Paying the price for standing tall: Fluid mechanics of prostate pathology

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madman

Super Moderator
Abstract

Background:
Age‐dependent increase in the incidence of benign prostatic hyperplasia (BPH) and prostate cancer (PCa) are both related to cell proliferation and survival controlled by intraprostatic free testosterone (FT) concentration. Paradoxically, BPH and PCa occur as circulating testosterone levels decrease, so any possible relationship between testosterone levels and development of BPH and PCa remains obscure.

Results: In BPH the enlarging prostate is exposed to high testosterone levels arriving directly from the testes at concentrations about a hundredfold higher than systemic FT. This occurs because venous blood from the testes is diverted into the prostate due to the elevated hydrostatic pressure of blood in the internal spermatic veins (ISVs). Elevated pressure is caused by the destruction of one‐way valves (clinically detected as varicocele), a unique phenomenon related to human erect posture. While standing, human males are ISVs vertically oriented, resulting in high intraluminal hydrostatic pressures—a phenomenon not found in quadrupeds. In this communication, we demonstrate the fluid mechanics' phenomena at the basis of varicocele leading to prostate pathology.

Conclusions: So far, varicocele has been studied mostly for its etiologic role in male infertility and, thus, for its effects on the testes. It is becoming clear that varicocele is a major etiologic factor in BPH and likely also in PCa. Restoring normal testicular venous pressure by treatment of the abnormal ISV's in varicocele has been shown to avert the flow from the prostate with the effect of reducing prostate volume, alleviating symptoms of BPH, and increasing concentrations of circulating FT.







9 | CONCLUSIONS

1. The reasons for the age‐dependent increase in the levels of testosterone in the prostate can be understood from the fluid mechanic's analysis of the reversal of blood flow from testicles to the prostate.

2. Failure of the OWVs in ISVs, the major conduit of venous blood from the testes, increases hydrostatic pressure in the testicular drainage system, reduces the supply of oxygenated blood to testicular tissue, and leads to male infertility and decreased testosterone production. The same hydrostatic feature diverts venous blood from the testes directly to the prostate. As this blood takes to the prostate undiluted testosterone (rather than a hundredfold lower concentration normally supplied by arterial blood), it stimulates prostate cell proliferation leading to prostate enlargement and possibly cancer.

3. Testosterone levels in peripheral blood do not reflect testosterone levels in the prostate and are not related to prostate pathology.


4. Preventing the flow of undiluted FT from the testes directly to the prostate can arrest and reverse, if performed early, the development of BPH, and, possibly, localized PCa. This is accomplished by occluding all vertically oriented malfunctioning veins of the testicular venous drainage bilaterally.
 

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madman

Super Moderator
Screenshot (1909).png

FIGURE 1 Schematic presentation of the anatomy and venous blood flow in normal and pathological testicular and prostatic venous drainage systems. A, Under normal conditions, most venous blood from the testes drains into the internal spermatic veins (ISVs) where one‐way valves assist in lifting it towards the heart. From the prostate, venous blood is driven by the upwards pressure gradient of 6 mm Hg in the venous plexus/Santorini plexus of the prostate to the vena cava (where the pressure is –5 mm Hg). B, Destruction of one‐way valves in ISVs reverses downwards the direction of the hydrostatic pressure in the right ISV up to 27 mm Hg and up to 32 mm Hg in the left ISV. This produces the pressure gradient from the deferential vein (DV) in the direction of the prostatic venous plexus (PVP) partially diverting the free‐testosterone rich testicular venous efflux via DV to PVP and Santorini plexus directly into the prostate. C, Occlusion of the faulty ISVs and their newly formed collaterals (indicated by the gray areas) eliminates the pathological venous overpressure and restores normal pressure relationships within the testes/prostate venous system, and reestablishes normal pressures within the venous drainage system. CI, common iliac vein; CV, cremasteric vein; DV, deferential vein; II, internal iliac vein; ISV, internal spermatic vein; IVC, internal vena cava; K, kidney; OWV, one‐way valve; P, prostate; PP, pampiniform plexus; PVP, prostatic venous plexus; RV, renal vein; SAN, Santorini plexus; SV, scrotal vein; T, testis; VP, vesicular plexus; VV, vesicular vein [Color figure can be viewed at wileyonlinelibrary.com]
 

madman

Super Moderator
Screenshot (1910).png

FIGURE 2 Venographic visualization of the prostate and its relationship to the testicular venous system. Intravenous contrast material was introduced into the lower part of the ISV of the patient with bilaterally destroyed one‐way ISV valves. Following the destruction of one‐way valves within internal spermatic veins, hydrostatic pressure in the testicular venous drainage is higher than in prostate venous drainage resulting in testicular venous backflow into the prostate along the pressure gradient from pampiniform plexus via the deferential vein and Santorini's plexus. This is visualized by the contrast material “blush” to the prostate capsular region. In this case, the contrasting blush can be considered to represent the abnormal venous blood flow from the testes in the absence of one‐way valves; it contains free testosterone at concentrations hundredfold above that in arterial blood that arrives in the prostate by the prostatic artery. (Reproduced from Gat et al11 with permission.)
 

Joe Sixpack

Active Member
Now if they could only develop a treatment for BPH based on the ideas in this paper. Would be a major improvement from what we have available now.

It is also reassuring to see that high levels of circulating androgens are not the cause of BPH. I have had a doctor tell me this in the past.

Good find Madman. And God bless you for crawling pubmed so I don't have to!!
 
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