Pygeum africanum for the treatment of patients with benign prostatic hyperplasia: a systematic review and quantitative meta-analysis

A UPLC- MS/MS Method to Quantify β-Sitosterol and Ferulic Acid of Pygeum Africanum Extract in Bulk and Pharmaceutical Preparation

This study uses a liquid chromatography-electrospray ionization-tandem mass spectrometry method to determine β-Sitosterol and Ferulic acid in Pygeum africanum extract. Chromatographic separation of the two analytes was performed on an ACQUITY UPLC H-Class system coupled with Xevo TQD mass spectrometer and HSS T3 C18 column (2.1 X 50 mm, 1.8 μm). Mobile phase A consisted of an aqueous solution of 0.1% formic acid (v/v), and mobile phase B was 0.1% formic acid (v/v) in methanol pumped through a gradient elution mode. Mass spectrometer parameters were optimized using an electrospray ionization source in the positive and negative ionization modes. The quantification of the two analytes was performed using multiple reaction monitoring transitions. The method was fully validated per (FDA) guidelines regarding linearity, accuracy, precision, carryover and selectivity. The proposed method was applied successfully to determine the two investigated compounds in commercially available pharmaceutical products.

The African cherry: A review of the botany, traditional uses, phytochemistry, and biological activities of Prunus africana (Hook.f.) Kalkman

ETHNOPHARMACOLOGICAL RELEVANCE

Prunus africana (Hook.f.) Kalkman (Rosaceae), commonly known as "Pygeum" or "African cherry", occurs in mainland montane forests scattered across sub-Saharan Africa, Madagascar, and some surrounding islands. Traditionally, decoctions of the stem-bark are taken orally for the treatment of a wide variety of conditions, such as benign prostatic hyperplasia (BPH), stomach ache, chest pain, malaria, heart conditions, and gonorrhoea, as well as urinary and kidney diseases. The timber is used to make axe handles and for other household needs. The dense wood is also sawn for timber.

AIM

The fragmented information available on the ethnobotany, phytochemistry, and biological activities of the medicinally important P. africana was collated, organised, and analysed in this review, to highlight knowledge voids that can be addressed through future research.

MATERIALS AND METHODS

A bibliometric analysis of research output on P. africana was conducted on literature retrieved, using the Scopus® database. The trend in the publications over time was assessed and a network analysis of collaborations between countries and authors was carried out. Furthermore, a detailed review of the literature over the period 1971 to 2021, acquired through Scopus, ScienceDirect, SciFinder, Pubmed, Scirp, DOAJ and Google Scholar, was conducted. All relevant abstracts, full-text articles and various book chapters on the botanical and ethnopharmacological aspects of P. africana, written in English and German, were consulted.

RESULTS

A total of 455 documents published from 1971 to 2021, were retrieved using the Scopus search. Analysis of the data showed that the majority of these documents were original research articles, followed by reviews and lastly a miscellaneous group comprising conference papers, book chapters, short surveys, editorials and letters. Data were analysed for annual output and areas of intense research focus, and countries with high research output, productive institutions and authors, and collaborative networks were identified. Prunus africana is reported to exhibit anti-inflammatory, analgesic, antimicrobial, anti-oxidant, antiviral, antimutagenic, anti-asthmatic, anti-androgenic, antiproliferative and apoptotic activities amongst others. Phytosterols and other secondary metabolites such as phenols, triterpenes, fatty acids, and linear alcohols have been the focus of phytochemical investigations. The biological activity has largely been ascribed to the phytosterols (mainly 3-β-sitosterol, 3-β-sitostenone, and 3-β-sitosterol-glucoside), which inhibit the production of prostaglandins in the prostate, thereby suppressing the inflammatory symptoms associated with BPH and chronic prostatitis.

CONCLUSIONS

Many of the ethnobotanical assertions for the biological activity of P. africana have been confirmed through in vitro and in vivo studies. However, a disparity exists between the biological activity of the whole extract and that of single compounds isolated from the extract, which were reported to be less effective. This finding suggests that a different approach to biological activity studies should be encouraged that takes all secondary metabolites present into consideration. A robust technique, such as multivariate biochemometric data analysis, which allows for a holistic intervention to study the biological activity of a species is suggested. Furthermore, there is a need to develop rapid and efficient quality control methods for both raw materials and products to replace the time-consuming and laborious methods currently in use.

