Dr. G Jaysee John 1, Dr. Priyanka Kapoor 1, Dr. Shivram 1
1PG Scholar Department of Organon of Medicine, Dr. MPK Homoeopathic Medical College Hospital & Research Centre (Under Homoeopathy University), Saipura, Sanganer, Jaipur. (Raj.)
ABSTRACT: Benign Hypertrophy of Prostate (BPH) or Adenomatous enlargement of the prostate is the nonmalignant enlargement of the prostate gland. It refers to stromal and glandular epithelial hyperplasia that occurs in the periurethral transition zone of the prostate that surrounds the urethra.1 This article represents a brief overview of BPH and homoeopathic view point along with diagnostic and management approaches after critical analysis of different source books so as to enable the reader to get all aspects of the disease on a one common plane.
KEYWORDS: BPH, Homoeopathy, IPSS, Postvoid.
ANATOMY: The prostate develops around 12th week of intrauterine life. It has 5 lobes: Anterior, posterior, 2 lateral and 1 middle lobe or median lobe. Median lobe is situated in between the two ejaculatory ducts and the urethra.
The classification of the prostate into different zones was done by McNeal. It is divided into the peripheral zone (PZ), which lies mainly posteriorly and from which most carcinomas arise, and a central zone (CZ), which lies posterior to the urethral lumen and the ejaculatory ducts as they pass through the prostate.
There is also a periurethral transitional zone (TZ), from which most benign prostatic hyperplasia (BPH) arise.2
EPIDEMIOLOGY: Benign prostatic hyperplasia (BPH) mainly effects men of increasing age.
By age 50 years, about 50% of men are diagnosed, by 80 years, 90% of men are diagnosed. The greatest prevalence occurs among men ages 70 to 79 years.3,4
PATHOPHYSIOLOGY: BPH affects both glandular epithelium and connective tissue stroma to variable degrees. BPH typically affects the submucous group of glands in the transitional zone, forming a nodular enlargement. This overgrowth compresses the PZ glands into a false capsule and causes the appearance of the typical ‘lateral’ lobes.
ASSOCIATED THEORIES FOR BPH:
Hormonal theory:
Within the prostate, testosterone is converted to Di hydro testosterone (DHT) by the help of enzyme 5-α reductase, this androgen thought to be the main mediator of prostatic hyperplasia. The clinical importance of DHT became clear when patients treated with orchiectomy and 5-alpha-reductase inhibitors (which stop conversion of testosterone to DHT) showed decrease in BPH symptomatology. With increasing age, levels of androgens come down and there is corresponding increase in levels of oestrogen which stimulates the prostatic gland and produces BPH.
Role of cytokines:
Cytokines contribute to prostate enlargement by an inflammatory response and by inducing epithelial growth factors. As the prostate enlarges due to hyperplasia, the portion of the urethra that passes through the prostate is compressed, lead to decrease urinary outflow and cause obstructive symptoms. The patient develops bladder hyperactivity, inflammation, and distension as bladder smooth muscle cells enlarge to maintain urine flow in response to resistance from prostatic obstruction. These changes cause oxidative stress and free radical formation, as well as alterations to the alpha-adrenergic nerves of the bladder, resulting in storage symptoms.
Neoplastic theory:
According to this theory there is proliferation of all elements of prostate like fibrous, muscular and glandular.
COMPLICATIONS OF BPH:
Urethral changes: Urethra gets compressed, elongated and convert into a narrow longitudinal slit lead to urinary flow obstruction. This effect is more with median lobe enlargement (due to enlargement of subcervical glands).
Bladder changes: Bladder muscles hypertrophy lead to formation of fasciculations.
Retention of urine in diverticuli lead to secondary infection and stone formation.
BPH BACK MUSCLE PRESSURE EFFECTS ON THE BLADDER
Bladder Muscle Hypertrophy
Fasciculations
Sacculations
Diverticuli
Stasis, infection, stone
Changes in the ureter and kidneys: Bilateral hydronephrosis and bilateral hydroureter are the end result of BPH. Which may lead to renal failure.
