Causes of BPH

Question:

Discuss About The Connected A Three Lumen Urethral Catheter?

BPH or Benign Prostate hyperplasia is a disease in which the prostate of a male enlarges in size. The growth is non cancerous and happens because of the prostate stromal cell hyperplasia. The growth is associated with the proliferation of the smooth muscle, connective tissue and the epithelial cells present within the transition zone in the prostate gland.

The report is discussing a case study of a 60-year-old patient, Mr. Alan Jones who was having urinary symptoms due to the Benign Prostatic hyperplasia (BPH). The patient is obese and has diabetes Mellitus Type 2. Mr. Jones is also an alcoholic who drinks a bottle of wine every night. The surgery was performed under spinal anesthesia and the process of the surgery was transutheral resection of the prostate (TURP). The bladder of the patient is connected to a three lumen urethral catheter. After his surgery, the patient is reported to have large blood clots in his urine.

The purpose of the report is to discuss the pathophysiology of his condition and the reason of the deterioration of the patient. The report also discusses the nursing management of the patient. The report also justifies the role of the members of the healthcare team.

Albeit, the androgen hormones (testosterone and other related hormones) plays a big role in BPH development, but it does not directly causes the hyperplasia. The studies reported that Dihydrotestosterone (DHT), a metabolite of testosterone works as a mediator for the growth of the prostate (Kim et al., 2013). The metabolite is synthesized within the prostate because of the reaction of enzyme 5α-reductase as the testosterone circulates within the prostate. DHT works in the autocrine function in the stromal cells and in the epithelial cells, it works in the paracrine function (Bostanci et al., 2013).

There is a record that estrogen might play a big role in causing BPH. It is estimated that the estrogen converts to androgen locally in the prostate tissue and initiates the cell proliferation.

The onset of BPH is mainly age related and it rises markedly with age. It is reported that the volume of the prostate relatively increases with age. Some theories suggest that the weakening of the muscular tissue and fibrosis actually causes BPH. The role of the smooth muscle is actually prevalent in the onset of BPH as the myofibers of the muscular tissue gets broken because of aging and loses the potential for regeneration (Patel, & Parsons, 2014).

Case study of Mr. Alan Jones

There are some reports that suggested that the onset of BPH has some genetic component. The study stated that 50% of men who is less than 60-year-old and underwent the surgery of BPH have inherited the disease. The pattern of inheritance shows that the pattern of inheritance is autosomal dominant (Haj-Ahmad, Abdalla, & Haj-Ahmad, 2014).

The increased amount of adipose tissues aids in the increase of prostate volume. The adipose amount is directly proportional to the increase of the prostate volume. The BMI (Basic Metabolic Index) is also proportional to the onset of BPH.

The activity of the enzymes aromatase and 5α-reductase increases as the males’ age. These enzymes are responsible for the conversion of testosterone and the other androgen hormones to dihydrotestosterone and estrogen (Gandaglia et al., 2013). As the testosterone and the androgen hormone metabolizes, the level of testosterone decreases and the level of estrogen and DHT rises (Kim et al, 2012). The raised level of estrogen causes the hyperplasia of the cells. As the median and the lateral lobes of the prostate have glandular composition, they are enlarged. The anterior lobe of the prostate enlarges less as it has little glandular structure (Gandaglia et al., 2013).

TURP or transurethral resection of the prostrate is the surgical removal of a part of the prostrate. TURP syndrome is one of the most important risks associated with the TURP (Uddin et al., 2017). The initial symptoms of the TURP syndrome include a feeling of dizziness, headache, bradycardia or slow heartbeat and feeling sick. The initial TURP symptoms if not treated can develop risks that are threatening to life, which may result to seizures, breathing problem, cyanosis and may even lead to coma.

The pathophysiology of the TURP syndrome includes the circulatory overload, water intoxication, hyponatremia, toxicity of glycine, ammonia and hypotension. The prostrate bed that has the venous network and the endometrium are found to uptake small amounts of fluid. This uptake in the fluid results in the significant decrease in the concentration of the serum and sodium (Ishio et al., 2015). This in turn results in the increase in the blood volume and the systolic and diastolic pressure following the failure of the heart. A neurological disorder is caused due to the increase in the content of the water in brain. This water intoxication also results in the seizures and coma and the fall in the serum sodium concentration.

Pathophysiology of TURP syndrome

The proper functioning of the excitatory cells especially the heart and brain is carried out by sodium and the decrease in its concentration leads to hyponatremia, which involves restlessness, confusion and coma (McGowan-Smyth, Vasdev & Gowrie-Mohan, 2015).

The glycine toxicity, which is the result of the TURP syndrome, is threatening to retina and heart. Acute myocardial infarction may be a fatal outcome in patients who is suffering from TURP syndrome (De Lucia et al., 2014). The patients with the TURP syndrome are exposed to bacterimia, septicemia or toxemia where the bacteria may enter into the circulatory system and lead to a toxic state. The patient temporarily experience severe chills, fever and hypotension.

Patients who are suffering from TURP syndrome need intensive nursing care. It is the duty of the nurse to maintain the stability of homeostasis, providing comfort of the patient and preventing the onset of any complication (Frede & Rassweiler, 2017). It is also the duty of the nurse to provide the information to the patient and his family regarding the prognosis and the treatment of the syndrome. The nurse must assess the urine output of the patient in case of impaired urinary elimination. The nurse must also instruct the patient to assume the normal posture during micturition and carry out a regular check up of the incision and dressing. It is also the duty of the nurse to observe regularly the loss of excessive blood if there is any and the initiation of any infection. The nurse must keep a record of the time, the voiding amount, urgency and the incapability of retaining urine. The patient must encourage the patient to void if he experiences the urge and follow the instructions that is provided by the nurse. The nurse should provide the patient with essential information that would help the patient to deal with his disease. This may also make the patient to return to the normal life.

