As the prostate gland enlarges, it extends upward into the bladder and inward, causing bladder outlet obstruction (Fig. 75-1). In response, the urinary system is affected in several ways. First, the detrusor (bladder) muscle thickens to help urine push past the enlarged prostate gland (McCance et al., 2010). In spite of the bladder muscle change, the patient has increased residual urine (stasis) and chronic urinary retention. The increased volume of residual urine often causes overflow urinary incontinence, in which the urine “leaks” around the enlarged prostate causing dribbling. Urinary stasis can also result in urinary tract infections and bladder calculi (stones).

FIG. 75-1 Benign prostatic hyperplasia (BPH) grows inward, causing narrowing of the urethra.

In a few patients, the prostate becomes very large and the man cannot void (acute urinary retention [AUR]). The patient with this problem requires emergent care. In other patients, chronic urinary retention may result in a backup of urine and cause a gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis) if BPH is not treated. These problems can lead to chronic kidney disease as described in Chapter 71.

Patient-Centered Collaborative Care

Assessment

History

When taking a history, several standardized assessment tools are used to help the health care provider determine the severity of lower urinary tract symptoms (LUTS) associated with prostatic enlargement. One of the most commonly used assessments is the International Prostate Symptom Score (I-PSS), which incorporates the American Urological Association Symptom Index (AUA-SI) (Fig. 75-2) as questions 1 through 7. The additional question included on the I-PSS is the effect of the patient’s urinary symptoms on quality of life. Most patients complete the questions as a self-administered tool because it is available in many languages. If the patient is illiterate or does not feel like reading the questions, the nurse or health care provider can ask them. Be sure that older men wear their glasses or contact lenses, if needed.

FIG. 75-2 The International Prostate Symptom Score (I-PSS).

Planning and Implementation

Improving Urinary Elimination

Planning: Expected Outcomes

The patient with BPH is expected to have a normal urinary elimination pattern without urinary hesitancy, urgency, or infection.

Interventions

Patients with symptomatic BPH are first treated with nonsurgical interventions, such as drug therapy. The Concept Map on p. 1634 shows nursing assessment and collaborative interventions for the patient with BPH.

Nonsurgical Management

Drug therapy is a popular option for treating BPH. For patients with AUR or for those who do not respond or cannot tolerate drug therapy, noninvasive procedures or surgery is the treatment of choice.

Drug Therapy

Drugs from two major categories may be used alone, but most commonly they are given in combination. The health care provider usually prescribes a 5-alpha reductase inhibitor (5-ARI) as first-line drug therapy. Examples of these drugs are finasteride (Proscar) and dutasteride (Avodart). Normally, testosterone is converted to DHT in the prostate gland by the enzyme 5-alpha reductase. By taking an enzyme-inhibiting agent, the patient’s DHT levels decrease, which results in reducing the enlarged prostate.

Nursing Safety Priority

Drug Alert

Remind patients who are being treated with a 5-ARI for BPH that they may need to take it for as long as 6 months before improvement is noticed. Teach them about possible side effects, which include erectile dysfunction (ED), decreased libido (sexual desire), and dizziness due to orthostatic hypotension. Remind them to change positions carefully and slowly.

The alpha-adrenergic receptors in prostatic smooth muscle enable the prostate gland to respond to alpha-1 selective blocking agents, such as tamsulosin (Flomax), alfuzosin (Uroxatral), doxazosin (Cardura, Cardura-1 ), terazosin (Hytrin), and silodosin (Rapaflo). Tamsulosin is also available as an over-the-counter (OTC) drug. These drugs relax smooth muscles in the prostate gland, creating less urinary resistance and improved urinary flow. They also cause peripheral vasodilation and reduced peripheral vascular resistance.

