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BPH

by John Daemer Halasan Kinoc on Monday, 18 October 2010 at 14:27

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 in
middle-aged and elderly men. To be accurate, the process is one of hyperplasia rather
than hypertrophy, but the nomenclature is often interchangeable, even
amongst urologists (see Textbook of Benign Prostatic Hyperplasia, Roehrborn CG et al.
2002, Chapter 6 "The Pathology of Benign Prostatic Hyperplasia, Bostwick DG). It is
characterized by hyperplasia of prostatic stromal and epithelial cells, resulting in the
formation of large, fairly discrete nodules in the periurethral region of the prostate. When
sufficiently large, the nodules compress the urethral canal to cause partial, or sometimes
virtually complete, obstruction of the urethra, which interferes the normal flow of urine.
It leads to symptoms of urinary hesitancy, frequent urination, dysuria (painful urination),
increased risk of urinary tract infections, and urinary retention. Although prostate specific
antigen levels may be elevated in these patients because of increased organ volume
andinflammation due to urinary tract infections, BPH is not considered to be
a premalignant lesion.

Adenomatous prostatic growth is believed to begin at approximately age 30 years. An


estimated 50% of men have histologic evidence of BPH by age 50 years and 75% by age
80 years. In 40-50% of these patients, BPH becomes clinically significant.[1]

Lifestyle

Patients should decrease fluid intake before bedtime, moderate the consumption of
alcohol and caffeine-containing products, and follow timed voiding schedules.

[edit]Medications

The two main medications for management of BPH are alpha blockers and 5α-reductase
inhibitors.

• Alpha blockers (technically α1-adrenergic receptor antagonists) are the most


common choice for initial therapy in the USA[15][16] and Europe.[17] Alpha
blockers used for BPH include doxazosin,[18] terazosin, alfuzosin,[19]
[20] tamsulosin, and silodosin. All five are equally effective but have slightly
different side effect profiles.[21] The older
drugs phenoxybenzamine and prazosin are not recommended.[22] Alpha blockers
relax smooth muscle in the prostate and the bladder neck, thus decreasing the
blockage of urine flow. Common side effects of alpha blockers include orthostatic
hypotension, ejaculationchanges, nasal congestion, and weakness.
• The 5α-reductase inhibitors finasteride[23] and dutasteride[24] are another
treatment option. These medications inhibit 5a-reductase, which in turn inhibits
production of DHT, a hormone responsible for enlarging the prostate. Effects may
take longer to appear than alpha blockers, but they persist for many years.
[25] When used together with alpha blockers, a reduction of BPH progression to
acute urinary retention and surgery has been noted in patients with larger
prostates.[26] Side effects include decreased libido and ejaculatory or erectile
dysfunction.[23]

Antimuscarinics such as tolterodine may also be used, especially in combination with


alpha blockers.[27] They act by decreasing acetylcholine effects on the smooth muscle of
the bladder, thus helping control symptoms of an overactive bladder.

Sildenafil citrate shows some symptomatic relief, suggesting a possible common etiology
with erectile dysfunction.[28]

[edit]Herbal remedies

People often seek herbal remedies for BPH.[29] Several are approved in European
countries, but none in the USA. Saw palmetto extract from Serenoa repensis one of the
most extensively studied. It showed promise in early studies,[30] though later trials of
higher methodological quality indicated no difference from placebo.[31][32][33]

Other herbal medicines that have research support in systematic reviews include beta-
Sitosterol[34] from Hypoxis rooperi (African star grass) and pygeum(extracted from the
bark of Prunus africana),[35] while there is less substantial support for the efficacy of
pumpkin seed (Cucurbita pepo) and stinging nettle(Urtica dioica) root.[36] There is
weak evidence that pollen extracts frp, rye grass (Secale cereale) may also correlate with
modest symptomatic relief.[37]

