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Men begin to experience diseases of the prostate beginning with the onset of puberty and the physical, hormonal and biochemical maturation of the organs of reproduction. This trend continues throughout the rest of our lives, even into old age when our reproductive capacities have declined. Depending upon a variety of factors, such as genetic makeup, overall health and potential exposures, each man will experience different challenges when it comes to disease exposure and development of symptoms, as we are unique and complex individuals.
The conventional medical approach to men's health in general has been to utilize suppressive therapies to allow for a quick resolution of symptoms. The theory is that if there are no symptoms, the disease must no longer be present. This approach overlooks the effects of any disease process on the entire organism in contradistinction to the naturopathic model of looking for the root cause of the disorder and treating it holistically. In the conventional medical paradigm, it has long been postulated that it is the organism or offending agent that is the cause of the disease and once eradicated, the disease has been eliminated. In the naturopathic/holistic view it is rather the soil or internal environment that contributes to whether the person develops an infection or other malady, as while we all are exposed to various organisms or the conditions that predispose one to developing a disease, not everyone will do so.
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The prostate is a fibro muscular and glandular organ comprised of five lobes weighing about 20 grams. The urethra passes through the prostate where it connects with the ejaculatory ducts for delivery of sperm with ejaculation. The prostate gland because of its biochemical makeup and location is in essence the guard gate (from Ancient Greek prostates, which means "one who stands before," "protector," "guardian")1 to the male reproductive system and as such its overall health is important to decreasing the risk of developing the various prostate diseases and afflictions that affect men during their lifetime. The prostate gland is high in enzymes, prostatic specific antigen, prostatic acid phosphatase, beta-microseminoprotein, zinc and citric acid or vitamin C, the combination of which makes prostate fluid slightly acidic. The concentration of zinc in the prostate is estimated to be 500 to 1000 times greater than blood levels as it is essential for the prevention of prostatic hypertrophy, functions as an immune modulator, and protects against the effects of heavy metals such as cadmium and lead. Addition of fluid from the seminal vesicles during ejaculation causes the solution to become more alkaline in order to survive the acidic vaginal environment. Prostatic specific antigen plays a role in liquefying seminal fluid ejaculate to allow sperm to migrate easily.
The view can be taken that the prostate gland is a dynamically functioning organ, which like all organ systems, is responsive to the environment in which it exists. An example would be its response to an exposure to an infective agent, during which there is an intense tissue inflammatory reaction resulting in hyperplasia and destruction of tissues as well as a proliferation of white blood cells. Acute reactions with proper treatment usually resolve but may leave behind some fibrous scarring. If incompletely treated however, the excretory ducts are unable to clear the tissue debris contributing to a state of chronic inflammation characterized by aggregates of lymphocytes, plasma cells, and macrophages within the gland. These same changes are also found with normal changes of aging but to a lesser degree. Repeated prostate infections contribute over time to additional pathological changes making the likelihood of developing prostatic hypertrophy and repeated infections greater.
Disease of the prostate follows essentially the same pattern of inflammation in general where inflammation is seen as an adaptation, a coordinated and protective response as well as a period of recovery once the initial insult has been eliminated. Acute inflammation may be triggered by exogenous sources such as microbes or allergens as well as endogenous sources such as oxidative stress from advanced glycan end products (AGE's), lipoproteins or glycosylation.2
Essentially every disease process has a beginning, middle, end and recovery period, all of which are crucial to restoration of cellular and organ homeostasis. If any one of these are disrupted or circumvented, then an environment that fosters chronic disease remains and symptoms continue, even after the "causative agent" has been eliminated.
In patients with diabetes or hyperlipidemia, it becomes much harder for there to be a return to normal function because the environment or soil is compromised. Therefore, the prostate gland becomes much more susceptible to developing disease and takes longer to recover once it does. Often, the condition cannot be entirely eliminated until blood glucose and/or lipid levels are normalized.
Early in life our homeostasis set point margins are able to adapt to insults and often recover on their own, returning to optimal levels. This is because our auto-regulating system (ARS), a complex cybernetic system that merges and integrates control and corrective feedback mechanisms in order to maintain optimal homeostasis, functions at a much higher level. As we age however, this ability wanes resulting in more pronounced and longer lasting symptomology. This especially can occur if symptoms have been suppressed through various drug therapies that disrupt this complex mechanism, ultimately leading to chronic disease.3 Along with the normal changes of aging, this is one of the reasons it takes longer to recover from any disease process the older we get.
Despite the fact that bacteria are only found with 5% to 10% of prostate infections, antibiotics are routinely prescribed and are often accompanied by NSAIDS or other anti-inflammatory medicines to treat the symptoms. Frequently, after the course of therapy is finished, the initial symptoms return with the same or similar therapeutic regimen prescribed. Often this regimen is repeated multiple times, further adding to the likelihood of developing a chronic condition because the healing process has not been able to complete its cycle.
While there is temporary relief from the symptoms of inflammation, inflammation is of itself a homeostatic mechanism employed by the body to eliminate the offending agent and should be viewed as a cleansing process. Under normal conditions, the interstitial fluid environment is alkaline but becomes acidic due to the accumulated excess wastes from the inflammation. With repeated suppression, the system has difficulty eliminating or can no longer excrete the acidic waste materials. When allowed to complete its action, the body's healing process generally does so in a timely and thorough manner, but when cut short by NSAIDS and repeated courses of antibiotics, a chronic disease cycle ensues.