Nursing Safety Priority

Drug Alert

If giving alpha blockers in an inpatient setting, assess for orthostatic (postural) hypotension, tachycardia, and syncope (“blackout”), especially after the first dose is given to older men. If the patient is taking the drug at home, teach him to be careful when changing position and to report any weakness, lightheadedness, or dizziness to the health care provider immediately. Bedtime dosing may decrease the risk for problems related to hypotension. Drugs used to treat erection problems (e.g., Viagra) can worsen these side effects. Teach patients taking a 5-ARI or alpha blocking drug to keep all appointments for follow-up laboratory testing because both drug classes can cause liver dysfunction.

The most effective drug therapy approach for many patients is a combination of a 5-ARI drug and an alpha-1 selective blocking agent. A commonly prescribed drug regimen is finasteride and doxazosin. Newer drugs, such as Jalyn, provide a combination of dutasteride and tamsulosin in a once-a-day capsule.

Other drugs may be helpful in managing specific urinary symptoms. For example, low-dose oral desmopressin, a synthetic antidiuretic analog, has been used successfully for nocturia (Wang et al., 2011). Drugs being tested for their effectiveness in treating BPH include bisphosphonates, ezetimibe (Zetia), Botox, and Nymox.

Complementary and Alternative Therapies

Although many men use Serenoa repens (saw palmetto extract), a plant extract, to help manage the urinary symptoms associated with BPH, studies on the effectiveness of this herb have not shown that it is effective (Tackland et al., 2009). Teach patients who want to try these herbs and other natural substances that scientific evidence to prove they are useful is lacking. However, if they choose to take them, remind them to check with their health care provider before taking any OTC natural substance. Some herbs interfere with prescription drugs the patient may be taking for other health problems. Side effects, such as abdominal pain, nausea, and vomiting, are mild, reversible, and infrequent (Agbabiaka et al., 2009).

Other Nonsurgical Interventions

Other interventions that may reduce obstructive symptoms include those that cause the release of prostatic fluid such as frequent sexual intercourse. This approach is helpful for the man whose obstructive symptoms result from an enlarged prostate with a large amount of retained prostatic fluid.

Teach patients with BPH to avoid drinking large amounts of fluid in a short time; to avoid alcohol, diuretics, and caffeine; and to void as soon as they feel the urge. These measures are aimed at preventing overdistention of the bladder, which may result in loss of detrusor muscle tone. Teach patients to avoid any drugs that can cause urinary retention, especially anticholinergics, antihistamines, and decongestants. Emphasize the importance of telling any health care provider about the diagnosis of BPH so that these drugs are not prescribed.

If drug therapy or other measures are not helpful in relieving urinary symptoms, several noninvasive techniques are available to destroy excess prostate tissue using a variety of heat methods (thermotherapy). These procedures are often done in a physician’s office or another ambulatory care setting. Examples include:

• Transurethral needle ablation (TUNA) (low radiofrequency energy shrinks the prostate)

• Transurethral microwave therapy (TUMT) (high temperatures heat and destroy excess tissue)

• Interstitial laser coagulation (ILC), also called contact laser prostatectomy (CLP) (laser energy coagulates excess tissue)

• Electrovaporization of the prostate (EVAP) (high-frequency electrical current cuts and vaporizes excess tissue)

Prostatic stents may be placed into the urethra to maintain permanent patency after a procedure for destroying or removing prostatic tissue. All of these highly technical treatments use local or regional anesthesia and do not require an indwelling urinary catheter. They are also associated with less risk for complications such as intraoperative bleeding and erectile dysfunction when compared with traditional surgical approaches. Patients can return to their usual activities in a day or two.

