Men’s Health: Approaches to Treating an Enlarged Prostate

The noncancerous but troublesome condition known as BPH affects most men, and if left untreated can lead to serious health problems.

Almost all men will experience enlargement of the prostate as they grow older. Also known as benign prostatic hyperplasia (BPH), the noncancerous condition occurs when the prostate, the gland responsible for producing fluid for the semen, becomes enlarged.

BPH affects 50% of all men over the age of 60 and an estimated 90% of men by the time they reach age 85. Because the prostate gland surrounds the urethra, enlargement of the prostate can cause blockage of the tube that carries urine and sperm out of the body. About half of men with BPH will develop lower urinary tract symptoms that require treatment—difficulty or pain urinating, frequent urination, and a feeling of urgency to urinate or incontinence. Untreated symptoms could lead to more serious health conditions such as bladder infections, bladder stones, or kidney damage.

Though researchers have yet to pinpoint the exact cause of BPH, experts believe it may be due to the normal fluctuations of hormones, especially testosterone, that occur with age. Evidence suggests both chronic and acute inflammation may contribute to growth of the prostate through a variety of mechanisms, including oxidative stress.

The Cleveland Clinic and other healthcare providers recommend men start seeing a urologist from age 40.

While BPH is not associated with an increased risk of prostate cancer, the American Cancer Society and the American Urological Society recommend prostate cancer screenings for men over age 55, and at age 40 for men who have a family history of the disease. The Cleveland Clinic and other healthcare providers recommend men start seeing a urologist from age 40.

In addition to reviewing a patient’s medical history and conducting a physical exam, BPH is usually diagnosed with a digital rectal exam to determine the size, texture, and shape of the prostate, and to detect any hard areas that could be cancer. Additional tests may be done to evaluate urine flow and how much urine is left in the bladder after urination, and the doctor may order a blood test to check prostate-specific antigen (PSA). 

Conventional Treatments

Common treatments for BPH include medication and surgery. Medications such as finasteride (brand name Proscar) and dutasteride (Avodart), belong to a class of 5-alpha reductase inhibitors (5-ARIs) that decrease production of a hormone involved in the growth of the prostate. While these drugs appear to be the most beneficial for treating men with larger prostates, they also come with side effects such as impotence and decreased libido, and a recent Canadian cohort study found they may lead to depression.

Alpha blockers are another class of drug commonly used to treat BPH, which includes tamsulosin (Flomax) and silodosin (Rapaflo). These drugs relax the muscle in the prostate to relieve bladder outlet obstruction. They may cause dizziness, retrograde ejaculation, and rhinitis, and recent research found a significantly increased risk of dementia in men taking this class of drug.

Recent research published in the Journal of Urology found both of these common classes of BPH drugs are associated with a greater risk of heart failure. Among 175,201 men with BPH over the age of 66 with no history of heart failure, the researchers found a 22% increased risk for developing heart failure among users of alpha blockers, while men using 5-ARIs were found to have a 9% increased risk. Those using a combination of the two had a 16% increased risk of heart failure. The findings suggest these drugs may not be the best approach for treating BPH symptoms over the long term.

Recent research published in the Journal of Urology found both of these common classes of BHP drugs are associated with a greater risk of heart failure.

The “gold standard” of surgery for BPH is transurethral resection of the prostate, in which the tissue blocking the urethra is removed under general anesthesia, which can cause side effects such as impotence, incontinence, and retrograde ejaculation. Other less invasive procedures include transurethral laser or electro-vaporization; water vapor therapy to shrink the prostate; or use of UroLift implants to create an open urethral channel. These are newer techniques, so more research is needed to determine their long-term effectiveness and possible side effects.

A new minimally invasive treatment called Optilume uses a drug-coated balloon catheter to alleviate obstruction and maintain the opening. The pilot trial of Optilume was found to be more effective, with fewer adverse side effects, than other surgical treatments, and a larger controlled clinical trial is now underway.

Complementary Therapies

Dr. Andrew Weil, founder and director of the Andrew Weil Center for Integrative Medicine at the University of Arizona, says that men with mild symptoms of BPH may be able to manage them with lifestyle measures, such as avoiding alcohol and caffeine, exercising regularly, urinating as soon as the urge arises, and avoiding liquids within two hours of bedtime. As many prescription and over-the-counter drugs, including antidepressants, antihistamines, diuretics, and pain relievers, can aggravate symptoms, Dr. Weil advises against them.

Complementary therapies for BPH, such as lifestyle changes, herbal supplements, and acupuncture, are growing in popularity. Dr. David S. Rosenthal, professor of medicine at Harvard Medical School and medical director of the Leonard P. Zakim Center for Integrative Therapies at the Dana-Farber Cancer Institute, says many complementary strategies are safe but lack evidence of efficacy. He advises patients to discuss these therapies with their physicians.

Herbal and Nutraceutical Supplements

The extracts from the berries of saw palmetto (serenoa repens) are among the most popular herbal supplements for BPH, with clinical evidence it can help shrink the prostate and may promote healthy prostate function. Recent meta-analyses found saw palmetto may be similar in effectiveness to 5-ARI drugs without the adverse effects, and is clearly more effective than a placebo. One review of 21 trials concluded the men treated with saw palmetto had reduced urinary tract symptoms, less frequent nighttime urination (nocturia), and better rate of urine flow. A recent double-blind, randomized study of men aged 40-65 with BPH examined the efficacy of saw palmetto oil enriched with beta-sitosterol, compared to saw palmetto oil alone and a placebo. The study found that the beta-sitosterol–enriched saw palmetto oil significantly decreased BPH severity over the 12-week treatment period and was superior to saw palmetto oil alone.

