Mr. S.B. is a 72-year-old man on follow-up at the outpatient clinic for recurrent urinary tract infections, managed with antibiotics. Three months ago, he was received at the emergency department presenting with acute urine retention, which was managed with analgesics and urethral catheter fixation for relief. He was sent for an abdominopelvic scan and sent home on antibiotics with a diagnosis of prostatomegaly secondary to benign prostatic hyperplasia for further follow-up at the surgical outpatient clinic. Unfortunately, Mr. S.B. was lost to follow-up at the outpatient clinic.
Two days ago, he was received at the emergency department with the same complaint; acute urine retention where a urethral catheterization was attempted but was unsuccessful, warranting his admission for a suprapubic catheter placement. He was also examined and worked up for the diagnosis of BPH, with prostatomegaly showing on an abdominopelvic scan and PSA levels of 7ng/ml. He is scheduled for a prostatectomy when he consents to the procedure.
Mr. S.B. is anxious about the surgical procedure and has asked for time to think about it. He would like to know if there is a way that he can improve his voiding symptoms without surgery or catheterization. He also heard and read a little about the PSA test and is afraid that with PSA levels above 4ng, he is at risk or has prostate cancer. Lastly, he would like to know what complications he is at risk for and how to take care of the suprapubic catheter.
Mr. S.B. is likely to make uninformed decisions if he is not educated on his condition. Therefore, he must be educated to ensure that he makes the right decisions for the best outcome for his health. Educating Mr. S.B. will not only be helpful to him but will also improve my knowledge of the topic, making me feel equipped and ready to help another person with a similar, if not the exact, problem.
Elimination
Before the onset of symptoms, he would void 2-3 times daily. His urine was clear in color, with no burning sensation or pain during urination. He would move his bowel once a day in the morning, and he had a brown and well-formed stool with no blood or foul smell.
Now, he reports voiding more than ten times daily and cloudy urine with a burning sensation and pain during urination. He still moves his bowels once a day, experiences hard stool, and sometimes needs laxatives to have a bowel movement. His stool is brown and well-formed, with no blood or foul smell. He experiences on-and-off constipation and bloating with mild abdominal distention, relieved after emptying his bowels.
What can he do? Mr. S.B. can take a constant low dose of laxatives to ensure he passes less hard stools; he should also increase his water intake and eat high-fiber food to reduce the chances of constipation.
Sleep/Pattern
Mr. S.B. reports sleeping more than 8hrs straight before the onset of symptoms. He would go to sleep at around 10 pm, his earliest time sleeping being at 9 pm, and wake up at 6 am, the earliest time he could wake up being at 4 am. He did not have trouble falling asleep and did not require medications to promote sleep. During the day, when tired, he would nap for about an hour. He did not exercise and would get a headache after walking or jogging, even for 15mins, which was relieved by rest.
Since the development of symptoms, Mr.S.B reports getting about 6hrs of sleep at night; his sleep would be distracted in the night as he would wake up about four times a night to go and void, often not falling back to sleep for a while because of the sensation of burning urine and a feeling of incomplete emptying. He still has no trouble falling asleep and does not take any medications to promote sleep. During the day, he takes multiple naps because he feels exhausted.
Coping/Stress
Before the onset of symptoms, he would cope with stress by playing golf and watching movies. He would also spend time with family and friends doing fun activities, often smoking and drinking a beer or two. He would cope with his problems by talking to his wife and brother. He has no traumatic events in his life and describes his life as fulfilling.
Now, he participates in the same fun activities. However, he does not go out as often these days owing to his symptoms but stays home with his wife, who is still there to support him. He was admitted to the hospital due to acute urine retention for suprapubic catheterization.
