BENIGN PROSTATE HYPERTROPHY: A CALL FOR ADEQUATE NURSING MANAGEMENT



SEMINAR PRESENTED TO
THE DEPARTMENT OF NURSING SCIENCE

FACULTY OF HEALTH SCIENCE AND TECHNOLOGY
COLLEGE OF HEALTH SCIENCES

IN
PARTIAL FULFILLMENT OF THE COURSE
NURSING SEMINAR (COURSE CODE: NSC  514)





ABSTRACT
Benign prostate hyperplasia or benign prostate hypertrophy is the enlargement of the prostate gland in men due to increase in size and number of cells of the gland. Because the prostate surround the male urethra at its junction with the bladder, its enlargement occludes the urethra causing urine retention or stasis of urine flow exposing the urinary tract to infections. Precipitation of the salts contained in urine can cause bladder stones or kidney stones. Apart from the above mentioned problems, other symptoms associated with prostate enlargement include weak urinary stream, prolonged emptying of the bladder, abdominal straining, hesistency, urgency, irregular need to urinate, incomplete bladder emptying, post urination dribbling, nocturia,and many others. BPH  has been shown by different studies to be caused by testosterone, dihydrotestosterone synthesized from testosterone, estrogen, dietary factors, smoking, heavy alcohol consumption, and diabetes. The management of BPH involves relief of pain and pressure by catheterization and suprapubic cystotomy to aid irrigation of urine. Other managements include medications such as alpha blockers which relaxes the smooth muscles of the bladder neck and prostate to enhance safe flow of urine from the bladder through the urethra, prostatectomy, and saw palmetto herbal product which works like finasteride, a 5-alpha reductase inhibitor that interferes with the conversion of testosterone to dihydrotestosterone inhibiting prostate growth.




INTRODUCTION
Benign prostate hypertrophy or Benign prostate hyperplasia is a non-cancerous increase in the size and number of cells that make up the prostate. (Schmitz 2009).The three(3) significant words will be explained thus: Benign is described as a non invasive condition or illness that is not serious even though treatment may be required for health or cosmetic reasons.(Bailleire’s nurses’ dictionary 2005). Prostate is a gland surrounding the male urethra at its junction with the bladder, during ejaculation it produces fluid which forms part of the semen.(Balleire’s nurses dictionary 2005).Hypertrophy is the increase in size of an organ or tissue due to increase in size of the cells while Hyperplasia is the increase in size of an organ or tissue due to increase in number of the cells.(Dorland’s medical dictionary 2003).To be accurate, the process is one of hyperplasia than hypertrophy but the nomenclature is often interchangeable even amongst urologists.

In approximately one half of men 50 years and above, the prostate gland enlarges extending upward into the bladder and obstructing the outflow of urine by encroaching on the vesicle orifice. In United states, benign prostate hyperplasia is responsible for 375,000 hospital stays each year (Gilchrist 2004).Prostate growth is believed to begin at approximately age of 30years.An estimated 50% of men have histological evidence of BPH by age 50years and 75% by age of 80years.In 40-50% of these patients BPH becomes clinically significant. (Schmitz 2009).Prostate enlargement is only found in males since women do not have prostate gland. Prostate enlargement is only seen in older adult men and not in younger males. This is because prostate enlarges over the course of many years of exposure to male hormones and young males have not had enough year of exposure for symptoms of BPH to emerge.

Benign prostate hyperplasia is caused by male hormones particularly testosterone. Men that live western lifestyle have much higher incidence of symptomatic BPH than men that live a traditional or rural lifestyle. This is confirmed by a research in China showing that men in rural areas have very low rates of clinical BPH while men living in cities adopting western life have a skyrocketing incidence of this condition(Wikipedia 2009).The most common symptoms are increased frequency of urination, urgency,  nocturia, dysuria, hesistency and many others.BPH can be diagnosed by ultrasound examination, rectal examination, renal function test, prostate specific antigen blood test among others(Brenda, Suzanne, Kerry, Janice 2008).

The management of BPH include medical and surgical management. The relief of pressure and pain is by catheterization and suprapubic cystostomy.It is therefore very imperative that BPH should be detected early and when detected strict intervention should be maintained using proper techniques to avoid morbidity and loss of life. This study is discussed under the following specific objectives:
1. To describe the anatomy of the prostate gland.
2. To describe the pathophysiology of prostate enlargement.
3. To discuss the management of BPH.
4 .To discuss the importance of adequate Nursing management.





