Nursing Care for Benign Prostatic Hyperplasia (BPH)

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland. Because of its position, surrounding the posterior part of the urethra, an enlargement of the gland causes an obstruction to the outflow of urine. The enlargement is due to the development of nodules inside the gland. This is usually due to the effect of androgens on the prostatic cells, but can also be due to inflammation secondary to obesity, chronic infection and autoimmune disease.

Who’s most at risk for BPH?

Individuals most at risk for BPH are generally older men. In fact, it’s estimated that 70% of men age 60 to 69 have BPH, while 80% of men older than 70 have the condition. Additionally, genetics may play a role and a man who has a family history of bladder cancer (not prostate cancer) is at higher risk. 

Some modifiable risk factors for BPH are obesity, metabolic syndrome, excess caffeine intake, sedentary lifestyle, excessive alcohol consumption (defined as three or more drinks per day).

What are the complications of BPH?

Complications of BPH include:

• Acute urinary retention
• Urinary tract infection (UTI)
• Bladder stones
• Renal failure due to hydronephrosis
• Thickening of the bladder wall, which leads to weakening and an inability to empty fully

Next, you’ll learn how to care for patients with BPH using the Straight A Nursing LATTE Method. Ready? Let’s do this!

L: How does the patient LOOK?

The signs and symptoms of BPH are generally focused on urinary issues. However, it’s important to note that in some cases, BPH can be asymptomatic, especially in the early stages. The urinary symptoms can be categorized into storage issues and emptying or voiding issues.

Issues around urine storage include urinary frequency and urgency, nocturia and, in some cases, incontinence. Issues around emptying include a slow or weak stream of urine, straining to void, the urine stream stopping and starting during voiding, urinary hesitancy, and dribbling after voiding.

And, obviously, the patient with BPH will have an enlarged prostate which is discovered with a digital rectal examination performed by the physician or nurse practitioner. 

A: How do you ASSESS the patient with BPH?

The main assessments for BPH are going to be around the patient’s urinary habits, history and current symptoms. 

• Assess for hematuria, which can be due to congested vessels in the prostate or bladder. Note that hematuria could be a sign of a more serious condition, such as cancer.
• Assess for urinary retention by using a bladder scanner to assess the volume of urine in the bladder. You can also assess for abdominal distention which indicates bladder distention is present.
• Assess for post-void residual (PVR) after the patient voids. You can do this with a bladder scanner, or by performing a straight cath procedure. A PVR of less than 50 ml indicates adequate bladder emptying, while a PVR above 200 ml is considered abnormal.
• Ask the patient about issues with incontinence and how many times he urinates at night (nocturia).
• Evaluate the patient’s current medications as some can cause issues with voiding such as anticholinergics and sympathomimetics. 

T: What TESTS are ordered for benign prostatic hyperplasia?

Benign prostatic hyperplasia is diagnosed by the physician or nurse practitioner based on the presence of symptoms and the absence of other conditions that could cause those symptoms. Specific tests include:

