The aim of this essay is to discuss a urological condition of the author’s choice. The author will clarify what the prostate gland is, where it is located, and its functions as well as pathological conditions such as benign prostate hyperplasia (BPH). The author will identify and analyse the presenting symptoms, clinical investigations which lead to diagnosis and will conclude with important symptoms and investigations related to specific prostate condition in this essay. The prostate gland is a solid, chestnut-shaped organ surrounding the first part of the urethra.
The prostate gland is situated immediately under the bladder and in the anterior of the rectum. The prostate gland produces secretions that form part of the seminal fluid during ejaculation. The ejaculatory ducts from the seminal vesicles pass through the fluid during ejaculation. The ejaculatory ducts from the seminal vesicles pass through the prostate gland to enter the urethra. The prostate gland weighs only a few grams at birth. Enlargement starts at puberty from the effect of androgen hormones and stops at around the age of 20, when it reaches its adult weight of about 20 grams.
In most men, the prostate begins to enlarge further after the age of 50. The prostate gland consists of two main zones; an inner zone (which produces secretions responsible for keeping the lining of the urethra moist) and an outer zone (which produces seminal secretion). (Stevenson, 2003). BPH is a benign prostate disease in which the prostate gland grows in size. The sheer bulk of the prostate may compress the urethra which runs through the centre of the prostate, impeding the flow of urine from the bladder through the urethra to the outside; this is known as outflow obstruction.
This leads to urine retention and the need for frequent urination. If BPH is severe, complete blockage can occur (Kirby and McConnell, 2002). Kirby and McConnell, 2002 went on to say an enlarged prostate is common particularly in older males, the prostate sits at the neck of the bladder, straddling the tubes which carry urine and semen, it has been described as a walnut sized, its provides nutrients and protection for the sperm about to make the long journey to the womb, should it enlarge too much, can be obstruction and even complete blockage of urine from the bladder to the penis.
When caused by simple enlargement with no involvement it is referred to as BPH its impact can be far from benign (Stevenson, 2003). The function of this is to give the adequate secretions which nourishes from and gives to medium to be passed on to the womb. Histologically, it’s divided into two parts, central zone and peripheral zone. Enlargement does not necessary courses symptoms, but when symptoms appears its due to impingement of prostatic urethra. Symptoms are rear before 40 years of age, but quite common after 70 years of age.
More than half of men in their sixties and as many as 90% in their seventies and eighties have some symptoms of BPH as the prostate enlarge tissue layers surrounding it inhibit expansion, inward pressure then constricts the urethra as a result, the bladder wall becomes thicker and irritable contracting even when it contains small amount of urine eventually causes bladder weakness and loses the ability to empty itself trapping urine inside, over 50% of men will have some problem with passing urine by the time they reach 60 years of age (Kirby and McConnell, 2002).
Kirby and McConnell stated that as the prostate continues to grow during most of a man’s life, enlargement doesn’t usually causes problems until later on, BPH, rarely causes symptoms before the age of 40, they went on to say more than half of men their sixties and as many 90% in their seventies and eighties have some symptoms of BPH as the prostate enlarge tissue layers surrounding it inhibit expansion, inward pressure then constricts the urethra as a result, the bladder wall becomes thicker and irritable contracting even when it contains small amount of urine eventually causes bladder weakness and loses the ability to empty itself trapping urine inside, over 50% of men will have some problem with passing urine by the time they reach 60 years of age (Kirby and McConnell, 2002). Many of the symptoms of BPH stem directly from obstruction of the urethra and resultant incomplete bladder emptying. The symptoms of BPH can vary but the most common ones include a hesitant, interrupted, weak stream of urine, urgency and leaking or dribbling and more frequent urination at night, Acute Urinary Retention (AUR), Lower Urinary Tract (LUT), frequency nocturia, urgency leaking and dribbling. Severity of symptoms does not necessarily correlate with the degree to which the prostate gland is enlarged (Billington, 1999). The first symptoms for some men may be complete inability to pass urine and consequent urinary retention.