[edit]Minimally invasive therapies

The European Urology Review[38] published in 2009 that two Israeli doctors, Yigal Gat
and Menahem Goren, who discovered the main reason for the gland's enlargement, have
also developed the Gat-Goren nonsurgical method for BPH.[39] Using an interventional
radiological technique that reduces prostate volume and reverses BPH symptoms, the
treatment, known as super-selective intra-prostatic androgen deprivation (SPAD) therapy,
involves a percutaneus venography and sclerotherapy of the internal spermatic vein
network, including associated venous bypasses and retroperitoneal collaterals. The
European Urology Review also declared that using the Gat Goren nonsurgical method
results in decreased prostate volume, which leads to significantly decreased nocturia,
improved urine stream, and also improves emptying of the urinary bladder, since the
reduction in prostate volume increases the diameter of the prostatic portion of the urethra
and therefore may also prevent urinary retention.
While medication is often prescribed as the first treatment option, there are many patients
who do not achieve success with this line of treatment. Those patients may not achieve
sustained improvement in symptoms or they may stop taking the medication because of
side-effects.[40] There are options for treatment in a urologist's office before proceeding
to surgery. The two most common types of office-based therapies are Transurethral
microwave thermotherapy (TUMT) and Transurethral Needle Ablation (TUNA). Both of
these procedures rely on delivering enough energy to create sufficient heat to cause cell
death (necrosis) in the prostate. The goal of the therapies is to cause enough necrosis so
that, when the dead tissue is reabsorbed by the body, the prostate shrinks, relieving the
obstruction of the urethra. These procedures are typically performed with local
anesthesia, and the patient returns home the same day. Some urologists have studied and
published long-term data on the outcomes of these procedures, with data out to five years.
The most recent American Urological Association (AUA) Guidelines for the Treatment
of BPH in 2003 lists minimally invasive therapies including TUMT and TUNA as
acceptable alternatives for certain patients with BPH.[41]

Transuretheral microwave therapy (TUMT) was originally approved by the FDA in 1996,
with the first generation system by EDAP Technomed. Since 1996, other companies have
received FDA approval for TUMT devices, including Urologix, Dornier, Thermatrix,
Celsion, and Prostalund. Multiple clinical studies have been published on TUMT. The
general principle underlying all the devices is that a microwave antenna that resides in a
urethral catheter is placed in the intraprostatic area of the urethra. The catheter is
connected to a control box outside of the patient's body and is energized to emit
microwave radiation into the prostate to heat the tissue and cause necrosis. It is a one-
time treatment that takes approximately 30 minutes to 1 hour, depending on the system
used. It takes approximately 4 to 6 weeks for the damaged tissue to be reabsorbed into the
patient's body. Some of the devices incorporate circulating coolant through the treatment
area with the intent of preserving the urethra while the microwave energy heats the
prostatic tissue surrounding the urethra.

Transuretheral needle ablation (TUNA) operates with a different type of energy, radio
frequency (RF) energy, but is designed along the same premise as TUMT devices, that
the heat the device generates will cause necrosis of the prostatic tissue and shrink the
prostate. The TUNA device is inserted into the urethra using a rigid scope much like a
cystoscope. The energy is delivered into the prostate using two needles that emerge from
the sides of the device, through the urethral wall and into the prostate. The needle-based
ablation devices are very effective at heating a localized area to a high enough
temperature to cause necrosis. The treatment is typically performed in one session, but
may require multiple sticks of the needles depending on the size of the prostate.

[edit]Surgery

If medical treatment fails, and the patient elects not to try office-based therapies or the
physician determines the patient is a better candidate for transurethral resection of
prostate (TURP), surgery may need to be performed. In general, TURP is still considered
the gold standard of prostate interventions for patients that require a procedure. This
involves removing (part of) the prostate through theurethra. There are also a number of
new methods for reducing the size of an enlarged prostate, some of which have not been
around long enough to fully establish their safety or side-effects. These include various
methods to destroy or remove part of the excess tissue while trying to avoid damaging
what remains. Transurethral electrovaporization of the prostate (TVP), laser TURP,
visual laser ablation (VLAP), ethanol injection, and others are studied as alternatives.

Newer techniques involving lasers in urology have emerged in the last 5–10 years,
starting with the VLAP technique involving the Nd:YAG laser with contact on the
prostatic tissue. A similar technology called Photoselective Vaporization of the Prostate
(PVP) with the GreenLight (KTP) laser have emerged very recently. This procedure
involves a high-power 80-watt KTP laser with a 550-micrometre laser fiber inserted into
the prostate. This fiber has an internal reflection with a 70-degree deflecting angle. It is
used to vaporize the tissue to the prostatic capsule. KTP lasers target haemoglobin as the
chromophore and typically have a penetration depth of 2.0 mm (four times deeper than
holmium).

