LUTS in non-BPH conditions
Bladder hypersensitivity
- Sensory urgency may be the presenting symptom in the patients with DO, poor relaxation of the urethral sphincter, interstitial cystitis, BOO, or neurogenic voiding dysfunction. Recent investigations found the urothelial release of neurotransmitters such as acetylcholine, adenosine triphosphate, and the neuropeptide substance P, and the increased expression of the transient potential receptor vanilloid receptor subfamily and purinergic receptor P2X3 indicate that the urothelium plays an important role in the transduction of bladder sensation [rx,rx].
- Adenosine triphosphate production increases with aging. These physiological changes in elderly men indicate that bladder hypersensitivity and overactive bladder (OAB) are responsible for DO and inadequate contractility in elderly men [rx].
Polyuria
- A number of patients have a large daily urine output (>2800 mL). Patients may have polydipsia and high water intake, and therefore, they have a frequency with a voided volume >350 mL and are likely physiologically normal [rx]. The metabolic status of these patients should be checked with evaluations of diuretic intake and conditions such as diabetes, azotemia, hyperlipidemia, and sleep apnea syndrome.
Psychological Factors
- Psychological, social, and psychiatric factors might also cause frequency in male patients. These patients may have high levels of distress and anxiety. The symptoms may worsen in relation to work or stress and several diseases such as uremia, infection, or cancer.
Urothelial Dysfunction
- Sensory urgency might be a micromotor urgency due to micromotion of the detrusor during rapid bladder filling such as in diuresis. Patients may have severe urgency when their bladder volume is small. This condition might be the cause of urothelial dysfunction such as in trigonal mucosal dysfunction.
- Increased nerve growth factor levels have been found in bladder biopsies of patients with sensory urgency, chronic cystitis, and interstitial cystitis compared with levels in controls [rx]. Intravesical onabotulinumtoxinA has been found to decrease symptoms of OAB and interstitial cystitis. The production of nerve growth factor was reduced after onabotulinumtoxinA treatment in patients with neurogenic or idiopathic DO [rx].
Overactive Bladder
- DO can be due to idiopathic reasons, myogenic overactivity, poor cortical perfusion, postobstructive DO, the aging process, or detrusor hyperactivity with impaired contractility (DHIC). In men with LUTS, BOO should be excluded first. Patients with benign prostatic obstruction (BPO) but without OAB symptoms might develop de novo OAB after TURP, suggesting the destruction of the trigone mucosa might result in OAB [rx].
- Treatment of patients with BPH with BOO and OAB should include agents relieving the urethral resistance and antimuscarinics as well when OAB symptoms cannot be resolved after treating with an alpha-blocker alone or combined with a 5 alpha-reductase inhibitor.
Nocturia and nocturnal polyuria
- Nocturia is the third most bothersome LUTS. The prevalence of nocturia increases to 80% in patients over 80-year-old. It is one of the most common causes of a disturbed sleep pattern in the elderly. The causes of nocturia include DO, a hypersensitive bladder, BOO, nocturnal polyuria, or a small bladder capacity.
- When the nocturnal urine volume >900 mL or more than 35% of the daily voided volume, nocturnal polyuria is likely. Lack of diurnal desmopressin rhythm can be the cause of nocturnal polyuria and can be treated with exogenous desmopressin [rx]. For patients with combined nocturnal polyuria and BOO or OAB, combined multiple medications are necessary to relieve the complex male LUTS.
Poor relaxation of the urethral sphincter
- Among the various causes of non-BOO male LUTS, poor relaxation of the urethral sphincter is most frequently encountered [rx]. Patients might have symptoms of hesitancy, intermittency, small caliber urine, or postvoid dribble. Some patients might also have storage symptoms such as urgency or frequency.
- Learned habits, chronic prostatitis, pelvic floor hypertonicity, occult neuropathy, or increased bladder sensitivity have been postulated to lead to poor relaxation of the urethral sphincter. These voiding symptoms might have a great impact on QoL, especially in young men.
Pain Symptoms
- Several bladders or bladder outlet conditions can cause pain in men. Interstitial cystitis, BOO, a poorly compliant bladder, and transitional cell carcinoma can cause a painful bladder. Urinary tract infection, urethral stricture, BPO, and chronic prostatitis can cause a painful urethra. Treatment of pain symptoms in men is not easy and should be based on the exact diagnosis of the pain.