ANATOMY OF THE PROSTATE GLAND


Diagram:







Description: The prostate gland lies in the pelvic cavity in front of the rectum and behind symphysis pubis surrounding the first part of the urethra. It consists of an outer fibrous covering, a layer of smooth muscle and glandular substance composed of columnar epithelial cells. The prostate has a base, an apex and four (4) surfaces, posterior, anterior and two (2) inferolateral surfaces. The base of the prostate is closely related to the neck of the urinary bladder. The prostatic urethra enters the middle of the base near its anterior surface. The apex is inferior and is related to the superior fascia of urogenital diaphragm. The posterior surface rests on the ampulla of the rectum thus this surface can be palpated by a digit in the rectum. Anterior surface is convex and extends from the apex to the base. The inferolateral surfaces of the prostate meet anteriorly with the convex anterior surface and rests on the fascia covering the levator ani muscles.
Functions: The prostate gland secrets a thin, milky fluid appearance. It contains a clotting enzyme which thickens in the vagina increasing the likelihood of semen being retained close to the cervix. The fluid contains proteins which include protoelytic enzyme, prostatic acid phosphate, and prostate specific antigen. Another important prostate function is controlling the flow of urine during ejaculation. A complex system of valves in the prostate sends the semen into the urethra during ejaculatory process and a prostate muscle called the sphincter seals the bladder, thereby preventing urine from entering into the bladder.
Blood supply: The prostate gland is supplied by the inferior vesical artery and middle rectal artery.
Venous supply: This is by the prostatic venous plexus around the sides and base of the prostate which drains into the internal iliac artery.
Lymphatic drainage: The lymph vessels terminate in the internal iliac and sacral lymph nodes.
Nerve Supply:  Parasympathetic nerves arise from the pelvic splanchnic nerves, S2, S3, and S4 and Sympathetic fibres from inferior hypogastric plexuses.







PATHOPHYSIOLOGY OF BENIGN PROSTATE HYPERPLASIA
Diagram of Enlarged Prostate










Benign prostate hyperplasia simply means prostate enlargement. It is a non-cancerous increase in the size and number of cells that make up the prostate. BPH is a progressive disease that undergoes rapid enlargement during puberty but the growth is retarded once puberty is completed. At middle age, the prostate begins growing again but very slowly this time. Testosterone which is a male hormone is responsible for prostate growth, as men grow older, the prostate grows slowly but continuous. Due to the slow progression of the growth, most men do not notice any symptoms of BPH until they are older and prostate has grown to such a size that it impinges on the outflow of urine from the bladder.(Bostwick,Roerhbornch et al,2002).In addition, the circulating testosterone is usually converted to dihydrotestosterone (DHT) which is a more powerful enhancer of prostate enlargement, as men get older, DHT synthesis takes place in the stromal cells of the prostate and enlarges the gland until it blocks normal urinary flow causing urinary retention and pains. Estrogen, a female hormone that aids in the development of ovaries can also adversely affect the prostate. Some of the men suffering from BPH have being found to have high level of estrogen and low level of testosterone, estrogen plays the same role as testosterone in enlarging the prostate gland (Wikipedia 2009).Recent studies have also identified smoking both current and former smoking, heavy alcohol consumption, diabetes and dietary factors to affect prostate growth in African American men. 
(Joseph, Harlow, Wei et al 2003).                                                                                              
The enlargement of the prostate leads to symptoms; such as storage and  voiding symptoms as classified by Bostwick (2002).The storage symptoms include:  urinary frequency which is urinating much more often than normal, urgency that is having a sensation that you need to urinate immediately, incontinence that is involuntary leakage of urine, nocturia-getting up to urinate at night. The voiding symptom include: weak urinary stream, hesistancy meaning difficulty starting the urine stream, intermittency meaning the stream starts and stops intermittently, straining to void, dribbling, dysuria (painful urination). These storage and voiding symptoms are evaluated using the international prostate symptom score(IPSS) questionnaire designed to assess the severity of BPH. Other generalized symptoms of BPH include fatigue, anorexia, vomiting, epigastric discomfort. Urinary retention results in stasis of urine which harbor bacterias and increases the risk of urinary tract infections. Urinary retention can be acute when there is inability to void and chronic when the residual urinary volume gradually increases and bladder distends. Also urinary bladder stones are formed from the crystallization of salts such as calcium phosphate, magnesium phosphate, ammonium phosphate, uric acid and its salts(urates) due to urine retention.(Barocas,Salem et al 2009).

