Medicinal Plants Widely Used In The Treatment Of Bph
3.1. Cucurbita pepo
3.1.1. Preclinical Studies
3.1.2. Clinical Studies
3.2. Epilobium parviflorum and E. angustifolium
3.2.1. Preclinical Studies
3.2.2. Clinical Studies
3.3. Hypoxis hemerocallidea
3.3.1. Preclinical Studies
3.3.2. Clinical Studies
3.4. Solanum lycopersicum
3.4.1. Preclinical Studies
3.4.2. Clinical Studies
3.5. Pinus pinaster
3.5.1. Preclinical Studies
3.5.2. Clinical Studies
3.6. Roystonea regia
3.6.1. Preclinical Studies
3.6.2. Clinical Studies
3.7. Prunus africana
3.7.1. Preclinical Studies
3.7.2. Clinical Studies
3.8. Secale cereale
3.8.1. Preclinical Studies
3.8.2. Clinical Studies
3.9. Serenoa repens
3.10. Urtica dioica
3.10.1. Preclinical Studies
3.10.2. Clinical Studies
What Is Benign Prostatic Hyperplasia
Benign prostatic hyperplasiaalso called BPHis a condition in men in which the prostate gland is enlarged and not cancerous. Benign prostatic hyperplasia is also called benign prostatic hypertrophy or benign prostatic obstruction.
The prostate goes through two main growth periods as a man ages. The first occurs early in puberty, when the prostate doubles in size. The second phase of growth begins around age 25 and continues during most of a mans life. Benign prostatic hyperplasia often occurs with the second growth phase.
As the prostate enlarges, the gland presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty completely, leaving some urine in the bladder. The narrowing of the urethra and urinary retentionthe inability to empty the bladder completelycause many of the problems associated with benign prostatic hyperplasia.
Combinations Of Different Medication Classes
Alpha blockers and 5ARIs. The recognition that alpha blockers provide early symptomatic relief, whereas 5ARIs provide long-term disease management led to the idea of combining both drugs in the medical management of men with LUTS and clinical BPH. Two 1-year randomized, placebo-controlled studies failed to show a significant benefit of combination therapy over monotherapy with the alpha blocker alone.25,26
Cumulative incidence of progression in the Medical Therapy of Prostatic Symptoms study. Reprinted with permission from McConnell J et al.1 Copyright © 2003 Massachusetts Medical Society. All rights reserved.
What Is The Difference Between Prostate Cancer And Benign Prostatic Hyperplasia
Prostate cancer is a common type of cancer that develops in your prostate gland. Early-stage prostate cancer rarely causes symptoms. However, as it progresses, it shares many of the same symptoms as BPH. These symptoms include a weak urine flow, pain when ejaculating or peeing and frequent urges to pee. Prostate cancer may spread to your bones, lymph nodes or other parts of your body. Treatment options include radiation therapy and surgery.
BPH symptoms are similar to prostate cancer symptoms. However, BPH isnt cancer, and it doesnt increase your risk of developing cancer. It wont spread to other parts of your body. Treatment options include medicines, surgery and minimally invasive procedures.
F Grading The Strength Of Evidence For Major Comparisons And Outcomes
The overall strength of evidence for primary outcomes of KQ1 within each comparison will be evaluated based on five required domains: study limitations directness consistency precision and reporting bias.23 Based on study design and risk of bias, study limitations will be rated as low, medium, or high. Consistency among studies will be rated as consistent, inconsistent, or unknown/not applicable based on the whether intervention effects are similar in direction and magnitude, and statistical significance of all studies. Directness will be rated as either direct or indirect based on the need for indirect comparisons when inference requires observations across studies. That is, more than one step is needed to reach the conclusion. Precision will be rated as precise or imprecise based on the degree of certainty surrounding each effect estimate or qualitative finding. An imprecise estimate is one for which the confidence interval is wide enough to include clinically distinct conclusions based upon established noticeable differences when available. Other factors that may be considered in assessing strength of evidence include dose-response relationship, the presence of confounders, and strength of association.
