Managing Benign Prostatic Hyperplasia: Where Herbal Therapies May Fit Alongside Standard Treatment

Marius Markevičius

Respublikinė Klaipėdos ligoninė

Benign prostatic hyperplasia (BPH) is a condition that primarily affects men over the age of 40. Although its exact cause remains unclear, it is characterized by lower urinary tract symptoms, including increased daytime urinary frequency, nocturia, urinary urgency, a weak urinary stream, and hesitancy. Urologists have a broad range of medical treatment options available, which are selected based on the patient's predominant symptoms, prostate size, International Prostate Symptom Score (IPSS), erectile function, and personal preferences. Phytopharmaceuticals play a relatively small but clinically meaningful role in the management of BPH. The aim of this review is to present the phytopharmaceuticals currently used worldwide and in Lithuania for the treatment of urinary symptoms. According to some studies, these herbal preparations may offer effectiveness comparable to conventional medications.

Introduction

Benign prostatic hyperplasia (BPH) is a pathological condition characterized by lower urinary tract symptoms (LUTS) in men over 40 years of age. These symptoms include urinary urgency, urinary incontinence, a weak urinary stream, increased urinary frequency, and recurrent urinary tract infections. Histologically, BPH is defined by the proliferation of epithelial and stromal cells within the periurethral region of the prostate gland. Understanding the natural history of BPH helps determine the stage at which patients typically seek urological care and guides appropriate treatment decisions.

Epidemiology

Benign prostatic hyperplasia has a significant impact on men's quality of life. Approximately one in three men over the age of 50 experiences lower urinary tract symptoms associated with BPH (LUTS/BPH). Histological evidence of BPH is present in approximately 90% of men older than 85 years. Epidemiological studies evaluating factors such as religious affiliation, socioeconomic status, sexual activity, alcohol consumption, hypertension, and other lifestyle variables have shown that most of these factors have little or no significant effect on the development or progression of BPH. The impact of smoking remains controversial, with some studies identifying it as a risk factor for disease progression while others have found no significant association. In contrast, obesity and an elevated body mass index (BMI) have consistently been identified as important risk factors for both the development and progression of benign prostatic hyperplasia [3] (Table).

Table. Factors Influencing the Risk of Developing Benign Prostatic Hyperplasia (BPH) and Lower Urinary Tract Symptoms (LUTS)
Factors That Reduce the Risk of BPH and LUTS
Alcohol consumption: 30–60 g/day
Smoking ≥2 packs/day (or physical activity resulting in the expenditure of ≥862 kcal/day)
Factors That Increase the Risk of BPH and LUTS
Diabetes mellitus
Hyperglycemia
Prostate volume >40 mL
BMI >35
Hypertension
Waist circumference >102 cm

Conservative Treatment of Benign Prostatic Hyperplasia

Conservative treatment should always begin with an assessment of the severity of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS). Symptom severity is commonly evaluated using the International Prostate Symptom Score (IPSS) questionnaire. In addition, clinicians should identify the symptoms that are most bothersome to the patient, perform appropriate diagnostic tests to confirm the diagnosis—including urinalysis, prostate-specific antigen (PSA) testing, ultrasonography, and urodynamic studies—and discuss all available treatment options, including alternative approaches. Patients with mild to moderate BPH/LUTS can often be managed with active monitoring, while pharmacological treatment is recommended if conservative non-drug measures fail to provide sufficient symptom relief. It is important to educate patients about factors that may worsen their condition and provide practical advice to help reduce symptoms [1, 4–7].

