Benign Prostatic Hyperplasia (BPH)

The prostate is a walnut-sized gland in the male reproductive system that sits just below the bladder and surrounds the upper part of the urethra (i.e., the tube that carries urine from the bladder) and makes fluid that is part of semen. Benign prostatic hyperplasia (BPH) is a condition in which the prostate gland is enlarged and not cancerous.^[1] BPH commonly affects older men; it’s estimated that about 50% of men > 50 years of age have evidence of BPH, and the prevalence of BPH increases further with advancing age.^[2]

As the prostate gets bigger, it presses against and narrows the urethra. The bladder wall also becomes thicker, and over time, the bladder may weaken and lose the ability to fully void.^[1] With that said, the correlation between prostate size and symptom severity is inconsistent; some men with substantially enlarged prostates experience few symptoms. The symptoms of BPH largely overlap with the early symptoms of prostate cancer and include:^[3]

• A frequent and urgent need to urinate, especially at night
• Trouble starting a urine stream
• A weak or interrupted (i.e., stops and starts several times) urine stream
• Dribbling at the end of urination
• Incomplete urination

BPH is most often diagnosed based on the patient’s symptoms (typically assessed using the International Prostate Symptom Score questionnaire), their medical history (e.g., prior surgeries, medication use, sexual history, fluid consumption), and a digital (i.e., finger) rectal exam.^[1] To differentiate BPH from other conditions that can cause lower urinary tract symptoms, a urinalysis is also commonly performed to detect material in the urine associated with metabolic disorders, renal dysfunction, or urinary tract infection.^[4]

The severity of symptoms determines the medical treatment selected. Treatment options include watchful waiting (i.e., lifestyle advice) and medications, which either relax the smooth muscles of the prostate and bladder neck to improve urine flow (i.e., alpha-blockers, phosphodiesterase-5 inhibitors) or block the conversion of testosterone to dihydrotestosterone (DHT) to prevent further enlargement of the prostate (i.e., 5-alpha reductase inhibitors). If the former treatments fail to improve symptoms, minimally invasive procedures or surgery to reduce prostate size and/or to widen the urethra may be indicated.^[1]

Because oxidative stress and inflammation are implicated in the development of BPH, research has mainly focused on the effect of different polyphenols (i.e., plant compounds with potent antioxidant and anti-inflammatory effects). With the exception of saw palmetto, most of the studies were conducted in rodents.^[5]

• saw-palmetto
• lycopene
• Flax seed
• soy-isoflavones
• green-tea-extract
• resveratrol

Obesity and metabolic-syndrome (a disorder characterized by a combination of insulin-resistance, abnormal blood lipids, high-blood-pressure, and elevated waist circumference) have been associated with an increased risk of BPH in observational studies,^[2] so a healthy diet that facilitates weight loss is likely beneficial.^[6] Additionally, reducing total liquid intake and the intake of caffeinated and alcoholic beverages, specifically, are commonly recommended to improve symptom management.^[1]

Physical activity levels in accordance with the guidelines from the World Health Organization (i.e., 150–300 minutes of moderate-intensity or 75–150 minutes of vigorous-intensity aerobic exercise and two resistance exercise sessions per week) are recommended to improve cardiometabolic risk factors (e.g., high-blood-pressure, insulin-resistance) and reduce body fat, which are associated with an increased risk of BPH. Over-the-counter “decongestants" commonly used for common-cold and flu symptoms should be avoided because they can exacerbate lower urinary tract symptoms.^[2] Limited evidence suggests acupuncture may also improve lower urinary tract symptoms.^[7]

The precise causes of BPH are not well understood, but several factors — both modifiable and nonmodifiable — have been implicated, including hormones (i.e., dht, estrogen), genetics, dietary factors, inflammation, and oxidative stress.^[8] According to some evidence, the risk of BPH is increased by four-fold in people with a first-degree relative with BPH.^[9] Also, metabolic-syndrome is consistently associated with an increased risk of BPH,^[10] so it may be involved in the development and progression of the condition.