Surgical Management

For patients who are not candidates for nonsurgical management or do not want to take drugs or have other treatment options, surgery may be performed. The gold standard continues to be a transurethral resection of the prostate (TURP) in which the enlarged portion of the prostate is removed through an endoscopic instrument. The newer holmium laser enucleation of the prostate (HoLEP) procedure is a minimally invasive surgical technique that is gaining popularity. For a few men, an open prostatectomy (entire prostate removal) may be performed (see discussion of Surgical Management on p. 1639 in the Prostate Cancer section). Some or all of these criteria indicate the need for surgery:

• Acute urinary retention (AUR)

• Chronic urinary tract infections secondary to residual urine in the bladder

• Hematuria

• Hydronephrosis

Preoperative Care

When planning surgical interventions, the patient’s general physical condition, the size of the prostate gland, and the man’s preferences are considered. The patient may have many fears and misconceptions about prostate surgery, such as believing that automatic loss of sexual functioning or permanent incontinence will occur. Assess the patient’s anxiety, correct any misconceptions about the surgery, and provide accurate information to him and his family. Regardless of the type of surgery to be performed, provide information about anesthesia (see Chapter 17). The patient may have other medical problems that increase the risk for complications of general anesthesia and may be advised to have regional anesthesia. Epidural and spinal anesthesia are the most common types of anesthesia used for a TURP. Because the patient is awake, it is easier to assess for hyponatremia (low serum sodium), fluid overload, and water intoxication, which can result from large bladder irrigations.

After a TURP, all patients have an indwelling urethral catheter for at least a day. Be sure that they know that they will feel the urge to void while the catheter is in place. Tell the patient that he will likely have traction on the catheter that may cause discomfort. However, reassure him that analgesics will be prescribed to relieve his pain. Explain that it is normal for the urine to be blood-tinged after surgery. Small blood clots and tissue debris may pass while the catheter is in place and immediately after it is removed.

Operative Procedures

The traditional TURP is a “closed” surgery. To perform the procedure, the surgeon inserts a resectoscope (an instrument similar to a cystoscope, but with a cutting and cauterizing loop) through the urethra (Fig. 75-3). The enlarged portion of the prostate gland is then removed in small pieces (prostate chips). A similar procedure is the transurethral incision of the prostate (TUIP), in which small cuts are made into the prostate to relieve pressure on the urethra. This alternate technique is used for smaller prostates. To prevent bleeding and excess clotting, a fibrinolytic inhibitor like tranexamic acid (Cyklokapron) may be used during surgery.

FIG. 75-3 Transurethral resection of the prostate procedure used for benign prostatic hyperplasia.

The disadvantage of a TURP is that, because only small pieces of the gland are removed, remaining prostate tissue may continue to grow and cause urinary obstruction, requiring additional TURPs. Also, urethral trauma from the resectoscope with resulting urethral strictures is possible.

In many large medical centers around the world, specialists can perform newer surgical treatments, such as the holmium laser enucleation of the prostate (HoLEP) (Eltabey et al., 2010). For this procedure, the surgeon uses the laser to remove the obstructive prostatic tissue and push it into the bladder for removal and seals all blood vessels. Very little blood is lost during the short procedure and is therefore safe for patients taking anticoagulants.

Postoperative Care

After both the TURP and HoLEP procedures, a urinary catheter is placed into the bladder. Traction is often applied on the catheter for the patient having a TURP by pulling it taut and taping it to the patient’s abdomen or thigh. If the catheter is taped to the patient’s thigh, instruct him to keep his leg straight. The patient having the HoLEP procedure has a urinary catheter overnight, but the patient with a TURP has a catheter in place for several days. In some cases, the patient is discharged with the catheter in place.

Considerations for Older Adults

When caring for older men who may become confused after surgery, reorient them frequently and remind them not to pull on the catheter. If the patient is restless or “picks” at tubes, provide a familiar object such as a family picture for him to hold for distraction and a feeling of security. Do not restrain the patient unless all other alternatives have failed.

Remind the patient that because of the urinary catheter’s large diameter and the pressure of the retention balloon on the internal sphincter of the bladder, he will feel the urge to void continuously. This is a normal sensation, not a surgical complication. Advise the patient not to try to void around the catheter, which causes the bladder muscles to contract and may result in painful spasms. Chart 75-1 summarizes the nursing care for patients having a TURP.

