Benign prostatic hyperplasia or hypertrophy (BPH) is a gradual enlargement of the prostate gland (hyperplasia) due to an increase in the size of the cells (hypertrophy). The breakdown of the balance between cellular proliferation and cell death results in excess prostate cells, causing BPH.
BPH is very common, affecting half of men by age 60. As men age, the prostate grows. The urethra runs through the prostate gland, so it becomes partially or completely blocked due to enlargement pressure, which results in difficulty urinating. If untreated, it may lead to kidney or bladder complications.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Disturbed Sleep Pattern
- Risk for Deficient Fluid Volume
- Risk for Urinary Tract Injury
- Urinary Retention
Nursing Process
Medications are typically attempted before surgery is performed. Dietary changes, weight loss, exercise, and pelvic floor training are noninvasive and low-cost methods to reduce BPH symptoms that the nurse can educate the patient about.
The nurse must understand how to care for the patient hospitalized for surgical procedures for BPH, including monitoring urine output and characteristics, catheter care, and discharge instructions.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to benign prostatic hyperplasia.
Review of Health History
1. Assess the patient’s general symptoms.
Prostate gland enlargement causes symptoms that tend to worsen over time, such as:
- Early symptoms:
- Weakened urine stream
- Increased urgency and frequency of urination
- Increased urination at night (nocturia)
- Inability to start (hesitancy) or continue urination
- An unsatisfied feeling of bladder emptying
- Late symptoms:
- Dribbling towards the end of urination
- Urinary retention
- Urinary incontinence
- Bladder distention
- Blood in the urine (hematuria)
- Urinary stasis
- Urinary tract infections
- Painful urination (dysuria)
2. Determine the patient’s risk factors.
Factors that increase the risk of BPH include the following:
- Older age (up to 90% of men over 80 experience BPH symptoms)
- Metabolic syndromes (glucose intolerance, insulin resistance, and dyslipidemia)
- Obesity
- Hypertension
- Genetic factors (first-degree family history)
- Sedentary lifestyle
3. Review the patient’s medical history.
While the cause of prostate enlargement is unknown, it is believed that aging, changes in the cells, and lower levels of testosterone play a role. Interestingly, men who had their testicles removed at an early age do not develop BPH.
4. Assess for complications.
The following are health complications that can result from an enlarged prostate:
- Urinary tract infections
- Bladder or kidney stones
- Conditions affecting the bladder nerves
5. Review the patient’s medications.
Certain medications can worsen BPH symptoms, including:
- Decongestants
- Antihistamines
- Diuretics
- Tricyclic antidepressants
6. Note any past surgeries.
Investigate if there is scarring in the bladder from past surgery. This scarring may contribute to prostate enlargement.
7. Interview the patient using a subjective questionnaire.
The American Urological Association Symptom Index/International Prostate Symptom Score measures the severity of BPH symptoms.
8. Review the client’s fluid intake.
Alcohol, coffee, and caffeinated soda can increase diuresis and the urge to urinate.
Physical Assessment
1. Perform a physical examination.
Note for a palpable bladder, enlarged or tender lymph nodes in the groin, or a swollen or tender scrotum. When inspecting the external genitalia examination, assess for the following:
- Discharge from the urethra
- Narrowing of the urethral opening (meatal stenosis)
- If the foreskin covering the penis can be pulled back (phimosis)
2. Perform a digital rectal examination.
The nurse can assess the client’s prostate by performing a digital rectal examination to identify the size, shape, and abnormalities like nodules.
Diagnostic Procedures
1. Evaluate blood tests.
Blood tests include:
- Renal function tests (BUN, creatinine) to monitor for kidney problems
- Prostate-specific antigen (PSA) may be elevated
2. Assess urine characteristics and output.
Evaluate the urine for abnormalities through the following tests:
- Urine dipstick: checks for the presence of infection, microscopic hematuria, protein, or glucose
- Post-void residual volume: determines how much urine remains in the bladder after urinating
- Frequency-volume chart: tallies the fluid intake and urine output
- Urodynamic studies: measure the urine flow through the bladder, sphincters, and urethra
3. Investigate the genitourinary system.
Prepare the patient for imaging procedures like:
- Transrectal ultrasound: measures and assesses the prostate with an ultrasound probe placed into the rectum
- Cystoscopy: views the bladder and urethra with a flexible scope device through the urethra
4. Anticipate a possible biopsy.
Prostate biopsy utilizes transrectal ultrasonography to identify or rule out prostate cancer by examining the sample tissue. Prostate cancer and BPH can have similar symptoms.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with benign prostatic hyperplasia.
