Transcription
Are you up all night urinating? Has your stream slowed down? Are you going more often or having to rush to the bathroom? Then this podcast is for you!
Welcome back to the Reena Malik MD podcast, your source for evidence-based medical and sexual health content. I'm Dr. Reena Malik, urologist and pelvic surgeon. Today, we're diving deep into a condition that affects millions of men worldwide—benign prostatic hyperplasia, or BPH.
We'll cover what it is, why it happens, how you might be able to prevent it, the truth about supplements, and the various treatment options that are available to you to help manage these symptoms.
So let's start off: What is BPH? Well, BPH, or benign prostatic hyperplasia, is an enlargement of the prostate. Now, the prostate is a walnut-sized gland located just below the bladder, surrounding the urethra—that's the tube that carries urine out of the body, or as I like to call it, the "P tube." BPH occurs when this gland gets bigger.
Now, you may not know this, but it is incredibly common. By the age of 60, about 70% of men have BPH. Let me say that again: by the time you're 60, 7 out of 10 men will suffer from BPH, and by the time you're 80, that number jumps to 80%. But having an enlarged prostate doesn't always mean that you're going to have symptoms, and the size of the enlargement doesn't always correlate with symptoms. Sometimes you'll get an exam by your doctor, and they'll say, "Well, your prostate is not that big," but your symptoms are really bothersome. So it's more than just the size; very often, it's because there is some degree of enlargement.
Now, what sort of symptoms are there? When you do have symptoms, they're typically related to urination. So here are the things you might see:
- Increased urinary frequency: going to the bathroom more often, more than eight times a day.
- Urinary urgency: a sudden and strong desire to urinate that you can't delay.
- Nocturia: waking up more than one time at night to urinate; more than one time is considered abnormal.
- A weak stream: having a less strong or forceful stream compared to what it was like when you were maybe in your 20s.
- Hesitancy: essentially a difficulty starting urination.
- Intermittency: the stopping and starting of your urinary stream.
- Incomplete emptying: feeling like you can't fully empty your bladder.
- Post-void dribbling: meaning you urinate, think you're done, and then get a little bit of dribble afterwards.
- Leakage: usually leakage because you have to go but can’t make it to the bathroom, or sometimes you can have leakage because your bladder gets so full that you have what we call overflow incontinence.
These symptoms can affect people variably, meaning that some people are really not bothered, but for others, these are significantly impacting their quality of life, particularly in those patients who wake up at night to urinate. Not only are they at risk for falling on their way to the bathroom—which is very concerning, particularly in older patients—because once you fall and go to the hospital because of that fall, your risk of dying goes up to 20% over the next year. These falls are really serious, so that's a big issue for me.
Secondly, you're not getting good sleep; you're waking up all the time, you're tired, and you can't fall back asleep. This can really affect your quality of life.
Now, the other important thing to realize is that BPH is not cancer. Having a large prostate does not mean that you have cancer, and it doesn't increase your risk of prostate cancer.
So now, why does BPH occur? Let's get into the science. Benign prostatic hyperplasia is a complex process, and it can involve issues with hormones, genetics, and inflammation. Hormones do play a significant role, particularly in the prostate. We know that the formation of the prostate, or its size, is sensitive to what we call DHT. This is a byproduct or conversion product of testosterone.
So, we know that some men who have a large prostate will have higher levels of DHT, but that's not everybody. It's not just due to testosterone because if it were, testosterone—which decreases with age—would mean that people’s prostates wouldn't continue to increase. So this is where these other factors come into play. Inflammation is a big one. Chronic low-grade inflammation in the prostate can promote growth and can be caused by a variety of different things.
This can include things like infections, so you may have bacterial or viral prostatitis or infections. You can have some hormonal changes that are inflammatory or even autoimmune changes, and also changes in the prostate microbiome. Interestingly, when you have inflammation, it triggers the release of certain growth factors like the epidermal growth factor, insulin-like growth factor, and transforming growth factor beta. These then send signals and stimulate cell growth and division, causing what we call cell proliferation and leading to the enlargement of the prostate.
