Unraveling the Prostate Paradox: The Aging Man’s Enigma

Last Updated on December 23, 2023 by Max

Introduction

It’s one of medicine’s most intriguing puzzles – as men age, their testosterone levels drop, but oddly, their prostate, an organ that relies on testosterone to grow, expands. This seemingly paradoxical phenomenon isn’t just a fascinating puzzle for scientists to solve. It has real-life implications for millions of men who suffer from an enlarged prostate, or benign prostatic hyperplasia (BPH), a common condition with age.

This blog post delves into this curious paradox, its underlying mechanisms, and what the latest research reveals about potential treatment approaches. We’ll journey deep inside the prostate’s inner workings, unravel the unexpected role of varicocele (a condition affecting the veins in the testicles), and explore the groundbreaking Gat Goren method. Plus, we’ll discuss two minimally invasive procedures – Prostatic Artery Embolization (PAE) and Varicocele Sclerotherapy – and examine the possibility of combining them to combat BPH more effectively. So, solutions are already available to help you reclaim your quality of life. Take your time, weigh your options, and make an informed decision if you’re wrestling with bothersome BPH symptoms. Let’s take the first step together, shall we?

The Unexpected Player

Why do men get their prostates enlarged with age? Well, it’s a bit of a paradox. As men age, testosterone levels drop, but the prostate, which needs testosterone to grow, gets bigger. Seems odd, right? The secret lies in the powerful hormones found within the prostate itself.

Let’s break it down. Testosterone is a key player in muscle cell growth, including prostate cells. However, as we age, the circulating levels of this hormone in our bodies decline. One would expect the prostate’s growth to slow or halt under these conditions. But the reality? Quite the opposite happens. The prostate continues to grow, and this problem has left scientists scratching their heads for a while.

The answer, intriguingly, is hidden deep within the prostate. The prostate isn’t just a passive organ; it’s an active participant in its growth story. It’s not just about the testosterone circulating in the bloodstream. It’s about the testosterone that gets converted inside the prostate into a more potent hormone called dihydrotestosterone (DHT). This conversion is made possible by an enzyme called 5α-reductase in the prostate. So even though the amount of free testosterone in the blood might decrease with age, the prostate keeps the party going with its DHT production.

Now, where does all this testosterone come from, you ask? The plot thickens with the involvement of a condition known as varicocele, a disease affecting the veins in the testicles. As we get older, these veins can get damaged, leading to a disruption in the blood drainage of the reproductive system. This disruption causes a detour for the testosterone-laden blood, redirecting it straight into the prostate. In other words, the prostate starts receiving a deluge of testosterone from a source it never expected.

This unprecedented influx of testosterone causes a hormonal surge within the prostate, accelerating cell growth and causing the prostate to enlarge. This, in essence, is the underlying mechanism that drives the age-related enlargement of the prostate.

Despite age-related declines in circulating testosterone levels, the prostate grows, which seems paradoxical since testosterone promotes the proliferation of muscle cells, including those in the prostate. The key here is that while testosterone concentration in the blood decreases with age, intraprostatic testosterone and dihydrotestosterone (DHT) levels and androgen receptor activities remain consistently high. The enzyme 5α-reductase in the prostate transforms approximately 90% of free testosterone (FT) into DHT, a more potent hormone that more readily associates with the androgen receptors. Numerous studies have demonstrated DHT’s critical role in the pathology of BPH​​.

The Link Between Varicocele and BPH

Studies have found a link between varicocele and BPH. Varicocele, a condition characterized by the damage of one-way valves in the internal spermatic veins, has been found in all cases of BPH in several studies. Moreover, there is a high correlation between varicocele at the ages of 20-25 years and the development of BPH in men of 45 years​​.

