Stress and the Prostate

Men with benign prostatic hyperplasia (BPH) often find the condition stressful. It's easy to see why. Urinary urgency that triggers a frantic hunt for a bathroom will jangle the most placid gent, and nighttime urination that interrupts sleep can only add to mental distress. If they're under stress, some young men with normal prostates can also find it hard to urinate; doctors call it paruresis or the "shy bladder syndrome."

If the symptoms of BPH can cause stress, is the reverse also true? Doctors have learned that stress can contribute to many medical conditions, ranging from palpitations, heart attacks, and hypertension to asthma, heartburn, colitis, and skin rashes. But even though mental stress can affect many of the body's organs, the prostate has been considered exempt from psychic influences. Two reports may begin to modify that view.

Stress, Hostility, and BPH

To study stress and the prostate, doctors evaluated 83 men with an average age of 68. The men had all been diagnosed with BPH and were enrolled in the Medical Therapy of Prostatic Symptoms (MTOPS) study at the University of Iowa; some of the patients were taking medication for BPH while others were not. Each man underwent a complete urologic evaluation that included ultrasound measurements of his prostate and of the amount of urine that remained in his bladder after normal urination. All the men also completed questionnaires designed to measure lifelong stress, recent stress, and hostility.

BPH progresses over the course of a man's later years. But lifelong stress did not appear to stimulate growth of the prostate. If anything, men who reported high levels of lifelong stress tended to have slightly smaller glands than their more placid peers.

Recent stress was another matter. Men who reported high levels of recent stress had more difficulty emptying their bladders than men who did not experience recent stress. And hostility appeared to exacerbate the effects of recent stress; men with both factors had the largest post-voiding residual urine volumes.

In a second report from the MTOPS study, researchers compared objective measurements of prostate size and function with several indicators of stress as revealed on questionnaires. To see if physiologic evidence of mental stress also corresponds to BPH symptoms, they asked the men to take a mental stress test. The volunteers were given two minutes to prepare a speech defending themselves against an accusation of shoplifting, after which they delivered the speech in front of a video camera. To measure the stress response, the scientists monitored blood pressure and stress hormones throughout the test. The men who showed the strongest physiologic response to mental stress also reported the most severe BPH symptoms, and they also retained the largest amounts of urine after voiding.

The prostate and its nerves   The prostate and its nerves   A rich network of nerves surrounds the prostate and may explain the link between stress and symptoms.

Possible Mechanisms

There are two possible links between the mind and the prostate. One involves the body's hormones. A part of the brain called the hypothalamus controls the endocrine system's "master gland," the pituitary. In turn, the pituitary regulates the production of many hormones, including the male hormone testosterone. Enlargement of the prostate depends on testosterone. Long-term changes in the hypothalamic-pituitary-testicular connection could affect the growth of the prostate — but the study of stress and the prostate did not find evidence to support that possibility.

The other possibility involves the sympathetic nervous system. Stress triggers the release of adrenaline. The prostate and the bladder neck contain alpha-receptors that respond to adrenaline by stimulating smooth muscle cells in the prostate and bladder (see figure). When the muscle cells contract, they narrow the urethra, making it harder for a man to empty his bladder. That's why cold remedies that contain pseudoephedrine or other medications that activate alpha-receptors can make it difficult for men with BPH to urinate. And it also explains why many men with BPH get symptomatic relief from alpha-blockers such as terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), and alfuzosin (Uroxatrol). By activating the sympathetic nervous system, stress may slow the flow of urine in men with BPH and prevent the bladder from emptying completely.

The sympathetic nervous system may also play a role in the link between hypertension and symptoms of BPH, according to a report from Dutch scientists. Since hypertension may indicate increased activity of the sympathetic nervous system, high blood pressure and stress could share a common mechanism for increasing the severity of BPH symptoms.

Perspectives

The MTOPS reports raise interesting questions, but they do have limitations. Since all the men already had BPH when they entered the study, it might be hard to detect long-term factors that could promote (or protect against) BPH. And since some of the patients were already on medication at the time of the study, the possible effects of stress might have been blunted.

Despite the limitations, these two reports raise questions that deserve further investigation. And if nothing else, they add another dimension to the many benefits of stress reduction; for his bladder and prostate as well as his heart and his head, every man should do his best to relax.

Reducing the Stress of BPH

Stress may aggravate the symptoms of BPH — and having BPH can be plenty stressful on its own. Until recently, many doctors recommended surgery for BPH just because the prostate was enlarged, regardless of whether or not the patient was stressed or distressed by his symptoms. That's no longer the case. For one thing, medication has replaced surgery as the first treatment for most men with BPH. In addition, even medication is usually held in reserve until a man finds his BPH symptoms bothersome.

Here is a reminder of some simple steps that help you live with BPH, reducing the stress caused by bothersome symptoms:

• Reduce your intake of fluids, particularly after dinner.

• Limit your intake of alcohol and caffeine and avoid them after midafternoon; both are diuretics that increase urine flow.

• Avoid medications that stimulate muscles in the bladder neck and prostate. Pseudoephedrine (Sudafed) and other decongestants are the chief culprits.

• Avoid medications with anticholinergic properties that weaken bladder contractions. Antihistamines such as diphenhydramine (Benadryl) and many others are the most common offenders. Various antidepressants and antispasmodics have similar properties.

• If you are taking a diuretic for high blood pressure or heart problems, ask your doctor to consider reducing your dose or substituting another medication that will work just as well.

• Don't let your bladder get too full. Over time, stretching will weaken your bladder muscle, increasing your risk of acute urinary retention.

• Never pass up a chance to use the bathroom, even if your bladder does not feel full. Take your time, so you empty your bladder as much as possible. Plan to stop at regular intervals during car trips.

• When you are in new surroundings, learn the location of the bathroom before you really need it.

• Request aisle seats on airplanes, in theaters, and at sporting events.

• Be sure there are no obstacles between your bedroom and your bathroom. Keep night-lights on so you won't stumble or fall when you get up to urinate at night, but avoid bright lights and other stimuli that can activate your nervous system and make it harder for you to get back to sleep.