The Gerson Institute of Ayurvedic Medicine

Scott Gerson, M.D., Ph.D. (Ayurveda) Medical Director, Jupiter Medical Center Dept. of Integrative Medicine Division of Education and Research

 

 

 

 

 

Lake Mary Clinic, Gerson Ayurvedic Spa, and Panchakarma Facility: at 635 Primera Blvd. Lake Mary, Florida 32746

Jupiter Medical Center at The Calcagnini Center for Mindfulness
1210 S. Old Dixie Highway, Jupiter, Florida 33458, Suite M-117.2

 

 

 

 Telephone: (561) 263-MIND (6463); option 2 (407) 549-2800

Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (“BPH”) is an enlargement of the prostate gland. The prostate is a walnut sized gland (average weight 11 grams) found only in men. It is located just below the bladder and surrounds the urethra (the tube through which urine flows from the bladder and out through the penis). BPH is erroneously defined as benign prostatic hypertrophy, which is very different term from hyperplasia and incorrect. Hyperplasia means an increase in newly formed cells (the actual process in BPH) while hypertrophy refers to the enlargement of previously existing cells with no new cells added. In BPH, this increase in cells forms firm nodular structures which eventually compress the urethra and sometimes the bladder and rectum as well. BPH does not lead to prostate cancer.

Benign prostatic hyperplasia affects about 210 million males worldwide (2010) which is approximately 6% of the human race. The prostate starts to enlarge when men are in their 30’s and gets larger in most men the older they get. While the prevalence rate is 2.7% for men aged 45–49, it increases to 24% by the age of 80 years.

Why Do Men Have Prostate Glands?

The function of the prostate is to secrete a slightly alkaline, milky white fluid that constitutes 50–75% of the volume of the semen. The other components of semen are spermatozoa and seminal vesicle fluid. The alkalinity of semen helps neutralize the acidity of the vagina, and prolongs the survival of sperm. The prostatic secretions make up the initial portion of the ejaculate and contains the vast majority of the spermatozoa. Compared with the few spermatozoa expelled in seminal vesicular fluid, prostatic fluid spermatozoa have better motility and longer survival.

Cause of BPH

We do not understand the cause of benign prostatic hyperplasia from the western perspective but we do know that there are both hormonal and genetic factors. Fifty percent (50%) of men who develop significant BPH before the age of 64 demonstrate an autosomal dominant pattern of inheritance. But there are less than 10% of men who show this genetic connection when it develops after the age of 64.

Testosterone, and especially its metabolite dihydrotestosterone (DHT), seem to play a major role in the development of BPH. This is evidenced by the finding that boys who are castrated early in life do not develop the condition. On the other hand, supplementing these boys with exogenous testosterone does not increase their risk for developing BPH.

DHT is synthesized in the prostate from circulating testosterone by the action of the enzyme 5α-reductase. DHT binds to nuclear androgen receptors and signals production of growth factors that are mitogenic (promotes cell division). DHT is 10 times more potent than testosterone in this regard because it binds to the androgen receptor more strongly. The importance of DHT in causing nodular hyperplasia is supported by clinical observation that men given inhibitors of 5α-reductase such as finasteride (Propecia, Proscar) show marked decreases in the DHT content of the prostate as well as reduced prostate volume in many cases and reduced symptoms, in some cases.

If one were to biopsy and examine prostates around the globe, benign prostatic hyperplasia would be found in a vast number of men particular over the age of 70. However, rates of clinically significant, symptomatic BPH differ dramatically depending on lifestyle. Men who lead a western lifestyle (eat red meat, consume alcohol, are overweight or obese, are sedentary) have a much higher incidence of symptomatic BPH than men who lead a more healthy or rural lifestyle. Much work remains to be done to completely clarify the causes of BPH.

Symptoms of BPH

· Weak urinary stream

· Prolonged emptying of the bladder

· Abdominal straining

· Hesitancy

· Irregular need to urinate

· Incomplete bladder emptying

· Post-urination dribble

· Irritation during urination

· Frequent urination

· Nocturia (frequent urination during the night)

· Urgency

· Incontinence (involuntary leakage of urine)

· Bladder pain

· Dysuria (painful urination)

· Problems in ejaculation

Medications

The two main conventional Western medications for the treatment of BPH are:

(1)"alpha blockers" (actually alpha-1 adrenergic receptor antagonists) and

(2) 5α-reductase inhibitors.

