Enlargement of the prostate affects 50% of all men over age 60 and almost 90% of men over age 80. There were 375,000 U.S. hospitalizations for this condition in 1993.
Prostate Gland Anatomy
The prostate is a walnut sized gland located between the base of the bladder and the base of the penis. The urethra drains the bladder and passes through the center of the prostate and then into the penis. The prostate is made of firm glandular tissue surrounded by a fibrous capsule. It contains muscular tissue which squeezes prostatic fluid into the urethra as part of an ejaculate. It also is surrounded by nerves that are critical to men for achieving and maintaining an erection.
Benign Prostatic Hypertrophy
Benign Prostatic hypertrophy (BPH) is a universal condition in men as they age. BPH is initially characterized by a decrease in the force of the urine stream beginning as men reach their 40?s or 50?s. Urination takes longer and longer. Eventually, there is incomplete emptying of the bladder and men note the need to awaken from sleep to urinate (nocturia). They may have to urinate five or more times at night if they delay treatment. Sometimes, medications such as decongestants may exacerbate difficulties in urination because of their effect on the nerves of the prostate that squeeze the urethra.
Detection of BPH
Prostatic hypertrophy is detected with a digital rectal exam (DRE), as is early prostate cancer. Both conditions affect men as they age. It is important to distinguish between the two conditions since they are treated completely different and have dramatically different consequences. On DRE, the prostate of BPH feels smooth, but may be enlarged to a peach size. A blood test for Prostatic Specific Antigen (PSA) rises in men as they age but usually remains under 4.0 ug/ml in BPH. Prostate cancer tends to have higher levels of PSA. If the physician is uncertain that the DRE is completely normal or the PSA is borderline, a Directed Rectal Ultrasound (DRUS) is often performed. A small probe inserted in the rectum can provide a two dimensional image of the prostate, looking for irregular nodules associated with cancer. If uncertainty still exists, a transrectal biopsy using a thin needle is recommended. Assuming the biopsy results do not show cancer (negative biopsy), treatment for BPH begins. Generally, only a DRE and PSA are performed prior to making the diagnosis of BPH.
Although men of all ages may get infections, those with enlarged prostate glands may have difficulty with prolonged episodes. Often the diagnosis of chronic prostatitis may be obscured by the symptoms of benign prostatic hypertrophy. The evaluation and treatment of prostatic infections requires careful follow-up to ensure the infection is eradicated. The treatment period may require several months. A history of prostatitis , however, does not increase the risk of BPH. For more information on prostatic infections, see an article and patient handout in American Family Physician.
Three types of treatment are commonly used for BPH. Two involve the use of medication and one is surgical. The surgical treatment is called a trans-urethral resection of the prostate (TURP). A probe with blades at the end is inserted in the penis. The blades are rotated when they are inside the prostatic urethra scraping away the inside of the urethra and widening the passageway. This is sometimes referred to as a "Roto-rooter" in layman?s terms. The recovery from the TURP involves using a urinary catheter for several days and the entire recovery process takes several weeks. It usually provides several years of relief. Risks of surgery include bleeding, infection, impotence and incontinence (involuntary loss of urine). A pilot may return to flying after the surgeon has cleared him or her to return to full activity following the surgery. The surgery should be reported on the next FAA physical exam. Controllers must get specific clearance from the Regional Flight Surgeon before returning to work. Other forms of surgical approaches are currently under study including laser therapy, heat and microwave treatment.
Medical Treatment - Alpha blockers
Recently, two types of medical treatment have gained popularity. One type involves using medication to relax the muscles in the prostate. Medications of this type are called alpha blockers. They were initially used to control high blood pressure. Naturally, a potential side effect is low blood pressure and even fainting, particularly when arising in the morning when first starting the medication. For this reason, medications are initially given in low doses and gradually increased over several days to weeks. The medications work immediately. These medications only relieve the symptoms of BPH, but do nothing to slow the progression of the condition. Commonly used medications include terazosin (Hytrin), doxazosin (Cardura) and tamsulosin (Flomax).
The FAA will approve pilots to fly and controllers to control on these medications after they are stabilized on their FINAL dose and tolerate the medication without side effects. The major side effect is lowered blood pressure, possibly with lightheadedness on standing. Pilots may return to flying when cleared by their AME or after reporting to the FAA. Controllers report through the Regional Flight Surgeon. The reports should include the reason the medication is prescribed, the dosage and frequency, a listing of the blood pressure on the final dose and a statement regarding the absence of side effects.
Medical Treatment - Testosterone Inhibition
The second category of medication inhibits the conversion of testosterone and it's action on the prostate. Prostatic growth is slowed or reversed. This medication works gradually and may require several weeks to note any improvement in urinary symptoms. It must be taken continuously to maintain its effect. The medications in this category include finasteride (Proscar). Finasteride has recently been approved in lower doses as a possible hair growth stimulant and to slow male balding. It is marketed under the name Propecia. The major side effect is sexual dysfunction or impotence in about 4% of men taking the product. The FAA will allow pilots to fly on this medication once they have taken it for at least two days without any side effects. The pilot may report this medication at his next FAA medical examination. Controllers must report use through the Regional Flight Surgeon before returning to duty.
Herbal Treatment - Saw Palmetto
Recently, the use of the herb saw palmetto for treatment of benign prostatic hypertrophy has gained popularity. The saw palmetto tree, Serena repens, produces a fruit whose fat soluble extract is very useful in treating the symptoms of Benign Prostatic Hypertrophy (BPH). Its activity comes from the reduced uptake of the powerful male hormone dihydroxytestosterone (DHT) in the cells of the prostate and by inhibiting the enzyme 5-alpha-reductase. The commercial medication finasteride (Proscar) also works by blocking 5-alpha-reductase. Numerous controlled and blinded studies on humans have demonstrated the effectiveness of saw palmetto. Its action may be equal to finasteride, with a faster onset of action and far fewer, less significant side effects. Saw palmetto does not affect serum PSA levels, which are sometimes used to screen for prostate cancer.
A 1998 review article in the Journal of the American Medical Association (JAMA) documents a meta-analysis of 18 randomized controlled trials of saw palmetto verifying saw palmetto's effectiveness in short term studies. The FDA prohibits the sale of saw palmetto as a medical treatment for BPH, but does not regulate its use as a "nutritional supplement." The German Commission E approves its use with a recommended dose of 320 mg of the standardized lipophilic extract.
Pilots and controllers electing to use saw palmetto should buy from a manufacturer who meets the FDA Good Manufacturing Practices. Contact us for more specific information. Use of this product is not reportable to the FAA on your medical application. However, visits to healthcare practitioners are reportable.
For a more specific personal explanation to your questions or those concerning aeromedical certification, contact VFS for a private consultation. For help in reporting treatment for and obtaining clearance from the FAA to fly and control with these conditions, refer to the VFS Confidential Questionnaire. If you are a VFS Corporate Member, these services are FREE to you.