Benign Prostatic Hyperplasia - Physical and Psychological Demands - Essay Example

Benign Prostatic Hyperplasia Vicky Brown UCLA Introduction This paper is a case study of a Hispanic male complaining of decreased urinary flow. The patient reports that the problem started two years ago and has worsened over the last two weeks. He has been experiencing increased nocturia and passes urine at least five times a night. He also reports decreased strength in the flow of urine and slight terminal dysuria. Yesterday, he had trouble starting the micturition process, which affects his daily activities. However, he reports that he has not had any radiating pains. He has never sought any treatment previously and does not go for any workouts. This paper analyzes sand creates a comprehensive care plan for acute/chronic care, disease prevention and health promotion for this patient and his condition, benign prostatic hyperplasia. Thus, the analysis entails studying the patient’s condition in details. The analysis entails defining the condition, signs and symptoms of the disease, conducting diagnostic tests to detect the condition and the different options available in the management of the condition. The paper also discusses the holistic and integrated management of the patient and studies the implications of the condition to the family and the patient. The analysis will also focus on the challenges of managing the patient and the strategies that can be used to address these challenges. During the diagnosis process, history taking and physical assessment are key elements for attaining the right diagnosis. According to his medical history, the patient has never sought any medical attention concerning the current health concern. He does not have any recent hospitalization and has never had any surgical operation. Reportedly, the patient uses Cardizem 240mg and Zocor20mg daily for high blood pressure and elevated cholesterol. He does not have a known allergy to any food or drug. The patient has a master’s degree in engineering and an income of 65,000.00 per year. He does not have financial problems and has a good health insurance coverage, which he does not use. He is married and has support from his family and friends. After conducting the necessary investigations and assessment, it established that the patient was suffering from benign prostatic hyperplasia (BPH). Benign Prostatic Hyperplasia (BPH) BPH is a common condition in aging men. It is associated with lower urinary tract symptoms and tends to affect the daily activities of an individual. In addition, the condition affects the rest activity patterns of its victims (Parsons, 2009). It is most common among men who are aged more than 40 years. By the age of 60 years, 50% of men already have BPH (Tabloski, 2012). It affects as many as 90% of men aged 85 years and above. In fact, it is the second most prevalent cause of surgical interventions for men aged 60 years and above (Wein et al, 2011). Pathophysiology The cause of BPH is not clearly understood. However, testicular androgens are suspected to be involved. Dihydrotestosterone (DHT) and estrogens are suspected to be involved. BPH is mainly observed to occur in men with high levels of estrogen (Tabloski, 2012). The prostate tissues become more sensitive to estrogens and less reactive to DHT. The condition develops over prolonged period, with rather slow and insidious changes. It results from a complicated interaction, which involves resistance in the prostatic urethra and spastic and mechanical effects and pressure from the bladder, neck or urethra, causing an incomplete emptying of the bladder and urinary retention (AUA, 2012). The hypertrophied lobes of the prostrate may tend to cause obstruction of the bladder neck or urethra, leading to incomplete emptying of bladder and urine retention (Tabloski, 2012). This situation may result in the gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis). Because of urine retention, the patient may suffer from UTIs because the retained urine is a good medium for the development of infectious microorganisms (Kaplan, 2010). Urine retention may also be caused by consumption of over-the-counter drugs that contain decongestants. A possible effect of these drugs is the prevention of the relaxation of the bladder neck and urine release. In addition, frequent consumption of drugs that contain antihistamines may weaken the contraction of the bladder muscles, resulting in urine retention, difficulty in urination and painful urination (Parsons, 2009). The risk factors for BPH include cigarette smoking, heavy consumption of alcohol, obesity, low activity levels, hypertension heart diseases and a western diet, which contains high levels of animal fats and proteins and low levels of fiber (Parsons, 2009). Signs and Symptoms The symptoms of BPH vary from mild to severe and could involve lower urinary tract symptoms or not. The severity of the symptoms worsens with age and the majority of patients report having moderate to severe symptoms (Campbell et al., 2011). Obstructive and irritating symptoms include frequency, urgency in micturition, nocturia, hesitancy in starting the micturition process, decreased and intermittent force of stream (Parsons, 2009). Others include incomplete emptying of the bladder and abdominal straining when urinating and a decrease in the volume and the force of urinary stream, dribbling, and complications of urinary retention. Retention of high volumes of urine can lead to retention whereas