by Norman D. Ford, Health Reporter
Few men die of Prostate Enlargement but living with its symptoms impairs the Quality-of-Life of millions of older men each year and may indirectly shorten their life expectancy
Few men die of Benign Prostate Hyperplasia (BPH) , a urinary dysfunction caused by enlargement of a man's prostate. In fact, BPH is frequently described as a Quality-Of- Life condition with little or no direct effect on health or life expectancy. Its symptoms typically include urgency to void; a hesitant, interrupted, weak or dribbling urine stream; possible urine leakage; and more frequent trips to the bathroom, especially at night. These symptoms are classified as mild, moderate or severe. And depending on their severity, these symptoms can profoundly affect the Quality-Of-Life of men afflicted with BPH.
For instance, men with moderate or severe BPH may prefer to stay within reach of a bathroom in case of a sudden urge to void. Men who experience frequent urges to void may avoid movie theaters, ball games, meetings, or funerals, or giving a talk, or playing golf, or similar situations-- including riding in another person's car--where they cannot easily excuse themselves to go to a toilet.
Some drugs that relieve BPH symptoms may cause dizziness which, at times, may prevent a man from driving or operating machinery or joining a walking club or riding a bicycle for exercise. Older men often prefer to tolerate BPH symptoms rather than take drugs with adverse side effects or face the risks of anasthesia or surgery. A popular way to avoid embarrasment is to wear adult diapers.
And there's the rub!
All too often, it's the lifestyle changes that a man makes in order to live with BPH that tends to worsen his Quality-of-Life --and even to shorten his life expectancy--rather than the symptoms themselves. No one knows exactly how many years of life are lost by giving up bicycling or group hikes or gym classes or other forms of exercise because of BPH symptoms or of dizziness due to taking a drug to relieve them. But there's little doubt that BPH symptoms are responsible for much of the depression and isolation that afflict millions of older American men.
How does an enlarged Prostate cause BPH symptoms?
It happens because one section of the urethra--the tube which carries urine from the bladder to the penis--is enclosed by the Prostate gland. When an enlargement occurs on the inner part of the Prostate, it squeezes the urethra just like you might pinch a straw. At the same time, the smooth muscles of the Prostate may also constrict. And both squeeze the urethra, significantly slowing the urine flow.
At this point, we must emphasize that BPH is an entirely different disease to Prostate Cancer. Having BPH does not lead to Prostate Cancer, nor does having Prostate Cancer lead to BPH. BPH is far more common than Prostate Cancer but it is entirely possible for both diseases to exist at the same time.
BPH symptoms occur, because in most men, starting at around age 40, the Prostate gland begins to slowly increase in size. By age 65-70, the majority of men have mild-to-moderate BPH symptoms.
Although BPH symptoms progress slowly, or may even stabilize, in most cases urinary symptoms slowly worsen. By then, most men are well on in years. In fact, the percentage of men with significant BPH symptoms is roughly equal to a man's age. At age seventy, approximately 70 percent of men have mild-to-moderate BPH symptoms; and by age eighty, 80 percent have moderate-to-severe symptom scores.
Despite all this, the only life-threatening danger occurs should the urethra become so completely blocked that a man is unable to void at all. Called Acute Urinary Retention (AUR), this is an emergency condition which requires dialling 911 or seeking immediate medical help. In western nations, it is becoming increasingly rare and can be almost totally avoided through proper treatment.
Exactly What Is The Prostate?
The Prostate is a small, walnut-sized gland enclosed in a dense, fibrous capsule that surrounds a section of the urethra immediately below the bladder.
The Prostate is both a gland and a muscle. As a gland, it produces a milky fluid that is mixed with sperm from the testicles to form semen. As a muscle, it ejaculates this seminal fluid during a sexual climax.
The Prostate muscle also acts as a gate to control the flow of urine through the adjacent urethra. It does so by controlling two shut-off valves called sphincter muscles. The Internal Sphincter Muscle is located at the exit from the bladder and the External Sphincter Muscle is where the urethra exits the Prostate.
The Prostate grows steadily through youth until by adult-hood it is the size of a walnut. As a man reaches middle-age, it begins to slowly grow again and may eventually reach the size of a tennis ball.
The Prostate is divided into two zones: the outer or Peripheral zone and the Inner or Transition Zone. Most Prostate Cancer tumors develop in the Peripheral Zone which is on the outer surface where they can be felt by the gloved finger of a physician during a Digital Rectal Exam. (Only one third of abnormal growths detected in this way are actually diagnosed as Prostate Cancer.)
The Inner or Transition Zone cannot be examined by a Digital Rectal Exam but an abnormal growth here is much more likely to be due to BPH than to Prostate Cancer.
What Fuels Abnormal Prostate Growth?
Prostate Enlargement is primarily fuelled by several male hormones called Androgens. Androgens stimulate the activity of the male sex organs and control development of male characteristics. The key Androgen is the hormone Testosterone.
Within its tissue, the Prostate carries an enzyme called 5-Alpha-Reductase (5AR). An enzyme acts as a catalyst to help a chemical process in the body. When the enzyme 5AR encounters Testosterone in the Prostate, it catalyzes it into Di-Hydro-Testosterone (DHT), a much more powerful and active Androgen than Testosterone itself. It is this potent Di-Hydro-Testosterone that fuels most Prostate growth and that seems primarily responsible for development of BPH. By contrast, men who lack sufficient 5AR fail to develop normal male characteristics and a normal-sized prostate, and they rarely, if ever, develop BPH.