Chart 75-1 Best Practice For Patient Safety & Quality Care

Care of the Patient After Transurethral Resection of the Prostate

• Monitor the patient closely for signs of infection. Older men undergoing prostate surgery often also have underlying chronic diseases (e.g., cardiovascular disease, chronic lung disease, diabetes).

• Help the patient out of the bed to the chair as soon as permitted to prevent complications of immobility. Older men may need assistance because of underlying changes in the musculoskeletal system (e.g., decreased range of motion, stiffness in joints). These patients are at high risk for falls.

• Assess the patient’s pain every 2 to 4 hours, and intervene as needed to control pain.

• Provide a safe environment for the patient. Anticipate a temporary change in mental status for the older patient in the immediate postoperative period as a result of anesthetics and unfamiliar surroundings. Reorient the patient frequently. Keep catheter tubes secure.

• Use normal saline solution for the bladder irrigant unless otherwise prescribed. Normal saline solution is isotonic.

• Monitor the color, consistency, and amount of urine output.

• Check the drainage tubing frequently for external obstructions (e.g., kinks) and internal obstructions (e.g., blood clots, decreased output).

• Assess the patient for reports of severe bladder spasms with decreased urinary output, which may indicate obstruction.

• If the urinary catheter is obstructed, irrigate the catheter per agency or surgeon protocol.

• Notify the physician immediately if the obstruction does not resolve by hand irrigation or if the urinary return becomes ketchup-like.

Nursing Safety Priority

Critical Rescue

After a TURP, monitor the patient’s urine output every 2 hours and vital signs, including pain assessment, every 4 hours for the first postoperative day. Assess for postoperative bleeding. Patients who undergo a TURP or open prostatectomy are at risk for severe bleeding or hemorrhage after surgery. Although rare, bleeding is most likely within the first 24 hours. Blood transfusions are commonly given after a TURP surgery but are not needed after the HoLEP procedure. Bladder spasms or movement may trigger fresh bleeding from previously controlled vessels. This bleeding may be arterial or venous, but venous bleeding is more common.

If the bleeding is arterial, the urinary drainage is bright red or ketchup-like with numerous clots. If arterial bleeding occurs, notify the surgeon immediately, and irrigate the catheter with normal saline solution per physician or hospital protocol. In rare instances, the surgeon may prescribe aminocaproic acid (Amicar) to control bleeding. If this drug does not work, surgical intervention may be needed to clear the bladder of clots and to stop bleeding.

If the bleeding is venous, the urine output is burgundy, with or without any change in vital signs. Inform the surgeon of any bleeding. Closely monitor the patient’s hemoglobin (Hgb) and hematocrit (Hct) levels for anemia as a result of blood loss.

When the urinary catheter is removed, the patient may experience burning on urination and some urinary frequency, dribbling, and leakage. Reassure him that these symptoms are normal and will decrease. The patient may also pass small clots and tissue debris for several days after the TURP. Instruct him to increase fluid intake to at least 2000 to 2500 mL daily, which helps decrease dysuria and keep the urine clear. An older patient who has renal disease or who is at risk for heart failure may not be able to tolerate this much fluid. By the time of discharge (usually 2 to 3 days after surgery), he should be voiding 150 to 200 mL of clear yellow urine every 3 to 4 hours. By discharge, pain is minimal and analgesics may not be required.

Observe for other possible but uncommon complications of TURP, such as infection and incontinence. Teach the patient that sexual function should not be affected after surgery but that retrograde ejaculation is possible. In this case, most of the semen flows backwards into the bladder so only a small amount will be ejaculated from the penis.

Community-Based Care

The patient with benign prostatic hyperplasia (BPH) is typically managed at home. Patients who have surgery are also discharged to their home or other setting from where they were admitted. Some patients, especially those who have had a TURP, may have temporary loss of control of urination or a dribbling of the urine. Reassure the patient that these symptoms are almost always temporary and will resolve. Assist the patient and his family in finding ways to keep his clothing dry until sphincter control returns. Instruct him to contract and relax his sphincter frequently to re-establish urinary control (Kegel exercises). External urinary (condom) catheters are not used except in extreme cases because they may give the patient a false sense of security and delay urinary control.

