GENERAL OBJECTIVE To widen and improve our knowledge & ability in rendering effective nursing care to patient with

Benign Prostatic Hyperplasia

Specific Objectives: To enhance our knowledge regarding Benign Prostatic Hyperplasia To be able to know its signs and symptoms, risk factors, incidence with its possible complications To be capable of identifying the ideal laboratory tests and diagnostic examinations for such case including the actual tests done to our patient To discuss and refresh our ideas regarding the anatomy and physiology of the affected system. To illustrate and explain its Pathophysiology. To present and interpret the laboratory examinations done to our patient. To give attention to the ideal and actual surgical, medical, nursing and pharmacological management given to our patient To formulate priority nursing care plan based on identified nursing problems. To be familiar with the medications prescribed and ordered to the patient. To be able to give health teachings appropriate for our patients condition. To be kept informed regarding the latest issues related to BPH

INTRODUCTION

Other Names Benign Enlargement of the prostate Benign Prostatic Hypertrophy Adenofibromyomatous Hyperplasia

The prostate is the genital organ most commonly affected by benign and malignant neoplasm. Benign enlargement of the prostate gland is an extremely common process that occurs in nearly all men with functioning testes. Hyperplasia is a general medical term referring to excess cell replication or enlargement. Benign prostatic hyperplasia (BPH) is a noncancerous growth of the prostate

gland.

It

is

the

most

common

noncancerous

form

of

cell

growth

in

men

and

usually begins with microscopic nodules in younger men.

Incidence Histologic evidence of prostate enlargement begins mainly about the third decade of life in man and increases proportionally with aging. Specifically, about 43% of men in their 40s will have evidence of BPH, as will 50% of men in their 50s, 75% to 88% in their 80s, and nearly 100% of men reaching the ninth decade of life.

Cause The exact cause of BPH is unknown.

Risk Factors Age Male Alcoholism Race Family History Ethnicity Obesity DM Hypertension

Signs and Symptoms Weak urinary stream Prolonged emptying of the bladder Abdominal straining Hesitancy Irregular need to urinate Incomplete bladder emptying Post-urination dribble Irritation during urination Frequent urination Nocturia (need to urinate during the night) Urgency Incontinence (involuntary leakage of urine) Bladder pain Dysuria (painful urination) Problems in ejaculation

Complications Acute Urinary Retention Strain on the bladder Bladder stones Urinary Tract Infections (UTI) Bladder or Kidney damage Incontinence. Retrograde ejaculation - If during surgery the muscle that is involved in ejaculation may be cut, semen may travel backward into the bladder during an orgasm, instead of traveling out of the body through the urethra. Pneumonia Blood Clots Excessive bleeding Impotence

PATIENTS PROFILE: Code Name: BI Age: 73 y/o Gender: Male Civil Status: Married Birthdate: July 7, 1938 Birthplace: CabaruanTayum Abra Address: Cabaruan Tayum Abra Nationality: Filipino Religion: Roman Catholic Name of Hospital: APH Ward: Medical Ward-MPW-Bed # 1 to Surgery Date/Time of Admission: September 30, 2011 @ 02:33 am Admitting Physician: Dr. Agnes Tamayo Chief Complaint: Hypogastric pain 2 days PTA accompanied by dysuria Admitting Diagnosis: UTI t/c BPH Final Diagnosis: Attending Physician: Dr. Roy Seares Date & Time of Operation:10-04-11 @ 3:56 pm Operation done: Exploratory Laparotomy Surgeon: Dr. Felino Burgos Anesthesiologist: Alamada Matumadi

NURSING HISTORY

Past History of Illness Patient BI didnt experience being hospitalized during his childhood but claims to have the common illnesses of a child such as fever, cough and colds and mumps and used to treat it with herbals medications present in their community. He claims that he completed his childhood immunizations and verbalizes that he has no known allergies to any food and drugs. According to patient BI, his condition started 11 years ago when he noticed that there is a growing mass at his right inguinal area and what he knew is that its just a pannakaleng and a size of a monggo bean and hoped that it will disappear after a few days so, he didnt sought any medical consultation until his condition persists which the mass became larger and about a size of a hopia which is slightly flattened ,again he just ignored it knowing that it will not last and hoping that it will heal in its own time. But unfortunately the mass continued to grow and this causes him to experience pain and difficulty of urinating.

Present History of Illness Because his condition continued to persist this prompted him to seek consultation at the Abra Provincial Hospital on September 30, 2011 @ 2:33 am. He was admitted by Dr. Agnes B. Tamayo with a chief complaint of hypogastric pain accompanied by dysuria. His admitting diagnosis was UTI t/c BPH. The immediate management included an IVF of D5LRS 1 liter regulated to 30 gtts/min. The intravenous to follow was D5LRS x 8 hours. Vital Sign were ordered to be monitored and recorded every 4 [Link] was maintained. Diagnostic Tests and laboratory examinations such Complete Blood count, Urinalysis, Ultrasound of KUB and prostate and included abdominal x-ray of the pelvis and HP view,12-Lead Electrocardiogram, and BUN, CREA ,serum sodium and potassium tests. On 5:40 pm patient BI was ordered to be in NPO by Dr. Burgos and to insert NGT-consent. On October 01, 2011 IVF to follow was D5LRS 1L + 2 amps moriamin regulated to 30 gtts/min ten D5LRS 1 L + 2 amps Vit. BC regulated to 30 gtts/min. For Emergency Right Inguinal Exploration, ordered by Dr. Felino Burgos. On October 03,2011patient was on NPO and mitral patch was put on his left chest. October 04, 2011 patient was still on NPO @ 3:30 pm he was forwarded to OR for his operation with latest V/S of BP: 140/100 mmhg, PR: 88 bpm, RR: 21 cpm and Temperature of 37.7C.

