What’s the best treatment for a benign enlarged prostate (BPH)?
The current trend of relieving urological symptoms surgically may only address part of the problem. A holistic approach to optimising metabolic health ensures the best long-term outcome.
Andy, a 62-year-old gentleman, was devastated to discover that he had an enlarged prostate. He initially presented with distressing symptoms of frequency of urine during the day and waking several times at night to visit the toilet. This forced him to rush to go and often could not make it, resulting in accidents. Due to poor stream, he had to strain and did not feel his bladder fully emptied.
Scans showed an enlarged prostate and a biopsy confirmed benign prostate hyperplasia (BPH). As Andy was reluctant to accept a surgical removal, he started taking pills to relax the prostate muscles and open the urinary passage. He was obese with a BMI of 31 and was also taking medications to control his diabetes, high blood pressure and high cholesterol.
“I need to start a trouser fund, as my clothes are falling off me”
Being put on yearly scans to follow his prostate progress and to ensure that it did not turn malignant made Andy very distressed, so he eventually attended The Vitality Clinic, hoping for treatment to resolve his condition naturally and effectively.
After a few months on a personalised healthcare plan that included a healthy diet, regular exercise, and appropriate dietary supplements, he reported, “I need to start a trouser fund, as my clothes are falling off me.”
He had lost more than 10% of his body weight (10 kg), and his blood pressure, blood sugar, and cholesterol were all normalised. More importantly, his urology symptoms improved significantly, and he was highly reassured. He has less urinary frequency and urgency and enjoys uninterrupted sleep at night, with no further accidents.
Benign prostate hyperplasia or enlargement is an unregulated overgrowth of the prostate gland, causing bladder outlet obstruction. This blog will discuss whether BPH is a hydraulic problem that should always be managed surgically or a metabolic problem that will benefit from a holistic approach centred on lifestyle modification. Also – does it turn into cancer? And what are the common complications?
BPH is highly prevalent in older men, affecting 60% of men over 50, increasing to 80% in those over 70. It is ranked the fourth most prevalent disease in men over 50.
Is BPH a metabolic condition?
Growing evidence shows that BPH is a metabolic disorder triggered and fuelled by metabolic disease. We will look at the research a little later.
The enlarged prostate results in distressing lower urinary tract symptoms (LUTS) with a negative impact on quality of life. However, studies have reported that up to 50% of men presenting with LUTS also have metabolic syndrome. Despite this, diagnosis and treatment of BPH usually occur in the urology surgical department.
Understanding the relationship between metabolic syndrome, LUTS, and BPH would help us devise a practical approach to BPH and LUTS.
Prostate growth and development
Androgen plays an essential role in the development of the male genital tract. It promotes growth and differentiation of the prostate gland, which weighs 1.5 grams at birth and 10 grams in early puberty, doubling by age 20. Prostate size then remains constant until mid-late adult life. At this stage, instead of whole gland growth, selective growth involves the periurethral (around the urethra) zone, the site involved in developing BPH. This can manifest as a benign prostate enlargement or prostate obstruction, both associated with the development of progressive LUTS.
LUTS start as frequency of urine, urgency, hesitancy (difficulty initiating urination), need to strain, weak urine stream, inability to empty the bladder fully, nocturia, and urinary incontinence.
Evidence that metabolic syndrome causes BPH
We will review the medical literature on the link between BPH and metabolic risk factors, such as central obesity, hypertension, high blood glucose, abnormal blood fat – high triglyceride, and low HDL (good) cholesterol.
In the Baltimore Study, obese individuals were 3.5 times more likely to have an enlarged prostate than slim participants. Each one-unit increase in BMI corresponded with a 0.41 mL increase in prostate volume.
Hypertensive patients in another study had larger prostate and a higher annual benign prostate growth than controls. Another study with 2,372 participants found that hypertensives were more likely to suffer from LUTS.
Abnormal blood fat (dyslipidaemia) was significantly associated with BPH. In Taiwan, men with BPH had significantly higher total and LDL but lower HDL cholesterol levels than men without BPH.
An American study of 51,529 men aged 40–75 enrolled and followed for more than 16 years confirmed that central obesity was associated with the incidence and progression of LUTS.
In one substantial study, those with central obesity (waist size >109cm) had a 2.4-fold greater likelihood of being surgically treated for BPH than those with a waist size of <89cm.
Another multi-centre study also suggested that central obesity (waist >102cm) was the main factor in determining BPH post-surgical complications.
How metabolic syndrome causes BPH
Metabolic syndrome results in high insulin (hyperinsulinaemia) and impaired glucose metabolism. High insulin promotes prostate cell proliferation, resulting in benign prostatic hyperplasia (BPH) and prostate enlargement.
High insulin also interferes with the androgen level, which is necessary for the development of the male genital organ. Insulin increases the sex hormone binding globulin (SHBG), which binds androgen, leaving a low effective free androgen. However, belly fat releases more oestrogen. The imbalance between androgen and oestrogen can lead to prostatic hyperplasia.
Again, belly fat releases aromatase, an enzyme that converts testosterone into oestrogen. Raised oestrogen exerts negative feedback on the brain (pituitary gland and hypothalamus). This inhibits gonadotropin release and, consequently, androgen production. The “double whammy” results in a hypogonadism state.
Hormonal imbalance explains why BPH does not happen in men who have their testicles removed earlier in life.
Can BPH be cancerous?
BPH is not a precancerous condition and does not increase the risk of prostate cancer. It is the most common benign cancer. It occurs in the periurethral (central) part of the prostate, while cancer usually happens in the periphery (outer zone) of the prostate. BPH does not lead to cancer, but BPH and prostate or bladder cancer can coexist in the same patient.
BPH can increase prostate-specific antigen (PSA) levels but to levels far less than those diagnostic for prostate cancer.
Previously, digital rectal examination (DRE) helped distinguish between normal and enlarged prostates. A benign prostate surface feels smooth, while a malignant prostate feels hard and lumpy. DRE lost its clinical value with the availability of modern medical technology.
Complications
If you have symptoms of BPH, you should visit your doctor. This condition can result in acute urinary obstruction, which is very distressing and often requires a long-term indwelling catheter. Without treatment, it can obstruct the urinary passage, causing stasis, recurrent urinary infections and bladder stones. The obstruction can progress to cause back-flow of urine into the kidneys, damaging them and resulting in chronic renal (kidney) failure.
Other closely related metabolic conditions
Erectile dysfunction (ED) and hypogonadism can be other manifestations of the metabolic problem. High insulin impairs vascular nitric oxide production, which is essential for erection and vascular health. Insulin lowers effective free androgen (see above). This interferes with the development of the gonads, resulting in hypogonadism (shrinkage of the sex organ) and loss of sexual function.
Treating insulin resistance should, therefore, benefit ED and hypogonadism.
Management
With the medical establishment currently focused on managing the urological problem, it will take a significant effort to convince the public and profession to correct metabolism instead of managing BPH and associated LUTS.
However, we can address modifiable risk factors, such as poor diet, lack of physical activity, smoking and drinking habits. In that case, we can avoid or reverse metabolic syndrome and related BPH and LUTS.
I will quote some study results that confirm the effectiveness of natural solutions.
Obesity, exercise and weight reduction
Substantial evidence in the medical literature suggests that weight loss of more than 10% of body weight improves metabolism and positively impacts BPH and associated LUTS.
In a Korean study, physical activity played a role in LUTS incidence. Sedentary men experienced severe LUTS, while those pursuing more physical activity were less likely to suffer.
An Australian study of men aged ≥45 years demonstrated that severe LUTS decreased with increasing physical activity.
Fruit and vegetables
High levels of fruit and vegetables were significantly associated with lower BPH symptoms. Other studies found that eating more dark and leafy vegetable significantly reduced the risk of LUTS. Again, high intake of fruit and vegetables rich in β-carotene, lutein, and vitamin C via diet, not supplements, was inversely related to BPH.
In Chinese men, alcohol consumption of seven drinks or more per week is independently associated with an increased risk of moderate to severe LUTS.
However, green tea and saw palmetto may shrink the prostate naturally, which helps relieve LUTS.
Conventional treatment may help, but at a high cost – statins
Few reports claimed that statin significantly reduced prostate volume, improved LUTS, and slowed the clinical progression of BPH, possibly by lowering cholesterol and inflammation levels.
The decrease in prostate volume was more significant in those who received simvastatin than atorvastatin, in obese than normal weight patients, and in those with abnormal than normal blood fat following the statin interventions. The reduction in prostate volume was related to decreased total cholesterol and IL-6 (inflammation marker) levels and increased HDL (good guy) cholesterol.
Moderate or severe LUTS was more significant in men with diabetes compared with men without diabetes. For the men suffering from diabetes, those taking metformin had a lesser chance of suffering moderate or severe LUTS than those who did not. However, prostate volume and PSA level were not significantly associated with diabetes treatment.
In women, changes similar to BPH occur in the ovaries, resulting in polycystic ovary syndrome (PCOS). This usually presents with excessive body hair and infertility in obese ladies. We will discuss this in detail in our next blog.
So, my friends, you can see that, whilst benign prostate enlargement CAN be managed surgically, the underlying metabolic risk factors that may have caused the problem in the first place are in this way ignored, leaving them to trigger far more severe issues – heart disease, diabetes, dementia, stroke – in later life.
So, if you do have LUTS or an enlarged prostate (BPH), checking and managing your metabolic components may resolve both the immediate prostatic problem AND your longer-term health endangerment.
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References
Metabolic syndrome and benign prostatic hyperplasia: An update
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5717972/
Metabolic Syndrome and Benign Prostatic Hyperplasia: Evidence of a Potential Relationship, Hypothesised Aetiology, and Prevention
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3162215/
Benign Prostatic Hyperplasia: A New Metabolic Disease of the Aging Male and Its Correlation with Sexual Dysfunctions
https://onlinelibrary.wiley.com/doi/10.1155/2014/329456
Androgen action in prostate function and disease
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5902724/