If this is beginning to read like a boring technical book, don't give up here! Because, as you'll read, it's entirely possible to inhibit the amount of 5-Alpha-Reductase in the Prostate. And, as a result, to block production of the potent Di-Hydro-Testosterone which is responsible for Prostate Enlargement in most older men. Besides, you don't have to read this entire report in a single evening. But if your goal is to beat BPH, you definitely do need to read it, absorb it and learn the terminology. Otherwise, you cannot make an intelligent choice concerning your treatment.
So What Happens Next?
Besides slowing the urine flow from the bladder when voiding, Prostate Enlargement also results in incomplete emptying of the bladder. After urinating, a man may feel that his bladder still is partially full.
In response, the bladder tries to develop more muscle to help constrict and empty the bladder. Gradually, this thickens the bladder wall thus reducing the bladder's capacity to expand and store urine. The inevitable result is more frequent urination.
Eventually, the bladder muscles become weak and fatigued , resulting in urgent, sometimes uncontrollable urges to void, and frequent passage of small amounts of urine. When a man with this condition consumes more than a normal amount of fluid-- say 3 cups of tea instead of one--urine build-up in the bladder may overflow the bladder's capacity and Overflow-Incontinence occurs. This prompts the External Sphincter Muscle to go into spasm, making it difficult to start or stop urination. Actually, Overflow-Incontinence is fairly common in older men and, through a different pathway, in older women also.
Choosing Your Own Treatment Option
While the ultimate goal of all BPH treatment is to avoid a complication which threatens the urinary tract, such as AUR, most other treatments are indicated only by the way a man perceives how his Quality of Life is being impaired by his urinary symptoms.
Threats to your urinary tract excepted, as long as you can live with your symptoms, you may continue to avoid most types of conventional treatment. And the key to beating BPH is first, to learn everything you can about this very common man's health problem, then to use this know-how to take an active role in choosing your treatment along with your health care provider.
The Six Treatment Options For BPH
The treatments are listed below in the order in which they are usually applied.
Watchful Waiting: passive, do-nothing monitoring under medical supervision.
Intelligent Watchful Waiting: by adding lifestyle and behavorial therapies--including our Live To Be 90 Lifestyle Plan--the do-nothing Watchful Waiting option is transformed into a more successful, do-it-yourself form of active treatment.
Herbal Therapy: is another alternative treatment in which a man takes one or more herbal medicines on a daily basis. Chances of success are increased if it is combined with Intelligent Watchful Waiting.
Alpha-Blocker Drugs: A passive therapy in which you do nothing except take prescription drugs prescribed by your doctor that relax the blocked section of your urethra to increase the flow. The drugs are quite effective and work promptly but may have to be taken permanently.
Enzyme Inhibitor Drugs: Another passive therapy in which you take a drug called a 5-Alpha-Reductase-Inhibitor (5ARI) prescribed by your doctor. By gradually shrinking the prostate, 5- ARIs take the pressure off the urethra, allowing urine to flow more freely. Frequently, Alpha-blockers and 5-ARIs are taken in combination. As the prostate begins to shrink, the Alpha-Blockers may become unnecessary. But the 5-ARIs must be taken permanently.
Surgery or Other Invasive Intervention: TURP (Trans-Urethral Resection of the Prostate) is the gold standard of BPH surgery and provides the most certain relief but may involve bleeding, infection and other risks. Several less invasive forms of surgery are available but may be less effective and require re-treatment. All types of surgery-- especially those involving general anasthesia--incur greater risk and possible harm to older men. So much so, that nowadays, most physicians hesitate to prescribe Prostate surgery for men over 70.
Knowledge Is Power
No doctor can order a man to take any of these options and choice of treatment is being increasingly left to the patient himself in conjunction with counseling by his physician. Generally, the optimal strategy is to use the least invasive approach that will achieve the desired improvement in symptoms--and to prevent or postpone surgical intervention.
Which means that the more you know about BPH and its various treatments, the smarter the choice you can make about which treatment to take. And by reading this report and absorbing it, the more power you're likely to have over your BPH . The information in this report is designed to provide a basic understanding of the disease, almost comparable to that of the average non-specialist M.D. However, this report is for information only and is not a substitute for a medical examination or treatment.
Assessing Your Personal I-PSS Score
The first step is to learn how severe your personal symptoms really are.
You can easily do that by answering the following I-PSS (International Prostate Symptom Score) Questionnaire. Score yourself from 1-to-5 in answer to each question.
SCORE
0 = Not at all
1 = Less than one time in 5
2 = Less than half the time
3 = About half the time
4 = More than half the time
5 = Almost always
QUESTIONS
1. How often have you had a sensation of not emptying your bladder completely after you finish urinating?
2. How often have you had to urinate again less than two hours after you finished urinating?
3. How often have you found you stopped and started several times when you urinated?
4. How often have you found it difficult to postpone urination?
5. How often have you had a weak urinary stream?
6. How often have you had to push or strain to begin urination?
7. How many times do you most typically get up to urinate from the time you go to bed till the time you get up in the morning? Score according to the number of times with 5 for five or more times. Then add up your total score.
YOUR SYMPTOM SEVERITY
0-7 = Mild
8-18 = Moderate
19-35 = Severe
Note: Your score is an indication of your Lower Urinary Tract Symptoms (LUTS), it is not a diagnosis of BPH. Almost a third of LUTS symptoms are not due to BPH but to other causes such as hypertension, diabetes or pre-diabetes, Parkinson's, an infection, a bladder dysfunction or stone, a spinal injury, abdominal obesity, a sedentary lifestyle, or a urethral stricture or scar. Only a doctor or urologist can diagnose BPH.