Manage BPH
1. Manage the underlying cause.
There are several treatments available for BPH. Patients with mild or no symptoms may only need a “wait and watch” approach with lifestyle modifications like avoiding fluids before bedtime.
2. Administer medications as ordered.
The most common medications prescribed for BPH are the following:
- Alpha-blockers (doxazosin, prazosin, terazosin)
- 5-alpha reductase inhibitors (dutasteride, finasteride)
- Combination therapy (alpha-blockers and 5-alpha reductase inhibitors at the same time)
- Phosphodiesterase inhibitors (tadalafil)
3. Consider the use of alternative medicine as recommended.
Several types of herbal formulations and plant-derived chemicals have gained favor for the treatment of BPH, such as the following:
- Saw palmetto
- African plum tree extract
- Rye grass pollen
- Stinging nettle
- Pumpkin seeds
4. Prepare the patient for possible surgery.
Transurethral Resection of the Prostate (TURP) is the gold standard for treating bladder outlet obstruction (BOO) caused by BPH. The following are some of the reasons to proceed with surgical intervention:
- Retention of urine
- Failed urination trials
- Recurrent hematuria
- Urinary tract infection
- Kidney obstruction
- Failed medical treatment
- Financial constraints related to long-term therapies
5. Anticipate the use of minimally invasive procedures.
The majority of minimally invasive procedures use heat to destroy prostatic tissue. Heat is given in a limited and regulated manner to prevent complications associated with TURP. They also permit the administration of milder anesthesia, resulting in less anesthetic risk for the patient. These procedures include the following:
- Transurethral incision of the prostate
- Laser prostatectomy
- Transurethral needle ablation
- High-intensity ultrasound energy therapy
- Water vapor thermal therapy
- Waterjet ablation therapy
- Prostatic urethral lift
6. Collaborate with the healthcare provider for prostate removal.
Open or robot-assisted prostatectomy (prostate removal) may be necessary for men with very large prostates.
7. Perform catheter care.
Catheter care is essential for patients with intermittent bladder or suprapubic catheters to relieve symptoms or monitor urine output.
8. Perform continuous bladder irrigation.
Following TURP, CBI is performed to decrease blood clots in the bladder and maintain the flow and patency of urine after surgery. The nurse titrates the flow of saline into the bladder to keep the urine light pink to clear.
Prevent BPH
1. Promote an active lifestyle.
Men with early-stage prostate cancer who exercised vigorously for at least three hours per week activated more repair cells than those who did not exercise.
2. Exercise the pelvic muscles.
Kegel exercises are very beneficial for individuals suffering from BPH symptoms. Teach the patient to clench their pelvic muscles to hold back their urine. Squeeze the muscles for a few seconds and then release. Three sets of ten Kegels per day should help with bladder control.
3. Reduce weight.
BPH and prostate cancer risk are increased by belly obesity. Men can lose belly fat by eating a balanced diet and engaging in regular exercise.
4. Encourage vegetables and reduce fat.
A diet low in fat and red meat and high in protein and vegetables may reduce the risk of symptoms related to BPH.
5. Refrain from caffeine and excessive alcohol.
Caffeine and alcohol can increase urine production, irritate the bladder, and exacerbate urinary symptoms.
6. Encourage regular and scheduled urination.
Promote the following bathroom habits:
- When the urge to urinate is felt, advise the patient to urinate immediately.
- Schedule bathroom breaks regularly.
- Teach about double voiding. Without straining, instruct the patient to urinate again to empty the bladder.
7. Find an alternative for medications.
If the cause of the narrowing of the urethra is a medication (such as a decongestant or antihistamine), discuss an alternative with the healthcare provider.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for benign prostatic hyperplasia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for benign prostatic hyperplasia.
Acute Pain
A distended bladder, renal colic, urinary tract infection, and procedures can cause acute pain associated with benign prostatic hyperplasia (BPH).
