Benign prostate hyperplasia and homoeopathic approach

Dr Neeta

ABSTRACT
Benign prostate hyperplasia is a non-neoplastic enlargement of the prostate gland, which occur commonly after the age of 50 years. BPH is rarely life threatening but affects the individual quality of life in varying degree. Various therapeutic modalities for the treatment opted are medications, balloon dilation and surgical measures that are costly, have diminished the quality of life in terms of peri-operative and post-operative complications. Homeopathy treat constitutionally and helps to avoid surgical removal of prostate.

KEY WORDS: BPH, AUASI, PSA

INTRODUCTION
Benign prostate hyperplasia is defined as the proliferation of smooth muscle and epithelial cells within the prostatic transition zone.¹

Approximately 50% of men > 50 years of age will have pathological evidence of BPH, with this number increasing to >80% as men reach their eighth decade of life and older.²

ETIOPATHOGENESIS:
Sex hormones– testicular androgens are required in the prostate for the development of BPH. The enzyme steroid 5α-reductase 2 is bound to the nuclear membrane, converts testosterone into dihydrotestosterone (DHT). The stroma and epithelium of the prostate interact via cellular signalling mechanisms mediated by DHT and DHT-dependent growth factors. Development of BPH involves the disruption of the DHT-supported homeostasis between cell proliferation and cell death allowing proliferative process to predominate.

An enzyme called 5 a-reductase, which is present in high concentration in prostate, converts testosterone to 5-dihydrotestosterone (DHT). Moreover, oestrogenic steroids secreted the adrenal cortex in aging male play a part in disrupting the balance between DHT and local peptide growth factors thus increasing the risk of benign prostatic hyperplasia.²

Inflammation– infective aetiology that triggers the development of BPH. T cells are known to secrete various growth factors that promote stromal and glandular hyperplasia of the prostate.²

Smooth muscle- a substantial portion of the prostate gland is made up of smooth muscle. α1 adrenoceptor in the prostate tissue is responsible for the active tension in prostate smooth muscle. Stimulation of these receptors resulting in increase in prostatic urethral resistance causing symptoms of outflow obstruction.²

The neoplastic therapy- According to this theory benign enlargement of the prostate is considered to be a benign neoplasm i.e., adenoma or adenomyoma of the gland. As there may be considerable fibrous tissue involved in such neoplasm it may be also fibromyoadenoma.³

PATHOLOGY³
The changes are mainly of two types – overgrowth of the glandular elements and overgrowth of connective tissue elements.

Overgrowth of glandular elements makes the prostate gland softer in consistency in comparison to overgrowth of connective tissue element, in which the consistency will be firmer. Enlargement of the gland is due to formation of one or more nodules. These nodules fuse together form one mass which can be readily shelled out.

The two lateral lobes and the median lobe are frequently involved in hyperplasia. When the sub cervical glands are involved in hyperplasia, the median lobe enlarges. It gradually projects upwards into the bladder through the internal sphincter.

RISK FACTORS FOR BPH
Age: BPH increases with age. Autopsy studies have observed a histological prevalence of 8%, 50% and 80% in the 4th, 6th and 9th decades of life, respectively.⁴

Race: observational studies comparing black, Asian and white men have produced variable results. Studies of black men in the US have observed an increased prostate transition zone and total volume compared with white men. Decreased risk of clinical BPH in Asian compared with white men.⁴

Physical activity: increased physical activity and exercise has been constantly linked to decreased risk of BPH surgery, clinical BPH.⁴

Metabolic syndrome: metabolic syndrome includes hypertension, dyslipidemia, glucose intolerance, central obesity and insulin resistance with compensatory hyperinsulinemia. These men had faster annual prostatic growth than those without components of metabolic syndrome. Annual prostatic growth rate increased by 47% with type 2 diabetes mellitus, 17% with hypertension, 36% in obese men, 31% with low levels of HDL cholesterol and 28% with high levels of fasting insulin.²

Diet: a clear correlation between diet and the development of BPH and LUTS has not been shown. However, some evidences suggests that various macronutrients and micronutrients might influence the risk of development of BPH and LUTS. A significant increased risk for BPH was shown with frequent consumption of cereals, bread, eggs and poultry. Studies suggested that low occurrence of BPH in Asian men, as well as in vegetarian men can be attributed to low fat and high fiber diet.⁵

CLINICAL FEATURES
The symptoms of BPH are commonly divided into obstructive and irritative symptoms.

