Metabolic syndrome and benign prostatic hyperplasia: An update

Awareness and prevalence of self-reported benign prostatic hyperplasia: a cross-sectional study in Saudi Arabia

Background

Benign prostatic hyperplasia (BPH) is a prevalent condition in older men, causing significant morbidity. Despite recent progress, essential concerns of the disease remain under-researched. This study aims to assess knowledge and estimate self-reported prevalence of BPH in Saudi Arabian men. Understanding BPH prevalence in Saudi Arabia is essential for healthcare planning, resource allocation, public awareness, early detection, intervention, research, and addressing regional variations.

Method

A cross-sectional study was conducted from February to May 2022 using a validated questionnaire. Univariate and multivariate statistical methods assessed knowledge of BPH among 559 adult Saudi men (mean age: 47.2 years) and its association with demographic variables.

Results

The self-reported prevalence rate of BPH for Saudi Arabian men was 12.0%. Most adults (74.2%) were aware that BPH is a risk factor for prostate cancer and 75% were aware of the increased risk of BPH in older people. Furthermore, 44.5% of participants associated nocturia with BPH, while 76.6% related urinary tract infection (UTI) with BPH. The study demonstrated a significant association between BPH awareness and marital status (p = 0.02), level of education (p = 0.02), and employment status (p = 0.04).

Conclusion

While men in Saudi Arabia generally had sufficient knowledge about BPH, there was a knowledge gap regarding certain risk factors like obesity and cardiac diseases. To address this, an educational program should be developed for both the general population and those at high risk of BPH.

Benign Prostatic Hyperplasia and Incident Cardiovascular Disease

BACKGROUND

Data regarding the relationship between benign prostatic hyperplasia (BPH) and incident cardiovascular disease (CVD) are scarce. We aimed to clarify the association of BPH with the risk of developing CVD using a nationwide epidemiological database.

METHODS AND RESULTS

This retrospective observational cohort study analyzed data from the JMDC Claims Database between 2005 and 2022, including 2,370,986 men (median age 44 years). The primary endpoints were myocardial infarction (MI), angina pectoris (AP), stroke, heart failure (HF), and atrial fibrillation (AF), which were assessed separately. BPH was observed in 48,651 (2.1%) men. During a mean (±SD) follow-up of 1,359±1,020 days, 7,638 MI, 52,167 AP, 25,355 stroke, 58,183 HF, and 16,693 AF events were detected. Hazard ratios of BPH for MI, AP, stroke, HF, and AF were 1.04 (95% confidence interval [CI] 0.92-1.18), 1.31 (95% CI 1.25-1.37), 1.26 (95% CI 1.18-1.33), 1.21 (95% CI 1.16-1.27), and 1.15 (95% CI 1.07-1.24), respectively. We confirmed the robustness of our primary findings through a multitude of sensitivity analyses. In particular, a history of BPH was associated with a higher risk of developing CVD, even in participants without obesity, hypertension, diabetes, or dyslipidemia.

CONCLUSIONS

Our analysis of a nationwide epidemiological dataset demonstrated that BPH was associated with a greater risk of developing CVD in middle-aged men.

Features of patients referring to the outpatient office due to benign prostatic hyperplasia: analysis of a national prospective cohort of 5815 cases

BACKGROUND

Evidence on clinical presentation of benign prostatic hyperplasia (BPH) is scarce, and studies involving outpatients are lacking. We aimed to provide an insight into the contemporary Italian scenario of BPH-affected outpatients using symptom scores (International Prostate Symptom Score [IPSS], BPH Impact Index [BII]), and to compare characteristics of patients with known BPH and those first-diagnosed at the visit.

METHODS

"IMPROVING THE PATH" project working group designed a questionary prospectively administered to BPH-affected outpatients by urologists. A cross-sectional study was performed. Data were adjusted for patient age as a potential confounding factor.

RESULTS

Of 5815 patients enrolled, BPH was already diagnosed in 4144 (71.3%), and not in 1671 (28.7%). Patients with known BPH, compared to newly diagnosed, were older (median 68 versus [vs] 55), had more frequent smoking (smoker 27.2 vs 22.6%, and ex-smoker 16.4 vs 12.5%) and drinking habits (55.4 vs 45.1%), were more frequently affected by hypertension (60.0 vs 42.4%), obesity (15.3 vs 9.6%), diabetes (17.9 vs 12.5%), and cardiovascular diseases (14.2 vs 9.5%), p < 0.001. At IPSS, moderate and severe symptoms correlated with already known BPH (56.1 vs 47.3% and 24.8 vs 7.8%), whereas newly diagnosed patients showed milder symptoms (44.9 vs 19.1%), all p < 0.001. At BII, concern for one's health and time lost due to urinary problems were higher in patients with known BPH (p < 0.001). For these patients, the urologist changes at least one of the ongoing medications in 63.5%. For patients newly diagnosed, supplements/phytotherapeutics, alpha-blockers, and 5-alfa reductase inhibitors were prescribed in 54.6%, 21.6%, and 7.1%, respectively.

CONCLUSIONS

Despite medical treatment, natural history of BPH leads to a progressive deterioration of symptoms. This may reflect the difference between newly diagnosed patients and those with known BPH in lifestyle and associated comorbidities. A healthy lifestyle and treatments including local anti-inflammatory agents may delay worsening of symptoms and improve quality of life.

