Elimination Disorders: Benign Prostatic Hyperplasia, Encopresis, Enuresis, Hypospadias, Urinary Calculi, Bowel Obstruction
Benign Prostatic Hyperplasia (BPH): Quality of Life and Pathophysiology
General Impact on Quality of Life: BPH interferes with daily activities and sleep patterns.
Demographics and Prevalence:
BPH primarily affects men older than .
By the age of , approximately of men will have BPH.
It is identified as the second most common cause of surgical intervention in men older than .
Anatomical Changes: The condition involves an enlargement of the prostate which causes hypertrophy of the muscle within the bladder, obstructing the urethra and bladder neck.
Hormonal Mediators:
Androgens: Produced by the adrenal gland and testes, these support testosterone function.
Dihydrotestosterone (DHT): A metabolite of testosterone that serves as a critical mediator of prostatic growth.
Pathophysiology: BPH occurs in men with elevated estrogen levels. The enlargement causes incomplete bladder emptying and urinary retention, which can lead to:
Hydroureter: Dilation of the ureters.
Hydronephrosis: Dilation of the kidneys.
Urinary Tract Infections (UTIs): Frequent due to urinary stasis.
Risk Factors:
Western Diet: High in animal fat, protein, and refined carbohydrates; low in fiber.
Erectile Dysfunction (ED): Associated with the condition.
Chemical Exposure: Pesticides and farming chemicals.
Lifestyle: Heavy alcohol consumption.
Assessment, Diagnosis, and Management of BPH
Patient Assessment and History:
Nocturia: Often the first symptom indicating BPH or prostate cancer.
Urinary Stream: Assess how long it takes to initiate a stream, the consistency of the stream, and the presence of dribbling at the end.
Urine Character: Assess the color and amount of urine.
Diagnostic Testing:
Prostate-Specific Antigen (PSA) Blood Test: Used to screen for cancer. PSA is slightly elevated in BPH but extremely elevated in prostate cancer.
Digital Rectal Exam (DRE): Used to assess prostate size and consistency; typically begins annually for men at age .
Post-Void Residual Urine Test: Measures the extent of urine flow obstruction.
Urinalysis (UA): May show elevated White Blood Cells (WBC) or hematuria due to infection or inflammation.
Uroflowmetry: Determines urine volume from the bladder and degree of blockage.
Cystoscopy: Insertion of a scope through the urethra to view the internal bladder and prostate enlargement.
Pharmacological Therapy:
Alpha Adrenergic Blockers (e.g., Alfuzosin, silodosin, prazosin, tadalafil, oxybutynin): Relax the smooth muscle of the bladder neck and prostate to improve urine flow.
5-alpha-reductace inhibitors: These medications, such as finasteride and dutasteride, work by inhibiting the enzyme that converts testosterone to dihydrotestosterone (DHT), which leads to a reduction in prostate size and alleviation of urinary symptoms.
Combination Therapy: Use of Doxazosin and Finasteride together to reduce clinical progression.
Oxybutynin: Used to treat bladder spasms.
Complementary Medicine: Saw Palmetto (Salpamalto) is used by some to interfere with testosterone conversion to DHT, though not typically recommended by physicians.
Medication Side Effects and Compliance: In 5-alpha-reductace inhibitors: Side effects include decreased libido, ejaculatory dysfunction, erectile dysfunction, and Gynecomastia (abnormal breast enlargement in men) can lead to non-compliance, especially in middle-aged or younger men.
Lifestyle Modifications:
Urinate at the first urge.
Cessation of caffeine and alcohol.
Distribute fluid intake in small amounts throughout the day; avoid fluids within of bedtime.
Avoid over-the-counter cold/sinus medications (cholinergics/vasoconstrictors) without consulting a physician. These can cause acute urinary retention.
Reduce stress and exercise regularly.
Surgical Interventions for BPH
Transurethral Microwave Therapy (TMT): Application of heat directly to prostate tissue, causing it to become necrotic and slough away.
