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THE FOLLOWING MEDICAL AND SCIENTIFIC MATERIAL IS FOR CONSUMER INFORMATIONAL AND EDUCATIONAL PURPOSES ONLY UNDER SECTION 5 OF DSHEA.
Supporting the health of the prostate gland is an important goal for men who want to avoid common problems that may occur with aging.
The prostate gland is the male organ that produces semen. It is located beneath the bladder and surrounds the urethra which is the tube through which urine flows out of the bladder. The prostate remains relatively small in size until men reach middle age. However, in men who are in their mid to late forties, the prostate gland begins to expand, especially around the urethra. As men continue to age, it commonly increases from approximately the size of a walnut to that of a plum. In men with significant prostate enlargement, it may eventually reach the size of an orange. In some cases, the urethra may become compressed by the prostate gland so that the flow of urine is partially or completely blocked. The muscles that surround the urethra may also become chronically tense. Thus, the urine may not flow out of the bladder easily.
This type of prostate problem is now called benign prostatic hyperplasia (BPH) (previously called benign prostatic hypertrophy). In other words, it is a benign (non-cancerous) enlargement of the prostate. It is estimated to affect only 8% of men up to the age of 40, but 50% of men in their 60's, 60% of men in their 70's, and 90% of those who are 80 years of age or older. A significant percentage of men with this type of prostate enlargement will develop moderate to severe lower urinary tract symptoms that can greatly affect their quality of life. However, some men have much worse symptoms than others. In some men with only modest prostate enlargement the symptoms can be severe. In other men with quite enlarged prostate glands, the symptoms may be minor. The degree of muscle tension around the urethra may be the deciding factor in whether a man experiences severe obstructive symptoms.
Many men with BPH feel the need to urinate more frequently, and will be particularly bothered at night, with the result that they are awakened frequently. This increased urination at night is called nocturia, and can be very problematic in contributing to sleep loss. Incomplete emptying of the bladder due to pressure on the urethra by the prostate gland is usually the cause of nocturia. There may be difficulty initiating a urine stream, or having to stop and start the flow of urine and not being able to completely empty the bladder. In some men there will also be a feeling of urgency about urinating, the need to rush to the bathroom. Rarely, there may be blood in the urine, a condition called hematuria. For most men, these are the types of symptoms caused by BPH. However, in some men there may be more serious complications of BPH that can include urinary tract infections, bladder stones, damage to the bladder when it becomes stretched and weakened due to incomplete emptying, kidney damage caused by urine retention and frequent infections. Although BPH does not progress to prostate cancer or increase the risk for prostate cancer, similar symptoms may occur due to other serious conditions so men should always consult their physicians if any of these symptoms occur.
There are a number of lifestyle changes that may help lessen the troubling symptoms of benign prostatic hyperplasia:
• One of the most obvious helpful changes is decreasing the intake of caffeine and alcohol since these beverages increase the production of urine and the need to frequently urinate.
• It is also be helpful to avoid drinking anything during the last two hours before bedtime. This may at least reduce the incidence of middle-of-the-night trips to the bathroom and the sleep loss they can cause.
• Another helpful strategy is to develop a regular exercise program. Men who are inactive are more likely to retain urine. Even moderate exercise may help with urinary symptoms caused by BPH. In one study, it was shown that men who exercised as little two to three hours per week, had a 25% lower risk of BPH symptoms compared with men who didn't exercise.1 Regular physical activity is associated with a decrease in occurrence of BPH, in surgery for BPH, and in the symptoms of BPH.
• It can also be important to talk to your physician about any drugs you are taking that might worsen BPH symptoms. For example, if you are prescribed diuretics (water pills), check to see if the timing of the medication or the dosage can be adjusted to decrease the chance that these drugs could worsen your symptoms. Also discuss with your physician the use of decongestants or antihistamines since these medications can tighten the muscles around the urethra, making it more difficult to urinate. In general, go over your entire medication list with your physician and discuss whether any of the drugs you are taking might be contributing to a worsening of your symptoms.
• Don't delay heading to the bathroom when you feel the need to urinate. Urinating as soon as the need arises can help prevent the bladder muscle from being stretched and damaged.
• Consuming an optimal diet may help support long-term prostate health. In particular, an important step for men is to avoid unhealthy fats, particularly any foods that contain partially hydrogenated oils (â€œtrans fatsâ€), including margarine and fried foods. Consumption of these unhealthy fats can promote a deficiency of important essential fatty acids that may adversely affect prostate health.
Standard Medical Therapies
There are a number of prescription drugs approved for the treatment of BPH, and troubling symptoms may be significantly reduced in men treated with these medications. Combination therapy with one drug from each of the two classes of medications now approved for the treatment of BPH is can also be used, and may be more effective for some men.