In a guy without varicocele, here’s how the whole testosterone travel adventure works:

1. The testosterone story begins in the testes, the main production house of this hormone. Free testosterone (Free T), the active form of the hormone, is produced here.
2. Once produced, this Free T hops on a ride through the Internal Spermatic Vein vein. Imagine this vein as a highway leading away from the testes. The Free T is off to meet the rest of the body.
3. This vein merges with the body’s main bloodstream, like a small road joining a major highway. This is where the testosterone gets diluted or spread out into the larger pool of blood.
4. The diluted testosterone travels throughout the body in this bloodstream highway, reaching various destinations, including the prostate.
5. Once it reaches the prostate, the testosterone enters the cells, contributing to the normal growth and function of the prostate.

So, in simple terms, in a guy without varicocele, testosterone gets produced in the testes, travels via a vein to the main bloodstream, where it spreads out, and then finds its way to the prostate. This healthy process ensures the right balance of hormones for the body to function as it should.

When the one-way valves in the internal spermatic vein are damaged, the vein can no longer effectively serve as a drainage system. This leads to the redirection of undiluted FT flow straight from the testes into the prostate. The venous blood cannot flow upwards and is diverted into other channels common with the prostate. As a result, the prostate becomes inundated with undiluted androgen, around 100 times above the normal level, from an unexpected source. This sudden influx of undiluted androgen accelerates prostate cell production and prolongs cell lifespan, contributing to the development of BPH​​. This phenomenon, known as the “backdoor phenomenon,” helps explain why testosterone-dependent BPH can occur even as serum testosterone levels decline with age. Therefore, treating varicoceles could potentially stop the “flooding” of the prostate with high concentrations of testosterone, which has been observed in patients with varicocele​.

The Impact of Varicocele on Prostate Cancer: Flooding the Prostate with Testosterone

The proposed mechanism of BPH explains that testosterone fuels cell growth in the prostate tissue, regardless of whether it leads to BPH or PC. This sheds light on why previous studies attempting to establish a direct link between BPH and PC have failed. However, it’s important to note that the development of cancerous growth in the prostate requires specific factors, such as genetic mutations, hormonal imbalances, inflammation, and genotoxic environmental influences. These factors determine whether the prostate cells undergo malignant transformation and initiate cancerous growth.

Varicocele disrupts the normal drainage system, causing an increase in hydrostatic pressure within the testicular veins. As a result, testosterone-rich blood from the testicles is redirected into the prostate, leading to higher testosterone concentrations within the prostate tissue. Considering the influence of varicocele on testosterone levels within the prostate, it is reasonable to speculate that individuals with varicocele may be more prone to aggressive forms of PC. On the other hand, those without varicocele, who do not experience this flooding of testosterone, may have slower-growing PC.

Nevertheless, the treatment of varicocele, aimed at restoring normal blood flow and reducing the influx of testosterone into the prostate, holds potential benefits beyond its impact on benign prostatic hyperplasia. By addressing varicocele, it is plausible that the progression of slow-growing prostate cancer could be slowed down. This hypothesis requires further investigation and clinical studies to evaluate the long-term effects and efficacy of varicocele treatment in the context of prostate cancer management.

Gat Goren Method: A Unique Perspective

The Gat Goren method is a non-surgical treatment for benign prostatic hyperplasia (BPH) developed by Dr. Yigal Gat and Dr. Menachem Goren. This method is based on the theory that varicocele, a vascular condition characterized by the damage of one-way valves in the internal spermatic veins, plays a significant role in the development of BPH.

The Gat Goren method focuses on treating this varicocele through a procedure known as sclerotherapy of the spermatic vein. Sclerotherapy is a minimally invasive procedure involving the injection of a solution into the veins to divert blood flow away from the varicocele. This method can significantly shrink prostate volume and function by reducing the influx of testosterone to the prostate gland. Sclerotherapy of the spermatic vein has been observed to relieve the prostate volume in over 80% of men, significantly improving prostate symptoms. This study establishes a clear pathophysiological link between bilateral varicocele and BPH​.

According to this theory, as the one-way valves in the internal spermatic vein are damaged, the vein can no longer effectively serve as a drainage system, leading to an increase in hydrostatic pressure and redirection of undiluted free testosterone (FT) from the testes into the prostate. This sudden influx of undiluted androgen accelerates prostate cell production and prolongs cell lifespan, contributing to the development of BPH.

