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Patient Information: BPH treatment

URO SPECIAL. Special pages for special problems. Information on frequent urological problems. Impotence - Interstitial Cystitis - Vasectomy Reversal   KIDNEY. An introduction about the location and form of the kidneys, and their function in daily human life. About what may go wrong and how to find out. And what can be done about it.   BLADDER. Where is it located and what is it for. Can it cause trouble; and if it does, what kind of trouble. Which examinations exist. Which kind of solutions are there when it does not function properly.   PROSTATE. An organ that, especially in the elderly, is quite often thought and talked about, although many do not know what it is for and/or where it can be found. How does one go about to find out whether the prostate does or does not do what it is intended to do, whether it is obstructing etc. How can problems be solved. Included is a questionnaire to get an estimate on the severity of urinating problems.   PENIS. An organ that, especially in the younger, is quite often thought and talked about, while most do know what it stands for and how it looks like. Many people, however, do not know how it (he) works and what can be done if it (he) does not work.   TESTICLE. Like the kidneys, the testicles are supplied in duplicate. They harbour two distinct functions. What can go wrong and how can we solve that. How can the testicles be tested.   UROLOGY. What kind of doctor is a urologist anyway, what does he/she do. Which part of the body 'belongs' to the 'urologic area'. Also the location of the small print. UROPANEL: questions to the urologists' panel.
BPH Treatment
Based on information from various sources

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What is BPH?


PROSTATEThe prostate is a relatively small chestnut-sized organ, which only exists in the male and is to be found right underneath the bladder at the beginning of the urethra. At its front lies the pubic bone and at its backside the rectum. The prostate encircles the urethra. The prostate is a gland and consists of billions of small tubes that secretes seminal fluid, a milky substance that combines with sperm produced in the testicles to form semen (i.e. nearly 95% of semen volume is prostate fluid). During sexual climax, muscles in and around the prostate propel this mixture through the urethra and out through the penis.

In a number of men, the prostate can get enlarged during the years: Benign Prostatic Hyperplasia or BPH. It remains unknown why this happens only in a great number, but not in all men. Although the male sex-hormone testosterone is necessary for a normal development and growth of the prostate ('without testosterone no enlargement'), a very high testosterone production (the testosterone level may be quite different between men) does not automatically lead to BPH.
Also, an enlarged prostate does not always produce symptoms. Some men have a very large prostate, but have no difficulty passing urine; other men can not pass urine at all, but have only a slightly enlarged prostate.
When BPH does give trouble, it usually starts off with a loss of strength of the urinary flow. It takes longer for the bladder to empty. This is caused by the enlarged prostate (which is wrapped around the urethra) constricting the urethra, diminishing the passage of urine and causing a diminished flow. The flow will decrease over a period of many years, so it often goes unnoticed. Moreover, a lot of men think that a diminished flow comes naturally with age. In time, the enlarged prostate will start irritating the bladder, causing some men to go to the toilet more often, while even at night they may have to get up several times to pass urine.
Fortunately, the bladder, which acts as an engine for the urinary flow, is capable of enhancing its strength during the years. This is often visible as large muscle bundles at cystoscopy. Unfortunately, this gathering of strength of the bladder can not go on forever: at a certain point the bladder is at the top of its strength and it will fail the competition with the ever growing, ever more constricting prostate. From this moment on the bladder will not be able to empty itself completely. If the prostate keeps on growing, ever increasing amounts of urine will remain in the bladder after 'emptying' it; this is such a slow process, that it will generally not be noticed - right until, often after a party (alcohol has a negative effect on muscle strength as a whole, and bladder strength in particular), the patient is unable to pass urine altogether.

Of course, it does not have to come this far. Sometimes, the prostate just stops growing any further. Often, the prostate may stop growing for several years and thereafter start growing again. In a number of cases, the symptoms will cause the patient to go to his doctor: a weak flow of urine, trouble starting voiding, dribbling after passing urine, going to the toilet more often. In other cases, complications will be the reason to visit the doctor:

Prostatic cancer fortunately does not belong to the list.

Nowadays, most men arrive at the doctors office in time. If treatment is postponed for too long, then either therapy gets more difficult or even impossible (when the bladder is distended beyond repair). Elsewhere on UROlog you will find a questionnaire, helping you to find out whether it is necessary to consult a doctor for your voiding problems or not. If you have problems passing urine, but the answer provided by the questionnaire still leaves you in doubt, you are advised to consult you doctor. Possible further urological examinations are:

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Why treat it?