Familial History of Illness Our patient claims that both his maternal and paternal side had a history of Hypertension and Diabetes.

Social History of Illness Patient BI is a high school graduate at Holy Ghost School at Tayum. There he met her wife and they got married when he was 22 years old. They were bless with seven children but unluckily one of their children die d/t an illness which is unrecalled. Our patient is a farmer and claims to walk in a very far place carrying a sack which contains different types of foods which they will use as a BARTER on the place they would go.

Lifestyle and Diet Our patient is a smoker since he was 22 years old and just stops it prior to his hospitalization. He is also an alcoholic drinker and started when he was 27 years old. He also claims that he is fun of eating salty and fatty foods and verbalizes to drink coffee and often this serves as his meal before going to the farm. ABRAHAM MASLOWS HIERARCHY OF NEEDS October 04, 2011 at 9:00 am-5th day of Hospitalization Physiologic Needs Patient can breathe normally at room atmospheric air therefore with effective breathing pattern. With an IVF of D5 LRS1 liter + 2 amps moriamin x 8 hours @ 400 cc level, regulated at 30 drops per minute, hooked at the Left cephalic vein, patent and infusing well. On Nothing per Orem. Patient was febrile body temp of 37.6 C IFC-UB was draining well approximately 550 mL orange in color. Didnt Defecated within the shift and verbalizes absence of defecation within 5 days. He has inadequate rest periods d/t his condition. With inactive sex life due to his present condition.

Safety and Security Patient is well-attended by the nurses on duty, student nurses and the attending physician. His children are always there to assist in his needs and ensured his safety. He is provided with clean linens as well as clothes.

Love and Belongingness Patients children stayed with him at the hospital and gave him love and care. His children always provides him his needs and assists him in his ADLs. The financial support provided by their children and relatives made him feel loved and cared for.

Self-esteem Patient is worried about his present condition which is an expression of diminished selfesteem.

Self-actualization According to our patient he is already self-actualized because God had given him many years to be with his family who are very loving and supportive.

PHYSICAL ASSESSMENT October 04, 2011 at 10:00 am-5th day of Hospitalization

A. GENERAL PHYSICAL SURVEY Conscious and coherent. Appears to be in his stated chronological age. Appears to be weak With Fair hygiene and grooming Kyphosis posture

VITAL SIGNS: BP: 120/90 mmHg T: 37.6 C PR: 75bpm RR: 21 cpm

B. MENTAL STATUS Client is alert, awake with eyes open and looking at the student nurses making the interview. Client responds appropriately to the topic being discussed. He felt pity towards himself due to his present condition. Listens to student nurses and responds with full and free-flowing thoughts during the interview. Aware of self, other people, time and place.

C. CEPHALOCAUDAL ASSESSMENT i. SKIN ii. HAIR Blackish-white hair noted (-) dandruff Has dark skin complexion. (+)scar noted on both his lower extremities Poor skin turgor.

iii.

HEAD AND FACE Head is normocephalic and proportionate to body size. Face on centered head position. Similar color as the skin complexion. Presence of moles

iv.

EYES Lashes are short and evenly distributed; curled outward. Pupils equally round and reactive to light accommodation. Both eyes had coordinated movements in all directions. Decreased visual acuity as verbalized. Slightly sunken eye balls

v.

EARS Ears are equal in size and similar appearance. Aligned with the outer canthus of the eyes. Color is the same as face. Decrease hearing acuity

vi.

NOSE Nose has the same color as the face. Symmetrical nares. No lesions and nodules noted. No nasal flaring.

vii.

MOUTH Lips relatively symmetrical; (-) lesions and swelling. dry lips. With incomplete set of teeth. Tartar noted.

viii.

NECK With full range of motion. No jugular vein distension noted.

ix.

UPPER EXTREMITIES With D5 LRS1 L + 2 amps moriamin x 8 at 400 cc level, hooked at the left cephalic vein, patent and infusing well.

x.

CHEST Presence of mitral patch @ the left chest No tenderness noted upon palpation.

xi.

ABDOMEN Minimal ascites noted Abdominal girth of 75 cm Navel centrally located. (+) hypogastic pain as verbalized

BOWEL ELIMINATION o Absence of Bowel Movement for 5 days as claimed

xii.

GENITO-URINARY URINE ELIMINATION o With intact IFC-UB draining approximately 550 cc within our shift; orange in color

xiii.

LOWER EXTREMITIES With full range of motion. With visible weakness noted. (+) brownish to blackish scars noted.

