Prostaic Hyperplasia (Benign)

Benign prostatic hyperplasia (BPH) affects over 50% of men in the lifetime. The incidence is increasing with advancing age: 5-10% at age 30, over 90% over age 85.

Diagnostic summary:

· Symptoms of bladder outlet obstruction: progressive urinary frequency, urgency and nocturia, hesitancy and intermittency with reduced force and calibre of urine.

· Enlarged, non-tender prostate

· Uremia if prolonged obstruction.

General considerations

· Affects over 50% of men in their lifetime.

· Androgen-dependent disorder of metabolism: free testosterone (T)levels decrease with age: prolactin, oestradiol, sex-hormone-binding lignand, luteinising hormone (LH), and follicle-stimulating hormone (FSH) levels increase, increased synthesis of potent androgen dihydrotestosterone (DHT) from T by 5-alpha-reductase and decreased hydroxylation metabolism of T and DHT due to inhibition by elevated oestrogens.

· Ultimate effect: increased intraprostatic DHT: prostatic androgen receptors have a fivefold greater affinity for DHT than T; BPH tissue has three-to four fold greater net ability to increase tissue levels of DHT.

Diagnostic considerations

· ICIM is of the opinion that the current diagnostic arrangements for prostate disorders can not be recommended. It has, therefore, introduced a One-Stop Prostate Assessment (which has five component parts: Questionnaire and Consultation; Uroflowmetry; Urine Analysis; Ultrasound Examination; and Prostate-Specific Antigen Reading - all within one hour). The primary aim of this assessment is risk reduction. Early detection is an approach that promotes vigilance for signs and symptoms that may be indicative of early disease. It is based on the premise that it is easier to treat and cure if it is detected early.

· Symptomatic in only 50-60 % of men with macroscopic enlargement: many men symptomatic without macroscopic enlargement: hyperplasia constricts in urethral men.

· Rule out prostate cancer using prostate-specific antigen (PSA) part of the ICIM Medics Prostate Assessment. Normal < 4 ng/ml; elevation > 10 highly indicative of prostate cancer (90% of cases); there may be cancer without PSA elevation; mid-range elevations can occur with BPH, prostatitis, urinary retention, ejaculation, and exercise. However, the ICIM prostate assessment automatically checks uro-flow, urine analysis plus ultrasound.

Therapeutic considerations

· Natural course of untreated disease process: bladder outlet obstructuib, urinary retention, kidney damage.

· TURP (transurethral resection of the prostate): high rate of morbidity.

Nutritional factors

· Avoid pesticides; increase zinc and essential fatty acids; keep cholesterol levels < 200 mg/dl.

· Diet: high-protein diet (total calories: 44% protein, 35% carbohydrates, 21% fat) inhibits 5-alpha-reductase; low-protein diet (10% protein, 70% carbohydrates, 20% fat) stimulates the enzyme; speculative because never clinically tested on men with BPH.

· Zinc: reduces size of prostate and symptomatology in most patients; intestinal uptake is impaired by oestrogens (increased in men with BPH), enhanced by androgens; inhibits 5-alpha-reductase; inhibits specific binding of androgens to the cytosol and nuclear receptors; inhibits prolactin secretion, reducing prostatic androgen uptake.

· Alcohol: beer raises prolactin levels; higher alcohol is definitely associated with BPH, especially beer, wine and sake.

· Essential fatty acids: can significantly improve symptoms in many patients; may correct underlying EFA deficiency since prostatic and seminal lipid levels and ratios are often abnormal.

· Amino acids: combination of glycine, alanine, and glutamic acid relieves many symptoms; mechanism of action unknown; amino acids may act as inhibitory neurotransmitters, reducing feelings of full bladder.

· Cholesterol: metabolites are cytotoxic, carcinogenic, accumulate in hyperplastic or cancerous prostate tissue; epoxycholesterols degenerate epithelial cells, triggering increased hyperplastic regeneration.

· Soy: rich in phytosterols (e.g. beta-sitosterol) that decrease cholesterol; improve BPH. Servings of soybeans, tofu, or other soyafood provides beta-sitosterol; associated with decreased risk of prostate cancer due to isoflavonoids genistein and daidzein (‘phytoestrogens’) acting on oestrogen receptors and inhibiting 5-alpha-reductase.

· Pesticides and other contaminants increase 5-alpha-reduction of steroids. At ICIM a blood test can be conducted to evaluate possible exposure to pesticides and toxicity.

· Diethylstibestrol (DES) produces changes in rat prostates histologically similar to BPH.

· Cadmium: antagonists of zinc: increases activity of 5-alpha-reducatse: effects on BPH unclear. ICIM can also conduct blood testing for exposure and sensitivity to Cadmium and other metals where appropriate.

Botanicals

· Order of relative efficacy: Serenoa > Cernilton > Pygeum > Urtica; each plant has a slightly different mechanism of action.

· Therapy must be tailored to individual patient needs.

· Chance of clinical success determined by the degree of obstruction indicated by residual urine volume: levels < 50ml excellent; 50-100ml quite good; 100-150ml tougher to improve within 4-6 weeks; > 150ml botanicals not likely to improve symptoms significantly.

· Serenoa repens (sal palmetto): liposterolic extract of fruit of palm significantly improves signs and symptoms; inhibits DHT binding to receptors; inhibits 5-alpha-reducase; interferes with intraprostatic oestrogen receptors; 90% of mild to moderate cases improve in all symptoms (especially nocturia) within 4-6 weeks.

· Cernilton flower pollen extract: 70% overall success rate in 35 years of European experience; 70% reduction in nocturia and diurnal frequency; significant reductions in residual urine volume; some anti-inflammatory action; contractile effect on bladder while relaxing urethra; inhibits growth of prostate cells.

· Pygeum africanum : African evergreen tree; bark used historically for urinary tract disorders; bark components; fat-soluable sterols and fatty acids; all research based on extract standardised to 14% triterpenes including beta-sitosterol and 0.5% n-docosanol; effective in reducing symptoms and signs, especially early cases; serenoa gives greater relief, better tolerated, higher urine flow rate, less residual urine, serenoa does not produce effects thatPygeum has on prostate secretion.

· Urtica dioica (stinging nettle): fewer studies; more effective than placebo; interacts with binding of DHT to cytosolic and nuclear receptors.

Therapeutic approach

· Therapeutic goals which ICIM Medics advocate: normalise prostate nutrient levels; restore steroid hormones to normal levels; inhibit excessive conversion of T to DHT; inhibit DHT receptor binding; limit promoters of the hyperplastic process, e.g. prolactin.

· Severe BPH: acute urinary retention may require catheterization; for relief, advanced case may not quickly respond to natural therapy, and may require short-term alpha-1 antagonist (e.g. Hytrin or Cordura) or surgery.

· Diet: initially high-protein, low-carbohydrate, low in animal fats, high in unsaturated oils; after patient responds, adopt a more normal diet; limikt alcohol; avoid drug-, pesticide- and hormone-contaminated foods; limit cholesterol-rich foods; eat soy foods regularly.

· Supplements:

• - Zinc picolinate preferred, maximum of 6 months; monitor copper status)
• - Flax oil
• - Glycine
• - Glutaminic acid
• - Alanine

· Botanicals

• - Serenoa
• - Flower pollen
• - Pygeum extract
• - Urtica extract
• - Lycopene extract

ICIM Medics offer a One-Stop Non-Invasive Prostate Assessment. For more information on this topic please call ICIM Medics on +353 45 844 819 or email us at info@icim.ie

Tags: Prostate, Prostate Cancer