large residual volumes can lead to azotemia and renal failure (Kaplan, 2010). The generalized symptoms are fatigue, anorexia, vomiting and pelvic discomfort. A patient may also experience urinary incontinence, painful ejaculation, painful urination, foul-smelling urine and unusual coloration of the urine (Parsons, 2009). The symptoms usually originate from blockage of the urethra or from an overworked bladder from attempts to pass urine through a blocked bladder (Parsons, 2009). The size of the prostate cannot be used to determine the severity of the blockage. Sometimes patients may not know they have a blockage until they start experience difficulties in passing urine. Differentiating the Disorder from Normal Development Under normal conditions, a mature individual should void approximately 5 to 6 times a day. However, a patient of BPH may void up to 20 times a day. The nature of micturition of a BPH patient entails the patient experiencing a great urge and urgency to visit the toilet. The patient may not even be able to contain the urine. This should not be the case in normal circumstances. A BPH patient has decreased and intermittent force of stream. In normal circumstances, there should be pressure in the stream when passing urine. Additionally, normal passing of urine is not accompanied by a sensation of incomplete emptying of the bladder and abdominal straining. However, this is not the case for BPH patients (Kaplan, 2010). Progression Trajectory of BPH Majority of BPH patients who seek medical attention demonstrate moderate improvement from the symptoms, with a decrease in the challenges associated with the condition and an improved perception on quality of their lives. The symptoms presented on the lower urinary tract because of BPH tend to affect the sexual wellbeing and erectile functions of most patients. The risk for progression of BPH is elevated in patients with higher prostate volumes and PSA levels. There is a reduction of 39% progression of BPH in patients under doxazosin and 34% in patients under finasteride. On the other hand, there is a 66% reduction of the BPH progress in patients under a combination therapy and 64% in patients under surgery (Wein et al., 2011). Assessment and Diagnostic Tests for BPH There are several ways in which a healthcare worker can diagnose benign prostatic hyperplasia including taking thorough personal and family history of a patient. In taking the health history, focus must be on the urinary tract, previous surgical procedures, general health, family history of prostate diseases and fitness, in cases of surgery. The health practitioner also needs to ask assess a patient’s present symptoms, when the symptoms began and their frequency. Questions must also be asked on whether a patient has a history of recurrent UTIs, the types of medications already used, the amount of fluids consumed and whether a patient takes caffeine and alcohol (Parsons, 2009). Patients are often given a voiding diary to record the volume of urine they void and the frequency of urination. ADRE is done to reflect a large, rubbery and non-tender prostate gland. It is also recommended that a urinalysis is done to screen for hematuria and urinary tract infections. PSA levels are also obtained for patients with life expectancy of at least 10 years. This is important in the management of patient with prostate cancer. The AUA symptom index can be used to assess the severity of the symptom (Kaplan, 2010). Physical Exam During physical examination, a health practitioner should examine a patient’s body thoroughly by checking for any discharges from the urethral opening, enlargement or tenderness of the lymph nodes and swelling of the scrotum. Practitioners should also perform digital rectal examinations on patients (Porth &Matfin, 2012). Medical Tests Some of the medical tests that can be conducted are urinalysis, prostate-specific antigen (PSA) blood test, urodynamic tests, cystoscopy, trans-rectal ultra sound and biopsy. Urodynamic tests focus on the blade’s ability to contain urine and empty steadily and completely. One of the tests is uroflowmetry. This test assesses the rapidity at which the bladder releases urine. The other test is post-void residual measurement, which measures the amount of urine that remains in the bladder after urinating. Cystoscopy, which establishes the existence of blockages or stones within the urinary tract, is the other urodynamic test. The other test for diagnosing BPH is trans-rectal ultrasound, which produces images to show the size of the prostate and other abnormalities in the prostate (Kaplan, 2010). In case invasive therapy is considered, urodynamic studies and urethra-cystoscopy, and ultrasound may be necessary. Complete blood studies are also helpful and key to proper diagnosis of BPH. The state of the cardiac and respiratory systems need to be carefully assessed since most BPH patients tend to have cardiac and respiratory problems, maybe because of their advanced ages (McCance&Huether, 2012). Treatment Options of BPH There are varieties of ways of managing BPH. The techniques include lifestyle changes, medication. Some of these techniques are minimally invasive procedurally and surgically. The choice of treatment is based on the severity of the symptoms, the extent to which the condition affects a patient’s activities and a patient’s preference. It is worth noting that in case the prostate is mildly enlarged, the patient may not need to seek any treatments and can just come for checkups without any medications, unless the symptoms become more severe (Kaplan, 2010). Medications A health practitioner can prescribe medications to stop the growth of or even shrink the prostate or to reduce the symptoms of BPH. The available medications are alpha blockers, phosphodiesterase-5 inhibitors, 5-alpha reductase inhibitors and combination medications (Lepor, 2011). Alpha-blockers relax the smooth muscles within the prostate and the neck of the bladder to improve urine flow and to reduce the blockage of the bladder. Some of these alpha-blockers are terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral) and silodosin (Rapaflo) (AUA, 2012). Phosphodiesterase-5 inhibitors reduce lower urinary tract symptoms by relaxing the muscles of the urinary tract. An example of these drugs is Tadalafil (Cialis). 