ANATOMY AND PHYSIOLOGY

The prostate (from a Greek word literally means "one who stands before", "protector", "guardian") is a compound tubuloalveolar exocrine gland of the male reproductive system in most mammals. It is a walnut sized gland that is only present in men. It is located just below the bladder and top of the penis. This gland surrounds the urethra (the tube through which urine flows from the bladder and out through the penis). Prostate gland is partly muscular and partly glandular.

Functions The function of the prostate is to store and secrete a slightly alkaline fluid, milky or white in appearance, that usually constitutes 2030% of the volume of the semen along

with spermatozoa and seminal vesicle fluid. The alkalinity of semen helps neutralize the acidity of the vaginal tract, prolonging the lifespan of sperm. The alkalinization of semen is primarily accomplished through secretion from the seminal vesicles. The prostatic fluid is expelled in the

first ejaculate fractions, together with most of the spermatozoa. In comparison with the few spermatozoa

expelled together with mainly seminal vesicular fluid, those expelled in prostatic fluid have better motility, longer survival and better protection of the genetic material (DNA). The prostate also contains some smooth muscles that help expel semen during ejaculation.

1. Secretions Prostatic secretions vary among species. They are generally composed of simple sugars and are often slightly alkaline. In human prostatic secretions, the protein content is less than 1% and includes proteolytic enzymes, prostatic acid phosphatase, and prostate-specific antigen. The secretions also contain zinc with a concentration 5001,000 times the concentration in blood.

2. Regulation To work properly, the prostate needs male hormones (androgens), which are responsible for male sex characteristics. The main male hormone is testosterone, which is produced mainly by the testicles. Some male hormones are produced in small amounts by the adrenal glands. However, it is dihydrotestosterone that regulates the prostate.

3. Development The prostatic part of the urethra develops from the pelvic (middle) part of the urogenital sinus (endodermal origin). Endodermal outgrowths arise from the prostatic part of the urethra and grow into the surrounding mesenchyme. The glandular epithelium of the prostate differentiates from these endodermal cells, and the associated mesenchyme differentiates into the dense stroma and the smooth muscle of the prostate. The prostate glands represent the modified wall of the proximal portion of the male urethra and arises by the 9th week of embryonic life in thedevelopment of the reproductive system. Condensation of mesenchyme, urethra and Wolffian ducts gives rise to the adult prostate gland, a composite organ made up of several glandular and non-glandular components tightly fused within a common capsule.

Structure 1. Zones The "zone" classification is more often used in pathology. The idea of "zones" was first proposed by McNeal in 1968. McNeal found that the relatively homogeneous cut surface of an adult prostate in no way resembled "lobes" and thus led to the description of "zones." The prostate gland has four distinct glandular regions, two of which arise from different segments of the prostatic urethra: Name Fraction of gland Description The sub-capsular portion of the posterior aspect of the Peripheral (PZ) zone Up to 70% in prostate gland that surrounds the distal urethra. It is from this portion of the gland that ~7080% of prostatic cancers originate. This zone surrounds the ejaculatory ducts. The central Central zone (CZ) Approximately 25% normally zone accounts for roughly 2.5% of prostate cancers although these cancers tend to be more aggressive and more likely to invade the seminal vesicles. ~1020% of prostate cancers originate in this zone. The Transition (TZ) zone transition zone surrounds the proximal urethra and is 5% at puberty the region of the prostate gland that grows throughout life and is responsible for the disease of benign prostatic enlargement. Anterior fibroThis zone is usually devoid of glandular components, composed only, as its name suggests,

young men

muscular zone (or Approximately 5% and stroma)

of muscle and fibrous tissue.

2. Lobes The "lobe" classification is more often used in anatomy. Anterior lobe (or isthmus) Posterior lobe Lateral lobes roughly corresponds to part of transitional zone roughly corresponds to peripheral zone spans all zones

Median lobe (or middle lobe) roughly corresponds to part of central zone

DIAGNOSTIC EXAMINATIONS Ideal Laboratory Examinations 1. Complete Blood Count This is to determine blood components and the response to inflammatory processor if there is a presence of infection 2. Fasting Blood Sugar This is to measure the blood glucose level. 3. BUN This is an indicator of renal function and perfusion, dietary intake of CHON and the level of protein metabolism. 4. Creatinine In men with symptoms, blood tests are performed to measure a substance called serum creatinine, which is a marker for kidney trouble. Kidney problems exist in an average of 13.6% of BPH patients. Studies have reported rates as high as 30% and as low as 0.3% 5. Urinalysis A urinalysis may be performed to detect signs of bleeding or infection. Aurinalysis

involves a physical and chemical examination of urine. In addition, the urine is spun in a centrifuge to allow sediments containing blood cells, bacteria, and other particles to collect. This sediment is then examined under a microscope. Although

urinaryinfection is uncommon in younger men, it occurs more frequently in older men, particular ly those with BPH. A urinalysis also helps rule out bladder cancer. 6. Fecalysis Aids in the evaluation of the digestive efficiency and the integrity of the stomach and intestines. 7. Transcortin or Cortecosteroid Binding Protein (CBG) It is performed in clients suspected of hyperfunction or hypofunction of adrenal gland. 8. Chest X-ray This is to rule out respiratory cause of referred pain. May be obtained to

detect pulmonary disease and the status of respiratory problems or trauma.

