BPH ( Benign prostatic hyperplasia) – NON SURGICAL MANAGEMENT

Benign prostatic hyperplasia (BPH), also called benign enlargement of the prostate (BEP), adenofibromyomatous hyperplasia and benign prostatic hypertrophy, prostate gland enlargement can cause bothersome urinary symptoms. Prostate problems are common in men 50 and older. Benign prostatic hyperplasia is nonmalignant (noncancerous) enlargement of the prostate gland. Untreated prostate gland enlargement can block the flow of urine out of the bladder and can cause bladder, urinary tract or kidney problems.

The prostate is a small organ about the size of a walnut. It lies below the bladder (where urine is stored) and surrounds the urethra (the tube that carries urine from the bladder). The prostate makes a fluid that helps to nourish sperm as part of the semen (ejaculatory fluid).

Causes and Risk Factors of BPH

·      Aging - Prostate gland enlargement rarely causes signs and symptoms in men younger than 40. By 55, about 1 in 4 men have some signs and symptoms. By 75, about half of men report some symptoms.

·      Family history. Having a blood relative such as a father or brother with prostate problems means more likely to have problems as well

·      Excessive DHT: DHT (dihydrotestosterone), a substance that is the result of a conversion of testosterone by an enzyme called 5-alpha reductase. BPH is an “androgen-dependent disease,” which means it is influenced by the male hormone (androgen) testosterone. The prostate will not grow unless it is “directed” to do so by testosterone, which is made mainly by the testes

·      Elevated estradiol: It’s natural for men to have some of the female hormone estrogen (in the form of estradiol). When estradiol levels are too high, however, and the ratio is out of balance, men can experience fatigue, increased body fat, loss of libido and an enlarged prostate. An imbalance between estrogen and testosterone increases DHT activity, and thus encourages prostate cells to grow.

·      Overweight/Obesity: Being overweight, especially around the midsection, raises the risk of excessive prostate growth. The link between obesity and BPH may be related to the reduced testosterone levels seen in the obese. Also, a drop in testosterone means there’s an accompanying rise in estrogen levels, which can increase the activity of DHT and thus prostate growth.

·      Diabetes mellitus : Having diabetes increases the risk of developing BPH, perhaps significantly. The diabetes-BPH link may also be related to the damage that diabetes does to blood vessels. If the vessels that service the prostate are damaged, an enlarged prostate may be the result. 

·      High “Bad” Cholesterol : Those who had higher levels of the notorious “bad” cholesterol, low-density lipoprotein (LDL), were more likely to develop BPH than men who had normal LDL levels. (Parsons 2008) When the researchers divided the men into three groups (high, medium, low), those with “high” LDL levels were four times more likely to have BPH than those in the “low” group.

·      High blood pressure: Although no one is exactly sure how high blood pressure may trigger or worsen BPH, researchers have found a link between hypertension and BPH. 

·      Sedentary lifestyle: A lack of exercise may increase your chances of developing BPH, possibly because exercise helps fight obesity, type 2 diabetes, insulin resistance, and other risk factors associated with BPH.

Clinical Features:

Symptoms are classified as storage or voiding

·      Storage symptoms include urinary frequency, urgency, urgency incontinence, and voiding at night (nocturia).

·       Voiding symptoms include urinary stream hesitancy (needing to wait for the stream to begin), intermittency (when the stream starts and stops intermittently), straining to void, and dribbling. Pain and dysuria are usually not present. 

·      Urinary frequency - The need to urinate frequently during the day or night (nocturia), usually voiding only small amounts of urine with each episode

·      Urinary urgency - The sudden, urgent need to urinate, owing to the sensation of imminent loss of urine without control

·      Hesitancy - Difficulty initiating the urinary stream; interrupted, weak stream

·      Incomplete bladder emptying - The feeling of persistent residual urine, regardless of the frequency of urination

·      Straining - The need strain or push (Valsalva maneuver) to initiate and maintain urination in order to more fully evacuate the bladder

·      Decreased force of stream - The subjective loss of force of the urinary stream over time

·      Dribbling - The loss of small amounts of urine due to a poor urinary stream

·      Physical examination over the suprapubic area for signs of bladder distention and a neurological examination for sensory and motor deficits.

·      The digital rectal examination (DRE) is an integral part of the evaluation in men with presumed BPH. During this portion of the examination, prostate size and contour can be assessed, nodules can be evaluated, and areas suggestive of malignancy can be detected. Findings suggestive of Benign Prostatic Hyperplasia are Symmetric prostatic enlargement, Smooth and Firm but elastic 

Lab Tests Used to Diagnose BPH

Several tests help the physician identify the problem and decide treatment to be needed. The tests vary from patient to patient, but the following are the most commonly used tests to diagnose BPH and other problems in the urinary tract:

·        Digital rectal exam

·        Prostate specific antigen test (PSA test):- PSA stands for Prostate Specific Antigen and is a protein enzyme made in your prostate gland

·        Rectal ultrasound 

·        Urine flow study

·        Cystoscopy.

Risk Analysis and PSA Range - Normal: 0-4 ng/ml, Slightly Elevated: 4-10 ng/ml, Moderately Elevated: 10-20 ng/ml, Highly Elevated: 20+ ng/ml.

Complications

Complications related to bladder outlet obstruction secondary to BPH include the following: Urinary retention, Renal insufficiency, Recurrent urinary tract infections, Gross hematuria, Bladder calculi, Renal failure or uremia (rare).