Discussion
Suprapubic catheter care
Urinary catheterization is a standard procedure in hospitals (Sweeney, 2022). Suprapubic catheterization, also called suprapubic cystostomy, although not as common as urethral catheterization, is a critical surgical intervention for patients with benign prostatic hyperplasia with acute urinary retention and an unsuccessful urethral catheterization attempt. Compared to urethral catheterization, suprapubic catheterization has a lower incidence of urinary tract infections but is a procedure that requires more surgical skill to perform. Complications of suprapubic catheterization include; recurrent catheter blockage by debris, persistent urethral urine leakage, abdominal wall and urinary infections associated with chronic use, and injury to the surrounding viscera during insertions (Adam, 2022). Nurses should remember a few golden rules when caring for patients or teaching patients to care for themselves with a suprapubic catheter. First is the four-week rule; a patient should not change the suprapubic catheter for four weeks after the first placement to allow for the catheter tract to be established. Second, when changing a suprapubic catheter, the new catheter should be inserted within 5-10 minutes of removal of the old catheter, so as not to lose the catheter tract or have a complicated re-insertion. Therefore, a patient should always have a spare catheter in case of accidental removal and be taught how to insert it if necessary. This option of the patient or carers undertaking the catheter change should be considered as it increases the patient’s independence. Catheter changes should be undertaken at intervals suggested by the manufacturer. However, the duration can be reduced if difficulties arise, such as catheter blockages between changes. The change should be carried out by staff who have been instructed about the technique and complications of suprapubic catheter changes. (Sweeney, 2022)
Prostate-specific antigen and prostate cancer
Absolute elevations in prostate-specific antigen (PSA) poorly discriminate between benign prostatic hyperplasia and prostate cancer and may result from both (Devlin et al., 2021). Although PSA measurement has some benefits in managing benign prostatic hyperplasia, its requirement in the initial workup for the condition is controversial. Many authorities determine that it may not be necessary for the treatment course (Nordström et al., 2018). This is especially true for patients where an early diagnosis of prostate cancer would provide no benefit to these patients; for example, men with less than a ten-year life expectancy. As a benefit, baseline PSA measurement before and after the intervention may provide a surrogate for treatment efficacy, as PSA levels and prostate enlargement are strongly correlated (Chinni et al., 2022). Additionally, PSA measurements are strong predictors of the risk of developing acute urine retention, among other complications of benign prostatic hypertrophy.
About its relation to prostate cancer, modifications to the PSA assays have been developed to distinguish benign prostatic hypertrophy from prostate cancer better. Higher PSA density (serum PSA divided by prostate volume measured by transrectal ultrasound), for example, and PSA velocity (annualized rate of rise in PSA) have been shown to correlate better with the diagnosis of prostate cancer than a single PSA level measurement. PSA level should always be correlated to the physical examination of the prostate gland through a digital rectal exam. Although the size of the prostate is difficult to ascertain in a digital rectal exam, the size of the prostate is rarely important unless surgery is contemplated. In this case,e a prostate ultrasound may help assess the size of the gland. However, the consistency of the prostate and identification of areas of irregularity, especially any tight areas which may suggest prostate cancer, is critical. Absolute PSA levels should, therefore, always be interpreted in conjunction with the physical examination and can not, as a single measurement, show that a patient has prostate cancer.
Improving voiding symptoms in BPH
Benign prostatic hyperplasia and associated lower urinary tract symptoms commonly affect older men, with reports of up to 50% occurrence over the age of 50yrs and the increasing incidence with increasing age (Kim et al., 2017). Benign prostatic hyperplasia anatomically compresses the urethra, causing increased bladder outlet resistance. This results in lower urinary tract symptoms, including difficult voiding such as hesitancy, straining, weak stream, intermittency, a sensation of incomplete emptying, and symptoms of irritable voiding such as frequency, urgency, urge incontinence, and nocturia. The development of benign prostatic hyperplasia is under genetic and environmental control (Madersbacher et al., 2019). A large body of evidence indicates that modifiable metabolic and lifestyle factors are essential in the pathophysiology of benign prostatic hyperplasia and the development of lower urinary tract symptoms. These include factors such as (a) obesity and diabetes, which is associated with increased levels of a hormone known as dihydrotestosterone that contributes to the pathophysiology of benign prostatic hyperplasia, (b) exercise, where a lack of physical activities has been shown to worsen urine retention; even small amount of exercise can help reduce urinary symptom and (c) diet; dietary changes such as limiting beverages in the evening an hour or two before bedtime and reducing the amount of caffeine and alcohol intake can reduce the amount of urine formed and decrease the irritation to the bladder, improving the overall quality of life.