Association of Benign Prostatic Hyperplasia With Multimorbidity Among Older Adults: Insights From the Longitudinal Ageing Study in India (LASI), First Wave

Introduction Population ageing is expected to be accompanied by an increase in multi-morbidity, i.e. the co-occurrence of multiple chronic conditions simultaneously. Benign prostatic hyperplasia (BPH) is a non-malignant disease prevalent in ageing men. Both BPH and multi-morbidity are known to have a significant impact on quality of life. The objective of this study was to determine the association between BPH and multimorbidity among older adults and the elderly population in India. Methods This is an analytical cross-sectional study involving secondary data from the nationally representative Longitudinal Ageing Study in India (LASI) Wave I 2017-18. Multivariable logistic regression analysis was conducted to study the association between BPH and multimorbidity while accounting for other associated factors. Results Compared to those having no co-morbidities, the odds of having BPH increased with the increasing number of co-morbidities. Those with at least two co-morbidities were twice as likely (aOR=2.19; 95%CI 1.78-2.72), and those with at least four co-morbidities were almost six times as likely (aOR=5.78; 95%CI 2-16.72) to have BPH as compared to those with no co-morbidities. The association was stronger among males >60 years. Conclusion Self-reported benign prostatic hyperplasia was found to be strongly associated with multi-morbidity. The need of the hour is the inclusion of BPH within the framework of a national health programme. Health technology assessment of high-risk screening strategies for BPH may be conducted among patients with multimorbidity. Research into the impact on the quality of life of those affected by both BPH and multimorbidity will help highlight this as a priority problem for decision-makers.

Effects of the CB1 receptor antagonists AM6545 and AM4113 on metabolic syndrome-induced prostatic hyperplasia in rats

Metabolic syndrome (MetS) is a combination of metabolic disorders that can predispose individuals to benign prostatic hyperplasia (BPH). The inhibition of the cannabinoid 1 (CB1) receptor has been used to treat metabolic disorders in animal models. This study reports the use of a peripherally restricted CB1 antagonist (AM6545) and a neutral CB1 antagonist (AM4113) to improve MetS-related BPH in rats. Animals were divided into three control groups to receive either a normal rodent diet, AM6545, or AM4113. MetS was induced in the fourth, fifth, and sixth groups using a concentrated fructose solution and high-salt diet delivered as food pellets for eight weeks. The fifth and sixth groups were further given AM6545 or AM4113 for additional four weeks. Body and prostate weights were measured and prostate sections were stained with hematoxylin eosin. Cyclin D1, markers of oxidative stress and inflammation, and levels of the endocannabinoids were recorded. BPH in rats with MetS was confirmed through increased prostate weight and index, as well as histopathology. Treatment with either AM6545 or AM4113 significantly decreased prostate weight, improved prostate histology, and reduced cyclin D1 expression compared with the MetS group. Groups treated with CB1 antagonists experienced reduced lipid peroxidation, recovered glutathione depletion, restored catalase activity, and had lower inflammatory markers interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α). MetS rats treated with either AM6545 or AM4113 showed reduced concentrations of anandamide (AEA) and 2-arachidonoylglycerol (2-AG) in the prostate compared with the MetS group. In conclusion, the CB1 antagonists AM6545 and AM4113 protect against MetS-induced BPH through their anti-proliferative, antioxidant, and anti-inflammatory effects.

Leptin Mediates Prostate Stromal Cell Proliferation, Smooth Muscle Contraction, and Mitochondrial Function in Benign Prostate Hyperplasia

Introduction

Leptin is a metabolic peptide hormone produced by adipocytes, with proven roles in proliferation of prostate cancer cells and of prostate cells in animal models of benign prostatic hyperplasia (BPH). Thus, the role of leptin as a molecular link connecting BPH and lower urinary tract symptoms (LUTS) suggestive of BPH with metabolic symptoms appears feasible but is still unknown. In fact, a connection between metabolic syndrome and BPH is becoming increasingly evident from epidemiologic studies. Key factors of Lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH/LUTS) are increased prostate smooth muscle tone, and prostate enlargement. Here, we examined the effects of leptin on contraction of human prostate smooth muscle and on growth of stromal cells.

Methods

We performed microarray analysis to identify genes (fold change ≥ 1.5) associated with BPH/LUTS progression, such as those involved in proliferation, apoptosis, and mitochondrial metabolism, in rat prostate tissue (data from GSE129561). We then used electric field stimulation (EFS) to induce frequency-dependent, neurogenic contractions of human prostate strips, which were enhanced by leptin. We also examined the effect of leptin on human prostate stromal cells (WPMY-1) and found increased cell proliferation and viability upon exposure. To explore the underlying mechanism, we conducted mitochondrial stress assay using near-infrared (NIR) fluorescent dye and flow cytometry (FACS) analysis and observed reduced cellular apoptosis and preserved mitochondrial membrane potential (∆ψM) after leptin treatment.

Results

Microarray analysis reveals that leptin regulates prostate smooth muscle contraction and stromal cell proliferation, shedding new light on its involvement in BPH/LUTS pathogenesis and mitochondrial function. We found that leptin enhanced the proliferation rate of prostate stromal cells relative to the control group (0.67 ± 0.05 vs 0.54 ± 0.08, p-value= 0.024). Moreover, leptin (100 ng/mL) potentiated the frequency-dependent, neurogenic contractions of prostate strips elicited by EFS (p= 0.047 between leptin and control group). We also show that leptin treatment increased the mitochondrial membrane potential of prostate stromal cells and inhibited mitochondrial apoptosis.

Discussion

Our results indicate that leptin stimulates the contractility and proliferation of smooth muscle and stromal cells in the human prostate, implying a potential role for leptin in exacerbating BPH/LUTS in obese men. Leptin modulation may be a beneficial therapeutic strategy for patients with metabolic syndrome and BPH/LUTS. Further studies are warranted to elucidate the mechanisms and implications of the leptin system in BPH/LUTS.

A guide to diagnosing and treating benign prostatic hypertrophy

Benign prostatic hypertrophy (BPH) is a condition where the prostate becomes enlarged. It affects all men and is part of the ageing process. Globally, the incidence rates of BPH have risen by 70% between 2000-2019. When left untreated, it can lead to acute urinary retention, impaired bladder emptying, urinary tract infections, bladder stones, kidney failure or gross haematuria. In this article, Linda Nazarko describes the causes and consequences of BPH along with treatment options that are available for it.