Management:

Lifestyle changes and Natural remedies

Making some lifestyle changes can often help control the symptoms of an enlarged prostate and prevent your condition from worsening. Try these measures:

·        Limit beverages in the evening. Don't drink anything for an hour or two before bedtime to help you avoid wake-up trips to the bathroom at night.

·        Don't drink too much caffeine or alcohol. These can increase urine production, irritate your bladder and worsen your symptoms.

·        Limit decongestants or antihistamines. These drugs tighten the band of muscles around your urethra that control urine flow, which makes it harder to urinate.

·        Go when you feel the urge. Try to urinate when you first feel the urge. Waiting too long to urinate may overstretch the bladder muscle and cause damage.

·        Schedule bathroom visits. Try to urinate at regular times to "retrain" the bladder. This can be done every four to six hours during the day and can be especially useful if you have severe frequency and urgency.

·        Stay active. Inactivity causes you to retain urine. Even a small amount of exercise can help reduce urinary problems caused by an enlarged prostate.

·        Urinate — and then urinate again a few moments later. This is known as double voiding.

·        Keep warm. Colder temperatures can cause urine retention and increase your urgency to urinate.

·        Increase intake of fruits, vegetables and whole grains, soy, and green tea, foods rich in omega 3 oils (cold-water fish – salmon, sardines, mackerel) and in zinc (raw pumpkin seeds for omega-3 and zinc)

·        reduce foods high in fat and cholesterol (butter and margarine, beef and
whole milk), sweet foods, and refined carbohydrates (white bread and white-flour pasta)

Some of the herbal treatments that have been suggested as helpful for reducing enlarged prostate symptoms include:

·        Saw palmetto extract, made from the ripe berries of the saw palmetto shrub

·        Beta-sitosterol extracts, made from several plants, such as certain grasses and trees

·        Pygeum, an oil made from the bark of an African prune tree

·        Ryegrass extract, made from ryegrass pollen

·        Stinging nettle extract, made from the root of the stinging nettle plant

Homoeopathic Management

Homoeopathy considers the person as a whole, and takes account of the physical and psychological characteristics of the patient. It involves a detailed case history, which serves as ray of hope to both the patient- i.e., the one who is abused, as well as the offender. The patient has an opportunity to be heard and understood from her own perspective .After careful case taking and analyzing the case, the homeopathic physician decides on the remedy which suits the patient’s needs. The remedy is chosen depending upon the patient’s characteristic traits and symptoms. This list of remedies is meant for use with the guidance of a qualified homoeopath.

An clinical trail has been conducted in 220 men’s (aged 30-90 years) suffering from BPH in odisha india. This study compared homeopathic treatment strategies using constitutional medicines (CM) or organopathic medicines(OM) alone or in combination(BCOM) in patients suffering from BPH. The study result shows treatment response was highest with BCOM (38.24%) compared to OM (31.62%) and CM (30.15%).

Apis mellifica: Stinging pain during urination that is worse when the final drops are passing is a strong indication for this remedy. Discomfort may also involve the bladder. The prostate area is swollen and very sensitive to touch. The person may feel worse from heat and from being in warm rooms, with improvement from being out in open air or from cool bathing.

Causticum: Urine loss when the person coughs or sneezes often indicates a need for this remedy. Once urine has started passing, the person may feel pressure or pulsation extending from the prostate to the bladder. Causticum is also indicated when sexual pleasure during orgasm is absent or diminished.

Chimaphilla umbellata: This remedy is often helpful when the prostate is enlarged, with urine retention and frequent urging. The person may have the feeling that a ball is lodged in the pelvic floor, or experience pressure, swelling, and soreness that are worse when sitting down.

Clematis: This remedy is often indicated when swelling of the prostate seems to have narrowed or tightened the urinary passage. Urine usually emerges slowly, in drops instead of a stream, with dribbling afterward.

Conium :

This remedy is useful in chronic hypertrophy of the prostate with difficulty in voiding urine, it stops and starts and there is an accompanying catarrh of the bladder. The suitability of conium to the complaints of the aged should be considered. Depressed, timid  with weak memory.

Lycopodium: This remedy may be helpful if urine is slow to emerge, with pressure felt in the prostate both during and after urination. The prostate is enlarged, and impotence may also be a problem. People who need this remedy often suffer from digestive problems with gas and bloating, and have an energy slump in the late afternoon.

Pulsatilla: Prostate problems with discomfort after urination and pains that extend to the pelvis or into the bladder (often worse when the man is lying on his back) suggest a need for this remedy. There may also be a bland, thick, yellow discharge from the penis. Pulsatilla is usually suited to emotional individuals who want a lot of affection and feel best in open air.

Sabal serrulata: A frequent urge to urinate at night, with difficulty passing urine, and a feeling of coldness in the sexual organs, suggest a need for this remedy. It is sometimes also used in lower potencies for urinary incontinence in older men. This remedy is made from saw palmetto which is also used as an herbal extract for similar prostate problems.

Staphysagria: This remedy may be indicated if a man feels burning pain in his urinary passage even when urine is not flowing, and urine retention is troublesome. Men who are likely to respond to Staphysagria are often sentimental and romantic, and may also have problems with impotence (most often caused by shyness).

Thuja: When the prostate is enlarged, and the person has a frequent urge to urinate, with cutting or burning pain felt near the bladder neck, this remedy may bring relief. After urine passes, a dribbling sensation may be felt. A forked or divided urine stream is sometimes seen when this remedy is needed.