9. Electrocardiogram (ECG)

Is

an essential

tool

in evaluating cardiac rhythm. Electrocardiography

detects and

amplifies the very small electrical potential changes between different points on the surface of the body as a myocardial cell depolarize to repolarize, causing the heart to contract. 10. Colonoscopy Is the endoscopic visualization of the large intestine from rectum to cecum. It is the visual examination of the lining of the entire colon with a flexible fiber optic endoscope

Ideal Diagnostic Examinations 1. Direct Rectal examination Palpation of the prostate through the rectum may reveal a markedly enlarged prostate. It is dependent on the skills of the doctor. It has to be borne in mind that rectal examination can increase PSA levels in patients without malignancy. The test helps rule out prostate cancer or problems with the muscles in the rectum that might be causing symptoms, but it generally underestimates the prostate's size. It is not accurate for diagnosing prostate cancer, and is never the primary diagnostic tool for either BPH or cancer. 2. Prostate Specific Antigen (PSA) To rule out cancer as a cause of uriary symptoms. 3. Uroflowmetry To determine whether the bladder is obstructed, the speed of urine flow is measuredelectronically using a test called uroflowmetry. The test cannot determine the cause of obstruction, which can be due not only to BPH, but possibly also to abnormalities in the urethra, weak bladder muscles, or other causes. 4. Urethrocystoscopy A urethrocystoscopy, also called cystourethroscopy, may be performed in men diagnosed with BPH, particularly if they are surgical candidates or if other urinary tract problems are suspected. Such problems include blood in the urine, infection, interstitial cystitis,

bladder cancer, or prior surgery or injury. The physician can determine the presence of a number of structural problems, including enlargement of the prostate, obstruction of the urethra or neck of the bladder, anatomical abnormalities, or the presence of stones.

5. Postvoid Resideal Void (PVR)

One of the important tests for urinary incontinence is the postvoid residual urine volume (PVR), the amount of urine left after urination. Normally, about 50 mL or less of urine is left; more than 200 mL is a definite sign of abnormalities. Measurements in between require further tests. The most common method for measuring PVR is with a catheter, a soft tube that is insertedinto the urethra within a few minutes of urination. PVR can also be measured usingtransa bdominal ultrasonography. 6. Ultrasound Ultrasound of the prostate does not require a catheter and gives an accurate picture of the size and shape of the prostate gland. Ultrasound is very beneficial when planning surgery and determining treatment options and gauging their effectiveness. Ultrasound may also be used for detecting kidney damage, tumors, and bladder stones.

Actual Laboratory Examinations Complete Blood Count Result Parameters HGB HCT RBC MCV MCH MCHC PLT WBC Result 14.4g/dL 44.0% 4.87x 10/mm3 90.0 um 29.6Pg 32.7 g/L 369 10/mm3 10.9 H x 10/mm3 Date done: 9-30-2011 Normal Values 11-16.5 35.0-50.0 3.80-5.80 80.0-97.0 26.5-33.5 31.5-35.0 150 - 390 3.5-10.0

INTERPRETATION: The CBC result reveals a high number of WBC which implies presence of infection.

URINALYSIS Parameter Color Transparency RBCs Pus Cells Amorphous urates pH Specific gravity Albumin Glucose Crystals Bacteria Result Dark Yellow Slightly turbid 8-9/hpf 5-10/hpf (++)few 6.0 1.010 Negative Negative (+)rare (++)few

Date done: 9-30-2011 Reference Yellow amber Clear Negative Negative Negative 4.6-8.0 1.005-1.030 Negative Negative Negative Negative

Interpretation: Presence of RBCs , pus cells, amorphous urates, crystals and bacteria indicates possible presence of infection and renal malfunction.

CLINICAL CHEMICAL SECTION Test BUN Crea Na + K+ Cl Full Name Blood Urea Nitrogen Creatinine Sodium Potassium Chloride Result 25.9mg/dL 1.7 mg/dL 130.3mmol/L 4.35mmol/L 90.2mmol/L

Date done: 10-01-11 Reference 8-25 0.5-1.7 135 148 3.50-5.30 98-107

INTERPRETATION: Increase number of BUN and below the normal range of Chloride may possibly due to renal malfunction.