Prostatic Specific Antigen
Prostatic specific antigen (PSA) is a serine protease produced almost exclusively by the prostate gland. PSA has little diurnal variation and thus samples obtained at varying times of the day will provide an accurate measure.4 Variations in PSA values are often seen when samples are performed in different laboratories due to different methodologies. The PSA is a nonspecific test of prostate function that can be elevated for any number of reasons but has been largely used as a measure for detection of prostate cancer. PSA can be elevated due to inflammation from infection, following ejaculation or digital rectal exam, benign prostatic hypertrophy, urinary tract infection, aging, high cholesterol levels5,6 prostate cancer and trauma such as catheterization or biopsy.4 More controversial is whether bicycle riding affects a rise in PSA.
More recently, use of PSA as a marker for disease, especially prostate cancer (CAP), has been questioned as increased use has resulted in more diagnostic procedures and treatment for CAP than was previously seen.7,8 About 40% of men with organ confined CAP will have a normal PSA9 and autopsy studies show that 30% of men over age 50 who have no clinical evidence of CAP have cancer foci present.10
Use of total and free PSA provides a better evaluation for prostate cancer, but should be used in conjunction with other testing such as prostate cancer antigen-3 (PCA-3), a measure of the probability CAP will be found on biopsy, and the TMPRSS2-ERG, which predicts tumor aggression level. Additional testing such as color Doppler ultrasound provides information on tumor size, density, location and vascularity, while the 3Tesla MRI can be used for high resolution imaging of suspect lesions.
Many of the patients that I see with elevated PSA's often show up because they wish to avoid a biopsy, something that is more often than not the first procedure offered by their urologist. Before I refer for color Doppler, I will perform a few additional blood tests such as fasting chemistry screen and lipid panel, CCRP, and a CBC to look for inflammation, infection, or any other organ system disease and elevated cholesterol. I perform either a 2 or 3 glass urinalysis following prostate massage to look for infection.
While the prostate gland is considered to be the first line of defense against infection to the male genital-urinary tract, it is the urethra that is first exposed to potential infecting organisms. Non-gonococcal urethritis due to Chlamydia trachomatis and Ureaplasma urealyticum are found in up to 50% of the cases, but other organisms such as Mycoplasma hominis, Candida albicans, and Trichomonas are also found.11,12 With the exception of Trichomonas, the other organisms are often found on routine culture of the perineal area of men and vaginal tract of women and do not cause symptoms of infection. This is because the environment is not conducive to allowing the organisms to set up "housekeeping," and the organism and host remain in a symbiotic relationship.
Because of the biphasic life cycle of Chlamydia, Ureaplasmin and Mycoplasma, infestation in the male genital urinary tract often produces no symptomology. This biphasic lifestyle pattern also makes it more difficult to eradicate an infection with antibiotics once it occurs, often leading to a return of symptoms following treatment. Urethritis in men usually presents with a purulent (gonococcal) discharge or a whitish mucoid (non-gonococcal) discharge, which is the body's attempt to eradicate the infection.
Prostatitis and Chronic Prostatitis
Acute bacterial prostatitis is as previously mentioned, only found about 5% to 10% of the time and is accompanied by fever, chills, low back and perineal pain. Affected individuals usually have problems with urination including frequency, urgency, and difficulty initiating urine flow and pain with urinating along with frequent urination at night. Digital rectal examination shows a swollen, tender and indurated gland. There may be a urethral discharge present, but this is more often seen with chronic prostatitis.13
Chronic prostatitis can occur following an incompletely treated acute prostatitis when the healing reaction has not had a chance to go to completion. Bacteria may be found but more often other agents such as Chlamydia, Ureaplasmin, Mycoplasma, Trichomonas or allergens contribute. Signs and symptoms are similar to that found with acute onset prostatitis but usually are experienced to a lesser degree. Men will complain that they experience exacerbations and remissions of symptoms but that they never fully go away. Sometimes this condition can last for years and is almost always exacerbated by stress.
Most of the men I see have had numerous courses of antibiotics and anti-inflammatories as well as numerous tests, none of which has resolved their symptoms or provided a definitive diagnosis.
Benign Prostatic Hypertrophy
Enlargement of the prostate gland is caused by an abnormal over-growth or swelling of tissue, termed hyperplasia. The increase in size is felt to occur because of an alteration in the testosterone/estrogen ratio and the effects of estrogen upon accumulation of androgens in the prostate.14 As the central sulcus surrounding the urethra is higher in estrogen receptors, hypertrophy occurs resulting in urinary obstruction associated with BPH. Urinary obstruction can occur with little overall glandular enlargement but with time the prostate gland can become quite enlarged resulting in urinary obstruction to the point that bladder capacity and function are affected. This ultimately may result in permanent indwelling catheterization. Nodular hyperplasia is differentiated on the basis of whether the nodularity is due to granular proliferation or dilation or to fibrous or muscular proliferation of the stroma.14 Additionally, because of the close proximity of the bladder sphincter to the prostate, symptoms of frequency and urgency to urinate will occur due to prostatic irritation and enlargement.
On autopsy BPH is found in more than 70% to 75% of men who are age 60 or older. Of these only about 25% exhibit symptoms, which has led some to question whether the variable nature of BPH is a normal part of the aging process.9,15
Men may also develop corpora amylacea or "prostatic concretions" a dense accumulation of calcified proteinaceous material that becomes lodged in the gland. While prostatic calcification is relatively common, their presence may result in symptoms that resemble chronic prostatitis, BPH, chronic pelvic pain syndrome, and urinary tract infection. With time, the concretion becomes a breeding ground for infection as it becomes difficult to eradicate due to poor circulation.
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