Treatment of Benign Prostatic Hyperplasia by Natural Drugs

Benign prostatic hyperplasia (BPH) is one of the most common urinary diseases affecting men, generally after the age of 50. The prevalence of this multifactorial disease increases with age. With aging, the plasma level of testosterone decreases, as well as the testosterone/estrogen ratio, resulting in increased estrogen activity, which may facilitate the hyperplasia of the prostate cells. Another theory focuses on dihydrotestosterone (DHT) and the activity of the enzyme 5α-reductase, which converts testosterone to DHT. In older men, the activity of this enzyme increases, leading to a decreased testosterone/DHT ratio. DHT may promote prostate cell growth, resulting in hyperplasia. Some medicinal plants and their compounds act by modulating this enzyme, and have the above-mentioned targets. This review focuses on herbal drugs that are most widely used in the treatment of BPH, including pumpkin seed, willow herb, tomato, maritime pine bark, Pygeum africanum bark, rye pollen, saw palmetto fruit, and nettle root, highlighting the latest results of preclinical and clinical studies, as well as safety issues. In addition, the pharmaceutical care and other therapeutic options of BPH, including pharmacotherapy and surgical options, are discussed, summarizing and comparing the advantages and disadvantages of each therapy.

Self-Assessed Benefits of a Prostate Health Formulation on Nocturia in Healthy Males With Mild Lower Urinary Tract Symptoms: An Open Label Study

Background

Nocturia is the most bothersome lower urinary tract symptoms (LUTS) and can significantly reduce men's quality of life. It is often poorly managed with conventional treatments.

Objective

The purpose of this study was to evaluate the self-assessed benefits of a prostate health dietary combination formulation on mild LUTS, especially nocturia in healthy males.

Methods

In an open label clinical study, thirty healthy male subjects with mild LUTS took one daily capsule of the product for 60 days. The primary outcome was self-assessed severity of LUTS using the International Prostate Symptoms Score (IPSS) questionnaire at Day 1 (baseline), Day 30 and Day 60. Safety and compliance were also evaluated.

Results

At Day 60, IPSS significantly decreased from baseline by 16.3% (3.6 ± 2.1 vs. 4.3 ± 1.5, p < 0.05). Although the reduction in IPSS did not reach statistical significance at Day 30, it was mostly driven by a 30.7% decrease (p < 0.05) in the nocturia sub-score compared with baseline. While 37% of subjects reported at baseline waking up 2‒3 times/night to void, none did so after taking the study product for 60 days. Compliance was very high throughout the study. No adverse events related to the study product were reported.

Conclusions

The study product might be a safe alternative for individuals willing to explore a non-conventional approach to manage their nocturia. A larger randomized placebo-controlled clinical trial is warranted to confirm these results. Clinical trial registry: Clinical Trials.gov. Registration number (September 1st, 2016): NCT02886832.

Review of the experience and evidence of Pygeum africanum in urological practice

CONTEXT

Pygeum africanum(P. africanum) is still being employed in urology practice for the treatment of lower urinary tract symptoms secondary to benign prostate hyperplasia.

EVIDENCE ACQUISITION

A non-exhaustive review has been carried out about P. africanum, its mechanisms of action "in vitro" as well as "in vivo", clinical trials and routine clinical practice.

EVIDENCE SYNTHESIS

The conclusions of the review and the reflections of the authors on the use of P. africanum are described.

CONCLUSIONS

Although with an evidence level IV (based on expert opinion) the use of P. africanum seems to be an option in the urological therapeutic arsenal.

Effect of Indigenous and Introduced Arbuscular Mycorrhizal Fungi on Growth and Phytochemical Content of Vegetatively Propagated Prunus Africana (Hook. f.) Kalkman Provenances

Prunus africana bark contains phytochemical compounds used in the treatment of benign prostatic hyperplasia and prostate cancer. It has been shown that this plant establishes association with arbuscular mycorrhizal fungi (AMF). AMF are involved in nutrient uptake, which may also affect plant growth and secondary metabolites composition. However, there is no information regarding the role of AMF in the growth and phytochemical content of P. africana. A pot experiment was carried out to assess the response of 8 months old vegetatively propagated P. africana seedlings inoculated with indigenous AMF collected from Mount Cameroon (MC) and Mount Manengumba (MM) in Cameroon, Malava near Kakamega (MK) and Chuka Tharaka-Nithi (CT) in Kenya. Mycorrhizal (frequency, abundance and intensity), growth (height, shoot weight, total weight, number of leaf, leaf surface) and phytochemical (total phenol, tannin and flavonoids) parameters were measured three months after growth of seedlings from two provenances (Muguga and Chuka) with the following inoculation treatments: MK, CT, MC, MM, non-sterilized soil (NS) and sterilized sand as non-inoculated control. Results showed that seedling heights were significantly increased by inoculation and associated with high root colonization (>80%) compared to non-inoculated seedlings. We also found that AMF promoted leaf formation, whereas inoculation did not have any effect on the seedling total weight. AMF inoculum from MM had a higher tannin content, while no significant difference was observed on the total phenol and flavonoid contents due to AMF inoculation. Pearson's correlation was positive between mycorrhizal parameters and the growth parameters, and negative with phytochemical parameters. This study is the first report on the effect of AMF on the growth and phytochemical in P. africana. Further investigations are necessary to determine the effect of single AMF strains to provide better understanding of the role of AMF on the growth performance and physiology of this important medicinal plant species.

