When someone asked, “Where’s the bathroom?” at a house party a few months back, a fellow guest quipped, “The women always know where the bathroom is—and guys who have BPH.”
His comment grabbed my attention largely because I happened to be working on this story at the time. But it also illustrated this point: BPH—benign prostatic hyperplasia, aka enlarged prostate—is so prevalent it’s become fodder for conversation around the water cooler or, in this case, at a garden party in East Sac.
With such socially crimping and sleep-depriving symptoms as frequent urination and a “stop and go” flow, BPH can wreak havoc on a man’s life and lifestyle, prompting these questions: Can this voiding issue be avoided? And why has it become so commonplace?
Here’s what three local experts—and the guy from the party—had to say.
It’s an aging thing. If it seems like every other man you talk to has prostate problems, you’re probably hanging with an older crowd. About half of all men between 51 and 60 have BPH, according to the Urology Care Foundation, and the number rises with age; for men over 80, the rate jumps to up to 90 percent. So why does this little gland the size of a walnut stir up trouble as men get older? For starters: It keeps growing. “Almost all men’s prostates will continue to grow throughout their lives,” says Serena Yang-Loudin, M.D., a urologist with Mercy Medical Group in Sacramento. If the prostate begins pressing on the urethra (the tube that connects the bladder to the penis), symptoms result.
While Anatomy 101 helps to explain why BPH is so common, there’s another factor to consider: longevity. “In part, incidence rates of enlarged prostate are rising because people are living longer,” says Christopher Evans, M.D., FACS, professor and chair of the Department of Urologic Surgery at UC Davis. Men are also seeking treatment more proactively than in the past, he adds—so it’s possible that what seems to be a growing problem is not growing at all; it’s just come out of the closet.
Sometimes, you can blame your dad. Age isn’t the only risk factor. Ray Bradshaw, the guy at the party who joked about his own BPH, believes his genetics are partly to blame. “I know one of the risk factors is having a blood relative, and my dad had BPH,” says Bradshaw, a longtime Sacramentan. Now in his mid-70s, Bradshaw says his symptoms began in his late 40s or early 50s, but he didn’t know what it was. Neither, as it turns out, did his doctor. “I noticed I would dribble a little after I peed, and I complained to my doctor about it, but he just advised me to ‘stand there a few minutes longer,’” he says, chuckling at the memory. “He didn’t say anything about BPH at the time.” (Bradshaw has since changed doctors.)
Hormones may also play a role in the BPH story. Studies suggest that as men age and testosterone levels drop, the resulting higher proportion of estrogen may contribute to the prostate’s growth. “For males, increasing estrogen is not a good thing,” says Dennis Godby, N.D., a California-licensed naturopathic doctor in private practice in midtown. For BPH patients encountering such hormonal shifts, Godby has found some success prescribing progesterone. “I’ve had dozens of men say the prescribed bio-identical progesterone has been helpful for BPH,” he says. While logic might suggest a prescription to testosterone would be the answer, that approach can backfire, says Godby. “I’m a proponent of testosterone, but the downside is that some of that can convert into estrogen, which is what you don’t want,” he explains. Progesterone, he says, can help counter that.
Lifestyle matters. Obesity and inactivity are also known risk factors for BPH, and studies show diabetes and heart disease may raise risk, too. For Godby, this is preaching to the choir. “The American lifestyle is the primary reason prostate problems are so prevalent, just as it is for other disease processes,” he says. “A healthy lifestyle is really the ticket for all of these conditions.” It’s a message we’ve been hearing for decades but apparently need to hear again: Good health begins with such practices as managing your body-fat percentage, bumping up your intake of fruits and veggies, eating “healthy” fats and moving that body. Research suggests such measures not only enhance general health but can help protect the prostate, too. Other prostate-specific helpers, according to Godby, include cooked tomatoes, pumpkin seeds, zinc and essential fatty acids (such as those found in fish oil). “Try drinking decaffeinated green tea instead of coffee, cut back on sugar and processed foods, and minimize alcohol,” he suggests. “Beer is the worst offender.”
A running machine himself (he founded The Run: Moving Natural Medicine Forward), Godby is especially passionate on the subject of exercise. “Exercise is absolutely critical,” he says. “I think more and more research is going to be done on prostate and exercise.” He may be right: One Harvard Health Professionals Follow-up Study, based on questionnaires from more than 30,000 men, showed that physically active men were less likely to suffer from BPH. Benefits were reported even by men whose activity level was low to moderate, such as walking regularly at a medium pace. Men with BPH might also benefit from working with a pelvic floor specialist, Godby adds. “Even though they [specialists] mainly see women, they can be helpful to men by providing specific exercises to strengthen the pelvic floor.”
Medication can help. Conventional meds and their potential for unsavory side effects make them a last resort for many. But they do curb symptoms and surely beat the alternative for some, especially those with very large prostates, says Mercy’s Yang-Loudin. “Short of surgery, these medications are the only way to decrease the size of the prostate,” she says. Standard treatment involves alpha blockers (which relax prostate and bladder muscles, improving urine flow) and 5-alpha reductase inhibitors (which shrink the prostate by blocking production of the male hormone DHT), either separately or together. Though side effects can range from mild to menacing, such as abnormal ejaculation and erectile dysfunction, Yang-Loudin reminds us that this isn’t a deal breaker for all patients and shouldn’t exclude their use. “The most important thing is to appropriately counsel patients and manage their expectations,” she says.