MANAGEMENT OF BENIGN PROSTATE HYPERTROPHY:
The patient suffering from benign prostate hypertrophy usually present with acute pain at the lower abdomen arising from the full bladder and pressure of enlarged prostate on the urethra. Pain is relieved through catheterization to empty the bladder and suprapubic cystotomy(an incision into the bladder through the abdomen to provide drainage. After relieving pain using catheter or suprapubic cystotomy, the patient is now diagnosed to estimate the severity and extent of benign prostate hypertrophy. Diagnostic investigations the patient can undergo include; Digital rectal examination, prostate specific antigen blood test, renal function test, complete blood studies, and ultrasound examination. Digital rectal examination reveals a large, rubbery and non tender prostate gland. Prostate specific antigen is synthesized by tumor cells and released into the circulation in abnormal amounts. The PSA level indicates the presence of prostate tissue. Renal function tests include serum creatinine levels to determine whether there is impairment from prostatic back pressure and evaluate renal reserve. Complete blood studies are performed because hemmorrhage is a major complication of prostate surgery, it helps in early detection of clotting defects and treatment. Ultrasound examination of the testicles, prostates, and kidney is often performed to rule out malignancy and hydronephrosis (Thomas,Jones et al 2010).
The diagnosis and the extent of the enlargement will determine the type of treatment to be given which may be conservative management or surgical intervention( Brenda, Suzanne, Kerry, Janice  2008).

         CONSERVATIVE  MANAGEMENT:
This is the nursing intervention given when the patient’s problem do not need surgery.
·        Assessment on Admission: After admission for treatment, the nurse assesses how BPH has affected the patient’s lifestyle. During assessment the nurse can ask the following questions; Has the patient’s activity level or activity tolerance changed? What is the presenting urinary problems described in the patient’s own words? Has he lost weight? Has the patient experience erectile dysfunction? Does he appear pale? and others. This information helps determine how soon the patient will be able to return to normal activities after treatment.
·        Observation:  The nurse observes the patient’s vital signs, Temperature, blood pressure, Pulse, and Respiration to detect deviation from normal. The nurse also observes his lower abdomen for distented bladder due to urine retention.
·        Psychological care: The nurse clarifies the nature of the surgery and expected postoperative outcomes and their management. He is encouraged to verbalize his feelings and concerns in order to reduce patient’s fear. Divertional therapy, touching the patient and listening to his complains can help maintain psychological stability.
 
·        Investigations: The nurse assists the patient to go for prescribed tests and assembles them for the physician to make diagnosis.
·        Hygiene:  The nurse maintains personal and environmental hygiene to prevent nosocomial infection and increase patient’s morale. The nurse encourage the patient to take his bath at least twice a  day, the nurse also assist the patient if he cant help himself in bathing, shaving, mouth cleaning, combing and cleaning his bedsides.

·        Catheter care: Catheterization is for drainage of urine from the bladder to relief pressure and pain. The nurse ensures that the catheter is well lubricated before insertion to reduce pain. There should also be maintenance of aseptic technique during insertion of the catheter to prevent infection from catheter contamination. The nurse ensures that the catheter is removed when due, the nurse also ensure proper emptying of the bladder to enhance flow of urine and reducing risk of infections. During bowel elimination, the nurse advices the patient not to apply much pressure to prevent the catheter from falling off and to achieve this the nurse advices the patient to be eating light and low residue meal to prevent constipation. Prescribed Frusemide (lasix) may be given by the nurse to promote urination thereby helping to keep the catheter patent. The nurse constantly observes the lower abdomen, an over distended bladder manifests a distinct, rounded, swelling above the pubis, to ensure that the catheter is not blocked or kinked, and that the catheter is not compressed by the weight of the patient which can cause retention of urine in the bladder leading to bleeding severe pain and shock.
·        Medication: There are two(2) main medications, alpha adrenergic blockers and 5-alpha  reductase inhibitors(Kirby,2004). Alpha adrenergic blockers example terazosin, doxazosin, tamsulosin relax the smooth muscle of the bladder neck, prostate and urethra to improve urine flow and relieves benign prostate hypertrophy symptoms. Side effects include orthostatic hypotension, ejaculation changes, nasal congestion, and weakness while   5-alpha reductase inhibitors example finasteride have been effective in preventing the conversion of testosterone to dihydrotestosterone to decrease prostate size. Prescribed analgesics example ibuprofen can be given to reduce pain.
There is also a herbal medication known as Saw Palmeltto. This active element comes from the fruit of the American dwarf palm tree. Research has shown that the efficacy of Saw Palmetto is similar to that of 5-alpha redutase inhibitors like finasteride and the herbal product may be better tolerated and less expensive(Gordon and Shaughnessy,2003).Saw palmetto functions by interfering with the conversion of testosterone to dihydrotestosterone. It should not be used with finasteride, dutasteride or medications containing estrogen.
·        Nutrition: Protenious meal is given to increase immunity. Also soft and light meal is encouraged to prevent constipation that cause straining during bowel elimination that can displace indwelling catheter.
·        Rehabilitation: Because the patient have been on catheter, he might have partially lost  control of micturition, the nurse helps the patient to regain control by calling on the patient to empty his bladder when the urge to urinate comes. Observe the patient’s ability to control the urge further after removing catheter to ensure that the patient is not still suffering from the symptoms of BPH example incontinence, urgency among others.
·        Advice on discharge: The nurse advices the patient to take his drugs accordingly involving the family during advice because they will help the patient adhere to advices if he forgets. The nurse reviews the anatomy of affected gland again to increase understanding and for the patient to further appreciate management. The nurse advices the patient to keep to all follow up appointments and report to the hospital for any unusual symptoms.