African Herbal Remedies with Antioxidant Activity: A Potential Resource Base for Wound Treatment

The use of traditional herbal remedies as alternative medicine plays an important role in Africa since it forms part of primary health care for treatment of various medical conditions, including wounds. Although physiological levels of free radicals are essential to the healing process, they are known to partly contribute to wound chronicity when in excess. Consequently, antioxidant therapy has been shown to facilitate healing of such wounds. Also, a growing body of evidence suggests that, at least, part of the therapeutic value of herbals may be explained by their antioxidant activity. This paper reviews African herbal remedies with antioxidant activity with the aim of indicating potential resources for wound treatment. Firstly, herbals with identified antioxidant compounds and, secondly, herbals with proven antioxidant activity, but where the compound(s) responsible for the activity has not yet been identified, are listed. In the latter case it has been attempted to ascribe the activity to a compound known to be present in the plant family and/or species, where related activity has previously been documented for another genus of the species. Also, the tests employed to assess antioxidant activity and the potential caveats thereof during assessment are briefly commented on.

Herbal Supplements for Prostate Enlargement: Current State of the Evidence

OBJECTIVE

To provide a comprehensive review of the current state of herbal supplement market for lower urinary tract symptoms (LUTS) and correlate the ingredients of each product with available scientific evidence.

MATERIALS AND METHODS

Twenty-seven products from Amazon.com that were advertised as herbal supplements for LUTS and had listed their active ingredients were selected. Active ingredients were reviewed on Google Scholar. Product price, warranty, and consumer review information were also collected.

RESULTS

A total of 58 unique active ingredients were identified. The mean number of ingredients was 8.26 (standard deviation 5.25). Whereas 17 (63%) products had an ingredient with a systematic review to support their use, 20 (74%) had an ingredient with conflicting evidence based on systematic reviews. Out of the supplements that contained ingredients supported by literature, all (100%) products simultaneously had other ingredients with no, conflicting, or refuting evidence. There was no (0%) product that contained only scientifically proven ingredients. There is no scientific study to evaluate these supplements as a whole.

CONCLUSION

Despite the widespread use of herbal supplements for LUTS, there is scant scientific evidence to support their safety and efficacy. Lack of adequate regulation and government support for research and development are some of the factors that disincentivize researchers to study safety and efficacy of these products. We encourage physicians to warn their patients on the lack of adequate evidence to support the safety and efficacy of many of these supplements.

A pilot study of clinical results of Odyliresin (Iresine celosia) in symptomatic benign prostatic hyperplasia

Aim:

The aim of this pilot clinical trial was to determine if Odyliresin ( Iresine celosia), a cytochrome-flavoprotein with a powerful anti-oxidant action on cells, has a therapeutic effect on benign prostatic hyperplasia-related lower urinary tract symptoms, reducing symptoms and prostate volume, improving the patient’s quality of life and eventually limiting the number of patients who require surgery or endoscopy after medical treatment.

Methods:

Thirty patients with benign prostatic hyperplasia-related lower urinary tract symptoms were recruited and followed up. Primary outcomes were assessed using International Prostate Symptom Score symptom questionnaires, quality of life score, examination, prostate-specific antigen, transrectal ultrasound, uroflowmetry with post-void residual volume. Once recruited, patients were assigned for treatment: alpha-antagonist (alfuzosin 10 mg)+Odyliresin ( Iresine celosia) 2 ml, 20 drops once daily.

Results:

The results for quantitative variables were expressed as mean values and standard deviation as they were all normally distributed (Shapiro–Wilk test). The study included 30 patients with an average age of 68 years (range 56–80 years). The statistical analysis of data reports significant improvement of mean values of maximum urinary flow rate (+1.2, p=0.050), average flow rate (+0.47, p>0.002), International Prostate Symptom Score (–4.8, p=0.000), quality of life (–1.4, p=0.000), total prostatic volume (–1.7, p=0.000), prostatic adenoma (–6.9, p=0.000) and post-void residual volume (–17.8, p>0.004) between baseline and 12 months after treatment. No patient had acute urinary retention during treatment or need for benign prostatic hyperplasia-related surgery at the end of the 12-month treatment.

Conclusions:

All patients with benign prostatic hyperplasia-related lower urinary tract symptoms received both alphalitic and Odyliresin treatment. Clinical parameters and uroflowmetry parameters significantly improved, adenoma volume and post-void residual volume were significantly reduced at 12 months. This is the first clinical experience with Iresine celosia, a phytotherapeutic agent with no scientifically proven clinical efficacy so far in benign prostatic hyperplasia.

