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New research on Saw palmetto shows that it helps sexual symptoms in men with an
enlarged prostate




Benign Prostatic Hyperplasia (BPH) is a common problem seen in older men. Epidemiological studies suggest that histological signs of BPH are present in 50% of men aged 50 and almost all 80 year old men [1].



As the prostate enlarges, it impinges on the urethra, making it more difficult for urine to flow out of the bladder. This gives rise to what is termed the 'obstructive' urinary symptoms:



" Poor or weak urine flow
" Hesitancy (difficulty starting urination)
" Dribbling at the end of urination




However, obstructive symptoms do not completely explain all the symptoms associated with BPH. An enlarged prostate also appears to irritate or interfere with the nerves controlling the bladder giving rise to 'irritative symptoms' [2]. These are:




" Frequent need to urinate
" Urgent need to urinate (known as urgency)
" Having to get up at night to urinate (nocturia - or night-time urination)




As the problem progresses, an enlarged prostate can also lead to the presence of residual urine in the bladder. This arises because of inability to empty the bladder completely, leaving a small pool of urine even if a man feels that urination is complete.




This 'residue' of stagnant urine increases the tendency for bacterial infections to develop [2]. Clinically, men do not often get cystitis and when they do, it is almost always due to an enlarged prostate.



Sexual dysfunction and the enlarged prostate



The enlarged prostate is not the only problem of the genito-urinary system that can trouble an older man. With increasing age, there is a greater likelihood of developing sexual dysfunction - a set of symptoms encompassing impotence, ejaculatory disorders and loss of libido.



The key factors contributing to sexual dysfunction are:



" Decreased arterial blood flow (the result of 'narrowing of the arteries', arteriosclerosis or atheroma)
" Underlying disease such as diabetes, hypertension, high cholesterol levels, declining liver function, other chronic illness
" Side effects of prescribed medication




Of these, perhaps the most significant factor and predictor of sexual dysfunction is BPH. For instance, men with an enlarged prostate are nearly 4 times more likely to develop erectile dysfunction during the first 2 years after the start of symptoms, compared to men without BPH.




Other studies show that men aged between 30 and 80 have a 38% chance of having erectile dysfunction if they do not have BPH, but 72% if they do. The more severe the symptoms, the more frequent and severe the occurrence of erectile and ejaculatory dysfunctions. [3]




Conventional treatment of BPH does not help sexual dysfunction



It is well-known that standard synthetic medication that may be prescribed as first-line treatment for BPH also increases the likelihood of sexual dysfunction. Erectile dysfunction affects up to 38% of men using 5-alpha-reductase inhibitors such as finasteride, and up to 30% of long-term users of alpha-blockers such as tamsulosin experience abnormal or retrograde ejaculation. [4,5]



The medical response to this dilemma has been to treat these sexual side effects with phosphodiesterase-5 inhibitors such as Viagra - this is a good example of polypharmacy resulting from the need to treat or compensate for a side effect, is expensive and, as one would expect, does not eliminate the problem completely.



It remains the case that sexual function side-effects are the main reason for men stopping prescribed BPH treatment.




What is the role of Saw palmetto?



It is clear that there is strong research data to support the use of Saw palmetto for treating the irritative and obstructive symptoms seen in men with mild to moderate BPH. [6, 7, 8, 9]



At the same time, traditional herbal literature and formularies record the long-standing, empirical use of Saw palmetto by herbalists to treat a number of sexual problems such as loss of libido and impotence.



For example, one account of a patient treated with Saw palmetto for BPH and loss of libido ends with the patient not only restored to his normal vigour but also bemoaning the law which made it illegal for him to have more than one wife [10]



The new research on Saw palmetto



These observations have lead to this question - as Saw palmetto clearly helps urinary symptoms associated with an enlarged prostate, might the herb also help improve the symptoms of sexual dysfunction associated with BPH?



A clinical trial was designed to answer this question. It is the first to specifically recruit men with BPH who were also suffering from sexual dysfunction, and using tests and indicators to quantify the problem.



In the pilot study, 69 men (average age 57 years) with a history of BPH and sexual dysfunction of more than 2 months were treated with Saw palmetto for a period of 8 weeks. The study monitored the effects of the herb on the urinary symptoms of BPH as well as sexual function. [11]



Men with other causes of sexual dysfunction (eg. stress, depression, use of prescribed BPH medication and other drugs known to cause sexual dysfunction) were excluded from the study.



Assessment of bladder symptoms was achieved using the validated International Prostate Symptom Score (IPSS). This showed that symptoms improved by an impressive 51% (from 14.4 to 6.9) during the 8 week study period - in line with previously known research data on the efficacy of Saw palmetto.



Sexual function was assessed using the validated scoring systems - the Brief Sexual Function Inventory (covering sexual drive, erections, ejaculation, and overall satisfaction) and the Urolife BPH Quality of Life (QoL) questionnaire, which covers sexual desire, satisfaction with erections and satisfaction with sex life.



Over the 8 weeks, ability to achieve and keep an erection improved by 64% and problems with lack of drive and ejaculation improved by 54%. Feelings of sexual drive improved by 47% and ability to achieve an erection firm enough to have sexual intercourse improved by 42%. An improvement of 35% in the symptoms listed in the Urolife questionnaire was observed.



Both study participants and investigators judged Saw palmetto to have a beneficial effect, with the investigators being particularly impressed by the safety associated with the remedy. When asked what Saw palmetto had helped most during the study, 8% of the patients indicated erectile function, 26% libido, and 66% erectile dysfunction and libido together.



This pilot study was not placebo controlled and it is clear that more research is needed. Nevertheless, it provides us with the first research evidence that Saw palmetto can help with symptoms of sexual dysfunction associated with BPH - the first clinical data to support one of the traditional indications championed by herbalists many years ago.




[1] Madersbacher S, Studer U E. Benige Prostatahyperplasie. Schweiz Med Forum. Nov 2002; 45: 1068-73
[2] Wilt TJ, et al. Benign prostatic hyperplasia. Part 1 - Diagnosis. BMJ 2008; 336:146-9
[3] Rosen RC, et al. Sexual dysfunction and lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). Eur Url 2005; 47(6): 824-837
[4] Carbone DJ, Hodges S. Medical therapy for benign prostatic hyperplasia: sexual dysfunction and impact on quality of life. Int J Impot Res 2003; 15(4): 299-306
[5] Erdemir F, et al. 5-alpha reductase inhibitors and erectile dysfunction; the connection. J Sex Med 2008; 5(12): 2917-2924.
[6] Iglesias-Gato D, et al. androgen-independent effects of Serenoa repens extract (Prostasan) on prostatic epithelial cell proliferation and inflammation. Phytother Res. 2011; doi 10.1002/ptr3537
[7] Wilt T, et al. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2002(3);Cd001423.doi: 10.1002/14651858.CD001423
[8] Tacklind J, et al. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2010(2); CD001423.doi:10.1002/14651858.CD001423.pub2.
[9] Riedi E, et al. Natural treatment for BPH. Ars Medici, 2005,2:3.
[10] Dr A. L Davidson, Mount Pleasant, Utah, 1896, Traditional Use of Saw Palmetto
[11] Suter A et al. Phytother Res. 2012 Apr 23. doi: 10.1002/ptr.4696



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