SURGICAL MANAGEMENT:
Prostatectomy is the surgical removal of part or the whole prostate. It is indicated in BPH and also for patients with prostate cancer. The surgical procedure include: Transurethral resection of the prostate, suprapubic prostatectomy, perineal prostatectomy, retropubic prostatectomy, Trasurethral incision of the prostate, laparasopic radical prostatectomy (Brenda, Suzanne, Kerry, Janice 2008)
Transurethral Resection of the Prostate (TURP): This is the most common procedure used. It is carried out through endoscopy. The surgical and optical instrument is introduced directly through the urethra to the prostate which can be viewed directly. The gland is removed in small chips with an electrical cutting loops. TURP can cause retrograde ejaculation because removal of prostatic tissue at the bladder neck can cause the seminal fluid to flow backward into the bladder rather than forward through the urethra during ejaculation. After surgery, flushing with infusion follows.
Suprapubic prostatectomy: Is one method of removing the gland through an abdominal incision. An incision is made into the bladder, the prostate gland is removed from above. Suprapubic infusion of intravenous fluid example sodium chloride is given to flush the particles of the prostate and arrest bleeding(Nthumba,Bird 2006).
Perineal Prostatectomy: This involves removal of the gland through an incision in the perineum. This approach is practical when other approaches are not possible. The incision may easily be contaminated because the wound is near the rectum. Therefore, proper wound dressing is required to prevent infection.
Retropubic prostatectomy: An incision is made in the lower abdomen and prostate is removed by going behind the pubic bone without entering the bladder.
Laparascopic radical prostatectomy: This is a laparoscopic procedure involving four small incisions made in the abdomen used to remove the entire prostate for treatment of prostate cancer.