RISK FACTORS: Increasing age, metabolic syndrome, family history of BPH, obesity, history of diabetes, black race, a diet high in starches and meat, excessive alcohol intake, smoking may be a risk factor for BPH, a sedentary lifestyle can increase the risk of developing BPH or intensify the severity of lower urinary tract symptoms (LUTS) in patients who already have the condition.
CLINICAL FEATURES:
| Storage Symptoms | Voiding symptoms |
| Urinary frequency | Difficulty initiating urinary stream |
| Urinary urgency | Urinary hesitancy |
| Urinary incontinence | Straining to void |
| Nocturia | Decreased urinary flow |
| Dysuria | Intermittency |
| Dribbling | |
| Incomplete bladder emptying |
Frequency: increased frequency of micturition particularly at night is the earliest symptoms.
Nocturia occurs, patient get up in the middle of the night twice or thrice to pass urine.
Urgency: due to prostatic enlargement there is vesicle introversion of sensitive mucous membrane of prostatic urethra within the bladder, it cause internal sphincter to stretch and prevents contraction. It results urgent desire to pass urine.
Haematuria: due to prostatic congestion.
Difficulty in micturition.
Acute and chronic retention of urine.
Symptoms of uraemia: It include headache drowsiness and even haematemesis.5
DIFFERENTIAL DIAGNOSIS:
The following conditions can coexist with Bladder outflow obstruction (BOO):
- Idiopathic detrusor muscle over activity
- Neuropathic bladder dysfunction due to diabetes, strokes, Parkinson’s disease
- Degeneration of bladder smooth muscle giving rise to impaired voiding and detrusor instability
- Bladder neck stenosis
- Bladder neck hypertrophy
- Prostate cancer
- Urethral strictures
DIAGNOSIS:
Careful History Taking: specific questions about storage and voiding symptoms
- The American Urological Association Symptom Index (AUASI) and The International Prostate Symptom Score (IPSS) are subjective questionnaires that can be used to help evaluate lower urinary tract symptoms and their effect on patients suffering from BPH.
- The score is classified as mild (0-7), moderate (8-19), or severe (20-35).
| In the past month: | Not at all | Less then 1 in 5 Time | Less then half the Time | About half the Time | More then half the Time | Almost Always |
| 1 Incomplete Emptying
How often have you had the sensation of not emptying your bladder? |
0 | 1 | 2 | 3 | 4 | 5 |
| 2 Frequency
How often have you had to urinate less than every two hours? |
0 | 1 | 2 | 3 | 4 | 5 |
| 3 Intermittency
How often have you found you stopped and started again several times when you urinated |
0 | 1 | 2 | 3 | 4 | 5 |
| 4 Urgency
How often have you found it difficult to postpone urination? |
0 | 1 | 2 | 3 | 4 | 5 |
| 5 Weak Stream
How often have you had a weak urinary stream? |
0 | 1 | 2 | 3 | 4 | 5 |
| 6Straining How often have you had to strain to start urination? | 0 | 1 | 2 | 3 | 4 | 5 |
| None | 1 Time | 2 Time | 3 Time | 4 Time | 5 Time | |
| 7Nocturia
How many times did you typically get up at night to urinate? |
0 | 1 | 2 | 3 | 4 | 5 |
Digital rectal examination (DRE):
Done to assess the size, shape, and consistency of the prostate gland. Done in left lateral position (or in knee elbow position).The urinary bladder must be empty before examination. The index finger is usually used and should face the anterior surface of the rectum. An enlarged prostate is soft, smooth, boggy, mobile, and with an central sulcus. Persistence of median sulcus is a definite sign of this condition which is often obliterated in carcinoma. The rectal mucosa moves freely over the gland. (in case of carcinoma rectal mucosa not moves freely) The prostate may not be felt enlarged if only the median lobe is enlarged. Any nodules or indurations, which may suggest prostate cancer.
Grading of prostate:
- The prostatic lobes protrude minimally into the rectal lumen by 1-2 cm, the median sulcus is palpable
- Prostatic lobes protrude > 2 cm but < 3 cm into the rectal lumen and median sulcus is obliterated
- Protrusion of 3-4 cm
- Protrusion > 4 cm, most of the rectal lumen is filled by the projecting prostatic lobes.