When medications are not sufficient to relieve symptoms, minimally invasive procedures performed through the urethra may help lessen the symptoms of BPH. For men whom none of these measures provides relief or who have recurrent infections, hematuria, or renal insufficiency, major surgery is an option. In men with severe symptoms who are not at high risk for complications, surgery is sometimes considered an appropriate initial treatment.2
Alpha blockers drugs work by relaxing the muscles around the neck of the bladder, thus making it easier to urinate. Included in this class are terazosin (Hytrin®), doxazosin (Cardura®), tamsulosin (Flomax®), and alfuzosin (Uroxatral®). These drugs work best in men with only moderately enlarged prostate glands and many men will see an improvement in symptoms within the first couple of days. Side effects are usually mild but can include lowered blood pressure, dizziness, headache, gastrointestinal irritation, nasal congestion, decreased release of semen during ejaculation, and a risk of an eye problem called intraoperative floppy iris syndrome.
Enzyme inhibitors (5-alpha reductase inhibitors) are drugs that decrease the conversion of testosterone into dihydrotestosterone, a hormone that stimulates prostate cells to grow. Included in this class are finasteride (Proscar®) and dutasteride (Avodart®). Enzyme inhibitors can take quite some time to work. Although there may be some improvement in urine flow after the first few months on one of these drugs, the full effects may not be seen for a year. However, these drugs can reduce the need for surgery in men with moderate to severe BPH, and can also reduce the incidence of urinary retention. Side effects can include decreased libido (sexual desire), erection problems, and decreased release of semen during ejaculation.
Minimally invasive procedures include transurethral microwave therapy (TUMT) which uses microwave heat to shrink prostate tissue; transurethral needle ablation (TUNA) which uses radio waves to destroy the part of the prostate that is blocking urine flow; interstitial laser therapy (ILT) which uses a laser to destroy overgrown prostate tissue; and prostatic stents which are metal coils inserted into the urethra to widen it and keep it open. These procedures may work to reduce symptoms, particularly in men with only moderate BPH. However, there are varying risks with each procedure and a chance of side effects that can include painful urination for a period of time after the procedure. The need for re-treatment is somewhat greater with these less invasive techniques than with traditional surgical approaches.
Surgery is now recommended only in men for whom medications or minimally invasive procedures have failed or for men with certain complications such as repeated episodes of urinary retention, especially if it results in kidney damage, repeated urinary tract infections, bladder stones, and/or blood in the urine. The four types of surgery that are most commonly performed are (1) transurethral resection of the prostate (TURP), a major surgical procedure that removes prostate tissue and usually works to reduce symptoms but can also cause serious side effects including retrograde ejaculation, erectile dysfunction, recurrent urinary tract infections, painful urination, and blood in the urine); (2) transurethral incision of the prostate (TUIP) in which small cuts are made in the prostate gland where it meets the bladder, thus allowing the urethra to expand, which usually improves symptoms in three to four weeks but can cause side effects including retrograde ejaculation and erectile dysfunction; (3) laser surgery in which a laser is used to destroy a portion of prostate tissue, often with the result of very quick symptom improvement, but with the risk of side effects including painful urination and retrograde ejaculation; and (4) open prostatectomy in which the inner part of the prostate gland is removed, a procedure that is considered the most effective for men with extreme prostate enlargement but which often causes side effects including retrograde ejaculation, erectile dysfunction, and urinary incontinence.
Balloon dilation (water-induced thermotherapy) has only recently been FDA-approved so less is known about long-term effectiveness or side effects. In this procedure, a balloon is inserted into the section of the urethra that is closest to the prostate gland, after which warm water is injected into the balloon in order to destroy excessive prostate tissue and improve urinary flow.
There are a number of natural agents that have been studied in relationship to the maintenance of prostate health, several of which are commonly used in many European countries for the treatment of BPH. In fact, Phyto-pharmaceuticals (plant-based therapies), including extracts from saw palmetto and stinging nettle roots, represent up to 80% of all therapies prescribed for BPH in Europe.3 For people concerned about prostate issues, some of these natural herbal and micronutrient therapies may help support prostate function and prevent worsening of BPH symptoms. Quite a few research studies now show the benefits of herbal remedies such as saw palmetto, stinging nettles and pygeum for reducing urinary symptoms. Because these therapies affect prostate growth and function in different ways, a combination may yield a synergistic effect that is significantly greater than any that may be possible with a single agent.