PREOPERATIVE NURSING MANAGEMENT:
·        This is nursing intervention given from the period of time from when the decision for surgical intervention is made and the patient is admitted for preparation of the surgery to when the patient is transferred to the operating room.
·        Assessment: The nurse check and record vital signs. The nurse takes history on how BPH has affected the patient’s lifestyle. During assessment the nurse can ask the following questions; Has the patient’s activity level or activity tolerance changed? What is the presenting urinary problems described in the patient’s own words? Has he lost weight? Has the patient experience erectile dysfunction? Does he appear pale? among other questions. This information helps to determine how soon the patient will be able to return to normal activities after prostatectomy.
·        Care of bladder and drainage of urine:  The nurse catheterizes the patient to empty the bladder. The nurse ensures that the catheter is well lubricated before insertion to reduce pain. There should also be maintenance of aseptic technique during insertion of the catheter to prevent infection from catheter contamination. The nurse observes the catheter for blockage and kink to prevent urine retention.
·        Investigations: The nurse fills forms and sends for the following investigations as ordered: Digital rectal examination which reveals a large, rubbery and non tender prostate gland. Prostate specific antigen is synthesized by tumor cells and released into the circulation in abnormal amounts. The PSA level indicates the presence of prostate tissue. Renal function tests include serum creatinine levels to determine whether there is impairment from prostatic back pressure and evaluate renal reserve. Complete blood studies are performed because hemmorrhage is a major complication of prostate surgery, it helps in early detection of clotting defects and treatment. Ultrasound examination of the testicles, prostates, and kidney is often performed to rule out malignancy and hydronephrosis (Thomas, Jones et al 2010).Fasting blood sugar to rule out diabetes mellitus. The nurse then assembles these laboratory results.
·        Psychotherapy: The nurse establishes communication with the patient to assess his understanding of the diagnosis and of the surgical procedure. The nurse clarifies the nature of the surgery and expected postoperative outcomes and their management. He is encouraged to verbalize his feelings and concerns and ask questions in order to reduce patient’s anxiety. The nurse encourages bed rest to calm the patient. Before surgery the nurse reviews the patient on the anatomy of the affected structures and their function in relation to the urinary and reproductive system using diagrams and other teaching aids to increase understanding and relief fears. The nurse involves the family of the patient to help him emotionally.
·        Consent: The nurse presents consent form for the patient’s approval and acceptance of surgery, to give legal backing to the surgeon, anaesthetists, nurses, and protect patient from unauthorized procedure.
·        Other Cares:
-         The nurse ensures that the patient maintained nil per oral atleast    12hours before surgery.
-           The nurse prepares the surgical site by cleaning and shaving.
-           Elastic compression stockings are applied before surgery for  prevention of deep vein thrombosis, if the patient will be placed in a lithotomy position during surgery.
-           An enema is usually administered on the morning of the surgery to empty the bowel.
-           Other medications is given as prescribed, example prophylactic antibiotics.
-           The nurse accompanies the patient to the theatre with case note, laboratory results and ultra sound film.
-           The nurse finally prepares postoperative bed with resuscitation tray, vital signs tray, oxygen, and suction machine.
POSTOPERATIVE NURSING MANAGEMENT:
·        This is the nursing intervention given from the period the patient is admitted to post surgical ward till after follow up evaluation.
·        Reception: The nurse receives the patient in the post operative bed.
·        Position: Keep patient in a dorsal position with the head turned to one side to prevent aspiration until he regains consciousness.
·        Clear airway maintenance: The nurse does this by ensuring adequate ventilation and suctioning when necessary. Observe the rate, rhythm,and symmetry of chest movement, breath sound.
·        Observations: The nurse observes patient’s vital signs, at frequent interval of 15minutes. Thereafter they may be taken less frequently if it remain stable.
-     The nurse observes the drainage bag, dressings, and incision site for evidence of bleeding.
·        Maintenance of patency of the catheter: The nurse ensures that the catheter is removed when due, the nurse also ensures proper emptying of the bladder to enhance flow of urine and reducing risk of infections. During bowel elimination, the nurse advices the patient not to apply much pressure to prevent the catheter from falling off and to achieve this the nurse advices the patient to be eating light and low residue meal to prevent constipation. Prescribed Frusemide (lasix) may be given by the nurse to promote urination thereby helping to keep the catheter patent. The nurse constantly observes the lower abdomen, an over distended bladder manifests a distinct, rounded, swelling above the pubis, to ensure that the catheter is not blocked or kinked, and that the catheter is not compressed by the weight of the patient to prevent retention of urine in the bladder and preventing bleeding, severe pain and shock.
·        Maintaining fluid balance: The nurse monitor fluid output through the catheter. Amount of fluid used for irrigation must be closely monitored to determine whether it is being retained. She monitors signs of electrolyte imbalances example low blood pressure, confusion, hyponatraemia, documents and reports to the surgeon.
·        Relieving Pain: The nurse assesses the cause, location and the severity of pain. The nurse administers medications example flavoxate, a smooth muscle relaxant which can help relax the bladder muscle that usually undergoes spasms continuously or intermittently increasing pain. The nurse also administer analgesics example ibuprofen which reduces pain by inhibiting prostaglandin synthesis, she can also change the patient to his favourable position.
·        Administer prescribed drugs: The nurse administers analgesics for relief of pain, antibiotics for combating infection, haematenics and vitamins to aid body building and repair.
·        Wound care: Maintain cleanliness, asepsis, and dryness of surgical wound to aid healing. –Remove alternate stitches on seventh day after surgery and remaining next day.
·        Feeding: The nurse advices the patient to eat soft meal example fruit juice, after 24 hours of surgery - Protenious meal is given to aid healing and increase immunity. –Soft and light meal will also prevent constipation that cause straining during bowel elimination, this can displace indwelling catheter.
·        Advice on discharge:  The nurse gives advise on the followings:                  
-           To report to his doctor if bleeding occurs.                                                                                                      
-           To avoid straining, heavy lifting, vigorous exercise for about one month to             prevent bleeding due to increased abnormal pressure.
-           To take his drugs as required.
-           To report to his doctor for any signs of infection, example, fever, chills,      severe pain.                                                                                                           
-           The nurse stress on the importance of perineal exercise example kegel exercise which is tightening the perineum and speed the return of sphincter control.
-           To avoid sexual intercourse, long car trips, and driving a car until the doctor permits.
-           To keep to all follow up appointments.                                                                                                        