The broader implications of these findings are significant. If varicocele predisposes men to prostatic pathology later in life, it could be beneficial to establish criteria for preventive treatment via interventional radiology. Treating varicocele could also restore circulating testosterone levels in aging men and ‘naturally’ revive sexual function​.

PAE versus Varicocele Sclerotherapy 

Prostatic Artery Embolization (PAE) and Varicocele Sclerotherapy are minimally invasive procedures used to treat different conditions, but both can impact Benign Prostatic Hyperplasia (BPH).

Prostate Artery Embolization (PAE) and Varicocele Sclerotherapy are two different procedures used to manage Benign Prostatic Hyperplasia (BPH) symptoms.

1. Prostate Artery Embolization (PAE): This minimally invasive procedure involves injecting small particles into the arteries that supply the prostate gland to reduce blood flow and cause the prostate gland to shrink. The primary purpose of PAE is to reduce the size of the enlarged prostate and alleviate BPH symptoms. Multiple studies have reported that PAE significantly improves lower urinary tract symptoms, quality of life, and urinary flow rate while decreasing prostate volume. However, the long-term durability of PAE is still uncertain.
2. Varicocele Sclerotherapy (also part of the Gat Goren Method): This procedure involves the injection of a sclerosing agent into the varicocele to close off the faulty veins causing the varicocele. The primary goal is to redirect the blood flow into normal veins. According to the Gat Goren theory, this varicocele treatment can result in a reduction in prostate volume and an improvement in BPH symptoms. The theory suggests that the varicocele condition leads to excess testosterone flowing to the prostate, causing it to enlarge. Treating the varicocele reduces this extra testosterone flow, potentially reducing prostate size and symptom improvement. One study supporting this theory found that varicocele sclerotherapy substantially reduced prostate volume and improved symptoms in over 80% of the patients.

Similarities and Differences

The main similarity between PAE and Varicocele Sclerotherapy is that they are both minimally invasive procedures that can positively affect BPH symptoms. They also work by altering the blood flow in the body – PAE by blocking the blood flow to the prostate and Varicocele Sclerotherapy by redirecting the blood flow in the scrotum.

However, the procedures differ in their primary targets and treatment mechanisms. PAE targets the prostate and is designed specifically for BPH treatment, while Varicocele Sclerotherapy primarily treats varicocele. The impact on BPH from Varicocele Sclerotherapy is a secondary effect based on the theory of testosterone reflux.

It’s worth noting that while there’s clinical support for PAE as a treatment for BPH, the support for Varicocele Sclerotherapy as a BPH treatment is primarily based on the Gat Goren theory, which, while compelling, is not universally accepted in the medical community. 

So what is next?

What about combining these two treatment methods at the age of BPH risk? Combining these two treatments or implementing preventive monitoring of varicocele in younger generations could be an avenue to explore further. However, this approach would require careful consideration and further research.

To determine the viability of combining treatments, clinical trials would be necessary to establish whether the simultaneous use of Prostatic Artery Embolization (PAE) and Varicocele Sclerotherapy could improve the outcomes for BPH patients. This could be particularly useful in cases where one therapy alone may not be fully effective, or the patient’s medical condition makes them a suitable candidate for both procedures. It’s also worth considering the potential side effects and complications of combining these two treatments, as both involve altering blood flow within the body.

On the other hand, monitoring varicocele in younger generations may help prevent or delay the onset of BPH in later life. Early intervention could reduce the severity of symptoms and improve the quality of life for those at risk. However, the cost-effectiveness and practicality of widespread monitoring also need to be considered. A balance should be struck between preventive healthcare and potential overdiagnosis or overtreatment.

Furthermore, the relationship between varicocele and BPH, although suggested by several studies, needs further substantiation through more rigorous scientific research. As the Gat Goren theory is not unanimously accepted within the medical community, more studies validating this theory are necessary before it can become standard medical practice.

It’s a fascinating study area, and these questions are at the forefront of urological research. As we gain a deeper understanding of the connections between varicocele, BPH, and the aging process, we will uncover more effective treatment strategies and possibly even ways to prevent BPH from developing in the first place.