- Transitional cell carcinoma of the bladder usually mimics interstitial cystitis in men with LUTS and painful bladder syndrome. Urine cytology and repeat random bladder biopsy are necessary to find early bladder carcinoma.
Postprostatectomy Male Lower Urinary Tract Symptoms
- Over half of patients with postprostatectomy LUTS had a small total prostate volume and resected adenoma weight, indicating their LUTS were non-BPH or non-BOO conditions before TURP [rx]. Detailed cystoscopy and video urodynamic study are necessary for these patients especially when they are diagnosed with residual BPH or BOO and are planning to undergo repeat transurethral surgery. DHIC, bladder hypersensitivity, or OAB can also cause male LUTS in the presence of a small BPH.
Other conditions
- Urethral sphincter pseudodyssynergia in patients with chronic stroke, intracranial lesions, Parkinson’s disease, and spondylolisthesis can cause severe empty symptoms or storage symptoms in elderly men [45]. These patients might have BPH, but the LUTS are caused by conditions other than BPH. Urethral stricture or urethral meatal stenosis can also cause BOO and LUTS, especially in patients who have had transurethral procedures.
Alpha-blockers | Dosage | Side effects |
---|---|---|
|
1 mg once daily to start; may increase up to 20 mg/day | Asthenia, hypotension, dizziness, somnolence |
|
1 mg once daily to start; may increase up to 8 mg once daily | Orthostatic hypotension, fatigue, dyspnea |
|
0.4 mg once daily | Dizziness, rhinitis, abnormal ejaculation |
Alfuzosin | 10 mg once daily | Fatigue, edema, rhinitis, headache, upper respiratory tract infection |
5-ARIs | ||
|
5 mg once daily | Impotence, decreased libido, decreased semen quantity at ejaculation, decreased semen PSA, gynecomastia (rare) |
|
0.5 mg once daily | Impotence, decreased libido, decreased semen quantity at ejaculation, decreased semen PSA, gynecomastia (rare) |
Adapted from the Cleveland Clinical Journal of Medicine.14 5-ARIs = 5-alpha reductase inhibitors; PSA = prostate-specific antigen.
Drug | Dosage | Mechanism | Side effects |
---|---|---|---|
|
5 mg once daily | 5α-reductase inhibitor | Impotence decreased libido, decreased semen quantity at ejaculation, decreased semen prostate-specific antigen, gynecomastia (rare) |
|
0.5 mg once daily | 5α-reductase inhibitor | Impotence decreased libido, decreased semen quantity at ejaculation, decreased semen prostate-specific antigen, gynecomastia (rare) |
|
1 mg once daily to start; may increase up to 10 mg/day | α1-adrenergic receptor antagonist | Asthenia, hypotension, dizziness, somnolence |
|
1 mg once daily to start; may increase up to 8 mg once daily | 1-adrenergic receptor antagonist | Orthostatic hypotension, fatigue, dyspnea |
|
0.4/0.8 mg once daily | α1-adrenergic receptor antagonist | Dizziness, rhinitis, abnormal ejaculation |
|
2.5 mg t.i.d./5 mg b.i.d./10 mg once daily | α1-adrenergic receptor antagonist | Fatigue, edema, rhinitis, headache, upper respiratory tract infection |
|
160 mg twice daily | Mixed | Aggravate chronic gastrointestinal disease such as peptic ulcer |
Androgen Deprivation Therapy
- The biological basis of androgen ablation therapy lies in the observation that the embryonic development of the prostate is dependent on the androgen dihydrotestosterone (DHT) [rx]. Furthermore, castration in men before puberty resulted into regression of prostatic enlargement.[rx] Androgen deprivation causes the reduction in prostatic volume that is believed to reduce the static component of BPH.[rx]
- Reversible androgen deprivation can be achieved by the use of progestational agents (hydroxyprogesterone acetate,[rx] megesterone[rx]) capable of decreasing serum testosterone levels by inhibiting the release of luteinizing hormone. Suppression of sex steroid production on the basis of desensitization and down-regulationof pituitary gonadotropin releasing hormone (GnRH) receptor by agonistic GnRH analogs [rx] (nafarelin acetate, leuprolide) resulting in the blockage of gonadotropin release from the anterior pituitary gland is a well-established approach in the treatment of BPH.[rx,rx]
- Furthermore, antiandrogens like cyproterone acetate] and flutamide[rx] competitively inhibit the ligand (DHT) binding to the androgen receptor and are used therapeutically in BPH. Several lines of evidence indicate the role of estrogen along with androgen in BPH. Estrogens are mainly produced in men by aromatase activity by the peripheral conversion of testicular and adrenal androgen into estradiol. The estrogenic effect presumably includes its stromal and epithelial interaction that regulates the proliferative activity of the prostate and alteration in the sensitivity of the prostate toward androgens.[rx] Aromatase inhibitors like atermestone[rx] and abiraterone[rx] that block the peripheral conversion have found application in pharmacological treatment of BPH.
