— Dr Kulwant Singh
Dean: Faculty of Homoeopathy, Vinoba Bhave University
One of the hot spots in the body. It is reddish brown, size of an English walnut. It can disturb one’s sleep by requiring several trips to the bathroom each night or kill a man by producing uremic poisoning. In old age it can become a site for cancer too. The prostate is a gland which contributes greatly to one’s sexual life. It is a principal storage depot for the seminal fluid, without which chances of pregnancy will be about zero. At each ejaculation, testicles provide over 150-200 million sperms cells. The prostate produces a fluid that dilutes them and this fluid contains proteins, enzymes, fats and sugars to nourish the fragile sperm, alkalinity to overcome the deadly acidity of the female tract and a watery medium in which the sperm can swim towards female egg.
It is very astonishing fact to know that the condition BPH has been explained in Ayurvedic texts long back. The anatomical position of the prostate gland, symptoms of prostate enlargement and its remedies are explained in Acharya Sushruta. The anatomical position of prostate gland is described in Ayurvedic classics as follows. In Yogaratnakara it has been described as –
“Naabheradhasthaatsanjaatha Sanchaari Yadi Vaachalaha
Ashteelaavad Ghano Granthiroodhwar Maayata Unnataha”
Which means “Below umbilicus (NAABHI), there is a hard gland which is little bit bulged and changes its place some times and some times stays stationary. This gland is like “Ashteela” (A small stone used to sharpen swords). This gland when affected by vitiated vata causes a disease called “vataashteela” (or benign prostate hypertrophy).
Sushruta explains the structure, anatomical position of prostate gland and the symptoms of prostate enlargement as follows.
“Shacranmaargasya Basheshcha Vaayurantaramaashritaha
Ashteelaavadghanam Granthimmoordhvamaayata Munnatam”
Which means – the place between rectum and bladder is occupied by vitiated vata it affects the easy flow of urine, stools and semen by enlarging the gland “ Ashteela”.
From the size of an almond in puberty, due to hormonal signals, it grows in size. It has three lobes or sections, enclosed side by side in a capsule. The small urinary tube that empties the bladder, passes over the middle lobe. Anything that happens there to swell the prostate — infection, inflammation, cancer, hypertrophy – can enlarge these lobes and thus obstruct the flow of urine , causing a wide spectrum of misery. With partial obstruction, urine backs up in the bladder and becomes a stagnant pool; bacteria often invade the pool, multiply and cause serious infection, retention, hydronephrosis etc. In an adult male, the prostate usually weighs about 20 grams. Almost all of this mass develops during puberty in response to hormonal changes associated with maturation. The prostate literally doubles in size during puberty. If a man is lucky, and some are, the prostate never again undergoes any changes in size. Unfortunately, for men between the age of 40 and 59, nearly 60% can be shown to already be suffering from benign prostatic hyperplasia or prostate enlargement. This usually does not present a noticeable problem until after the age of 50. By the age of 80, however, some 85% of all men suffer from one or more symptoms of BPH. As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself and urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with prostate enlargement.
Benign prostatic hyperplasia (formerly called hypertrophy) in some ways is the male equivalent of menopause. The primary effect of BPH is a progressive decrease in the ability to empty the bladder as the prostate enlarges and applies pressure to the urethra. Retained urine from this obstruction at first can interfere with sleep as the sufferer wakes up in the middle of the night. At other times, pressure may make it impossible to properly control urine flow (incontinence). Retained urine in the bladder can allow bacterial growth and infection. Urine may flow back up the tubules to the kidneys and cause infection there. In severe cases of retention, urine even can find its way into the blood (uremia) with toxic consequences.
THEORIES FOR Prostate Enlargement
1. HORMONIC THEORY: As age advances , male hormones diminish, while estrogen does not. Tissues are enlarged due to predominance of estrogenic hormone. This is involuntary hyperplasia like fibro adenoma of breast.
2. NEOPLASTIC THEORY: Benign neoplasm. It is composed of fibrous tissues, granular tissues and muscles and is known as fibro-myo-adenoma.
Prostate enlargement is strongly related to normal ageing. Some of the factors involved are quite well understood. Nevertheless, there also is substantial disagreement about other issues. Prostate enlargement can be called an aspect of male menopause because an increased ratio of estrogen to testosterone is active in prostate enlargement. just as, conversely, in women passing through menopause the ratio of testosterone to estrogen increases. It is generally accepted that hormone ratios and hormone clearance are involved in prostate enlargement, but the exact ways in which these lead to the enlargement of prostate has yet to be definitively explained. Testosterone, the “male” hormone, is at its peak during adolescence. It decreases thereafter, and the rate of decrease sharpens by about age 50. The decline in testosterone production typically calls into play the compensatory release of other hormones which are stimulants to testosterone production. These cannot prevent the decline in testosterone levels, but they can lead to an elevated rate of transformation of testosterone into 5-alpha-dihydrotestosterone (DHT) and/or to the increased binding and/or to the decreased clearance of DHT from prostate cells. Testosterone is converted to DHT by the enzyme 5-alpha-reductase. Ultimately, it is DHT’s actions which cause the enlargement of the prostate. DHT binds to specific receptors on the prostate cells usually referred to as androgen receptors. It then is transported into the nucleus of these cells where it attaches to the DNA and ultimately turns on prostate growth. As will be explored in more detail below, current research indicates that DHT is a necessary, but not a sufficient cause in the etiology of BPH.