5-alpha reductase inhibitors block the production of DHT, which collect in the prostate and could cause prostate growth. Examples are finasteride (Proscar) and dutasteride (Avodart), which prevent the advancement of prostate growth or shrink the prostate (Lepor, 2011). Finasteride and dutasteride act more slowly than alpha blockers. However,they are used mainly for moderately enlarged prostates. Sometimes combination of more than one class of medications helps improve the symptoms. A combination of alpha-blockers and antimuscarinics are quite effective for patients with overactive bladder symptoms, (Porth&Matfin, 2012). Minimally Invasive Procedures In case medications are ineffective for a patient, several invasive procedures that relieve the symptoms of BPH are available. Examples of these procedures are transurethral needle ablation, transurethral microwave thermotherapy, high-intensity focused ultrasound, water-induced thermotherapy and prostatic stent insertion (Lepor, 2011). These procedures help in the destruction of enlarged prostate tissues and in the widening of the urethra. Hence, they relieve blockage and urine retention caused by BPH. Most of these procedures are carried out by transurethral methods, which mainly entail the insertion of a catheter or cystoscopy via the urethra up to the prostate. The choice of an invasive procedure to perform depends on a patient’s general health and the presenting symptoms (Porth&Matfin, 2012). Surgical Intervention The surgical removal of the enlarged prostate tissue is a long-term treatment for BPH. Surgical intervention is recommended when medication and minimal invasive procedures are not effective because symptoms are severe and troublesome to the patient or when complications set in. Although surgical procedures are used to remove the troublesome tissue and relieve the symptoms, they do not cure BPH (McCance & Huether, 2012). Some surgical procedures used to remove enlarged prostate tissues include transurethral resection of the prostate (TURP), laser surgery, open prostatectomy or transurethral incision of the prostate (TUIP). The procedures are performed underanesthesia. Immediately after performing a BPH surgery, a Foleycatheter is inserted through the penis opening to drain urine from the bladder into a drainage pouch. Physical and Psychological Demands Like many other conditions, BPH causes a lot of stress to patients and their friends and families. The stress is both physical and psychological. First BPH triggers great urgency and frequency for the patient to visit the toilet, interfering with their daily activities (McCance & Huether, 2012). This feature of BPH causes psychological stress to a patient. That is, it affects the manner in which the patient perceives themselves and their self-esteem. The patient may develop low self-esteem because of the inability to control their elimination pattern. Second, it BPH affects the productivity of a patient at home and at the work place. The patient is often not able to concentrate on his or her work as much as he/she used to prior to contracting the disease (Tanagho & McAninch, 2011). In addition, BPH causes a lot of financial inconveniences or stress to the family as well as the patient. The condition affects finances in that the patient has to incur financial costs while buying medications or purchasing other health management materials and advice. Worse still, the symptoms of BPH may interfere with the performance of a patient at work hence interfering with the financial growth. Moreover, in case a patient is constantly hospitalized, she or he may be unable to increase his/her financial productivity (McCance & Huether, 2012). Hospitalization bills and other bills resulting from the management of the condition also cause psychological trauma to the family and friends of the patient. The relatives or family may have to spend their own money to support the patient in treating and managing the condition. What is more, close relatives cannot evade feeling sympathy for the patient, affecting their psychological wellbeing and causing stress to them (Porth &Matfin, 2012). Key Concepts Successful management of the BPH requires the patient and the family to have a clear understanding of the condition and its management. They have to be involved in every stage of managing and treating the condition. There are severalconcepts that the health care provider must share with the family and the patient for optimal management. First, the healthcare provider must educate the patient on the techniques and principles of managing the condition (McCance & Huether, 2012). This sharing helps the patient to make an informed choice on the best