Lifestyle habits to prevent the development of benign prostatic hyperplasia: Analysis of Japanese nationwide datasets

Objectives

Benign prostatic hyperplasia (BPH) refers to nonmalignant hyperplasia of prostate tissue, which causes lower urinary tract symptoms and has become a global public health concern in the aging population. The purpose of this study is to identify modifiable factors, which would prevent or delay BPH development.

Methods

The association between BPH marker drugs and climate-, socioeconomic-, health condition-, and lifestyle habits-related variables was investigated by analyzing nationwide datasets which were collected in 2018, aggregated by prefecture (administrative unit), and published by Japanese ministries. Uroselective α₁ receptor blockers and dutasteride were used as marker drugs referring to BPH prevalence. Correlation analysis, multiple linear regression analysis, and binomial logistic regression analysis were conducted with 47 Japanese prefectures as the unit.

Results

The variables which showed |r| > 0.5 by correlation analysis were exercise habits (r = -0.5696), smoking habits (r = 0.6116), and daily drinking (r = 0.6001) for uroselective α₁ receptor blockers, and antihypertensive medication (r = 0.5971), smoking habits (r = 0.6598), a small amount of drinking (r = -0.5292), and serum alanine aminotransferase (r = 0.6814) for dutasteride. Multiple linear regression equations were constructed by including these variables (R ²  = 0.5453 for uroselective α₁ receptor blockers and R ²  = 0.5673 for dutasteride). Binomial logistic regression analysis found a significant association between climate in the resident area and BPH development.

Conclusion

This ecological study, analyzing Japanese nationwide datasets, demonstrates that healthy lifestyle habits, especially avoidance of smoking, implementation of exercise in daily life, and a small amount of alcohol consumption, are important to prevent or delay BPH development. High blood pressure and high serum alanine aminotransferase are suggested as risk factors of BPH development.

The global, regional, and national burden of benign prostatic hyperplasia in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Benign prostatic hyperplasia is a common urological disease affecting older men worldwide, but comprehensive data about the global, regional, and national burden of benign prostatic hyperplasia and its trends over time are scarce. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we estimated global trends in, and prevalence of, benign prostatic hyperplasia and disability-adjusted life-years (DALYs) due to benign prostatic hyperplasia, in 21 regions and 204 countries and territories from 2000 to 2019.

METHODS

This study was conducted with GBD 2019 analytical and modelling strategies. Primary prevalence data came from claims from three countries and from hospital inpatient encounters from 45 locations. A Bayesian meta-regression modelling tool, DisMod-MR version 2.1, was used to estimate the age-specific, location-specific, and year-specific prevalence of benign prostatic hyperplasia. Age-standardised prevalence was calculated by the direct method using the GBD reference population. Years lived with disability (YLDs) due to benign prostatic hyperplasia were estimated by multiplying the disability weight by the symptomatic proportion of the prevalence of benign prostatic hyperplasia. Because we did not estimate years of life lost associated with benign prostatic hyperplasia, disability-adjusted life-years (DALYs) equalled YLDs. The final estimates were compared across Socio-demographic Index (SDI) quintiles. The 95% uncertainty intervals (UIs) were estimated as the 25th and 975th of 1000 ordered draws from a bootstrap distribution.

FINDINGS

Globally, there were 94·0 million (95% UI 73·2 to 118) prevalent cases of benign prostatic hyperplasia in 2019, compared with 51·1 million (43·1 to 69·3) cases in 2000. The age-standardised prevalence of benign prostatic hyperplasia was 2480 (1940 to 3090) per 100 000 people. Although the global number of prevalent cases increased by 70·5% (68·6 to 72·7) between 2000 and 2019, the global age-standardised prevalence remained stable (-0·770% [-1·56 to 0·0912]). The age-standardised prevalence in 2019 ranged from 6480 (5130 to 8080) per 100 000 in eastern Europe to 987 (732 to 1320) per 100 000 in north Africa and the Middle East. All five SDI quintiles observed an increase in the absolute DALY burden between 2000 and 2019. The most rapid increases in the absolute DALY burden were seen in the middle SDI quintile (94·7% [91·8 to 97·6]), the low-middle SDI quintile (77·3% [74·1 to 81·2]), and the low SDI quintile (77·7% [72·9 to 83·2]). Between 2000 and 2019, age-standardised DALY rates changed less, but the three lower SDI quintiles (low, low-middle, and middle) saw small increases, and the two higher SDI quintiles (high and high-middle SDI) saw small decreases.

INTERPRETATION

The absolute burden of benign prostatic hyperplasia is rising at an alarming rate in most of the world, particularly in low-income and middle-income countries that are currently undergoing rapid demographic and epidemiological changes. As more people are living longer worldwide, the absolute burden of benign prostatic hyperplasia is expected to continue to rise in the coming years, highlighting the importance of monitoring and planning for future health system strain.

FUNDING

Bill & Melinda Gates Foundation.

TRANSLATION

For the Amharic translation of the abstract see Supplementary Materials section.

Triglyceride to high-density lipoprotein cholesterol ratio and total cholesterol to high-density lipoprotein cholesterol ratio and risk of benign prostatic hyperplasia in Chinese male subjects

Background

Lipid metabolism disorders contribute to the risk factor of prostatic hyperplasia. Lipid ratios have also attracted a lot of attention. Yet, research about the correlation of lipid ratios with prostatic hyperplasia is limited. Hence, the aim of this study was to investigate the association of lipid ratios with the risk of benign prostatic hyperplasia (BPH) in Chinese male subjects.

Methods

Healthy men who underwent routine health check-ups from January 2017 to December 2019 were recruited. Twenty-four thousand nine hundred sixty-two individuals were finally enrolled in this research. Binary logistic regression analysis was performed to investigate the relationship between lipid ratios and BPH in Chinese adults.