Based on these elements, we will assess the overall strength of evidence for each comparison and outcome as:23
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Current Therapies For Bph
At present, the primary goals of BPH treatment are to ameliorate LUTS, improve QOL, inhibit disease progression, and reduce complications. The treatment of BPH involves three different stages: watchful waiting, drug therapy, and surgical treatment . Watchful waiting is recommended by the AUA for patients in whom QOL has not been influenced by mild LUTS this strategy includes the implementation of dietary changes, exercise, education, and regular review . However, for patients with severe LUTS, watchful waiting is often ineffective and may delay optimal treatment such patients need to be administered appropriate medication. A range of drugs are currently available for the treatment of BPH, including 1-blockers, 5-ARIs, MRAs, PDE5Is, 3-adrenoceptor agonists, and plant extracts. Of these, the most commonly used drugs are 1-blockers, 5-ARIs, and a combination treatment featuring both 1-blockers and 5-ARIs .
What Is Medical Therapy For Bph
Medical therapy includes the use of drugs to relieve symptoms caused by hyperplasia, as well as the adoption of measures to keep urinary issues under control.
Medication is important in cases where symptoms are extreme and restrictive and impact significantly on patients quality of life. When this treatment does not have the effects expected, the alternative is surgery.
In less serious cases, however, patients may be able to manage their symptoms effectively through changes in habits and behaviour
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Why Does Bph Occur
The exact reason why benign prostatic hyperplasia develops is still unknown. There are many theories, all of which have the right to exist and have been confirmed in studies, but none of them can claim to be the ultimate truth. Benign prostatic hyperplasia is likely a polyetiological disease, that is, it has many developmental factors. Nevertheless, several factors have been established with certainty. Age and the increased amount of male sex hormones androgens, formed in the testicles, are major factors for the development of benign prostatic hyperplasia.
Benign prostatic hyperplasia is nodular hyperplasia of prostate cells. It is believed that the primary changes appear in the connective tissue, and then already affect the prostate gland. At the beginning small nodules are formed, consisting of rapidly multiplying cells. For a long time, there may be just an increase in the number of nodules, and after a certain period their gradual growth in size occurs. At the same time, the ratio of connective tissue to glandular tissue in the nodules varies, but more often the former prevails. At the same time, the following dependence was revealed: the larger the nodes , the greater the part of them is occupied by glandular components. It seems to be important because different structure leads to different effects of different drugs in conservative treatment.
B Searching For The Evidence: Literature Search Strategies For Identification Of Relevant Studies To Answer The Key Questions
We will search Ovid Medline, Ovid PsycInfo, Ovid Embase, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials for primary health outcomes published and indexed in bibliographic databases. We will attempt to assess long-term or rare harms with nonrandomized controlled trials and large controlled observational studies if RCTs are not available. Our search strategy includes relevant medical subject headings and natural language terms for LUTS/BPH . These concepts were combined with filters to select trials. We will supplement the bibliographic database search with forward and backward citation searching of relevant systematic reviews and other key references. We will update searches while the draft report is under public/peer review.
We will search for grey literature in ClinicalTrials.gov and to identify completed and ongoing studies. We will search for conference abstracts from the past three years to identify ongoing studies. Grey literature search results will be used to identify studies, outcomes, and analyses not reported in the published literature. Information from grey literature will also be used to assess publication and reporting bias and inform future research needs. Additional grey literature will be solicited through a notice posted in the Federal Register and Scientific Information Packets and other information solicited through the AHRQ Effective Health Care Web site.
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Search Strategy And Selection Criteria
This study followed PRISMA recommendations .9 The method and analysis were prespecified in advance and registered on the PROSPERO website . To identify published and unpublished trials, we used electronic databases including PubMed , Embase , and Cochrane clinical trial registers without language or date restriction, as well as performing a manual literature search. The detailed study protocol including search terms and strategy is provided in the supplementary material and supplementary table 1. Randomised parallel group design clinical trials comparing any two of the different surgical methods were eligible for inclusion. All methods are listed in table 1. Inclusion criteria were patients with a Qmax lower than 15 mL/s and an IPSS greater than 8. Exclusion criteria were patients with neurogenic bladder previous urethral, prostate, or bladder surgeries and suspected prostate cancer.