Now, when you think about BPH or any organ really, there's a balance between cells growing and cells dying. There are always new cells being created, for example, in our skin, as well as old cells being sloughed off. In BPH, there's an imbalance—more cells are growing than dying off, which leads to enlargement.
The other thing that happens as the prostate grows is that it creates areas where there are low levels of oxygen. These areas of hypoxia trigger more inflammatory substances, so we get this vicious cycle of growth, inflammation, low oxygen creating more inflammation, and creating more growth factors, leading to further enlargement.
Now, another factor is genetics. There's a hereditary component to BPH. If you have a close male relative, usually a father, who has had BPH at a young age (meaning before 60 years of age), you may be at higher risk. In fact, we find that people who do have a genetic component are more likely to get BPH symptoms as early as their 40s compared to those who don't have a genetic component.
Are you sick of going to the doctor only to have them talk at you for 15 minutes and leave without knowing exactly why they're prescribing you a certain medication and what exactly the next step is to take to optimize your health? Wouldn't it be great to finally find a doctor who actually listens to you, answers your questions, and doesn't rush you out the door?
Well, at my practice, Reena Malik MD, I aim to do just that. I specialize in taking care of patients who have issues with their sex lives, issues with their bladder, hormone health, or are having pain in their pelvic region or with sex. My goal is to give you the time and attention you deserve, so you can leave with a clear understanding of your condition as well as our treatment plan that's optimized for your goals.
During your visit, I’m 100% present with you for an entire hour, and after you leave, you can reach me. It is super easy to send me a message through our secure portal, and I'll get back to you within 24 to 48 hours—no questions asked, no hidden fees. Scheduling is easy; just visit our website, ReenaMalikMD.com/appointment. We see patients in both Irvine and Beverly Hills, California, and I see patients virtually in California, Florida, Illinois, Maryland, New York, New Jersey, and Virginia. Oh, and don't forget Texas! If you're outside these states, consider seeing me for an educational visit. I look forward to seeing you!
Another risk factor is what we call metabolic syndrome. This is where conditions like diabetes, high blood pressure, and obesity are linked to a higher likelihood of having BPH. In fact, having diabetes more than doubles your risk of BPH.
Another factor is the sympathetic nervous system. When you have increased activity of the sympathetic nervous system, this can cause an increase in smooth muscle tone of the prostate, which can contribute to symptoms. Anything that revs up your sympathetic nervous system— that fight-or-flight system—may make these symptoms worse.
Now that we know what factors go into creating an enlarged prostate, we can talk about prevention. We can't control every risk factor; we can't really control genetics, and we can't control aging. However, there are evidence-based things we can do to reduce our risk.
First and foremost: maintain a healthy weight. Studies have shown that men with a BMI over 35 have more than double the risk of developing BPH compared to men with a BMI under 25. A waist circumference over 40 increases the risk by about 50%. So, maintaining a healthy body weight and reducing body fat is crucial for reducing inflammation that can trigger this cascade.
The next thing, number two, is to stay active. Regular physical activity is very helpful; even light exercise has been shown to reduce the BPH risk by 30%. What’s light exercise? That’s about 2 hours of walking a week—less than 20 minutes a day. So really, even 20 minutes of walking a day can help reduce your risk. If you exercise regularly about six times a week, they've shown that these men have a 50% lower risk of BPH.
Next is diet. Diet does play a significant role. Limit high-fat red meats; daily red meat consumption—in the absence of data controlling for the kind of red meat you’re eating—presumably increases your BPH risk by about 30% compared to eating it less than once a week.
Eat more vegetables! Four or more servings of vegetables a day have been shown to reduce risk by about 30%. Another thing to consider adding is lycopene-rich foods. Tomatoes, especially cooked tomatoes, contain lycopene, which has been studied and shown to help potentially prevent BPH. Watermelon is another food rich in lycopene.
