Adult-Gerontology Acute Care Practice Guidelines
Definition
A.A histological change that develops within the prostate gland, which may lead to the presence of an enlarged prostate gland and associated lower urinary tract symptoms.
Incidence
A.50% of men over the age of 40 develop histologic evidence of benign prostatic hypertrophy (BPH).
1.30%–50% of these men develop bothersome lower urinary tract symptoms (LUTS).
B.Prevalence of BPH increases with age.
1.60% for men in their 60s.
2.Up to 90% for men in their 70s and 80s.
Pathogenesis
A.There is abnormal microscopic hyperplasia and macroscopic growth.
B.The detrusor muscle generates higher pressures, leading to frequency, urgency, and nocturia.
C.BPH may lead to bladder decompensation, with the bladder muscle no longer able to provide enough pressure to urinate.
D.The role of hormonal involvement in the development of BPH is still poorly understood, but there is evidence that the hormone androgen, which becomes dihydrotestosterone (DHT), plays a critical role in the growth of prostatic tissue.
Predisposing Factors
A.Advancing age.
B.Family history of BPH.
C.Ethnic background.
1.The risk of BPH is higher in black and Hispanic men than in white men and Asian men.
D.Diabetes and heart disease: Possible increased incidence in BPH.
E.Obesity: Possible association with increased prostate volume and LUTS.
Subjective Data
A.Common complaints/symptoms: LUTS.
1.Storage symptoms or irritative voiding symptoms: Frequency, nocturia, dysuria, decreased volume, urgency, or urge incontinence.
2.Voiding symptoms or obstructive voiding symptoms: Weak stream, intermittent stream, hesitancy, retention, abdominal straining, incomplete emptying, or post void dribbling.
B.Common/typical scenario.
1.Onset is gradual, with symptoms increasing over time.
2.Symptoms are often aggravated at night with significant nocturia, which may often cause difficulty sleeping.
3.Symptoms may be aggravated by cough/cold medications (antihistamines, pseudoephedrine).
C.Family and social history.
1.Increased likelihood if father or brother have history of BPH.
2.Increased physical activity: Possible protection against BPH.
D.Review of systems.
1.Constitutional: Weight loss or insomnia.
2.Neurological: Dizziness, weakness, tremors, or other signs that may indicate a neurological condition such as multiple sclerosis or Parkinson’s disease.
3.Genitourinary: LUTS; usually no flank pain.
a.Possible report of suprapubic fullness/tenderness.
b.Hematuria: Possible indication of genitourinary malignancy (bladder cancer).
4.Cardiovascular: Lower extremity edema that may indicate heart failure or diuretic use.
5.Endocrine: Polyuria, polyphagia, or polydipsia that may indicate diabetes mellitus or diabetes insipidus.
Physical Examination
A.Neurological.
1.Evaluate for musculoskeletal weakness, especially lower extremity motor and sensory function.
2.Evaluate gait.
B.Digital rectal examination (DRE).
1.To estimate prostate size, assess for prostatitis, or evaluate prostate nodules that may indicate prostate cancer.
2.Assess for anal sphincter tone; if absent or decreased, possible neurological disorder.
C.Abdominal.
1.Palpate for masses that may be pressing on the bladder.
D.Genitourinary.
1.Assess for costovertebral angle tenderness.
2.Assess for obvious urethral strictures and phimosis.
Diagnostic Tests
A.Urinalysis to exclude hematuria or possible infection.
B.Blood work.
1.Prostate specific antigen (PSA), especially if prostatic nodules are palpated on DRE or high concern for prostate cancer.
2.Basic metabolic panel to assess for renal function, electrolyte abnormalities, and hyperglycemia.
C.Imaging: CT or MRI generally not indicated.
D.Uroflowmetry: Measures the volume/time of urine accumulation.
E.Post void residual: Volume of urine remaining in bladder after voiding.
1.Obtain from bladder ultrasound/bladder scan if possible.
2.Straight catheterization if bladder ultrasound not available.
F.Urodynamic study to differentiate between bladder outlet obstruction and hypocontractile bladder. This may be necessary prior to surgical intervention for BPH.
Differential Diagnosis
A.Foreign body in urethra/bladder (stone or retained ureteral stents)
B.Meatal stenosis.
C.Urethral stricture.
D.Detrusor sphincter dyssynergia.
E.Neurogenic bladder (e.g., multiple sclerosis, Parkinson’s disease).
F.Bladder cancer.
G.Prostate cancer.
H.Overactive bladder.
I.Interstitial cystitis.
J.Infectious source: Acute cystitis, acute prostatitis/chronic prostatitis, or prostatic abscess.
K.Pelvic floor dysfunction.
L.Radiation cystitis.
M.Diabetes insipidus causing polyuria.
N.Diabetes mellitus causing polyuria.
Evaluation and Management Plan
A.General plan.