• Beta-sitosterol, one of the plant sterols found in many edible plants, has been reported to be useful for BPH. In one randomized placebo-controlled double-blind study, men receiving 20 mg of beta-sitosterol three times daily had a significant improvement in urinary flow and an improvement in symptoms compared to those given placebo.4 A second study of men receiving 130 mg of beta-sitosterol daily reported similar results.5 Although studies have not shown that it actually reduces prostate size, it has generally been shown to increase urine flow rates and reduce retention of urine in the bladder after urination.
• Pygeum is an extract taken from the bark of the African plum tree (Pygeum africanum). It has been shown to relieve symptoms in men suffering from BPH as well as to increase peak urinary flow rates. Pygeum is thought to inhibit growth factors responsible for prostatic cell overgrowth, and to reduce prostatic inflammation by inhibiting lipoxygenase enzyme activity. Thus, pygeum helps maintain normal functioning of the prostate. One study in men with benign prostatic hyperplasia (BPH) showed that 50 mg of pygeum given twice daily for two months yielded a reduction in prostate symptom scores of 40% and it increased quality of life scores by 31%.6 Nocturnal urinary frequency was also reduced by 32%. A review of the evidence from 18 randomized controlled trials involving 1,562 men diagnosed with symptomatic BPH who were treated with pygeum, either alone or in combination with other herbs, found that compared to placebo, pygeum significantly improved urologic symptoms and flow measures.7 The men treated with pygeum in these studies were more than twice as likely to report an improvement in overall symptoms. A later review of the data from these same trials found that pygeum treatment reduced night-time urination by 19% and residual urine volume by 24%, while increasing peak urine flow by 23%.8
• Rye grass pollen extract (Cernilton) is a beta-sitosterol-rich extract prepared from the rye-grass pollen Secale cereale that has been shown to provide some improvement in BPH symptoms, especially night-time urination. It is widely used as a treatment for BPH in Europe and Japan. In one placebo-controlled double-blind study of sixty men with urinary flow obstruction due to BPH, 69% of men treated with Cernilton for six months reported symptomatic improvement.9 There was a significant decrease in residual urine in the patients treated with Cernilton and in the size of the prostate as shown with ultrasound. A review article concluded that the evidence from 2 placebo-controlled and 2 comparative trials involving 444 men showed that treatment with Cernilton resulted in modest improvements in night-time urination, although no significant improvement in urinary flow rates or residual volume were noted.10
• Saw palmetto berry has been shown in several studies to improve many of the symptoms associated with BPH, including improving urinary tract function, reducing symptom scores, reducing night-time urination, and improving peak urine flow rates. Saw palmetto berry is an extract taken from the fruit of the American dwarf palm tree (Serenoa repens), a small tree that grows in tropical climates such as Florida. Although the precise mechanisms by which saw palmetto works are not clearly known, it appears that in part this herb works similarly to the drug finasteride (Flomax®) that is commonly prescribed for BPH. This drug works by inhibiting the production of dihydrotestosterone, a breakdown product of testosterone that is known to cause prostate enlargement. However, saw palmetto berry causes few if any side effects while finistride can cause a number of quite serious adverse effects. Saw palmetto berry is also far less expensive. Multiple studies have shown significant improvement in the majority of men given saw palmetto berry for BPH.
A review article published in the Journal of the American Medical Association (JAMA) concluded that the evidence from 18 randomized controlled trials involving 2939 men clearly showed that saw palmetto improved urologic symptoms and flow measures. Compared with the drug finasteride, these research studies showed that saw palmetto produces similar improvement in urinary tract symptoms and urinary flow rates but with a greatly decreased risk of side effects.11 A later review which looked at the results from 14 randomized clinical trials and three open-label trials that included 4280 patients using a particular saw palmetto product called Permixon confirmed these findings.12 The researchers found that those given saw palmetto berry had significant improvement in urinary tract symptoms, with improvement in peak flow rates and a significant reduction in nocturia, the need to urinate during the night can cause sleep loss and lowered quality of life.
A recent review also reported that treatment with saw palmetto berry extract improved symptom scores and peak urinary flow rates comparable to those seen with both alpha blocker and enzyme inhibitor medications, but without the sexual dysfunction side effects.13 The reviewers concluded that saw palmetto therapy has proven its role in the management of BPH and is a viable first-line treatment option.
Although it has been suggested that saw palmetto berry might lower PSA levels, a comprehensive review of the literature on the use of saw palmetto found no such effect.14 However it would be best to inform your physician that you are taking this therapy whenever you have your PSA checked.
