Benign Prostatic Hyperplasia

Introduction The process of urination is vital to the body for the removal of certain waste products. Normally, when the bladder gets full, urine is emptied from the body through the urethra in a process called urination. In urinary retention, a person’s bladder fills up and there is an urge to urinate but he is unable to completely empty his bladder. With chronic urinary retention, a person may be able to urinate, but he has some trouble starting a stream or emptying your bladder completely. He may urinate frequently, may feel an urgent need to urinate but have little success when he gets to the toilet; or he may feel he still have to go after having finished urinating. With acute urinary retention, he can't urinate at all even though he has a full bladder. Acute urinary retention is a medical emergency requiring prompt action. Acute urinary retention (AUR) is an extremely uncomfortable and potentially life-threatening condition characterized by a sudden inability to urinate associated with intense suprapubic discomfort. It is most often secondary to obstruction, but may also be related to trauma, medication, neurologic disease, infection, and occasionally psychological issues. Acute urinary retention (AUR) is one of the most significant, uncomfortable and inconvenient event in the natural history of benign prostatic hyperplasia (BPH). BPH is the virtual universal overgrowth of the prostate gland in men as they age. Various factors affecting BPH are age, genetic makeup, testosterone levels, and environment. As the prostate enlarges it compresses the urethra causing obstruction to urine flow. The urinary stream becomes smaller; there may be difficulty in initiating the stream, dribbling, and intermittent flow, frequency of urination, getting up at night to void (nocturia), inability to empty, or even inability to void at all (retention). Patient’s Profile Name: c Age: 69 Address: Civil Status: Married Chief Complaint: Difficulty in urinating ptc and bloody urine few days ptc Tentative Diagnosis: Acute urinary retention prob. Secondary to BPH History of Present Illness a. Present History Patient is 69 years old male retiree, a resident of PS Tagas, Tabaco City admitted at BRTTH with a chief complaint of dysuria. One week prior to consultation he had difficulty in urinating and presence of blood in the urine b. Medical History The patient claimed that he has hypertension and diabetes mellitus type II. Anatomy and Physiology Prostate gland The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is made of two lobes, or regions, enclosed by an outer layer of tissue. As the diagrams show, the prostate is located in front of the rectum and just below the bladder, where urine is stored. The prostate also surrounds the urethra, the canal through which urine passes out of the body. Scientists do not know all the prostate's functions. One of its main roles, though, is to squeeze fluid into the urethra as sperm move through during sexual climax. This fluid, which helps make up semen, energizes the sperm and makes the vaginal canal less acidic. Urinary Bladder The urinary bladder is a muscular sac for storing urine. The triangular base of the bladder, the trigone, is defined by the two ureters that deliver the urine and the one urethra that drains the urine. When empty, the bladder collapses, and folds (called rugae) from in the bladder wall. As it fills, the folds become distended and the bladder  becomes spherical. The wall of the bladder consists of three layers similar to those of  the urethra: the mucosa, the muscularis (here called the detrusor muscle), and the adventitia. Circular smooth muscle fibers around the urethra form the internal urethral sphincter. As a man matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. This second growth phase often results, years later, in BPH. Though the prostate continues to grow during most of a man's life, the enlargement doesn't usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their  seventies and eighties have some symptoms of BPH. As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself. Urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH. Pathophysiology Urinary retention can be caused by an obstruction in the urinary tract or by nerve problems that interfere with signals between the brain and the bladder. If the nerves aren't working properly, the brain may not get the message that the bladder is full. Even if you know that your