Results

After health examinations for more than 2 years, 18.46% of subjects were ascertained as incident BPH cases. Higher age, body mass index (BMI), prostate-specific antigen (PSA), triglycerides (TGs), low-density lipoprotein cholesterol (LDL-C), triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio, total cholesterol to high-density lipoprotein cholesterol (TC/HDL-C) ratio, and lower high-density lipoprotein cholesterol (HDL-C) were significantly associated with BPH risk, while total cholesterol (TC) was not significant. When quartiles of TG/HDL-C and TC/HDL-C were analyzed in multivariable model, higher TG/HDL-C and TC/HDL-C were associated with a risk of BPH (odds ratio [OR] = 2.11; 95% confidence interval [CI]: 1.89, 2.36; P-trend < 0.001; and OR = 1.67; 95% CI: 1.50, 1.85; P-trend < 0.001, respectively). In addition, stratified analyses based on the general population exhibited that with increasing age (≥35 years) the relationship of TG/HDL-C ratio with BPH risk was dominantly positive (all P-trend < 0.001, P-interaction = 0.001), and significant associations were also found in blood pressure strata and FBG strata (all P-trend < 0.001), except men with BMI ≥ 28 kg/m² were slightly weakened (OR = 2.01, 95% CI: 1.41, 2.85; P-trend = 0.04). Moreover, there were significant associations between quartiles of TC/HDL-C and the risk of BPH was observed mainly in age 55–64 years, BMI 18.5–23.9 Kg/m², blood pressure strata, and FBG strata. However, the P-value for a linear trend among those with BMI ≥ 28 Kg/m² in which participants at the highest quartile of TC/HDL-C had an OR of 1.45 (95% CI: 1.09, 1.93) was 0.594. Additionally, higher TG/HDL-C ratio (≥0.65) may be a risk factor for BPH in China adults of different age decades (≥35 years) with normal TG and HDL-C.

Conclusions

TG/HDL-C and TC/HDL-C were associated with BPH risk, TG/HDL-C was a powerful independent risk factor for BPH in Chinese adults, and higher TG/HDL-C ratio should be valued in male subjects with normal TG and HDL-C levels.

Carpal tunnel syndrome and trigger finger as related to benign prostatic hyperplasia: A retrospective nationwide cohort investigation

To describe the incidence of benign prostatic hyperplasia (BPH) after a diagnosis of carpal tunnel syndrome or trigger finger. We performed a retrospective study on national health registry comparing the incidence of BPH between a cohort of 9720 study patients and a comparison cohort of 38,880 control individuals. The crude hazard ratio (HR) and the adjusted HR were estimated by the univariable and the multivariable Cox proportional hazard model, respectively. The risks of BPH in different age groups and patients with or without comorbidities were also investigated. The cumulative incidence curves were obtained by the Kaplan-Meier method and assessed by the Log-rank test. Compared to the control cohort, patients with carpal tunnel syndrome increased the risk of BPH by 1.36 times (95% confidence intervals [CI] = 1.29, 1.43). Patients only diagnosed with trigger finger raised the risk of BPH by 1.31 times (95% CI = 1.22, 1.40). The HR of BPH for patients with both carpal tunnel syndrome and trigger finger relative to the controls was 1.43 (95% CI = 1.33, 1.54). We concluded that the likelihood of developing BPH was increased in patients with carpal tunnel syndrome or trigger finger.

Metabolic Syndrome and Overactive Bladder Syndrome May Share Common Pathophysiologies

Metabolic syndrome (MetS) is defined by a group of cardiovascular risk factors, including impaired glucose tolerance, central obesity, hypertension, and dyslipidemia. Overactive bladder (OAB) syndrome consists of symptoms such as urinary urgency, frequency, and nocturia with or without urge incontinence. The high prevalences of metabolic syndrome (MetS) and overactive bladder (OAB) worldwide affect quality of life and cause profound negative impacts on the social economy. Accumulated evidence suggests that MetS might contribute to the underlying mechanisms for developing OAB, and MetS-associated OAB could be a subtype of OAB. However, how could these two syndromes interact with each other? Based on results of animal studies and observations in epidemiological studies, we summarized the common pathophysiologies existing between MetS and OAB, including autonomic and peripheral neuropathies, chronic ischemia, proinflammatory status, dysregulation of nutrient-sensing pathways (e.g., insulin resistance at the bladder mucosa and excessive succinate intake), and the probable role of dysbiosis. Since the MetS-associated OAB is a subtype of OAB with distinctive pathophysiologies, the regular and non-specific medications, such as antimuscarinics, beta-3 agonist, and botulinum toxin injection, might lead to unsatisfying results. Understanding the pathophysiologies of MetS-associated OAB might benefit future studies exploring novel biomarkers for diagnosis and therapeutic targets on both MetS and OAB.

Oxidative Stress: A Putative Link Between Lower Urinary Tract Symptoms and Aging and Major Chronic Diseases

Aging and major chronic diseases are risk factors for lower urinary tract symptoms (LUTS). On the other hand, oxidative stress (OS) is one of the fundamental mechanisms of aging and the development of chronic diseases. Therefore, OS might be a candidate mechanism linking these two clinical entities. This article aims to summarize the studies on the prevalence of LUTS, the role of OS in aging and chronic diseases, and the potential mechanisms supporting the putative link. A comprehensive literature search was performed to identify recent reports investigating LUTS and OS in major chronic diseases. In addition, studies on the impact of OS on the lower urinary tract, including bladder, urethra, and prostate, were collected and summarized. Many studies showed LUTS are prevalent in aging and major chronic diseases, including obesity, metabolic syndrome, diabetes, cardiovascular disease, hypertension, obstructive sleep apnea, autoimmune diseases, Alzheimer’s disease, and Parkinson’s disease. At the same time, OS is a key component in the pathogenesis of those chronic diseases and conditions. Recent studies also provided evidence that exacerbated OS can cause functional and/or structural changes in the bladder, urethra, and prostate, leading to LUTS. The reviewed data support the concept that OS is involved in multiple risk factors-associated LUTS, although further studies are needed to confirm the causative relationship. The specific ROS/RNS and corresponding reactions/pathways involved in chronic diseases and associated LUTS should be identified in the future and could serve as therapeutic targets.