Prostate-specific antigen (PSA) level:
PSA levels often correlate with prostate size; normal value of PSA is below 4ng/ml. Value of PSA increase in BPH, prostatic carcinoma, prostatitis etc.
Urinalysis:
Urine is examined for glucose and blood; a midstream specimen should be sent for bacteriological examination, and cytological examination may be carried out if carcinoma in situ is thought possible.
Maintain voiding diaries:
Documenting the time voided, volume voided, and associated activities (such as fluid intake) in a voiding diary may help in BPH diagnosis, especially in patients with urinary frequency.
Blood urea and creatinine: raised levels indicate renal failure
Prostatic ultrasound:
Trans abdominal or transrectal prostatic ultrasound evaluate the size, shape, anatomy, and potential pathology of the prostate, also can assess the bladder and postvoid residual urine.
Measuring postvoid residual volume:
A postvoid residual volume measurement is recommended for patients with moderate or severe symptoms, defined by an IPSS score of 8 or greater.
Uroflowmetry: patient is asked to void urine from is full bladder into the flow meter than flow rate is assessed.
- Peak flow rate: normal is 20 ml/sec
- Doubtful peak obstruction is 10 -15 ml/sec
- Definite peak obstruction is < 10ml/sec
Cystourethroscopy:
Inspection of the urethra, the prostate and the urothelium of the bladder should always be done immediately prior to prostatectomy, whether it is being done trans urethrally or by the open route to exclude a urethral stricture, a bladder carcinoma and the occasional non-opaque vesical calculus.2,5,6
MANAGEMENT:
Dietary advice
- Lycopene– olive, tomatoes, watermelon, pink guava, papaya.
- Beta-carotene include: Carrots, Sweet potatoes, Spinach, Fruits like cantaloupe and apricots.
- Vitamin A- Green leafy vegetables and other green, orange, and yellow vegetables, such as broccoli, carrots, and squash. Fruits, including cantaloupe, and mangos, Dairy products.
- Vitamin C- Citrus fruits- lemon, oranges, guava, blue berries, mango, grapefruits, goose berries, green and red pepper.
- Dietary sources of alpha-linolenic acid include: Flaxseeds and flaxseed oil, soybeans, pumpkin seeds tofu. Walnuts.
- Selenium– eggs, cheese, mushrooms, oats, pork, wheat, grains, tuna fish, salmon, oyester, sun flower seed, soyabean.
HOMOEOPATHIC MEDICNES:
Baryta carbonica:-
Urging to urinate. Enlarged prostate. Hypertrophy of prostata; after urinating renewed straining with dribbling of urine; numbness in genitals for several minutes; frequent micturition.
Benzoicum acidum:-
Enuresis; dribbling, offensive urine of old men. Enlargement of prostata; sensibility of bladder with muco-purulent discharge; dysuria senilis; weak loins, when the gravel is trifling.
Chimaphila umbellata:-
Urging to urinate. Urine turbid, offensive, containing ropy or bloody mucus, and depositing a copious sediment. Burning and scalding during micturition, and straining afterwards. Must strain before flow comes. Scanty urine. Acute prostatitis, retention, and feeling of a ball in perineum. Fluttering in region of kidney. Sugar in urine. Unable to urinate without standing with feet wide apart and body inclined forward. Loss of prostatic fluid. Prostatic enlargement and irritation.
Conium maculatum:-
Much difficulty in voiding. It flows and stops again. Interrupted discharge. Dribbling in old men. Enlargement and induration of prostata cause intermittent urination in old people, urine flows and stops; discharge of prostatic fluid on every change of emotion.
Copaiva officinalis:-
Burning pressure; painful micturition by drops. Retention, with pain in bladder. Catarrh of bladder; dysuria. Swelling of orifice. Constant desire to urinate. Urine smells of violets. Greenish, turbid color; peculiar pungent odor. Induration of prostate, in old men, with no increase in size or slight augmentation with extreme hardness; burning and sensation of dryness in region of prostate gland and in urethra, with great pain while urinating, urine is emitted by drops.