Lifestyle and Non-Drug Measures

The following non-pharmacological strategies may help improve BPH/LUTS symptoms [1, 4–7]:

• Reduce fluid intake during periods when symptoms are most troublesome, such as avoiding drinks for 2–3 hours before bedtime to reduce nocturia or before long trips and important meetings.
• Limit or avoid caffeine and alcohol, as both increase urine production and irritate the bladder, contributing to urinary frequency, urgency, and nocturia.
• Urinate without straining and consider double voiding by relaxing for several minutes after urination before attempting to empty the bladder again.
• Use urge-suppression techniques, including penile compression, deep breathing, perineal pressure, or psychological distraction exercises, particularly in patients with predominant bladder irritability.
• Practice bladder training by gradually delaying urination during episodes of urgency to increase bladder capacity. Men who experience urine splashing while standing may benefit from sitting down to urinate.
• Treat constipation promptly using appropriate dietary measures or medication, as constipation can worsen urinary symptoms.
• Engage in regular physical activity at least two to three times per week, as physical inactivity has been associated with worsening urinary symptoms and an increased risk of acute urinary retention.

Medical Treatment

Drug therapy is generally recommended for patients with moderate BPH/LUTS symptoms. The main medication classes include:

1. Alpha-adrenergic blockers (tamsulosin, doxazosin, alfuzosin)
2. 5-alpha-reductase inhibitors (finasteride, dutasteride)
3. Muscarinic receptor antagonists (oxybutynin, tolterodine, solifenacin)
4. Phosphodiesterase type 5 inhibitors (tadalafil 5 mg)
5. Phytopharmaceuticals
6. Vasopressin analogues
7. Combination therapy

Surgical Treatment

Surgical intervention is indicated for patients with severe BPH/LUTS or when conservative treatment fails. Surgery is also recommended in the following situations:

• Recurrent urinary retention
• Overflow urinary incontinence caused by bladder overdistension
• Recurrent urinary tract infections
• Bladder stones or diverticula
• Recurrent hematuria associated with BPH
• Upper urinary tract dilatation with or without renal insufficiency
• Persistent symptoms despite appropriate conservative treatment
• Significant post-void residual urine after conservative therapy

Phytotherapy

Phytopharmaceuticals are produced from various parts of medicinal plants, including roots, leaves, seeds, pollen, bark, and fruits. Commercial preparations may contain a single plant extract or combinations of several botanical ingredients. The most commonly studied herbal products for BPH include saw palmetto (Serenoa repens), pumpkin seed, African potato (Hypoxis rooperi), African plum (Pygeum africanum), rye grass (Secale cereale), and stinging nettle (Urtica dioica) extracts [1]. These herbal preparations contain numerous biologically active compounds, including fatty acids, phenolic compounds, and antioxidants. As a result, phytopharmaceuticals may exert multiple biological effects, potentially improving urinary symptoms while also providing additional health benefits, such as supporting digestion or improving sleep. Many modern pharmaceuticals were originally derived from medicinal plants, with active compounds later isolated and refined into selective medications. Phytopharmaceuticals remain an important natural therapeutic option, and the herbal preparations most frequently discussed in the literature include saw palmetto, stinging nettle, African plum, and pumpkin seed. In Lithuania, herbal mixtures available in pharmacies or prepared by herbal practitioners commonly contain combinations of nettle, heather, yarrow, and saw palmetto fruit. A recent French study by Lukacs and colleagues found that approximately 92% of patients beginning treatment for BPH received monotherapy. Among these patients, alpha-1 adrenergic blockers were the most commonly prescribed medications (60.9%), followed by herbal preparations (26%) and 5-alpha-reductase inhibitors (13.1%) [8]. Current European Association of Urology (EAU) guidelines do not provide specific recommendations regarding the routine use of herbal preparations for BPH. Instead, phytopharmaceuticals may be considered based on the patient's predominant symptoms. They may be appropriate for men with mild symptoms or as adjunctive therapy alongside conventional BPH medications. In a review by Pagano and colleagues, phytopharmaceuticals were classified into two categories: (1) herbal medicines and (2) dietary supplements [9].

Dietary Supplements

Several dietary supplements may help support lower urinary tract health, including lycopene, selenium, and β-sitosterol.