Benign Prostatic Hyperplasia is a name for prostate that has grown bigger in a non-cancerous way. Nothing else. It is not a description of symptoms and many cases of BPH never need to be treated. If symptoms do arise, then they are mild in many cases. Often, elderly men need more time to get all urine out of their bladder because of obstruction of the stream by BPH, but many are pensioners and don't really mind: 'sure it takes me more time to pee, but then, so what? I've got all the time in the world!'.
As long as the patient is not ready for therapy of his BPH, there is no good reason for therapeutic action, unless delaying therapy would cause irrepairable damage. This could be the case when recurring bladder infections could lead to life-threatening kidney infections or worse, when the bladder becomes overstretched, when bladder stones get formed, etcetera. In those cases, treatment is indicated even when the patient sees no reason for it symptom-wise.

On the other hand, there are other diseases that can cause the same symptoms as BPH, like urethral strictures (a narrowing of the urethra), obstructing bladder stones or even bladder tumors that obstruct the outlet of the bladder. The symptoms associated with BPH are therefore nowadays called LUTS, Lower Urinary Tract Symptoms, to indicate that they may be caused by other things than just BPH - even women can have LUTS.
So in case of symptoms, it is a good idea to have it checked out, not only to come to the right diagnosis, but also to get an idea of the seriousness of the problem. Apart from that, looking into LUTS may reveal an early, and treatable, case of prostate cancer.

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Wait and See


Also called 'Watchful Waiting', this is not an actual treatment, but a process that involves having periodic examinations - about once a year - to see if your symptoms are causing you problems or becoming worse. Tests, like determining the strength of urine flow and the amount of urine that's left in the bladder after urinating, may help to determine if symptoms get worse. Often, a questionnaire will be repeated every now and then, since symptoms often develop so slow that a worsening can be hard to detect. Patients often are advised not to drink liquids before bedtime.
In most cases, the risks associated with 'watchful waiting' are small. Rarely a patient's symptoms may worsen rapidly and lead to a complete inability to urinate (acute urinary retention), bleeding, infections or damage to the kidneys or bladder. For the most part, however, progressive BPH is a gradual process, and patients usually will report a worsening of their symptoms or have them detected during a periodic examination before such dramatic problems result.

A further advantage of 'watchful waiting' is that prostate cancer checkups may also follow the same schedule and only involves a minor 'extra', like digital rectal examination and taking blood samples.

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Medication


Two types of drugs have proven successful in treating BPH. These are finasteride and dutasteride (marketed under the name Proscar™ and Avodart®) and the so-called alpha blockers.

Finasteride (Proscar™)and dutasteride (Avodart®)
Prostate growth is stimulated by testosterone, the male sex hormone. Within the prostate cell, testosterone is converted to dihydrotestosterone (DHT), which then stimulates prostate growth, although the original hormone(testosterone) has a stimulating effect of its own.
Finasteride, taken orally once a day, limits the production of DHT. In about fifty percent of men, the prostate will start to shrink, although this will take at least 6 months, while treatment usually lasts a few years, sometimes forever. The diminished prostate size will get urinary problems to improve or disappear.
Possible side effects of Proscar include difficulty achieving an erection and a decrease in sperm. A positive side effect may be that the rate of getting bald may go down (male baldness is partly influenced by hormones). Because Proscar is a relatively new drug, its long-term risks and benefits have not been fully documented.
The problem with Proscar is that the effect is only slightly better than a placebo, i.e. a 'fake' drug. This means that in many men the effect will either be absent or too weak to be detected. It does have a slightly better effect in larger prostates, so many urologists reserve the use of Proscar for patients with moderate BPH symptoms and a large prostate.

