Prostate Enlargement Protocol


The benign enlargement of the prostate gland affects most men over the age of 60. An enlarged prostate interferes with the flow of urine from the bladder, which can produce mild to severe urinary obstruction.

After age 60, the number of men who experience urinary difficulties caused by prostate enlargement may exceed 70%. Autopsy studies show that 40% of men in their 50s are afflicted with benign prostate enlargement (Recker 1996).

Those afflicted with benign prostate disease have trouble urinating, or voiding, and are often overly sensitive to the presence of any residual urine in the bladder. Older men often must get up several times a night to urinate and still do not feel they have completely emptied their bladders. The relentless frustration of chronic urinary urgency is a major cause of sleep disturbance and the loss of quality of life as men age.

The acronym used to describe prostate enlargement is BPH, and this may be an abbreviation for either benign prostatic hyperplasia (meaning an increase in the number of cells in the prostate) or benign prostatic hypertrophy (meaning an increase in the size of the prostate gland). In medical literature, hyperplasia and hypertrophy are used interchangeably to define prostate enlargement.

According to the American Heritage Dictionary, the word benign means: "of a kind and gentle disposition, of no danger to health, not recurrent or progressive, not malignant." This definition, though, is only partially correct: prostate enlargement is not malignant. However, prostate enlargement may not be "kind and gentle" because it can be a danger to health and may be recurrent and progressive.

prostate enlargement is one of the most prevalent health problems among aging men. It has been estimated that over 9 million men in the United States over the age of 50 and another 20 million men worldwide suffer from prostate enlargement. prostate enlargement symptoms include increased frequency of urination, a sudden urge to urinate, and difficulty in urinating or a weak flow of urine. It is possible that the excessive tissue growth can completely compress the urethra so that little or no urine can be passed.

At times, prostate enlargement may become so large that the growth pushes up and presses on the bladder. This pressure and squeezing can partially collapse the bladder and will decrease the volume of urine that the bladder can store. It may also cause a pool to be formed so that some residual urine is retained after the patient has voided.

prostate enlargement affects each man differently. Because each man is different and each manifestation of the disease is different, there is no single treatment for all men. There is also no absolute cure for prostate enlargement. Men who have the surgical transurethral resection procedure (TURP) may be free of symptoms for some time, but prostate enlargement may recur in some of them.

In the United States each year, about a half million men are treated for prostate enlargement with various types of surgery and drug therapy. The second greatest cost to Medicare, at over $2.5 billion a year, is for prostate enlargement treatments. Note: The single greatest cost to Medicare, at close to $3 billion per year, is for cataract treatments. The expense for cataracts is greater because it includes both men and women and both eyes are affected.

prostate enlargement versus Prostate CancER

Impact of Dihydrotestosterone
PSA
prostate enlargement is an excessive growth of normal prostate cells. In prostate cancer, a tumor consisting of abnormal cells is the culprit behind the disease. At first the tumor is small, but a tumor may eventually grow so large that it infiltrates and occupies the entire prostate.

Another difference is that a prostate with prostate enlargement will be fairly soft and pliable. A cancer tumor can be made up of very tightly packed cells. The posterior, or back portion of the prostate, is called the peripheral area and lies near the rectum. This portion of the prostate can be easily detected by a physician. During a digital rectal exam (DRE), when a physician puts his gloved finger in the rectum, he can usually detect the difference in the soft tissue of prostate enlargement and the hard lumpy tissue of cancer. An experienced physician can determine a wealth of information from a DRE. For example, he might be able to estimate the size of the prostate and feel any irregularities. The prostate should feel smooth and pliable, much like the tip of your nose. A cancer might feel much like one of the knuckles on your hand.

However, not all cancers can be felt. About 30% of prostate tumors are not palpable during DRE. Cancers can also be multifocal or have several small colonies that are not large enough to be felt. Fortunately, the prostate specific antigen (PSA) test is available. The PSA is a simple blood test that can detect very early stages of prostate cancer.

Prostate cancer has the capability to infiltrate nearby tissues and organs and metastasize to distant sites. prostate enlargement, on the other hand, stays within the prostate capsule. It seems a bit confusing that prostate cancer can invade the nearby seminal vesicles, but that prostate enlargement does not affect them. Men also have two Cowper's glands (also called bulbourethral glands) that are located near the prostate. Also interesting is that Cowper's glands have the same type of cells found in the prostate, but they are never affected by prostate enlargement. According to Dr. Donald Coffey of Johns Hopkins, no case of prostate cancer has ever been found in the Cowper's glands.