Lycopene

Lycopene is a fat-soluble carotenoid pigment naturally found in fruits and vegetables. Tomatoes are the richest dietary source, although significant amounts are also present in watermelon, papaya, pink grapefruit, and guava [9]. Lycopene accumulates in prostate tissue, although the exact mechanism by which it is transported to the prostate remains unclear. Its role in slowing the progression of benign prostatic hyperplasia (BPH) is not fully understood. Among carotenoids, lycopene possesses particularly strong antioxidant properties. Experimental studies suggest that it inhibits the proliferation of normal prostate cells while promoting apoptosis. Some research also indicates that lycopene-rich foods, particularly tomatoes, may help reduce the risk of both BPH and prostate cancer [9].

Selenium

Selenium is an essential trace mineral and a component of the antioxidant enzyme glutathione peroxidase. Rich dietary sources include Brazil nuts, fish, whole grains, wheat germ, soybeans, and sunflower seeds. Preclinical studies suggest that selenium may inhibit the development and progression of prostate cancer by promoting apoptosis in prostate cells [9].

β-Sitosterol

β-Sitosterol is a plant sterol found in African potato, maritime pine, and African plum. It has been reported to improve lower urinary tract symptoms associated with BPH and may enhance urodynamic parameters, including urinary flow rate and post-void residual urine volume [9].

Herbal Medicines

Saw Palmetto (Serenoa repens)

Saw palmetto is the most extensively studied herbal therapy for BPH. Its fruits have been used medicinally since the 19th century, and during the 20th century, saw palmetto extract became one of the ten best-selling herbal medicines in North America. The extract contains long-chain fatty acids, fatty alcohols, glycerides, phytosterols, and flavonoids, with phytosterols and fatty acids considered the principal active constituents [9]. Saw palmetto exerts multiple pharmacological effects. It inhibits both type I and type II 5-alpha-reductase enzymes, blocks the binding of dihydrotestosterone (DHT) to androgen receptors, suppresses prostate cell proliferation, reduces inflammation by inhibiting 5-lipoxygenase metabolites and arachidonic acid derivatives, decreases oxidative stress by inhibiting neutrophil-derived free radicals, and limits the growth of prostate epithelial cells stimulated by growth factors. Additional studies have demonstrated reductions in epidermal growth factor expression after three months of treatment, anti-edematous effects, anti-estrogenic activity within prostate tissue, and smooth muscle relaxation through calcium channel modulation. High-dose extracts have also been shown to induce apoptosis in prostate cells. Combining saw palmetto with other phytopharmaceuticals appears to enhance these pharmacological effects. For example, combining saw palmetto with selenium and lycopene has demonstrated stronger anti-inflammatory and antiproliferative activity than saw palmetto alone [10]. Saw palmetto is commonly used to treat mild to moderate BPH. A meta-analysis of 18 clinical trials found that it was significantly more effective than placebo and produced clinical outcomes comparable to finasteride, including reductions in symptom scores, improved urinary flow, and decreased nocturia and dysuria [15]. When combined with tamsulosin, saw palmetto significantly improved urinary parameters compared with tamsulosin monotherapy [16]. Similarly, the combination of saw palmetto, selenium, lycopene, and tamsulosin resulted in greater reductions in Total Prostate Symptom Score (TPSS) and greater improvements in maximum urinary flow than monotherapy [17]. Saw palmetto is also the only herbal therapy evaluated in long-term follow-up studies. A 36-month observational study published in 2010 demonstrated statistically significant improvements in urinary function [18]. A subsequent 10-year follow-up study published in 2013 reported no disease progression among treated patients. Quality of life improved significantly (p < 0.001), maximum urinary flow (Qmax) increased (p < 0.001), voided urine volume increased (p = 0.004), post-void residual volume decreased (p = 0.001), and prostate-specific antigen (PSA) levels remained stable (p = 0.02) [19]. Adverse effects are uncommon and generally mild, with headache, decreased libido, sexual dysfunction, and ejaculatory disorders reported in fewer than 2% of patients. Other studies have found no significant difference in adverse event rates compared with placebo [10].