• BPH Symptom Score Index – This is a tool developed by the American Urological Association to assess urinary symptoms. It includes seven areas that are scored based on how severe the symptoms are for the patient. The seven areas are incomplete emptying, frequency, intermittency, urgency, weak stream, straining to void and nocturia. A score of above 20 is considered severely symptomatic.
• Urinalysis – A urinalysis may be conducted to rule out other problems such as cancer, diabetes or UTI. The urinalysis will detect the presence of protein, blood, pus, glucose or bacteria in the urine.
• Urine culture – If UTI is suspected, a urine culture will provide information about the specific pathogen.
• Serum creatinine – Renal impairment can be both a cause of the symptoms and a complication of BPH, such as bladder outlet obstruction or hydronephrosis. A normal creatinine level for an adult male is generally around 0.7 to 1.3 mg/dL. 
• Prostate-specific antigen (PSA) – Though a test for prostate cancer, PSA levels are higher than normal in BPH and will increase as the prostate grows. This doesn’t mean the individual has cancer, though higher levels could indicate higher risk for prostate cancer in the future. Note that there are other reasons for an elevated PSA level such as vigorous bike riding and TURP surgery.)
• PSAD (PSA density) – This test may be conducted to differentiate if the cause of the elevated PSA level is due to BPH or prostate cancer. 
• Uroflowmetry – A uroflowmetry examines how fast the urine flows. Slower flowing urine is a sign of BPH.
• Postvoid residual volume test – Use a bladder scanner (ultrasound) or perform a straight cath procedure to measure the amount of retained urine after the patient voids. A PVR of less than 50 ml indicates adequate bladder emptying, while a PVR above 200 ml is considered abnormal.
• Cystoscopy – This exam utilizes a scope or camera to visualize the urethra and or the bladder. If the urethra narrows at the location of the prostate gland, this is a sign of an enlarged prostate.
• Urodynamic pressure flow study – This examination tests the pressure in the bladder during urination. It evaluates how much pressure the bladder requires before urination occurs, and how quickly the urine flows at that pressure. This test is likely to be done if the patient had a prior procedure for BPH but continues to have symptoms.
• Ultrasound – An ultrasound can show the size and shape of the prostate.
• CT and MRI – These are more detailed imaging studies that can determine the size and exactly where the prostate is enlarged. CT and/or MRI are generally conducted prior to surgery.

T: What TREATMENTS are provided for BPH? 

The first line treatment for BPH is lifestyle modification which includes things like limiting fluids before bed, limiting caffeine and alcohol intake, and limiting foods or beverages that irritate the bladder (such as spicy foods). The patient will also be encouraged to increase activity and maintain a healthy weight. 

Other simple things the patient can do to manage BPH symptoms are Kegel exercises, timed voiding and double voiding. Timed voiding means the patient attempts to void at regular intervals such as every 90 or 120 minutes. Double voiding is the practice of trying to void a few minutes after urinating.  

Treatments specific for urinary retention include:

Straight catheterization – A “straight cath” (sometimes called an I/O catheterization) may be performed on a schedule or in cases of acute retention. Because the prostate causes a partial obstruction of the urethra, a smaller gauge catheter may be needed. In some cases, a coude catheter may be necessary. The coude catheter has a slight bend at the tip that helps it get past obstructed areas of the urethra.

Intermittent catheterization is preferred over an indwelling catheter due to the much lower risk for UTI and many patients learn to perform this intervention at home (called “self cath”). Note that I/O catheterization is contraindicated in patients with recent urologic surgery such as a prostatectomy – those patients will either have an indwelling catheter that was placed during surgery or may require suprapubic catheterization instead.  

Medications

The two main types of medications used for BPH are alpha-adrenergic blockers and androgen inhibitors.

• Alpha-adrenergic receptor blockers relieve bladder outlet obstruction by relaxing the prostatic smooth muscle. Common side effects are dizziness, rhinitis, and hypotension. They are typically taken at bedtime to reduce the incidence of postural hypotension.
  • Common medications in this class are tamsulosin (Flomax) and silodosin (Rapaflo). Two medications you may see used are terazosin (Hyrtrin, which is more commonly used in Canada), and doxazosin (Cardura). Please note that both of these medications are considered Beers List drugs, which means they can cause potentially harmful effects in the elderly. Want to learn more about the Beers List? Check out this post here.
• Androgen inhibitors prevent testosterone from converting to dihydrotestosterone. This prevents the progression of BPH by preventing further prostate enlargement, and can cause a reduction in size after 6 to 12 months of usage. These medications cause some pretty unwelcome side effects including lower libido, sexual dysfunction, erectile dysfunction, gynecomastia and breast tenderness (yes, breast tenderness can occur in males, too!).
  • Common medications in this class are finasteride (Propecia – note this is also used to treat male pattern baldness) and dutasteride (Avodart).
• Herbal treatments are commonly used and include saw palmetto, stinging nettle, hypoxis rooperi (African star grass) and pygeum africanum (African plum). However, it’s important to note that they’re not typically recommended by providers due to the lack of FDA approval, and the many interactions they can have with pharmacologic medications.