way to manage BPH. The patient must be made aware that surgical operation is the last option for managing BPH and it is advisable only when the symptoms of the condition become sever. Additionally, care provider should educate patients on the different ways of coping with symptoms of the condition. For instance, to avoid frequent visits to the toilet, the patient can reduce the quantity of fluids they take, especially after dinner. This practice is advisable since the more the amount of fluids taken, the more the excretion demands. The patient also needs to be advised to limit the amount of alcohol and caffeine consumed because these diuretics increase urine flow (Tanagho & McAninch, 2011). In addition, patients and their families should be informed of the fact that some medications like decongestants stimulate the muscles of the bladder neck and the prostate. They should also be aware that other drugs like antihistamines weaken bladder contraction. Thus, the patient should avoid taking over-the-counter drugs and seek medical advice prior to consuming any drugs. The patient should also inform the doctor and other healthcare providers of his condition prior to receiving any kind of prescription from them (McCance & Huether, 2012). The patient needs to be informed that allowing his bladder to get full may weaken the bladder muscles and increase the chances of getting acute urinary retention. The patient must be advised to frequently stop over toilets whenever on a car trip, even when he does not have the urge and when in a new place to identify the washroom earlier than he may need it (Porth&Matfin, 2012). Interdisciplinary Team Personnel There is a need for interdisciplinary management of the patient for optimal management outcomes of the condition. This approach should involve different professions in the management of the condition. First, there is the nurse practitioner or the medical doctor who reviews the patient and recommends different investigations to be done to come up with the proper diagnosis (McCance & Huether, 2012). They are also responsible for recommending the correct management of the patient and ensuring that the management is carried out as per the expectations. The management encompasses the medications to be taken and any other procedures to be performed to treat the patient, such as the minimally invasive procedures and surgical operations (McCance & Huether, 2012). Second, there is a need for a urologist to see the patient for specialized treatment and management. The urologist conducts various investigations and may perform procedures such as transurethral needle ablation, transurethral microwave thermotherapy, high-intensity focused ultrasound, water-induced thermotherapy and prostatic stent insertion (Tanagho & McAninch, 2011). They also prescribe the best mode of management for the patient. There should also be a nurse to do a thorough history taking and physical examination of the patient and come up with nursing diagnosis of the patient, depending on the information obtained about the patient. The nurse then plans how to manage the patient depending on the diagnoses obtained. The management should have scientific rationale. Finally, the nurse then evaluates the outcome of the management, whether they met the expected goal (McCance & Huether, 2012). Some of the problems in BPH patient are knowledge deficit about their condition. The nurse should therefore educate the patient about the condition and the best way to manage it. The nurse should also ensure that the correct medications are given to the patient in the right dosages (McCance & Huether, 2012). The nurse has a responsibility of helping patients maintain their self-esteem and accept their condition. There is a need for lab technicians and specialists to conduct investigations on the patient’s condition. The tests are ADRE, PSA levels and AUA symptom index, used to assess the severity of the symptoms. Moreover, there is a need for a radiologist to conduct x-ray for differential diagnosis of the condition. A psychologist to assist the patient and his family to deal with the stress that comes along with such a disease is also necessary (Porth & Matfin, 2012). Finally, there is a need for a nutritionist to assist the patient make the right choice of foods and fluids to take since such as a patient is restricted from high intake of fluids and some foods for effective management (Tanagho & McAninch, 2011). Facilitators and Barriers During the management of any condition, there are factors that assist and others that hinder the effective management of the condition. BPH is not an exception. Some factors that may facilitate the management of this patient are strong family support. According to the social history of the patient, he has a strong family bond and the family is supportive. This situation will help the patient cope well with the disease process and the management of the condition (Porth & Matfin, 2012). Second, the patient seems to be financially stable. This would help the patient deal well with the management of the condition since he will be in a position to procure the needed medication for the management of the condition (Porth & Matfin, 2012). The patient will also be in a position to pay for bills needed for investigating the condition and procedures such as invasive procedures for managing the condition. The most obvious barrier to management of the patient is the patient’s ignorance about his health. The patient does not seem to have