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Look Up > Conditions > Benign Prostatic Hyperplasia
Benign Prostatic Hyperplasia
Overview
Definition
Etiology
Risk Factors
Signs and Symptoms
Differential Diagnosis
Diagnosis
Physical Examination
Laboratory Tests
Imaging
Other Diagnostic Procedures
Treatment Options
Treatment Strategy
Drug Therapies
Surgical Procedures
Complementary and Alternative Therapies
Patient Monitoring
Other Considerations
Complications/Sequelae
Prognosis
References

Overview
Definition

Benign prostatic hyperplasia (BPH) is noncancerous growth of the prostate gland that gradually narrows the urethra. The clamping effect eventually obstructs the flow of urine. As a result, the bladder fails to empty completely. Urine remaining in the bladder stagnates, leaving the patient vulnerable to infections, formation of bladder stones, and kidney damage. The condition usually presents itself gradually, via increased difficulty in urinating. Not infrequently, however, a patient suddenly suffers acute urinary retention, finding himself completely unable to urinate. BPH rarely causes symptoms in men under age 40, but affects many males over age 50. Four out of every five men who reach age 80 develop some symptoms of BPH. Some studies, so far unconfirmed, suggest that BPH occurs more frequently in married men than single men, and more often in the United States than in Europe.


Etiology

So far the causes are unknown. Three major theories involve different facets of the aging process in men. As men age, the amount of active testosterone in the blood decreases, resulting in a higher proportion of estrogen in the blood. Animal studies suggest that this excess estrogen increases the activity of promoters of cell growth in the prostate. Another theory targets dihydrotestosterone, a derivative of testosterone that may accumulate in the prostate and encourage the growth of cells there. The third theory suggests that cells in parts of the prostate "reawaken" in later life and direct other cells to grow or to become more sensitive to hormonal growth promoters.


Risk Factors
  • Age over 50
  • Partial urethral obstruction which can escalate to acute urinary retention as a result of sympathomimetic drugs or alcohol, exposure to cold temperatures, or a long period of immobility

Signs and Symptoms
  • Need to urinate frequently
  • Inability to sleep through the night without getting up to urinate
  • Difficulty starting urine stream
  • Decreased strength and force of the stream
  • Dribbling after urination
  • Blood in the urine, caused by bursting of small veins in the urethra and bladder
  • Burning sensation during urination, sometimes the result of bladder infections caused by urine backup
  • Not infrequently, complete inability to urinate, sometimes after taking sympathomimetic remedies, leading to a feeling of fullness in the bladder, followed by severe pain in the lower abdomen.

Differential Diagnosis
  • Acute prostatitis
  • Prostate cancer
  • Urethral blockage/stricture
  • Neurogenic bladder

Diagnosis
Physical Examination

Rectal examination indicates whether or not the prostate is enlarged. Nodules detected in the examination may indicate cancer. Tenderness suggests infection.


Laboratory Tests
  • Urine and blood tests serve to differentiate between BPH, infections such as acute prostatitis, and prostate cancer.
  • Analysis of urine sample identifies bacteria, if any, responsible for infection.
  • Blood tests for kidney function eliminate the kidney as a source of the problems.
  • Elevated level of prostate-specific antigen (PSA) in the blood indicates further evaluation of the patient for prostate cancer.

Imaging
  • Transrectal ultrasound measures the size of the prostate and indicates whether any abnormalities represent malignancies.
  • An intravenous pyelogram reveals any obstruction or blockage in the urinary tract.
  • A cystoscope inserted through the urethra images the prostate and checks for blockages of urine flow not caused by the prostate.

Other Diagnostic Procedures
  • Ask the patient to complete a prostate symptoms score questionnaire.
  • Post-void catheterization to determine amount of residual urine.

Treatment Options
Treatment Strategy

The choice among a variety of treatments depends on the age and overall health of the patient, the extent of prostate enlargement, and its effect on urination. Several recent studies suggest watchful waiting, rather than any specific treatment, for patients with mildly enlarged prostates. Regular checkups monitor the condition's progress and point the way to targeted treatment when symptoms worsen. Treatment should start once problems become truly bothersome or present a health risk. The choice among medical therapy, nonsurgical intervention, or surgery will depend on the extent of the discomfort and the risk.


Drug Therapies
  • Antibiotics of choice clear up infections prior to BPH treatment.
  • Alpha-adrenergic drugs such as terazosin (Hytrin) and doxazosin (Cardura) can relieve symptoms by relaxing tissues in the area of the prostate.
  • Finasteride (Proscar) inhibits production of the male hormone involved in prostate enlargement. It can shrink the prostate in some patients. However, it can take up to three months to relieve symptoms.