SECONDARY EFFECTS OF PROSTATIC ENLARGEMENT:
|URETHRA||The portion of urethra lying above the prostate becomes elongated. Distortion of prostatic urethra .|
|BLADDER||Musculature of bladder hypertrophies to overcome obstruction. Urine is stagnant and may form stones. Occasionally hematuria|
|URETER AND KIDNEY||Pressure on ureteric orifice , gradual dilation of ureter, hydronephrosis, ascending infection, nephritis|
|SEXUAL ORGANS||In early stages: increased sexual desireIn later stages: Impotence|
Symptoms of Prostate Enlargement
|FREQUENCY||§ Earliest symptom§ At first it is nocturnal§ Later: day and night§ Urgency due to stretched vesical sphincter|
|DYSURIA||§ Patient must wait for urination to start§ Useless to strain|
|STREAM||§ Variable§ Weak§ Tends to stop§ Starts and dribbles|
|PAIN||§ Only due to cystitis or acute retention of urine|
§ May be dull
§ Feeling of fullness in lower abdomen
|RETENTION||§ Acute retention of urine|
§ Retention with overflow, constant dribbling
|URINE||§ Occasional Haematuria|
|KIDNEY||§ Renal insufficiency|
|RECTAL EXAMINATION||§ Absence of full bladder§ Bimanual : Dorsal position : the enlargement can be felt|
PSA test results report the level of PSA detected in the blood. The test results are usually reported as nanograms of PSA per milliliter (ng/ml) of blood. In the past, most doctors considered PSA values below 4.0 ng/ml as normal. However, recent research found prostate cancer in men with PSA levels below 4.0 ng/ml (2). Many doctors are now using the following ranges, with some variation:
o 0 to 2.5 ng/ml is low
o 2.6 to 10 ng/ml is slightly to moderately elevated
o 10 to 19.9 ng/ml is moderately elevated
o 20 ng/ml or more is significantly elevated
|IVU||The shape and position of urethra will help in diagnosing, contraindicated in case of renal insufficiency|
|URINE FLOW STUDY||Sometimes the patient is asked to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests prostate enlargement.|
|OTHER||CYSTOURETHROSCOPY, ULTRA SONOGRAPHY|
COMPLICATIONS of Prostate Enlargement
- Acute Retention
- Chronic Retention: The bladder is not completely emptied after passing urine. Some urine remains in the bladder at all times. This is called ‘chronic (ongoing) retention’. This may cause recurring urine infections, or incontinence (as urine dribbles around the blockage rather than large amounts being passed each time patient goes to the toilet).
- Renal Failure
INDICATION FOR OPERATION
§ Acute retention
§ Chronic retention
§ Complications: stone, infections
- Catheterization: In case of retention of urine
- Transurethral microwave procedures. Prostatron, a device that uses microwaves to heat and destroy excess prostate tissue. In the procedure called transurethral microwave thermotherapy (TUMT), the Prostatron sends computer-regulated microwaves through a catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. A cooling system protects the urinary tract during the procedure. Although microwave therapy does not cure BPH, it reduces urinary frequency, urgency, straining, and intermittent flow. It does not correct the problem of incomplete emptying of the bladder. Ongoing research will determine any long-term effects of microwave therapy and who might benefit most from this therapy.
- Transurethral needle ablation. Transurethral Needle Ablation (TUNA) System for the treatment of BPH. The TUNA System delivers low-level radiofrequency energy through twin needles to burn away a well-defined region of the enlarged prostate. Shields protect the urethra from heat damage. The TUNA System improves urine flow and relieves symptoms with fewer side effects when compared with transurethral resection of the prostate (TURP). No incontinence or impotence has been observed
- Transurethral surgery. A procedure called TURP (transurethral resection of the prostate) is used for 90 percent of all prostate surgeries done for BPH. With TURP, an instrument called a resectoscope is inserted through the penis. The resectoscope, which is about 12 inches long and 1/2 inch in diameter, contains a light, valves for controlling irrigating fluid, and an electrical loop that cuts tissue and seals blood vessels. The surgeon uses the resectoscope’s wire loop to remove the obstructing tissue one piece at a time. The pieces of tissue are carried by the fluid into the bladder and then flushed out at the end of the operation. Transurethral procedures are less traumatic than open forms of surgery and require a shorter recovery period.
- Prostectomy . In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. The location of the enlargement within the gland and the patient’s general health help the surgeon decide which of the three open procedures to use.
- Laser surgery. In March 1996, FDA approved a surgical procedure that employs side-firing laser fibers and Nd: YAG lasers to vaporize obstructing prostate tissue. The doctor passes the laser fiber through the urethra into the prostate using a cystoscope and then delivers several bursts of energy lasting 30 to 60 seconds. The laser energy destroys prostate tissue and causes shrinkage. Like TURP, laser surgery requires anesthesia and a hospital stay. One advantage of laser surgery over TURP is that laser surgery causes little blood loss. Laser surgery also allows for a quicker recovery time. But laser surgery may not be effective on larger prostates. The long-term effectiveness of laser surgery is not known.
PROSTATE SELF CARE