Benign prostatic hyperplasia

Lower urinary tract symptoms (LUTS) are common and can affect up to 30% of men over the age of 65 years. The term LUTS encompasses storage, voiding and post-micturition symptoms; all of which can produce a significant impact on quality of life. There are many causes of LUTS. In addition to pathology within the urinary tract, LUTS can also be caused by medication, diabetes, heart failure, obstructive sleep apnoea and high levels of fluid intake. A common urological cause for symptoms is benign prostatic hyperplasia (BPH); a benign enlargement of the prostate gland that affects 30% of men between 50 and 60 years in age and up to 90% of men over the age of 85 years. This article aims to assist GPs to identify and understand the patient presenting with prostatic symptoms, and effectively manage BPH in a primary care setting.

Prunus africana (Hook.f.) Kalkman: the overexploitation of a medicinal plant species and its legal context

The linkage between herbal medicines and the sustainability of medical plants from which they are manufactured is increasingly being understood and receiving attention through international accords and trade labeling systems. However, little attention is paid to the fair trade aspects of this sector, including the issue of benefit-sharing agreements with traditional societies whose knowledge and resources are being exploited for commercial herbal medicine development and production. This article examines the case of Prunus africana (Hook.f.) Kalkman, from equatorial Africa. While the conservation and cultivation dimension of the trade in P. africana has been much discussed in literature, no research appears to have focused on the traditional resource rights and related ethical dimensions of this trade in traditional medicine of Africa. Serving as a cautionary tale for the unbridled exploitation of medicinal plants, the history of P. africana extraction is considered here in the context of relevant treaties and agreements existing today. These include the Nagoya Protocol, a supplementary agreement to the Convention on Biological Diversity, the Trade-Related Aspects of Intellectual Property Rights agreement from the World Trade Organization, and two African regional frameworks: the Swakopmund Protocol and the Organisation Africaine de la Propriété Intellectuelle Initiative. In the context of strengthening medicinal plant research in Africa, a novel international capacity-building project on traditional medicines for better public health in Africa will be discussed, illustrating how access and benefit sharing principles might be incorporated in future projects on traditional medicines.

[Phytotherapy in urology. Current scientific evidence of its application in benign prostatic hyperplasia and prostate adenocarcinoma]

OBJECTIVE

To evaluate the usefulness of phytotherapy in the treatment of the benign prostatic hyperplasia (BPH) and prostatic adenocarcinoma (ADCP).

ACQUISITION OF EVIDENCE

Systematic review of the evidence published until January 2011 using the following scientific terms: phytotherapy, benign prostate hyperplasia, prostatic adenocarcinoma, prostate cancer and the scientific names of compounds following the rules of the International Code of Botanical Nomenclature. The databases used were Medline and The Cochrane Library. We included articles published until January 2011 written in English and Spanish. We included studies in vitro/in vivo on animal models or human beings. Exclusion criteria were literature not in English and Spanish or articles with serious methodological flaws.

SYNTHESIS OF THE EVIDENCE

We included 65 articles of which 40 met the inclusion criteria. BPH: the most studied products are serenoa repens and pygeum africanum. There are many studies in favour of the use of phytotherapy but its conclusions are inconsistent due to the small number of patients, the lack of control with placebo or short follow-up. However the use of these products is common in our environment. ADCP: there is no evidence to recommend phytotherapy in the treatment of the ADCP. There are works on prevention but only at experimental level so there is no evidence for its recommendation.

CONCLUSIONS

The scientific evidence on the use of phytotherapy in prostatic pathology is conclusive not recommend ing the use of it for BPH or the ADCP.

Bioactive constituents in Prunus africana: geographical variation throughout Africa and associations with environmental and genetic parameters

Prunus africana--an evergreen tree found in Afromontane forests--is used in traditional medicine to cure benign prostate hyperplasia. Different bioactive constituents derived from bark extracts from 20 tree populations sampled throughout the species' natural range in Africa were studied by means of GC-MSD. The average concentration [mg/kgw/w] in increasing order was: lauric acid (18), myristic acid (22), n-docosanol (25), ferulic acid (49), β-sitostenone (198), β-sitosterol (490), and ursolic acid (743). The concentrations of many bark constituents were significantly correlated and concentration of n-docosanol was highly significantly correlated with all other analytes. Estimates of variance components revealed the highest variation among populations for ursolic acid (66%) and the lowest for β-sitosterol (20%). In general, environmental parameters recorded (temperature, precipitation, altitude) for the samples sites were not correlated with the concentration of most constituents; however, concentration of ferulic acid was significantly correlated with annual precipitation. Because the concentration of compounds in bark extracts may be affected by tree size, the diameter of sampled plants at 1.3m tree height (as proxy of age) was recorded. The only relationship with tree diameter was a negative correlation with ursolic acid. Under the assumption that genetically less variable populations have less variable concentrations of bark compounds, correlations between variation parameters of the concentration and the respective genetic composition based on chloroplast and nuclear DNA markers were assessed. Only variation of β-sitosterol concentration was significantly correlated with haplotypic diversity. The fixation index (F(IS)) was positively correlated with the variation in concentration of ferulic acid. Principal Components Analysis (PCA) indicated a weak geographic pattern. Mantel tests, however, revealed associations between the geographic patterns of bioactive constituents and the phylogenetic relationship among the populations sampled. This suggests an independent evolution of bark metabolism within different phylogeographical lineages, and the molecular phylogeographic pattern is partly reflected in the variation in concentration of bark constituents. The results have important implications for the design of strategies for the sustainable use and conservation of this important African tree species.