Electrocardiogram Parameter Heart Rate PR interval QRS duration QT/QTc P-R-T axis Result 81 bpm 156 ms 80 ms

Date done:10-02-2011

374/432 ms 46 51-107

Analysis:Normal sinus rhythm, Normal axis, Left atrial enlargement, T-wave inversion possible ischemia/ antero lateral.(Moderately abnormal ECG)

Actual Diagnostic Examinations ABDOMINAL ULTRASOUND RESULT September 30, 2011 Liver is not enlarged with smooth borders. Parenchymal reflectivity is homogenous and medium in level. No definite focal cystic or solid lesion seen. The intra and extra hepatic bile ducts are undilated. The portal venous radicles are not ecstatic. Gallbladder is not dilated having thin walls which measures 4.9 X 3.2 cm. No intraluminal echoes or perycholecystic fluid seen. Dilated fluid- filled small and large bowels are observed in the entire abdominopelvic region with signs of hyperactivity. The right kidney measures 7.0 X 3.5 cm. The left kidney measures 7.8 X 2.9 cm. Both kidneys are less than the average normal in size with adequate cortical thickness. Parenchymal echogenecity is also normal with delineable corticomedullary junctions. The right central echocomplexes are slightly dilated whereas the left are intact. No visible nephrolithiasis or focal lesion within. Perinephric spaces are intact. Pancreas, spleen, abdominal aorta, urinary bladder and prostate gland are obscured by the overlying dilated bowels. Minimal ascites is detected at the hepatorenal space and in between bowels. Scanning of the two visible masses in the right inguinal region shows complex fluid- filled structures with multiple small septations containing echogenic and hypoechoic fluid and irregularly

thickened walls. No color flow is detected on color Doppler study. No transducer tenderness or overlying abnormal skin changes.

IMPRESSION: Dilated fluid- filled bowels, could be due to ileus Vs. intestinal obstruction. Complex cystic right inguinal masses as described Mild renal Caliectasia, Right kidney Minimal ascites

IMANAGEMENT Ideal: Medications 1. Finasteride (Proscar)and dutasteride (Avodart) Inhibit production of the hormone dihydrotestosterone (DHT), which is involved with prostate enlargement. The use of either of these drugs can either prevent progression of prostate growth or actually shrink the prostate in some men. 2. Terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin(Uroxatral) and silodosin (Rapaflo) For the treatment of BPH. All five drugs act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction. These drugs belong to the class known as alpha blockers. *Terazosin and doxazosin were developed first to treat high blood pressure. *Tamsulosin, alfuzosin, and silodosin were developed specifically to treat BPH.

Therapies 1. Transurethral microwave procedures (TUMT) Transurethral microwave thermotherapy (TUMT), the device sends computer-regulated microwaves through a catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. A cooling system protects the urinary tract during the procedure. The procedure takes about one hour and can be performed on an outpatient basis without general anesthesia. TUMT has not been reported to lead to erectile dysfunction or incontinence. Although microwave therapy does not cure BPH, it reduces urinary frequency, urgency, straining, and intermittent flow. It does not correct the problem of incomplete emptying of the bladder. Ongoing research will determine any long-term effects of microwave therapy and who might benefit most from this therapy. 2. Transurethral needle ablation Minimally invasive transurethral needle ablation (TUNA) system for the treatment of BPH. It is a system that delivers low-level radiofrequency energy through twin needles to burn away a welldefined region of the enlarged prostate. Shields protect the urethra from heat damage. No incontinence or impotence has been observed.

3. Water-induced thermotherapy This therapy uses heated water to destroy excess tissue in the prostate. A catheter containing multiple shafts is positioned in the urethra so that a treatment balloon rests in the middle of the prostate. A computer controls the temperature of the water, which flows into the balloon and heats the surrounding prostate tissue. The system focuses the heat in a precise region of the prostate. Surrounding tissues in the urethra and bladder are protected. Destroyed tissue either escapes with urine through the urethra or is reabsorbed by the body. 4. High-intensity focused ultrasound The use of ultrasound waves to destroy prostate tissue is still undergoing clinical trials in the United States. The FDA has not yet approved high-intensity focused ultrasound.

Surgical treatment 1. Transurethral surgery In this type of surgery, no external incision is needed. After the patient is given general or spinal anesthesia, the surgeon reaches the prostate by inserting an instrument through the urethra. 2. Transurethral resection of the prostate (TURP) A procedure called transurethral resection of the prostate (TURP) is used for 90% of all prostate surgeries done for BPH. With TURP, an instrument called a resectoscope is inserted through the penis. The resectoscope, which is about 12 inches long and 1/2 inch in diameter, contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels. During the 90minute operation, the surgeon uses the resectoscope's wire loop to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into the bladder and then flushed out at the end of the operation. Most doctors suggest using TURP whenever possible. Transurethral procedures are less traumatic than open forms of surgery and require a shorter recovery period. After a TURP, most men have retrograde, or backward, ejaculation. In this condition, semen flows backward into the bladder during climax instead of out the urethra. 3. Transurethral incision of the prostate (TUIP) Another surgical procedure is called transurethral incision of the prostate (TUIP). Instead of removing tissue, as with TURP, this procedure widens the urethra by making a few small cuts in the bladder neck, where the urethra joins the bladder, and in the prostate gland itself. Although some people

