary urgency, hesitancy, which is trouble initiating urination, a weak urine stream, dribbling and straining to urinate, and nocturia.

These symptoms significantly impair quality of life.

If the bladder isn't emptied completely it can eventually cause kidney damage and even lead to kidney failure if not treated.

Also, the stasis of urine in the bladder increases the chance of kidney stones forming and it promotes bacterial growth which can lead to urinary tract infections or prostatitis, which is an infection in the prostate.

Fortunately, BPH does not increase the risk of developing cell mutations that lead to prostate cancer.

Benign prostatic hyperplasia is diagnosed by history and physical examination with a digital rectal examination, which is where a finger is inserted into the rectum to feel the prostate against the anterior wall of the rectum.

Levels of prostate specific antigen, or PSA, which is a substance produced by healthy prostate cells, are also elevated in benign prostatic hyperplasia, since there are more cells making the PSA.

A bladder scanner, which is a portable hand-held ultrasound device, can determine the post void residual volume which is the amount of urine left in the bladder after urinating.

Post void residual volume of greater than 100mL suggests urinary retention.

If an infection is suspected, a urine sample is collected for urinalysis and culture.

Treatment of BPH focuses on relieving the obstruction and allowing the urine to flow normally.

For mild symptoms, lifestyle changes may be enough to manage symptoms, such as avoiding liquids 1 to 2 hours before bedtime to reduce nocturia, retraining the bladder by scheduling regularly timed toileting, and attempting urination in complete privacy.

Placing feet solidly on the floor helps relax the pelvic muscles and encourages voiding, and double voiding promotes more efficient bladder evacuation.

This involves waiting for a few minutes, urinating, then trying to empty the bladder again.

Treatments include medications like alpha blockers, such as tamsulosin, which relax the muscles near the prostate and relieve the pressure on the urethra, allowing urine to follow more easily.

Other medications like finasteride, a 5α-reductase inhibitor, reduce the size of the prostate by inhibiting the conversion of testosterone into dihydrotestosterone.

If medications are not enough to relieve symptoms, there are surgical procedures that can help.

This includes techniques to ablate, or destroy, prostatic tissue using procedures such as transurethral resection of the prostate, which uses electrocautery energy; aquablation, that uses high pressure saline; and photoselective vaporization of the prostate, that uses laser energy.

Another procedure, a transurethral incision of the prostate, is where prostate tissue is left in place, but the urethra is widened.

In certain cases a prostatectomy, where all the prostate tissue is removed, is performed.

Okay, let’s get back to our client Martin and perform an assessment.

You enter the examination room where Martin has been waiting and introduce yourself as the registered nurse, wash your hands, and confirm his identity.

You ask Martin how he is feeling today, and he responds that he has been feeling fine, but during the past several months he’s been having difficulty urinating.

He says he used the bathroom just 10 minutes ago but his bladder still feels full.

Sometimes he has to push to get the flow started, and the flow is weak.

He often has to start and stop while urinating.