Transurethral Needle Ablation (TUNA): Uses radiofrequency energy via a needle to deliver localized heat, sparing surrounding tissues; dead tissue is reabsorbed.
Transurethral Resection of the Prostate (TURP):
The benchmark treatment for BPH.
Involves the surgical removal of the inner portion of the prostate using an endoscope through the urethra.
No external excision is made.
Transurethral Incision of the Prostate (TUIP):
Used for smaller prostates.
Involves one or two cuts at the prostate and the insertion of a prostate capsule to reduce constriction; no tissue is removed.
Bladder Irrigation Post-TURP
Purpose: A three-way irrigation system used after prostate procedures (especially TURP) to prevent clot formation and maintain urinary outflow.
I and O Management:
Fluid instilled must equal the amount drained.
Failure to empty the bladder can cause over-distention and induce hemorrhaging.
Example Calculation: If of fluid is instilled and the bag contains , then is irrigation and is urine output.
Nursing Considerations:
If a patient complains of pain, examine the tubing for obstruction and assess output.
Never clamp or stop the irrigation system, as this increases the risk of hemorrhage and clot obstruction.
Administer pain relief/narcotics as needed.
Encopresis in Children: Definition and Pathophysiology
Definition: Fecal incontinence in children who are usually already toilet-trained. The child loses control and has bowel movements in places other than the toilet (e.g., underwear) or while asleep.
Pathophysiology: Typically results from chronic constipation. As bowel movements build up inside the body, nerves and muscles control the release less effectively. Loose stool then leaks around the hardened, impacted mass of stool.
Diagnostic Tools:
Anorectal Manometry: Measures pressure within the gastrointestinal tract.
Rectal Motility Test: Evaluates muscle and nerve function.
X-ray: Visibly see impacted stool.
History: Review of toilet-training history and dietary habits (fiber intake).
Management and Treatment of Encopresis
Pharmacological Treatment: Stool softeners, laxatives, lubricants at the rectum, and antimicrobial agents if diarrhea is caused by infection. MiraLAX.
Behavioral Habits:
Sit on the toilet for several minutes after each meal. Establish routine and bowel training.
Reward the child for sitting on the toilet regardless of success.
Dietary Adjustments:
Increase fiber (fruit, vegetables, cereals).
Increase water intake.
Regular exercise, Kegel exercises.
Avoid milk, yogurt, cheese, and ice cream.
Surgery: Recommended only as a last resort for sphincter damage, prolapse, or irreparable nerve damage, involving surgical repair or a permanent colostomy.
Enuresis: Causes and Management
Definition: Bedwetting during sleep in children previously potty-trained, occurring more frequently in boys. (Older children age 7 or older)
Causes:
Physiological: Overproduction of urine at night or neurological deficits.
Psychological Stress: Starting school/daycare, a new sibling, death of a parent, divorce, or premature rigorous toilet training.
Assessment: Observe gait for motor dysfunction and test sensory function in the legs to rule out neurological disorders.
Interventions:
Moisture Alarms: Sensitivity devices in mattresses that wake children (age or older) when moistened.
Bladder Irritants: limit caffeine, or natural diuretics etc.
Bladder Training: Encourage regular scheduled voiding to help establish a pattern and reduce accidents.
Pharmacological: Imipramine Hydrochloride, Desmopressin acetate (DDAVP), or anticholinergics (to dry secretions).
Hypospadias: Presentation and Surgical Correction
Definition: A condition in boys where the urethra does not form normally, placing the opening in the wrong position on the underside (Ventral surface) of the penis.
Severity Levels:
Severe: Opening is closer to the scrotum.
Moderate: Midline on the shaft.
Mild: At the head of the penis but on the bottom.
Clinical Implications: Severe cases can cause erectile dysfunction and difficulties with sperm delivery; mild cases typically allow for normal urination and sex.
Surgical Management:
Usually performed at age .