Studies have found that a high-fat intake—more than 38% of your total energy intake through calories—increases BPH risk by 31%. Lastly, you want to manage your chronic conditions, as these all increase inflammation. Keeping conditions like diabetes, high blood pressure, and high cholesterol under control is not only good for your overall health but also good for your prostate.
Be mindful of medications; this is one you probably haven't heard of before. Some over-the-counter medications can actually worsen your BPH symptoms. One of these is antihistamines; these can relax the bladder, making it harder to empty. Another is decongestants like pseudoephedrine; these can tighten the smooth muscles, making urination much more difficult. Some antidepressants, particularly tricyclic antidepressants, can also negatively affect bladder function.
Now, it's important—if you're on antihistamines for allergies or need some of these medications—to talk to your doctor if you find that you're experiencing urinary symptoms and ask, "Is there something I can use instead?"
Quick break from this episode to let you know that I am so grateful you're spending part of your day with me. I started creating content online to empower people to learn more about their bodies without needing to go see a doctor, pay a co-pay, wait in a waiting room, or find parking. It has been one of the most rewarding experiences of my life. If you want to help support our mission of providing free education, please consider joining our premium membership. There you will have access to ad-free episodes that are released early, as well as free transcripts and the opportunity to ask me anything. These questions are answered in our monthly AMA episodes. Support the show and join today at reenaMalik.supercast.com.
Now, let's move on to supplements. Everyone always wants to know what they can take over the counter to help improve their symptoms. I'm going to start with the most studied supplement for BPH, and that's called saw palmetto. Early studies were really promising, but more recent high-quality trials have been done and have not shown significant benefits in comparison to placebo.
In one large study with over 3,000 men, they found that saw palmetto showed no difference in comparison to placebo in terms of improving urinary symptoms, even at high doses. Now remember, placebo is just a sugar pill or something that's taken that you think is going to improve your symptoms but doesn’t. I still find that some patients do benefit from trying saw palmetto, so I will suggest if you're going to try one, it may be something to consider. However, we do have very strong high-quality studies about saw palmetto that don’t show a benefit in large patient populations.
Next is beta-sitosterol. This has less data; some studies have shown some improvements in urinary symptoms and flow rates, meaning your flow is faster, but it's lacking a lot of long-term data.
The next one is P. africanum. This also has a Cochrane review available. A Cochrane review is essentially a very high-quality meta-analysis that's done as a systematic review of all the data, and they did that for saw palmetto as well as for P. africanum. It found some evidence of symptom improvement, but unfortunately, all the studies were short-term and of varying quality.
Pumpkin seed extract is another interesting one. Again, some studies have shown some modest benefits in symptom scores, but the results are not consistent, so sometimes you see a benefit, and sometimes you don't. Stinging nettle is not really studied by itself; it's usually combined with saw palmetto, and in those studies where it's been combined, they have seen some improvement in symptoms over a long period of time (96 weeks).
Last, lycopene. I mentioned dietary lycopene, like tomatoes and watermelon, which has shown some benefit. Supplement data on lycopene is less robust, so I’d rather you eat your lycopene than take a supplement.
It's really important to remember that supplements can really vary in quality quite significantly. To give you an example, one study looked at 27 saw palmetto products and found huge variability in the amount of active ingredient content. Only 7 of those 27 met criteria for a proper saw palmetto supplement, while 10 of them didn’t. You always have to remember that “natural” doesn’t always mean safe or effective. I like to say, "Botox is natural." You can find it in the environment, but a large dose of Botox will kill you.
So, you want to be thoughtful before you take a supplement because we don't always know what's actually in the bottle. Make sure if you're taking supplements to mention them to your doctor before starting them and also review the ingredients. Sometimes you may not realize that you’re taking a whole bunch of supplements and you're taking more than you think of each individual ingredient.