believe that TUIP gives the same relief as TURP with less risk of side effects such as retrograde ejaculation, its advantages and long-term side effects have not been clearly established. 4. Laser surgery In March 1996, the FDA approved a surgical procedure that employs side-firing laser fibers and Nd:YAG lasers to vaporize obstructing prostate tissue. The doctor passes the laser fiber through the urethra into the prostate using a cystoscope and then delivers several bursts of energy lasting 30 to 60 seconds. The laser energy destroys prostate tissue and causes shrinkage. As with TURP, laser surgery requires anesthesia. A hospital stay is not always necessary. One advantage of laser surgery over TURP is that laser surgery causes little blood loss. Laser surgery also allows for a quicker recovery time. But laser surgery may not be effective on larger prostates. The long-term effectiveness of laser surgery is not known. Newer procedures that use laser technology can be performed on an outpatient basis. Photoselective vaporization of the prostate (PVP) uses a high-energy laser to destroy prostate tissue and seal the treated area. Interstitial laser coagulation, unlike other laser procedures, is done by placing the tip of the fiberoptic probe directly into the prostate tissue to destroy it. 5. Prostatic stents A stent is a small device that is inserted through the urethra to the narrowed area and allowed to expand, like a spring. The stent pushes back the prostatic tissue, widening the urethra. It is designed to relieve urinary obstruction in men and improve the ability to urinate. The device is approved for use in men for whom other standard surgical procedures to correct urinary obstruction have failed.

Open surgery In the few cases when a transurethral procedure cannot be used, open prostatectomy, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. The location of the enlargement within the gland and the patient's general health help the surgeon decide which of the three types of open procedures to use. With all the open procedures, anesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he or she scoops out the enlarged tissue from inside the gland.

Holistic and alternative treatments Saw palmetto extract is commonly used in Europe to treat BPH. A review of studies shows that saw palmetto extract treatment can result in significant improvement in BPH symptoms.

Actual: PRE-OP: With Venoclysis of D5LRS 1L regulated at 30 gtts/min at 180 cc level hooked at the left cephalic vein, patent and infusing well NPO maintained

POST-OP: (10/04/11) D5LRS 1 L x 8 hours with SD of D5W L + 250 mg tramadol x 24 hours ;TF D5LRS 1 L x 8 hours

Pharmacological Management PRE-OP: HNBB 1 amp IV Ciprofloxacin 200 mg IV every 12 hours Tramadol 50 mg IV now then every 8 hours

POST-OP: Cefoxitin 1g IV every 8 hours Paracetamol 300 mg IV every 4 hours RTC Cefotaxime 1g IV every 8 hours Gentamicin 80 mg IV every 12 hours Diclofenac Sodium 75 mg now IV every 12 hours Salneb every 8 hours Ceftriaxone Na 1g IV every 8 hours

Nursing Management Established good nurse-patient relationship Monitored & recorded V/S every four hours

Maintained IVF regulation as ordered Checked/facilitated meds as ordered Advised pt. to do deep breathing exercise. Advised to have adequate rest. Positioned patient on bed comfortably I & O monitored and recorded. Health Teachings imparted

HEALTH TEACHINGS Emphasized the importance of eating nutritious foods such as vitamin C to boost immune system. Encouraged adequate rest to promote comfort and gain energy. Emphasized the importance of good personal hygiene to prevent the occurrence and transfer of microorganism. Assisted patient in changing position to prevent from any injury. Encouraged patient to do deep breathing exercise to promote lung expansion. Encouraged patient to abstain from vices like smoking and drinking that may irritate urinary tract. Advised the patient to limit OFI. Provided emotional support to gain confidence.

UPDATES GSK Launches First Drug to Reduce Prostate Cancer Risk GlaxoSmithKline (GSK) announced an important milestone in the Philippines with the launch of the new indication of dutasteride, a drug that has been shown to lower the risk of prostate cancer by 23% overall. FDA Approves Cialis to Treat Benign Prostatic Hyperplasia October 6, 2011 -- The U.S. Food and Drug Administration today approved Cialis (tadalafil) to treat the signs and symptoms of benign prostatic hyperplasia (BPH), a condition in which the prostate gland becomes enlarged, and for the treatment of BPH and erectile dysfunction (ED), when the conditions occur simultaneously. Cialis was approved in 2003 for the treatment of ED. The FDA has approved eight other drugs to treat symptoms of BPH: Proscar, (finasteride), Avodart (dutasteride), Jalyn (dutasteride plus tamsulosin), and the alpha blockers: Hytrin (terazosin), Cardura (doxazosin), Flomax (tamsulosin), Uroxatral (alfuzosin) and Rapaflo (silodosin). Cialis is manufactured by Indianapolis-based Eli Lilly and Co.

What is Cialis? Cialis (tadalafil) relaxes muscles and increases blood flow to particular areas of the body. Cialis is used to treat erectile dysfunction (impotence) in men. Cialis is also used to treat the signs and symptoms of benign prostatic hyperplasia (BPH), a condition in which the prostate gland becomes enlarged.