Digitalis purpurea:-
Continued urging, in drops, dark, hot, burning, with sharp cutting or throbbing pain at neck of bladder. Urethritis, phimosis, strangury. Full feeling after urination. Constriction and burning, as if urethra was too small. Enlarged prostate. Senile hypertrophy of prostate, dribbling discharge of urine and continued fullness after micturition or fruitless effort to urinate; throbbing pain in region of neck of bladder during the straining efforts to pass water; increased desire to urinate after a few drops have passed, causing the old man to walk about in distress, though motion increases desire to urinate.
Ferrum picricum:-
Pain along entire urethra. Frequent micturation at night. Smarting at neck of bladder and penis. Retention of urine. Enlarged prostate.
Iodium:-
Frequent and copious, dark yellow-green, thick, acrid with cuticle on surface. Swelling and induration of prostate gland and of testicles; incontinence of urine; stricture of urethra in the aged. Diseases of Prostate.
Natrium sulphuricum:-
Loaded with bile. Brisk-dust sediment. Excessive secretion. Diabetes. Enlarged prostata, pus and mucus in urine; sycosis.
Populus candicans:-
Severe tenesmus; painful scalding. Urine contains mucus and pus. Prostate enlarged. Pain behind pubis, at end of urination. Enlarged prostata; catarrh of bladder, painful urination, irritation of bladder and urethra.
Sabal serrulata:-
Constant desire to pass water at night. Enuresis; paresis of sphincter vesicae. Difficult urination. Cystitis with prostatic hypertrophy. Prostatic troubles; enlargement; discharge of prostatic fluid. This medicine has been recommended for various prostatic troubles, but its homoeopathic use seems confined to acute cases of enlarged and inflamed prostate. Sabal is not altogether useless in senile hypertrophy.
Thuja occidentalis:-
Urethra swollen inflamed. Urinary stream split and small. Sensation of trickling after urinating. Severe cutting after. Frequent micturition accompanying pains. Desire sudden and urgent, but cannot be controlled. Paralysis sphincter vesicae. Prostatic enlargement. Dysuria, retained urine. Frequent desire to urinate in the evening, amel. by lying down. Frequent pressing to urinate with small discharge, patient strains much. Discharge of prostatic juice in the morning on awaking.
Triticum repens:-
Frequent, difficult, and painful urination. Strangury, pyelitis; enlarged prostate. Incontinence; constant desire. Urine is dense and causes irritation of the mucous surfaces. Retention of urine in very old people from enlarged prostata, when there is a great deal of trouble in urinating.7,8,9
DISCUSSION & CONCLUSION:
Men with benign prostatic hyperplasia (BPH) often find the condition stressful. Symptoms like urinary urgency may disturb even the most relaxed fellow, and nighttime urination that interrupts sleep can only add to mental distress.
Keeping this in mind, proper diagnosis, investigations and management becomes matter of prime importance for well being of the patient, which is summarised in this article. Homoeopathy is a specialized system of medicine which treats the patient and not the disease. Homoeopathy believes in holistic individualized approach, and corrects disturbances in the vital force. However, use of therapeutically indicated medicines have been proved beneficial time to time.
REFERENCES:
1. Dhingra N, Bhagwat D. Benign prostatic hyperplasia: An overview of existing treatment. Indian Journal of Pharmacology. 2011; 43(1): 6-12. doi: 10.4103/ 0253-7613.75657.
2. Williams N, Bulstrode C. Bailey & love’s short practice of surgery. 25th edition.
3. Sausville J, Naslund M. Benign prostatic hyperplasia and prostate cancer: an overview for primary care physicians. Int J ClinPract. 2010; 64 (13):1740–1745.
4. Homma Y, Gotoh M, Yokoyama O. Outline of JUA clinical guidelines for benign prostatic hyperplasia. Int J Urol. 2011; 18 (11): 741–756.
5. Das S. A manual on clinical surgery. 9th Edition. Kolkata: Dr. S. Das Publications; chapter 37, 587.
6. S Rajgopal, S Anitha. Manipal manual of surgery. 4th Edition. 2014. 972-973.
7. Boericke W. Pocket Manual of Homoeopathic Materia Medica and Repertory. 9th Edition. New Delhi: B. Jain Publishers (P) Ltd; 2009.
8. Lilianthal S. Homoeopathic therapeutics. Reprint Edition. New Delhi: B. Jain Publishers (p) Ltd; 1996.
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