Benign Prostatic Hyperplasia

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Benign Prostatic Hyperplasia (BPH) is a common ailment affecting one third of men over fifty, half of all men over sixty and ninety percent of all men over the age of eighty five. Like grey hair, balding or wrinkles, BPH--enlargement of the prostate gland-- is a part of the ageing process. As the boomer generation turns sixty, the incidence of BPH is increasing and so is awareness of the value of CAM (complementary and alternative) disciplines in its management.

The condition is referred to as benign to distinguish it from prostate cancer, a malignant condition of the prostate. The use of the word "benign" does not however imply that BPH is not a troublesome and possibly dangerous condition. Whenever there is a gulma-- a tumour or space occupying lesion--symptoms will arise due to blocking of channels. In the case of BPH, it is the urethra, the mouth of mutravahasrotas, (urine carrying channels) which is partially or fully blocked, leading to significant symptoms.

As a junior house physician at a rural hospital in the UK in the seventies, I admitted many retired farm hands who suffered from undiagnosed and untreated BPH. These elderly men were rushed to hospital in severe pain because of urinary retention. In hospital we catheterised them, and then later performed a TURP, or trans-urethral resection of the prostate, still today the most common conventional treatment for BPH and one of the most frequently performed of all surgical procedures. Because retained urine is a breeding ground for pathogenic bacteria, catheterization could lead to problems with infection, so urinary antibiotics were administered along with the procedure. Nevertheless, one eighty year old developed septicaemia following his catheterization. His septicaemia was treated with intravenous erythromycin, one of the strongest antibiotics available at the time. He had a bad reaction to the antibiotic, developed liver failure and died. This experience, a physician's worst nightmare, only serves to illustrate the importance of detecting and managing BPH long before the point of urinary retention is reached.

Although BPH can occur in men of all prakruti types, Kapha individuals have a special tendency to develop benign swellings. Perhaps this is why the number of men over fifty with BPH is exactly one third of the number of men in that age group, potentially corresponding to the kapha segment of that population! A kapha provoked man over fifty is likely to complain of abdominal obesity, hypertension, sluggishness, low grade depression, nocturnal urination and low libido. Medical tests may show elevated blood sugar, raised cholesterol and hypothyroid as well as an enlarged prostate. His BPH must be seen in the context of generalized kapha syndrome. Symptoms that specifically indicate enlargement of the prostate include nocturnal urination, sensation of incomplete emptying, frequency of urination, slow or interrupted stream, dribbling, and straining to pass urine. Although the benign swelling is a predominantly kapha condition, there is a secondary pitta effect of inflammation and irritation of the bladder, giving rise to symptoms such as urgency of urination. Due to incomplete emptying of the bladder, additional symptoms of bladder infection may arise, including burning sensations and a greater increase in frequency.

In terms of differential diagnosis, it is important for the Ayurvedic practitioner to note that the symptoms of BPH are indistinguishable from those of prostate cancer. As the most common cancer other than skin cancer and second leading cause of cancer related death in men, prostate cancer must be excluded as a cause of the symptoms. A PSA (Prostate Specific Antigen) test is helpful but still can yield both false positives--BPH misdiagnosed as cancer--and false negatives--a cancer diagnosed as BPH due to a low PSA. Hence it is advisable that all men with prostate-related symptoms have a urology examination to exclude cancer before they commit to managing their condition with Ayurveda. Another important differential diagnosis for an older, overweight man with increased urination is diabetes, the symptoms of which include increased urination.

The following case histories illustrate many of the important features of BPH and kapha syndrome. Patient A, a sixty three year old retired widower, was complaining of frequent urination, nocturia, (nocturnal urination), obesity, a non-healing leg lesion, hypertension and thirst. He felt sluggish with low grade depression. He was extremely anxious because his acupuncturist had suggested that he might have diabetes. However, on deeper conversation, we noted that his frequency had a duration of two years, whereas thirst has been occurring only since he had been drinking an increased quantity of water, and could result from drinking water without minerals. His blood pressure had been as high as 165/110. His weight was 250 pounds at 5'11'' (the 92nd percentile for his age and height). Prakruti was V1P3K2 with vikruti V2 P4 K3. Kapha was noted in the thyroid and his basal temperature was slightly subnormal at 97.5. There was increased raw ojas indicating raised cholesterol and triglycerides. The bladder pulse was extremely weak. Based on this finding, it was felt that his increased urination was a symptom of BPH. Although tridoshically provoked, he had, symptomatically, a predominant kapha syndrome, complete with BPH, suspected pre-diabetes, obesity, hypertension and hypothyroid. A blood sugar test verified this diagnosis. With a fasting blood sugar of 105, he had pre-diabetes. This blood sugar level was not sufficient to cause polyuria, which would be noted at the renal blood sugar threshold of 180.

Patient B, a fifty seven year old marketing director, complained of abysmal motivation, lack of interest and enthusiasm, low libido, low appetite and BPH with nocturia. He noticed that spicy foods triggered his prostate symptoms. In effect, spicy foods were not enlarging his prostate but were contributing to the pitta component of bladder inflammation secondary to partial obstruction of the urethra. At 5' 11'' and 186 pounds he was overweight but not obese. His prakruti was V1P2 K3 with vikruti of V1.5 P3 K3.5. Pitta was pushing kapha in his thyroid gland and his basal temperature was between 95.5 and 94.0, a significantly low reading. These findings would be consistent with inflammatory thyroiditis such as Hashimoto's. We should also note at this point the interconnected nature of the endocrine system and the relationship between low thyroxin and low testosterone. This would be similar to the experience of women who often develop thyroid problems during menopause. (Diabetes or pre-diabetes as in patient A simply adds another dimension of under functioning endocrine glands as part of kapha syndrome.)