Another procedure termed Holmium Laser Ablation of the Prostate (HoLAP) has also
been gaining acceptance around the world. Like KTP, the delivery device for HoLAP
procedures is a 550 um disposable side-firing fiber that directs the beam from a high-
power 100-watt laser at a 70-degree angle from the fiber axis. The holmium wavelength
is 2,140 nm, which falls within the infrared portion of the spectrum and is invisible to the
naked eye. Whereas KTP relies on haemoglobin as a chromophore, water within the
target tissue is the chromophore for Holmium lasers. The penetration depth of Holmium
lasers is <0.5 mm, avoiding complications associated with tissue necrosis often found
with the deeper penetration and lower peak powers of KTP.

HoLEP, Holmium Laser Enucleation of the Prostate, is another Holmium laser procedure
reported to carry fewer risks compared with either TURP or open prostatectomy.
[42] HoLEP is largely similar to the HoLAP procedure; the main difference is that this
procedure is typically performed on larger prostates. Instead of ablating the tissue, the
laser cuts a portion of the prostate, which is then cut into smaller pieces and flushed with
irrigation fluid. As with the HoLAP procedure, there is little bleeding during or after the
procedure.

Both wavelengths, KTP and Holmium, ablate approximately one to two grams of tissue
per minute.

Post surgery care often involves placement of a Foley Catheter or a temporary Prostatic
stent to permit healing and allow urine to drain from the bladder.

Surgery Choices
Surgery that does not require an incision through the skin is usually used. The surgical
instruments are passed up the urinary opening in the penis to the location of the prostate.
This is described as a transurethral surgery of the prostate.

Transurethral resection of the prostate (TURP) is the surgery for benign prostatic
hyperplasia that has been studied the most. It is the surgery that is used the most to treat
symptoms of BPH. All other surgeries are compared to TURP. In TURP, part of the
prostate is removed.

Some of the other surgeries that have been studied and compared to TURP include:

• Transurethral incision of the prostate (TUIP), in which incisions are made in the
prostate that cause it to press less on the urethra.
• Laser therapy (transurethral laser coagulation and transurethral laser
vaporization), in which a laser is used to make incisions in or remove a portion of
the prostate.
• Transurethral microwave therapy (TUMT), in which microwave energy is used to
destroy a portion of the prostate through heating.
• Transurethral needle ablation (TUNA), in which a heated needle is used to
destroy a portion of the prostate.

In most cases, these treatments have been studied for only a few years, so their long-term
effectiveness is not yet known. There are some other surgeries that are used in rare cases.

The oldest surgical method to treat BPH is an open prostatectomy, in which an incision is
made through the skin to reach the prostate. Doctors use this method less often now, but
it is still preferred if the prostate is very large.

Transurethral Resection of the Prostate (TURP)

Transurethral resection of the prostate (TURP) is the gold standard to which other
surgeries for BPH are compared. This procedure is performed under general or regional
anesthesia and takes less than 90 minutes.

The surgeon inserts an instrument called a resectoscope into the penis through the
urethra. The resectoscope is about 12 inches long and 3/8 of an inch in diameter. It
contains a light, valves for controlling irrigating fluid, and an electrical loop to remove
the obstructing tissue and seal blood vessels. The surgeon removes the obstructing tissue
and the irrigating fluids carry the tissue to the bladder. This debris is removed by
irrigation and any remaining debris is eliminated in the urine over time.

Patients usually stay in the hospital for about 3 days, during which time a catheter is used
to drain urine. Most men are able to return to work within a month. During the recovery
period, patients are advised to
• avoid heavy lifting, driving, or operating machinery;
• drink plenty of water to flush the bladder;
• eat a balanced diet;
• use a laxative if necessary to prevent constipation and straining during bowel
movements.

