Benign Prostate Hypertrophy (BPH)

The prostate is a small, walnut-shaped gland located just below the bladder. The tube which carries urine from the bladder to the outside, the urethra, exits the bladder and runs directly through the middle of the prostate gland. Therefore, anything that causes the prostate to swell or enlarge will cause a constriction of the urethra, and potentially cause very bothersome urinary symptoms.

The prostate serves an important reproductive function—it produces the bulk of the seminal fluid. As a man ages, the prostate can become a source of several health problems. Younger men may experience prostatitis, an infection or inflammation of the prostate gland. Once a man is past 45, the prostate may begin to slowly enlarge, a condition known as BPH, or benign prostatic hypertrophy. This process may be very slow and gradual, or it can progress fairly rapidly. By the age of 60, most men have some degree of BPH.

As the prostate enlarges, it causes greater constriction of the urethra. As this occurs, the man may notice his urinary stream getting weaker, and he may begin to have difficulty getting the stream to start—a condition known as hesitancy. He may have the sense that his bladder won't fully empty. The frequency of trips to the bathroom will increase, and he may notice more trips to the bathroom in the middle of the night. Most annoyingly, there may be a gradually increasing sense of urgency—that is, when the urge to void is felt, it comes on more suddenly and strongly. If the urgency becomes bad enough, incontinence may occur.

Fortunately, there are a range of treatments for the symptoms caused by BPH, including prescription medications, minimally invasive procedures such as laser and microwave, and actual prostate surgery. As one considers each of these treatments, it is safe to say that as the effectiveness of symptom relief increases, so does the risk of side effects from the treatment. This is one of the reasons that men may choose to try an herbal supplement first.

Herbal supplements

When the BPH symptoms are mild or moderate, many men will try an over-the-counter herbal supplement. Many published studies have demonstrated the potential efficacy and safety of this approach. In Europe, where they are sold in prescription form, herbal products are actually the most popular form of BPH treatment. These herbal supplements contain various fatty acids and phytosterols (naturally occurring plant sterols), which are believed to be responsible for the symptom relief.

If you try an herbal product for BPH symptom relief, be aware of two factors. First—it may take 8 to 12 weeks to see improvement in your symptoms, so—give it a chance before you decide if it's working. Second, because the FDA does not regulate these products as stringently as they do prescription drugs, content accuracy and product purity cannot be taken for granted. Look for a product which has been independently certified for content purity and accuracy by one of the non-profit certification programs in the United States (the NSF or USP programs).

The most commonly studied ingredients are listed below.

  • Saw palmetto

    Saw palmetto, also known as Serenoa repens, is the herb most commonly used by men with the symptoms of BPH, or prostate enlargement. The medicinal component of saw palmetto is extracted from the berries of the saw palmetto plant, which is mainly found in the coastal regions of the southeastern U.S. Saw palmetto has been used for centuries, with its first use by Native Americans in the 1700's. Although its exact mechanism of action remains unknown, proposed mechanisms include anti-androgenic action, anti-inflammatory effects, and antiproliferative action. Many well-designed studies have shown that saw palmetto relieves the symptoms of an enlarged prostate when compared to placebo, and can provide symptom relief while causing fewer sexual side effects.

    Overall, saw palmetto has been shown to be safe, causes minimal side effects, and does not falsely lower PSA levels (which could mask the diagnosis of prostate cancer). Mild gastrointestinal distress has been reported infrequently, and can be alleviated by taking saw palmetto with food.

  • Beta-sitosterol

    Beta-sitosterol is a phytosterol that research has shown improves urinary tract symptoms and urinary flow in men with an enlarged prostate. Beta-sitosterol is generally used in nutritional supplements as part of a mixture of phytosterols including campesterol, stigmasterol, and brassicasterol. These phytosterols are thought to work due to anti-inflammatory effects and interference with cholesterol metabolism. Beta-sitosterol is often used by men with mild to moderate urinary tract symptoms. It has been well-tolerated in clinical trials, with mild gastrointestinal upset occurring in only 1.6% of men.

