Enlarged Prostate (BPH) Overview

The prostate is a walnut-sized, donut-shaped gland located below a man’s bladder. It produces most of the fluid in semen. It also has a tube running through it, the man’s urethra, which carries urine and semen out of his body. Unless it gets infected, a man’s prostate remains so unnoticed that many men hardly know they have one. But after age 30, the pesky little gland starts growing, and by a man’s mid-40’s, he may start having to get up at night regularly to urinate.

Prostate growth might signal prostate cancer, a leading cause of men’s cancer deaths, explains Baltimore urologist James Smolev, M.D., an assistant professor in the department of urology at Johns Hopkins. That’s why men over 45 should have annual prostate exams. But most midlife prostate growth is noncancerous, medically known as benign prostatic hypertrophy or BPH (“benign” means noncancerous, “hypertrophy” means enlarged).

As BPH progresses, a man’s swelling prostate pinches his urethra. In addition, the muscle tissue around his urethra tightens, pinching it even more. This process is painless, but it causes urinary difficulties: the need to urinate immediately (urgency), difficulty getting started (hesitancy), decreased flow, difficulty finishing (dribbling), and the most annoying, having to get up at night to urinate (nocturia).

Men’s prostates balloon because of age-related hormonal changes. After age 40, men’s free testosterone levels decline, while other hormone levels increase, notably, prolactin. “The ultimate effect of these changes,” says naturopath Joseph Pizzorno, N.D., president of Bastyr University, the naturopathic medical school near Seattle, “is an increase in the male sex hormone, dihydrotestosterone, in the prostate. Dihydrotestosterone is responsible for the overgrowth of prostate tissue that produces BPH.”

An enzyme, 5-alpha-reductase, converts testosterone to dihydrotestosterone. Many BPH treatments, both natural and pharmaceutical, work by interfering with this enzym’s action.

Half of men in their 50’s experience BPH symptoms, and the percentage rises with age. BPH usually gets worse over time, but its course is unpredictable, according to Richard Macchia, M.D., a professor and chair of the department of urology at the State University of New York Health Science Center in Brooklyn. Some men go from mild to severe symptoms in a half-dozen years. In others, the process takes 15 years. Some men never develop more than mild or moderate symptoms. And in a small percentage of men, symptoms diminish without any treatment. But most men go from one wake-up a night to two, or three, or more as they move through their late 40’s, 50’s, and 60’s. The only known risk factor for severe BPH is a family history.

When should a man get treated for BPH? “It’s an individual decision,” Dr. Smolev says. “When he feels persistently uncomfortable with his urination during the day, or when he gets fed up with getting up at night.”

How should he get treated? “Most physicians feel that drugs or surgery are the only solutions,” Dr. Pizzorno says, “but BPH often responds to nutritional and herbal approaches.”

Home Remedies for Prostate Enlargement

• Take time at the urinal. As BPH develops, it takes longer to start urinating and even longer to finsish, notes BPH expert Herbert Lepor, M.D., a professor of urology at New York University School of Medicine. His advice: Don’t rush. Relax at the urinal, which helps start your stream flowing. Take time at the end, which helps you push out the last few squirts.

• Quit quaffing. Don’t drink fluids after around 7 p.m., Dr. Lepor suggests.

• Cut the caffeine. Caffeine is a urinary irritant. Many men find some relief when they limit coffee, tea, colas, and chocolate, according to Dr. Lepor.

• Check your medicine cabinet. “Few men know that certain medications can aggravate BPH symptoms,” says family practitioner Anne Simons, M.D., an assistant clinical professor of family and community medicine at the University of California’s San Francisco Medical Center,” “cold formulas, and several drugs for ulcers, irritable bowel syndrome, depression, and high blood pressure (hypertension). If you have BPH and take any of these medications, ask your doctor or pharmacist if they might aggravate your symptoms, and if other drugs might be substituted.”

Prostate Enlargement and Diet

• Soy squelches symptoms. Compared with Americans, Japanese men suffer less BPH, according to Stephen Holt, M.D., a professor of medicine at Seton Hall University, in New Jersey. The reason appears to be their intake of tofu and other soy foods,” which contain plant estrogens. BPH is caused by the coversion of the male sex hormone, testosterone, into dihydrotestosterone. The plant estrogens in soy limit this conversion. So does pharmaceutical estrogen. Years ago, doctors tried treating BPH with pharmaceutical estrogen to suppress testosterone. It worked—but it also caused impotence, loss of muscle mass, and an overall ill feeling.” The estrogens in soy foods are chemically weaker than their pharmaceutical counterparts, so they don’t cause these side effects. But Dr. Holt says they can help control BPH.

