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Older men dread the thought of it, and comedians have made audiences laugh by describing the awkwardness of it. The digital rectal examination is a routine procedure performed by the family doctor on men starting at age forty. Maybe you have heard about this examination but wonder why it is recommended for older men.
It all starts with the prostate…
The prostate comes from the Greek word prostates, which means “protector†and is commonly known as the male G-spot. It is a walnut-size gland of the male reproductive system that surrounds the urethra, just below the bladder (see diagram below). The prostate is made of tubules (tiny tubes), alveoli (small hollow cavities), glands, and some smooth muscles. It is an exocrine gland because its role is to store and secrete a slightly alkaline (pH 7.29) fluid that constitutes 25%–30% of the volume of semen. Because the semen is more alkaline, it helps neutralize the acidity of the vagina and protects sperm after ejaculation.
The other function of the prostate is to send (through a valve system) semen into the urethra during ejaculation. Also, the prostate sphincter (a muscle) stops the flow of urine into the urethra during the ejaculatory process by sealing the bladder.
The prostate needs male hormones (androgens) to function properly. The major male hormone is testosterone, which is made primarily by the testicles. When testosterone reaches the prostate, it is converted to its more active form (dihydrotestosterone or DHT) by the enzyme 5α-reductase type 2.
As men age, the prostate cells tend to divide rapidly, leading to an enlarged prostate—a condition called Benign Prostatic Hyperplasia (BPH)—and is often diagnosed in men in their fifties and sixties. It is estimated that in 2010, two million Canadian men fifty years old or older will suffer from BPH. Although not initially a serious condition, BPH makes men more vulnerable to bladder infections and prostate cancer.
Prostate cancer is the most common kind of cancer affecting Canadian men. About 25,500 men were diagnosed with this disease in 2009 and an estimated 4,400 died from it.
As mentioned before, the prostate is greatly influenced by DHT. Although older men produce relatively less DHT (and testosterone) compared to estrogen, their prostate cells are more sensitive to estrogen. In turn, estrogen makes prostate cells more susceptible to the action of DHT. Over time, the cells divide excessively and the result is an enlarged prostate.
Many older men are unaware that they have developed BPH until they have difficulty urinating. The enlarged prostate gland narrows the upper part of the urethra and these men are unable to properly empty their bladders. The affected men may have to urinate several times during the day in an attempt to manage this condition. Unfortunately, advanced BPH can lead to urinary tract infections, bladder stones, and even kidney failure.
The digital rectal examination is a procedure done during a routine annual exam to help diagnose BPH. The doctor puts a rubber glove on one hand and inserts a lubricated index finger into the rectum of the patient. The patient is often bent over a table and has to relax. The doctor feels the size and shape of the gland in order to identify any asymmetry or inflammation. The whole procedure is painless and takes 10–25 seconds.
Also, the doctor may do a blood test to identify elevated prostate-specific antigen (PSA) levels. PSA is a protein produced by prostate cells, and it is normally low (up to 2.5 ng/dL). In BPH or in prostate cancer, the level of PSA can significantly rise (greater than 2.5 ng/dL).
Although the cause of BPH has not been identified, there are risk factors for developing this condition:
- Ethnicity: African American men are the most at risk, while Asians men have the lowest rates of BPH.
- Family history: men with three or more family members with the same condition.
- Medical conditions: obesity, heart and circulatory diseases, and type 2 diabetes.
The standard treatments for BPH are alpha-blockers and 5α-reductase inhibitors. The alpha-blockers relax the smooth muscle in the prostate and lower bladder. This results in better urine flow. The 5α-reductase inhibitors interfere with the action of the enzyme 5α-reductase, which in turn inhibits the production of dihydrotestosterone (DHT), the hormone causing the enlargement of the prostate.
The problem with standard treatments for BPH is that these drugs have side effects such as hypotension, weakness, nasal congestion, and erectile dysfunction. Also, these medications have to be taken every day for the rest of the patient’s life, and they only address the signs and symptoms of this condition.
Based on studies of older men populations, it is apparent that diet and lifestyle have a great impact on whether or not a man will develop BPH. A Western diet high in saturated fat, sugar, and red meat, as well as low fiber, is often correlated with BPH. Although the rate of this condition is much higher in African American men, ethnicity does not seem to be an important risk factor. In fact, Asian men have among the lowest rates of BPH as long as they follow a mostly vegetarian diet and an active lifestyle. When these men migrate to North America and adopt a Western diet, within one generation they show similar rates of BPH as Westerners.
Benign Prostatic Hyperplasia is often an uncomfortable subject for men. The digital rectal examination is even more embarrassing. The positive side is that monitoring the health of the prostate gland can prevent many complications—even death. Better yet, a change in diet and lifestyle can dramatically decrease the risk of developing this condition. Let’s just keep in mind that an older prostate gland is not necessarily an inflamed one.
Literary Truths
Here are some lifestyle and diet recommendations that can reduce the symptoms or the risks of developing Benign Prostatic Hyperplasia:
- Exercise: Physical activity is a great way to manage stress, and also to lose weight. As men age, they tend to accumulate fat in their abdomen, which puts extra pressure on the bladder.
- Omega-3 & -9 fatty acids: fatty fish such as salmon, mackerel, and herring are good sources of omega-3 fatty acids. Nuts, avocados, and olives contain significant amounts of omega-9 fatty acids. These good fats reduce the production of dihydrotestosterone (DHT) in the prostate.
- Fiber: increase daily intake of fiber to 20 g/day from whole grain, whole wheat, fruits, and vegetables. Soluble fiber is particularly good for lowering LDL (bad cholesterol). Vegetables tend to be good sources of lycopene, vitamin E, and selenium.
- Vegetarian diet: a non-organic Western diet high in saturated fats, simple sugars, and red meat promote inflammation in the prostate: There is a strong link between inflammation and the development of cancer.
- Water: caffeinated beverages (i.e., coffee) or alcohol are diuretics that stimulate urine production. Plain, moderate water intake is best for an already overactive bladder.
- Saw palmetto extract*: the deep purple berries of this plant may limit the progression of BPH. The extract has been extensively studied in Europe.
- African Pygeum extract*: the bark of this evergreen tree helps to control an overactive bladder. It also inhibits the growth of prostate cells.
* Keep in mind that before taking any herbal medicines, you need to consult with your doctor. Also, these herbs are effective only for mild to moderate BPH.
References
The aging male population and medical care for benign prostatic hyperplasia in Canada
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Cheung, E., P. Wadhera, T. Dorff & J. Pinski. “Diet and prostate cancer risk reduction.†Expert Review of Anticancer Therapy. 8.1 (Jan 2008): p43(8).
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D’Amico, F., M. Biancolella, K. Margiotti, J. KV Reichardt & G. Novelli “Genomic biomarkers, androgen pathway and prostate cancer.†Pharmacogenomics 8.6 (June 2007): p645(17).
Green K. and P. S. Campbell. “Saw Palmetto: An Effective Form of Phytotherapy in the Inhibition of Prostate Enlargement?†Journal of the Alabama Academy of Science (Jan-April 2000): p10.
How to Detect Prostate Problems
Naturally Reducing Prostate Inflammation
“Prevalence of delayed clinician response to elevated prostate-specific antigen values.†Mayo Clinic Proceedings 83.4 (April 2008): p439(7).
Prostate Cancer Canada Network
“Saw palmetto for BPH: a review of a meta-analysis. (Cat Clinic: critically appraised topics: using evidence-based medicine to answer clinical questions )(benign prostatic hyperplasia).†JAAPA-Journal of the American Academy of Physicians Assistants. 15.5 (May 2002): p59(4).
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