Possibly the most interesting development in BPH meds happened in 2011, when the FDA approved Cialis—yes, the same drug famously known to treat erectile dysfunction—for the treatment of enlarged prostate. Cialis (the brand name for tadalafil) may also be used to treat men who have both enlarged prostate and erectile dysfunction. Yang-Loudin says she prescribes low-dose Cialis for patients with BPH and ED who are sexually active and want to stay that way.
Common sense helps, too. Though Ray Bradshaw’s sleep is broken nightly by a midnight-to-2 a.m. bathroom call, he says he’d rather deal with that than the downsides of BPH drugs. “My doctor and I discussed drug treatments and their side effects, and she advised against it,” he says. “She told me the best thing I can do for this is to exercise as much as I can.” Bradshaw is following doctor’s orders, doing a 5-mile walk every morning and heading to the mountains weekly for long hikes. His other common-sense strategies include drinking most of his fluids (mainly water, some tea) early in the day and hitting the toilet several times right before bed. He’s even made a mission of locating his favorite public bathrooms, including those between his house and the grocery store. “What I’ve learned to do is adapt,” Bradshaw says. “It’s either adapt or give up.” His ability to laugh about it likely helps, too. “My stream is so weak now I can’t even write my name with it anymore, like when I was a kid,” he jokes. “I can’t even complete the ‘R.’” Bradshaw credits his doctor for helping him to make the best decision about managing his BPH, and he encourages others to do the same. “Work with your doctor,” he says, “or find a doctor you can work with.”
BPH is not cancer. Men who fear their plumbing problems are a prelude to prostate cancer should remember this: The “B” in BPH means benign. “There’s no known link between lower urinary tract symptoms and prostate cancer,” says UCD’s Evans. While this is good news for BPH sufferers, experts emphasize the importance of following the recommended screening guidelines for prostate cancer, which is the second-leading cause of cancer death in American men and often asymptomatic. Guidelines for the PSA (prostate-specific antigen) blood test and digital rectal examination are not one-size-fits-all. The American Urological Association recommends talking with a health care provider to determine whether to be screened. (You can find more information, including a prostate cancer screening assessment tool, at urologyhealth.org.)
While concerns about cancer tend to be front and center for men with BPH, don’t forget about that bladder, warns Mercy’s Yang-Loudin. “The organ that gets ignored a bit is the bladder,” she says, and that can be dangerous: Left unchecked, BPH can lead to bladder damage and infection. “It’s overall easy to fix a prostate issue, but once the bladder is involved, it can be much more serious,” she says. “The bladder can even give out.” Her advice? “As soon as men notice a problem with urination, they should see a doctor,” she says. “They shouldn’t assume it’s just because they’re getting older.” In addition to bladder issues, untreated BPH can lead to blood in the urine and kidney damage, according to the Urology Care Foundation.
The stigma is shrinking. Ray Bradshaw’s refreshing openness about his battle with BPH seems to suggest that the stigma around it is shrinking. UCD’s Evans says he’s seeing a shift, too. “I think men are not as reluctant to discuss it as they were in the past,” he says. Rampant marketing campaigns and commercials about men’s health issues—think Viagra and Cialis—have helped to raise awareness and make men more comfortable with formerly embarrassing topics, he says. With the wide range of treatment options available today, Evans says, “a man doesn’t have to get up to use the bathroom in the middle of the basketball game, or in the middle of the night. It’s all about quality of life.”
Lasers to the Rescue
Men requiring surgery for BPH who don’t want to go the “roto-rooter” route—that’s slang for TURP, transurethral resection of the prostate, long the gold standard—now have other, less-invasive options. UC Davis’ Evans is especially excited about the Holmium laser enucleation of the prostate, better known as HoLEP.
“The HoLEP is pretty new—we’re doing it here at UCD,” he says. “It’s a nice advancement for urinary obstructive symptoms.”
Lasers are cool tools. In this case, one is used to remove the excess prostate tissue that’s blocking urine flow. It requires no incisions, offers rapid recovery and—best of all—has been shown in studies to effectively eliminate BPH symptoms.
To learn more about HoLEP and other prostate surgeries, visit the Urology Care Foundation website, urologyhealth.org.
The Great Saw Palmetto Debate (and Other Herbs)
Most studies on herbal treatments for BPH are mixed, including the much-ballyhooed saw palmetto. But it has been shown in some studies to be effective, as have the following herbs:
- Cernilton, rye-grass pollen extract
- Pygeum africanum
- Urtica dioica (stinging nettle)
Always consult a doctor before taking these or other herbal remedies.
Source: Textbook of Natural Medicine, Third Edition, Vol .2 (2006); WebMD
BPH: Common Symptoms
- Frequent and/or urgent urination
- Feeling the bladder is full (even after urinating)
- Weak urine flow
- Stop-and-start urination
- Trouble starting to urinate
- Needing to push or strain to urinate
Source: Urology Care Foundation