Nursing Diagnosis: Acute Pain
Related to:
- Distended bladder
- Renal colic
- Urinary tract infection
- Catheter insertion
- Surgical procedures
As evidenced by:
- Complaints of bladder or rectal spasm
- Facial grimacing
- Distraction behaviors
- Restlessness
- Altered vital signs
- Diaphoresis
Expected outcomes:
- Patient will verbalize relief from bladder or urinary tract pain.
- Patient will demonstrate interventions to ease discomfort.
Assessment:
1. Perform a pain assessment.
Poor pain management can result from inadequate assessment of acute and chronic pain. The key to effective pain management begins with an accurate pain assessment.
2. Identify triggering factors.
Assess for factors that trigger or worsen pain, such as movement, urination, or ejaculation.
3. Review urinalysis results.
A urinalysis should be performed to assess for an infection contributing to pain, causing burning with urination, flank or bladder pain.
Interventions:
1. Encourage sitz baths and warm soaks.
Soothe perineal discomfort with a warm sitz bath for 20 minutes several times per day to relax the prostate and surrounding muscles.
2. Secure the catheter.
Securing the urinary catheter correctly to the client’s thigh prevents pain from an injury in the penile-scrotal junction and pulling on the bladder when turning or ambulating.
3. Relieve bladder spasms.
Administer antispasmodics as prescribed to minimize bladder spasms brought on by catheter sensitivity.
4. Promote prostate massage.
Prostate massage can relieve excess fluids that build up in the prostate and reduce the inflammation and pressure causing the pain. The patient can be instructed on how to do this themselves.
5. Relieve pain with medications.
Narcotics may be given following surgical procedures to relieve acute pain.
Disturbed Sleep Pattern
Disturbed sleep patterns associated with benign prostatic hyperplasia (BPH) can be caused by increased urination at night (nocturia).
Nursing Diagnosis: Disturbed Sleep Pattern
Related to:
- Nocturia
- Pain caused by BPH
- Increased urgency to urinate
- Increased frequency of urination
As evidenced by:
- Insomnia
- Irregular sleeping pattern
- Inadequate sleep quality
- Bladder pain
- Bladder irritability
- Frequent urination
- Restlessness
Expected outcomes:
- Patient will be able to verbalize restful sleep.
- Patient will demonstrate a calm and well-rested appearance.
- Patient will receive at least 8 hours of sleep nightly.
Assessment:
1. Ask the patient to document nocturia.
Have the patient document how often they awake at night to urinate. Patients can identify sleep disturbances and other elements that may affect the quality of their sleep for the provider to review.
2. Identify sleep habits.
Assessing practices/habits that may interfere with sleep can reveal patterns that aid in explaining sleeping issues.
3. Review medications.
Diuretics should not be taken close to bedtime if it can be avoided.
Interventions:
1. Encourage limiting fluid intake before bed.
Limit fluid intake 2-4 hours before bedtime, as advised. Instruct the patient to drink plenty of fluids during the day (particularly water) to prevent dehydration. Emphasize limiting their intake of alcohol and caffeine (soda, tea, and coffee), which causes diuresis.
2. Administer desmopressin as prescribed.
Desmopressin, a synthetic form of vasopressin, is used to replenish decreased levels of the hormone. It manages excessive thirst and prevents dehydration, and urine production, especially at night, limiting nocturia.
3. Shrink the prostate.
5-alpha reductase inhibitors like finasteride shrink the prostate and prevent hormonal changes that cause prostate growth which can reduce symptoms of BPH.
4. Provide compression stockings.
During the day, keep the legs elevated or apply a pair of compression stockings to promote fluid circulation to lessen the need to urinate at night.
Risk for Deficient Fluid Volume
Patients with benign prostatic hyperplasia have an enlarged prostate, which compresses the urethra and interferes with urinating. However, once the obstruction is removed, patients with BPH are at risk for deficient fluid volume due to post-obstructive diuresis, increasing the urine output and possibly causing dehydration and electrolyte imbalance.
Nursing Diagnosis: Risk for Deficient Fluid Volume
Related to:
- Disease process
- Postobstructive diuresis
- Polyuria
- Insufficient fluid intake
- Problems associated with fluid elimination (CKD, CHF)
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain a urine output of 0.5mL/kg/hr.
- Patient will remain free from any signs of dehydration, such as altered mental status, poor skin turgor, and alterations in vital signs.