Benign Prostate Hyperplasia to Countries and Regions: WARNING! EXTRAPOLATION ONLY. NOT BASED ON COUNTRY-SPECIFIC DATA SOURCES. The following table attempts to extrapolate the above incidence rate for Benign Prostate Hyperplasia to the populations of various countries and regions. As discussed above, these incidence extrapolations for Benign Prostate Hyperplasia are only estimates and may have very limited relevance to the actual incidence of Benign Prostate Hyperplasia in any region:

Country/Region Extrapolated Incidence Population Estimated Used Benign Prostate Hyperplasia in North America (Extrapolated Statistics) USA 467,707 293,655,4051 Canada 51,775 WARNING! (Details) 32,507,8742 Mexico 167,170 WARNING! (Details) 104,959,5942 Benign Prostate Hyperplasia in Central America (Extrapolated Statistics) Belize 434 WARNING! (Details) 272,9452 Guatemala 22,744 WARNING! (Details) 14,280,5962 Nicaragua 8,536 WARNING! (Details) 5,359,7592 Benign Prostate Hyperplasia in Caribbean (Extrapolated Statistics) Puerto Rico 6,208 WARNING! (Details) 3,897,9602 Benign Prostate Hyperplasia in South America (Extrapolated Statistics) Brazil 293,219 WARNING! (Details) 184,101,1092 Chile 25,202 WARNING! (Details) 15,823,9572 Colombia 67,388 WARNING! (Details) 42,310,7752 Paraguay 9,861 WARNING! (Details) 6,191,3682 Peru 43,870 WARNING! (Details) 27,544,3052 Venezuela 39,845 WARNING! (Details) 25,017,3872 Benign Prostate Hyperplasia in Northern Europe (Extrapolated Statistics) Denmark 8,621 WARNING! (Details) 5,413,3922 Finland 8,305 WARNING! (Details) 5,214,5122 Iceland 468 WARNING! (Details) 293,9662 Sweden 14,312 WARNING! (Details) 8,986,4002 Benign Prostate Hyperplasia in Western Europe (Extrapolated Statistics) Britain (United Kingdom) 95,993 WARNING! (Details) 60,270,708 for UK2 Belgium 16,481 WARNING! (Details) 10,348,2762 France 96,238 WARNING! (Details) 60,424,2132 Ireland 6,322 WARNING! (Details) 3,969,5582 Luxembourg 736 WARNING! (Details) 462,6902 Monaco 51 WARNING! (Details) 32,2702 Netherlands (Holland) 25,990 WARNING! (Details) 16,318,1992 United Kingdom 95,993 WARNING! (Details) 60,270,7082 Wales 4,647 WARNING! (Details) 2,918,0002 Benign Prostate Hyperplasia in Central Europe (Extrapolated Statistics) Austria 13,020 WARNING! (Details) 8,174,7622 Czech Republic 1,984 WARNING! (Details) 1,0246,1782 Germany 131,278 WARNING! (Details) 82,424,6092 Hungary 15,978 WARNING! (Details) 10,032,3752 Liechtenstein 53 WARNING! (Details) 33,4362 Poland 61,520 WARNING! (Details) 38,626,3492 Slovakia 8,638 WARNING! (Details) 5,423,5672 Slovenia 3,203 WARNING! (Details) 2,011,473 2 Switzerland 11,867 WARNING! (Details) 7,450,8672 Benign Prostate Hyperplasia in Eastern Europe (Extrapolated Statistics) Belarus 16,421 WARNING! (Details) 10,310,5202 Estonia 2,136 WARNING! (Details) 1,341,6642 Latvia 3,673 WARNING! (Details) 2,306,3062 Lithuania 5,746 WARNING! (Details) 3,607,8992 Russia 229,308 WARNING! (Details) 143,974,0592 Ukraine 76,023 WARNING! (Details) 47,732,0792 Benign Prostate Hyperplasia in the Southwestern Europe (Extrapolated Statistics)

