Originally published 1/22/2018
A 2009 study by Gat, et al. broke new theoretical ground on how a backup of venous blood flow can lead to benign prostatic hyperplasia (BPH) by saturating the prostate gland with testosterone; in turn, this theoretically contributes to hyperactive prostate cell activity, resulting in gland enlargement and urinary problems. This theory led to development of a procedure called prostate artery embolization (PAE) to block the blood’s backflow in the internal spermatic vein (ISV) on the left side of the testicles (detailed in the original blog below). PAE has been clinically tested since then, and shown to be safe and effective but not completely free from risk. By way of update, here are summaries of two 2021 publications:
- A May, 2021 paper out of Yale University offers follow-up urinary symptom changes among 240 men who had PAE between May 2013 – March 2020. Baseline urinary function and quality of life were obtained by standardized scoring questionnaires, which were repeated at one month and 36 months post-PAE for follow-up comparisons. At 1 month, total prostate/urinary symptoms and quality of life were markedly improved, especially voiding function. On average, improved scores were sustained through the 36 months follow up.[i]
- For the patient perspective, a small (15 patients) March, 2021 study out of Sweden sheds light on how men’s experience during and after the procedure, based on post-PAE interviews. It is noteworthy that the PAE procedure time was much longer (about 210 minutes) than typical (average 90 minutes), described by the authors as their “initial experience.” The interviews revealed that some men had “substantial improvement” in urinary function while others were satisfied to simply get fewer sleep interruptions; most could resume daily activities quickly but some felt tired, and a few reported bruising that initially concerned them. On balance, the authors wrote that “From the patients’ perspective, prostatic artery embolization is a well-tolerated method for treating benign prostate hyperplasia.”[ii]
Thus, it appears that for men with backflow problems in the left ISV, PAE is a reasonable treatment.
NOTE: The above statistics were the result of clinical trials. It is, however, the position of the American Urological Association that PAE for the treatment of lower urinary tract symptoms/benign prostatic hyperplasia outside of a clinical trial is not recommended, according to the expert opinion of a panel of urologists.
Think about plumbing in your home: “…backups have a potential for more wide-ranging problems than a sink backup or toilet clog. These issues should be handled quickly by an experienced plumber, ideally at the ‘slow drain’ stage before complete stoppage, to prevent system-wide problems…”[iii]
In 2009, Gat et al.[iv] published a paper that should have made a much bigger splash than it did. They accounted for the origin of two major prostate problems with one simple explanation: blood “backing up” into the prostate from the testicles.
It’s all about proper circulation
Blood constantly circulates from and to the heart. Arteries carry oxygenated blood away from the heart to all parts of the body, and veins return the depleted blood back to the heart and lungs to be re-oxygenated. Arteries pulsate (pump) in time with the heart creating a sort of hydraulic pressure. However, the pumping heart is not strong enough to force blood upward against gravity, e.g. from the toes up the legs into the torso—especially when you’re upright. So, veins rely on two features to keep blood from pooling from the hips down: one-way valves that keep blood from back-flow, and muscle contractions from physical movement that presses the venous (vein) blood onward in its journey back to the heart.
In men, the “plumbing” of blood flow from the testicles back to the heart is complicated. Special “pipes” called the internal spermatic veins (ISV) exist on the right and left sides of the testicles, but they take different routes. The one-way valves in the left ISV are more prone to become faulty due to the effects of gravity over time (aging). If they fail, and blood begins to pool, a network of swollen veins called varicocele begins to form, causing a bulge in the scrotal sac. If both the left and right ISVs fail, it’s called bilateral varicocele. Varicocele is considered the leading cause of male infertility, possibly due to raised temperature from extra blood flow, as well as congested space pressing on one or both testicles.
Poor drainage and backed-up testosterone
If left untreated, prostate problems can begin, because the ISVs also carry de-oxygenated blood away from the prostate. Varicocele can lead to a backup of testicular blood into the prostate because the pressure of the pooled blood is greater than the flow pressure from the prostate. Testicular blood is rich in testosterone, the hormone produced by the testicles and essential for men to develop reproductive organs and secondary sexual characteristics (deep voice, muscle mass, body hair, etc.) According to Gat’s paper, this forces a concentration of testosterone in the prostate gland, and in turn, accounts for prostate troubles much like poor home drainage leads to unpleasant and expensive problems. Suddenly, normal prostate cells are being bathed in “free” or bioavailable testosterone that easily acts on cells. Gat et al. theorize that the presence of a high concentration of free testosterone affects the genes of prostate cells, sending replication and error processes into high gear.
New treatment for two prostate abnormalities
If the Gat theory is correct, the “hyperactivity” of prostate cellular processes accounts for two abnormal conditions that can be treated by cutting off the supply of free testosterone:
- Benign prostatic hyperplasia (BPH) means enlargement of the prostate gland not related to cancerous activity. It is so common, especially in middle-aged and older men, that it’s almost regarded as a “normal” byproduct of aging. BPH can cause urinary frequency, difficulty with urine flow, disrupted sleep from more frequent nighttime urination, etc. The symptoms can lower quality of life, so men often seek treatment ranging from medications to invasive procedures to widen the urinary passage through the prostate. However, an image-guided procedure was developed by Gat & Goren to cut off the backflow of blood into the prostate by causing varicocele to close up and wither away. This cuts off the flow of free testosterone, and in the absence of testosterone, the prostate gland responds by shrinking as it returns to a more normal size. Clinical trials of the procedure have been successful, with few to no side effects, and have demonstrated that the free testosterone theory is on the right track.
- Prostate cancer is more dangerous than BPH because the mutant cancer cells may eventually have the capacity to spread (metastasize) to other parts of the body. Many cell lines of prostate cancer are considered “indolent” or so slow-growing that aggressive whole-gland treatment may not be called for. However, today’s biomarkers – or telltale genetic signatures – are not yet at a stage to predict with 100% confidence which prostate cancers are truly life-threatening. Gat’s theory brings a measure of hope to men with early stage prostate cancer. Their 2009 paper discussed 6 prostate cancer patients with low-risk disease who were treated with the same method used to reduce BPH. In 5 out of the 6, no evidence of cancer was found by biopsy six months after treatment.
Apparently the work of Gat et al. has not yet taken the worlds of urology and interventional radiology by storm. It often takes years for the medical community to embrace a new theory with an accompanying treatment innovation. Perhaps the lack of ongoing research to validate (or invalidate, as the case may be) the work of Gat and his colleagues. However, there is much common sense in what they have put forth, and time will tell if their research turns out to be a game changer for men with prostate cancer or BPH.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Ayyagair R, Powell T, Staib L, Liu B et al. Voiding and storage domain-specific symptom score outcomes after prostate artery embolization for lower urinary tract symptoms and urinary retention. Urology. 2021 May 4;S0090-4295(21)00367-8.
[ii] Holm A, Lindgren H, Bläckberg M, Augutis M et al. Patients’ perspective on prostatic artery embolization: A qualitative study. SAGE Open Med. 2021; 9: 20503121211000908. Published online 2021 Mar 12.
[iii] https://www.mrrooter.com/residential-services/sewer-system-backups/
[iv] Gat Y, Joshua S, Gornish MG. Prostate cancer: a newly discovered route for testosterone to reach the prostate : Treatment by super-selective intraprostatic androgen deprivation. Andrologia. 2009 Oct;41(5):305-15.
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