1.Obtain urinalysis/urine culture.
2.Obtain PSA if concern for prostate cancer.
3.Place Foley catheter for urinary retention or teach patient how to perform clean intermittent catheterization.
4.Observe for post obstructive diuresis with urinary retention.
5.Advise watchful waiting, with no treatment for men with mild symptoms and good quality of life.
6.Use pharmacotherapy: Alpha blockers or 5-alpha-reductase inhibitors (5-ARIs).
7.Obtain prostate biopsy if elevated PSA or prostatic nodule.
8.Order uroflowmetry/post void residual.
9.Order urodynamic study if indicated.
10.Advise surgery if indicated.
B.Patient/family teaching points.
1.Have a thorough discussion with patient and family about the usefulness of PSA screening test in detecting prostate cancer.
a.If the PSA is elevated, this will prompt prostate biopsy and possible treatment for prostate cancer, which may be a slow-growing disease.
b.In 2010, the U.S. Preventive Task Force recommended against PSA screening, stating that the test has no net benefit and that the harms outweigh benefits. The American Urologic Association in 2013 also started to recommend against routine cancer screening.
2.Discuss keeping a voiding diary.
3.Discuss possible side effects of medical therapy, including orthostatic hypotension, dizziness, and retrograde ejaculation.
4.Educate the patient with retention regarding how to perform clean intermittent catheterization because this is a better alternative to an indwelling Foley catheter.
5.Avoid becoming constipated because this aggravates symptoms.
C.Pharmacotherapy.
1.Alpha blockers, which rapidly relax the smooth muscles of the bladder neck and prostate without impairing bladder body contractility.
a.Most commonly used: Tamsulosin 0.4 mg daily (max 0.8 mg daily).
2.5-ARIs, which block intracellular DHT conversion.
a.Best for larger prostate glands (>40 mL).
b.Most commonly used: Finasteride 5 mg.
3.Antimuscarinic agents, which help with bladder overactivity.
a.Most commonly used: Oxybutynin 5 mg TID.
4.Phosphodiesterase-5 inhibitor, which is Food and Drug Administration (FDA) approved for LUTS secondary to BPH.
a.Tadalafil (Cialis): 2.5 to 5 mg; contraindicated in men taking nitrates, nonselective alpha blockers, and cytochrome P 450 inhibitors.
D.Discharge instructions.
1.Advise patients to limit caffeine, fluids, and alcohol. These may increase LUTS.
2.Advise them to avoid cold medications, antihistamines, and pseudoephedrine.
3.Advise them to seek medical attention if they are unable to void or have flank pain, gross hematuria, or passage of clots.
4.Advise them to discontinue alpha blockers with dizziness, lightheadedness, or falls.
Follow-Up
A.Monitor response to treatment with uroflowmetry, post void residual, and presence of symptoms.
B.Advise that urodynamic studies may be indicated if there is no improvement of symptoms with medical therapy.
C.Advise that surgery may provide relief in the case of excessive symptoms refractory to medical management. Some of the more common options include:
1.Transurethral resection of the prostate (TURP).
2.Holmium laser enucleation of the prostate (HoLEP).
3.Simple prostatectomy for large prostates greater than 100 mL.
Consultation/Referral
A.Urology.
1.Urinary retention.
2.Hematuria/clot retention.
3.PSA elevation, will need prostate biopsy.
4.Suspected genitourinary malignancy.
5.Failed medical treatment with moderate to severe symptoms.
B.Neurology: With any concern for neurological condition that may be causing LUTS.
C.Endocrinology.
1.For hyperglycemia.
2.Concern for diabetes insipidus.
Special/Geriatric Considerations
A.Many patients limit fluids due to symptoms; this may lead to dehydration, especially in geriatric individuals. Assess for dehydration and provide education to maintain a normal fluid intake.
B.Monitor the geriatric population for medication side effects.
1.Alpha-blockers: Hypotension and dizziness.
2.Anti-muscarinic agents: Dry mouth, constipation, and mental status changes.
a.Monitor for polypharmacy with other possible anticholinergic medications that patients may be prescribed or taking over the counter.
b.Studies have shown that transdermal oxybutynin and the newer anticholinergics may be better tolerated.
Bibliography
Deters, L. A. (2019, January 15). Benign prostatic hypertrophy (BPH) differential diagnoses., In E. D. Kim (Ed.), Medscape. Retrieved from http://emedicine.medscape.com/article/437359-differential
Kim, E. H., Larson, J. A., & Andriole, G. L. (2016). Management of benign prostatic hyperplasia. Annual Review of Medicine, 67, 137–151. doi:10.1146/annurev-med-063014-123902.
Nicholson, T., & Ricke, W. (2011, November-December). Androgens and estrogens in benign prostatic hyperplasia, past, present and future. National Institutes of Health, 82(4–5), 184–189. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179830