Obstructive symptoms include hesitancy, poor flow, intermittent stream, dribbling, sensation of poor bladder emptying, episodes of near retention of urine. Irritative symptoms such as frequency, nocturia, urgency, urge incontinence and nocturnal incontinence.⁶

Secondary effects due to enlargement of prostate³

1. I) Changes in the urethra
2. There is elongation of prostatic urethra, about twice its normal length.
3. The normal posterior curve of urethra is exaggerated.
4. Urethra takes the shape of anteroposterior slit due to enlargement of two lateral lobes and it compresses the urethra laterally.
5. Lateral distortion of the prostatic urethra occurs because of is enlargement of only one lateral lobe makes catheter insertion difficult.
6. II) Changes in the bladder
7. As the level of obstruction increases the detrusor muscle undergoes compensatory hypertrophy to overcome the increasing urethral resistance.

When the compensatory hypertrophy fails and vesicular muscle becomes exhausted and then urine is retained in the bladder which increases the risk to develop chronic urinary retention.

III) Change in Ureters and kidneys

1. Renal function may be decreased following infection of the kidney.
2. Reflux of urine into the ureter and ascending infection reaches the kidneys causes acute or chronic pyelonephritis.

DIAGNOSIS

• Diagnosis is from medical history of the patient, digital rectal examination and lab investigations.
• History of the patient:
• The medical history including life style habits should focus on the urinary tract, general health issues, specifically, medical conditions and symptoms and previous surgical procedures that lead to bladder dysfunction or excessive urine production (polyuria), family history of prostate disease.²
• Measurement of the serum prostate-specific antigen (PSA) which reflect prostate volume and being used as a marker for prostatic disease.²
• Ultrasonography: This can detect the size of prostate most accurately.9 Post void Residual Urine Volume is the volume of fluid remaining in the bladder immediately after the completion of micturition.³
• Symptom questionnaires
• American Urology Association Symptom (AUAS) score which assess the occurrence of seven symptoms characteristic of BPH. The total score reflects the overall severity of the patient’s condition.⁷

DIFFERENTIAL DIAGNOSIS³

Prostate cancer: has prevalence in older age group. Signs of enlarged lymph nodes in the abdomen or in the supraclavicular fossa.

Digital rectal examination shows cancerous hard nodules, irregular induration, obliteration of the median sulcus and non-mobility of the rectal mucosa over the enlarged prostate.

Prostate specific antigen (PSA) usually >10 nmol/ml.³

Prostatitis: presenting with fever, burning sensation during micturition, increased and urgency, purulent urethral discharge.

Digital rectal examination- tender and enlarged prostate.

Urinary tract infection (UTI): increased frequency of urine both in day and night, urgency, pain while urinating, haematuria and pyuria.

White blood cells along with ESR is elevated.

Overactive bladder: frequent urge to urinate, incontinence and nocturia. Ultrasound abdomen shows low post void residuals.

Bladder cancer: painless haematuria is most common and first symptom. Increased frequency, urgency, burning sensation on urinating and pain in pelvic region.

Urethral stricture: most common cause is traumatic mainly rupture of the membranous urethra following fracture of the pelvis and diminished flow of urine.

MANAGEMENT

GENERAL MANAGEMENT4: These are non-medical management were advised

1. a) To urinate when they first got the urge
2. b) To discontinue tobacco, alcohol and caffeine, especially after dinner
3. c) Not to drink lot of fluid at once
4. d) Avoid drinking fluids within two hours of bedtime.

SURGICAL MANAGEMENT²

Surgical options are options are available for men with BPH and are classified into three main groups:

Compression: This procedure involves the insertion of a device that compresses the prostate laterally, widening the urethral channel.

Adenoma debulking: debulking surgery involves the endoscopic removal of some of the adenomatous component that obstructs the outlet.

Adenectomy: the traditional approach and one of the oldest techniques to treat men with BPH having very large prostate usually >100 ml. For this approach, the adenoma is enucleated (removed whole) off its capsule.

HOMOEOPATHIC APROACH

According to classification of diseases by Dr. Samuel Hahnemann, BPH comes under True chronic disease which arises from chronic miasm.