Complications of TURP

Blood in the urine (hematuria) is common after TURP surgery and usually resolves by
the time the patient is discharged. Bleeding also may result from straining or activity.
Postsurgical bleeding should be reported to the urologist immediately.

Some patients have initial discomfort, a sense of urgency to urinate, or short-term


difficulty controlling urination. These conditions slowly improve as recovery progresses,
but it is important to remember that the longer the urinary problems existed before
surgery, the longer it takes to regain full and normal bladder function after surgery.

Up to 30% of men who undergo TURP experience problems with sexual function.
Complete recovery of sexual function may take up to 1 year. The most common, long-
term side effect of prostate surgery is retrograde ejaculation (dry climax), which results
when the muscle that closes the bladder neck during ejaculation is removed along with
the obstructing prostate tissue. Semen enters the wider opening to the bladder instead of
being expelled through the penis, causing sterility but not affecting the man's ability to
experience sexual pleasure. This complication is not an issue for most men requiring
prostate surgery.

Read more: Surgical Treatment for BPH, Complications of BPH Surgery - Benign
Prostatic Hyperplasia (BPH)/Enlarged Prostate - Urology
Channel http://www.urologychannel.com/prostate/bph/treatment_surg.shtml#ixzz12gWm
eBBC

Holium Laser Enucleation of the Prostate (HoLEP)

Holmium laser enucleation of the prostate (HoLEP) produces results that are similar to
TURP with fewer complications (e.g., less intraoperative bleeding). In this procedure, a
holmium laser is used to remove obstructive prostatic tissue and seal blood vessels.
HoLEP is usually performed as a day procedure in the hospital.

Benefits of HoLEP over traditional surgery include the following:


• Shorter hospital stay
• Shorter catheterization time
• Shorter recovery time

Approximately 10–15% of patients with large prostates (>100 gm) experience stress
incontinence after undergoing HoLEP. In most cases, incontinence resolves within 6
weeks.

Prostatectomy

If the prostate is greatly enlarged, if the bladder has been damaged, or if the patient has
complications prohibiting transurethral surgery, prostatectomy (removal of the
obstructing prostate) may be necessary. This procedure is sometimes the best and safest
approach.

Prostatectomy is performed under general or regional anesthesia. The surgeon makes an


external incision in the lower abdomen or in the perineum (area between the rectum and
the scrotum). If the surgeon accesses the prostate from the abdomen, the procedure is
called suprapubic or retropubic prostatectomy; surgery through the perineum is
called perineal prostatectomy. Once access is gained, the prostate is removed.

After prostate surgery, a urinary catheter is inserted to ensure bladder emptying. Urine
output and color and continuous bladder irrigation (CBI), if present, are monitored. Blood
in the urine is an expected side effect of prostate surgery. CBI is used to maintain the
effectiveness of the urinary catheter, remove blood clots, and cleanse the surgical area. If
bladder spasms occur, the surgeon should be notified.

Once they have been discharged from the hospital, patients should abstain from sexual
intercourse for 6 weeks after surgery. Strenuous activity and lifting is to be avoided
throughout the recovery period, which can take up to 8 weeks.

Potential complications include incontinence and impotence. Depending on the


procedure, stress urinary incontinence may result when pressure is put on abdominal
muscles. Urge incontinence and involuntary passing of urine while asleep also may
occur.

Patients are encouraged to use Kegel exercises to strengthen pelvic floor muscles and to
increase their water intake. Ejaculatory dysfunction and erectile dysfunction (impotence)
may occur, depending on the procedure.

Transurethral Incision of the Prostate (TUIP)

Transurethral incision of the prostate (TUIP) may be recommended to treat a prostate that
is not greatly enlarged. The surgeon makes one or more cuts in the bladder neck where
the urethra joins the bladder, extending into the prostate. This reduces the prostate's
pressure on the urethra and makes urination easier. TUIP may provide relief with a lower
incidence of retrograde ejaculation than TURP. However, its long-term benefits and risks
compared to TURP have not been established.

Transurethral Ultrasound-guided Laser Incision of the Prostate (TULIP)

Transurethral ultrasound-guided laser incision of the prostate (TULIP) is a new procedure


that is similar to TUIP, except that the cuts are made with a laser.

