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What Is BPH?

Is Benign Prostatic Hyperplasia Physiological?

Majid Ali, M.D.

 

BPH (benign prostatic hyperplasia) is a term used for an enlargement of the prostate gland which may or may not be associated with problems of urination. This occurs with such frequency that it may be considered physiological—"normal," in the common language—aspect of aging among men. Beginning at about the age of 45 years, there is progressive increase in the incidence of BPH with each passing decade. Nearly half of all men in their mid-fifties have some enlargement of the gland. Nearly 80 percent of men over the age of 80 years have some degree of hyperplasia.

Many mechanisms have been proposed to explain the development of BPH. In the older medical literature, BPH was sometimes considered to be a tumor, a view that is seen as obsolete by all modern pathologists. Other older theories attributed prostate enlargement to inflammation and consequences of poor circulation. Pathology textbooks generally dismiss those ideas these days, though I do not how anyone can say inflammation does not cause the enlargement of the gland since the inflammatory process causes swelling and enlargement in all tissues. The analysis of the aggregate evidence, however, clearly supports the hormonal theory of BPH. Specifically, with increasing age there is a continuing drop in the testosterone (and other male androgenic influences) and relatively increasing estrogenic influences with resulting estrogenic dominance over male hormones. There is also evidence to suggest that the outer portion of the gland is testosterone-dependent while the inner portion (which causes more obstructive symptoms) is estrogen-dependent (Franks).

As for symptoms caused by BPH, since the prostate gland encircles the bladder neck and the urethra, not surprisingly obstruction to the outflow of urine of varying degrees occurs with BPH. Specifically, one or more of the following symptoms may be experienced by individual patients:

.  Initial delay in beginning of urination;

.  Weakening of the urinary stream;

.  Thinning of the urinary stream;

.  A sense of incomplete voiding;

.  Double urination (a second urination occurring within minutes of the first one);

.  Dribbling of urine; and

.  Split urinary stream; and

.  Urinary retention (inability to urinate).

Diagnostic Procedures

The diagnosis of prostatic enlargement usually does not pose any difficulties. The increase in the size of the gland can usually be determined by one or more of the following methods:

.  Digital rectal examination (DRE);

.  Prostate ultrasound;

.  MRI examination of the prostate gland;

.  Direct visualization of the enlarged middle lobe of the prostate gland infringing on the urinary outlet with cystoscopy, a procedure in which the inside of the urinary bladder is examined by a urologist with a special instrument called uretheroscope.

Relationship Between BPH and Sexual Dysfunction

As discussed earlier, I consider the prostate gland as an essential sex organ. All disorders of this gland should be expected to cause a variety of sexual dysfunctions. The issue of the impact of benign prostatic hyperplasia on sexual function was recently discussed in the January 28, 2006 issue of Clinical Therapies by researchers at Brown University. They reported the following data concerning incidences of erectile dysfunction (ED) and ejaculatory dysfunction (EjD):

Incidence of Erectile dysfunction (ED)

.  Surgery, 10%

.  Minimally invasive therapies, 1%-3%;

.  Pharmacologic monotherapy or combination therapy, 3%-10%

Incidence of ejaculatory dysfunction (ED)

.  Surgery, 65%;

.  Minimally invasive therapies, 4%-16%;

.  Pharmacologic monotherapy or combination therapy, 0%-10%).

Among pharmacologic therapies for BPH, the frequency of EjD appears to be greater with Flowmax (tamsulosin, 10%) than with other alpha(1)-blockers (0%-1%) or the 5-alpha-reductase inhibitor finasteride (4%), based on data from a single-arm meta-analysis conducted by the American Urologic Association (AUA).

Preserving Prostate Health

In the Sun-Soil Model of the causation of chronic disorders, our focus is on issues of spiritual equilibrium (the "sun" issues) and on the health (ecologic integrity) of the bowel, blood, and liver ecosystems (the "soil-roots unit" of the plant). The prostate gland is not an exception. Thus, my program for preserving the health of the prostate gland is heavily focused on those elements (discussed at length in the preceding chapters). Specifically for the prostate gland, regular and active sexual activity is one the best approaches for preserving prostate health. It is a sad commentary on modern life that a growing segment of the adult populations in all parts of the planet Earth are not in stable, loving, and nurturing relationships that make this approach to the health of the gland practical. Beyond that, in this section I offer the following guidelines for nutritional and herbal (phytofactor) measures for prostate health.

.  Green tea is my top choice based on available historical, experimental, and clinical data. This subject is discussed at length in the chapter entitled "Spice Medicine."

.  Pomegranate taken in small amounts (one piece (or three to four ounces) three times a week. A UCLA study showed that 8 ounces of the juice contain 1.5 mmol of total polyphenols, and lengthen the doubling time of prostate cancer cells in animal model (slowed the rate of cancer cell growth) from 15 months to 37 months.

.  Blueberries in season, four to six ounces in season.

.  Fermented soybean products as replacement for wheat products, when possible;

.  Lycopene from tomatoes and other food items.

.  Nutritional / herbal formula to be taken four to five times a week (See table below for the composition of the formula sued at the institute.