Alpha blockers
Muscle fibers can be found in and around the prostate. The prostate produces seminal fluid, which is pushed out through the urethra during orgasm. This is the reason why these muscle fibers are there: to give that push. Unfortunately, these fibers also continuously compress the prostate a bit, and thereby also compress the urethra running through it.
Alpha blockers are a family of drugs that cause the muscles of the bladder neck and prostate to relax, producing an increase in urinary flow and improvement in BPH symptoms in about seventy percent of men. The alpha blockers must be taken continuously. They will not stop prostate growth, however, so the prostate may 'outgrow' the medication. Alpha blockers typically are taken orally once or twice a day.
Alpha blockers can have side effects, mainly dizziness and slight low blood pressure when standing up. Some patients may experience a socalled retrograde ejaculation or 'dry climax', a condition in which semen enters the bladder rather than being expelled through the penis. This has no impact on the feeling associated with orgasm. Although the semen is later harmlessly flushed out with urine, men with retrograde ejaculation may be sterile (unable to father children). Some of the side effects appear to be related to dosage levels. The newer alpha-blockers are more targeted towards the prostate and usually have less side effects. Alpha-blockers were initially used to lower bloodpressure, when it was found that a decrease of BPH symptoms was one of the side effects.
The following are among the most commonly prescribed alpha blockers:

  • Prazosin (Minipres™)
    Prazosin, marketed under the brand name Minipres™, is one of the first alpha-blockers to be used for BPH. It is probably the cheapest on the market.
  • Doxazosin (Cardura™)
    Doxazosin, marketed under the brand name Cardura™, is often used for both high blood pressure and BPH symptoms.
  • Terazosin (Hytrin™)
    Terazosin, marketed under the brand name Hytrin™, is one of the more recent additions, which can be taken once daily. Since it may cause blood pressure problems, its use must be carefully monitored.
  • Tamulosin (Flowmax™/Omnic™)
    One of the newer alpha blockers, tamsulosin typically produces few of the most commonly reported side effects. It is taken once daily.
  • Alfuzocin (Xatral™)
    Also one of the newer drugs, alfuzocin comes in different dosages: once, twice and three times daily.

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Thermotherapy


Transurethral microwave thermotherapy (TUMT) uses a special catheter with a tip containing an antenna to deliver microwave energy to the prostate, thus causing high temperatures within the prostate without affecting adjacent structures. The heat will kill prostate cells, so the prostate will effectively become smaller and less obstructing to urine flow. Sensors on the catheter and on a tube in the rectum enable monitoring of the temperatures throughout the procedure, and a cooling system circulates water within the catheter to protect the urethra. The procedure takes about an hour and is performed on an outpatient basis without anesthetic.
Due to the heating of the prostate and the resulting irritation, the prostate may swell up right after therapy, so usually afterwards a catheter is placed that will remain for about a week. The damaged prostate cells will be broken down by the body and its molecules re-used, a process that may take several months. Symptoms may start decreasing three weeks after TUMT.


Advantages of TUMT include the low impact of therapy on the physical condition and most patients resume normal activity immediately after treatment. There is virtually no blood loss through the urine. Disadvantages include the time it takes for the prostate to become smaller and a small chance on permanent retrograde ejaculation, i.e. a condition in which semen enters the bladder rather than being expelled through the penis. This has no impact on the feeling associated with orgasm. Although the semen is later harmlessly flushed out with urine, men with retrograde ejaculation may be sterile (unable to father children). The decrease in prostate size is less than achieved with surgery, while not all prostates are good candidates for TUMT.
Thermotherapy of the prostate is a recently added technique, which is still very much under development. There are a few companies that manufacture TUMT machines:
  • Prostatron™
    The first to enter the market for TUMT, many patients have been treated by a machine from this French company. In the early years, the effects of TUMT were minimal, but recent advances have proved that it works
  • Targis™
    The Targis™ is manufactured in the USA and offers a more targeted microwave delivery to the prostate, which has the advantage of a higher temperature in the prostate while the surrounding tissues are left unaffected. The treatment time can thus be shorter.
  • Prostalund™
    A TUMT machine made in Sweden, it represents the latest addition to the TUMT family, although it offers little more than the earlier machines.

