Benign Prostatic Hyperplasia Case Study (Harding & Snyder Case Study 70): Urinary Retention, TURP and Nursing Care

How to use this guide: the textbook case and its questions are copyrighted, so they are not reproduced here. Instead, this guide explains the clinical content the case tests and walks through an original practice case with model answers. Use it to study and to check your reasoning, then answer the questions in your textbook in your own words. It is not an answer key.

Benign prostatic hyperplasia: what the case tests

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland that is very common in aging men. The prostate surrounds the urethra just below the bladder, so as glandular and stromal tissue grows, it can narrow the urethra and block urine flow. Androgens (especially dihydrotestosterone, or DHT) and aging both contribute (Harding et al., 2023). BPH does not cause prostate cancer, but the two can coexist, which is why evaluation often includes a digital rectal exam (DRE) and, for some men, a prostate-specific antigen (PSA) test.

Clinical reasoning cases on BPH typically test recognition of lower urinary tract symptoms (LUTS), acute urinary retention, medication safety, catheter care, postoperative care after transurethral resection of the prostate (TURP) and discharge teaching. The American Urological Association (AUA) guideline sets current management standards (Sandhu et al., 2024).

Original practice case

Clinical reasoning questions and model answers

1. Why did Mr. Whitfield develop acute urinary retention?

His enlarged prostate had already narrowed the urethra. The cold medicine tipped him into retention in two ways: antihistamines such as diphenhydramine have anticholinergic effects that weaken bladder contraction, and decongestants such as pseudoephedrine stimulate alpha-adrenergic receptors in the bladder neck and prostate, tightening the outlet. Other common triggers include opioids, anesthesia, alcohol, cold exposure, delaying urination and immobility. Men with BPH should be taught to avoid these medicines or ask a pharmacist before using them.

2. What are the nursing priorities for acute retention?

• Confirm retention with a bladder scan and assess pain, distension and vital signs. His high BP and heart rate are likely due to pain.
• Insert a urinary catheter as ordered. If a standard catheter meets resistance at the prostate, do not force it, as this can cause trauma or a false passage. A coudé (curved-tip) catheter may pass more easily, and per policy only specially trained staff or the urologist should try further.
• Monitor the drained volume, urine color, hematuria and vital signs. Many protocols allow complete drainage, but some still advise clamping after a large volume; follow agency policy and watch for hypotension or bleeding.
• Monitor kidney function: back pressure from retention can cause post-renal acute kidney injury, which explains the rising creatinine.

3. How do the main BPH medications work, and what should the nurse teach?

The AUA guideline recommends alpha blockers as a first-line option for bothersome LUTS and 5-ARIs for men with prostate enlargement, alone or combined with an alpha blocker (Sandhu et al., 2024).

4. What is a TURP, and why was it chosen?

TURP removes obstructing prostate tissue through a scope passed into the urethra, so there is no external incision. Surgery is considered when symptoms are severe or medications fail, or when complications occur, such as recurrent retention, recurrent urinary tract infections, bladder stones, kidney damage or repeated bleeding (Sandhu et al., 2024). Other procedures include laser enucleation or vaporization, prostatic urethral lift, water vapor therapy and, for very large glands, simple prostatectomy.

5. How does the nurse manage continuous bladder irrigation after TURP?

• Purpose: sterile irrigation solution flows through one lumen of the three-way catheter and out the drainage lumen, which flushes blood and prevents clots from blocking the catheter.
• Titrate the flow rate to keep drainage light pink or clear without clots. Increase the rate for darker red drainage or clots, per orders.
• Calculate true urine output: total drainage minus irrigant infused. For example, 3,200 mL drained minus 2,800 mL irrigant = 400 mL urine.
• Watch for obstruction: sudden decrease in drainage, bladder distension, severe pain or leaking around the catheter. Check the tubing for kinks and irrigate manually if ordered.
• Bleeding: bright red drainage with clots that does not lighten, falling BP and rising HR may mean arterial bleeding. Notify the surgeon. Dark red drainage that clears with irrigation is more often venous.
• Bladder spasms are common and painful. They are treated with antispasmodic medicines such as oxybutynin or belladonna and opium suppositories, as ordered. Teach the patient not to try to void around the catheter.
• Keep the catheter secured to the thigh and maintain any ordered traction.

6. On the evening after surgery, Mr. Whitfield becomes confused and nauseated, with a BP of 168/98 and HR of 54. What could be happening?

These signs suggest TUR syndrome, which is dilutional hyponatremia and fluid overload caused by absorbing irrigation fluid through open venous sinuses during surgery. It is most associated with nonelectrolyte irrigants such as glycine and is less common with newer bipolar techniques that use saline. Signs include confusion, headache, nausea and vomiting, hypertension with bradycardia and, in severe cases, seizures. The nurse should check serum sodium, notify the provider, monitor neurologic status and intake and output, and prepare for fluid restriction, diuretics or hypertonic saline as ordered.

7. What discharge teaching does Mr. Whitfield need?

• Drink 2–3 L of fluid a day unless restricted, to keep urine dilute and flowing.
• Avoid straining, heavy lifting (more than about 10 lb), strenuous exercise and long car rides for several weeks; prevent constipation with fiber, fluids and stool softeners as ordered.
• Some blood in the urine can occur, especially around 10–14 days when scabs separate. Call for bright red bleeding, clots, inability to urinate, fever or burning.
• Dribbling and urgency usually improve; pelvic floor (Kegel) exercises help.
• Retrograde ejaculation (semen enters the bladder) is common after TURP. It is harmless but can affect fertility.
• Avoid decongestants and antihistamines that worsen retention, and continue follow-up, including any recommended prostate cancer screening.

Sample nursing care plan

Frequently asked questions

Does BPH increase the risk of prostate cancer?

No. BPH and prostate cancer are separate conditions, though they can occur together, so men still need appropriate screening discussions.

What is a post-void residual?

The amount of urine left in the bladder after voiding, measured by bladder scan or catheter. A high residual suggests incomplete emptying.

Why is a three-way catheter used after TURP?

One lumen inflates the balloon, one carries irrigation fluid in and one drains urine and irrigant out, which allows continuous irrigation.

Related reading: ageism and caring for older adults, subjective vs. objective nursing data and the nurse as health educator.

Conclusion

BPH cases test whether nurses can link an enlarged prostate to both chronic urinary symptoms and sudden retention, use medications safely, manage catheters and continuous bladder irrigation, recognize bleeding and TUR syndrome, and teach men how to protect their recovery. Careful assessment of output, drainage color and mental status catches most complications early.

References

Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis’s medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

Harding, M. M., & Snyder, J. S. (2019). Clinical reasoning cases in nursing (7th ed.). Elsevier Mosby.

Sandhu, J. S., Bixler, B. R., Dahm, P., Goueli, R., Kirkby, E., Stoffel, J. T., & Wilt, T. J. (2024). Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA guideline amendment 2023. Journal of Urology, 211(1), 11–19. https://doi.org/10.1097/JU.0000000000003698