Supplements for Prostate Health

• Think zinc. Dr. Pizzorno calls zinc “paramount to effective BPH prevention and treatment.” New York clinical nutritionist Shari Lieberman, Ph.D., agrees: “Zinc has been shown to reduce the size of the prostate and BPH symptoms.”” Zinc inhibits 5-alpha-reductase, the enzyme that converts testosterone to dihydrotestosterone. It also limits the action of prolactin, another hormone involved in BPH.” Good food sources of zinc include: whole grains, legumes, notably peanuts, seafood, fish, eggs, poultry (especially dark meat), and other meats.” But Dr. Pizzorno suggests supplementing with 60 mg of zinc picolinate a day for a maximum of six months.” (Supplementation for longer periods may contribute to other nutrient deficiencies, notably copper.”)

• Primrose for your prostate. Evening primrose oil is high is essential fatty acids (EFA’s). EFA’s are potent 5-alpha-reductase inhibitors, according to urologist A.C. Buck, of the Glasgow Royal Infirmary, in Scotland, who specializes in natural treatments for BPH.” Dr. Pizzorno says supplementation with EFA’s “has resulted in significant improvement for many BPH sufferers.”” He recommends 1 teaspoon a day (4 grams) of evening primrose oil, or sunflower, linseed, walnut, or soy oil.”

Herbal Medicine for the Prostate

• A palm tree for your prostate. “I’m betting my own prostate gland that herbal treatments work better than drugs or surgery,” says Maryland botanist/herbalist James Duke, Ph.D., author of The Green Pharmacy.” High on Dr. Duke’s list of effective herbal remedies is saw palmetto (Serenoa repens), a dwarf palm tree native to the Southeast U.S. Dr. Duke is not alone. In Germany, where herbal medicine is considerably more mainstream than it is in the U.S., more than half of German urologists prefer herbs—notably saw palmetto—to drugs as initial treatment of BPH, according to naturopath Donald Brown, N.D., a professor of herbal medicine at Bastyr University.”

Use of saw palmetto to treat urinary problems goes back centuries to the Native Americans of Florida and the Gulf Coast. During the 19th century, physicians throughout the South recommended it for prostate problems. During the 1960’s European herbal medicine researchers discovered that saw plametto fruits contain fatty acids (liposterols) that act as 5-alpha-reductase inhibitors.” Commission E, the German expert panel that judges the safety and effectiveness of herbal medicines for that nation’s counterpart of the Food and Drug Administration, approves saw palmetto for treatment of BPH.”

At least a dozen studies have shown that saw palmetto shrinks enlarged prostates and relieves BPH symptoms:

• One of the most impressive studies, conducted at 87 urology clinics in nine European countries, compared a standard European saw palmetto extract (Permixon, a French preparation) head-to-head against the pharmaceutical 5-alpha-reductase inhibitor, Proscar. The researchers gave the 1,098 participants either the herb (160 mg twice a day) or the drug (5 mg a day). After 26 weeks, both treatments showed about equal effectiveness. Proscar decreased BPH symptoms 39 percent vs. 37 percent for saw palmetto. Urine flow improved 30 percent in those taking the drug, 25 percent in men on the herb. But saw palmetto caused fewer erection problems and less libido loss.”

• A similar German comparison of saw palmetto and Proscar showed the same results. The researchers gave 309 men one or the other. Three years later, both groups showed about a 30 percent decrease in symptoms.”

• Belgian researchers measured prostate size, urine flow rate, and quality of life in 505 men with BPH, and then gave them saw palmetto extract. Six weeks later, their prostates were smaller, their urine flowed more freely, and they reported significantly improved quality of life. After 90 days on the herb, 88 percent of the men called the treatment “effective.””

• Finally, German researchers gave saw palmetto to 320 men with BPH. Six months later, their urine flow had increased significantly. Three-quarters of them were getting up less at night, and half reported less frequent daytime urination. These improvements were maintained for three years.”

The only reported side effect of saw plametto is occasional abdominal distress.”