As a man's Prostate gradually increases in size, so do his LUTS symptoms, and his Score in answer to the I-PSS questionnaire above. During treatment for BPH, you can test your progress by scoring yourself on the I-PSS Test at regular intervals. The I-PSS Test is identical to the AUA (American Urology Association) Scoring Test used in the U.S.
Can We Treat BPH With Diet And Exercise?
For decades, researchers have demonstrated that around 75 percent of all cases of Heart Disease, Type-2 Diabetes, High Blood Pressure or Obesity can be successfully prevented, slowed, stopped or permanently reversed by switching to a vegetarian diet combined with a daily exercise program.
Yet when these alternative therapies were used to treat BPH, success was considerably less dramatic. Not that they failed altogether. Diet, exercise and other non-medical therapies are part and parcel of our Intelligent Watchful Waiting and Herbal Therapy Treatments and they have helped slow the progress of thousands of cases of BPH. In fact, Herbal Therapy is the first line of treatment for BPH in much of Europe.
But despite some success with natural therapies, the time may come when treatment by pharmaceutical drugs becomes necessary. And should symptoms progress to where they cannot be controlled by drugs, Minimally-Invasive treatments or Surgery may be needed.
The entire Treatment Protocol for BPH is designed, step-by-step, to postpone for as long as possible having to resort to pharmaceuticals, and to hopefully avoid ever having to undergo any form of Minimally-Invasive Treatment or Surgery. By way of explanation, Minimally-Invasive Treatment refers to a series of recently developed methods for reducing Prostate size by the use of heat. Surgery, or Invasive Treatment, refers to reducing Prostate size by traditional surgical procedures. Both types of treatment are discussed in full later on in this report.
Typical steps in the treatment of BPH.
I-PSS Score: Mild, 0-7.
Watchful Waiting and Medical Exam
Intelligent Watchful Waiting (IWW)
Herbal Therapy
I-PSS Score: Moderate, 8-18.
IWW and Herbal Therapy may be continued for Symptom Scores of 15 or below. But after that, medical treatment with pharmaceutical drugs is the usual procedure.
I-PSS Score: 19 and above.
Drug Therapy may be continued but Minimally-Invasive Treatment or Surgery is often necessary when symptoms become severe and cannot be controlled by drug therapy.
So Which Treatment Is Best For You?
The thought of reading about Prostate treatments may make you yawn. But if you're a man with bothersome BPH symptoms, a careful reading of this review could make a huge difference in the Quality of the rest of your life.
No one can predict which treatment will work best for you or which won't. If your symptoms include AUR, frequent urinary tract infection, blood in your urine or bladder stones, severe symptoms like these are a strong indication that Surgery may be needed.
Yet if your symptoms are not as severe, your best treatment is usually the one which you and your doctor feel is best and right for you. But even if you have a moderately- high LUTS Score when taking the I-PSS quiz, if your symptoms are not really bothersome, you may need no other treatment than IWW--Intelligent Watchful Waiting.
A lot depends on the size of your Prostate. Enzyme Treatment works best on men with large Prostates. Or failing that, Minimally-Invasive Treatment or Surgery. That's because men with very large Prostates have a higher risk of AUR.
Age is another factor to consider. The older you are, the less well you can tolerate Surgery or anasthesia. And an already-existing health problem like heart disease, cancer or diabetes can make you a very poor candidate for Surgery.
Most men over 70 also prefer the fast relief from BPH symptoms provided by Alpha- Blocker drugs to the slower but longer term relief provided by Enzyme Treatment, Minimally-Invasive Treatment or Surgery.
Younger men who may still desire to father a child may also be concerned about undergoing Surgery or Minimally-Invasive Treatments that could damage sexual nerves or cause erection problems.
Surgical operations like TURP (Transurethral resection of the Prostate) are usually highly effective but may cause serious and painful side effects, including blood transfusions. Minimally-Invasive Treatments that use heat to shrink the Prostate are slightly less effective and are cheaper; recovery is also swifter and they cause fewer side effects. But some may require a repeat treatment after a few years.
Again, urologists who specialize in certain treatments often try to steer patients towards their own specialty, even though it may not always be the most appropriate treatment. Otherwise, try to choose a urologist-surgeon who is board-certified and has a record of successfully performing, each year, a large number of the same operations or treatments that you have decided upon.
THE FIRST STEP: Get A Medical Check-up
That's because your urological symptoms may not be due to BPH at all but to a variety of other causes. Most of these can be easily treated. So whenever your I-PSS quiz indicates a score of 4-5 or more, it's smart to consult a doctor for a diagnosis. Most men begin by visiting their family doctor. But if you suspect any kind of urinary tract problem, it's best if you can, to start right off by consulting a urologist (an M.D., who specializes in diseases of the kidney, bladder and urinary tract).
Urologists are better equipped to check out a man for urinary tract symptoms and you can often see one without a referral. The typical urologist is equipped to test patients for urinary flow, to see whether your bladder empties completely, to check out the size of your Prostate, and to tell whether your problem is in the bladder or kidneys rather than the Prostate. Urologists can also analyze a urine sample to detect infections, Prostatis or Prostate Congestion. And they can quickly identify whether your Prostate problem may be caused by High Blood Pressure, Prostate Cancer, Heart Disease or Diabetes, or may even be due to constipation.