Before you even start taking a supplement, I would argue that behavioral changes can be just as effective, if not more so. One recommendation is to look at how much you're drinking. If you are drinking enough fluid, your urine should be about a light yellow lemonade color. If you're drinking too little, it will be darker than that, and if you are drinking a lot, it'll be clear like water.
Now, clear like water once in a while is not a big deal, but if it’s always clear like that, you are definitely over-drinking. You want to ensure you're drinking enough; some people think, "Oh, I should drink less, then my urinary symptoms will be less." But in fact, if you drink too little, your urine will get very concentrated, and concentrated urine irritates the bladder lining, giving you even worse symptoms.
The next thing I generally recommend is to look at what you're putting in your body. If you're drinking or eating things that can irritate the bladder lining, it may be useful to try taking them out of your diet for just a couple of days. This is not like a GI problem where you have to do an elimination diet and take something out for several weeks; even a couple of days will allow you to see a difference.
One big offender is caffeine, and caffeine is not just coffee and tea, although those are the most common ones. I see patients who drink so much caffeine—I mean, they drink like six cups of coffee a day. Of course, your bladder is going to be irritated if you’re drinking that much caffeine! But caffeine can also be in chocolate, ice cream, and a whole variety of other things that you may not even realize you’re consuming. Those Celsius drinks and other sparkling waters often have caffeine, so that’s one thing to consider.
Another one is alcohol. We know that people will urinate more when they drink alcohol because it's a diuretic, but it can also irritate the bladder lining. So if you're having a glass of wine at dinner every night, that may be contributing to how much you wake up at night. Other things that can irritate the bladder include citrusy fruits and juices, sometimes tomato-based products (so while lycopene is great, it can sometimes irritate the bladder lining), spicy foods for some people, artificial sweeteners, and even carbonated beverages.
I've made a whole video on bladder irritants on my YouTube channel, so check that out if you want to review a little more detail about these.
The other thing to consider is specifically what you’re drinking at dinner. If you're waking up a lot at night, that would be where I'd start. If your symptoms are more during the day, then I would look at what you're drinking throughout the day. Also, how much are you drinking before bedtime? If you’re drinking a lot before bed, like within the last 2 hours, you’re definitely going to wake up more, so I tell patients to try to limit how much they drink before bedtime to see if there’s a difference.
Next is constipation. A lot of people don’t realize that constipation will actually make their bladder symptoms worse. When you're constipated, the stool fills up the rectum, which is right behind the bladder, pushing against it and making it more sensitive, worsening your symptoms.
Making sure you’re not constipated is very helpful! I've made content on my YouTube channel about a bowel recipe that I often use. You can also try over-the-counter remedies or natural regimens like prunes, which can be very helpful in reducing constipation. As we've already mentioned, weight loss can be helpful; in fact, reducing even 8% of your body weight can significantly improve your urinary symptoms.
And lastly, if you are smoking, quit smoking! Smoking is a huge bladder irritant, so please consider stopping smoking—not just for your prostate, but for your bladder, your lungs, and all the areas of your body that are being affected by the chemicals in smoking.
Now, if you've tried conservative management, if you've tried to prevent enlargement, and if you've tried a supplement, what can you do next? Let's talk about medical treatment. I’m not going to cover surgical treatments in this podcast because there are so many new treatments, and I want to ensure I give that topic the time it deserves. I'm going to do a whole episode on surgical treatment of BPH. If you're interested in learning about a specific surgical option, make sure you comment on the YouTube comment section or leave a comment on Spotify where I can see it, so I cover all the different types of surgical interventions.
The most common medical treatment is called alpha-blockers. These are often known as tamsulosin or by the brand name Flomax, or alfuzosin. These work by relaxing the prostate and bladder neck muscles, making urination easier because the urine can flow better across those relaxed smooth muscles.