• Help from Africa. Traditional herbalists in South Africa have long recommended the root of African star grass (Hypoxis rooperi) for prostate enlargement. European reserchers have shown that star grass root contains compounds (phytosterols, notable beta-sitosterol), that are 5-alpha-reductase inhibitors.” Two recent studies show that it helps relieves BPH:

• German researchers gave 200 men with BPH either a placebo or beta-sitosterol (20 mg three) times a day. The placebo group showed no change in urine flow, but men taking the herbal extract enjoyed significantly increased flow.”

• Another German team gave either a placebo or beta-sitosterol (130 mg a day) to 177 men with BPH. Six months later, the placebo group showed no change in symptoms, but those taking the star grass extract showed significant improvement.”

• More help from Africa. In Africa’s central and southern highlands grows an evergreen called pygeum or African prune (Pygeum africanum). For centuries, indigenous Africans have used a tea made from powdered pygeum bark to treat urinary problems.

European researchers have discovered that like star grass, pygeum bark is rich in the 5-alpha-reductase inhibitor, beta-sitosterol.” A standardized extract of pygeum bark has become the leading treatment for BPH in France,” based on several studies that have shown significant benefits.

Here’s one example: German researchers gave 263 BPH sufferers either a placebo or pygeum (50 mg) twice a day. After two months, one-third of the placebo group showed significant symptom improvement. But in the pygeum group, the figure was two-thirds.” “I’m persuaded that pygeum helps treat BPH,” says family practitioner Alan Gaby, M.D., a professor of nutrition at Bastyr University.”

• Pollenate your prostate. Back in 1959, a Swedish urologist showed that rye flower pollen extract helps treat BPH. The product he developed, Cernilton, became popular in Scandinavia, and spread to England, where it is known as ProstaBrit. Scientists aren’t sure how it works, but several studies show benefit—after at least six months of treatment.”

British researchers gave either a placebo or Cernilton to 60 BPH sufferers. After six months, 30 percent of the placebo group reported improvement, but among those taking Cernilton, the figure was 69 percent.”

Cernilton/ProstaBrit is available in some U.S. health food stores in 189 mg capsules. The recommended dose is two capsules a day.” But don’t use pollen if you have pollen-allergy hayfever.

• Nip nocturia with nettle. Nettle root (Urtica dioica) is an age-old European remedy for urinary problems. Modern research has shown that it contains a number of compounds, including phytosterols, that appear to offer some relief for BPH symptoms. Dr. Brown says nettle root works best in combination with saw palmetto or pygeum. He suggests using a standardized nettle root extract (120 mg a day).”

• The pumpkin prescription. A handful of pumpkin seeds a day: That’s the traditional BPH treatment in Turkey, Bulgaria, and the Ukraine. “In my experience, pumpkin seeds don’t do much by themselves,” say sAlan Brauer, M.D., founder of TotalCare Medical Center in Palo Alto, California, one of the nation’s first clinics to combine mainstream and complementary therapies.” “But in combination with saw palmetto and pygeum, they help.” Dr. Duke agrees: he munches on pumpkin seeds and blends them into a butter he calls Prosnut butter, which he uses like peanut butter. He cites three reasons why pumpkin seeds help treat BPH: “They contain chemicals called cucurbitacins that help prevent the conversion of testosterone into dihydrotestosterone. They’re also one of the richest plant sources of zinc—8 mg per half-cup serving. In Europe, Curbicin, is a popular treatment for BPH. It’s a combination of pumpkin seeds and saw palmetto.”

Hydrotherapy for Prostate Health

• The sitz solution. Naturopaths sometimes recommend hot sitz baths to relieve BPH symptoms. “They relax and open the urinary passageway,” Dr. Pizzorno explains. He recommends a three- to 15-minute bath at 105Ëš (hot) to 115Ëš (very hot).”

Chinese Medicine and the Prostate

• Clear damp Heat. Strengthen your Kidney. Chinese medicine views BPH as an excess of damp Heat aggravated by too much sex, alcohol, or spicy foods that impairs urine flow. “The Heat causes the enlargement, which the Chinese consider inflammation,” says San Francisco Chinese physician Efrem Korngold, L.Ac., O.M.D., co-author (with Harriet Beinfield, L.Ac.) of Between Heaven and Earth: A Guide to Chinese Medicine.” “The dampness comes from the fact that the prostate both holds fluid and secretes it.” The Kidney organ system is also involved because, in the Chinese view, it regulates the discharge of reproductive essence, and the factors that cause BPH, especially sexual excess, weaken it.

To treat BPH, Dr. Korngold recommends formulas containing diuretic, anti-inflammatory herbs that strengthen the Kidney, including: astragalus root, rehmannia root, codonopsis root, and vaccaria seed.