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LASER


High-energy light beams called lasers can be applied to a variety of surgical applications. The high temperature induced by a laser beam vaporizes human tissue. Using a modified cystoscope or transrectal ultrasound, the laser can be aimed at the prostate. Either general or spinal anaesthesia will be needed. The advantage of the use of laser for BPH are less blood loss than ordinary prostate surgery and quicker recovery. The procedure is less demanding of the patient than other surgical procedures. One of the drawbacks is the small amount of prostate tissue that can be removed with this technique, while the high temperatures involved may cause longlasting frequent urination due to bladder irritation. These two disadvantages have slowed down the initial advance of lasers in urology. Many urologists still use lasers, which have proved to be especially useful in rather small types of BPH. The following are the main laser treatments.
  • TULIP
    TransUrethral Laser-Induced Prostatectomy (TULIP) involves longitudinal cuts at the inside of the prostate under ultrasound guidance, thereby cutting restraining circular fibers, so the prostate may expand outwards, thereby diminishing the pressure and 'opening up' the urethra. It is a rather old technique that is not used much anymore, because successrate, i.e. improvement of symptoms, is low.
  • VLAP
    Visual Laser Ablation of the Prostate (VLAP) usually involves a socalled side-firing laser under cystoscopic guidance, i.e. the laser beam is deflected 90 degrees to the side. This enables vaporization of more prostate tissue than with TULIP and actually decreases prostate size.
  • Contact Laser
    This technique resembles the VLAP, although now the laser is brought into actual contact with the prostate tissue, whereas the VLAP needs to be held at a certain distance to avoid getting the laserprobe dirty.
  • Interstitial Laser Coagulation
    This procedure introduces a special fiberoptic probe directly into the prostate. At certain spots a controlled amount of obstructing prostate tissue is vaporized. The process is repeated as needed, and takes about 30 to 60 minutes to perform on an out-patient basis.
Apart from different techniques to apply laser light to prostate tissue, also different types of laser exist, each with its own technical pro's and con's.


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TURP


About 90% of all surgeries for BPH involve transurethral resection of the prostate (TURP). This procedure requires no external incision and takes about 90 minutes. It is considered the 'golden standard' in BPH treatment and all other therapies are compared to TURP.
After giving anesthesia, the urologist inserts an instrument called a resectoscope into the penis through the urethra. It resembles a cystoscope and contains a light, valves for controlling irrigating fluid and an special high-frequency electrical loop to cut tissue and seal blood vessels. This loop is used to remove the enlarged tissue in little pieces, small enough to fit through the resectoscope. The irrigating fluid is used to flush the prostate continuously and thus keep visibility at maximum. At the same time the resected pieces of prostate tissue are temporarely flushed into the bladder and flusehd out again at the end of the operation.
Patients usually must remain in the hospital for about 3 days after TURP surgery, during which a catheter must be used to drain their urine and flush out blood clots that may have been left after the surgery. After that, recovery usually is quick. Most men find their BPH symptoms improve rapidly and are able to return to work within a month.

Advantages of TURP are the quick recovery compared to the open prostatectomy and the fact that much more tissue can be removed than with the other semi-surgical means (Laser, TUMT). Disadvantages include the need for anaesthesia, possible blood loss during surgery, while recovery may take some time. The endresult in terms of improvement of symptoms is often remarkable, although urination may be too easy in te beginning when a new anatomical situation has to be incorporated into urinary functions. The most common, unavoidable, permanent side effect of prostate surgery is retrograde ejaculation ('dry climax'), which results when the tiny sphincter muscle that usually blocks off the bladder during ejaculation is cut during surgery, which is always the case. Semen then enters the bladder instead of being expelled through the penis, so the patient will be unable to father (any more) children.

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TUIP


When only part of the prostate is enlarged, it often causes narrowing of the bladder exit, the bladder neck.
In that case, a TUIP, transurethral incision of the prostate, may be advised. This procedure widens the urethra by making several small cuts in the neck of the bladder and in the prostate itself. This opens up the bladder exit and therefore makes urination easier. It is not a true alternative for other BPH therapies, since it only addresses a special kind of BPH.
The procedure is rather simple and not very demanding for the patient. It resembles a TURP and often nearly the same equipment is used for the procedure. General or spinal anaesthesia and a few days' in hospital will be needed and a catheter will be placed for a few days. Recovery is even quicker than with TURP. The endresult in terms of improvement of symptoms is good, although urination may be too easy in te beginning when a new anatomical situation has to be incorporated into urinary functions. The most common, unavoidable, permanent side effect of TUIP is retrograde ejaculation ('dry climax'), which results when the tiny sphincter muscle that usually blocks off the bladder during ejaculation is cut during surgery, which is always the case in TUIP or even intended. Semen then enters the bladder instead of being expelled through the penis, so the patient will be unable to father (any more) children.