Furthermore, these symptoms are not disease specific and the patient requires objective assessment in order that the most appropriate course of action can be taken. As the population ages the number of men presenting with BPH will increase and it is perhaps not surprising therefore that recent years have seen the advent of prostate assessment clinics. These clinics aim to reduce waiting times, lead to prompt referral of those with severe symptoms and better continuity and quality of care (Webb and Simpson, 1997). According to (Laker, 2002) causes of prostate enlargement are still not known but there are certain triggers which may contribute to BPH.
High levels of testosterone and dihydrotestosterone (DHT) an in balance between oestrogen and testosterone of DHT, possibly low protein high carbohydrate diets western diets. (Stevenson, 2003) argued that causes of BPH may be due to genetic factors, infection ethnicity most commonly Afro-Caribbean. The International Prostate Symptom Score (Barry et al 1992) is a recognized tool used to assess the severity of an individual’s symptoms. The use of a frequency volume chart can prove a helpful adjunct and will provide and indication of drinking patterns, maximum functional bladder capacity, frequency and the presence and degree of nocturia experienced. Any assessment should include reference to the impact that the individual’s prostate problem is having on life in general.
Other causes of urinary symptoms (such as infection), need to be excluded and a baseline assessment in keeping with that currently recommended by The Department of Health (2000a) applies no less to those presenting with prostate symptoms. Urodynamic studies are used to assess the degree of obstruction experienced. If the maximum flow rate is less than 10mls per second, there is a 90% chance of prostate obstruction (Abrams, 1997). However, when an individual present with acute urinary retention its immediate relief is an urgent priority if back pressure to the kidneys is to be prevented. Diagnosis is important, given the non-specific nature of prostatic symptoms and there are three recognised methods for distinguishing prostate cancer from BPH. The first method is Prostate Specific Antigen (PSA) testing.
Prostate-specific antigen is a glycoprotein protease secreted by prostatic epithelial cells that liquefies semen after ejaculation and is often increased in patients with BPH. It is measured by making a sample of the individual’s blood. Serum PSA levels are raised by prostate cancer, but also by several other conditions that affect the prostate gland such as prostatitis (infection). PSA level can also be raised by having a urinary catheter, prostate or bladder surgery and ejaculation. The normal rate is 0. 5 – 4ng/ml. 4 – 10ng/ml indicates 20% chance of cancer. More than 10ng/ml means 50% plus chance of cancer (Kirby et al 2000). Elevated serum PSA occurs in about 25% or more of men with BPH, and in most patients with prostate cancer of significant volume.
Therefore, PSA is not a diagnostic test for prostate cancer, but does afford an estimation of the probability of the presence of prostate cancer. In addition, it provides a useful surrogate estimate for prostate volume, since BPH the larger the gland, in general, the higher is the PSA level (Kirby and McConnell, 2002). Digital Rectal Examination (DRE) is another method used to diagnose BPH. In its early stages prostate cancer is seldom detectable through DRE. Overall DRE in isolation is less than 50 percent accurate in detecting prostate cancer and is usually done in conjunction with PSA (Department of Health 2000a). The size, consistency and mobility of the prostate are all important. A normal prostate is the size of a chestnut, smooth and elastic.
A hard nodular prostate, especially if fixed with adjacent tissue may be malignant. A tender prostate suggests prostatitis (Billington, 1999). The patient’s general practitioner usually performs DRE, but as with other aspect of assessment, a specialist nurse within a nurse led clinic sometimes undertakes the procedure. Transrectal needle biopsy is also another method used to diagnose BPH. An ultrasound probe is inserted to the wall of the rectum enabling specialist to see the prostate and biopsy (a sample of cell) is taken from different parts for histological examination. It can be uncomfortable or painful and the patient won’t need a general anesthetic, though he may be given a local one if needed.
There is a risk of infection with this procedure, as a result of which patients are usually prescribe a course of antibiotics and one will need to be admitted to hospital for antibiotics to be given intravenously (IV). Some men may have some bleeding in their urine or semen, or blood in their bowel motions, for up to three weeks (Department of Health, 2002). The treatment of BPH and cancer do have some similarities, but also marked differences and are considered separately for ease of discussion. In men with BPH, if there is no urgent reason to refer, a period of conservative treatment of three months is recommended (Abrams, 1997). Conservative reatment in this case consists of bladder training, advice on fluid intake and pelvic floor exercises, plus or minus anticholinergic drug if the patient is thought to have detrusor inability. It is not known for older men to experience a year or more during which their prostate irritates them, only for symptoms to get better without any treatment (Blandy, 1998). Drug therapy exists predominantly in the form of alpha-blockers and 5-alpha reductase inhibitors. Surgery is also an option for those with BPH who are experiencing persistent, moderate or severe symptoms. Surgical prostate ablation, by TURP (trans-urethra resection of prostate) or less frequently open prostatectomy is still the gold standard and produces the greatest measurable and longterm reduction in both symptoms and bladder outlet obstruction (Feneley et al 1999).