• Pin hope on acupuncture. Dr. Korngold also suggest acupuncture to help treat BPH, especially:

• Spleen 6. On the inside of your lower leg, four fingerwidths above the top of your ankle bone in the muscle just behind your shinbone (tibia).

Homeopathy

• Try a microdose medicine. An unusual cause of both BPH and prostatitis (see sidebar) is the formation of an ademona, a noncancerous mass of tissue, in the gland. In one study, Russian homeopaths used homeopathic medicines to treat 37 men with this problem. Of the 27 with a weak urine stream and frequent nightly wake-ups to urinate, 23 reported improvement within six months.”

Berkeley, California, homeopath Dana Ullman, M.P.H., author of The Consumer’s Guide to Homeopathy,” says the main homeopathic BPH treatment is Chimaphilla (pipsissewa), but homeopaths might also prescribe: Clematis (clematis), or Selenium (selenium).”

Prostate Surgery

Most men can live with getting up once or twice a night, but at a certain point, interrupted sleep interferes with quality of life, and men with BPH decide to have the condition treated.

Until recently, the only mainstream treatment for BPH was a surgical procedure called “transurethral resection of the prostate” (TURP). Under general anesthesia, the surgeon threads a flexible tube (resectoscope) up the man’s urethra and snips away enough overgrown prostate tissue to relieve urethral pinching. Through the 1990’s, about 400,000 TURPs were performed in the U.S. each year,” and urologists still consider the operation the “gold standard”” of BPH treatment. TURP requires a few days of hospitalization and a week or two of recovery at home.”

TURPs usually provide longterm relief of BPH symptoms, but the operation carries a small risk of infection, incontinence, and erection impairment. In addition, after a TURP, a strange thing happens during sex. Orgasm remains as pleasurable as ever, but instead of having semen spurt out of his penis, the man ejaculates backwards into his bladder (retrograde ejaculation or dry orgasm).” Semen then leaves the body during urination.

Post-TURP dry orgasm has several possible implications, Dr. Kennealy says. It can impair fertility, an issue in some marriages. Some couples like it because absence of semen makes sex less messy. Others feel that semen-free sex detracts from the intimate exchange of lovemaking. “The important thing to understand,” Dr. Kennealy says, “is that retrograde ejaculation is quite common after TURP, so couples considering prostate surgery should be emotionally prepared for it.”

Prescription Drugs for Prostate Treatment

These days, TURP’s are in the process of being replaced—or at least delayed—not only by all the natural treatments, but also by two prescription drugs—finasteride (Proscar, 5 mg a day) and terazosin (Hytrin, 1 mg a day). Hytrin relaxes the muscles around the urethra, widening it. Proscar reverses overgrowth of prostate tissue by interfering with 5-alpha-reductase, the enzyme that converts testosterone to dihydrotestosterone, the form of the hormone that stimulates prostate enlargement.” At the University of Texas Southwest Medical Center in Dallas, urologist John McConnel, M.D., gave 3,000 men either Proscar or a placebo for four years. During that time, 10 percent of the placebo group required surgery, but among those taking Proscar, the figure was only 5 percent.”

“Hytrin generally works best for men in their 50’s whose prostates have not grown that large,” explains William A. Norcross, M.D., a professor of family and preventive medicine at University of California, San Diego, School of Medicine.” “Proscar works best for men over 60., whose prostates are larger.”

Hytrin begins providing relief quickly and works for most men with only somewhat enlarged prostates. Possible side effects include: dizziness and lightheadedness.”

Proscar takes six months or so to show maximum benefit. Possible side effects include: diminished libido, ejaculatory problems, and a small risk of impotence.” The current trend is to use Hytrin and Proscar for as long as possible to postpone surgery, which has greater risks.

In addition, several surgical procedures that are less invasive then TURP have begun gaining acceptance. One is TUNA (transurethral needle ablation). Like TURP, it uses a catheter, but instead of cutting away excess tissue, it zaps it with radio waves. TUNA eliminates prostate overgrowth but has no effect on nearby nerves or muscles, meaning much fewer side effects, not to mention that TUNA costs considerably less than a TURP.”

Another TURP alternative uses microwaves instead of radio waves.” A catheter-laser system has also been approved by the Food and Drug Administration.” TURP alternatives have fewer side effects, but it remains unclear whether they provide the same degree of longterm benefit.”