Icariin ameliorates metabolic syndrome-induced benign prostatic hyperplasia in rats

Metabolic syndrome (MetS) is an immense health issue that causes serious complications in aging males including BPH. Icariin (ICA) is a flavonol glycoside that exerts a plethora of pharmacological effects. The present investigation tested the potential of ICA to ameliorate benign prostatic hyperplasia (BPH) induced by MetS in rats. Animals were allocated to 5 groups in which the first and second groups were kept on water and regular food pellets. MetS was induced in the third, fourth, and fifth groups by keeping the animals on high fructose and salt diets for twelve consecutive weeks. These groups were given vehicle, ICA (25 mg/kg), and ICA (50 mg/kg), respectively. MetS was confirmed by an increase in rats' weight, accumulation of visceral fat, insulin resistance, and dyslipidemia. This was accompanied by manifestation of BPH including increased prostate weight, prostate index, and histopathological alterations. Treating the animals with both doses of ICA significantly ameliorated the increase in weight and index of the prostate as well as altered prostate histopathology. In addition, ICA significantly decreased cyclin D1 expression, upregulated Bax, and downregulated Bcl2 mRNA expression. ICA prevented lipid peroxidation, reduced glutathione depletion, and catalase exhaustion, which further lowered markers of prostate inflammation such as interleukin-6 and tumor necrosis factor-α. Moreover, ICA prevented the decrease in prostate content of phosphorylated 5'-adenosine monophosphate (AMP)-activated protein kinase (pAMPK). In conclusion, ICA protects against MetS-induced BPH. This is due to its antiproliferative, proapoptotic, antioxidant, and anti-inflammatory activities as well as the activation of AMPK.

Is COVID-19 a risk factor for progression of benign prostatic hyperplasia and exacerbation of its related symptoms?: a systematic review

BACKGROUND

To explore the potential mechanisms of SARS-CoV-2 in targeting the prostate gland, leading to exacerbation of benign prostatic hyperplasia (BPH) symptoms and greater risks of BPH complications such as acute urinary retention.

METHODS

A categorized and comprehensive search in the literature has been conducted by 10 April 2021 using international databases including PubMed, Embase, Web of Science, Scopus, and Cochrane Library in line with the PRISMA guidelines recommendations. PICO strategy was used to formulate the research question. The following terms were used: urology, COVID-19, coronavirus, BPH, inflammation, androgen receptors, LUTS, IPSS, PSA, and SARS-CoV-2 or a combination of them. Studies with irrelevant purposes and duplicates were excluded. The selected studies were performed on humans and published in English.

RESULTS

The research revealed 89 articles. After title screening and considering exclusion criteria, 52 papers were included for the systematic review. BPH is a common condition affecting older men. SARS-CoV-2 infects the host cell by binding to angiotensin converting enzyme 2 (ACE2). A hyperactivated RAS system during infection with SARS-CoV-2 may lead to activation of pro-inflammatory pathways and increased cytokine release. Thus, this virus can lead to exacerbation of lower urinary tract symptoms (LUTS) and trigger inflammatory processes in the prostate gland. Since androgen receptors (AR) play an important role in the BPH pathophysiology and infection with SARS-CoV-2 may be androgen-mediated, BPH progression and its related symptoms can be a complication of COVID-19 through AR involvement and metabolic disturbances.

CONCLUSIONS

Based on the current findings, SARS-CoV-2 can possibly damage the prostate and worsen BPH and its related LUTS through ACE2 signaling, AR-related mechanisms, inflammation, and metabolic derangement. We encourage future studies to investigate the possible role of COVID-19 in the progression of BPH-related LUTS and examine the prostatic status in susceptible patients with relevant available questionnaires (e.g., IPSS) and serum biomarkers (e.g., PSA).

Periprostatic Adipose Tissue Microenvironment: Metabolic and Hormonal Pathways During Prostate Cancer Progression

The periprostatic adipose tissue (PPAT) is a site of invasion of prostate cancer (PCa) and is part of the microenvironment. It was shown that PPAT secretes factors and fatty acids (FAs) that alter the microenvironment of the PCa. The PPAT secretome of patients with PCa-T3 stage (PPAT-T3) has a metabolic profile enriched in several pathways related to energy production, indicating a greater energy requirement by the tumor, when compared to that of patients in the PCa-T2 stage (PPAT-T2). PPAT-T3 also shows enrichment in pathways related to hormone response, polyamine synthesis, and control of protein synthesis, through amino acid, RNA, and nucleotide metabolism. PPAT-T2 and PPAT-BPH secretomes have less complex metabolic profile, both related with energy balance, while PPAT-BPH has hormone response through insulin pathway. Undoubtedly, a deeper characterization of the human PPAT will lead to a better understanding of the disease and possibly allow new stratification factors and the design of a specific therapy that targets crucial components of the tumor microenvironment as another way to treat or control the disease.

Aerobic exercises ameliorate benign prostatic hyperplasia via IGF-1/IGF-1R/ERK/AKT signalling pathway in prostate tissue of high-fat-diet-fed mice with insulin resistance

This study investigated the changes in the prostate of high-fat diet (HFD)-fed mice with insulin resistance (IR) and explored the possible mechanisms of the effects of 8-week treadmill aerobic exercise on prostatic hyperplasia in insulin-resistant mice through the IGF-1/IGF-1R/ERK/AKT signalling pathway. Results showed IR in mice caused an increase in prostate-related indicators, such as prostate weight (PW) and prostate volume (PV), resulting in prostatic hyperplasia. The area of the glandular lumen and the height of the glandular epithelium in mice with IR were increased, which indicating that it caused prostatic hyperplasia through epithelial cell proliferation. In addition, the level of IGF-1 in serum and the expression of IGF-1R, ERK and AKT in prostate tissue of high-fat diet induced IR mice increased significantly, which might be related to the proliferation of prostate cells. However, aerobic exercise lowered the blood sugar, serum insulin and IGF-1; inhibited the combination of IGF-1 and IGF-1R on the prostate; down-regulated the expression of IGF-1R, ERK and AKT proteins; and then suppressed the expression of downstream proliferation genes, thereby achieving the purpose of inhibiting the proliferation of prostate epithelial cells. In conclusion. Eight weeks of aerobic exercise might improve the prostate hyperplasia in mice via down-regulating the serum insulin and IGF-1, thus enhancing the insulin sensitivity of insulin-resistant mice and regulating the IGF-1/IGF-1R/ERK/AKT signalling pathway by inhibiting the expression of IGF-1R, ERK and AKT in the prostate tissue. However, this exercise had no significant effect on PV, PW and prostate index (PI).