Alpha blockers relax smooth muscle in the prostate thereby decompressing the intraprostatic portion of the urethra which increases urine outflow. Alpha blockers used for BPH include terazocin (Hytrin-Abbott), doxazocin (Cardura-Pfizer), tamsulocin (Flomax-Astellas Pharma), alfuzocin (Uroxatral-Aventis), and silodosin (Rapaflo-Watson Pharm). There are no significant difference between any of these and all have side effects. Common side effects of alpha blockers include orthostatic hypotension, (sudden fall in blood pressure upon standing), priapism (persistent erection >4 hours), headaches, cardiac arrhythmias, nasal congestion, and weakness.

The 5α-reductase inhibitors finasteride (Proscar; Propecia-Merck) and dutasteride (Avodart-GlaxoSmithKline)-are the other treatment options. These medications inhibit 5a-reductase, which in turn inhibits production of DHT, the principal hormone which stimulates hyperplasia of the prostate. Side effects include decreased libido, depression (sometimes severe), anxiety, gynecomastia (increase in male breast size), ejaculatory and/or erectile dysfunction, and birth defects (these drugs are known to be teratogenic).

There are also other less common medications which have been used to treat BPH but without consensus or convincing track records (including Viagra, Cialis, and anticholinergics).

Western Herbal Therapies

Saw palmetto (Serenoa repens) is the herb that has been most thoroughly evaluated. Though trials conducted over the past two decade have been mixed, the overwhelming consensus is that saw palmetto provides mild to moderate improvement in urinary symptoms and flow measures for men with benign prostatic hyperplasia. Other Western herbal medicines which have less vigorous scientific support (but many positive trials) include: Prunus africana (Pygeum bark), Urtica dioca (Stinging Nettle root), beta-sitosterol plant extracts, and Curcubita pepo (pumpkin seeds).

Unlike the pharmaceuticals mentioned above, these plant-based medicines (when unadulterated, unprocessed, and properly grown and harvested) are without adverse side effects.

Finally, although beyond the scope of this article, it should be mentioned that both surgery and (so-called) minimally invasive laser procedures also exist for BPH.

In my view, none of the above Western treatments are acceptable as ideal treatment for BPH for obvious reasons including: ineffectiveness in many cases, the serious adverse effect listed above, high recurrence rate due to treating the symptom but not the root cause, hemorrhagic disorders, infection and other anesthetic problems, and operative complications.

The Ayurvedic Perspective

It is a very impressive that a condition almost exactly corresponding to BPH was described in Ayurveda two millennia ago. The anatomical position of prostate gland, symptoms of BPH and its remedies are explained in several of the ancient medical compendiums.

A fairly large number of disorders involving the genitourinary tracts and organs have been described but the one which corresponds most closely to BPH is called “vatāshteela”. “Ashteela” means “a small round stone used to sharpen sword blades”.

In the ancient text the Astanga Hrdayam (AH, Ni, IX 23-24), vātashteela is defined as a condition where a swelling or mass appears in between rectum and urinary bladder causing obstruction to passage of urine, feces and gas. In an older test, the Sushruta Samhita, there is an almost identical description:

Shacranmārgasya bastheshca vāyurantaramāshritahai        Ashteelāvadghanam granthimmōrdhvamāyata munnatam

“If the place between rectum and bladder is occupied by vitiated vata it disturbs the easy flow of urine, stools and semen by enlarging the gland Ashteela”.

Given that the prostate gland is the only structure lying between urinary bladder and rectum and that the symptoms observed in Vatashteela are very similar to those of enlarged prostate, the Vatashteela is confidently considered by scholars to correspond to BPH.

Nidana (Cause)

The causes of vatāshteela (BPH) according to tridosa siddhanta (dosha theory) is generally vitiated Vāta dosha and specifically vitiated apāna Vāta.

Apāna Vāta. is located below the umbilicus in the colon, rectum, anus, urinary bladder, uterus, ovaries, penis, testicles, umbilicus itself, thighs, and groins (inguinal areas).

The functions of apāna Vāta are voiding of urine, stools, and gas, ejaculation of semen, ovulation, elimination of menstrual blood and expulsion of fetus, locomotion, function of the various glands below the umbilicus (Skene's glands, Bartholin glands, prostate gland, bulbourethral glands, seminal vesicles).