How Is Benign Prostatic Hyperplasia Treated
Treatment options for benign prostatic hyperplasia may include
- lifestyle changes
- minimally invasive procedures
A health care provider treats benign prostatic hyperplasia based on the severity of symptoms, how much the symptoms affect a mans daily life, and a mans preferences.
Men may not need treatment for a mildly enlarged prostate unless their symptoms are bothersome and affecting their quality of life. In these cases, instead of treatment, a urologist may recommend regular checkups. If benign prostatic hyperplasia symptoms become bothersome or present a health risk, a urologist most often recommends treatment.
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How Is Benign Prostatic Hyperplasia Diagnosed
Your healthcare provider will review your medical history, ask you questions and perform a physical examination. Part of the physical exam involves a digital rectal exam.
During a digital rectal exam, your healthcare provider will carefully insert their gloved digit into your rectum. Theyll feel the edges and surface of your prostate, estimate the size of your prostate and detect any hard areas that could be cancer.
Your healthcare provider may also order:
- A survey to evaluate the severity of your symptoms.
- A urine flow test to measure the speed of your pee stream.
- A study to detect how much pee remains in your bladder after youve finished peeing.
- A cystoscopy to look into your bladder.
Table 1 Cost Of Bph Drugs Compared
The costs below are based on average wholesale prices to pharmacists and the lowest dosage costs to patients may be more.
Drug class $70.08 $112.99 Prices given are those charged by the online retailer drugstore.com as of Oct. 1, 2010 for a one-month supply . They do not take any discounts or insurance coverage into consideration. Drug prices may vary, and your pharmacy may charge more.
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Other Medicaments And Combination Therapy In Bph Treatment
Medical treatment of BPH includes both static and dynamic components . Moreover, phosphodiesterase-5 inhibitors , muscarinic receptor antagonists, and vasopressin analogs may also have beneficial effects on the BPH-LUTS. Muscarinic receptor antagonists licensed for storage symptoms improvement include darifenacin, fesoterodine, oxybutynin, propiverine, solifenacin, and tolterodine. Because the effects of their long-term administration have not been clarified yet, they should be administered with caution and regular IPSS evaluation. PDE5 inhibitors may also have potential in LUTS improvement, via reducing smooth muscle tone of the detrusor, prostate, and urethra. In Europe, among the licensed PDE5 inhibitors , only tadalafil has been approved for LUTS therapy. Its administration is contraindicated in patients who use nitrates, potassium channel openers, nicorandil, 1-blockers, or have cardiovascular problems . In the case of patients with nocturia, desmopressin administration can reduce total urine volume. During its application, regular monitoring of serum sodium levels is essential to prevent hyponatremia .
Why Would You Have Surgery For A Benign Prostate Condition
The prostate is the walnut-sized gland that surrounds the urethra in a male. The urethra is the tube that carries urine from the bladder to outside the body. One of the non-cancerous conditions that can affect the prostate is called benign prostatic hyperplasia , which is also known as enlarged prostate.
BPH is the most common prostate problem in men over age 50. About half of men in their 50s and as many as 90% of men in their 70s and 80s have enlarged prostates.
Enlarged prostate surgery is recommended if less invasive treatments have failed, or if you have severe symptoms such as:
- An inability to urinate.
- Excessive blood in the urine.
- Bladder stones.
Prostate cancer and infertility arent symptoms or causes of BPH. Benign prostatic hyperplasia doesnt cause erectile problems.
Prostate procedures for BPH range from minimally invasive treatments to more extensive surgeries. Your healthcare provider will help you decide which type of prostate surgery is best for you.