Your physician will take a complete medical history and you will be asked to name all the OTC and prescription medications you are taking, including herbal medications. For instance, anti-histamines or nasal decongestants can aggravate BPH symptoms as can Calcium Channel Blockers used for treating hypertension, while narcotic painkillers can inhibit muscle contractions in the bladder and urethra, and Saw Palmetto herbal medicine can dramatically lower your PSA reading.
To learn more about the possible cause of your urinary problem, your doctor may offer a PSA (Prostate Specific Antigen test) and a DRE (Digital Rectal Exam).
In the PSA test, a small blood sample is drawn and analyzed to reveal the amount of Prostate Specific Antigen in the bloodstream and Prostate. A single reading cannot confirm that you have either Prostate Cancer or BPH. But it does indicate the size of your Prostate.
Because the PSA test detects minute clusters of harmless, low-grade Prostate Cancer cells that are common in older men, it has led to a pandemic of unnecessary and often harmful over-treatment. As a result, the value of PSA testing has become a contentious issue among American physicians. Nowadays, many physicians are reluctant to offer it to men aged 75 and over. But since it does indicate the size and volume of a man's Prostate, it still plays a role in helping to diagnose BPH.
If you have a high PSA reading and your doctor suggests a biopsy for Prostate Cancer, ask about a Percent Free PSA Analysis, which helps differentiate BPH from Prostate Cancer. In this way, you can avoid a possibly unnecessary and often uncomfortable and expensive biopsy. And by the way, 80 percent of men aged 80 or over have detectable Prostate Cancer . Yet treating Prostate Cancer above age 80 does not increase life expectancy. Treatment can cause significent morbidity and is not generally recommended in this age group. (Note: all comments here about PSA apply only to men aged 75 and over.)
The Digital Rectal Exam, in which a physician inserts a gloved finger into the rectum to examine the Prostate, also results in many false positives. Yet it still yields valuable clues about the size and volume of an enlarged prostate.
No single test can confirm the diagnosis of BPH. But by assessing all of the information and test results just mentioned, your doctor can make a generally accurate appraisal of whether or not your urinary problem is due to BPH.
Assuming that your problem actually is BHP, your baseline statistics have already been established by your medical exam. So a man's next move is to choose which treatment to begin with, or whether he needs any treatment at all. This is a decision which each man must make for himself in conjunction with his doctor.
Treatment Stage 1: Watchful Waiting
Watchful Waiting: is an option usually reserved for men with mild symptoms who are not bothered by them. Or for men with moderate or even severe symptoms who do not find them unduly bothersome. It's really not a treatment at all but merely a do- nothing version of monitoring the progress of BPH.
The standard medical version of Watchful Waiting is to make no changes in diet or lifestyle and, in fact, to do nothing but continue to live exactly as you did before being diagnosed with BPH. Every six months you take the I-PSS quiz and undergo a brief medical check-up. If your I-PSS score increases, or your symptoms become worse or more bothersome, it may be a signal to switch to the next treatment up the line.
Treatment Stage 2: Intelligent Watchful Waiting
Intelligent Watchful Waiting transforms Watchful Waiting into an active treatment by adding lifestyle and dietary changes and a variety of Alternative Therapies. Among the most strongly-proven and compelling lifestyle traits for reducing risk of BPH are these:
Eat Less Animal Protein and Foods High In Calories: Based on a cohort of 51,000 men in the Health Professionals Follow Up Study, Suzuki et al found that risk of developing BPH rose with increasing calorie and protein intake; that translates into eating less, much less, of foods like meat, dairy products, eggs, trans-fatty acids, fried foods, cooking oils like safflower, sunflower and corn oils, and all foods made with white flour and sugar.
Stay active: another large study found that walking briskly for 3 hours or more each week, can cut the risk of BPH by one third.
Get Your Waist-to-Hip Ratio Back to Normal: If you are overweight, and especially if you 're prone to carry abdominal fat around the middle (being apple-shaped): several studies have concluded that getting your Waist- Hip Ratio back to .95 or below is a key factor in reducing risk for BPH. (Click on www.healthcalculators.org/calculators/waist_hip.asp/ to find your personal Waist-Hip Ratio.)
Avoid sitting for longer than an hour at a stretch without getting up and walking around.
Three Yoga asanas (exercises) can help modify BPH symptoms. They include Uddiyana Banda with Nauli , which may massage the Prostate and release urine remaining in the bladder after voiding; The Shoulder Stand may also release urine retained in the bladder; and KapalaBati (the Bellows Breath) may also help to massage the bladder area. Look up these postures in a book about Yoga in the library or have someone who practices Yoga demonstrate them for you.
Pilates is a popular form of floor exercises for strengthening core body muscles. Practicing Pilates exercises like the Double Straight Leg Stretch, Criss-Cross, Corkscrew, Saw, Neck Pull, Side Kicks, and Teaser can develop strong core body muscles in the abdominal area which support the bladder and Prostate. A good teach- yourself Pilates book is "Pilates, Body in Motion," by Alycea Ungaro, Dorling Kindersley, 2002. ISBN 0-7894-8400-5.
Avoid Inflammatory Foods: Several studies have pointed to an inflammation component in BPH. A Greek study in Athens found that both butter and margarine were associated with increased risk for BPH but fruit and olive oil were not.
Tomato sauce, soy products and Vitamin D-3 have also been identified as helping to reduce risk of BPH. Vitamin-D3 deficiency is widespread and has been linked to a score of common ailments from Osteoporosis to Heart Disease, Cancer, Multiple Sclerosis, muscle weakness and fatigue. (Click on www.cholecalciferol-council.com for more about Vitamin D-3.)