Patients having the HoLEP procedure typically stay in the hospital overnight and usually have no urinary symptoms after surgery. This procedure may soon replace the TURP as the gold standard for surgical management of the patient with BPH.

Nclex Examination Challenge

Physiological Integrity

A client had a transurethral resection of the prostate (TURP) yesterday. The staff nurse notes that the hemoglobin is 8.2 g/dL. What is the nurse’s best action?

A. Notify the charge nurse as soon as possible.

B. Irrigate the catheter with 30 mL normal saline.

C. Document the assessment in the medical record.

D. Prepare for a blood transfusion.

Prostate Cancer

Pathophysiology

Prostate cancer is one of the most common types of cancer in men in the world. Men older than 65 years have the greatest risk for the disease. In the United States, it affects African-American men more commonly than Euro-American men and at an earlier age. The exact cause for this difference is not known.

Testosterone and dihydrotestosterone (DHT) are the major androgens (male hormones) in the adult male. Testosterone is produced by the testis and circulates in the blood. DHT is a testosterone derivative in the prostate gland. In some patients, the prostate grows very rapidly, leading to noncancerous high-grade prostatic intraepithelial neoplasia (PIN). Patients with PIN are at a higher risk for developing prostate cancer than men who do not have that growth pattern.

Many prostate tumors are androgen sensitive (McCance et al., 2010). Most are adenocarcinomas and arise from epithelial cells located in the posterior lobe or outer portion of the gland (Fig. 75-4).

FIG. 75-4 The prostate gland with cancer and benign prostatic hyperplasia (BPH). Note that cancer normally arises in the periphery of the gland, whereas BPH occurs in the center of the gland.

Of all malignancies, prostate cancer is one of the slowest growing, and it metastasizes (spreads) in a predictable pattern. Common sites of metastasis are the nearby lymph nodes, bones, lungs, and liver (McCance et al., 2010). The bones of the pelvis, sacrum, and lumbar spine are most often affected. Chapter 23 describes staging categories of localized and advanced cancers.

Prostate cancer is likely caused by a number of factors, including androgens. Dietary factors, such as eating a diet high in animal fat (e.g., red meat) and complex carbohydrates or having a low fiber intake, increase the risk for prostate cancer. Men who have had a vasectomy or those who were exposed to environmental toxins, such as arsenic, may also be at increased risk for the disease (Held-Warmkessel, 2008; McCance et al., 2010).

Genetic/Genomic Considerations

Many gene mutations play a role in various types of prostate cancer. Some men with the most aggressive prostate cancers have BRCA2 mutations similar to those women who have BRCA2-associated breast and ovarian cancers. The most common genetic factor that increases the risk for prostate cancer is a mutation in the glutathione S-transferase (GST P1) gene. This gene is normally part of the pathway that helps prevent cancer (McCance et al., 2010).

Health Promotion and Maintenance

Teach men about the most recent American Cancer Society (ACS) guidelines for prostate cancer screening and early detection (ACS, 2011). The current recommendations are that men should make an informed decision about whether to have prostate cancer screening. Starting at the age of 50, men should discuss the options of having prostate-specific antigen testing with their health care provider. Men at a higher risk for prostate cancer, including African Americans or men who have a first-degree relative with prostate cancer before the age of 65, should have this discussion at age 45. Men who have multiple first-degree relatives with prostate cancer at an early age should discuss screening at age 40.

Although a family history of prostate cancer cannot be changed, certain nutritional habits can be altered to possibly decrease the risk for the disease. First, teach men to eat a healthy, balanced diet, including decreasing animal fat (e.g., red meat). Instead of red meat, remind them to eat more fish and other foods high in omega-3 fatty acids because they are thought to be helpful in preventing cancer. Also reinforce the need to increase fruits, vegetables, soy, and high-fiber foods.