- Though the androgen deprivation therapy has proved to be an effective treatment, their use was restricted because of associated side effects such as erectile dysfunction and loss of libido.[rx,rx] Therefore, search for the new drugs with more efficacies, selectivity, and relative broader therapeutic index was being pursued, and continued accrual resulted in the development of 5α-reductase inhibitors.
5α-Reductase Inhibitors
- Steroidal 5α-reductase is a NADPH-dependent enzyme that catalyzes the irreversible conversion of 4-en-3-oxo-steroid, that is, testosterone (T), the major circulating androgen in male adults, to the corresponding 5α-H-3-oxo-steroid, that is, DHT. Two isozymes of 5α-reductase have been cloned, expressed, and characterized on the basis of differences in chromosomal localization, tissue expression pattern, and biochemical properties.[rx]
- Within the prostate, locally produced DHT acts in a paracrine fashion to stimulate growth. However, excessive production of DHT is the cause of major androgen- related disorders such as prostate cancer, acne, female hirsutism, and BPH.[rx] Therefore, inhibitors of androgen action by 5α-reductase is a logical treatment of 5α-reductase activity disorder, that is, BPH. These agents suppress the DHT concentration by blocking the enzyme, resulting in shrinkage in the size of the prostate, increased peak urinary flow rates, and ultimately providing relief from the symptoms related to the static mechanical obstruction caused by BPH.[rx]
- Furthermore, the rationale for use of 5α-reductase inhibitors is rooted in the observation that these are more specific to DHT androgens action without affecting or lowering T level, thus capable of decreasing long-term side effect of castration due to loss of T without compromising the efficacy of hormonal therapy.[rx,rx] Finasteride and dutasteride are commercially available 5α-reductase inhibitors currently being used in the treatment of BPH.
Finasteride
- Finasteride (MK-906) synthesized in 1984, is chemically 17β-(N-tert-butyl-carbamoyl)-4-aza-5α-androst-1-en-3-one . It was the first 5α-reductase inhibitor approved in the United States in 1992 for the treatment of BPH.[rx] Finasteride is a competitive inhibitor of 5α-reductase type 2 with 10-fold high affinity than type 1 and forms a stable complex with enzyme. It has been reported that at clinical doses of 5 mg/day in human beings, it decreases the prostate DHT level by 70 to 90%, thus resulting in decreased prostate volume or size and improved urinary flow rate.[rx,rx]
- It has neither androgenic, antiandrogenic, other hormone related properties, nor it interferes with the binding of T or DHT to the androgen receptor.[rx] The investigators found significant improvement in finasteride-treated groups in term of increased flow rates and decreased prostate-specific antigen level. The most commonly reported side effects on finasteride long-term usage are decreased libido, ejaculatory dysfunction, or impotence, while some of the patients showed rashes and breast enlargement.[rx]
Dutasteride
- Dutasteride belongs to class of 4-aza-steroids and chemical name is 17-N-{2, 5-bis (trifluoromethyl) phenyl)}-3-oxo-4-aza-5α-androst-1-ene-17-carboxamide. [rx] It was approved by US FDA in 2002 for the symptomatic treatment of BPH. Unlike finasteride, dutasteride has been reported to be a nonselective competitive inhibitor of both 5α-reductase type 1 and 5α-reductase type 2 isozymes.