Phytotherapy: emerging therapeutic option in urologic disease

Phytotherapy belongs to the area of complementary and alternative medicine (CAM) and the definition of phytotherapy is the use of plants or plant extracts for medicinal uses. Interest in phytotherapy is growing in both Asian and western countries for its use in the prevention and management of disease, improvement of general health and anti-aging. And also, there are several studies about the efficacy of phytotherapy in urologic diseases like benign prostatic hyperplasia (BPH), erectile dysfunction (ED), late-onset hypogonadism (LOH) and infertility in males. Phytotherapy for BPH including saw palmetto, pygeum, and nettles, is under vigorous research for the therapeutic effect. No solid evidence showing better effective treatment modality for ED than placebo has been found yet for phytotherapy. Recently, a potent NO donor, L-arginine is under research with promising results. Phytotherapy is used by a number of patients with urological disease, and urologists need to have accurate knowledge about phytotherapy as well as keep a cautious approach. The possible effects and side effects should be defined and related to urologic patients by urologists.

Chemical constituents, anti-inflammatory and antioxidant activities of bark extracts from Prunus tucumanensis Lillo

The anti-inflammatory, antioxidant, antimicrobial and cytotoxic activities of the hexane (HE), chloroform (CE) and methanol (ME) extracts obtained from the bark of Prunus tucumanensis Lillo were investigated. Both ME and CE extracts displayed a significant in vitro anti-inflammatory activity similar to dexamethasone and to a commercial formulation (Pygeum) used for the treatment of benign prostatic hyperplasia (BPH). ME exhibited powerful antioxidant (67.6% relative to BHT) and free radical scavenging (RC50 = 5 ppm) activities, antimicrobial activities against Staphylococcus aureus and Mycobacterium smegmatis and did not show any cytotoxic effect on human-derived macrophage cells. Chemical analyses showed that (2 R,3 R)-3,5,7,3',5'-pentahydroxyflavan, β-sitosterol and β-sitosterol-3-O-β-D-glucopyranoside (daucosterol) are relevant components of ME.

Biological effect of human serum collected before and after oral intake of Pygeum africanum on various benign prostate cell cultures

Pygeum africanum (Tadenan) is a popular phytotherapeutic agent used in the treatment of symptomatic benign prostatic hyperplasia. The active compounds of the drug have not been identified, and determining the plasma concentration of the drug is, therefore, not possible. Because there are conflicting results on the efficacy of this drug, we aimed to investigate its effect on prostate cell growth in vitro using human serum collected before and after Pygeum africanum intake. We used primary and organotypic cultures of human prostatic stromal myofibroblast cell line WPMY and prostatic epithelial cell line PNT2. We also used fresh benign prostatic tissue. The serum of a treated man induced decreases in the proliferation of primary cells, organotypic cells and WPMY cells but not PNT2 cells. We also analysed the effect of treated serum on the gene expression profile of WPMY cells. The transcriptome analysis revealed an upregulation of genes involved in multiple tumour suppression pathways and a downregulation of genes involved in inflammation and oxidative-stress pathways. The oral intake of Pygeum africanum resulted in serum levels of active substances that were sufficient to inhibit the proliferation of cultured myofibroblasts prostatic cells. This inhibition was associated with changes in the transcriptome.

Outcomes and quality of life issues in the pharmacological management of benign prostatic hyperplasia (BPH)

BACKGROUND

Benign prostatic hyperplasia (BPH) is a common disease of the aging male population. BPH treatment includes a variety of pharmacological and surgical interventions. The goal of this paper is to review the natural history of BPH, outcomes of pharmacological management, effects on quality of life (QoL), future pharmacotherapies, and associated patient-focused perspectives.

MATERIALS AND METHODS

Medline searches for the keywords benign prostatic hyperplasia, BPH, alpha blockers, 5 alpha-reductase, and quality of life were performed. Relevant literature was reviewed and analyzed.

RESULTS

Alpha blockers, 5 alpha-reductase inhibitors, and phytotherapy are the three categories of pharmaceutical interventions currently available for BPH. Various clinical trials have shown that alpha blockers and 5 alpha-reductase inhibitors are safe, efficacious, and improve QoL in patients with BPH. The evidence for phytotherapeutics is not as convincing. The current armamentarium of pharmaceutical interventions are encompassed in these three classes of medications. New pharmacotherapies based on novel mechanisms are on the horizon.