Other methods that a patient can use to improve voiding symptoms include limiting the use of some drugs such as decongestants and antihistamines, which cause an increase in the tone of the internal sphincter; having scheduled bathroom visits; practicing double voiding; urinating and then going to urinate again a few moments later to reduce the feeling of incomplete emptying and keeping warm because colder temperatures worsen urine retention and increase the urgency to urinate.
Complications of benign prostatic hyperplasia
With the current advancements in diagnostic and interventional medicine, benign prostatic hyperplasia rarely causes complications. Most of these complications develop due to enlargement of the prostate, which, owing to its anatomical position, compresses the prostatic urethra at the bladder neck. This reduces the lumen of the prostatic urethra, causing lower urinary tract symptoms in these patients. The slow outflow of urine creates a favorable environment for bacterial infestation and multiplication, causing recurrent urinary tract infections as one of the complications. The urine stasis also predisposes the development of bladder stones secondary to the aggregation of salts found in urine. Patients with long-standing benign prostatic hyperplasia are at risk of a complete blockage of the prostatic urethra and development of urine retention, acute or chronic, which could be severe enough to cause backflow to the kidneys causing kidney damage and potentially lead to renal insufficiency. The continuous contraction of the bladder walls against a blocked outlet can result in bladder damage and gross hematuria in the worst cases. Even in the face of these complications, early intervention can ensure that these complications are avoided and that the patient’s quality of life can be improved if not maintained.
Management of benign prostatic hyperplasia
Many treatment options exist for managing benign prostatic hyperplasia (Kim et al., 2017), including watchful waiting and pharmacological, minimally invasive, and invasive surgical therapies. Watchful waiting is usually a therapy issued to patients with minimal symptoms gauged by a symptom score known as the International Prostate Symptoms Score (IPSS) (Langan, 2019). As treatment of benign prostatic hyperplasia and its associated lower urinary tract symptoms is aimed at improving the patient’s quality of life, watchful waiting should be accompanied by education and modifications in the lifestyle of the patient, such as weight loss, increased physical activity, and reduction in caffeine and alcohol intake. Patients should undergo yearly evaluation and be counseled appropriately on their risk for acute urinary retention, especially for patients with diminished urinary flow rates, larger prostate volumes, increasing prostate-specific antigen levels, and older age.
Medical therapy is first-line therapy for individuals with moderate-severe symptoms (Manov et al., 2020). Surgery, on the other hand, is usually reserved for patients who have failed to respond to medical management or have complications such as recurrent urinary tract infections, refractory urine retention, bladder stones, or renal insufficiency due to obstructive uropathy. Over the past 20yrs, advances in medical treatments for benign prostatic hyperplasia and lower urinary tract symptoms have led to a corresponding decline in the utilization of surgical procedures for this disorder. Medical management involves using medications to interrupt the pathophysiological mechanism of benign prostatic hyperplasia (Rastrelli et al., 2019). These classes of drugs include alpha-blockers, 5-alpha reductase inhibitors, and phosphodiesterase type 5 inhibitors. It is a common practice for a doctor to use a combination of these agents rather than monotherapy to manage benign prostatic hyperplasia and its associated lower urinary tract symptoms (Miernik & Gratzke, 2020).
Conclusion
Benign prostatic hyperplasia is characterized by the enlargement of the prostate gland at the bladder neck resulting in lower urinary tract symptoms and predisposing patients to complications such as urinary tract infections, bladder stones, and renal insufficiency, among others. Patients usually undergo a significant change in the quality of life owing to these symptoms and often require health education on the condition on top of medical or surgical intervention. Mr. S.B. was diagnosed with the condition two months ago but unfortunately was lost to follow-up. He now presents a complicated case of acute urine retention and a larger prostate gland volume requiring surgical intervention. This outcome and the need for surgery have made him very anxious, and he wished to have some of his concerns addressed.
Mr. S.B. appreciated the education on the relationship between prostate-specific antigen and prostate cancer; he was grateful to be informed on how to take care of his suprapubic catheter and how to improve his voiding symptoms if he chooses not to go ahead with the surgery. Information on the complications of benign prostatic hyperplasia was beneficial to him, and he reports that he is now inclined towards undertaking the surgery more than before. There is more to learn from Mr. S.B.’s case, and a follow-up is needed to ensure continued education and improved quality of care.
References
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