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Open Prostatectomy


If the prostate is greatly enlarged an open surgical procedure called a prostatectomy (removal of the prostate) may be necessary. This procedure is not to be confused with the radical prostatectomy, which is used in case of prostate cancer and is an entirely different type of surgery.
The patient receives spinal or general anaesthesia and the urologist makes an external incision, usually in the lower abdomen but sometimes in the perineum (the area between the rectum and the scrotum), depending upon the preference and experience of the urologist. Both approaches have the same effect and share the same (dis)advantages. The urologist opens the prostatic capsule, the 'skin' of the prostate and proceeds to remove the enlarged part of the prostate, which can often be easily freed from the surrounding normal prostatic tissue. A catheter is put through the urethra and in the bladder, which will remain inside for 5-7 days. The prostatic capsule is then closed again. Because it takes some time for the capsule to become watertight, the catheter is left for 5-7 days. In the mean time, it can be used to flush the bladder of blood clots and to drain urine from the bladder. The procedure is typically used for bigger prostates, when a TURP is impossible or would take too much time to perform.

The advantage of an open prostatectomy is the great amount of tissue that can be removed. Disadvantages include the need for anaesthesia, possible blood loss during surgery, and the fact that recovery may take some time. The endresult in terms of improvement of symptoms is often very remarkable and longer lasting than with other treatments, although urination may be too easy in te beginning when a new anatomical situation has to be incorporated into urinary functions. The most common, unavoidable, permanent side effect of prostate surgery is retrograde ejaculation ('dry climax'), which results when the tiny sphincter muscle that usually blocks off the bladder during ejaculation is cut during surgery, which is always the case. Semen then enters the bladder instead of being expelled through the penis, so the patient will be unable to father (any more) children.

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Other Therapies


Balloon Dilatation
Balloon dilatation of the prostate involves the insertion of a catheter in the urethra equipped with an inflatable balloon at the location of the prostate. When inserted, the balloon is inflated and the obstructing prostate lobes pushed to the side, thereby creating a wider and less obstructing prostate. Although this often works, it is always temporary and the prostate will become obstructed again within days to weeks. The advantage is that the procedure is simple and quick and can be done on an outpatient basis with local anaesthesia; the disadvantage is that it has to be repeated often. Because of the latter, and because there are better alternatives, the procedure is rarely done.

HIFU
The High Frequency Untrasound (HIFU) procedure uses focussed high energy ultrasound to heat up part of the prostate. An ultrasound probe is inserted into the rectum and ultrasound beams can be targeted at the prostate in much the same way as normal ultrasound is used to visualize the prostate. The high energy in case of HIFU will heat up the prostate to such an extent that the prostate cells are killed and later discarded by the body, much the same way as with TUMT. The technique is still quite experimental and experience is limited. Because the equipment needed is rather expensive, only a few centers can afford using it.

TUNA
Transurethral needle ablation of the prostate (TUNA) uses radiofrequency energy delivered by two tiny needles actually placed in the prostate by a special probe to heat the prostate and thereby kill prostate cells, so the prostate will shrink and the obstruction relieved. It can be done in an outpatient setting, and with minimal anesthesia requirements. It is a minimally invasive procedure carried out over a period of weeks. It uses a local anesthetic. During the procedure, a specially designed catheter is inserted through the penis to the prostate.
Clinical studies have demonstrated that TUNA provides significant improvement in urine flow and other symptoms of BPH although the procedure has not 'caught on' yet, possibly due to the varying degrees of success. Its long-term side effects are minor compared with those of such conventional procedures as TURP, but the repeated insertion of the catheter containing the antenna may cause irritation of the urethra, bleeding or painful bladder spasms.

Vaportrode
Transurethral vaporization of the prostate (TUVP), also known as vaportrode, is a new technique that involves direct application of high heat to the prostate tissue by means of a grooved roller-bar under cystoscopic guidance that vaporizes tissue very much like a laser does. Less tissue can be removed compared with TURP, but results are promising. Since it is a relatively new technique, side-effects are not yet completely mapped and long-term results still unknown. Advantages include low blood loss and quick recovery. There seem to be little disadvantages right after the procedure.
Because the costs involved in introduction of the technique are low and the procedure is easy to learn for experienced urologists, many have adopted the procedure.

