BPH is a non-malignant enlargement of the prostate and is one of the most common diseases in ageing men which can lead to lower urinary tract problems (LUTS). Approximately 25% of men in their 50’s, 50-60% in their 60’s, and 80-90% of all men 80 years or older, develop BPH.
The prostate grows in volume with age. Men with a family history of an enlarged prostate have an increased risk of developing BPH, more so when the affected relative is a brother as opposed to a father, and when the affected relative is younger than 60 years old.
Pathophysiology
The prostate is an accessory reproductive organ that functions in sperm transport and nourishment. It is made up of 3 histological zones (central, peripheral and transition zones). Enlargement of the prostate is central to BPH development and progression and involves 2 primary phases of progression:
- Pathological
- Clinical – manifests as LUTS
- symptoms include weakness of urinary stream, hesitancy, intermittency and incomplete emptying of the bladder, straining to void, urgency and need to urinate at night. As the prostate gland tissues enlarge, it can become prone to bleeding
No all men develop macroscopic BPH and only about half of men with macroscopic BPH will progress to the clinical stage with associated LUTS.
Aetiology
The prostate is dependent on testicular androgens for both its development and maintenance of its structural and functional integrity. Synthesised from cholesterol, androgenic hormones include testosterone and dihydrotestosterone (DHT). Testosterone is the main circulating androgen with 90% of production by the testes and the rest from adrenal glands. DHT, the most potent androgen in men, is metabolised from testosterone.
Androgen receptors mediate the effect of androgens and are critical for prostate maintenance. The presence of excess androgens and androgen receptors appear to enable the development of BPH. Importantly, inhibition of DHT can result in growth of the prostate gland.
Prostatic inflammation plays a crucial role in the pathogenesis of BPH whereby the inflammatory cells in the prostate can contribute to prostate growth.
Medical Intervention
Medical Therapy: Alpha Adrenergic Antagonists (ARAs) / 5-Alpha Reductase Inhibitors, work to slow down the progression of BPH
Surgical Therapy – When symptoms persist or progress whilst on medical therapy or where medial therapy is not longer tolerated, surgery is considered:
- Transurethral Resection of the Prostate (TURP) is the most common procedure performed. It is an endoscopic procedure in which obstructing tissue in the transition one is resected
- Bipolar Plasmakinetinc Resection
- Diode Laser Enucleation
- Prostatic Urethral Lift
- Aquablation – integrates ultrasonic imaging with surgeon guided high velocity water jet ablation
Diagnosis & Testing
- Questionnaire to track and store LUTS symptoms
- Rectal exam to evaluate size of the gland
- Urine analysis to distinguish between other conditions such as diabetes
- PSA markers provide an estimate of the prostate size. Normal PSA levels range from 0-4nanograms/mL. As the prostate grows with age, serum PSA increases and if the level is 3 nanogram/mL or higher further investigations are recommended. PSA is highly variable and may fluctuate based on the patients age, race, medications, or simultaneous urinary conditions. A diagnosis of BPH can not be made for PSA levels alone
Potential Functional Contributors to BPH
- Inflammatory processes may play an important role in the pathogenesis of LUTS. Obesity increases inflammatory cytokines from adipose tissue which in turn creates inflammation
- Men with Vitamin D deficiency have been found to have a high prostate volume and significantly lower mean urinary flow rate. However it is important to note that Vitamin D deficiency alone does not imply BPH, but where LUTS and low Vitamin D exist there is a likely correlation with BPH
- Different pathogens including bacteria and viruses could infect and induce inflammatory responses in the prostate. These include sexually transmitted organisms including Human Herpes Simplex 2 and 8 and Human Papillomavirus
- Hyperinsulinaemia (high insulin) – may directly increase hormones that increase the risk of BPH
- Cholesterol – high levels of HDL and total cholesterol are commonly seen in patients with symptomatic BPH
- Stress – studies have found that high diastolic blood pressure was associated with a greater transition in prostate volume
Nutrition to help prevent onset as well as support conditions
Foods to Avoid
- Refined vegetale oils (soy, corn, sunflower)
- Butter, margarine
- Limit red meat to once a week
- Simple carbohydrates – eg cookies, pastries, cake
Foods to Include
- Plant proteins – eg tofu, chickpeas, miso, legumes
- Oily fish – salmon, mackerel, anchovies, sardines, herrings
- Wholegrains – rice, oats, buckwheat, quinoa
- Eggs
- Tomatoes – fresh or puree
- Vegetables
- Cruciferous vegetables – broccoli, cabbage, kale, cauliflower
- Brightly coloured vegetables including beetroots, carrots, red onion, peppers
- Fruits – blueberries, raspberries, strawberries
- Nuts and Seeds
- Sweet Potato
- Anti inflammatory herbs including garlic, oregano, rosemary, turmeric
- Anti inflammatory oils including avocado, coconut, macadamia
Supplements to consider
- Vitamin D
- Nettle Root
- Lycopene
- Zinc
- Saw Palmetto
- Pycnogenol
Before taking any supplements, individuals should consult with their medical practitioner and or nutritionist
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