Above all, we strongly recommend that you adopt our Number One Healthy Lifestyle Plan asap. This is the most powerful health-building and disease-fighting lifestyle and diet program ever designed. For details, click on the report " Age Proofing Your Body Naturally" listed at the top of our Menu of Reports.
Other tips from the field of behavioral medicine include:
Limit beverages in the evening. Avoid drinking anything for 1-2 hours before bedtime.
Limit caffeine and alcohol. Both are mild diuretics which can irritate the bladder, increasing urine production and worsening symptoms.
Strictly avoid using anti-histamine or decongestants.
Stay warm: Cold temperatures promote urine retention and encourage urgency to void.
Drink an appropriate amount of fluid each day. Excessive fluid can heighten the urge to void while too little can concentrate the urine, irritating the bladder and setting off muscle spasms. Drinking the right amount of fluid should produce a pale-yellow colored urine.
Avoid anything that causes stress.
Bladder Retraining and the Kegel Maneuver
Two techniques for managing Overflow Incontinence due to an Overactive Bladder may also be helpful for managing Urgent Voiding due to BPH.
Bladder Retraining is the first technique and you can find several websites describing how to do it by typing in "Bladder Retraining" on your browser's search field. Here, however, is a brief outline of the most popular method for retraining your bladder.
1. Set your voluntary voiding schedule by completing a urinary log for 2-3 days or more, noting the shortest interval between voids.
2. Control your urge to void by using mind over matter. This means using distraction techniques to take your mind off your bladder. For instance, whenever the urge appears, try doing some other activity that requires your concentration. Then wait 1-2 minutes and go to the bathroom--whether or not you still feel the urge. At the next urge, try to wait 3-4 minutes before going. Keep this up until you can wait until your next scheduled voiding time.
3. Gradually retrain your bladder to go longer between voids. After each week, try to increase the intervals between voids by 30 minutes. Your ultimate goal is to go no more than every 2-4 hours and to significantly reduce the number of leaking accidents between these voids.
Pelvic Floor Muscle (Kegel) Exercises.
Pelvic floor muscle exercises are also known as Kegel Exercises for the doctor who developed them. They are done to strengthen the muscles that support the urethra, bladder and rectum. If you type in the words "Kegel Exercises" into your browser's search field, you will find several websites that gives detailed instructions for carrying out this technique.
Briefly, however, all you do is to lie on a bed or the floor and squeeze your rectum and genital area as though you are trying to hold your urine in. Hold this muscle squeeze for 4-5 seconds, then relax for 5 seconds. Keep repeating for 4 minutes 3 times a day. Each time, try to squeeze harder than before. After a few weeks, you should be able to avoid urges to void for increasingly longer periods.
All of the techniques for Intelligent Watchful Waiting are described for information only and you are advised to consult your doctor or urologist before starting to use them. Just as with ordinary Watchful Waiting, every six months you take the I-PSS quiz and undergo a brief medical check. The next treatment step is to add Herbal Therapy to Intelligent Watchful Waiting.
Treatment Stage 3: Herbal Therapy
Herbal Therapy: Although no therapeutic herbs have been approved for treating BPH by the FDA or the American Urological Association, growing evidence is emerging that at least two herbal supplements may help in reducing BPH symptoms. For I-PSS scores up to 16--or possibly higher if symptoms are not bothersome (and your doctor approves)--we would certainly contemplate a combination of IWW and herbal therapy for several months before resorting to drugs.
As we'll mention below, chances of success for therapeutic herbs is doubled when herbal treatment is combined with IWW. Herbs almost always cost less than drugs, don't require a doctor visit for a prescription, and they are readily available at pharmacies or health food stores or on the Internet.
When taking herbal medicine, we still recommend a twice yearly check-up with your doctor.
SAW PALMETTO
Saw Palmetto (Serenoa Repens) is the popular name for an extract of the dried, ripe berry of the dwarf palm tree, which grows in the Southeastern U.S. It is a common treatment for BPH in Western Europe and is a prescription drug in Germany.
European studies claim it reduces symptoms of BPH, increases urinary flow, enhances Quality of Life, is well tolerated and compares favorably with Alpha-Blocker drugs and the 5ARI finasteride Proscar. All this may well be true because analysis has shown that each ripe berry is rich in fatty acids and Beta-Sitosterols which appear to reduce the amount of Di-Hydro-Testosterone in the Prostate and to reduce inflammation. (Di- Hydro-Testosterone is believed to be the key hormone which fuels Prostate Enlargement.)
Based on lab studies of the fat-soluble sterols in Saw Palmetto berries, they appear to have properties that inhibit 5-Alpha Reductase in the Prostate's inner zone.
But the American medical community isn't so sure. The primary evidence for these claims, they say, consists of 3 meta-analysis (an overview) of existing studies, most of which are classified as randomized and controlled trials.
According to worstpills.org, the principal meta-analysis (Cochrane Data Base) was first published in the Journal of the American Medical Association in November, 1998 and has since been updated On-Line. The most recent review concluded that Saw Palmetto provided "mild-to-moderate improvement in urinary symptoms and flow measures and that Saw Palmetto might be as effective as Proscar (finasteride) in managing BPH but with fewer side effects."
