Severe prostate enlargement (shown in red) cannot be treated with nonprescription remedies. A balloon catheter is shown.
The prostate is easily overlooked by the average male for about the first four decades
of his life. It seldom causes overt symptoms during this time. However, as males age,
their attitudes toward health may change. They often begin paying attention to lay
publications that stress the importance of obtaining regular prostate checkups.
This heightened awareness may be partly due to the fact that half of all men aged 50 and above begin to experience symptoms of benign prostatic hyperplasia (BPH).1 Although this condition is not serious for most males, they may mistake its symptoms for those of prostate cancer. As large numbers of male “baby-boomers?enter their early 50s, pharmacists will receive more questions about such matters as BPH, prostatitis and prostate cancer, as well as medications that affect the prostate. This month’s patient information page describes BPH, while the balance of this article raises some medication-related issues with regard to the prostate.
Nonprescription nasal decongestants may have an adverse effect on urinary flow. Oral and topical OTC nasal decongestants were first reviewed by an FDA-appointed panel in 1976. At that time, there was no recommended warning pertaining to the prostate. However, in a 1985 document, the FDA described several comments submitted to the agency, questioniing the safety of nonprescription pseudoephedrine.2 One of the issues that concerned the correspondents was urinary retention with use of the drug. In its response, the agency mentioned that sympathomimetic agents, such as pseudoephedrine, can cause difficulty in urinating through their vasoconstrictive properties, and that elderly men with enlarged prostate glands would be particularly at risk for this effect. Therefore, the FDA required the following warning on all nasal decongestants intended for patients 12 years and older: “Do not take this product if you have difficulty in urination due to enlargement of the prostate unless directed by a doctor.?Pharmacists should warn older male patients about this contraindication at the point of purchase, in order to prevent extreme urinary difficulty that may necessitate catheterization.
Anabolic steroids (AS) have long been popular drugs of abuse. One report estimates that 6.6% of high school senior males in North America take them.3
In addition to the many irreversible adverse effects AS have on the body, the drugs also may affect the prostate. The prostate is sensitive to androgenic stimulation, as exhibited by the fact that its growth and development is mainly regulated by the male’s endogenous testicular secretion of testosterone.4
In adult males, a continuous output of testosterone is mandatory to maintain the prostate’s cellular integrity and functionality. In a novel observational study, a 49-year-old male body-builder who was using a “cocktail?of several different anabolic steroids, volunteered to have his prostate function measured for seven weeks.3 His prostate volume increased from 24.9 to 47.3 square centimeters; his urine flow decreased from 18.8 mL/second to 15.7 mL/second, and he noted a decrease in nocturnal urinary frequency to once or twice nightly. Four weeks after steroid administration ceased, the first two parameters approached, but did not reach, pre-steroid use levels.
If pharmacists are asked for advice about prostate problems by a male whose physique suggests the possibility of AS abuse, the patient should be referred to a physician. It would not be wise to suggest a nonprescription diuretic or herbal remedy without a medical examination, which might reveal a serious underlying condition.
The pharmacist should remember that any effects of AS are shared by the steroid precursors sold in pharmacies and health food stores. The most common of these products are DHEA and androstenedione.
With the growing popularity of herbal medicine, it is appropriate to examine those products that may benefit prostate function. Because these products do not require FDA approval and data supporting their benefit is less abundant than with prescription drugs, pharmacists may be wary of their use.
Patients with severe BPH and those who have not been diagnosed with the condition are not good candidates for herbal therapy. Those who are successfully self-treating mild to moderate forms of physician-diagnosed BPH should nonetheless be reminded of the importance of yearly medical exams. It is important for a physician to evaluate their response to therapy periodically. Saw palmetto (Serenoa repens) is probably the most popular plant extract used to treat BPH in the U.S., despite the fact that there is limited evidence to support its efficacy.5 Nausea and abdominal pain have been reported with its use.
Pygeum is an herbal remedy that gained favor in France for BPH. In one study, 134 Polish males were given pygeum in combination with nettle.6 The combination decreased residual urine and nocturia. Adverse effects were seen in five patients. This single study is insufficient to prove the effectiveness of pygeum alone and requires confirmation by other investigators.7
The study described above in which the combination of nettle and pygeum improved some urinary parameters is poorly supported with additional information on nettle alone. Nettle is known to cause allergies in some patients.