High-Fat Diet Induced Gut Microbiota Alterations Associating With Ghrelin/Jak2/Stat3 Up-Regulation to Promote Benign Prostatic Hyperplasia Development

The role of high-fat diet (HFD) induced gut microbiota alteration and Ghrelin as well as their correlation in benign prostatic hyperplasia (BPH) were explored in our study. The gut microbiota was analyzed by 16s rRNA sequencing. Ghrelin levels in serum, along with Ghrelin and Ghrelin receptor in prostate tissue of mice and patients with BPH were measured. The effect of Ghrelin on cell proliferation, apoptosis, and induction of BPH in mice was explored. Our results indicated that BPH mice have the highest ratio of Firmicutes and Bacteroidetes induced by HFD, as well as Ghrelin level in serum and prostate tissue was significantly increased compared with control. Elevated Ghrelin content in the serum and prostate tissue of BPH patients was also observed. Ghrelin promotes cell proliferation while inhibiting cell apoptosis of prostate cells. The effect of Ghrelin on enlargement of the prostate was found almost equivalent to that of testosterone propionate (TP) which may be attenuated by Ghrelin receptor antagonist YIL-781. Ghrelin could up-regulate Jak2/pJak2/Stat3/pStat3 expression in vitro and in vivo. Our results suggested that Gut microbiota may associate with Ghrelin which plays an important role in activation of Jak2/Stat3 in BPH development. Gut microbiota and Ghrelin might be pathogenic factors for BPH and could be used as a target for mediation.

Multicenter experience with photoselective vaporization of the prostate on men taking novel oral anticoagulants

Objective

Photoselective vaporization of the prostate (PVP) is a widely performed surgical procedure for benign prostatic obstruction. This approach has become particular favoured for men on anti-platelet and anticoagulation agents such as clopidogrel and warfarin but there is minimal published experience in the setting of novel oral anticoagulants (NOACs). This study was to examine the perioperative outcomes in men on NOACs undergoing PVP, with particular reference to perioperative morbidity.

Methods

A retrospective analysis of PVP datasets was undertaken from three centres in Sydney (Australia), Toulouse (France) and Boston (USA). Subjects who had been treated whilst on NOACs without discontinuation or bridging were identified. Perioperative outcomes and treatment parameters were examined and morbidity recorded according to Clavien-Dindo (CD) classification.

Results

There were a total of 20 subjects who had undergone PVP whilst NOACs had been continued during the perioperative period. The mean age was 77±6.5 years. The mean prostate volume, energy utilization and vaporisation time was 94±56 mL, 301±211 kJ, and 35±21 min respectively. The mean postoperative duration of catheterization and duration of hospitalization was 2.2±2.4 days and 2.4±2.4 days respectively. There was a single episode of urinary tract infection and four subjects required re-catheterisation for non-hematuric retentions.

Conclusions

This study supports the safety of men on NOACs undergoing PVP. Whilst this study represents the largest experience of PVP in these men, larger studies are necessary to confirm the safety of PVP in this group of men undergoing BPH-related surgery.

Patients with benign prostatic hyperplasia show shorter leukocyte telomere length but no association with telomerase gene polymorphisms in Han Chinese males

OBJECTIVE

Benign prostatic hyperplasia (BPH) is an age-related disease, occurring in >70% of men of age >60. Because telomeres and telomerase play a key role in aging and age-related diseases, and certain telomerase gene single nucleotide polymorphisms (SNPs) are shown to be associated with the susceptibility to age-related diseases, we wanted to determine the relationship between BPH and leukocyte telomere length (LTL) and telomere length-related single nucleotide polymorphisms (SNPs) of the telomerase holoenzyme genes.

METHODS

Peripheral blood was collected from both BPH patients and age-matched healthy male controls and genomic DNA was extracted. rs2736100 and rs2736098 at the TERT and rs12696304 at the TERC locus were analysed using pre-designed TaqMan SNP genotyping assay kits. LTL was determined using qPCR.

RESULTS

Patients with BPH had significantly shorter LTL (1.231 ± 0.532 vs 0.899 ± 0.322, P < 0.001). The genotyping results show similar frequencies in rs2736100, rs2736098 and rs12696304 between healthy and BPH individuals.

CONCLUSIONS

Shorter telomeres but not telomerase SNPs at the TERT and TERC loci, are associated with BPH. Short telomeres may promote senescence of a fraction of prostatic epithelial cells, while senescent cells in turn facilitate epithelial and stromal cell proliferation by the senescence-associated secretory phenotype mechanism, thereby eventually leading to BPH development.

Risk Factors for Prostate Volume Progression After Prostate-Transurethral Resection

Background

Many factors could contribute to the cases of residual benign prostate hypertrophy (BPH) volume after transurethral resection of the prostate (TURP), such as age, obesity, testosterone level, and inflammation. The goal of this study was to determine the risk of tumor necrosis factor-α (TNF-α), transforming growth factor-β (TGF-β) in prostate tissue, serum prostate-specific antigen (PSA), serum testosterone, and age in promoting prostate volume progression after TURP.