Prostatic Stents
A prostatic stent is a tiny, springlike device inserted into the urethra. When expanded, it pushes back the surrounding tissue and widens the urethra to permit an increased flow of urine. Prostatic stents are most often used for patients who have other medical problems that prohibit medication or surgery. Since other techniques are becoming more and more patient 'friendly', the stents are rarely used.
Prostatic stents have several advantages: they can be placed in less than 15 minutes under regional anesthesia, bleeding during and after surgery is minimal, and the patient can be discharged the same day or next morning. The disadvantages of stents are: positioning them at the right spot at the prostate level can be difficult (they can fall into the bladder or don't work), they may cause irritation and frequent urination, they may move and cause pain or incontinence, stones may be formed on the stent, and removing them - necessary in one-third of patients - can be difficult.
Several types of stents exist:

  • permanent metallic stents
  • stents made of 'memory' metal that expand when heated to human temperature
  • stents made of a material that is bio-degradable, i.e. they dissolve after a couple of months
  • stents made of plastic, that can be pulled out if necessary
The use of different stents is moostly governed by the experience of the urologist and the availability of the type of stent.

Diets and Herbs
Although most dietary or herbal treatments for BPH are pretty harmless, most have not been scientifically tested, while they are often based on assumptions of chemists and other laymen unfamiliar with the anatomy and the disease involved. The socalled placebo-effect of medication in BPH, the fact that many people get improvement of their symptoms just by taking a fake pill when they believe that it will cure them, is about 40 percent. This means that many men who will be cured by one of the many over-the-counter prostate therapies available. Although many manufacturing companies are reliable and know what they are doing, a number of them just want to sell a product and use any means to achieve that goal, including testimonies of men apparently cured by these products. The 40-percent rule mentioned above will ensure that many such men can be found.
Although many advertise with socalled natural remedies, it must be remembered that all remedies are natural, and nearly all pills that are prescribed by a doctor are nothing more than refined extracts of plants. The natural therapy just sells you the raw material, which ofcourse has a risk of also supplying you with undesired and possibly harmful materials. Natural therapy is not necessarily harmless (think about all the poisonous plants and animals).
Most recommendations found below have been picked up from various interbet sites.

The Natural Therapeutic Approach
The primary and immediate objective of a natural therapeutic approach in treating BPH is to control symptoms by inhibiting the conversion of testosterone into dihydrotestosterone (DHT). Although the most potent available drug in this category, finasteride, is now less often used because the effect on symptoms is disappointing, the 'anti-DHT' effect of the natural therapeutic approach has been proven to be only a fraction of that of finasteride. The second objective is the inhibition of estrogen at the prostate tissue receptors, which may be useful in inhibiting that hormone’s alleged tendency to promote excessive cell growth. The treatments outlined here include herbs that are said to accomplish these tasks. Nutrient and diet guidance is presented that perhaps supports the achievement of these goals.