Foreskin is often preserved and used for the repair; therefore, circumcision should be delayed.
Urinary Calculi: Forms, Risk Factors, and Diagnostics
Terminology: Also known as Kidney Stones (Nephrolithiasis) or Urolithiasis (when in the ureters).
Composition:
Calcium Oxalate/Phosphate: Most common.
Uric Acid: Associated with high acid concentrations, such as in gout.
Struvite Stones: Associated with alkaline urine.
Risk Factors: Dehydration, recurrent UTIs, family history, obesity, diabetes, and hypertension.
Diagnostic Testing:
Urine Collection: Measures calcium, oxalate, phosphorus, and uric acid.
Urinalysis: Evaluates specific gravity, hematuria, and crystals.
Urine pH: suggests uric acid stones; suggests Struvite stones.
Imaging: KUB (Kidney, Ureter, Bladder) X-ray, Non-contrast CT scan, Ultrasonography (to detect hydronephrosis), and MRI.
Clinical Manifestations and Treatment of Urinary Calculi
Clinical Manifestations:
Dull, aching flank pain.
Renal Colic: Severe, excruciating wave-like pain radiating to the genitalia and thigh.
UTI-like symptoms and hematuria.
Complications: Hydronephrosis - Kidneys produce urine behind the obstruction.
Pharmacological Treatment:
Allopurinol / Potassium Citrate: To dissolve uric acid stones.
Thiazide Diuretics: For hypercalciuria.
Pain Management: Narcotics as needed.
Surgical Procedures:
*Lithotripsy: Shockwave therapy to break stones; hematuria is expected after surgery, but external bruising should not occur.
Ureteroscopy: Laser beam used via a scope to break stones.
Uterolithotomy / Pyelolithotomy: Surgical removal of stones from the ureter or renal pelvis.
Percutaneous Nephrolithotomy: For larger stones when invasive measures are needed.
Patient Education:
Increase fluid intake to to per day (urine should be clear).
Avoid sugary beverages (e.g., limit sweetened cranberry juice).
Strain all urine and save stones for laboratory analysis.
Mechanical and Functional Bowel Obstructions
Mechanical Obstruction:
Extrinsic: Adhesions (kinking after surgery), hernias (protrusion through muscle), and abscesses.
Intrinsic: Intestinal tumors or strictures.
Intraluminal: Bowel lumen defects like Intussusception.
Functional/Paralytic Obstruction: Caused by Amyloidosis, muscular dystrophy, Diabetes mellitus, or Parkinson's disease.
Specific Mechanical Types:
Intussusception: One segment of the bowel telescopes into another, causing strangulation and necrosis.
Volvulus: Twisting of the sigmoid colon.
Hernia: Intestine protrudes through weakened muscle, potentially entering the scrotal sac.
Comparative Assessment and Management of Small vs. Large Bowel Obstructions
Small Bowel Obstruction (SBO):
Pathophysiology: Interference with nutrient and fluid absorption; fluid backs up leading to severe dehydration.
Symptoms: Crampy, colicky, wave-like pain due to persistent peristalsis; nausea and vomiting.
Acid-Base Imbalance: Vomiting hydrogen ions leads to metabolic alkalosis.
Management: NPO (Nothing by Mouth), IV rehydration, and mandatory NG tube for decompression.
Large Bowel Obstruction (LBO):
Pathophysiology: Progresses slower; dehydration occurs more gradually.
Symptoms: Constipation might be the only symptom for weeks; lower abdominal dull achy pain; ribbon-like stools in partial obstructions.
Management: Colonoscopy can clear gas or untwist bowel; surgical resection/colostomy for necrosis.
General Nursing Care:
Maintain patent NG tube and provide oral care. PH 5.5 is the goal to determine placement.
Monitor I&O and electrolyte studies.
Instruct patients not to suppress the urge to defecate.
Post-surgical education: Splint the site, avoid heavy lifting, and collaborate with wound care nurses for ostomy care.