  • Pygeum africanum

    Pygeum africanum is a tall evergreen tree that grows mostly in Southern Africa, Madagascar, and in some areas of Central Africa. The medicinal use of Pygeum bark dates back to ancient times, when it was used as a tribal remedy for bladder pains. Pygeum bark extract contains phytosterols (beta-sitosterol), pentacyclic triterpenes, and ferulic esters, which are thought to be the active ingredients. It is thought that beta-sitosterol is the primary active component, although this is not known for sure. The exact mechanism of action of Pygeum is not fully understood, but it has been shown to have anti-inflammatory effects and anti-edema properties.

  • Other Herbal Extracts for BPH

    Although the most evidence exists for saw palmetto, beta-sitosterol, and pygeum, there are a limited number of studies suggesting that other botanicals may also be beneficial for men with BPH. These include Nettle root, pumpkin seed, rye pollen, etc. However, more studies need to be conducted to determine the safety and efficacy of these products.

Precription Medications

There are two types of prescription medications used for BPH treatment—muscle relaxants and hormone blockers.

Proscar (finasteride) and Avodart (dutasteride) are the hormone blockers—technically known as 5-alpha reductase inhibitors. They work by blocking the body's production of the hormone which is actually causing the prostate to enlarge. By blocking this hormone, these drugs cause the enlarged prostate to slowly shrink in size. While it is true that these medications are actually reversing the enlargement process, they do so VERY slowly, typically taking 12 to 18 months to provide any real symptom relief. The medication must be continued indefinitely—if you stop taking it, the prostate will regrow to it's original size. In addition, because these drugs cause changes in hormone levels, some men will experience sexual side effects such as erectile dysfunction, loss of libido (sex drive), breast tenderness and reduced volume of ejaculate.

Flomax and Uroxatrol are the muscle relaxers—more formally known as alpha-blockers. They work by relaxing the little bits of muscle found throughout the prostate, which leads to reduced constriction of the urethra. Unlike Proscar or Avodart, which can take more than a year to work , Flomax and Uroxatrol usually provide symptom relief within days of starting them. However, they do NOT shrink the prostate at all, and if you stop taking the medication, the symptoms will return within a day or two. Finally, these two muscle relaxers can cause side effects such as dizziness, fatigue, nasal or sinus congestion, erectile dysfunction, and reduced ejaculate volume.

Minimally Invasive Procedures

There are a number of relatively new procedures which are intended to shrink the enlarged prostate by heating the obstructing tissue. These thermal therapies all have one thing in common—they use some type of energy to heat up the overgrown prostatic tissue. The energy may be delivered by microwave (Prolieve, Urologix, TUMT, etc), by radiofrequency current (TUNA) or by laser (Indigo Laser). These procedures are very safe, and usually performed on an outpatient basis under local anesthesia. However, it may take up to three months to see symptommatic relief.

Prostate Surgery

For many years, the gold standard for BPH symptom relief has been the surgical procedure known as a T.U.R.P.—which stands for Trans Urethral Resection of the Prostate. During a TURP, the urologist uses an electrocautery instrument inserted through the penis to trim away the prostate tissue which is causing the blockage. Performed in the hospital under anesthesia, the procedure is sometimes jokingly referred to by patients as a roto-rooter. Because this is a surgical procedure, there is the risk of bleeding and infection, although the procedure is considered very safe—even for men in their 80s or older.

In recent years, a variation on the TURP has been developed which, instead of using electocautery to remove the blocking prostate tissue, uses laser light to vaporize it. This procedure is known as a Laser PVP (Photo Vaporization of the Prostate). Several companies have developed lasers for this purpose, the most widely known being the Greenlight Laser PVP. Laser PVP must also be done under anesthesia, but may result in less risk of blood loss compared to a TURP.