- At clinical dose of 0.5 mg/day, it has been shown to decrease DHT levels >90%, by forming a stable complex with a slow rate of dissociation constant. Dutasteride was found to improve urinary flow rate, decrease the risk of AUR and need for surgery by reducing the size of enlarged prostate.[rx–rx] Improved efficacy of dutasteride (0.5 mg/day) over finasteride (5 mg/day) in terms of symptom score, maximal urinary flow rate, and quality of life has been reported in recently published article by Kumar et al.[rx]
Alpha Adrenergic Blockers
- The rationale for using α-adrenergic blockers is based on the fact that noradrenaline acts at α1-adrenergic receptors (α 1-AR) in the neck and sphincter of the urinary bladder to promote contraction and urinary retention, and control the smooth muscles in the prostate capsule and prostate urethra.[rx,rx]
- Therefore, selective α1-AR antagonists relieve the obstruction due to dynamic component by relaxing the smooth muscle in and around the prostate and bladder neck without affecting the detrusor muscle of the bladder wall. Molecular studies have further identified three subtypes of the α1-AR(α1A, α1B, and α1D). Their relative distribution and concentration in the prostate, bladder, neck, brain, and vascular smooth muscle have been exploited to develop uroselective α1-adrenergic antagonists and reduce side effects. The α1Bsubtype is predominant in blood vessels, whereas α1A is predominant in prostate.[rx]
- Prazosin was the first selective α1-AR antagonist investigated for BPH treatment.[rx] Prazosin contains a piperazinyl quinazoline nucleus and is selective α1-adrenergic antagonist, with affinity 1000-fold greater than that for α2-receptor. The adverse effects related to prazosin were postural hypotension along with stuffy nose, headache, and retrograde ejaculation on continuous use for a long period.[rx]
- The advent of selective α1-drugs, terazosin and doxazosin , the structural analog of prazosin, originally developed as antihypertensive agents.[rx] Terazosin and doxazosin with long half life are given once a day with dose titration over 1 to 2 weeks due to first dose syncope to a maximum of 10 mg for terazosin and 8 mg for doxazosin.[rx]
Tamsulosin
- Tamsulosin hydrochloride is a competitive antagonist of α1-AR with the chemical name (-)-(R)-5-[2-[[2-(o-Ethoxyphenoxy) ethyl] amino] propyl] -2-methoxybenzenesulfonamide.[rx] It was the third uroselective α1-AR antagonist with 10-fold more selectivity for α1A-receptor subtype compared with α1B-receptor subtype, approved for use in the treatment of symptomatic BPH.[rx]
- It is well absorbed orally with half-life of 5 to 10 hours and extensively metabolized by the cytochrome P450 system.[rx] A significant reduction in urinary flow has been observed after single dose (0.4 or 0.8 mg) administration of tamsulosin as compared with placebo.[rx] Tamsulosin have minimal cardiovascular effects and the risk of dizziness is less as compare with doxazosin and prazosin.[rx] The drug also demonstrated a lower probability of orthostatic hypotension, but a higher rate of ejaculatory dysfunction (10%), and does not appear to cause erectile dysfunction or reduced sexual drive.[41]
Alfuzosin
- Alfuzosin is a quinozoline-based α1-AR antagonist with similar affinity for all α1receptor subtypes .[rx,rx] It is available in an immediate (2.5 mg t.i.d.), sustained (5 mg b.i.d.), and extended release formulation (10 mg/day) to improve compliance.[7] According to AUA guidelines, alfuzosin has comparable clinical efficacy with tamsulosin and the other approved alpha blockers and does not cause ejaculatory dysfunction.[rx]
Alpha blockers
- Selective α1-blockers are the most common choice for initial therapy.[rx] They include alfuzosin,[rx][rx] doxazosin,[rx] silodosin, tamsulosin, and terazosin. They have a small to moderate benefit.[rx] All five are equally effective but have slightly different side effect profiles.[rx] Alpha blockers relax smooth muscle in the prostate and the bladder neck, thus decreasing the blockage of urine flow. Common side effects of alpha blockers include orthostatic hypotension (a head rush or dizzy spell when standing up or stretching), ejaculation changes, erectile dysfunction,[rx] headaches, nasal congestion, and weakness.
Combination Therapy
- The scientific rationale for combining 5α-reductase inhibitors and α1-AR antagonists is based on their different and complementary modes of action, helpful to manage static and dynamic component in patients with an enlarged prostate gland having symptoms of bladder outlet obstruction.