CONCLUSION

There are a variety of safe and efficacious medical therapies available for the management of BPH and it is important for the practicing physician to have an understanding of these pharmacotherapies and their potential impact on the patient. There is not enough evidence to make a recommendation regarding phytotherapy use. New classes of drugs for BPH will likely find their way into routine use.

The natural compounds atraric acid and N-butylbenzene-sulfonamide as antagonists of the human androgen receptor and inhibitors of prostate cancer cell growth

Extracts from the plant Pygeum africanum are widely used in the therapy of benign prostate hyperplasia (BPH) and in combinational therapy for prostate cancer, the second leading cause of cancer death and the mostly diagnosed form of cancer in men. The androgen receptor (AR) plays a crucial role in the development of the prostate as well as in prostate diseases. Even though the extracts from P. africanum are considered as beneficial for prostate diseases in clinical trials, and some active compounds for treatment of BPH could be identified, compounds responsible for AR inhibition and the molecular mechanism for inhibition of prostatitis need to be identified. Recently, atraric acid and N-butylbenzene-sulfonamide were isolated from a selective dichlormethane extract of P. africanum as two novel AR antagonistic compounds. The molecular mechanisms of AR inhibition were analyzed and are summarized here. Both compounds are the first known natural, complete and specific AR antagonist.

Antiproliferative and apoptotic effects of the herbal agent Pygeum africanum on cultured prostate stromal cells from patients with benign prostatic hyperplasia (BPH)

BACKGROUND

Previous reports show that the herbal agent Pygeum africanum (PA) used to treat benign prostatic hyperplasia (BPH) inhibits proliferation of prostate stromal cells from BPH tissues. To determine underlying mechanisms, we compared proliferative and apoptotic responses to PA between BPH and non-BPH prostate stromal cells with a focus on the specific reaction displayed by stromal cell subsets. An interaction of PA with growth factors and hormones was also investigated.

METHODS

Primary prostate stromal cells from BPH/LUTS patients undergoing open prostatectomy (n = 3) and patients without benign prostatic hyperplasia (BPH) undergoing cystectomy (n = 3) were treated with PA. Cells were characterized by immunofluorescence. Sensitivity to PA was determined using proliferation assays. Apoptosis, transforming growth factor B1 (TGFB1), fibroblast growth factor 2 (FGF2), vimentin, alpha smooth muscle actin (alphaSMA), and smoothelin expression were examined after PA treatment. Cell immunophenotype and proliferation were tested after incubating cells with PA plus either FGF2, TGFB1, vascular endothelial growth factor (VEGF), dihydrotestosterone (DHT) or 17beta-estradiol (E2).

RESULTS

Antiproliferative potency and apoptosis induced by PA on stromal cells were increased in BPH versus non-BPH cells. Apoptosis targeted alphaSMA+ cells, more abundant in BPH cells. Downregulation of TGFB1 expression was induced by PA. FGF2 increased cells sensitivity to PA. Incubation with other mitogenic factors like VEGF, DHT, and E2 decreased sensitivity to PA. Both TGFB1 and E2 blocked the antiproliferative activity of PA.

CONCLUSIONS

Results suggest that PA is antiproliferative and apoptotic on proliferative prostate fibroblasts and myofibroblasts but not on smooth muscle cells. Mechanisms of action include TGFB1 downregulation and inhibition of FGF2 specific signaling.

Redesigning a large-scale clinical trial in response to negative external trial results: the CAMUS study of phytotherapy for benign prostatic hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH), a common condition among older men, confers its morbidity through potentially bothersome lower urinary tract symptoms. Treatments for BPH include drugs such as alpha-adrenergic receptor blockers and 5-alpha reductase inhibitors, minimally invasive therapies that use heat to damage or destroy prostate tissue, and surgery including transurethral resection of the prostate. Complementary and alternative medicines are gaining popularity in the US. Two phytotherapies commonly used for BPH are extracts of the fruit of Serenoa repens, the Saw palmetto dwarf palm that grows in the Southeastern US, and extracts of the bark of Pygeum africanum, the African plum tree.

PURPOSE

The objective of the Complementary and Alternative Medicines for Urological Symptoms (CAMUS) clinical trial is to determine if phytotherapy is superior to placebo in the treatment of BPH.

METHODS

CAMUS was originally designed as a 3300-participant, four-arm trial of S. repens, P. africanum, an alpha-adrenergic blocking drug, and placebo with time to clinical progression of BPH, a measure of long-term efficacy, as the primary endpoint. Before enrollment started, a randomized, double-blind, placebo-controlled, single institution clinical trial showed that S. repens at the usual dose did not demonstrate any benefit over placebo with respect to symptom relief at 1 year. Consequently, the focus of CAMUS shifted from evaluating long-term efficacy to determining if any short-term (6-18 months) symptom relief could be achieved with increasing doses of S. repens, the phytotherapy most commonly used in the US for BPH.