  • Dietary Recommendations
    A low carbohydrate / high vegetable protein diet that includes raw pumpkin seeds, cold water fish (salmon, halibut, etc.), soy protein products, fresh vegetables and fruits, and flax oil and meal. Drink at least 3 quarts of fresh water daily. Choose organically grown foods when possible.
    Avoid alcohol (especially beer), processed foods, fast foods, hydrogenated oils and margarine, refined sugar and flour/white flour, animal fats, caffeine, commercially raised and processed meats and dairy products.
    Nutrient Support: Flax seed oil: 1 tablespoon daily, Vitamin C: 500 mg three times a day, Zinc: 30 to 50 mg daily, Vitamin E: 400 IU daily.
  • Herbal Therapeutics
    None of the following herbal remedies have significant side effects associated with regular use at the suggested doses. As with all medications, herbal or otherwise, more is not better and overdosing can lead to serious illness and even death. There is probably no danger if you carefully follow dosage outlines.
    Rarely, a herb at the prescribed dose will cause stomach upset or headache. This may reflect either the purity or the impurity of the preparation. It is often hard to tell what the manufacturor put in, while the products may even change over the years when ingredients are added or withheld. If possible, consult with a natural health practitioner such as a holistic medical doctor or licensed naturopathic or homeopathic physician before starting any alternative treatment plan.
    • Saw Palmetto (seranoa repens) — 160 mg standardized extract twice a day. Diminishes enzymatic conversion of testosterone to DHT and interferes with estrogen binding to receptors on prostate tissue, thereby presuambly shrinking the prostate. The effect is similar to that of finasteride, although less potent, and a decrease in prostate size cannot be measured.
    • Pygeum Africanum — 75 to 100 mg standardized extract twice a day. The action of this herb is similar to, but less potent than, that of saw palmetto.
    • Soy Isoflavones — 50 to 100 mg daily. Soy isoflavones contain phytoestrogens that bind with estrogen receptors exert an inhibitory effect. They are readily available in capsules and soy-based foods in the following concentrations:
      • soy protein powder: 20 to 50mg per tablespoon
      • tofu: 35 mg per cup
      • textured soy protein: 60 mg per cup
      • roasted soy nuts: 60 mg per cup
      • soy milk: 30 mg per cup
      • tempeh: 30 mg per cup
      It is supposed to shrink the prostate, but the effect could not be measured to date.
    • European Flower Pollen Extract — Acts as an anti-inflammatory while also inhibiting growth of prostate cells. No measurable effect.
    • Nettles (urtica dioica) — 500 mg daily. Stinging nettles have a long tradition as a urinary tract tonic. They have a mild diuretic action, so the urine production by the kidneys is enhanced. This therefore causes more urination as far as volume is concerned, but it has no effect on the ease of urination as such.
    • Hydrangea root has a long history in the treatment of enflamed or enlarged prostates. It can be found in different over the counter herbal prostate formulas. No proven effect beyond 40 percent.
  • Homeopathy
    A trained homeopathic practitioner is needed to diagnose and prescribe a remedy. None of the homeopathic remedies has been proven effective. For acute, symptomatic relief the following remedies are used. Standard dosage for acute symptom relief is 12c to 30c, 3 to 5 pellets 3 times aday until symptoms resolve.
    Warning: Most homeopathic remedies are delivered in a small pellet form that has a lactose sugar base. If you are lactose intolerant, be advised that a homeopathic liquid may be a better choice.
    • Chimaphilia umbellate: advised for retention of urine associated with an enlarged prostate. This is in fact a dangerous advice, because you should consult a doctor immediately when urination has completely stopped.
    • Pareira: For urinary retention due to BPH, especially that associated with painful urging or pain in the bladder. An even worse advice.
    • Selenium (homeopathic): For dribbling, impotence with associated constipation due to BPH.
  • Physical Medicine
    Contrast hot/cold sitz baths increase pelvic circulation, dispersing congestion. The general rule for contrast hydrotherapy is 3 minutes hot, 30 seconds cold for three cycles. Always end with cold to flush blood and waste from the region. At least they have been saying that for several centuries. Unfortunately, congestion is not the problem here, an enlarged prostate is. Apart from that it has been proven that the temperature in the prostate is not influenced by sitx baths. The prostate belongs to the core of the body. That means that the temperature is kept as steady as possible, even at the expense of loosing extremities to the cold (in freezing weather). So a simple sitz bath has no influence on prostet temperature.

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What to choose?


Once the decision has been made that therapy is necessary for BPH, other than 'watchful waiting', the decision on the type of therapy seems to be difficult: there is so much to choose from!
This is, however, not the case.

There is not a free choice regarding treatment procedure, because that is largely determined by the size and shape of the prostate, the quality of the bladder and the type and seriousness of symptoms. For instance, when the prostate has completely blocked the bladder exit and the patient is unable to urinate at all, there is no place for medication; a catheter has to be placed at once to ensure passage of urine and further treatment planned to significantly reduce prostate volume. On the other hand, when BPH symptoms are minor and complete emptying of the bladder is still possible, medication, diet/herbal therapy (if you believe in that) or minimal invasive therapy (Laser, TUMT) may be an option.
TURP remains the mainstay and golden standard of BPH therapy, with excellent results as far as symptoms are concerned and overall moderate disadvantages; apart from large prostates (where an open prostatectomy should be performed) and/or patients in bad physical condition, TURP usually gets good results and patients are satisfied.
Patient and urologist together decide what treatment, if any, should be given. In some cases there are many options to choose from, while in others there may only be one, i.e. no choice.

In general, the following may be used as a guide for treatment choice, although it is not to be considered a firm rule:



 
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