- The rationale for this recommendation is a rapid relief of symptoms by the α1-AR antagonists, without targeting the underlying disease process and a mid or more sustained relief of symptoms by the 5α-reductase inhibitors.[rx] The efficacy and safety of the treatment with different combinations versus treatment with either agent alone has been investigated by different groups in large mulitcentral trials.[rx,rx]
- The combination of avodart and tamsulosin (CombAT)[rx,rx] study is underway to further examine the role of combination (dutasteride and tamsulosin) over the α1-AR antagonists (tamsulosin). It would be a major step in assessing the combination therapy and the findings will assist in making treatment decision. These studies demonstrated a higher incidence of impotence with combination therapy compared with 5α-reductase inhibitors, in addition to higher incidence of α1-AR antagonists-mediated dizziness, hypotension.[rx] Cost-effectiveness studies by Nickel suggest that the combination therapy is more suitable for men at high risk for BPH progression (i.e., with high symptom score, large prostate volume and low qmax value) who are able to tolerate the increased side effects.
Phytotherapy
- Numerous plant based products (phytotherapy) are commonly used for self treatment of lower urinary tract symptoms and can be prescribed in some European countries. Systematic reviews have suggested that both saw palmetto and Pygeum africanum provided modest improvement in urinary symptoms and flow.[rx rx]However, a recent high quality randomised trial found that saw palmetto was no more effective than placebo in men with BPH and moderate to severe symptoms.[rx] Ongoing trials are assessing long term effectiveness and safety of varying doses of both saw palmetto and Pygeum africanum.
- Finasteride and dutasteride have both been shown to reduce PSA levels by approximately 50% after 6 months.[rx] This PSA suppression is maintained over time. If PSA rises while on a 5-ARI, a check on drug compliance is in order. If the patient has been taking the drug as prescribed, a referral should be made to a urologist.
Phytochemical Agents
- The use of plant-derived nonnutritive compounds with protective or disease-preventive properties for urinary symptoms with BPH has gained widespread interest, probably due to perceived reduction in side effects, and desire to maintain control over their treatment.[rx,rx]
- However, the use of these phytochemicals is controversial as most of the studies have not been subjected to the rigorous preclinical pharmacological testing and formal clinical trials. Moreover, the active ingredients and dosage of active medication is unknown, quality is not publicly controlled, and mechanism of action is not clear.[rx] The extensively studied phytotherapeutic agent Serenoa repens (saw palmetto) has shown mild to moderate efficacy in reducing nocturia, increasing maximal urinary flow, and improving Symptom Score in men with BPH.[rx]
Saw Palmetto
- Saw Palmetto, extract of the berries of the dwarf palm tree of S. repens (family Arecaceae) is most widely used.[rx] The liposterolic extract contains β-sitosterol, chemically related to cholesterol, which has inhibitory effects on 5α-reductase. Various additional mechanisms have also been suggested, including inhibition of binding of DHT to cytosolic androgen receptors in prostate cells and anti-inflammatory effect.
- However, it has no effect on prostate volume or the prostate-specific antigen test, but slightly decreases the prostate epithelium. It does not cause impotence, but the herb may aggravate chronic gastrointestinal disease such as peptic ulcer.[rx] It has been reported that oral administration of 160 mg S. repens twice daily for 1 to 3 months is generally superior to placebo in improving subjective and objective symptoms of BPH. ProSafe Forte is a phytochemical composition specially developed by Danor to prevent and ameliorate BPH and prostatic carcinogenesis.[rx] Serenoa repens is currently available in France, Germany, and Spain.[rx]
Others
- Novel approaches like gene therapy,[rx] COX-2/LOX-5 inhibitors,[rx] vitamin D 3analogues,[rx] antibody-dendrimer conjugates,[rx] oxytocin antagonists,[53] and radionucleotide therapy[rx] are currently exploring their role in BPH. NX-1207 has been recently announced as new treatment for the BPH.
NX-1207
- NX-1207, originally derived for treatment of Alzheimer’s disease, was later on tested for its potential role in treatment of BPH. This novel drug, developed by Nymox, is currently under Phase 3 clinical trial. It has been reported that men treated with single dose (2.5 mg dose) of NX-1207 had statistically significant improvements; the drug is administered in an office procedure that takes only a few minutes without any pain or discomfort. In addition, there were no sexual- or blood pressure-related side effects. Unlike currently approved BPH medications, NX-1207 treatment does not require the patient to take pills daily for the rest of his life (http://www.Nymox.com,).[rx,rx]
Surgical treatment
- Surgical interventions are considered in case of severe symptoms and complications like urinary retention, renal failure and infection that are weighed carefully against the risk and benefits of the various treatment options.