RESULTS

Results are anticipated in 2011.

CONCLUSIONS

Trial design occurs in an environment of continually evolving information. In this case, emerging results from another trial suggested that a study of long-term efficacy was premature, and that an effective dose and preparation of S. repens had to be established before proceeding to a long-term clinical trial.

Dietary patterns, supplement use, and the risk of benign prostatic hyperplasia

It has long been appreciated that a healthy lifestyle plays a critical role in cardiovascular health. It is now apparent that the same is true in the development of benign prostatic hyperplasia (BPH). Prospective cohort data originating from recently published randomized trials on the medical treatment of BPH and prevention of prostate cancer have been invaluable. A growing body of evidence suggests that exercise and the intake of specific macronutrients and micronutrients through regular diet play a beneficial role. Most strikingly, the magnitude of these effects is similar to medical therapies using alpha-blockers and 5-alpha-reductase inhibitors. The use of supplements for prostate disease is a multibillion dollar business in the United States, and supplements are more commonly prescribed than medical therapy in many countries. In contrast to consumption of micronutrients through regular diet, supplemental intake of micronutrients and phytotherapies currently lack evidence to support their efficacy.

Benign prostatic hyperplasia and lower urinary tract symptoms in African Americans and Latinos: treatment in the context of common comorbidities

Benign prostatic hyperplasia (BPH), with accompanying lower urinary tract symptoms (LUTS), is a common age-related condition associated with a variety of cardiovascular, metabolic, and sexual comorbidities. While there is debate, in the United States race and ethnicity, particularly among Latinos and African American men, may confer an elevated risk for BPH and LUTS. Hypertension and deficits in sexual health are more common among African American men, while both Latino and African American men experience more metabolic-related disorders, including diabetes mellitus, insulin resistance, and end-stage renal disease. Although socioeconomic factors may play a significant role in these disparities, pathological and genetic variations between patients of different races and ethnicities are additional factors in the development of BPH. The proliferation of available treatments for BPH demands greater discernment in treatment selection, and comorbidities represent a central criterion upon which choice of appropriate BPH therapy should be based. This article reviews common comorbidities in minority populations, describes challenges to BPH management, and discusses medical, surgical, and phytotherapeutic treatment options.

The Long-Term Outcome of Medical Therapy for BPH

OBJECTIVES

The lack of cure with medical therapy implies life-long treatment emphasising the need for a thorough understanding of the long-term outcome. We review the natural history, markers for progression, placebo effect, efficacy, pharmacoeconomic aspects, and preventive measures.

METHODS

Literature review with particular reference to long-term controlled studies using plant extracts, alpha1-blockers, 5alpha-reductase inhibitors (5-ARIs), and combination therapy.

RESULTS

There is a long-lasting (>or=12 mo) placebo response of symptoms (20% decrease) and maximum flow rate (10% rise). The five long-term controlled trials of plant extracts are inconclusive and therefore their role in contemporary medical management is still controversial. The alpha1-blockers provide fast amelioration of symptoms yet have no relevant impact on the risk of acute urinary retention or surgery. Combination therapy should be reserved for moderately or severely symptomatic patients with a high risk of progression; in the majority of patients the alpha1-blocker can be safely stopped after 6-12 mo. The preventive use of 5-ARIs in men with no or mild symptoms at risk of progression is scientifically sound yet not generally accepted mainly for economic reasons.

CONCLUSIONS

A sharp contrast exists between the duration of the longest controlled trial (4.5 yr) and the situation in real life with treatment periods up to one or two decades of life. Real-life and registry data will be the only source of this important information in the future.

Phytosterol Pygeum africanum regulates prostate cancer in vitro and in vivo

BACKGROUND

Prostate cancer is an important public health problem. It is an excellent candidate disease for chemoprevention because prostate cancer is typically slow growing and is usually diagnosed in elderly males. Pygeum africanum (Prunus africana or Rosaceae) is an African prune (plum) tree found in tropical Africa. An extract from the bark of Pygeum africanum has been used in Europe as a prevention and treatment of prostate disorders including benign prostatic hypertrophy (BPH). More recently in the USA, the phytotherapeutic preparations of Pygeum africanum and Saw palmetto have been marketed for prostate health including prostate cancer prevention and treatment.

METHODS

The anti-cancer potential of Pygeum africanum has been tested both in vitro (PC-3 and LNCaP cells) and in vivo (TRAMP mouse model).

RESULTS

In tissue culture, ethanolic extracts (30%) of Pygeum africanum inhibited the growth of PC-3 and LNCaP cells; induced apoptosis and altered cell kinetics; down regulated ERalpha and PKC-alpha protein, and demonstrated good binding ability to both mouse uterine estrogen receptors and LNCaP human androgen receptors. TRAMP mice fed Pygeum africanum showed a significant reduction (P = 0.034) in prostate cancer incidence (35%) compared to casein fed mice (62.5%).