Other methods of ablation for example laser. Conservative treatment is the preferred option for men with mild symptoms as the disease progression is uncertain and often slows (Billington, 1999). The Bristol Urological Institute suggest that if the patient wishes to try drug therapy, an alpha-blocker (for example, prazosin) is the treatment of first choice for BPH since its effects if any, are immediate (Feneley et al, 1999). These drugs improve both filling and voiding symptoms in BPH by relaxing smooth muscle and reducing urethral resistance. However, some drugs are now said to be more urospecific or selective and therefore to have fewer side effects (for example, alfuzosin).
Nonetheless, patients using these drugs should be adviced of potential side effects such as postural hypotension and dizziness. The use of 5-alpha reductase inhibitors to shrink the epithelial part of the gland is another option. The action of drugs such as finasteride is to reduce the size of the prostate by suppressing plasma levels of dihydrotestosterone (DHT), is the principle agent causing prostatic enlargement. DHT is a hormone derived from testosterone and is more potent than testosterone and acts on the prostate gland and on other sexual organs. DHT is produced within the prostate gland. Without DHT a male would not develop his external sexual organs or his prostate. DHT is necessary for the normal growth and development of the prostate.
It presence is also necessary for the pathologic enlargement of the prostate in older men. Because the presence of DHT is necessary for the development of BPH, a therapeutic approach to treating this condition is to reduce the formation of DHT by blocking the enzyme 5-alpha reductase. Men receiving alpha reductase inhibitors need to be informed about potential side-effects such as impotence, reduce ejaculate volume loss of libido, dysfunction such as a smaller amount of erection, breast tenderness or enlargement (Billington, 1999). Enlarged prostate could be treated with both alpha-blockers and 5-alpha reductase for some men the use of both therapies is more effective treatment than single drug therapy. -alpha reductase inhibitors reduce the size of the prostate, but since a reduction in size does not always bring about symptom relief these medications will not give satisfactory results, in many cases, however, when stop taking these medications symptoms usually returns. Surgical treatment of BPH most commonly involves transurethral resection of the prostate (TURP) is a gold standard of effective treatment for BPH. An instrument is passed along the urethra to the prostate gland and the enlarge prostate is pared away from inside the urethra. The aim of this technique is to relieve the obstruction at the bladder neck and thereby relieve the retention of urine. The process of TURP may have to be repeated several times as the prostate continues to enlarge and the frequency at which surgery has to be repeated varies between individual.
The procedure is usually performed under general anesthetic and is a relatively successful option for those who are fit enough to undergo surgery, possible side-effects include bleeding sometimes required transfusion salt imbalance from fluid absorption, impotence less than 5% and 1-2% incontinent. (Barry and Roehrborn, 2000). Laser therapy is becoming increasingly popular, although TURP is still the more usual procedure (Downey, 2000). Several laser approaches have been used such as, endoscopic laser ablation of the prostate, in which a side firing probe is inserted via a cystoscope. Intestinal laser, in which the lateral lobes are perforated with a laser fibre laser energy is applied to the interior of the adenoma. Some patients may however, experience postoperative pain and difficulty in passing urine for some weeks, because laser ablation involves higher temperatures than either hyperthermia or thermotherapy.
Therefore, suprapubic catheterisation may be necessary for several days or even weeks after the procedure (Kirby and McConnell, 2002). Other alternatives such as the use of radio waves, microwaves and insertion of a prostatic stent (a coil-like catheter that sits in the prostatic urethra) are also used (Downey, 2000). Temporary or permanent have been used to maintain expansion of the prostatic urethra. Although they are effective in relieving obstruction in patients with urinary retention, they provide only modest improvements in symptoms scores and urine flow rate in patients with BPH without retention. In transurethral microwave thermotherapy, microwave radiaton is applied to the prostate by a urethral catheter.