Invasive procedures
- The gold standard for the surgical treatment was the removal of obstructing tissue by open prostatectomy[rx] in early 1900s, which is now replaced by transurethral resection of the prostate (TURP). TURP is the hallmark of the urologist, the one against which other therapeutic measures are compared. It takes 20 to 30 minutes to resect an average gland weighing 30 g and carry the risks for complications like bleeding, infections, retrograde-ejaculation and low semen, low PSA level, and hospital stay including impotence and incontinence. Transurethral incision of the prostate (TUIP) or bladder neck incision is recommended for smaller gland weighing <25 g and has been found to be less invasive than TURP, but the long-term effectiveness in comparison with TURP is yet to be determined.[rx]
Minimal Invasive Procedures (MIT)
- Over the last few years, the number of MIT has been established to achieve sa substantial improvement in the symptoms attributed to BPH. These MIT utilizes an endoscopic approach to ablate the obstructing prostatic tissue.
Transurethral electrovaporization (TUVP)
- TUVP is the modification of TURP and TUIP, and utilize high electrical current to vaporize and coagulate the obstructing prostate tissue. Long-term efficiency is comparable with TURP, but a number of patients has been found to experience irritative side effects.[rx]
Transurethral Microwave Thermotherapy (TUMT)
- More specific destruction of malignant cells without affecting normal cells can be achieved by raising the temperature of the cells using low-level radiofrequency (microwave) in the prostate up to 40 to 45°C (hyperthermia), 46 to 60°C (thermotherapy), and 61 to 75°C (transrectal thermal ablation).[rx] TUMT has been found to be safe and cost effective, with reasonable improvement in urine flow rate and minimal impairment on sexual function.[rx]
Transurethral needle ablation (TUNA)
- It is a simple and relatively inexpensive procedure which utilizes needle to deliver high-frequency radio waves to destroy the enlarged prostatic tissue. TUNA is a successful treatment for small-sized gland and it poses a low or no risk for incontinence and impotence.[rx]
Laser ablation
- Laser prostatectomy has become an increasingly widespread form of MIT. Four types of lasers have been used to treat LUTS, namely neodymium: yttrium-aluminum-garnet (Nd: YAG) laser, holmium YAG laser (Ho:YAG), potassium titanyl phosphate (KTP), and diode laser. It has been found to be safe and effective technique, with significant improvement in urinary flow rates and symptoms. Short operative time, minimal blood loss and fluid absorption, decreased hospital stay, impotence rates, and bladder neck contractures are few of the advantages of laser prostatectomy over the TURP and other conventional techniques.[rx]
High-intensity focused ultrasound (HIFU)
- Effective protein denaturation and coagulative necrosis of prostatic tissue have been achieved by using HIFU frequencies of 4 MHZ. Significant increase in uroflow and a decrease in postvoid residual volume have been observed, but the cost is three times higher than that of TURP.[rx]
Transurethral Ethanol Ablation of the Prostate
- Transurethral injection of absolute ethanol into the lateral lobes of prostate produces necrotic effect on prostatic tissues, leading to fibrosis and shrinkage. Significant improvement has been reported in AUA symptoms score. Continual research is going on to dilute negative factors like urinary retention, pain, dysuria, and prolonged period of catheterization with the aim to deliver safe, effective, and economical potential treatment.[rx]
Water-Induced Thermotherapy
- It is a simple technique that uses a cylindrical balloon to circulate hot water, resulting in even coagulation necrosis in the prostate by raising the temperature of the prostatic cells up to 60 to 70°C, without having major effect on nontargeted tissues.[rx]
Plasma kinetic tissue management system (Gyrus)
- Gyrus is a new technique under development and vaporizes the obstructing tissue by using plasma energy in a saline environment. Procedure has been found to be safe and effective with minimal risk of water intoxication (TURP syndrome) and generally reserved for patients on high risk.[rx]
Polyphenols | Source | Activity |
---|---|---|
Myricetin | Red wine | 5α-reductase inhibition (rx) |
Baicalein | Scutellaria baicalensis and Scutellaria lateriflora | 5α-reductase inhibition (rx) |
Fisetin | Strawberries, apples, grapes | 5α-reductase inhibition (rx) |
Daidzein | Soybeans | 5α-reductase inhibition (rx) |
Kaempferol | Apples, broccoli, onions, tomatoes | 5α-reductase inhibition (rx) |
Caffeic acid-phenethyl ester | Propolis | 5α-reductase inhibition (rx) |
Octyl gallate | Octanol and gallic acid (produced from plant tannins) | 5α-reductase inhibition (rx) |
Dodecyl gallates | Gallic acid (from plan tannins) | 5α-reductase inhibition (rx) |
Surgery for BPH
There are different types of surgical procedures that can help treat BPH when medications are not effective. Some procedures are either not invasive or minimally invasive and can often be done in your doctor’s office or clinic (outpatient procedures). Others are more invasive and need to be done in a hospital (inpatient procedures).