Worstpills.org also pointed out that of 21 studies in the 1998 meta-analysis, only one was placebo-controlled, making it almost impossible to ascribe any effect to Serenoa Repens itself. Also, the trials were of short duration , lasting an average of only 13 weeks. Only one trial involved Saw Palmetto alone and was published in a medical journal after 1987. . . and this study showed an improvement of only six percent over placebo after six months. This meant that Saw Palmetto had no impact on primary flow rates which would have been a far more objective measure of effectiveness. All other trials were documented in obscure medical journals, most of which could no longer be accessed.
Worstpills concluded that no Saw Palmetto study had never shown any impact on development of urinary obstruction or on the need for surgery to relieve BPH symptoms. Thus no conclusive evidence exists that Saw Palmetto is effective for treating BPH.
Saw Palmetto May Shrink Wallets, not Prostates concludes new Study
Supporting this view is a new 12-months, randomized, placebo-controlled, double-blind study of 225 men with moderate-to-severe BPH symptoms, published in the February 9, 2006 issue of the New England Journal of Medicine. In the study, 112-men took two 160 mgs doses daily of Saw Palmetto while 113-men took a placebo pill. Upon the study's conclusions, the authors announced that those taking the herb experienced no greater benefit than those taking the placebo. But they also advised that, "men taking the herb who feel like it's helping them, should continue taking it."
That's because approximately one-third of the benefit derived from any drug or herbal medicine is due to the placebo effect. The placebo effect is the healing power due to the patient's BELIEF in the ability of the medication to heal, rather than any benefit derived from chemical agents in the medication itself. The study also concluded that Saw Palmetto poses no safety hazards or adverse side effects.
Interestingly, the study authors selected what experts considered the top-notch Saw Palmetto product, capsules marketed in the U.S by Rexall Sundown Co. It was also pointed out that the disappointing study results may have been due to the fact that study participants had moderate-to-severe BPH symptoms while prior studies had shown that Saw Palmetto works best for men with mild-to-moderate symptoms.
Yet, contrary to the conclusion of American researchers, European sources point to considerable evidence supporting the effectiveness and lack of side effects for Saw Palmetto. Also that Serenoa Repens has been used for decades as a prescription drug in Germany and as a first line medical treatment in France. Both facts suggest that Saw Palmetto must have some effectiveness as well as an acceptable level of safety.
Meanwhile, Consumer Reports says it may ease mild symptoms. And we'll all know the final word in February, 2007 when the National Institutes of Health concludes its randomized, placebo-controlled study of the effectiveness of Saw Palmetto in relieving BPH symptoms.
Meanwhile, before you dismiss Saw Palmetto as just a weak, folk remedy, consider this. In Germany, Saw Palmetto is marketed as the prescription drug Permixon, in which the herb is standardized and subject to the same quality controls as drugs. But Permixon is not available in the U.S. Instead, in America Saw Palmetto is sold as a dietary supplement without any guarantee of quality or purity or that you are actually getting the amount indicated on the label.
In the U.S., the best guarantee of quality is to buy Saw Palmetto manufactured by a reputable supplement manufacturer in bottles of capsules on which the label indicates that the extract consists of 272 mgs (80-85) percent fatty acids and sterols, and which carries an expiry date. Cheap brands, we are told, may use powdered Saw Palmetto with weaker potency.
In the U.S., Saw Palmetto is often combined with other herbs for BPH and marketed as Prostate Formulas or Prostate Health Capsules. All of which means that Saw Palmetto available in the U.S., could be weaker and less pure than in Permixon, and possibly contaminated with other substances.
Secondly, we strongly recommend combining Saw Palmetto--or other therapeutic herbs-- with Intelligent Watchful Waiting. In this way, both therapies may work synergistically to provide the maximum benefit that natural treatments can bestow.
As with Proscar, it may take several months before your I-PSS score begins to drop.
Adverse side effects are rare but may include headache, gastric intestinal upset, hypertension, impotence and diminished sex drive. The usual consumption is 320 mgs per day.
AFRICAN PYGEUM
African Pygeum (aka Pygeum Africanum or Prunus Africana) is an extract of the bark of the African prune tree. It was first discovered by European travelers in Africa where it had been used for decades by local people to treat "old man's disease" as BPH was known. Since then, it has become the second most widely-used herbal therapy for BPH and has been used in Europe since 1960, especially in France.
Fewer studies have been made on African Pygeum than on Saw Palmetto but the principal active ingredient appears to be Beta-Sitosterol, a poly-sterol and a known anti-inflammatory agent. It may also have a weak estrogen effect which inhibits 5AR. While no one is quite certain how it works, several studies have demonstrated that Pygeum may well be an effective remedy for BPH.
Ishani et al, made a meta-analysis of 18 randomized, controlled studies conducted 1996-2000 on more than 1,500 men. The review concluded that African Pygeum extract yielded significant improvement in the combined outcome of urological symptoms and flow measures. Men taking African Pygeum were more than twice as likely to report improvement in overall symptoms than those on a placebo. Overall, Nocturia was reduced 19% and residual urine volume by 24% while peak urine flow increased by 23%.
One trial reviewed was for a six months initial period but was then extended for another 18 months of open-label treatment and follow-up. The original benefits continued throughout the entire period. However, African Pygeum did not appear to shrink the Prostate. And in several studies, it did not increase flow rate nor reduce the amount of urine left over in the bladder after voiding.
Scientific acceptance of these results was also hindered due to most studies being of short duration (3-6 months) and to a lack of standardized preparation. Despite this, 3 randomized, controlled studies of Beta-Sitosterol conducted 1986-1997 by Wilt et al, consistently found that this sterol improved urological symptoms and flow measures.