Complementary therapies for BPH, such as lifestyle changes, herbal supplements, and acupuncture, are growing in popularity.

Beta-sitosterol is a type of phytosterol—a plant compound that blocks cholesterol from being absorbed. Found in pecans, avocados, and pumpkin seeds, the supplement has been shown in a review of studies to improve BPH symptom scores by 35% and peak flow rate by 34%, while reducing the amount of urine retained in the bladder after urination (postvoid residual volume) by 24%, although it has not been shown to reduce the size of the prostate gland.

Pollen has been used for centuries as a traditional medicine. One recent umbrella analysis of five systematic reviews found evidence to support the use of grass and flower pollen extracts for treating BPH symptoms. Another review examined rye pollen extract and found it improved self-rated urinary tract symptoms including nocturia, but more research is needed to draw any conclusions on efficacy.

A randomized, double-blind, placebo-controlled trial concluded that lycopene, a component found in tomatoes, may slow BPH progression, reduce symptoms, and is safe and well tolerated. Lycopene has known antioxidant and anti-inflammatory properties and, in combination with selenium and saw palmetto, has been shown to reduce prostate inflammation and improve symptom scores and urinary flow in patients who are taking the alpha blocker drug tamsulosin.

A new whole tomato-based food supplement (WTBS) has been developed by the Italian Health Ministry as a potential treatment for prostate health. This supplement includes lycopene and other anti-inflammatory tomato micronutrients. Research has shown that tomato consumption reduces inflammation by decreasing inflammatory cytokines in overweight men. A new randomized double-blind, placebo-controlled study published in January 2021 in the Journal of Translational Medicine found that the Italian WTBS reduced the levels of inflammatory cytokines and significantly improved urinary tract symptoms and quality of life in BPH patients, without any side effects.

Dr. Weil says it may take at least eight weeks of using supplements before seeing improvement of symptoms, and Dr. Rosenthal advises patients who wish to use supplements to start with one supplement at a time.

Diet Recommendations

Epidemiological studies have demonstrated that diet plays an important role in the incidence and development of prostatic conditions such as BPH, showing a significant link between diet-related metabolic conditions such as obesity and diabetes and the development of BPH. An eight-year study of 3,523 men with BPH found a strong association with animal protein intake and BPH, leading experts to recommend reducing meat consumption and meeting protein needs with plants and seafood.

Epidemiological studies have demonstrated that diet plays an important role in the incidence and development of prostatic conditions such as BPH.

A diet high in fruits and vegetables is also recommended. The Prostate Cancer Prevention Trial found that men who consumed at least four servings of vegetables daily had a significantly lower risk of BPH than those who ate less than one serving daily. Another study found that participants who ate a low-fat, high-fiber diet containing plant proteins, whole grains, fruits, and vegetables and got daily aerobic exercise were able to improve factors associated with BPH, such as insulin levels and estradiol/testosterone ratios.

Research has demonstrated a direct association between starchy foods, such as white bread, pasta, and rice, and BPH. The glycemic response produced by these foods in the body can increase insulin-like growth factors, which are believed to stimulate the development of BPH, and thus should be minimized in the diet. This association was not found with sugars from fruit.

Catechins—antioxidants that are found in green tea—have been found to help manage BPH and enhance prostate function and the immune system. Men who consume green tea should opt for the decaffeinated version, because caffeine can stimulate the bladder and aggravate urinary symptoms.

Additional research suggests that zinc, vitamin D, and foods containing whole soy can all help reduce risk of BPH or reduce lower urinary tract symptoms. Dr. Weil recommends men eat plenty of fruits, vegetables, and healthy fats. These foods are rich in antioxidants, polyphenols, and omega-3 fatty acids, which have all shown benefits in clinical trials. While more research is needed on nutritional practices for the prevention and treatment of BPH, experts agree these nutritional modifications can improve overall health without adverse effects.

Acupuncture

A recent systematic review and meta-analysis of 661 men with BPH comparing acupuncture with placebo acupuncture that does not manipulate traditional acupuncture points found that acupuncture significantly improved a variety of moderate to severe BPH symptoms in the short term. Another small randomized controlled pilot trial found that patients taking conventional medicine who were administered moxibustion (burning dried mugwort) at certain acupuncture points on the body had a greater improvement in BPH symptoms when compared with patients who took medicine without the moxibustion treatments.

Early Detection

Many men find it difficult to talk about urological symptoms. A recent study conducted by OnePoll and commissioned by Olympus in honor of Men’s Health Month 2021 found that 64% of men are more likely to put off seeing a doctor for health concerns they’re uncomfortable discussing, and 62% delay seeing a doctor for an issue that makes them feel “old.”

Many men find it difficult to talk about urological symptoms. . . . But early detection is critical.

But early detection is critical. It’s especially important for men who have contracted COVID-19 not to ignore symptoms. A new systematic review published online in Prostate Cancer and Prostatic Diseases found that the coronavirus may trigger hormonal disruptions and cause inflammation that can damage the prostate and lead to worsened symptoms of BPH.

“There are so many supposedly ‘taboo’ health issues, particularly for men, that we might not realize are common until we start to discuss them with others,” says Dr. Jed Kaminetsky, clinical assistant professor at NYU Medical Center and a board-certified urologist in New York City. Getting those routine check-ups can detect issues before they become serious, and BPH is a prime example, says Dr. Kaminetsky. He advises men not to procrastinate on preventative care: “This Men’s Health Month, there’s no reason to be reticent when talking with your loved ones, and your doctor, about your health issues. These conversations can help reveal the best treatment options for improving your quality of life.”