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Appendix A: Search Strategy
Efficacy Versus Patient Expectation
From the above discussion, it is quite clear that there is a ceiling for the efficacy of medical therapy in terms of symptom improvement. The standard medications, such as alpha-adrenergic receptor blockers and 5ARIs, as well as various combinations, such as alpha blockers plus 5ARIs, alpha blockers plus antimuscarinic agents, and alpha blockers plus PDE-5 inhibitors, achieve an improvement in IPSS somewhere between 3 and 7 points . Even using selective drugs or a combination of drugs for specific patients at lesser or greater risk, with larger or smaller prostates, higher or lower PSA, or more voiding or more storage symptoms, the fundamental observation is that no medical therapy has ever achieved an improvement in the symptom score approaching 10 points from baseline. In addition, part of the symptomatic improvement is due to a placebo effect, as evidenced by the strong placebo response in virtually all placebo-controlled, randomized clinical trials.
Several studies have attempted to correlate patients expectations and interpretations of improvement in the symptom score by matching global objective assessment against the actual observed changes in the IPSS.34,35
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Guidelines For The Treatment Of Benign Prostatic Hyperplasia
Yunuo Wu, PharmDCreighton University School of Pharmacy and Health Professions
Michael H. Davidian, MD, MSAssociate Professor of MedicineCreighton University School of Medicine
Edward M. DeSimone II, RPh, PhD, FAPhAProfessor of Pharmacy SciencesCreighton University School of Pharmacy and Health ProfessionsOmaha, Nebraska
US Pharm. 2016 41:36-40.
ABSTRACT:Benign prostatic hyperplasia is a common disorder in men with an incidence that increases with age. BPH often requires therapy when patients begin to experience lower urinary tract symptoms that affect quality of life. Current management strategies involve lifestyle modifications, pharmacotherapy, phytotherapy, and surgical interventions as indicated. Pharmacists are in the unique position of being accessible sources of healthcare information for the BPH patient population. Understanding the symptoms of this disorder and therapy options will be beneficial for pharmacists who have increased chances to answer BPH-related questions from their patients.
What Causes Benign Prostatic Hyperplasia
The cause of benign prostatic hyperplasia is not well understood however, it occurs mainly in older men. Benign prostatic hyperplasia does not develop in men whose testicles were removed before puberty. For this reason, some researchers believe factors related to aging and the testicles may cause benign prostatic hyperplasia.
Throughout their lives, men produce testosterone, a male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in their blood decreases, which leaves a higher proportion of estrogen. Scientific studies have suggested that benign prostatic hyperplasia may occur because the higher proportion of estrogen within the prostate increases the activity of substances that promote prostate cell growth.
Another theory focuses on dihydrotestosterone , a male hormone that plays a role in prostate development and growth. Some research has indicated that even with a drop in blood testosterone levels, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage prostate cells to continue to grow. Scientists have noted that men who do not produce DHT do not develop benign prostatic hyperplasia.
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Should I Go With A Treatment
If your symptoms become worse, it’s time to talk to your doctor about an active treatment. Some things to ask yourself and your doctor about each option:
- How much will my condition improve?
- How long will the effects last?
- Is there a chance that the treatment will cause problems?
From there, you can talk with them about medications, supplements or surgery.
Background And Objectives For The Systematic Review
Benign Prostatic Hyperplasia is a “histologic diagnosis that refers to the proliferation of smooth muscle and epithelial cells within the prostatic transition zone.”1 Men are likely to develop BPH as they age. Half of men ages 51 60 years old and 80 percent of men over 80 years old have BPH according to autopsy data.2
About half of men with BPH develop an enlarged prostate gland, called benign prostatic enlargement , and among these, about half develop bladder outlet obstruction .3 BOO and/or changes in smooth muscle tone and resistance that can accompany BPH often result in lower urinary tract symptoms .1 LUTS are storage disturbances, such as daytime urinary urgency and nocturia, and/or voiding disturbances, such as urinary hesitancy, weak stream, straining, and prolonged voiding.2 LUTS affect an estimated three percent of men ages 4549 years old and 30 percent of men over 85 years old.2 Urinary hesitancy, weak stream, and nocturia are the most commonly reported LUTS.4 BPH/LUTS negatively impact quality of life2,3 and cost the United States over $1 billion annually.3
Monotherapy with 5-ARI agents finasteride and dutasteride is another option for LUTS/BPH and BPE.7 Systematic reviews demonstrate that 5-ARIs are safe and effective13,14 and may be better than ABs in preventing disease progression .14
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