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). 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.

Nasal Decongestants

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. 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

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.
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.

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. 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.

Herbals

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 benign prostatic hyperplasia 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. Nausea and abdominal pain have been reported with its use.

Pygeum is an herbal remedy that gained favor in France for benign prostatic hyperplasia. In one study, 134 Polish males were given pygeum in combination with nettle. 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.

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. 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 benign prostatic hyperplasia 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. 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. Their effects on the prostate are less well-known. In one study, 68 men with benign prostatic hyperplasia were investigated regarding their smoking history. 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.

Following the line of questioning above, there are some patients who will fall out of the simple algorithm, for several reasons.

(1) They self-diagnosed their prostate problem. In this case, they should be referred to a physician. Their condition may be serious (e.g., prostate cancer), and a legitimate diagnosis must be made as soon as possible so that appropriate treatment can begin.

(2) They have been given a prescription or referral for a diagnosed prostate problem, but do not wish to fill the prescription or visit the physician. They may fear adverse reactions, added costs, or even that cancer will be diagnosed. In this case, the pharmacist should recommend that the patient use the prescribed product or make the appointment with the specialist. If the patient prefers herbal therapy, he should discuss this option with his physician.

(3) The patient filled the prescription or saw the specialist, but wishes to purchase the herb, either without or against the advice of his physician. If the patient is purchasing the herb without the knowledge of the physician, the pharmacist should describe the ability of herbs to alter the course of prescription therapy, perhaps to the detriment of the patient. If the patient is purchasing the herb against the physician’s advice, the pharmacist may choose to advise against this course of action.

Internet Resources

As with any topic, a search of the Internet for advice on prostate problems does not always lead to safe, accurate information. Many sites are associated with particular key words, regardless of whether they offer quality information on that topic. For instance, if one uses “prostate cancer“ as a search term, links to sites advertising herbal mixtures purported to promote prostate health will appear. One such site describes the herbal blend used in its product as “supportive of the special nutritional needs of the prostate, helping to prevent possible problems associated with prostate.“ The product contains saw palmetto, synergistic herbs (not listed), amino acids, zinc and beta-carotene combined with “prostate tissue concentrate.?Another link leads to an ad for homeopathic family kits. Like herbals, home-opathic cures do not have to undergo FDA review and approval, and data supporting their efficacy are limited. Critics say the products are so highly diluted that in many cases no active ingredient remains, making them nothing more than placebos. Neither herbal nor homeopathic products are appropriate for a patient with prostate dysfunction who has not seen a physician.

Patients need to be sure that the information they find on the Internet comes from a reputable source. They should also know that when it comes to prostate health, nothing should replace professional medical care.

Information

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).

There are several symptoms of BPH:

(1) When you try to urinate, the flow does not start right away.

(2) The flow may start and stop several times during urination.

(3) Your urine flow is not as strong as it was when you were younger.

(4) Even after you feel that all urine has been eliminated, there is an uncomfortable dripping of urine that you cannot stop.

(5) You find yourself straining your abdominal muscles to help empty your bladder.

(6) You need to empty your bladder frequently and with urgency.

(7) You feel the urge to urinate during the night.

Even if your symptoms match those listed, it may not mean that you have BPH. Some more serious conditions share the same symptoms, so you should see a doctor if you are bothered by any of these problems.

Herbal Products: Several herbs are sometimes recommended for treating BPH. These herbs include saw palmetto, nettle and pygeum. You should never use any product that you can buy without a prescription to treat BPH, unless you have seen your doctor and discussed the treatment with him or her. One reason for this is that more severe forms of BPH cannot be effectively treated with herbal or other nonprescription products you may see advertised. Also, only a doctor can accurately diagnose prostate problems. If you have a serious underlying disease, such as prostate cancer, it should be diagnosed as early as possible. Use of herbs or other products can make you feel as if you are “doing something“ for the problem, and cause you to put off a physician appointment. Then, when you can no longer deny the need to see a doctor, the cancer may have advanced to a more serious stage that is less likely to be curable.

Even if your doctor has recommended an herbal treatment for your prostate condition, it is still important for you to go for regular check-ups. Your doctor will want to make sure that the product is working effectively and that the condition has not gotten any worse. If your symptoms do not improve or you notice any increase in symptoms while taking an herbal product for BPH, you should notify your doctor.

Like any drug, herbal remedies can cause side effects, such as nausea, abdominal pain, and even allergic reactions.

If you ever have trouble with your prostate, the first thing you should do is make an appointment with a doctor.