Patients and Methods

This was a prospective cohort study on 83 BPH patients who underwent TURP at five hospitals in Bali, Indonesia. Trans-rectal ultrasonography (TRUS) was carried out to examine the prostate’s size. Three years after, we redo the TRUS examination to collect the data of the latest prostate size. TNF-α, TGF-β, serum PSA, testosterone, and age were registered for analysis. We used Pearson’s and Spearman’s correlation tests and multivariate analytic linear regression test (coefficient β) by SPSS 13.0 software.

Results

Age, testosterone, PSA, TNF-α, TGF-β were positively correlated to prostate’s volume progression. The prostate volume was strongly correlated with age (r= 0.749, p <0.001), PSA level (r=0.896, p <0.001), testosterone level (r=0.818, p <0.001), and TGF-β (r=0.609, p <0.001). The TNF-α level has a weak correlation to prostate’s volume progression (r=0.392, p <0.001).

Conclusion

TNF-α, TGF-β, PSA, testosterone, and age were significant as the risk factors in promoting the prostate volume progression after TURP.

Therapeutic use of pulsed electromagnetic field therapy reduces prostate volume and lower urinary tract symptoms in benign prostatic hyperplasia

Background

Benign prostatic hyperplasia (BPH) etiology remains poorly understood, but chronic low‐grade inflammation plays a role. Pulsed electromagnetic field therapy (PEMF) (1‐50 Hz) is effective in reducing tissue inflammation.

Objectives

We designed a pilot study to evaluate the effects of PEMF on prostate volume (PV) in BPH.

Materials and Methods

This is a prospective interventional trial on 27 naive patients with BPH and lower urinary tract symptoms (LUTS). At baseline (V₀), all patients had blood tests, transrectal ultrasound, and questionnaires (IPSS, IIEF‐15) and received a perineal PEMF device (Magcell^®Microcirc, Physiomed Elektromedizin). PEMF was delivered on perineal area 5 minutes twice daily for 28 days, then (V₁) all baseline evaluations were repeated. Afterward, nine patients continued therapy for 3 more months (PT group) and 15 discontinued (FU group). A 4‐month evaluation (V₂) was performed in both groups.

Results

A reduction was observed both at V₁ and at V₂ in PV: PV_V0 44.5 mL (38.0;61.6) vs PV_V1 42.1 mL (33.7;61.5, P = .039) vs PV_V2 41.7mL (32.7;62.8, P = .045). IPSS was reduced both at V₁ and at V₂: IPSS_V0 11 (5.7;23.2) vs IPSS_V1 10 (6;16, P = .045) vs IPSS_V2 9 (6;14, P = .015). Baseline IPSS was related to IPSS reduction both at V₁ (r_s = 0.313;P = .003) and at V₂ (r_s = 0.664;P < .001). PV reduction in patients without metabolic syndrome (ΔPV_V1nMetS −4.7 mL, 95%CI −7.3;‐2.0) was greater than in affected patients (ΔPV_V1MetS 1.7 mL, 95%CI −2.69;6.1)(P = .017, Relative Risk_MetS = 6). No changes were found in gonadal hormones or sexual function.

Discussion

PEMF was able to reduce PV after 28 days of therapy. Symptoms improved in a short time, with high compliance and no effects on hormonal and sexual function or any side effects. Patients with moderate‐severe LUTS and without MetS seem to benefit more from this treatment.

Conclusion

PEMF reduces PV and improves LUTS in a relative short time, in BPH patients. These benefits seem greater in those patients with moderate‐severe LUTS but without MetS.

Mecanismos inflamatorios involucrados en la fisiopatología de la hiperplasia prostática benigna

La obstrucción del tracto de salida ha sido asociada con la hiperplasia prostática benigna (HPB), dado el crecimiento progresivo del adenoma, lo cual lleva a un incremento en la resistencia al flujo urinario, junto con un efecto deletéreo en la función renal. Se han descrito múltiples teorías asociadas con el desarrollo de la hiperplasia. Entre las cuales se encuentran: La edad, el incremento en la actividad simpática, alteraciones hormonales, el síndrome metabólico y la inflamación crónica. En los últimos años, el rol de la inflamación prostática local en el entendimiento de la patogénesis y progresión de la HPB ha cobrado relevancia. Esa hipótesis plantea que infiltrados inflamatorios conllevan a una lesión tisular, generando así un proceso crónico de cicatrización que condiciona el incremento en el tamaño prostático. El presente artículo se enfoca en describir los mecanismos inflamatorios involucrados en la fisiopatología de la hiperplasia prostática benigna.

Optimization of pharmacotherapy of patients with prostate adenoma with hormonal and metabolic disordes: correction of vitamin D deficiency with “Aquadetrim”

Introduction: Modern studies demonstrate an epidemiological and pathogenetic role of systemic hormonal and metabolic disorders in men with prostate adenoma (PA), so it is obvious that a pharmacotherapeutic correction of these disorders can increase the efficacy of the traditional therapy of the disease.

Aim of study: To investigate the frequency, relationships among themselves and with PA local parameters of key systemic hormonal and metabolic disorders (obesity, insulin resistance, testosterone deficiency, vitamin D deficiency) and to develop practical algorithms for optimizing diagnosis and management based on an integrative approach.

Material and Methods: The results of a comprehensive examination of 160 patients with PA (main group; average age 62.3 ± 4.2 years) and 30 healthy men without PA of the same age (control group), including: collection of anamnesis and complaints; questionnaires; physical, hormonal and sonographic studies, – are presented. Pharmacotherapeutic correction methods were tested in some patients of the main group. The data was processed using descriptive and comparative statistics.