African Plum (Pygeum africanum)

African plum bark contains phytosterols, including β-sitosterol, pentacyclic triterpenes, fatty acids, and alcohols. It has traditionally been used in African medicine to treat urinary disorders. The extract inhibits 5-alpha-reductase activity, suppresses prostate fibroblast proliferation, reduces inflammation, inhibits prolactin-mediated cholesterol accumulation within the prostate, and protects bladder tissue against oxidative stress and proteolytic enzymes [9]. It also inhibits androgen and progesterone receptors, decreases PSA production, and suppresses prostate cancer cell growth [10]. A meta-analysis of 18 randomized clinical trials involving 1,562 men found that African plum significantly improved urinary symptoms and urodynamic parameters, reducing nocturia by approximately 19% and increasing urinary flow by 23% [9]. Improvements in TPSS scores, sperm quality, and quality of life were also reported. The treatment was generally well tolerated [10]. However, most published studies included relatively small patient populations and short follow-up periods. Nevertheless, available evidence suggests that African plum may significantly improve urinary symptoms compared with watchful waiting and may provide benefits comparable to saw palmetto [11]. Experimental studies have also suggested a potential role in reducing prostate cancer risk among high-risk individuals [12].

Rye Grass (Secale cereale)

The active components of rye grass pollen extract have not been clearly identified. Proposed mechanisms include inhibition of 5-alpha-reductase, alpha-adrenergic blocking activity, and anti-inflammatory effects [9]. Clinical evidence remains limited. The largest available study demonstrated improvements in urinary symptoms, particularly nocturia, although no significant changes were observed in urinary flow, prostate volume, or post-void residual urine compared with placebo. In another study involving 240 patients, participants received 750 mg daily during the first year followed by 375 mg daily for the next three years. Long-term treatment reduced prostate volume, urinary retention, and the need for surgery, although improvements in urodynamic parameters became apparent only after four years. Rye grass pollen extract appears safe and is also used for chronic prostatitis and chronic pelvic pain syndrome [10].

Pumpkin Seed

Pumpkin seeds contain phytosterols, fatty acids, alpha-tocopherol (vitamin E), and zinc. Traditionally, they have been used for their antioxidant and anti-inflammatory properties, although the primary active component has not been identified. Pumpkin seed preparations are believed to inhibit 5-alpha-reductase activity, reduce TPSS scores, and improve quality of life. Clinical trials have shown greater benefits when pumpkin seed is combined with saw palmetto, cranberry, lycopene, or African plum. These combinations have been associated with lower symptom scores, improved urinary function, reduced PSA concentrations, and decreased residual urine volume. Pumpkin seed preparations have demonstrated an excellent safety profile with no serious adverse effects [10].

Common Nettle (Urtica dioica)

Common nettle has long been used in traditional medicine for treating joint disorders, acne, diabetes, and urinary complaints. It contains phytosterols, minerals, tannins, salicylic acid, malic acid, and histamine. Nettle extract suppresses prostate cell metabolism and growth, inhibits proteolytic enzymes involved in urinary tract infections, and weakly inhibits 5-alpha-reductase [9]. Clinical evidence remains inconsistent. One trial demonstrated reduced TPSS scores and increased maximum urinary flow after six months of treatment, whereas another found no significant benefit. Combining nettle with saw palmetto significantly reduced obstructive urinary symptoms and inflammation compared with placebo. Overall, however, evidence supporting nettle monotherapy remains limited. The extract is generally safe, although occasional allergic reactions and gastrointestinal side effects have been reported [10].

Willowherb (Epilobium spp.)

More than 200 species of willowherb exist worldwide. These plants contain flavonoids, ellagitannins, and phytosterols. Oenothein B is believed to be the principal active compound. Experimental studies have demonstrated antioxidant, anti-inflammatory, analgesic, antiproliferative, and enzyme-inhibiting effects, including inhibition of hyaluronidase, aromatase, peroxidases, and type II 5-alpha-reductase. However, clinical evidence remains extremely limited, with only one study evaluating willowherb in combination with saw palmetto. No clinical trials have assessed willowherb alone [10].