Each year about 500,000 men are diagnosed with prostate enlargement compared to approximately 180,000 men who are diagnosed with prostate cancer. Although over 30,000 men die each year from prostate cancer, very few men die as the result of prostate enlargement. However, just a few decades ago, prostate enlargement was the cause of many deaths. If the urethra was completely blocked, urine would soon fill the bladder and then back up into the kidneys, soon causing uremic poisoning. It has been said that uremic poisoning was one of the contributing causes of the death of Thomas Jefferson. Today a man can be catheterized to drain the bladder. There are also several treatments for prostate enlargement that did not exist a few years ago.

Impact of Dihydrotestosterone (DHT) on Prostate Growth
One cause of prostate enlargement is overproduction of a hormone metabolite called DHT, which is considered a prime culprit in the development of prostate enlargement and possibly prostate cancer. The stimulating nature of DHT in the development of prostate disease is well documented because castration before age 40 prevents prostate enlargement and prostate cancer. Additionally, castration is a proven therapy to reverse both benign and malignant prostate disease. These findings suggest that strategies to reduce DHT levels would prevent many forms of prostate disease.

Evidence that DHT is a cause of prostate disease comes from observations as early as 1979: Men with low blood levels of DHT maintained a small prostate compared with men with average DHT levels who experienced enlarged prostates (Bartsch et al. 1979).

Testosterone is converted into DHT by the enzyme 5-alpha reductase, which increases as men grow older, causing elevated DHT production, decreased serum testosterone, and the enlargement of the prostate gland. When the action of 5-alpha reductase is blocked, dramatic reductions in DHT levels occur. The reduction in DHT production via the inhibition of 5-alpha reductase produces a normalization of prostate volume and improvements in urinary and sexual function in some men suffering from benign prostatic hypertrophy.

Besides male humans, several animals have prostates. But strangely, only humans and dogs are afflicted with prostate enlargement. As you will read later in this protocol, excess levels of DHT are only one cause of the epidemic of prostate enlargement.

PSA
prostate enlargement cells produce PSA, but only about one-tenth as much as a comparable cancer cell mass. Cancer cells are packed very tightly together, which may form a hard lump. When a doctor does a DRE, he feels for any lumps or any irregularities in the gland.

The PSA test is a simple blood test that can detect prostate cancer in its very early stages. The PSA test is not perfect, but it is the best test that we have for any form of cancer.

PSA may be age related. It is normal to have a small amount of PSA in the blood, but if PSA becomes elevated and continues to rise, it may correlate very closely with any cancer activity. A 50-year-old man may have a PSA of 2.5 ng/mL and still be normal. For a man of 60, PSA may be as high as 3.5 ng/mL and still be normal. If you have a small amount of PSA due to prostate enlargement, your PSA should remain fairly constant in additional tests that you have about every 3-6 months. A man with a large prostate due to prostate enlargement may have a PSA as high as 10 ng/mL.

Not all physicians or HMOs offer the PSA test. If the test is not offered, you should ask for it. It may save your life.

There is usually a large amount of PSA in the semen of each ejaculation. When first ejaculated, the semen is a thick gel-like substance. PSA helps to liquify the ejaculate so that the sperm cells can more easily navigate through the substance.

The Prostate LocatiON

Androgen and Estrogen Receptors
As noted earlier, the prostate is located just below the urinary bladder. The base, or top, of the prostate is intimately connected to the urinary bladder sphincter, or valve. The urethra, or channel for the voiding of urine, passes through the center of the prostate. The apex, or lower end, of the prostate is connected to the penis.

Benign Prostatic Hyperplasia (prostate enlargement) is the most common type of tumor in mature men. It is a benign growth, which means it may enlarge but will not spread to other locations in the body. The tumor can cause discomfort and may grow to completely close the bladder neck, preventing urination. This condition occurs because the tumor usually grows in the transitional zone and periurethral gland region located at the prostate base near the bladder neck. (Anatomical Chart Company 2002®, Lippincott Williams & Wilkins.)

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The prostate in a baby boy is about the size of a pea. At the onset of puberty, the testes begin producing testosterone. The androgen receptors (ARs) of the prostate cells respond to the testosterone. This causes the significant growth of the prostate. The prostate maintains AR expression throughout life. The androgens are food for the prostate cells. Without it, the cells will shrivel up and starve (Walsh et al. 1997).

At the end of puberty, the prostate will be about 26 grams or slightly less than 1 oz. At about 50 years of age, in about 50% of men, the prostate will again begin to enlarge. Approximately 90% of men over 80 will have significant prostate enlargement. The prostate may even grow to the size of a grapefruit. (Dr. August Roumani reported that he removed a prostate weighing over 600 grams or about 1.25 pounds. Of course, this was an extreme case.) Ordinarily, the prostate with prostate enlargement would weigh from 60-100 grams. However, all men are different; therefore, a man may have prostate enlargement symptoms with a prostate that is no larger than 35 grams.