 

Composition for the Prostate Gland Formula In use At the Institute

African pygeum extract

Saw palmetto

L-alanine

L-glycine

L-glutamic acid Zinc

Manganese

Pantetheine

Lactoferrin

100 mg

150 mg

25 mg

200 mg

300 mg

40 mg

10 mg

20 mg

2 mg

 

Other elements which may be considered include: quercitin, trimethylglycine, grapeseed extract, lycopene, and nettles.

Treatment Options for BPH

All of the elements presented in the preceding section for prostate health are directly applicable to the treatment of BPH. However, only about one-half of individuals with well-developed BPH can expect to control their symptoms and shrink their enlarged glands with those measures. The following are my guidelines for individuals who fail to respond well to natural measures:

Procedures

.  Transurethral resection of the prostate (TURP)

.  Transurethral microwave thermotherapy (TUMT), also called prostate hyperthermia)

.  Open prostatectomy for massively enlarged glands

.  Alcohol injections and laser therapies are uncommon and not fully evaluated options.

.  Prolonged catheterization (fraught with the danger of recurrent urinary tract infections and so not recommended)

The procedure for prostate hyperthermia(TUMT) may appear to be less invasive than the TURP prcedure but is niot necessarily the case. The week in which I finished the draft of this chapter, I saw two men with BPH. One had hyperthermia procedure and had to wear a catheter for two weeks. The second man underwent a TURP procedure and left the hospital on the second day without a catheter. The wound healing after both types of procedures proceeds at the same rate. Thus, I consider both TUMT and TURP procedures good options. My choice will depend upon the level of expertise and procedural skill of the operating surgeon.

Prescription Drugs

Lowering PSA by blocking an enzyme called 5-alpha reductase, which converts testosterone into a more potent androgenic hormone called dihydrotestosterone, abbreviation. Avodart lowers PSA by blocking both type 1 and type 2 of the enzyme 5-alpha reductase. Usual dose 0.5 mg for BPH, 5 mg for lowering PSA. Caused death of both androgen-dependent (LNCaP) and androgen-independent (PC-3) cell lines. Proscar lowers PSA by blocking only type 2 of the enzyme 5-alpha reductase.

.  Alpha-blockers (Flowmax)

.  5-alpha-reductase inhibitors (Avodart, Proscar)

.  Alfuzosin, doxazosin, terazosin, tamsulosin, dutasteride, and finasteride

.  Combined therapy with alpha-blockers and 5-alpha-reductase inhibitors

For the general interest of reader, I include here some text giving the position taken by the British Journal of Urology (Int) on the matter. In its May 2006 issue, the journal published a position paper authored by researchers at the Department of Health Policy and Administration, School of Public Health, and Division of Urology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina. It included the following text:

What is the 'best' treatment depends on the value that an individual and society place on costs and consequences. alpha-Blockers are less expensive than the alternatives, and are effective at relieving patient-reported symptoms. Unfortunately, they have little effect on clinical outcomes and have the highest BPH progression rate. Other treatments have lower disease progression and better clinical outcomes, but are more expensive and entail more invasive treatments, and/or more uncertainty. CONCLUSIONS: Treatment decisions are made using a variety of information, including the cost and consequences of treatment. The best treatment depends on the patient's preference and the outcome considered most important. alpha-Blockers are very effective at treating urinary symptoms but do not improve clinical outcomes, including disease progression, relative to other treatments. TURP remains the 'gold standard' for surgical procedures. The desire to avoid TURP or the 2 weeks of catheterization associated with TUMT might affect a patient's treatment decision when symptoms are severe. Therefore, more information about patient preferences and risk aversion is needed to inform treatment decision-making for BPH.

Additional Comments About BPH Drugs

In closing this chapter, I include some additional comments about drug therapies for BPH. As mentioned earlier, drugs that block the conversion of the male hormone testosterone into DHT (dihydrotestosterone) are claimed to improve prostate health by shrinking the gland. Below, I reproduce some text taken from the website of the manufacturer of Avodart:

Avodart works by lowering the amount of the male hormone, dihydrotestosterone (DHT), leading to shrinkage of the enlarged prostate in most men. Just as it took your prostate time to grow, it also takes time for your prostate to shrink. Avodart can begin shrinking the prostate in as early as one month and has been shown to maintain reduction of prostate size out to 4 years in clinical studies. If your prostate is smaller, it will put less pressure on your urethra. Avodart has been shown to improve symptoms after 3 to 6 months, with continued improvement out to 2 years; improvement was maintained out to 4 years. When AVODART shrinks the prostate, it stops the symptoms associated with Enlarging Prostate from getting worse. Studies have shown that treatment with Avodart for 2 years lowers the chance of acute urinary retention (AUR) and the risk of needing prostate surgery. Most other medicines that treat the prostate do not reduce your risks of developing AUR or needing prostate surgery.

The following is some additional text from the Avodart website that might interest the reader:

Women who are pregnant or may become pregnant should not handle Avodart capsules. If a woman who is pregnant with a male baby gets enough Avodart into her body after swallowing it or through her skin after handling it, the male baby may be born with abnormal sex organs. What are the special precautions about Avodart? Men treated with Avodart should not donate blood until at least 6 months after their final dose to prevent giving Avodart to a pregnant female through a blood transfusion. Tell your doctor if you have liver problems. Avodart may not be right for you.

 

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