Read more: Surgical Treatment for BPH, Complications of BPH Surgery - Benign
Prostatic Hyperplasia (BPH)/Enlarged Prostate - Urology
Channel http://www.urologychannel.com/prostate/bph/treatment_surg.shtml#ixzz12gWto
4Mf

Medication to Treat BPH

5-Alpha reductase inhibitors such as finasteride (Proscar®) and dutasteride (Avodart®)


prevent the conversion of testosterone to the hormone dihydrotestosterone (DHT). In
many cases, a treatment period of 6-month is necessary to see if the therapy is going to
work. These drugs are taken orally, once a day. Finasteride is available in tablet form and
dutasteride is available as soft gelatin capsules. Patients should see their physician
regularly to monitor side effects and adjust the dosage, if necessary.

Side effects include reduced libido, impotence, breast tenderness and enlargement, and
reduced sperm count. Long-term risks and benefits have not been studied.

Women who may be pregnant must avoid handling dutasteride capsules and broken or
crushed finasteride tablets because exposure to the drugs may cause serious side effects
to the fetus. Intact tablets are coated to prevent absorption through the skin during normal
handling. Patients should wait at least 6 months after dutasteride treatment to donate
blood to prevent pregnant women from being exposed to the drug through blood
transfusion.

Alpha blockers relax smooth muscle tissue in the bladder neck and prostate, which
increases urinary flow. They typically are taken orally, once or twice a day.

Read more: Medical Treatment for BPH - Benign Prostatic Hyperplasia (BPH)/Enlarged
Prostate - Urology
Channel http://www.urologychannel.com/prostate/bph/treatment_med.shtml#ixzz12gX8g
okt

Commonly prescribed alpha blockers include the following:

• alfuzosin (UroXatral®), extended-release tablet taken once daily


• doxazosin (Cardura®), tablet taken once daily
• prazosin (Minipress®), capsule taken 2 or 3 times daily
• silodosin (Rapaflo™), capsule taken once daily
• tamsulosin hydrochloride (Flowmax®), capsule taken once daily
• terazosin (Hytrin®), capsule taken once daily

Patients taking an alpha blocker require follow-up during the first 3 or 4 weeks to
evaluate the effect on symptoms and adjust the dosage, if necessary. Side effects include
headache, diarrhea, dizziness, low blood pressure, fatigue, weakness, and difficulty
breathing. Long-term risks and benefits have not been studied.

Read more: Medical Treatment for BPH - Benign Prostatic Hyperplasia (BPH)/Enlarged
Prostate - Urology
Channel http://www.urologychannel.com/prostate/bph/treatment_med.shtml#ixzz12gXC
cYZk

HOW TO INTERVENE

Your patient who's having a prostatectomy needs the following supportive care:

Preoperatively, make sure he and his family understand the prostate's location and
function, the pathophysiology of BPH, and what to expect after surgery.

Listen to your patient's concerns about hospitalization, treatment, and urinary


dysfunction. Respond with accurate information to foster his understanding and reduce
his anxiety.

After surgery, provide continuous bladder irrigation using a three-way indwelling


catheter. Use 0.9% sodium chloride to flush away prostatic debris, irrigate the surgical
areas, and minimize bleeding. Titrate the irrigation flow to the amount of bleeding; if the
amount of blood or number of clots in the urine increases, increase the flow and check
the catheter more frequently. Maintain irrigation until the urine outflow is slightly pink or
clear.

Monitor your patient's wound drains, dressings, and catheter drainage for excessive
bleeding. Although hematuria is normal, notify the physician if frank bleeding occurs.

Assess your patient for pain, including bladder spasms after irrigation. Belladonna and
opium suppositories may help stop the spasms.

Assess him for local and systemic signs and symptoms of infection. Practice meticulous
aseptic technique for wound and catheter care.

Teach your patient that he may have urine incontinence after his catheter is removed, but
emphasize that the problem typically is temporary.

Tell him to drink plenty of fluids. Maintaining adequate urine output keeps sediment and
clots from blocking the urethra.

As part of your discharge teaching, discuss sexual problems your patient may have, such
as retrograde ejaculation or impotence. Sexual counseling may be helpful if he develops a
problem.