• Zinc is a mineral thought to support healthy prostate function. The concentration of zinc in the prostate gland is much higher than in other tissues. Many physicians recommend zinc for patients with BPH. However, research on its usefulness for BPH is very limited. In one small study, 19 men with BPH were treated with 150 mg of zinc daily for two months, and then 50 to 100 mg daily. The researchers reported that in 74% of the men, the prostate became smaller.15 It's always important to balance zinc supplementation with a small amount of copper. The accepted supplementation ratio is 15 mg of zinc to 1 mg of copper. Taking zinc alone could otherwise create a copper deficiency. Consuming too much zinc (greater than 75 mg per day) may also have an immune depressing effect so always review the complete list of supplements you are taking with your doctor or health care professional.
• Stinging nettles root (Urtica dioica) extract appears to increase urinary volume and the maximum flow rate of urine in men with moderate BPH.16 In a six-month double-blind placebo-controlled trial that included 620 men supplementation with this herb was shown to relieve symptoms and improve disease severity.17 At the end of the trial, 81% of men treated with stinging nettles root extract reported improvement in urinary symptoms, compared to only 16% of those taking placebo. Residual urine volume decreased substantially in these men, while peak flow rates improved significantly. Stinging nettles root is often combined with both saw palmetto and pygeum to treat BPH, a combination also shown in double-blind trials to be effective. 18
1. Physical activity and benign prostatic hyperplasia.Arch Intern Med 1998;158:2349—56. Platz EA, Kawachi I, Rimm EB, et al.
2. Managing benign prostatic hyperplasia. Am Fam Physician. 2002;66:77—84. Dull P, Reagan RW, Bahnson RR.
3. Extracts from fruits of saw palmetto (Sabal serrulata) and roots of stinging nettle (Urtica dioica): Viable alternatives in the medical treatment of benign prostatic hyperplasia and associated lower urinary tracts symptoms. Planta Med. 2001 Aug;67(6):489-500. Koch E.
4. Randomized, placebo-controlled, double-blind clinical trial of beta-sitosterol in patients with benign prostatic hyperplasia. Lancet 1995;345:1529—32. Berges RR, Windeler J, Trampisch HJ, et al.
5. A multicentric, placebo-controlled, double-blind clinical trial of ß-sitosterol (phytosterol) for the treatment of benign prostatic hyperplasia. Br J Urol 1997;80:427—32.. Klippel KF, Hiltl DM, Schipp B.
6. Efficacy and acceptability of tadenan (Pygeum africanum extract) in the treatment of benign prostatic hyperplasia (BPH): a multicentre trial in central Europe. Curr Med Res Opin. 1998;14(3):127-39. Breza J, Dzurny O, Borowka A, et al.
7. Pygeum africanum for the treatment of patients with benign prostatic hyperplasia: a systematic review and quantitative meta-analysis. Am J Med. 2000;09(8):654-64. Ishani A, MacDonald R, Nelson D, Rutks I, Wilt TJ.
8. Pygeum africanum for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2002;(1):CD001044. Wilt T, Ishani A, Mac Donald R, Rutks I, Stark G.
9. Treatment of outflow tract obstruction due to benign prostatic hyperplasia with the pollen extract, cernilton. A double-blind, placebo-controlled study. Br J Urol. 1990 Oct;66(4):398-404. Buck AC, Cox R, Rees RW, Ebeling L, John A.
10. Cernilton for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2000;(2):CD001042. Wilt T, MacDonald R, Ishani A, Rutks I, Stark G.
11. Saw palmetto extracts for treatment of benign prostatic hyperplasia. JAMA. 1998;280:1604-1609. Wilt TJ, Ishani A, Stark G; MacDonald R, Lau J, Mulrow C.
12. Updated meta-analysis of clinical trials of Serenoa repens extract in the treatment of symptomatic benign prostatic hyperplasia. BJU International 2004 Jul;93(6):751-756. Boyle P, Robertson C, Lowe F, Roehrborn C.
13. Role of phytotherapy in men with lower urinary tract symptoms. Curr Opin Urol. 2005 Jan;15(1):45-8. Fong YK, Milani S, Djavan B.
14. Saw palmetto for the treatment of men with lower urinary tract symptoms. J Urol. 2000;163(5):1408-1412. Gerber GS.
15. Zinc and the prostate. Oral presentation. American Medical Association Annual Meeting, Chicago, 1974. Bush IM, Berman E, Nourkayhan S, et al.
16. Pharmacological effects of sabal and urtica extracts as a basis for a rational medication of benign prostatic hyperplasia. Urologe 1994;334:90—5. Koch E, Biber A.
17. Urtica dioica for treatment of benign prostatic hyperplasia: a prospective, randomized, double-blind, placebo-controlled, crossover study. J Herb Pharmacother 2005;5:1—11. Safarinejad MR.
18. Efficacy of a combined Sabal-Urtica preparation in the treatment of benign prostatic hyperplasia (BPH). Urologe B 1996;36:292—300. Metzker H, Kieser M, Höscher U.