NURSING CARE PLAN OF A PATIENT UNDERGOING PROSTATECTOMY
PREOPERATIVE NURSING CARE PLAN
Nursing diagnosis
Nursing objectives
Nursing intervention
Scientific Principle/rationale
Evaluation
1.Anxiety about surgery and its outcome
The patient will demonstrate reduced anxiety within 2hours of nursing intervention.
1.Establishing communication with the patient.

2.Clarify nature and reason of surgery and outcomes.

3.Encourage the patient to verbalize his feelings and concerns.

4.Diversional therapy like discussing other issues or watching television.

5.Invite patient’s relative to stay around him.
1.To assess his understanding of the disorder and where to help him.
2.To increase understanding and reduce fear.



3.This reduces fear and help the nurse to clear him more.


4.This will partly remove his mind from his problem
and surgery.



5.This makes him feel he is not alone and calm his anxiety.
The patient demonstrated reduced anxiety after 2 hours of nursing intervention.
2.Pain(acute) related to bladder distention.



















3.Knowledge (deficit) about factors related to the disorder and treatment protocol.
































The patient 24hours before surgery will relate understanding of disorder and treatment regimen.
1.Catheterise the patient.




2.Ensure that the catheter is well lubricated before insertion

3.Maitain catheter patency.

4.Maintain an unobstructed gravity flow, example kinking.

1.Review the patient on the anatomy of affected structures and their function using a diagram.
2.Involve the wife and family during the review.
3.Provide the patient with postoperative outcomes and its management.


4.Explain reason for every procedure.



5.Explain the function of prescribed drugs given.
1.To empty the bladder and relief pressure nd pain.


2.In order not to increase pain.





3.To  prevent urine retention and relief pain.

4. To prevent back flow of urine and retention.


1.To enable him have full understanding of his problem.




2.They will help him understand more.

3.To increase knowledge and understanding of  postoperative outcomes and its management.



4.To involve patient in management and this happens only if he understands his problem.

5.To help the patient understand treatment regimen and comply to medication.
The patient reported relief of pain after 2hours of nursing intervention.

















The patient 24hours before surgery related full knowledge of his problem.


























POST OPERATIVE NURSING CARE PLAN OF A PATIENT UNDERGOING PROSTATECTOMY
Nursing diagnosis
Nursing objectives
Nursing intervention
Scientific Principle/rationale
Evaluation
1.Pain(acute) related to surgical incision, catheter placement and bladder spasm.
 Patient will complain less of pain within 48hours post operatively.
1.Keep patient quiet and comfortable during immediate post operative period.

2.Reduce unnecessary movement.

3.Give prescribed analgesic example ibuprofen 800mg per day.
4.Give smooth musle relaxant to relief spasm of bladder example flavoxate.
1. This prevents episodes of spasms and bleeding.





2.To reduce pain from surgical incision.

3. Ibuprofen inhibits prostaglandin synthesis thereby relieving pain.


4.To calm bladder spasm and reduce pain.
 Patient did not complain of pain 36hours of intervention as evidenced by his relaxation and calmness.
2.Fluid volume,deficient,high risk for related to trauma to highly vascular area with excessive blood loss.
Patient will not exhibit signs of hypovolaemia throughout the period of hospitalization.
1.Monitor vital signs every 15minutes until stable.


2.Check the drainage bag, dressing, and incision site for evidence of bleeding.

3.Keep accurate intake and output records and account for irrigating fluid.


4.Watch and monitor blood transfusion.
1.Vital signs monitoring afford early detection of deviation from the normal functioning of the body.
2.Early detection of bleeding prevents further blood loss.


3. To regulate fluid balance as venous sinusoids of the bladder may absorb the irrigating fluid.



4.Observation ensures that the specified and prescribed dosage is being transfused.                          
Patient did not exhibit signs of hypovolaemic shock as evidenced by normal blood pressure and pulse rates.
3.Urinary elimination, impaired related to indwelling catheter.
Patient will have adequate bladder drainage throughout hospitalization.
1.Irrigate the bladder with sterile normal saline,frequency based on amount of bleeding.
2.Maintain patency of catheter.

3.Palpate the lower abdomen.