Outpatient procedures
Outpatient procedures involve inserting an instrument into your urethra and into the prostate gland. They include:
- Transurethral needle ablation (TUNA): Radio waves are used to scar and shrink prostate tissue.
- Transurethral microwave therapy (TUMT): Microwave energy is used to eliminate prostate tissue.
- Water-induced thermotherapy (WIT): Heated water is used to destroy excess prostate tissue.
- High-intensity focused ultrasonography (HIFU): Sonic energy is used to eliminate excess prostate tissue.
Inpatient procedures
Inpatient procedures might be recommended if you have any of the following symptoms:
- kidney failure
- bladder stones
- recurrent urinary tract infections
- incontinence
- a complete inability to empty the bladder
- recurrent episodes of blood in the urine
Inpatient procedures include:
- Transurethral resection of the prostate (TURP): It is the most commonly used surgical treatment for BPH. Your doctor inserts a small instrument through your urethra into the prostate. The prostate is then removed piece by piece.
- Simple prostatectomy: Your doctor makes an incision in your abdomen or perineum, which is the area behind your scrotum. The inner part of your prostate is removed, leaving the outer part. After this procedure, you may have to stay in the hospital for up to 10 days.
- Transurethral incision of the prostate (TUIP): This is similar to TURP, but your prostate isn’t removed. Instead, a small incision is made in your prostate that will enlarge your bladder outlet and urethra. The incision allows urine to flow more freely. You aren’t always required to stay in a hospital with this procedure.
Polyphenol | Source | Mechanisms of action |
---|---|---|
Epigallocatechin-gallate | Green tea | Suppression of oxidative stress, diminution of inflammatory markers (IL-Iβ, IL-I6, and TNF-α; inhibition of IGF-I and IGF-II and upregulation of PPAR-α and PPAR-γ (Jinglou and Hongping, 2016) |
Lignan | Flaxseeds, sesame seeds | 5α-reductase inhibition (Evans et al., 1995) |
Genistein | Fava beans, soybeans | 5α-reductase inhibition (Evans et al., 1995) |
Biochanin A | Soy, Peanuts | 5α-reductase inhibition (Evans et al., 1995) |
Enterolactone | Flaxseed and sesame sees | 5α-reductase inhibition (Evans et al., 1995) |
Flavocoxid | Scutellaria baicalensisand Acacia catechu | Inhibition of growth factor expression and suppression of inflammation through inhibition of cyclooxygenase-2 and 5-lipoxygenase activities ( |
Equol | Soya | Binding to 5α-DHT by sequestering 5α-DHT from the androgen receptor (rx) |
Anthocyanin | Soya | Suppression of cellular proliferation through induction of apoptosis (rx). |
Lycopene | Tomato | Upregulation of caspase-3 and suppression of IL-6 (rx) |
Kolaviron | Garcinia kola | Inhibition of 5α-reductase and suppression of oxidative stress in the prostatic tissue (rx) |
Secoisolariciresinol diglucoside | Flaxseed | Stimulation of increased expression of G-protein-coupled estrogen receptor 1 (rx) |
References
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- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477638/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3989819/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3062123/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2698785/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5509197/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5717991/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440415/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472850/
- https://en.wikipedia.org/wiki/Benign_prostatic_hyperplasia
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