Results and Discussion: In the patients with PA, a significantly higher frequency of concomitant systemic hormonal and metabolic disorders formed at a younger age was established, compared to the men without PA, and significantly worse local characteristics of PA compared to the patients with PA without such (p &lt; 0.05). Reliable connections of some studied systemic hormonal and metabolic disorders with one another and with local parameters of PA (p &lt; 0.05) were revealed. A more severe vitamin D deficiency in the patients with PA compared to the control group was revealed, and the safety and a significant positive effect of its drug compensation on the parameters of hormonal and metabolic status and PA in D-deficient men with PA were shown (p &lt; 0.05).

Conclusion: The results of the study confirm an important role of the studied systemic hormonal and metabolic disorders in the pathogenesis of PA and the need for their diagnosis and pharmacotherapeutic correction in all patients with PA on the basis of an integrative approach, according to the proposed algorithms.

Oxidised low-density lipoprotein, a possible distinguishing lipid profile biomolecule between prostate cancer and benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) and prostate cancer (PCa) share common conditions such as lower urinary tract symptoms (LUTS) and dyslipidaemia. Whether an extensive lipid profile analysis could discriminate between BPH and PCa was the objective. Thirty-six (36) BPH and twenty (20) PCa outpatients of a urology clinic plus forty (40) controls without LUTS, but normal PSA, were recruited. Body mass index (BMI), lipid profile (total cholesterol [CHOL], triglycerides [TG], high-density lipoprotein [HDL], very-low-density lipoprotein [VLDL], low-density lipoprotein [LDL] and Castelli's risk index I [CR I] [TC/HDL]), oxidised LDL, apolipoprotein E, ceramide and PSA were determined. Mean ages for BPH, PCa and control were 69 ± 13, 67 ± 10 and 53 ± 7 years respectively. Most parameters apart from BMI and HDL were significantly different compared to the control group. oxLDL for BPH versus control, PCa versus control and BPH versus PCa was significant (p < 0.001, p = 0.02 and p < 0.001 respectively). Ceramide showed significant group differences. Between BPH and PCa, total cholesterol, LDL and Apo E were significantly different (p = 0.00, p = 0.01 and p = 0.03 respectively). Apo E could potentially be a discriminating biomarker. Receiver operating characteristic curves for TPSA, Apo E and oxLDL demonstrated sensitivity of 69.44 and specificity of 88.24 for oxLDL, hence more discriminatory.

Preventing Lethal Prostate Cancer with Diet, Supplements, and Rx: Heart Healthy Continues to Be Prostate Healthy and "First Do No Harm" Part I

PURPOSE OF REVIEW

To discuss the overall and latest observations of the effect of diet, lifestyle, supplements, and some prescription heart healthy medications for prostate cancer prevention.

RECENT FINDINGS

The concept of maximizing heart health to prevent aggressive prostate cancer continues to be solidified with the addition of more prospective observational and randomized controlled trial data. Heart healthy is prostate healthy, but heart unhealthy is prostate unhealthy. The primary goal of reducing the risk of all-cause and cardiovascular disease (CVD) morbidity and mortality also allows for maximizing prostate cancer prevention. The obesity epidemic in children and adults along with recent diverse research has only strengthened the nexus between heart and prostate health. Greater dietary adherence toward a variety of healthy foods is associated with a graded improved probability of CVD and potentially aggressive cancer risk reduction. Preventing prostate cancer via dietary supplements should encourage a "first do no harm", or less is more approach until future evidence can reverse the concerning trend that more supplementation has resulted in either no impact or an increased risk of prostate cancer. Supplements to reduce side effects of some cancer treatments appear to have more encouraging data. Medications that improve heart health including statins, aspirin, and metformin (S.A.M.), and specific beta-blocker medications are primarily generic or low-cost and should continue to garner research interest. A watershed moment in medical education has arrived where the past perception of a diverse number of trees seemingly separated by vast distances, in reality, now appear to exist within the same forest.

Increased risk of atrial fibrillation in patients with benign prostatic hyperplasia: A population-based cohort study

OBJECTIVE

The objective was to compare the rate of onset of atrial fibrillation (AF) in patients with benign prostatic hyperplasia (BPH) as compared with controls.

METHODS

We performed a retrospective study on national health registry comparing the incidence of AF between a cohort of 15 670 BPH patients and a propensity-matched cohort of 15 670 control patients. Univariable and multivariable Cox proportional hazards models were performed to estimate the hazard ratios (HR) and 95% confidence intervals (CI) of incident AF associated with BPH. A subgroup analysis was performed to evaluate the risk of AF among BPH patients whether they received a BPH surgery or not as compared with those without BPH.

RESULTS

We found a 4.77 incidence rate per 1000 person-years in the BPH group, compared to 3.76 in the control group. After controlling for the confounders, a significant association between BPH and risk of incident AF was shown with an adjusted HR = 1.19, 95% CI = 1.11-1.28) and this association was attenuated once surgical intervention for BPH has been applied (adjusted HR = 0.86, 95% CI = 0.76-0.97).

CONCLUSIONS

This study supported the notion that BPH is associated with greater AF occurrence.

Diet-Induced Hyperinsulinemia as a Key Factor in the Etiology of Both Benign Prostatic Hyperplasia and Essential Hypertension?

Benign prostatic hyperplasia and hypertension are common age-related comorbidities. Although the etiology of benign prostatic hyperplasia (BPH) is still largely unresolved and poorly understood, a significant age-independent association was found between BPH and hypertension, indicating a common pathophysiological factor for both diseases. It has previously been suggested that the development of essential hypertension may be related to diet-induced hyperinsulinemia. This study follows the question, whether BPH may develop due to the same mechanism, thereby explaining the well-known comorbidity of these 2 disorders. The scientific evidence presented shows that BPH and hypertension share the same pathophysiological changes, with hyperinsulinemia as the driving force. It further shows that significant dietary changes during human history cause disruption of a finely tuned metabolic balance that has evolved over millions of years of evolution: high-insulinemic food, typical of current “Western” diets, has the potential to cause hyperinsulinemia and insulin resistance, as well as an abnormally increased activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system, alterations that play a pivotal role in the pathogenesis of BPH and hypertension.