Other Androgen and Estrogen Receptors
At the onset of puberty, the penis also has androgen receptors, which cause it to grow. But after puberty the penis loses its ability for androgen-dependent growth. After puberty, no amount of testosterone will cause further growth, although severe deficiency of tes-tosterone can cause penile shrinkage.

There are several similarities to breast development and penile development. At the onset of puberty, females will have estrogen receptors that cause breast development. But after puberty, the breast loses it dependence for estrogen growth and no amount of estrogen will cause further breast enlargement.

Symptoms of prostate enlargement

Tabulating the Symptoms
prostate enlargement has several symptoms. Depending on age, a man may have some or all of these symptoms; however, treatment may not be needed. Most of these symptoms may also be present in prostate cancer.

Decreased strength and force of the stream. One of the most notable symptoms is reduced urinary stream. This may be due to bladder outlet obstruction. The obstruction may also be caused by a compression of the urethra within the prostate gland.
Urinary frequency during the day. Some men are rarely able to pass a restroom without stopping to use it. Normally, urination should not be more than once every 2 hours during the day unless large amounts of liquids such as coffee, tea, or beer are being consumed. The prostate may be so large that it is pressing on the bladder so that the capacity of the bladder is diminished. The normal bladder in a man should have a capacity of 12-17 oz. (Most medical measurements are listed in milliliters or cubic centimeters, which are the same: 1 oz is 29.57 mL or 29.57 cc. The normal bladder will hold from 355 mL or cc and up to 502 mL or cc.)
Nocturia (needing to urinate several times at night). Most men, and many women, must get up at least once during the night to urinate, especially if they have consumed large amounts of fluids in the evening before bedtime. However, men who have prostate enlargement may need to get up several times during the night, only to void a small amount each time. It is possible that the prostate has become so enlarged that it presses on the bladder and prevents the bladder from holding as much as it normally should. If a man cannot get back to sleep, it may cause sleep deprivation. Nocturia is the most common prostate enlargement symptom that causes men to see their physician. Nocturia is not definitive that you do or do not have prostate enlargement. Even if a man has had a radical prostatectomy, he still may have to get up 2 or more times each night.
Urgency. There may be a feeling of urgency or that you cannot wait or need to urinate immediately.
Hesitancy. A man may require several seconds trying to find the right button to push to get urination started. Time and place may also make a difference. If in a crowded public restroom and it seems as if others are staring at you and your anatomy, finding the right button to push may be difficult even if you do not have prostate enlargement. If you have difficulty urinating, try sitting on the commode. In some men, sitting seems to help relieve the obstruction slightly.
Straining. Straining may be required to force urine through the constricted urethra. This can cause thickened bladder muscles. Constant straining may also cause the bladder muscles to simply not work at all. Many men wake up in the morning with an erection and an urge to urinate. In this case, straining is almost always required to start urination. The reason is that the bladder sphincter is designed to remain closed in the presence of an erection. This prevents any ejaculate that might occur from entering the bladder. After a TURP, this valve is usually damaged. When the valve is damaged, and an ejaculation occurs, quite often the semen takes the shorter route into the bladder. This is called retrograde emission (to be discussed in more detail later).Dribbling and difficulty in stopping. One symptom is difficulty in starting urination, but there may also be difficulty in being able to stop, at least not completely stop. A man with prostate enlargement may think that urination is finished. However, almost immediately there will be leaking of urine. Leaking is often embarrassing and can be worsened by stress (e.g., being late for an important appointment or in a hurry).
Decreased size or caliber of the stream. The urine stream in a young man can be about a quarter of an inch in diameter. However, a man who has prostate enlargement might have a stream that is less than a sixteenth of an inch in diameter. This could be due to the constriction of the prostatic portion of the urethral tube.
A feeling of still needing to urinate. A man may have just finished urinating but still feel as if the bladder is not empty.
Dysuria (pain) or burning during urination. Any pain or burning sensation during urination could be due to irritation of the urethra. If the patient is unable to completely empty the bladder, it may lead to bacterial infection, which may cause pain and burning during urination. Pain and burning could also indicate an inflammation, prostatitis, bladder stones, or prostatic stones.
Complete retention of urine. The complete retention of urine is an emergency situation. The patient should be immediately hospitalized and treated. If there is nausea, dizziness, or unusual sleepiness, these symptoms may be caused by kidney damage due to urine blockage.

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