The interdisciplinary team for Alan Jones who would provide care before his discharge involves the hospital staff of the OT, a counselor and a dietician. They would play a crucial role in providing proper care to him before being discharged so that his health condition gets improved in less amount of time. The nurses in the OT should organize proper planning of his discharge. Since his urine contains large amount of blood clots, they should consult the doctor to remove the clot with the help of syringe containing sterile water containing salt. Since his pain score was 0/10, the staff should keep a check on his pain levels in a regular manner and provide appropriate medications if required (Heidenreich et al.,2014). The nursing staff should keep a check and monitor if there are any abnormal signs and symptoms. They should monitor several health parameters such as respiration rate, blood pressure, pulse, and temperature of Alan Jones. They should make sure that his health condition is stable enough to discharge him after 2 days. The nursing staff of the OT should advise him to follow several precautions such as reduced intake of alcohol as he has a medical history of obesity and diabetes. They should also provide proper follow-ups to the patient and his son after the surgery to explain the dosage of medicaments that were prescribed to him. They should provide anti-nausea medicines if he experiences any symptoms of nausea or vomiting after the surgery. They should be patient while dealing with him and should follow all the moral values and ethics of nursing profession (Pannick et al., 2015).

Nursing management of TURP syndrome

The counselor should interact and make him feel positive to avoid any psychological issues of distress and anxiety that might occur after the surgery. This will make him comfortable and improve his trust in the healthcare services provided to him. A dietician should be appointed for him to follow a nutritious diet, exercise regularly and improve his social interaction with his family members and friends. Alan Jones can also be provided physiotherapy sessions and rehabilitation if advised by the doctors (Huri, Akel & ?ahin, 2016).

Hence, it can be concluded that several measures after the surgery of Alan Jones that should be taken by the clinicians and the nursing staff to avoid different types of infection, injury or accidents .The nurses and the doctors should provide safety to the patient to reduce the   risk of complications, rate of recovery. This will help in reducing the increased stay in the hospitals and unnecessary deaths of patients.  The nursing staff, counselor and the dietician should provide appropriate care to Alan Jones after the surgery so that he is not attacked by any kind of infectious agent. They should also monitor his health condition and provide proper follow-ups to prevent any other signs and symptoms that might occur after the surgical procedure. The hospital staff should have a responsible attitude and be patient while providing care to him. The hospital management, doctors and the nurses should support him and his family members.

References:

Bostanci, Y., Kazzazi, A., Momtahen, S., Laze, J., & Djavan, B. (2013). Correlation between benign prostatic hyperplasia and inflammation. Current opinion in urology, 23(1), 5-10.

De Lucia, C., Femminella, G. D., Komici, K., Rengo, G., & Ferrara, N. (2014). Risk of Myocardial Infarction in the Pathophysiology and Treatment of Prostatic Diseases. MYOCARDIAL INFARCTIONS, 77.

Frede, T., & Rassweiler, J. J. (2017). Management of Postoperative Complications Following TURP. In Practical Tips in Urology (pp. 493-501). Springer London.

Gandaglia, G., Briganti, A., Gontero, P., Mondaini, N., Novara, G., Salonia, A., … & Montorsi, F. (2013). The role of chronic prostatic inflammation in the pathogenesis and progression of benign prostatic hyperplasia (BPH). BJU international, 112(4), 432-441.

Haj-Ahmad, T. A., Abdalla, M. A., & Haj-Ahmad, Y. (2014). Potential urinary miRNA biomarker candidates for the accurate detection of prostate cancer among benign prostatic hyperplasia patients. Journal of Cancer, 5(3), 182.

Heidenreich, A., Bastian, P. J., Bellmunt, J., Bolla, M., Joniau, S., van der Kwast, T., … & Mottet, N. (2014). EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent—update 2013. European urology, 65(1), 124-137.

Huri, M., Akel, B. S., & ?ahin, S. (2016). Rehabilitation of Patients with Prostate Cancer. In Prostate Cancer-Leading-edge Diagnostic Procedures and Treatments. InTech.

Ishio, J., Nakahira, J., Sawai, T., Inamoto, T., Fujiwara, A., & Minami, T. (2015). Change in serum sodium level predicts clinical manifestations of transurethral resection syndrome: a retrospective review. BMC anesthesiology, 15(1), 52.

Kim, M. K., Zhao, C., Kim, S. D., Kim, D. G., & Park, J. K. (2012). Relationship of sex hormones and nocturia in lower urinary tract symptoms induced by benign prostatic hyperplasia. The Aging Male, 15(2), 90-95.

McGowan-Smyth, S., Vasdev, N., & Gowrie-Mohan, S. (2015). Spinal anesthesia facilitates the early recognition of TUR syndrome. Current urology, 9(2), 57-61.

Pannick, S., Davis, R., Ashrafian, H., Byrne, B. E., Beveridge, I., Athanasiou, T., … & Sevdalis, N. (2015). Effects of interdisciplinary team care interventions on general medical wards: a systematic review. JAMA internal medicine, 175(8), 1288-1298.

Patel, N. D., & Parsons, J. K. (2014). Epidemiology and etiology of benign prostatic hyperplasia and bladder outlet obstruction. Indian journal of urology: IJU: journal of the Urological Society of India, 30(2), 170.

Uddin, M. M., Amin, R., Rahman, M. M., Chowdhury, S. M., Khan, M. R., & Islam, M. R. (2017). Retrospective Review of TURP Done in One Year and Report on Postoperative Outcome. KYAMC Journal, 4(1), 321-325.