Assessment:
1. Assess the patient’s hydration status and urine output.
The patient’s intake and output should be assessed and monitored in patients with BPH as it can drastically change due to post-obstructive diuresis, resulting in the depletion of the patient’s total fluid volume.
2. Assess results of diagnostic studies.
Uroflowmetry can help determine the severity of urethral blockages as well as the type of treatment needed. A cystoscopy and transurethral ultrasound may also be indicated.
3. Perform post-void residual assessment.
A post-void residual > 1500 mL is more likely to result in post-obstructive diuresis.
4. Monitor laboratory studies, including renal function and electrolytes.
Patients with BPH are at risk for developing electrolyte imbalances, especially hyponatremia, as fluid and sodium are excreted. While initial eGFR, BUN, creatinine, and electrolyte levels won’t predict the severity of diuresis, they are useful to compare and monitor post-diuresis.
Interventions:
1. Decompress the bladder.
Insertion of a urinary catheter allows for complete and immediate drainage of the bladder without increased complications. Post-obstructive diuresis normally resolves within 24 hours, but the nurse must monitor closely for dehydration, electrolyte imbalances, and shock.
2. Closely monitor lab values, urine samples, and vital signs.
Patients should have their electrolyte and renal function reassessed at least every 12 hours. A urine sample can assess for urinary sodium, potassium, and osmolality. Monitor vital signs for alterations indicative of hypovolemia.
3. Encourage fluid replacement.
Patients who are alert and oriented should be encouraged to replace lost fluids orally. Cognitively-impaired patients may receive IV fluids. Excessive fluid intake should be avoided as this can exacerbate diuresis.
4. Continuously monitor the urine output.
Urine output exceeding 200 mL per hour for 2 consecutive hours can help diagnose post-obstructive diuresis and requires close monitoring. When POD has resolved, the patient’s 24-hour urine output will be less than 3L.
Risk for Urinary Tract Injury
Patients with benign prostatic hyperplasia risk developing urinary tract injury from the mechanism of prostate enlargement, compressing the urethra, and blocking urine flow. Complications may arise, such as infections or calculi, increasing the risk of injury. The patient may also require catheterization, which can cause urethral injury.
Nursing Diagnosis: Risk for Urinary Tract Injury
Related to:
- Urinary tract obstruction
- Enlarged prostate
- Disease process
- Catheter insertion
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will remain free from any signs of urinary tract injury, such as hematuria.
- Patient will experience unobstructed urination with a urine output of 0.5–1.0 mL/kg/hr.
Assessment:
1. Assess and monitor the patient’s urinary elimination patterns.
Assessing the patient’s urinary elimination patterns and characteristics like frequency, odor, consistency, volume, and color can help evaluate and confirm urinary tract injury and other problems.
2. Assess laboratory values, including complete blood count, urinalysis, and serum creatinine levels.
Blood tests, urinalysis, and serum creatinine levels can help determine bladder infection and renal function.
Interventions:
1. Instruct on bladder training.
Patients with BPH may benefit from alternative strategies to manage obstruction and urgency through bladder training like urinating every 2-3 hours to reduce urinary stasis and acute urinary retention.
2. Encourage adequate fluid intake.
Restricting fluids should be avoided as this can increase the risk of developing urinary tract infections and renal calculi, resulting in urinary tract injury.
3. Assist in the aseptic insertion of a urinary catheter.
If there is a sizable obstruction, a urinary catheter may be inserted to prevent urinary retention in patients with BPH. Select the correct catheter size and type to prevent urinary tract injury. It is often difficult to insert a Foley catheter with an enlarged prostate, and the patient may require a coudė catheter.
4. Encourage the patient to avoid bladder irritants.
Bladder irritants like alcohol and caffeine should be avoided as this can increase prostatic voiding symptoms and the risk of developing bladder distention, overactivity, and urinary tract injury.
Urinary Retention
Urinary retention and associated symptoms are expected findings with benign prostatic hyperplasia (BPH).
Nursing Diagnosis: Urinary Retention
Related to:
- Enlargement of the prostate
- Blockage of urine flow
- The inability of the bladder muscles to contract adequately
As evidenced by:
- Urinary frequency
- Urinary hesitancy
- Failure to empty the bladder
- Dribbling urine
- Overflow incontinence
- Sensation of bladder fullness
- Dysuria
- Bladder distention
- Residual urine
Expected outcomes:
- Patient will not experience a post-void residual greater than 50 mL.