Ayurvedic management of BPH includes herbal therapies as well as dietary changes, yoga and specific prostate care practices. All men over fifty can benefit from the yoga and prostate care practices on a preventative basis. Supportive herbs can also be used on a preventative basis-- Men's Support, for example, is an excellent formula for daily support of the prostate and male reproductive system.

In terms of dietary changes, as patient B illustrates, it is good to avoid inflammatory foods, including spicy, pittagenic items as well as those foods to which one is allergic. This will help reduce bladder inflammation and hence lower the level of symptoms. A kapha reducing diet will also help reduce symptoms of BPH. For example, Patient B, with a kapha prakruti, found it best to avoid gluten and cow dairy, food which are both highly allergenic and too heavy and sticky for kapha.

Asanas which move blood flow in the pelvis or press on the perineum are essential for male health. These include Jatara parivartasana, (rolling the legs to the side when lying on the back,) uttanasana or forward bend, salabhasana or locust, dhanurasana or bow, vajrasana (Moslem prayer pose) and suptavajrasana (some call these virasana and suptavirasana ) baddha konasana, haunamanasan, ardha matsendrasana, ( spinal twist),and mayurasana (peacock pose). Inversions such as shoulder stand may also be helpful. A daily routine that includes some of these poses will support prostate health. Older men who are unfamiliar with yoga and may find many of these poses difficult can seek the help of a yoga therapist in adapting the poses for their needs.

Specific practices that support the prostate should be an important part of every man's daily routine. Just as the teeth need to be cleaned daily to prevent cavities, the prostate gland must also be properly maintained. Daily castor oil massage of the prostate, using cold-pressed castor oil, takes only a few minutes each day. The prostate may be massaged either anally or at the perineum, to maintain a healthy prostate and to prevent hyperplasia or cancer. In addition, daily perineal exercise should be performed, to squeeze and pump the prostate. The best way to do this is to practice ashvini mudra. This consists of rapid contractions of the anal sphincter while holding the breath on the inhale and applying jalandhara bandha, or chin lock. Ashvini mudra not only enhances circulation and lymphatic drainage of the prostate gland, but also raises the sexual and creative energies which, if blocked at the level of the prostate gland, may give rise to disorders. According to Gheranda Samhita, verses 82 and 83, ashvini mudra awakes the kundalini shakti, gives strength and vigour, and prevents premature death. The marma point for the prostate is Trik marma (subcutaneous pressure point) at the tip of the coccyx. This should be massaged daily.

Herbs of value in BPH are in large part also those herbs that support the thyroid and help manage kapha syndrome. For both Patient A and Patient B, the formula included Punarnava, which balances kapha, helps reduce swellings, and strengthens the thyroid. Chitrak helps increase metabolism, catalyzes the action of Punarnava in reducing swellings and kindles agni in the thyroid. Shilajit, an important ingredient in both Men's Support and Trim Support, has a scraping effect, reducing swelling of the prostate while also rejuvenating the thyroid and supporting metabolism. Ashwagandha is of course always of value in issues relating to the male reproductive system. Patient B, who complains of low libido as well as prostate symptoms, now takes a teaspoon of Ashwagandha at bed time. Since he is sensitive to cow's milk, the usual anupan for Ashwagandha in this situation, he takes his Ashwagandha in warm almond milk. (Almonds, like cows milk, support shukra and ojas.) Gokshura is an excellent choice, since it is a urinary antiseptic, improves urine flow, soothes the urinary tract, shrinks the prostate, kills yeasts and fungi that may be causing urinary problems and is anti-cancer well. In Patient A, we could also note that Gokshura reduces blood sugar and lowers blood lipids, while for Patient B could benefit from Gokshura's famed aphrodisiac effect, which is due to its content of steroidal saponins. Vidari is another herb that is of value for shukra dhatu, improving libido and sperm count and helping shrink the prostate. Colon health and prostate health are closely related, since the prostate is situated in front of the rectum. Maintaining a clean and healthy rectum through the regular use of Triphala is an important way to support prostate health.

Some men who present for Ayurvedic care are already taking Flomax (tamsulosin HCl). Flomax is an alpha-adrenergic blocker which relaxes the smooth muscle of the bladder and urethra, causing urine to flow freely. It is a purely symptomatic treatment which does nothing to shrink the prostate. Since Ayurvedic treatments work more slowly, not symptomatically, it may be beneficial to continue the use of Flomax for a few months until the Ayurvedic formula has had time to reduce prostate swelling, rendering Flomax unnecessary. We have not noticed any adverse effects from combining the two treatments.

Supporting the prostate through diet, yoga, prostate care practices and regular use of herbs that are beneficial for the urinary tract and shukra dhatu is essential for all middle aged and older men. A formula such as Men's Support should be used alternate months for men who have no symptoms and regularly for those who have noticed the onset of symptoms. With proper Ayurvedic care, it may be possible to avoid troublesome symptoms and invasive surgical treatment.

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Alakananda Ma M.B., B.S. (Lond.) is an Ayurvedic Doctor (NAMA) and graduate of a top London medical school. She is co-founder of Alandi Ayurveda Clinic and Alandi Ayurveda Gurukula in Boulder Colorado, as well as a spiritual mother, teacher, flower essence maker and storyteller. Alakananda is a well known and highly respected practitioner in the Ayurveda community both nationally and internationally.

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