If he's to be discharged with a catheter, teach him about catheter care and drainage.

Tell him to notify his physician at once if he develops signs and symptoms of infection,
such as fever, chills, or redness, swelling, or drainage at his incision site.

If he still has prostate tissue, remind him that he could develop BPH again. Encourage
him to obtain follow-up care to assess for development of urethral strictures.

Complications

Because BPH causes urinary obstruction, a patient may have one or more of the
following complications:

• urinary retention or incomplete bladder emptying, leading to urinary tract


infection (UTI) or calculi
• bladder wall trabeculation
• detrusor muscle hypertrophy
• bladder diverticula and saccules
• urethral stenosis
• hydronephrosis
• overflow incontinence
• acute or chronic renal failure
• acute postobstructive diuresis.

Diagnostic tests

The following tests help to confirm this diagnosis:

• Excretory urography may indicate urinary tract obstruction, hydronephrosis,


calculi or tumors, and filling and emptying defects in the bladder.
• Elevated blood urea nitrogen and serum creatinine levels suggest impaired renal
function.
• Cystoscopy allows the physician to determine the size of the gland and identify
the location and degree of obstruction.
• Urinalysis and urine culture show hematuria, pyuria and, when the bacterial count
exceeds 100,000/mm3, UTI.
• Prostate-specific antigen levels are routinely drawn on males with prostatic
symptoms to rule out prostate cancer.

Key nursing diagnoses and patient outcomes

Impaired urinary elimination related to obstruction of the urethra. Based on this nursing
diagnosis, you’ll establish these patient outcomes. The patient will:

• be able to empty the bladder effectively


• identify signs and symptoms of urine retention and seek medical attention.

The patient and family or caretaker will:

• demonstrate skill in managing urine elimination problem.

Risk for infection related to potential for urine retention. Based on this nursing diagnosis,
you’ll establish these patient outcomes. The patient will:

• have urine that will remain clear yellow, odorless, with no sediment, and free
from bacteria
• not experience signs and symptoms of UTI.

Urge urinary incontinence related to obstruction of the urethra. Based on this nursing
diagnosis, you’ll establish these patient outcomes. The patient will:

• regain continence
• not experience complications of urinary incontinence such as skin breakdown
• seek medical or surgical treatment.

Nursing interventions

• Prepare the patient for diagnostic tests and surgery as appropriate.


• Obtain a urine culture if UTI is suspected. Administer antibiotics as ordered for
UTI, urethral procedures that involve instruments, and cystoscopy.
• If urine retention occurs, insert an indwelling urinary catheter (difficult in a
patient with BPH). If the catheter can’t be passed transurethrally, assist with
suprapubic cystostomy (under local anesthesia).
• Avoid giving a patient with BPH decongestants, tranquilizers, alcohol,
antidepressants, or anticholinergics because these drugs can worsen obstruction.

Monitoring

• Monitor and record the patient’s vital signs, intake and output, and daily weight.
Watch closely for signs of postobstructive

P.93

diuresis (such as increased urine output and hypotension), which may lead to
serious dehydration, lowered blood volume, shock, electrolyte losses, and anuria.

• Observe the patient for signs and symptoms of UTI, such as dysuria or changes in
urine appearance.
Patient teaching

• If an indwelling urinary catheter has been used to maintain urine flow until
surgery can be done, the patient may experience urinary frequency, dribbling and,
occasionally, hematuria after the catheter has been removed. Reassure him and his
family that he’ll gradually regain urinary control.
• Teach the patient to recognize the signs of UTI. Urge him to immediately report
these signs to the physician because infection can worsen obstruction.
• Instruct the patient to follow the prescribed oral antibiotic regimen, and tell him
the indications for using gentle laxatives.
• Urge the patient to seek medical care immediately if he can’t void, if he passes
bloody urine, or if he develops a fever.
• Advise the patient that it may take several months of medical therapy before
symptoms improve; emphasize the importance of regular follow-up.
• Instruct the patient to avoid heavy lifting, straining, and operating heavy
machinery until cleared by his physician. Advise him to increase fluid intake to
produce 2 L of urine in 24 hours. Provide information on resuming sexual
activity.