4.Irrigate catheter gently,rotate catheter gently to move drainage opening away from bladder wall or clot.
1.Irrigation removes blood clot from the bladder.


2.Free flow catheter maintains flow of urine and eliminates clots.
3.Palpation ensures that there is no blockage of catheter as an over distented bladder presents a rounded swelling above the pubis.
4.Irrigation and rotation of the catheter encourage the free flow of irrigation fluid and urine.
Patient had adequate bladder drainage throughout hospitalization evidenced by unobstructed flow of urine.
4.Infection, high risk for, related to invasive procedures.
Patient will not show signs and symptoms of infection, such as pyrexia t and purulent drainage from drains and catheter.
1.Maintain aseptic technique.
2.Frequently check the incision site for signs of infection.

3.Change dressings when soiled.


4.Give high protein diet.
1.To prevent the invasion of infection.
2.Early detection of infection prevents excalation.

3.Micro organisms survive more in wet medium.


4.High protein increases antibody production and provides adequate resources for tissue repair.

Patient did not show any sign of infection as evidenced by the wound healing by first intention.
5.Skin integrity, impaired related to surgery.
Patient’s wound will heal by first intention within 7days post operatively.
1.Monitor the incision for signs of infection.
2.Check the vital signs 4 hourly and record.
3.Dress wound under aseptic technique.
4.Give prescribed antibiotic example Ampicillin.
1.Prompt monitoring of incision detects wound infection.
2.An increase in vital signs indicates infection,thus the 4 hourly checking.
3.Asepsis promote wound healing.
4.Ampicillin has a bacteriostatic and bacteriocidal effect.
Patient’s wound healed by first intention within 7 days as evidenced by no wound infection.








IMPORTANCE OF ADEQUATE NURSING MANAGEMENT OF BPH
Men with benign prostate hypertrophy experience serious complication when not properly managed. These complications may be as a result of late diagnosis and improper management. Adequate surgical, medical  and nursing management of benign prostate hyperplasia is important to prevent these complications which include: Hemorrhage, catheter obstruction, infections, sexual dysfunction, deep vein thrombosis, Renal failure, and prostate cancer.
Hemorrhage: The immediate dangers after prostatectomy are bleeding and hemorrhagic shock. This risk is increased with prostate hyperplasia because hyperplastic prostate gland is very vascular. Bleeding may occur from the prostatic bed or also as a result of clot formation which then obstruct urine flow. Bright red bleeding with increased viscosity and numerous clots usually indicate arterial bleeding. Venous blood appears darker and less viscous. Arterial hemorrhage usually requires surgical intervention example Suturing or transurethral coagulation of bleeding vessels, whereas venous bleeding may be controlled by applying prescribed traction to the catheter so that the balloon holding the catheter in place applies pressure to the prostatic fossa. The nurse gives high proteinous meal to replace lost blood. It has been reported that bleeding is the major cause of loss of life postoperatively, therefore adequate management, which include close and careful observation of the patient to dictate early bleeding signs and early adequate intervention given to save the life of the patient is very important.
Catheter obstruction: An obstructed catheter pre and postoperatively produces distension of the prostatic capsule and resultant hemorrhage. After surgery like transurethral resection, the catheter must be drained well to prevent obstruction and the nurse ensures the irrigation fluid is maintained. Prescribed Frusemide (lasix) may be given by the nurse to promote urination and initiate postoperative diuresis thereby helping to keep the catheter patent. The nurse constantly observes the lower abdomen, an over distended bladder manifests a distinct, rounded, swelling above the pubis to ensure that the catheter is not blocked causing retention, preventing bleeding, severe pain and shock.
Infection: Urinary tract infections like cystitis and epididymitis are possible complications after prostatectomy. The nurse works hard to prevent infection from occurring by doing the following:
Care of the catheter: This is very important to limit infection occurrence; the nurse ensures that the catheter is removed when due, the nurse also ensure proper emptying of the bladder to enhance flow of urine and reducing risk of infections. There should also be maintenance of aseptic technique during insertion of the catheter to prevent infection from catheter contamination.  
Care of surgical wound: Is also necessary to prevent infection from occurring. The nurse maintains aseptic technique during wound dressing to prevent infecting the wound leading to more complication and high cost of treatment. Adequate diet is given to boost immunity and reduces the rate by which the body is invaded by organisms.
Personal hygiene is also highly important, the nurse encourage assisted bath which reduces source of infection and boost patient’s morale.
Sexual dysfunction: Inadequate surgery exposes the patient to sexual dysfunction related to erectile dysfunction, decreased libido and fatigue. The patient may report these issues weeks or months after surgery. The surgeon discusses relieve and treatment with the patient. To restore erectile dysfunction medications or surgically placed implants can be used. Reassurance that the usual level of libido will return after recuperation from surgery is often helpful for the patient and his partner. If the patient is finding it difficult to demonstrate significant adjustment to sexual dysfunction, a referral to sex therapist may be indicated. The nurse counsels the patient and encourages him to report problem early for proper and early intervention.
Deep vein thrombosis: During management, the patient can be placed on heparin, elastic compression stockings can be worn to prevent deep vein thrombosis. This is because patients undergoing prostatectomy have a high incidence of deep vein thrombosis and pulmonary embolism. The nurse encourages passive limb exercise to enhance venous return and prevent deep vein thrombosis.
Renal failure: This can occur as a result of bladder stones and kidney stones development which is due to stasis or accumulation of urine. The nurse cares and monitor the catheter steadily to prevent stasis or accumulation of urine. The nurse administers smooth muscle relaxants to relax the bladder neck, the prostate, and the urethra to enhance flow of urine preventing accumulation of urine,precipitation of salts, and formation of bladder stones and kidney stones.
Prostate cancer: Improper management of benign prostate hyperplasia can lead to cancer of the prostate which can metastasize to other surrounding organs leading to high cost of treatment and may be loss of life. Therefore, the nurse and the surgeon should endeavour to perform their duties accurately and appropriately.The nurse should carefully observe the patient while in the hospital , listen to his complains, ensure he goes for blood tests as prescribed, monitor his vial signs and report deviations from normal, in order to prevent and diagnose cancer early,and also for early intervention.