Weighing it all up, it appears that Pygeum Africanum may be well worth taking for its Beta-Sitosterol content alone. In fact, several large supplement manufacturers offer a combination of Saw Palmetto and Pygeum Africanum in capsules. Whether you buy Pygeum Africanum alone or mixed with Saw Palmetto, the label should guarantee that the Pygeum is 13 mgs (13%) Total Sterols. If it doesn't, be suspicious. The daily dosage is usually from 80 to 100 mgs.
Anecdotal evidence also exists for taking Stinging Nettle capsules (a homeopathic remedy) or by brewing and drinking herb teas such as Cernilton or Small Flowered Willow Herb Tea.
If at all possible, though, a combination of both behavioral and herbal remedies should certainly be tried before resorting to pharmaceuticals because they are safer and in many cases, equally effective. But if your symptoms continue to worsen, the next traditional step is to begin taking one or more prescription drugs.
When natural treatments no longer work, it's probably time for drug treatment to be considered. Most BPH drugs offer a conservative, non-surgical approach without serious side effects and appear well-tolerated. Two types of drugs are used to treat BPH: Alpha-Blockers and Enzyme Inhibitors.
ALPHA BLOCKER DRUGS (Adrenoreceptor Antagonists).
Commonly, Alpha-Blocker drugs are the first choice drugs and they work by relaxing muscles in the bladder neck, Prostate and urethra, allowing the bladder to empty and urine to flow through more freely.
Alpha-Blockers reduce major symptoms for two-thirds of men with BPH. They act quickly, reaching maximum effect in about ten days. They tend to lower blood pressure in men with hypertension. And they may reduce risk of AUR and Surgery. One 4-year study of men with enlarged Prostates found that, without Alpha-Blocker treatment, one in every 7 untreated men experienced AUR or had to undergo Surgery by the end of the study.
Alpha-Blockers are usually prescribed for men with an I-PSS score of 14-22, or perhaps higher if symptoms are not bothersome. And you must see your doctor periodically for a check-up while taking BPH drugs.
Alpha-Blockers come in two types:
The older Non-Selective type acts on both the Prostate and Vascular System and lowers blood pressure. The dosage must be "titrated" or adjusted by your doctor for the best compromise between adverse side effects and relief from BPH symptoms. Both Alpha-Blockers in this class are FDA-approved and include:
Doxazosine (Cardura)
Terazosin (Hytrin). Although considered the least-expensive Alpha-Blocker, Terazosin is claimed to be almost as effective as the newer Selective Alpha-Blockers, and when titrated, has almost equal side effects.
The newer Selective Alpha-Blockers relax only the muscles in the Prostate area. They do not require titrating and are claimed to cause fewer side effects and to lead to more rapid symptom improvement. Both Alpha-Blockers in this class are FDA-approved and include:
Tamsulosin (Flomax), is an Alpha-Adrenergic antagonist claimed to cause more rapid symptom relief and less dizziness or other side effects than Non-Selective Alpha- Blockers. Dosage begins at the low end with 0.4 mgs per day and works up gradually to a maximum of 0.8. In older men, Tamsulosin may cause fewer side effects than Alfuzosin (see below). Tamsulosin can also be had in a slow-release version. Its website www.flomax.com/ provides more information.
Alfuzosin (Uroxatral). Worsepills advises not using this Alpha-Blocker until 2010 while other sources say it may cause liver and kidney problems and can worsen Stress- Incontinence. It may take 2-6 weeks before initial side effects improve.
All Alpha-Blockers may cause similar side effects that include dizziness when standing up which, though usually mild, is experienced by 15 percent of men taking these drugs. Actually, Alpha-Blockers were originally developed to lower blood pressure and they still can cause a sudden drop in blood pressure that leads to dizziness or fainting. In turn, this could lead to loss of balance and falls, fractures or head injuries. Loss of balance is most common with the first dose or when changing doses or when treatment is interrupted for a few days.
Additionally, 8 percent of men taking these drugs may experience headaches, fatigue or asthenia.
All Alpha-Blockers are taken as a once-a-day pill and a good tip for avoiding side effects is to take your medication at bedtime. Alpha-Blockers may also interact with impotence drugs like Viagra, Levitran or Cialis to cause excessively low blood pressure.
ENZYME INHIBITORS (5-Alpha-Reductase Inhibitors)
When Alpha-Blockers fail to work, most physicians turn next to a drug that functions in an entirely different way. It blocks production of an enzyme called 5-Alpha- Reductase (5AR). 5AR exists in the Prostate to help transform (catalyze) the male hormone Testosterone into the much more active and powerful hormone Di-Hydro-Testosterone (DHT). In turn, Di-Hydro-Testosterone attaches to receptors on Prostate cells and fuels the growth of Prostate enlargement.
When an Enzyme Inhibitor breaks this chain reaction by inhibiting production of 5- Alpha-Reductase in the Prostate, it stops production of Di-Hydro-Testosterone. Prostate growth then all but ceases. And gradually, very gradually, the Prostate shrinks back to a more normal size.
5-Alpha-Reductase comes in two isoforms: Type 1 is found in the skin, liver, Prostate and kidneys while Type 2 exists in male genitalia and the Prostate. There are two 5ARI drugs, one focusing on each isoform. The drugs are:
Finasteride (Proscar). A Type 2 isoform inhibitor, finasteride was developed first and has been in use for some years. It has been widely tested and been found to typically reduce Di-Hydro-Testerone by 70 percent or more. It has also been shown to prevent or delay onset of Prostate Cancer in men 55 and older by about 55 percent. Click on www.proscar.com/ for more information.