The vitiation of Vāta and apāna Vāta is commonly caused by:

  Supressing the urge of urination

  Supressing the urge of defecation

  Over-indulgence in sex.

  Physical and mental overexertion

  Consumption of dry, very cold foods and beverages

  Consumption of excessive pungent, bitter, and astringent tasting foods

  Indigestion (due to improper food combinations)

  Eating insufficient quantities of food

  Old age

  Excessive exposure to wind

  Excessive stimulation from television, computer, cellphones, etc

  Loud music

  General weakness

  Prolonged grief, fear, anxiety

 

Diagnosis

The clinical presentation, age, and lifestyle of the patient can generally confirm the diagnosis however there are a handful of other conditions which must be ruled out. These include: prostate infection, prostate inflammation, bladder infection, overactive bladder, interstitial cystitis, prostate or bladder cancer.

A digital rectal examination (DRE) should be performed to examine the size of prostate by inserting a finger into the rectum. A distended bladder can be felt per abdomen. Ultrasound examination can be done to determine the post-void residual volume. Routine urine analysis and culture will be done to rule out infections or blood in the urine. Although BPH does not cause prostate cancer, a prostate-specific antigen (PSA) blood test is normally performed.

Treatment

Due to the Vata nature of vātashteela (BPH), all Vata-reducing dietary and lifestyle measures will be useful. Please refer to any introductory book or website on managing Vata dosha. There you will find guidelines for a Vata-reducing diet which is important. Some specific recommendations for BPH include not suppressing the natural urge to urinate, defecate, or pass flatus. In fact, none of the 13 natural urges should be suppressed. This means going to the bathroom when you first get the urge. Avoid alcohol, tobacco, coffee and ice cold drinks as these all vitiate Vata. Avoid constipation. A daily teaspoon of triphala or psyllium husk seed powder and at least 35 grams of fiber each day will help. Reduce excess mental stress which also vitiates Vata. Stay warm and well-hydrated by drinking warm water in small sips throughout thee day. These are just a few of the Ayurvedic lifestyle recommendations.

Ayurvedic Medicines

There are medicines administered via both the oral and rectal routes. One or more of these can be used simultaneously under a physician’s supervision.

1        . 1. Brihatyadi Gana Basti (enema sequence) has been shown to be effective. Brihatyadi Gana is a decoction of five herbs recommended by Acharya              Sushruta for the treatment of all urine-retention related conditions. On that basis it has been used in vātashteela with excellent success. The five                herbs are:  Brhati (Solanum indicum), Kantakari (Solanum xanthocarpum), Kutaja (Holarrhena antidysenterica), Patha (Cissampelos pariera), and                       Yashtimadhu    (Glycerrhiza glabra).

Equal quantities of these herbs are boiled in water to make a decoction to which specific amounts of honey, salt, oils, are added. Depending on the proportion of ingredients the resulting enema solution will be either oil- or decoction based, and the two types are alternatively administered for eight days.

2.          2. Kanchanara Guggulu 1-3 grams two times daily with food            

3          3. Varunadi Kwath A kwath is a simple liquid infusion. Varuna (Crataeva nurvala) has been used since the time of Sushruta for various Vata and Kapha         conditions. Some of its qualities are that it dissolves stones, relieves swellings, improves digestion, and alleviates urinary obstructions.

Traditional dose is 30-60 ml three times daily.

4           4.Chandrapraha Vati 2 tablets two times daily 30 minutes before food

5.          5.. Shilajit 1-2 tablets two times daily with food

 

References

Sushruta: Sushruta Samhita Ayurved Dipika Hindi Vyakhya Purvardha edited by Dr.Ambika Datta Shastri, Published by Choukhamba Sanskrit Sansthan (S.Su.38   – 31, 32)

Ashtanga Hrudayam : Nirmala Hindi Vyakhya by Dr Bramhananda Tripathi, Published by Choukhamba Sanskrit Pratishtan Delhi.(NI.9-23) (AH.NI.IX, 23-24)

Ashtanga Hrudayam : Nirmala Hindi Vyakhya by Dr Bramhananda Tripathi, Published by Choukhamba Sanskrit Pratishtan Delhi.(NI.9-23) (AH.CH.XI, Sharngadhara Samhita:–Dipika Hindi Vyakhya Visheshvyakt – Dr. Bramhanda Tripathi, Published by  Choukhamba Surbharti Prakashan Varanasi, reference-5,20