These work quite well; it usually takes about a month to see the full effect, but they often work even sooner than that. Sometimes they do have some side effects. The one I always caution my patients about is retrograde ejaculation. Now, tamsulosin, which is the most commonly prescribed one, has a very high rate of retrograde ejaculation, meaning that when you ejaculate, you will have a lower volume or no volume since it will be going back into the bladder rather than out towards the opening.
Fortunately, we do have other options, like alfuzosin, which has a lower risk of retrograde ejaculation. That is a risk. Another is that some people can get dizzy when they stand up too quickly. They stand up quickly and feel a little dizzy, and then they can have to sit back down. Also, if you have to have surgery on your eyes, it can cause what we call floppy iris syndrome. So, if you're about to have any surgery on your eyes, make sure to tell your urologist so they don't prescribe this, because otherwise, it can make that surgery much more difficult for the ophthalmologist.
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The next type of medication is called 5-alpha reductase inhibitors. These are medications called finasteride or dutasteride. They work by blocking the conversion of testosterone to DHT. Remember, the prostate is very sensitive to DHT, and this works by shrinking the prostate.
These can take a long time to work; sometimes it can be as early as 3 months, but sometimes it can take as long as 9 months to see a benefit. These medications, in lower doses, are also used for hair loss, which may be a nice side effect. However, there are two major side effects I want you to be aware of. One is that a small subset of people experience sexual side effects that are very bothersome in terms of affecting libido, which can be serious because it may take a long time to resolve. I've talked about these in more detail in a YouTube video about finasteride and tamsulosin, so I’ll link that here.
The other side effect to know about is that these medications do not cause prostate cancer. However, if you're taking these medications, they reduce your PSA—a screening test for prostate cancer—by half. What we've found in the data is that, when you're taking these medications, if you get prostate cancer, you are more likely to have a higher-grade prostate cancer than if you weren't taking the medication.
Now, it doesn't mean that it causes prostate cancer, but there is this risk, and I suspect that part of it is due to it reducing your PSA. So when you look at that number, in your mind or your doctor's mind, it should be doubled for screening purposes.
Now, the last medication that many people don't talk about is phosphodiesterase-5 inhibitors. These are essentially tadalafil, which is the medication we use for erections, but at low doses, it works by relaxing smooth muscle to help with prostatic symptoms. It’s actually a great medication, particularly if you're having both erectile dysfunction and BPH because you can take one medication that will help with both.
Side effects can include having head cold symptoms, stuffiness, or congestion, or muscle aches. But usually, at the low dose, most people do pretty well. Now, you can use combinations; you can take both alpha-blockers and 5-alpha-reductase inhibitors, most commonly Flomax and finasteride. It has been shown in very good solid trials that this is even better for large prostates and those who have more severe symptoms.
So talk to your doctor; make sure you're maximizing your medical therapy if you want to avoid having surgery. We can do higher doses of medication or take more than one medication at a time to see if we can improve your symptoms without needing surgery.
Now, the good news is that we now have so many options for BPH, whether they're procedures or surgeries that can help you achieve symptom relief. So if you're sick of taking medications or don’t want to take medications, it's a great option to consider.
And be on the lookout; if you like this podcast, make sure to subscribe or follow my podcast on whatever platform you’re using. Also, subscribe to my YouTube channel because I will be doing a deep dive into all the surgical options. I’ll be reviewing the data and telling you exactly what to expect after each of these options. I may even have some guests on who are world experts in some of these newer options, and we can discuss what you can expect from the perspective of someone who has done hundreds, if not thousands, of these operations.
Okay, guys, thank you so much for joining me on today's episode of the Reena Malik MD podcast. If you found this episode helpful, do me a solid favor—tag this podcast, take a screenshot, and share it on your social media with your friends and colleagues. I think everyone needs access to high-quality educational content that is completely 100% free. That’s why I do this, and I want more and more people to have access to it so that they can then be empowered to make accurate, evidence-based decisions for their bodies. And as always, take care of yourself, because you're worth it.