Dutasteride (Avodart): Inhibits 5AR in both isoforms and has been demonstrated to reduce production of Di-Hydro-Testosterone by over 90 percent. Click on www.avodart.com/ for more information.
While Dutasteride seems to work more swiftly, both drugs appear to have similar benefits and drawbacks. Both reduce the size of the Prostate over time. They also reduce incidence of bothersome urinary symptoms and they appear to make Surgery or AUR significantly less likely. It usually takes up to 3 months for an 5ARI to reach maximum strength in the Prostate and 3-6 months to begin reducing Prostate size. Thus Prostate shrinkage is slow and incomplete and it may take 18 months or more for it to shrink by 25 percent. It's true that results vary and that in some men the drugs appear to work faster. In some men, the Prostate has shrunk by almost 50 percent. But it can take months to discover whether a 5ARI will work for you.
For example, in 3 placebo-controlled trials with Avodart on a total 4,325 men, the pooled results showed an average reduction in Prostate volume by 26 percent after 24 months and by 27 percent after 48 months. After another 4-year trial of finasteride, the overall rate of urinary retention fell by 57 percent and Prostate volume by 18 percent. The same trial found finasteride to be as effective as Alpha-Blockers and more effective in preventing AUR and need for Surgery. All studies demonstrated that 5ARIs are eminently suited for long term use by older men.
Most importantly, the drugs are effective only in men with very large Prostates, typically glands with a volume of 40 milli-liters or more. Smaller glands simply lack sufficient fibro-muscular tissue for the drugs to work on.
Side effects have been relatively mild and center predominently around loss of libido, gynecomastia (male breast enlargement and tenderness), and impotence or ejaculation problems. There's a slight risk of male breast cancer or possible allergic reactions like rashes. 5ARIs have no known intereaction with Alpha-Blockers. But they do interact with Digoxin, Warfarin, Calcium Channel antagonists and Cholestyramine and you should not use them if you have Prostate Cancer.
Both drugs have a profound effect on PSA readings, reducing them by 50 percent. The dosage is usually one .5 mg capsule per day.
How Well Do Enzyme Inhibitors and Alpha-Blockers Work Together?
Several trials of different Alpha-Blockers teamed up with one or other 5ARIs have shown an 80 percent reduction in risk of an AUR event as well as better symptom scores and significantly less need for surgery or non-invasive treatments vis-a-vis taking a single drug alone
Nowadays, it's commonplace for men with large Prostates to be put on a combination of both types of drugs together. Before you go this route, though, bear in mind that two different drugs may have more side effects than just one, and that using a combo will invariably be more expensive.
Treatment Stage 5: Surgery and Minimally-Invasive Treatment
Surgery may become necessary when symptoms are severe or cannot be controlled by drug therapy. If you have AUR, frequent urinary tract infection, bladder stones or blood in the urine, you probably need some form of Stage 5 Treatment.
This entire area of BPH Treatment has been expertly reviewed and completely covered in Mayo Clinic's Benign Prostate Hyperplasia report.
We therefore recommend that you now click on the CLICK HERE link below that will take you to Mayo Clinic's BPH Guide.
Before you do, though, jot down these important instructions.
1. Look at the top right of Mayo Clinic's page. Under "Article Tools" click on the link "All Sections." This takes you to the print version of the entire BPH Guide.
2. Scroll down the BPH Guide to the heading "Minimally-Invasive Therapies" and read the entire report from here on to the end.
Ready? Then CLICK HERE to go to Mayo Clinic's BPH Guide. Written by world renowned experts, this report will give you the most complete and up-to-date analysis of both Surgical and Minimally-Invasive Treatments for BPH.
Links To Other BPH Websites
Click Here to go to the splendid International Health News Prostate Series by Canadian Nutritionist Hans R. Larsen and William R. Ware, Ph. D., Emeritus Professor of Chemistry, University of Western Ontario. Though slightly technical, these Research Reports are MUST reading for any man with symptoms of--or interest in--Benign Prostate Hyperplasia. On the IHN page, click on the Archives button in left margin and go to the 3 Newsletter copies listed below.
International Health Newsletter #158, June, 2005. Research Report = The Prostate: Small Gland, Big Problems, by Hans R. Larsen, M.,Sc, Ch., E.
International Health Newsletter #159, July-Aug 2005. Research Report = Benign Prostate Hyperplasia, a Not-So-Benign Condition, by Dr. Ware. Part I. Causes, Diagnosis and Prevention.
International Health Newsletter #160, Sept 2005. Research Report = Benign Prostate Hyperplasia, a Not-So-Benign Condition, by Dr Ware. Part II. Conventional and Alternative Treatment.
These reports plus others are also available in an On-Line book that you can download from IHN.
CAUTION: Though these reports are based on documented studies in professional journals or on advisories from leading university medical schools and research institutes, they are intended for information only and should not be regarded as medical advice or instruction. For diagnosis and treatment of specific symptoms and diseases, disorders or dysfunctions, consult your physician. If you smoke or are over 35 or have symptoms of--or are at risk for--any chronic or degenerative disease, you should check with your doctor before beginning to exercise or making any changes in lifestyle or diet. However, fitness organizations like the American College of Sports Medicine invariably believe that the risk of NOT exercising far exceeds any risk in beginning a gradually increasing program of daily exercise. Thus if you experience any pain or problem while exercising, or making any other lifestyle change, stop and see your doctor at once.