SUMMARY
Benign prostate hypertrophy or benign prostate hyperplasia is the enlargement of the male gland prostate due to increase in size and number of cells that make up the gland. Because the prostate surround the male urethra at its junction with the bladder, its enlargement occludes the urethra causing urine retention or stasis of urine flow exposing the urinary tract to infections. Precipitation of the salts contained in urine can cause bladder stones or kidney stones, nitrogenous waste can also be accumulated causing azotemia. Apart from the above mentioned problems, other symptoms associated with prostate enlargement include weak urinary stream, prolonged emptying of the bladder, abdominal straining, hesistency, urgency, irregular need to urinate, incomplete bladder emptying, post urination dribbling, nocturia, irritation during urination, frequency, incontinence, bladder pain, dysuria, problem in ejaculation. BPH  has been shown by different studies to be caused by testosterone, dihydrotestosterone synthesized from testosterone, estrogen, dietary factors, smoking, heavy alcohol consumption, and diabetes. The management of BPH involves relief of pain and pressure by catheterization and suprapubic cystotomy to aid irrigation of urine. Other managements include medications such as alpha blockers which relaxes the smooth muscles of the bladder neck and prostate to enhance safe flow of urine from the bladder through the urethra, prostatectomy, and saw palmetto herbal product which works like finasteride, a 5-alpha reductase inhibitor that interferes with the conversion of testosterone to dihydrotestosterone inhibiting prostate growth. I finally recommend awareness campaign among elderly men for early diagnosis and proper treatment.
                                           
                                                 CONCLUSION
This study showed that men of 50years and above of all race have the potential to suffer from prostate enlargement because the male hormone that causes it is in all men, as these hormones are gradually secreted in all men, the prostate enlarges gradually as well and at a time starts to exert pressure on the bladder neck and urethra to block or reduce flow of urine from the bladder to the exterior. Complications of BPH and prostatectomy is costly, therefore the nurses and urologists should adequately and carefully manage the patients, preventing high morbidity, high treatment cost due to complications and most importantly preventing loss of life.
                                             RECOMMENDATION:
Having discussed benign prostate hyperplasia as a common condition among the elderly men, the following recommendations will aid to reduce occurrence of BPH:
1.         Awareness campaign by health institutions will help to bring the elderly men to the hospitals for early diagnosis and treatment without complications.

2.         The public health nurse should inculcate on their programme, health education on BPH.
3.         Medical practitioners should encourage the elderly that comes for check up to go for urologic tests since BPH is almost a must-occur problem due to the presence and secretion of androgens in men.
4.         Seminars and health talk should be prepared and given by urologists on      the problem of BPH among the elderly and make them see the importance of early diagnosis.














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Joseph, Harlow and Wei (2003): in www.wikipedia.BPH.com

Kirby (2004):in Brenda, G.B, Suzanne, C.S, Kerry H.C,
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