bladder is full, the bladder muscle that squeezes urine out may not get the signal that it is time to push, or the sphincter muscles may not get the signal that it is time to relax. A weak bladder muscle can also cause retention. As a man ages, his prostate gland may enlarge. Doctors call the condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy. As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. As a result, the bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself, so urine remains in the bladder. The pathophysiology of bladder outlet obstruction in men with BPH has been attributed to both static and dynamic factors. The static obstruction is due to the bulk enlargement of the prostate encroaching upon the prostatic urethra and bladder outlet, whereas the dynamic obstruction is related to the tension of prostate smooth muscle. Diagnostic Evaluation and Lab Examination a. Ultrasound of whole abdomen * Normal * Gassy epigastria, gassy filled bowel loops * Empty bladder b. CBC WBC| 8. 1| RBC| 4. 16| Hemoglobin| 103| Hematocrit| 0. 31| Platelet| 273| c. Urinalysis Specific gravity| 1. 025| pH| 5. 0| Sugar| (-)| RBC| 13-15| Medical Treatment and Evaluation Treatment a. Admit to surgical ward. b. Labs: Ultrasound -CBC -Urinalysis c. I ; O q 4H d. Intravenous Rehydration e. Indwelling Catheter – To facilitate accurate measurement of urinary output for critically ill patients, Drug Study Ciprofloxacin Action: Interferes the conversion of intermediate DNA fragments into high-molecular-weight DNA in bacteria; DNA gyrase inhibitor. Indication: Adult urinary tract infections (including complicated); c hronic bacterial prostitis; acute sinusitis; lower respiratory skin, bone, joint infections; infectious diarrhea, exposure to inhalation anthrax; conjunctivitis, corneal ulcers (ophthalmic). Dose: PO 500mg q12h Adverse Effects: CNS: Headache, dizziness, fatigue, insomnia, depression, restlessness, seizures, confusion. GI: Nausea, constipation, increased ALT, AST, flatulence, insomnia, heartburn, vomiting, diarrhea, oral candidasis, dysphagia, pseudomembranous colitis, dry mouth INTEG: Rash, pruritis, uriticaria, photosensitivity, flushing, fever, chills, MISC: Anaphylaxis,Stevens-Johnson Syndrome MS: Tremor, arthalgia, tendon rupture Nursing Considerations: * Assess patient for previous sensitivity reaction Identify urine output; if decreasing, notify prescriber (may indicate nephrotoxicity); also check for increased BUN, creatinine. Nursing Care Management Ongoing Assessment * Monitor Intake and Output. * Assess Vital signs| Provides information about fluid balance, renal function as well as guidelines for fluid replacement. BP, Pulse, RR, and Temperature indicate response to fluid status. | Diet * Low Sodium diet| A diet high in sodium may raise blood pressure and caus e fluid retention, resulting in swelling of the legs and feet. | Sex Being sexually active may help keep the urethra open. But the patient should not get sexually aroused without ejaculating because the urethra may get blocked. Some treatments may also cause sexual problems. These problems usually do not last forever and most can be helped. Complications * Urinary Tract Infection * Bladder Damage * Chronic Kidney Disease| Urine is normally sterile, and the normal flow of urine usually prevents bacteria from growing in the urinary tract. When urine stays in the bladder, however, bacteria have a chance to grow and infect the urinary tract. If the bladder becomes stretched too far or for long periods, the muscle may be permanently damaged and lose its ability to contract. If urine backs up into the kidneys, permanent kidney damage can lead to reduced kidney function and chronic kidney disease. If you lose too much of your kidney function, you will need dialysis or a kidney transplant to stay alive. | References: Mosby, Elsevier. Mosby’s Guide for Nurses, 6th edition. Missouri, St. Louis: 2005 http://www. pennmedicine. org/encyclopedia/em_DisplayAnimation. spx? gcid=000136;ptid=17 http://www. nsbri. org/humanphysspace/focus4/ep-urine. html http://kidney. niddk. nih. gov/kudiseases/pubs/UrinaryRetention/ http://www. uptodate. com/contents/acute-urinary-retention http://www. ncbi. nlm. nih. gov/pmc/articles/PMC1477632/ http://www. scribd. com/doc/5989689/Case-Study-BPH http://wps. prenhall. com/wps/media/objects/3918/4012970/NursingTools/ch48_NCP_UrinElim_1316-1317. pdf http://www. drugs. com/cg/urinary-retention-in -men-aftercare-instructions. html