According to H A Robert:

Where we find fibrous changes, we may be sure there is a sycotic influence. The attempt to suppress sycotic manifestation, met with a very prompt and decided renewal of the stigmatic power and energy. After such an attempt, the destructive progress of the disease becomes more rapid, and often leads rapidly to malignancies.⁸

CONSTITUTIONAL APPROACH: The word constitution comes from the Latin word, constituere, which means to set up, to establish, to form or make up. Constitution means inherent in the natural frame, or inherent nature.⁹

REPRESENTATION OF BPH IN VARIOUS REPERTORIES:

Boericke’s Repertory:¹⁰

Chapter: Prostste gland, Rubric: Hypertrophy

Aloe., Arg.n, Bar.c, Canth, Chimaph, Cim, Ferr.pic, Hydrang, Pop.t, Senec, Solid; Sul; Thiosin, Thuja

Alfal.; Am.m.; Benz.ac.; Cal.fl.; Calc iod.; Chrom.s.; Con.; Eup. purp.; Gels.; Graph.; Hep.; Iod.; Kali bich.; Kali br.; Lyc.; Med.; Ol.sant.; Oxyden.; Parieara; Picr .ac.; Pip.m; Puls.; Rhus ar.; Sabal.; Sars.; Senec.; Solid.; Staph.; Tritic.

Murphy’s Repertory:¹¹

Chapter: Disease, Rubric: Prostate, Sub-rubric: benign enlargement. BAR-C., CALC., CON., DIG., FERR. PIC., PULS., SABAL., THUJ., Aloe., am-m., benz ac., berb., chim., cimic dulc., ferr-m., gels., hydrang, hyos., iod.,

kali-i., lyc., med., merc., nat-c., nat-s., nit-ac., pareir., phos., pop., psor., sec., sel., senec., sil., spong., staph., sulph., thiosin.

Kent’s repertory:¹²

1. A) PROSTATE GLAND- ENLARGEMENT

BAR-C., CALC-C., CON., DIG., PULS., Amm-m., apis., aur m., benz-ac., berb., chim., ferr-m., hyos., iod., kali-i., lyco., med., merc., nat-c., nat-m., nit-ac., pareir., phos., psor., sec., sel., sil., spong., staph., sulph., thuja.

1. B) PROSTATE GLAND – SWELLING

CHIM, Con., dig., iod., puls.

THERAPEUTICS ON BENIGN PROSTATE HYPERPLASIA¹³

ALOE SOCOTRINA: incontinence in aged, bearing down sensation. Enlarged prostate. Scanty and high coloured urine. Constant bearing down pain in rectum, whether gas or stool will come. Relieved by cold water, open air.

BARYTA CARBONICA: has special influence on old age and infancy. Indicated in diseased of old age, who have hypertrophied prostate, indurated testes. Very sensitive to cold, offensive foot sweat. Urging to urinate, burning in urethra on urination.

CALCAREA CARBONICA: has action on glands, skin, bones. Increased local or general perspiration, swelling of glands, sensitive to cold. Apprehension, worse towards evening. Irritable bladder.

CONIUM MACULATUM: acts on glandular system, indurating and engorging it, alternating its structure like scrofulous conditions. Much difficulty in voiding. It flows and stops again. Interrupted discharge of urine. Dribbling in old men.

FERRUM PICRICUM: indicated in senile hypertrophy of the prostate. Pain along entire urethra. Frequent micturition at night. Retention of urine.

LYCOPODIUM CLAVATUM: it is a remedy for urinary and digestive disturbances. It has marked regulating influence on glands. Pain in back before urinating, ceases after flow, slow in coming, must strain. Retention. Polyuria at night time.

PULSATILLA PRATENSIS: increased desire for urination, when lying down. Involuntary micturition at night time, while coughing or passing flatus. Thirstless. Worse on heat, towards evening, lying on left side. Better by open air.

SABAL SERRULATA: is a remedy for irritability of genito-urinary organs. Has remarked action on prostatic enlargement, urinary difficulties. Acts on membrano-prostatic part of the urethra. Constant desire to pass urine at night. Cystitis with prostatic hypertrophy.

SULPHUR: frequent micturition, especially at night. Enuresis in scrofulous. Must hurry, sudden call to urinate. Desire for sweets. Difficult in thinking. Delusion, thinks rags are beautiful.

THUJA OCCIDENTALIS: the main action of thuja is on skin and genito-urinary organs. It produces sycotic dyscrasia. Worse damp humid weather. Urinary stream split and small. Frequent micturition accompanying pains. Desire sudden and urgent, but cannot be controlled.

DISCUSSION

Benign prostate hyperplasia is proliferation of smooth muscle and epithelial cells of the prostate gland occur commonly after the age of 50 years. Symptoms of lower urinary tract will affect quality of life of the person. Homeopathic constitutional treatment will help in improving the symptom and also surgical intervention.

REFERENCE

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 Dr Neeta
PG Scholar, Department of practice of medicine
UGO Dr Swetha B.P
Government Homeopathic medical college and hospital
Dr. Siddhaiah Puranik road, Basaveshwarnagar, Bengaluru, 560079.