Surgical treatment

The surgery for benign prostatic hyperplasia is a transurethral resection of the prostate (TURP). In this procedure, the prostate is accessed via a resectoscope inserted through the urethra. A thin filament is threaded through to the prostate and the tissue is trimmed and blood vessels cauterized. The tissue is irrigated out with a continuous flow of fluids and the patient will come out of surgery with continuous bladder irrigation in place. 

After the procedure, monitor the patient’s urine output very closely to assess for volume and color. Initially the urine will be reddish and become lighter in color as bleeding from surgery resolves. Measure output against how much irrigant has been infused. Too much fluid in the bladder could cause it to rupture or lead to hydronephrosis. Additionally, keep a close eye on the catheter for clots and kinks that could obstruct outflow.

Complications of TURP include UTI (due to the indwelling catheter), ejaculatory dysfunction, urethral strictures, incontinence, hemorrhage and something called TURP syndrome. TURP syndrome is severe hyponatremia that occurs when irrigation fluid (which may be highly hypotonic) is absorbed into the bloodstream during surgery. If TURP syndrome occurs during surgery, the surgery is stopped. Whether it occurs during or after surgery, it is also treated with a diuretic such as furosemide, which eliminates the excess fluid. In some cases, hypertonic saline may be needed. Some signs of TURP syndrome include nausea, vomiting, confusion, bradycardia and hypertension.

The reason hypotonic solutions may be used in TURP is because of the type of cautery system utilized. The electrical conducting properties of “normal saline” prohibit its safe use with conventional monopolar cautery systems. However, thanks to the development of bipolar electrocautery systems, we can now use isotonic saline as an irrigation fluid and instances of TURP are drastically reduced. 

Prostatectomies may also be performed robotically, laparoscopically or via an open approach, though the TURP procedure is more common.

E: How do you EDUCATE the patient about BPH?

A key component of your teaching will be around the behavior and lifestyle modifications for BPH. These include: 

• Teach the patient to keep a 3-day record that tracks when they void and their fluid intake. This is helpful when evaluating symptoms of BPH.
• Teach the patient how to perform Kegel exercises. 
  • Identify the pelvic floor muscles (the muscles used to stop the flow of urine).
  • Tighten these muscles and hold for three to five seconds, then relax for five seconds. Repeat ten times per session and aim for three sessions per day.
  • This may be easier to do when lying down at first, but as the muscles get stronger, they should also perform Kegel exercises while sitting, standing and walking.
• Teach the patient how to utilize timed voiding to help prevent incontinence and double voiding to reduce the volume of urine left in the bladder after urinating.
• Teach the patient to stay hydrated, which helps reduce the risk for UTI.
• Instruct the patient to limit fluids before bed, limiting caffeine and alcohol intake, and limiting foods or beverages that irritate the bladder (such as spicy foods). 
• Inform the patient that physical activity and maintaining a healthy weight are important lifestyle modifications for BPH.
• If taking tamsulosin, advise the patient to avoid driving until they know how the medication affects them.

Specific teaching for TURP procedure

In addition to the risks and benefits of surgery that are explained the surgeon, some key education points are: 

• Avoid strenuous activities for about 6 weeks after the procedure.
• Drink plenty of water to flush out the bladder.
• Constipation can be minimized by eating fiber, staying hydrated and taking a stool softener such as docusate (Colace).
• Avoid sexual activity for 4-6 weeks after surgery.
• Notify the MD if they develop a fever, are unable to urinate, or notice blood or blood clots in the urine.
• If the patient is discharged with an indwelling catheter, teach catheter care:
  • Clean the meatus with soap and water daily
  • Maintain adequate hydration, which helps prevent UTI
  • Keep the bag lower than the bladder to prevent the backflow of urine and UTI
  • Keep the tubing anchored to the thigh to minimize irritation
  • Report blood in the urine and signs of infection (cloudy urine, pain, fever)

Review BPH again while you’re on the go in episode 259 of the Straight A Nursing podcast. Tune in wherever you get your podcast fix, or straight from the website here.

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