Patients requesting herbs commonly used for treating prostate symptoms should be asked a set of questions to explore their motivation for herb purchases.8 The aim of the simple algorithm presented is to minimize any risk to the patient.
Algorithm: The initial question in the algorithm is, “Has a physician diagnosed a problem with your prostate??The patient may answer in the affirmative. They may have been diagnosed with any of several conditions, ranging from BPH to prostatitis, prostate infection or prostate cancer. If a physician has indeed diagnosed the patient’s prostate problem, the logical next question is, “Were you given a prescription medication for your prostate condition or a referral to another physician
(e.g., an oncologist for prostate cancer)??If the answer is affirmative, the pharmacist should discover whether that medication (e.g., terazosin, doxazosin, tamsulosin, finasteride) is being taken or whether that specialist is being seen.9 If the patient is following the advice of the diagnosing physician, the pharmacist should attempt to ascertain whether the use of the herb has been suggested by the original physician or specialist as an adjunct to prescription medications. If it is, the pharmacist should remind the patient that the product should be taken in the doses advised by the physician, not those recommended in a health food store.
Cigarettes and the Prostate
|Product Cigarettes are known to
affect urinary function; they multiply the risk of bladder cancer by a factor of four.11
Their effects on the prostate are less well-known. In one study, 68 men with BPH were
investigated regarding their smoking history.2 The researchers uncovered an
inverse relationship between prostate volume and cigarette smoking. This finding may be
due to elevated levels of estradiol found in male smokers, and also to a small reduction
in serum testosterone. Of course, this small difference in risk of prostate cancer to the
smoker does not justify continued use of cigarettes, especially in light of the greatly
enhanced risk of lung cancer and other deadly conditions.
Problems with the Prostate
|The prostate gland is found only in men. It doesn’t get much attention most of the time, but there are some serious problems that can arise from the prostate that all males should be aware of.|
Benign Prostatic Growth: The prostate is a small, heart-shaped gland
that surrounds the passage (the urethra) through which urine must flow to exit the body.
As men get older, it is common for their prostates to become enlarged. By the age of 80
years, 80% of all men have this problem. The enlargement places pressure on the urethra
and can make it difficult for urine to pass through. This condition is known as benign
prostatic hyperplasia (BPH).
Remember, if you have questions, Consult Your Pharmacist.
1. Assassa RP, Osborn DE, Castleden CM. Male lower urinary tract symptoms: Is surgery
always necessary? Gerontology. 1998;44:61-66.
2. Anon. Cough, cold, allergy, bronchodilator and antiasthmatic drug products for over-the-counter human use; Tentative final monograph for over-the-counter nasal decongestant drug products. Fed Reg. 1985;50:2220-2241.
3. Wemyss-Holden SA, Hamdy FC, Hastie KJ. Steroid abuse in athletes, prostatic enlargement and bladder outflow obstruction—Is there a relationship?
Br J Urol. 1994;74:476-478.
4. Jin B, Turner L, Walters
WAW, et al. Androgen or estrogen effects on human prostate.
J Clin Endocrinol Metab.
5. Herbal Supplements, in Pray WS. Nonprescription Product Therapeutics. 1st ed. Baltimore, MA: Lippincott Williams & Wilkins; 1999: 757-779.
6. Krzeski T, Kazon M, Borkowski A, et al. Combined extracts of Urtica dioica and Pygeum africanum in the treatment of benign prostatic hyperplasia: Double-blind comparison of two doses. Clin Ther. 1993;15:1011-1020.
7. Simpson RJ. Benign prostatic hyperplasia. Br J Gen Pract. 1997;47:235-240.
8. Guzley GJ. Alternative cancer treatments: Impact of unorthodox therapy on the patient with cancer. South Med J. 1992;85:519-523.
9. Jonler M, Riehman M, Bruskewitz RC. Benign prostatic hyperplasia. Drugs. 1994;47:66-81.
10. Marshall KG. Prevention. How much harm? How much benefit? 3. Physical, psychological and social harm. CMAJ. 1996;155:169-176.
11. Kupeli B, Soygur T, Aydos K, et al. The role of cigarette smoking in prostatic enlargement.
Br J Urol. 1997;80:201-204.