CONCLUSION

Pygeum africanum, which is widely used in Europe and USA for treatment of BPH, has a significant role in regulation of prostate cancer both in vitro and in vivo and therefore may be a useful supplement for people at high risk for developing prostate cancer.

Pygeum africanum extract inhibits proliferation of human cultured prostatic fibroblasts and myofibroblasts

OBJECTIVE

To investigate the effect of Pygeum africanum (PA) extract on the proliferation of cultured human prostatic myofibroblasts and fibroblasts; this extract is used for treating urinary disorders associated with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Primary cultures of prostatic stromal cells were obtained from histologically confirmed human BPH by enzymatic digestion. Cell proliferation was measured by 5-bromo2'-deoxy-uridine (BrdU) incorporation assays, and cytotoxicity by luminescent quantification of adenylate kinase activity.

RESULTS

Cultured cells were labelled by an anti-vimentin antibody, and most of them by an alpha-smooth-muscle-actin antibody, revealing the presence of fibroblasts and myofibroblasts. BrdU incorporation tests showed that proliferation of cultured human stromal cells, stimulated by fetal calf serum, by basic fibroblast growth factor and by epidermal growth factor, was dose-dependently inhibited by PA extract (5-100 microg/mL). Except at 100 microg/mL, no acute cytotoxicity of the extract was detected after 24 h of culture. Similarly, the extract dose-dependently inhibited the proliferation of Madin-Darby canine kidney epithelial cells, but to a lesser extent; whatever the dose of extract, no acute toxicity was evident on this cell line.

CONCLUSION

PA extract inhibits the proliferation of cultured human prostatic myofibroblasts and fibroblasts. We propose that cultured human prostatic cells offer a reliable model for preclinical screening of therapeutic agents, and to study the mechanisms underlying the inhibition of proliferation.

Managing patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

Many men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia can be managed safely and effectively by primary care providers. After a basic evaluation to exclude other diseases that may cause lower urinary tract symptoms, quantifying the degree of symptoms and bother, and perhaps making an assessment of prostate size, the primary care provider can determine which men require immediate evaluation by a urologist and which men may choose among various treatment options, including watchful waiting and various single agent or combination medication strategies. Recent information about risk factors for disease progression has also helped to inform patient decisions on which treatment option is best for the individual patient. The purpose of this review is to provide primary care providers with an approach to the management of men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

Effect of ethanol on protection of urinary bladder function by grape suspensions

OBJECTIVES

To compare the protective effects of grape suspensions prepared in an aqueous vehicle with grape suspensions prepared in an 8% ethanol vehicle in rabbits subjected to partial outlet obstruction. The hypothesis was that the presence of ethanol would increase the absorption of the beneficial components of the grape suspensions and thus increase their protective ability. The use of ethanol in these studies was not to simulate wine.

METHODS

A total of 48 New Zealand white rabbits were separated into eight groups of 6 rabbits each. Groups 1 and 3 were pretreated by oral gavage for 3 weeks with grape suspensions in water; groups 2 and 4 were treated with vehicle. Groups 5 and 7 were treated with the grape suspensions in 8% ethanol, and groups 6 and 8 were treated with ethanol vehicle. Groups 1, 2, 5, and 6 underwent sham operations, and groups 3, 4, 7, and 8 underwent partial outlet obstruction. Three weeks after surgery, the rabbits were evaluated.

RESULTS

The bladder weight had significantly increased in all obstructed groups. The contractile responses to field stimulation and carbachol were reduced in all obstructed groups, although the responses in both grape-treated groups were greater than both vehicle-treated groups. The contractile responses to potassium chloride were significantly reduced by partial outlet obstruction in both obstructed groups similarly.

CONCLUSIONS

Both grape suspensions provided protection against obstructive-induced bladder dysfunction. The ethanol preparation of the grape suspension was not better than the aqueous preparation.

Phytotherapie bei BPS

For decades, plant extracts have been amongst to the most popular drugs for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH)/benign prostatic enlargement (BPE). Only a few of the many published studies meet the criteria of the WHO-BPH consensus conference. The few placebo-controlled, long-term (>/=6 months) studies suggest a positive effect of some extracts (saw palmetto, beta-sitosterol, urtica, rye-grass, saw palmetto/urtica combination) on LUTS; an effect on uroflow, post-void residual volume, prostate volume and PSA was not consistently demonstrable. Randomised trials against an active comparator (alpha1-blocker, 5alpha-reductase inhibitors) are difficult to interpret. Due to the lack of prospective studies, several meta-analyses have been published that can not, however, replace prospective studies. None of the BPH-guidelines currently recommend plant extracts, yet universally conclude that this is an interesting approach. Further prospective studies using WHO standards are required to reliably determine the role of such extracts in the management of elderly men with LUTS due to BPH/BPE.