Azerbaijan 12,532 WARNING! (Details) 7,868,3852 Portugal 16,761 WARNING! (Details) 10,524,1452 Spain 64,155 WARNING! (Details) 40,280,7802 Georgia 7,476 WARNING! (Details) 4,693,8922 Benign Prostate Hyperplasia in the Southern Europe (Extrapolated Statistics) Italy 92,468 WARNING! (Details) 58,057,4772 Greece 16,958 WARNING! (Details) 10,647,5292 Benign Prostate Hyperplasia in the Southeastern Europe (Extrapolated Statistics) Albania 5,645 WARNING! (Details) 3,544,8082 Bosnia and Herzegovina 649 WARNING! (Details) 407,6082 Bulgaria 11,973 WARNING! (Details) 7,517,9732 Croatia 7,162 WARNING! (Details) 4,496,8692 Macedonia 3,249 WARNING! (Details) 2,040,0852 Romania 35,605 WARNING! (Details) 22,355,5512 Serbia and Montenegro 17,242 WARNING! (Details) 10,825,9002 Benign Prostate Hyperplasia in Northern Asia (Extrapolated Statistics) Mongolia 4,382 WARNING! (Details) 2,751,3142 Benign Prostate Hyperplasia in Central Asia (Extrapolated Statistics) Kazakhstan 24,119 WARNING! (Details) 15,143,7042 Tajikistan 11,167 WARNING! (Details) 7,011,556 2 Uzbekistan 42,064 WARNING! (Details) 26,410,4162 Benign Prostate Hyperplasia in Eastern Asia (Extrapolated Statistics) China 2,068,686 WARNING! (Details) 1,298,847,6242 Hong Kong s.a.r. 10,918 WARNING! (Details) 6,855,1252 Japan 202,804 WARNING! (Details) 127,333,0022 Macau s.a.r. 709 WARNING! (Details) 445,2862 North Korea 36,150 WARNING! (Details) 22,697,5532 South Korea 76,822 WARNING! (Details) 48,233,7602 Taiwan 36,233 WARNING! (Details) 22,749,8382 Benign Prostate Hyperplasia in Southwestern Asia (Extrapolated Statistics) Turkey 109,727 WARNING! (Details) 68,893,9182 Benign Prostate Hyperplasia in Southern Asia (Extrapolated Statistics) Afghanistan 45,413 WARNING! (Details) 28,513,6772 Bangladesh 225,114 WARNING! (Details) 141,340,4762 Bhutan 3,480 WARNING! (Details) 2,185,5692 India 1,696,347 WARNING! (Details) 1,065,070,6072 Pakistan 253,553 WARNING! (Details) 159,196,3362 Sri Lanka 31,703 WARNING! (Details) 19,905,1652 Benign Prostate Hyperplasia in Southeastern Asia (Extrapolated Statistics) East Timor 1,623 WARNING! (Details) 1,019,2522 Indonesia 379,786 WARNING! (Details) 238,452,9522 Laos 9,664 WARNING! (Details) 6,068,1172 Malaysia 37,464 WARNING! (Details) 23,522,4822 Philippines 137,357 WARNING! (Details) 86,241,6972 Singapore 6,934 WARNING! (Details) 4,353,8932 Thailand 103,311 WARNING! (Details) 64,865,5232 Vietnam 131,657 WARNING! (Details) 82,662,8002 Benign Prostate Hyperplasia in the Middle East (Extrapolated Statistics) Gaza strip 2,110 WARNING! (Details) 1,324,9912 Iran 107,512 WARNING! (Details) 67,503,2052 Iraq 40,414 WARNING! (Details) 25,374,6912 Israel 9,873 WARNING! (Details) 6,199,0082

Jordan 8,937 WARNING! (Details) 5,611,2022 Kuwait 3,595 WARNING! (Details) 2,257,5492 Lebanon 6,016 WARNING! (Details) 3,777,2182 Saudi Arabia 41,085 WARNING! (Details) 25,795,9382 Syria 28,695 WARNING! (Details) 18,016,8742 United Arab Emirates 4,019 WARNING! (Details) 2,523,9152 West Bank 3,681 WARNING! (Details) 2,311,2042 Yemen 31,893 WARNING! (Details) 20,024,8672 Benign Prostate Hyperplasia in Northern Africa (Extrapolated Statistics) Egypt 121,232 WARNING! (Details) 76,117,4212 Libya 8,969 WARNING! (Details) 5,631,5852 Sudan 62,351 WARNING! (Details) 39,148,1622 Benign Prostate Hyperplasia in Western Africa (Extrapolated Statistics) Congo Brazzaville 4,775 WARNING! (Details) 2,998,0402 Ghana 33,059 WARNING! (Details) 20,757,0322 Liberia 5,400 WARNING! (Details) 3,390,6352 Niger 18,094 WARNING! (Details) 11,360,5382 Nigeria 28,271 WARNING! (Details) 12,5750,3562 Senegal 17,284 WARNING! (Details) 10,852,1472 Sierra leone 9,371 WARNING! (Details) 5,883,8892 Benign Prostate Hyperplasia in Central Africa (Extrapolated Statistics) Central African Republic 5,960 WARNING! (Details) 3,742,4822 Chad 15,192 WARNING! (Details) 9,538,5442 Congo kinshasa 92,882 WARNING! (Details) 58,317,0302 Rwanda 13,121 WARNING! (Details) 8,238,6732 Benign Prostate Hyperplasia in Eastern Africa (Extrapolated Statistics) Ethiopia 113,618 WARNING! (Details) 71,336,5712 Kenya 52,530 WARNING! (Details) 32,982,1092 Somalia 13,226 WARNING! (Details) 8,304,6012 Tanzania 57,450 WARNING! (Details) 36,070,7992 Uganda 42,032 WARNING! (Details) 26,390,2582 Benign Prostate Hyperplasia in Southern Africa (Extrapolated Statistics) Angola 17,485 WARNING! (Details) 10,978,5522 Botswana 2,610 WARNING! (Details) 1,639,2312 South Africa 70,793 WARNING! (Details) 44,448,4702 Swaziland 1,862 WARNING! (Details) 1,169,2412 Zambia 17,560 WARNING! (Details) 11,025,6902 Zimbabwe 5,848 WARNING! (Details) 1,2671,8602 Benign Prostate Hyperplasia in Oceania (Extrapolated Statistics) Australia 31,715 WARNING! (Details) 19,913,1442 New Zealand 6,360 WARNING! (Details) 3,993,8172 Papua New Guinea 8,632 WARNING! (Details) 5,420,2802

WARNING! EXTRAPOLATED STATISTICS ONLY! Not based on data sources from individual countries. These statistics are calculated extrapolations of various prevalence or incidence rates against the populations of a particular country or region.