- Patient will verbalize a reduction in hesitancy, dribbling, and bladder fullness.
Assessment:
1. Assess urine elimination patterns.
Changes in urination in BPH include increased urges and frequency (both during the day and at night), a weak urine stream, and urine leakage or dribbling.
2. Palpate the patient’s bladder.
Bladder distention is caused by increased pressure. It can lead to diverticula, trabeculation, and hypertrophy of the bladder detrusor. Urine output is gradually hindered when the prostatic urethra’s lumen extends and constricts.
3. Observe urine characteristics.
Due to urinary retention, urine may have a dark color and a foul scent. Patients may also have blood in the urine. These symptoms could signal an underlying infection.
4. Identify additional signs and symptoms.
Additional signs and symptoms include hypertension, edema, changes in mentation, bloody urine or semen, painful ejaculation, and frequent lower back, hip, pelvis, or thigh pain.
Interventions:
1. Assess post-void residual (PVR) volume.
After the patient has urinated, assess the amount of urine left in the bladder using a bladder scanner. A PVR of less than 50 mL is considered normal, while greater than 200 mL is inadequate emptying.
2. Provide catheterization.
Catheterization prevents urinary retention and eliminates the possibility of ureteral stricture in patients with BPH. An enlarged prostate can make inserting a catheter difficult. If the nurse is unable to complete the task, a urologist can be consulted to insert a catheter using a guidewire.
3. Relax the muscles.
Provide alpha-adrenergic antagonists as ordered to ease the muscle tissue in the prostate gland and arteries, enhancing blood and urine flow.
4. Administer antibiotics.
Administer antibiotics as prescribed if an infection is present due to the growth of bacteria from urinary stasis.
5. Refer to a urologist.
Because urinary retention interferes with the natural flow of urine, urinary retention is regarded as an urgent medical issue. Urologists are specialists who care for patients with urinary retention and BPH.
References
- Bocco, D. (2022, December 19). 7 foods to prevent an enlarged prostate. Healthline. Retrieved September 2023, from https://www.healthline.com/health/enlarged-prostate-diet
- Busch Center. (2021, May 20). 5 exercise tips for a healthy prostate. Busch Center | Setting the Standard. Retrieved September 2023, from https://buschcenter.com/5-exercise-tips-for-a-healthy-prostate/
- Cleveland Clinic. (2023, August). Benign prostatic hyperplasia (BPH): Symptoms & treatment. Retrieved September 2023, from https://my.clevelandclinic.org/health/diseases/9100-benign-prostatic-hyperplasia#symptoms-and-causes
- Deters, L. A. (2023, August 17). Benign prostatic hyperplasia (BPH) treatment & management: Approach considerations, Alpha-blockers, 5-Alpha-Reductase inhibitors. Diseases & Conditions – Medscape Reference. Retrieved September 2023, from https://emedicine.medscape.com/article/437359-treatment#showall
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Galan, N. (2023, May 15). Enlarged prostate diet: Foods to eat and avoid. Medical and health information. Retrieved September 2023, from https://www.medicalnewstoday.com/articles/321079#foods-to-eat
- Mayo Clinic. (2021, April 13). Benign prostatic hyperplasia (BPH) – Diagnosis and treatment – Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/diagnosis-treatment/drc-20370093
- NallN, R. (n.d.). Everything you need to know about nighttime urination. Healthline. Retrieved January 2023, from https://www.healthline.com/health/sleep/excessive-urination-at-night#treatment
- National Center for Biotechnology Information. (2022, May 8). Benign prostatic hyperplasia – StatPearls – NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK558920/
- Ng, M., & Baradhi, K. M. (2022, August 8). Benign prostatic hyperplasia – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved September 2023, from https://www.ncbi.nlm.nih.gov/books/NBK558920/#:~:text=The%20development%20of%20benign%20prostatic,in%20clinical%20manifestations%20of%20lower
- Urology Care Foundation. (n.d.). Benign prostatic hyperplasia (BPH). Retrieved September 2023, from https://www.urologyhealth.org/urology-a-z/b/benign-prostatic-hyperplasia-(bph)
- Silvestri, L. A., & Silvestri, A. E. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
- WebMD. (2016, November 10). What is BPH? https://www.webmd.com/men/prostate-enlargement-bph/what-is-bph