African Potato (Hypoxis rooperi)

Also known as African star grass, Hypoxis rooperi has traditionally been used to treat infections, diabetes, cancer, heart disease, neurological disorders, and urinary tract conditions. The plant contains phytosterols, polysaccharides, and lignans. Although preclinical studies have not demonstrated significant inhibition of 5-alpha-reductase, laboratory studies have shown anti-inflammatory effects through inhibition of cyclooxygenase (COX-1 and COX-2) activity and prostaglandin synthesis. Clinical evidence remains limited, but a six-month placebo-controlled trial demonstrated improvements in urinary flow, reductions in residual urine volume, and lower TPSS scores. Gastrointestinal complaints were the most commonly reported adverse effects [10].

Tomato (Lycopersicum esculentum)

Tomatoes account for approximately 85% of dietary lycopene intake. They also contain glycoalkaloids, salicylates, flavonoids, and carotenoids. Lycopene has been associated with a reduced incidence of prostate adenocarcinoma and has been included in many men's multivitamin supplements since 2003 [13,14]. It inhibits prostate cell proliferation, suppresses type I 5-alpha-reductase activity, promotes apoptosis, provides antioxidant protection, and reduces androgen receptor expression, leading to lower PSA concentrations. Interestingly, tomato extracts appear to exert stronger anticancer effects than purified lycopene alone, suggesting that additional tomato-derived compounds contribute to their biological activity. Clinical studies have shown that tomato products and lycopene supplementation reduce PSA concentrations, decrease oxidative DNA damage, and increase apoptosis. Effective supplementation typically involves approximately 15 mg daily for 3–6 months. Clinical outcomes improve further when lycopene is combined with saw palmetto extract [10].

Maritime Pine (Pinus pinaster)

Maritime pine contains diterpenes, coumarins, flavonoids, and vitamin C. Its principal active component is β-sitosterol. Supplementation at approximately 130 mg daily has been reported to improve quality of life, reduce post-void residual urine volume, lower TPSS scores, and increase maximum urinary flow. However, not all studies have confirmed these findings [10].

Royal Palm (Roystonea regia)

Royal palm fruit contains high concentrations of free fatty acids and demonstrates antioxidant activity. It competitively inhibits 5-alpha-reductase and appears to block alpha-adrenergic receptors more effectively than saw palmetto, although less potently than tamsulosin. Experimental studies suggest that combining royal palm extracts with tamsulosin provides greater symptom improvement than tamsulosin alone. However, clinical evidence remains limited, and most available data come from animal studies, making its safety profile in humans difficult to assess.

Conclusions

The range of phytopharmaceuticals available for managing BPH is broad and diverse. Variability in plant sources, extraction methods, and formulation makes direct comparisons between products challenging. While some studies report excellent clinical outcomes, others fail to demonstrate significant benefits. Both the European Association of Urology and the American Urological Association acknowledge that robust clinical evidence for many individual phytopharmaceuticals remains limited. Nevertheless, there is growing interest in incorporating selected herbal preparations into BPH management recommendations. Among the available phytopharmaceuticals, saw palmetto (Serenoa repens) currently has the strongest clinical evidence supporting its use. Although nettle preparations remain popular in traditional herbal medicine, scientific evidence supporting their efficacy is relatively limited. African plum and tomato-derived preparations have also demonstrated promising results in clinical studies but are less frequently used in routine clinical practice.

Practical Recommendations

To help maintain prostate health, the following lifestyle measures may be beneficial:

1. Eat more tomatoes and drink tomato juice regularly.
2. Consume approximately two-thirds of a cup of pumpkin seeds daily.
3. Follow a healthy diet rich in leafy vegetables and plant-based foods while limiting animal products, particularly red meat, and reducing salt intake.
4. Stay physically active and drink more than 2 liters of water daily.
5. Men over 40 should consider an initial urological evaluation, while men over 50 experiencing urinary symptoms should undergo regular follow-up to help prevent complications associated with benign prostatic hyperplasia.

Source: Lietuvos gydytojo žurnalas (Lithuanian Doctor's Journal)