

Benign Prostatic Hyperplasia

For the majority of men enlargement of the prostate gland is an inevitable fact of aging.  Benign Prostatic Hyperplasia, BPH, will affect greater than 50% of men over age 50, and 1/3 of these men will experience symptoms.  By 70-85 years of age the number of men with BPH climbs to 90%.  Fortunately, contrary to popular belief, BPH does not seem to increase the risk of developing prostate cancer, and there are a variety of helpful treatment regimens.


The prostate is a walnut-sized gland that sits in front of the rectum and below the bladder. It produces seminal fluid, a substance that provides a medium for sperm and lubricates the urethra, the tube that empties the bladder. Hyperplasia involves an increase in prostate cell number. Since the urethra runs through the prostate it can become progressively constricted by encroaching prostate cells and surrounding glandular tissue. The process often results in changes in urination, some severe enough to affect the quality of life.  The most common symptoms are frequent urination during the day and night (nocturia).  Nocturia can become particularly vexing by interfering with sleep and, consequently, affecting daytime alertness and performance.  Other symptoms can include changes in the urinary stream; difficulty initiating or completing the urine stream; urgency, irritation or pain with urination; loss of urine (incontinence); or blood in the urine due to straining with urination.


BPH is thought to develop through the influence of both testosterone and estrogen.  The main player seems to be the hormone Dihydrotestosterone (DHT), a strong testosterone metabolite derived from the conversion of testosterone by the enzyme 5-alpha reductase.  DHT will increase the number of prostate cells and the size of the gland.  Estrogen increases the response to DHT in the prostate gland.  Many conventional pharmaceuticals and complementary supplements influence these hormones to render their therapeutic response.  Other medications/supplements and approaches treat inflammation or proliferation.

Treatment OptionsMen's room

Treatment decisions are based on the severity of symptoms and the effect they are having on the individual’s quality of life.  Options range from observation to surgery.  A popular conventional drug is finasteride (Proscar), which works by inhibiting 5-alpha reductase, thereby decreasing DHT.  A similar drug in this class is dutasteride (Avodart). Other conventional medications are alpha-1 blockers that work to relax the overactive smooth muscle cells in the enlarged prostate.  Some of these are also used for treatment of high blood pressure. Alfazosin (Uroxatral), tamsulosin (Flomax), terazosin, doxazosin (Cardura), and silodosin (Rapaflo) are alpha-1 blockers that are considered more selective for the prostate. Rarely, symptoms are considered severe enough to suggest surgical removal of part of the prostate.  This procedure carries the risk of sexual dysfunction and incontinence.

There are many complementary options to consider that are safe and may be effective for mild to moderate symptoms.  As always, beginning early to prevent progressive gland enlargement is a prudent idea.  Since inflammation is a component of the process, an anti-inflammatory diet is suggested.  This involves consumption of plenty of brightly colored fruits and vegetables, whole grains, and healthy fats, such as olive oil, avocado, nuts and seeds, and lean protein, including cold water fatty fish, soy and legumes.  Decrease sugar and saturated fats, and avoid trans-fats/partially-hydrogenated fats.  Consumption of phytoestrogens (plant-based chemicals similar to human estrogen) may compete with the stronger naturally-produced estrogens.  Therefore, it may be helpful to use more soy, legumes, red clover, flaxseed, chia seed and sesame seeds in the diet. Round out prevention with regular aerobic exercise, as it may decrease the risk of BPH by up to 25%. When symptoms are present avoid symptom irritants such as caffeine, alcohol, tobacco and spicy foods.

Other lifestyle recommendations include consuming liquids in frequent but smaller amounts, and avoiding consumption of fluids within two hours of bedtime. Decongestants and antihistamines can aggravate symptoms and their use should be limited. Void when the urge is present, and perhaps double void to prevent dribbling. Practice relaxation techniques, as stress can trigger urgency.

The popular herb saw palmetto has mixed research supporting its ability to relieve symptoms in mild to possibly moderate cases.  Saw palmetto is a well-tolerated 5-alpha reductase inhibitor and anti-inflammatory agent. It shrinks the number of cells that surround the urethra, decreases DHT levels and reduces markers of prostate inflammation.  Onset of action is longer than conventional medications, one to two months when compared to finasteride and perhaps up to twelve months when compared to alpha-1 blockers.

Pygeum is used alone or in combination with saw palmetto.  It is a well-tolerated supplement that is thought to work as an anti-inflammatory and anti-proliferative agent. Its long-term safely has not been determined in conventional studies. 

Stinging nettle root is popular in Germany, and it has some preliminary supportive studies. 

Beta-sitosterol is able to provide symptom relief, possibly due to its anti-proliferative effect, and it has the additional benefit of acting as a cholesterol–lowering agent. 

Pumpkin seed and soy are natural food sources of beta-sitosterol, and it can also be found in certain cholesterol-lowering margarines.

Rye grass pollen extract seems to have multiple mechanisms of action. It is sold as a prescription product, Cernilton, in Western Europe, Japan, Korea and Argentina, and appears to be safe and effective for up to six months. 

Garlic has demonstrated help in improving urinary flow in preliminary studies, and vitamin E in combination with some of the supplements mentioned has shown promise in limited clinical trials.

Green tea extract, pomegranate, selenium and lycopene may also help maintain and promote normal prostate function.

The severity of BPH symptoms does not correlate well with the size of the prostate gland.  Additionally, BPH does not appear to increase the risk of developing prostate cancer.  However, a man with BPH runs the same risk as any man of developing prostate cancer, and symptoms are similar.  It is critical that men discuss any potential symptoms with their health care provider, and follow health-maintenance suggestions for prostate surveillance.

More detailed information on BPH is available on the Mayo Clinic site. Be well.



Ann Carey Tobin, MD

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