Surgical Procedures
  • Balloon urethroplasty, carried out as an outpatient procedure, widens the urethra, thus easing the flow of urine. Its long-term effectiveness remains unclear.
  • Transurethral microwave therapy, performed on an outpatient basis without anesthesia, uses microwaves to destroy excess prostate tissue.
  • Transurethral hyperthermia, under investigation by researchers, uses a series of heat treatments to shrink enlarged tissue. The procedure can cause such side effects as irritation and bleeding of the urethra.
  • Prostatic stents, under study in Europe, widen the urethra from the inside by pushing back prostatic tissue. Used only if other measures cannot be utilized or are not effective.
  • Transurethral resection of the prostate (TURP) is the operation performed in 90% BPH surgeries. About 5% of patients retain some urinary incontinence after surgery.
  • Transurethral incision of the prostate, a less invasive form of TURP, widens the urethra by making small cuts in the bladder neck and the prostate. Its advantages and long-term side effects remain to be established.
  • Open prostatectomy, approached through an external incision instead of the urethra, offers an alternative for a greatly enlarged prostate or in cases of bladder damage.
  • Laser surgery vaporizes obstructing prostate tissue, without causing as much nerve damage as TURP. Today used infrequently.

Complementary and Alternative Therapies

May be very helpful to add to watchful waiting management of BPH. Saw palmetto is widely used in Europe. Saw palmetto in conjunction with nutrition may be very effective.


Nutrition
  • Zinc (60 mg/day)—has been shown to reduce the size of the prostate.
  • Selenium (200 mcg/day)—antioxidant concentrated in the prostate
  • Essential fatty acids (1,000 to 1,500 IU one to two times/day)—anti-inflammatory, for optimum prostaglandin concentrations
  • B6 (100 to 250 mg/day)—reduces the elevated levels of prolactin found in BPH
  • Amino acids glycine, glutamic acid, and alanine (200 mg/day of each)—provide symptomatic relief
  • Avoid alcohol, especially beer, and saturated fats.
  • Pumpkin seeds have been used historically to help maintain a healthy prostate.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

  • Saw palmetto (Serenoa repens)—studies suggest this can be as effective as Proscar. Dose of 160 mg bid is difficult to achieve in tea or tincture; extract standardized for 85% to 95% of fatty acids and sterols is recommended.
  • Stinging nettle root (Urtica dioica)—for BPH stages 1 and 2. Increases urinary flow and volume. Daily dose of 4 to 6 g of drug or equivalent preparation.

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use three to five pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

  • Chimaphila umbellata is specific for retention of urine with an enlarged prostate
  • Conium for BPH with a feeling of heaviness in the perineum, especially with premature ejaculation
  • Pareira for urinary retention with BPH, especially with painful urging or pain in the bladder
  • Selenium for BPH with dribbling, impotence, and constipation
  • Thuja occidentalis for BPH, specifically if there is a forked stream of urine and/or genital condyloma

Physical Medicine
  • Kegel exercises increase pelvic circulation and improve muscle tone.
  • Contrast sitz baths. Fill one basin with hot water, one with cold water. Sit in hot water for three minutes, then in cold water for one minute. Repeat three times to complete one set. One to two sets per day, three to four days per week, increases pelvic circulation and relieves congestion.

Patient Monitoring

Rectal examination of patients at least annually following prostate surgery. Encourage postsurgical patients to drink plenty of water to flush the bladder, eat a balanced diet to prevent constipation, avoid caffeine, heavy lifting, and straining during bowel movements.


Other Considerations
Complications/Sequelae
  • Patients may also experience bladder stones or prostatitis.
  • Occasionally, scar tissue around the bladder opening or in the urethra, resulting from surgery, requires treatment within a year of surgery.

Prognosis

Ineffectiveness of medical treatments may indicate the need for surgery, which usually offers about 15 years of relief from BPH. Ten percent of men who undergo surgery eventually need a second operation for enlargement; most of these patients had their first surgery at an early age. Less than 33% of men with BPH have occult prostate cancer.


References

Berkow R, Beers MH, et al., eds. Merck Manual of Medical Information: Home Edition. Whitehorse Station, NJ: The Merck Publishing Group; 1997.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:201.

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:119, 141, 286, 341, 388-389.

Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed. Rocklin, Calif: Prima Publishing; 1998:480-486.

Prostate Enlargement: Benign Prostatic Hyperplasia. The National Kidney and Urologic Diseases Information Clearinghouse. NIH publication no. 91:3012.

Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats Publishing; 1988:82-84.


Copyright © 2000 Integrative Medicine Communications

This publication contains information relating to general principles of medical care that should not in any event be construed as specific instructions for individual patients. The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. The reader is advised to check product information (including package inserts) for changes and new information regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein.