The need for treatment depends on symptoms, test results and whether any complications of BPH have developed, which is unusual. Generally, alternative and drug treatment is used for mild to moderate obstruction and surgery is recommended for severe obstruction and complications of BPH, which can include urinary retention (unable to pass any urine and needs to be relieved by inserting a catheter into the bladder), recurrent urinary infections, bladder stones, ‘overflow’ incontinence and kidney failure.
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Watchful waiting |
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Alternative treatments |
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» nutrition |
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» supplements |
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» herbal remedies |
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Drug treatment |
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» alpha blockers |
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» finasteride |
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Surgery |
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» transurethral resection of the prostate (TURP) |
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» laser vaporisation of the prostate. |
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» laparoscopic prostatectomy |
Watchful waiting
The natural history of urinary symptoms due to BPH is that, if left untreated and over a period of time, one-third will get better (due to the bladder muscle becoming more powerful, so overcoming the obstruction more effectively), one-third get worse and one-third stay the same. This is the rationale for watchful waiting (observation alone) in men with BPH whose urinary symptoms are not particularly bothersome. Men still need follow-up with objective tests as symptoms do not always accurately reflect the degree of bladder obstruction.
Alternative treatments for BPH
Nutrition and the use of supplements and herbs can be used to modify the metabolism of testosterone and oestrogen and so reduce prostate size and hopefully symptoms.
Nutrition
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Eat more fruit, vegetables, whole grains, soy, beans, seeds, nuts, olive oil, and cold-water fish (salmon, tuna, sardines, halibut, and mackerel). |
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Eat less dairy products, refined food, fried foods, hydrogenated oils, alcohol and caffeine. |
Supplements
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amino acids – glycine, alinine and glutamic acid (200 mg of each daily) to reduce urinary frequency urgency and hesitancy. |
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sitosterol – 120 mg daily in 3 divided doses may help reduce symptoms. Taken at a dose of 500 mg 3 times a day beta-sitosterol also lowers cholesterol. |
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flaxseed meal – grind and eat 2-4 tbsp daily. An alternative is to take 1 tbsp of flaxseed oil daily. Flaxseed oil is also a good source of the essential fatty acid alpha-linolenic acid (an omega-3 fatty acid). |
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flower pollen – follow product directions. It has been used in Europe for over 25 years to treat BPH. Flower pollen is not the same as bee pollen. |
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zinc – 30–50 mg daily. Zinc competes with copper for absorption; therefore, when supplementing long term with zinc, copper should also be supplemented. There are supplements available that contain both zinc and copper. |
Herbs
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saw palmetto –reduces the size of the prostate via its oestrogenic effect and so relieves symptoms of BPH. Recommended dosage is 320 mg of extract a day. |
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pygeum – reduces symptoms of BPH. Recommended dosage is 100-200 mg of extract twice a day. |
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stinging nettles – the concentrated extract reduces symptoms. Recommended dosage is 120 mg daily. |
BPH Drug treatment
alpha blockers relax smooth muscle at the exit of the bladder reducing the resistance to urinary flow. Approximately 2/3 patients notice an improvement in symptoms. This family of drugs was originally introduced to control high blood pressure and so is designed to be used daily for several years. Because it lowers the blood pressure it can cause dizziness, headache and tiredness.
5-alpha reductase inhibitors prevent the conversion of testosterone to its more powerful form dihydrotestosterone and so gradually reduce the size of the prostate over a period of years. They are only really effective in men with large (>40 ml) prostates. Possible side effects include reduced libido, impotence, breast tenderness and enlargement and a reduced sperm count. Women who are pregnant must avoid exposure to the drug because of possible side-effects to the foetus.
Surgery for BPH
TURP
Transurethral resection of the prostate (TURP) involves coring out the central part of the prostate (rather like one might core out the centre of an apple) to physically enlarge the channel one passes urine through. It was the first ‘keyhole’ operation and remains the standard to which other operations for BPH are compared. It is performed under general or spinal anaesthetic, usually lasts 30 minutes and involves no incisions on the outside. It is performed using a hot wire loop, which is used to remove the prostate in slivers, inserted into the urethra via a telescope. These are washed out at the end of the operation and a catheter is inserted for 1-2 days, through which irrigation fluid flows into the bladder to rinse any blood in it.
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An occlusive prostate |
TURP in progress |
Patients are discharged from hospital after 3 days and should avoid heavy physical exercise for 2 weeks. Urinary flow is usually markedly improved immediately but frequency may take 6-12 weeks to completely settle. All patients experience retrograde ejaculation after TURP i.e. sperm going back into the bladder at the time of climax, rather than coming out of the penis, and being washed out of the bladder the next time it is emptied. There is also a 5% risk of impotence after TURP, usually in men aged over 70 years.
GreenLight™ photoselective vaporisation of the prostate (PVP)
PVP uses a high-energy laser to vaporize prostate tissue and seal. Its advantages over TURP are less bleeding and a much shorter catheterisation time and hospital stay. The procedure is performed via a telescope inserted into the urethra under spinal or general anaesthetic and usually lasts 30-60 minutes.
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GreenLight laser vaporisation of the prostate |
Laparoscopic prostatectomy
Very large (>200 ml) prostates might be more safely and efficiently removed from the outside-in, as opposed to the inside-out method of telescopic removal. Traditionally, this has been done via an incision on the lower abdomen but can equally be done telescopically using a similar technique to that used to performed laparoscopic prostatectomy for localised prostate cancer (of which I have done more than 1,000 cases), but without the risks to continence or potency.
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