Medical treatment of BPH
While surgery remains the most effective therapy for genuine outflow most men do not require surgery in the first instance.
As mentioned elsewhere, if there are no risk factors and the PSA is normal, many men will be happy with the reassurance that their symptoms are not significantly different from the average for their age. If their symptoms are bothersome however, medical treatment is indicated. In general, men with poor bladder emptying, recurrent infections or a large prostate "middle lobe" tend to have a poor response to medical therapy. There are currently two groups of drugs which have been shown to improve symptoms and flow rates in men with BOO. In addition to thetose medicines a number of herbal or over the counter remedies exist and some men believe that diet plays a part.
Not all men will benefit from drug therapy and of course if symptoms remain bothersome despite treatment, urological referral is appropriate.
Alpha blockers act by relaxing the smooth muscle of the prostate and have varying degrees of selectivity. The major problem with these drugs has historically been of low blood pressure (hypotension), but the most recently developed are more selective and have a lower risk of this. My own practice is to recommend these drugs to men with small prostates (the serum PSA is a good guide to this): normally a selective alpha blocker such as Tamsulosin (Flomax) or Alfuzosin (Xatral) is used. In elderly men who have hypertension, the use of a less selective alpha blocker such as Prazosin may treat both the prostate and the hypertension: this is often a decision for the primary care physician rather than the urologist. Most patients who respond to alpha blockers will have a noticeable improvement in their urinary flow within a few weeks. It may however take some months for storage symptoms to improve.
For men with larger prostates (PSA greater than 2.5 µg /l with no concern about malignancy) there is now evidence that treatment with the 5a -reductase inhibitors Dutasteride (Avodart) or Finasteride (Proscar) can produce a durable reduction in prostate size and symptoms over a long time period by local inhibition of hormonal activity in the prostate. It seems to confer a reduced risk of retention or need for surgery. Patients should however be warned that, unlike alpha blockers, it may take some time before a symptomatic benefit is seen.
Recent studies have suggested an additional benefit in using both drugs together, but there is a significant drop out rate due to side-effects, and it remains to be seen if the economics support the extra cost of two therpies.
Numerous herbal therapies exist and some may be of benefit although most evidence is available for the drugs mentioned above.
A number of plant extracts may be able to shrink the prostate and possibly to reduce the abnormal interaction between prostate glandular cells and their neighbouring cells. Men should be aware that these drugs may cause a drop in the serum PSA, so any man with a worry over prostate cancer should enquire about this before starting treatment.
While the treatments available are in general terms safe if purchased from a reputable supplier, they have not been exposed to long term reviews of their overall safety. The following are treatments with good theoretical reasons for being effective which I have used in the past with success.
Saw Palmetto (Serenoa Repens) extract
This is the extract of a palm which ahs similar properties to Proscar in its effect within the prostate. It may be able to shrink the prostate over a period of months and improve symptoms in this way. My feeling is that the evidence for its effect at present is not as strong as for Proscar. Some side effects (principally sexual) may occur and these will reverse on stopping treatment. There are many preparations of this medicine available: around 750-1000 mg of standardised herbal extract are probably required for it to be effective. This medicine may reduce the PSA levels, so it is advisable to have a PSA check prior to starting therapy.
African Violet (pygeum africanum) extract
A preparation which ahs been shown in the laboratory to have an effect on prostate fibroblasts and which may act by interfering with abnormal signals sent between cells in the prostate. The evidence for its effectiveness is less than for the other treatments mentioned above.
Other Herbal treatments
Claims are made for other treatments including pollen extract, nettle root, pumpkin seeds, rye grass, algal preparations and many other "natural" remedies. While these are unlikely to do any harm I am unconvinced by the current evidence for their use.
Diet in the Treatment of prostate disease
Nutrition and Prostate disease information sheet
There is growing evidence that diet can play a
crucial role in the development and probably also in the progression and
behaviour of some cancers among which prostate cancer is certainly a prime
candidate. What we do know is that some
groups of men are much more likely to get prostate cancer than others and the
risks are modified by diet. For
example, Chinese and Japanese men seem to have one of the lowest risks of
prostate cancer but if they move to a Western lifestyle in the
For patients who are concerned about or who have been diagnosed with prostate cancer, I usually recommend a number of dietary strategies which, while not proven to be of specific benefit in the clinical situation have certainly been shown to have activity in both our research labs and others. There is also mounting evidence for their place in the overall development of the disease and thus strategy to supplement the diet seems sensible.
The first rule is that one shouldn’t change ones life so dramatically that one feels depressed by the changed lifestyle ! Therefore it is important to approach everything in moderation. Certainly men who have a high fat and particularly a high animal fat diet do seem to have increased risk of tumours. In laboratory animals which are fed a higher fat diet the tumours grow at a more rapid rate. I therefore recommend that men should try to cut out where possible, red meat fats and substitute lean poultry, game or fish where appropriate. Green and yellow vegetables particularly those of the brassica (cabbage, cauliflower and broccoli ) family are certainly beneficial in some population studies.
From the point of view of supplementation there is no question that the tomato pigment Lycopene may have an effect in delaying the progression of prostate cancer at least in the very short term and it does seem to be a general protective element in whether men get the disease or not. I therefore recommend a Lycopene supplement in the dose of between 5 to 15mg per day. Lycopene may not be fully absorbed from the gut in the absence of certain vitamins and it is therefore appropriate to take a multivitamin supplement with the antioxidant vitamin E and C included in it.
As mentioned above, Soya seems to have a beneficial effect probably through the chemicals Dadzein and Genestein so a Soya supplement or one Soya protein meal per week will do no harm and may do some good.
Lastly the trace elements zinc and selenium are very important for prostate metabolism ; there is evidence that men who are deficient in zinc may have an increased risk of prostate cancer and certainly there is also evidence that selenium deficiency may also increase the risk of the disease and that selenium supplementation may reduce the risk. To this end I would recommend supplementation of both of these.
To summarise, men who are concerned about their prostate health would do well to follow a diet rich in vegetables and low in animal fat with not too much alcohol. A supplement of Lycopene as well as a Soya supplement make sense and these can be complimented by taking a general antioxidant vitamin supplement as well as a supplement of zinc and selenium.
All of the supplements mentioned above can be obtained from any reputable health food shop although it is still the case that the Lycopene may need to be ordered.
Copyright (c) 1999-2001 GH Muir. All rights reserved.
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