any knowledge about the importance of his health wellbeing. He seems to have minimal interest in visiting hospitals except when his condition gets worse. Despite having a high level of education, he does not go for frequent visits, hindering the proper management in that the patient may cease seeking health care, once he notices some improvement in his status. He may also not see the need to comply with medications (McCance & Huether, 2012). The other obstacle to treatment would be his Hispanic culture. There may be a language barrier between the healthcare provider and the patient with the patient not being able to understand some things, unless explained in his language (Porth & Matfin, 2012). Additionally, in the Hispania culture, some conditions are best managed by traditional healers, and medical practitioners only make it worse. The family of the patient may influence the patient into seeking help from such healers rather than concreting on the medical management (Porth & Matfin, 2012). Strategies to Overcome the Identified Barriers The strategies put in place to overcome the barriers are health education about the condition and the need to be cooperative during the management of the condition. The education should be on the complications that can rise in case the patient does not comply with the management. These complications are acute urinary retention, chronic, or long lasting, urinary retention blood in the urine, urinary tract infections (UTIs), bladder damage and kidney damage (Tanagho & McAninch, 2011). Health education will help the patient deal with cultural beliefs about the disease. The other strategy is a good follow-up for the patient. There is need to follow-up the patient at home and ensure that he complies with the medications and other modes of management. The family members also need to be educated on the proper management of the patient so that they assist in the area of compliance (Tanagho & McAninch, 2011). Conclusion BPH is a common condition amongst elderly men. It is also attributed to family history. It is characterized by an enlarged prostate gland. However, it is not carcinogenic. BPH affects approximately 50% of males aged between 51 and 60 and 90% of men over the age of 80 years. BPH cannot lead to cancer and it is not cancer. Men should seek the advice of healthcare providers whether they need screening for prostate cancer, even if their prostate is enlarged or not. In case a patient is diagnosed with BPH, it is advisable they discuss all the treatment options available with their urologist. With the help of urologist, patients are better placed to decide whether surgical treatment or medication is best for them. For the medical treatment of BPH, Alpha-blockers are the most effective. However, they may not guard against the progression of BPH and may cause BHP-related health problems. For males with large prostates, 5-alpha-reductase inhibitors work best as they decrease progression of BPH over time. The combination of Alpha-blockers drugs and 5-alpha-reductase inhibitors delivers the best benefits. However, they also provide the most risk of possible risks. The symptoms are the main cause of concern most patients. Our patient in the case study presented with the same symptoms as those of a patient suffering from the condition. The investigations also proved that he was suffering from BPH. Management of such a condition needs a holistic and interdisciplinary approach. The nurse must take a comprehensive history and do a thorough physical exam prior to managing the patient. An urologist, medical doctor, lab specialist, radiologist and psychologist must also be involved in the care. The family should also not be left out during the care of the patient, for the best outcome. Surgery should be seen as the last option of managing BPH if medications and other less invasive procedures fail. The patient must be fully educated about their condition, treatment methods and possible complications of the condition and treatment. References American Urological Association (AUA) (2012). “Guideline on the Man-Agreement of Benign Prostatic Hyperplasia (BPH).” Retrieved on October 27, 2014 from http://www.auanet.org/content/guidelines-and-quality-Care/clinical-guidelines. cfm?sub=bph Campbell, M. F., Wein, A. J., and Kavoussi, L. R. (2011). Campbell-Walsh urology: Editor-in-chief, Alan J. Wein ; editors, Louis R. Kavoussi ... [et al.]. Philadelphia: W.B. Saunders. Kaplan, S. A. (2010). “Update on the American Urological Association Guidelines for the Treatment of Benign Prostatic Hyperplasia.” Reviews in Urology, 8(1), 10-7. Lepor, H. (2011). “Alpha Blockers for the Treatment of Benign Prostatic Hyperplasia.” Reviews in Urology, 9(4), 181-90. McAninch, J. W., Lue, T. F., and Smith, D. R. (2013). Smith & Tanaghos general urology: Editors, Jack W. McAninch, Thomas F. Lue. New York: McGraw-Hill Professional. McCance, K. L., Huether, S. E., and Parkinson, C. F. (2012). Pathophysiology: The biologic basis for disease in adults &children: study guide & workbook. St. Louis, Missouri: Mosby. Parsons, J. K. (2009). “Modifiable Risk Factors for Benign Prostatic Hyperplasia & Lower Urinary Tract Symptoms: New Approaches to Old Problems.” The Journal of Urology, 178(2), 395-401. Porth, C., and Porth, C. (2011). Essentials of pathophysiology: Concepts of altered health states. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. Tabloski, P. A. (2012). Gerontological nursing.Upper Saddle River, NJ: Pearson Education. Read More