Local temperature is monitored by a probe positioned in the rectum and the urethra is cooled during the procedure. However, even when enlargement is benign open prostatectomy, whereby an incision is made in to the abdomen and the whole prostate gland is removed, is occasionally necessary. It is done under general or spinal anaesthetic. Usually an incision is made through the lower abdomen, although sometimes the incision is made between the rectum and the base of the penis. A catheter may be placed in the bladder through the lower abdominal skin to help flush the bladder (postoperative bladder irrigation) and another catheter comes out of the penis to drain the urine.
This procedure requires a slightly longer hospital stay and recovery period than TURP (Game and Farrer, 2001) Every surgery carries risk; prostate surgery can result in urinary incontinence and retrograde ejaculation, aside from the possibility of immediate post-surgical complications such as haemorrhage and hypovolaemic shock (Morrison et al, 2001). Post-surgical urinary incontinence is attributed to the trauma associated with surgery in the area of the bladder neck, dilation of the urethral sphincters and the insertion of large gauge urinary catheters to facilitate irrigation (Laker, 2002). Laser therapy and newer treatments such as trans-urethral ablation tend to be associated less incontinence (Downey, 2000). Nearly all men who have undergone TURP experience retrograde ejaculation. Small numbers of men also suffer impotence.
Both impotence and urinary incontinence are associated with open prostatectomy (Downey, 2000) and therefore it is important that consent to surgery is informed and that men are aware of the potential urinary and sexual problems that may follow. Several options exist to promote post-surgical urinary incontinence and this excludes pelvic floor re-education and bladder training programmes. Insertion of an artificial urethral sphincter may be an option for a small proportion of men with intractable post-prostatectomy incontinence (Cheater, 1996). Reviewing long term outcome following sphincter implantation concluded that post male prostatectomy incontinence seem especially amendable to such treatment, (Venn et al, 2000).
Holmium laser enucleation of the prostate combined with mechanical morcellation represents the latest refinement of holmium. Holmium is an alternative for the surgical treatment of BPH which allows complete removal of intact lobes of the prostate (Surgical Oncology, 2003). To conclude this essay, the author have discussed about Benign Prostatic Hyperplasia (BPH), the symptoms, diagnosis and treatment. Having undertaking the study on BPH, this has expand the author’s knowledge and skills. The author is going to use this to expand on her role profile into incorporating her role profile in the delivery of specialist nurse-led clinic. References Abrams, P. (1997) Urodynamic. 2nd ed. London, Springer Barry, M. K. 1992) The American urological association symptoms index for benign prostatic hyperplasia. Journal of Urology. P. 148, 1549-1557. Barry, M. and Roehrborn, C. (2000) Benign Prostatic Hyperplasia-what are the effects of surgical treatment? Clinical Evidence. P. 4, 457-458 Billington, A. (1999) Prostate disease. Nursing Standard. P. 13, 25, 49-53 Cheater, F. (1996) Promoting urinary continence. Nursing Standard. P. 10, 42, 47-54 Department of Health (2000) The NHS Prostate Cancer Programme. London; Department of Health Downey, P. (2000) The Orostate. In Downey P (ED) Introduction to urological nursing. London Feneley, R. C. (1999) Urology guidelines for GPs. Bristol; Urological Institute Game, C. and Farrer, H. 2001) Disorders of the male reproductive tract. Medical- Surgical Nursing; A core text. Melbourne; Churchill Livingstone Kirby, R. (2000) Shared care for prostatic diseases. 2nd ed. Oxford. ISIS Medical Media Laker, C. (2002) Urological nursing. London; Scutari Press Morrison, M. (2001) The urinary system. In Alexander, M. Fawcett, J. N, and Runciman, P. J. Nursing Practice: Hospital and Home. Edinburgh; Churchill Livingstone Venn, S. N. (2000) The long-term outcome of artificial urethral sphincters. Journal of Urology. P. 164, 3, 702-707 Webb, V. and Simpson, R. (1997) Older man’s burden. Nursing Times. P. 93, 5, 77-80 World Journal Surgical Oncology (2003). P. 1186, 1477