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Urological health Part 2: Nutrition for urological health, Prostate cancer and Andropause in Men


Man eating healthy

Eating for general urological health


The Mediterranean diet shows promising results preventing and managing urological diseases The mediterranean diet mostly consists of wholegrains, legumes, fruits, vegetables, nuts and olive oil. Dairy, red meat, sugar, processed foods and saturated fats are limited while focussing more on fish, chicken and plant-based protein. The Mediterranean diet is high in fibre and antioxidants. The MD is associated with a lower risk of obesity, metabolic syndrome, Type 2 Diabetes, and certain cancers including stomach, colorectum, pancreas and liver. 

 

Phytochemicals, like carotenoids, found in plants may have cancer- fighting properties. Carotenoids may have a protective role in the development of urological cancers including prostate, bladded and kidney cancer. Lycopene is one of the carotenoids that may decreased prostate cancer risk.  Many studies have confirmed the preventative potential of carotenoids, but large randomized trials of supplementation are needed to establish specific guidelines and recommendations. Because of this, it is recommended to include all fruit and vegetables for cancer preventions. Urological cancers including bladded, prostate and kidney cancer are affected by environmental factors and dietary habits. Obesity and metabolic syndrome is a risk factor for kidney cancer and increases the risk of bladder and prostate cancer.

 

A healthy diet is important in managing urological and renal diseases like an overactive bladder, prostatitis, interstitial cystitis, and chronic renal failure. Dietary recommendations are disease specific and should also be individualized. Here are some key recommendations for common urological conditions (note that these should still be individualized):


Overactive bladder (OAB):

Sudden involuntary contraction of muscles in the bladder causing urinary urgency. OAB may be caused by MS, dementia, Parkinson and diabetic neuropathy. Estrogen deficiency in postmenopausal women.


Dietary consideration:

  • Avoid caffeine and caffeinated beverages like coffee, tea, fizzy drinks and energy drinks. Caffeine is a diuretic and increase urine output, therefore should be avoided

  • Limit acidic fruit juice like orange and grapefruit juice as these may alter the pH of the urine and exacerbate symptoms

  • Limiting acidic foods like tomatoes may also be helpful

  • Alkalizing the urine may be beneficial by taking 2-4 g of sodium bicarbonate 2 x per day

  • Avoid artificial sweeteners

  • A high fibre diet is recommended to prevent constipation (which may put pressure on the pelvic floor muscles)

  • In postmenopausal women foods containing phytoesterogens like yam and carrot is recommended

  • 600 IU of vitamin D per day mau result in relaxation of the muscles in the bladder

  • Mild to moderate fluid restriction, especially at night, may be necessary

 


Interstitial cystitis (IC):

Persistent desire to urinate, urinary frequency, voiding small volumes of urine and pelvic pain. May be caused by defects in the lining of the bladder.


Dietary recommendations:

  • Avoid citrus foods

  • Avoid caffeine and fizzy drinks

  • Avoid artificial sweeteners

  • Avoid alcohol

  • Calcium glycerophosphate and sodium bicarbonate supplementations may be beneficial to manage symptoms

  • A elimination diet (avoiding bladder irritants) may be beneficial to identify triggers

 


Prostatitis:

Inflammation of the prostate gland causing discomfort, and increased urinary frequency, urgency, pressure sensation and often fever.


Dietary recommendations:

  • A wheat and gluten free diet may be beneficial

  • Limit / avoid spices and hot peppers

  • Avoid alcohol

  • Follow a high fiber diet to prevent constipation

  • Zinc supplementation may be beneficial

 


Benign prostatic hyperplasia (BPH):

Characterized by symptoms such as reduced urine flow, frequent urination, urgency, and nocturia.


Dietary recommendations:

  • Plant-based diet—rich in beans, peas, lentils, vegetables, and sesame seeds, similar to the Mediterranean diet—has been shown to improve urinary symptoms and lower the risk of developing lower urinary tract symptoms (LUTS)

 

Nephrolithiasis:

Kidney stones (calcium, uric, struvite and cystine).


Dietary recommendations:

  • Drink enough fluids

  • Uric Acid Stones: Reduce intake of red meat and shellfish due to high purine content, which increases uric acid levels. Focus on fruits, vegetables, and whole grains, and limit alcohol

  • Calcium Oxalate Stones: Avoid high-oxalate foods such as spinach, nuts, and rhubarb. While calcium intake should not be excessively restricted (as it can affect bone health), avoid high-calcium foods like dairy products

  • Calcium Phosphate Stones: Limit sodium intake to reduce calcium loss in urine. Also, avoid high-oxalate foods

  • Cystine Stones: Reduce consumption of meat and salt,and increase intake of fruits and vegetables to lower urine acidity

 

 

Erectile dysfunction (ED):

Linked with age, diabetes, hypertension, and cardiovascular disease.


Dietary recommendations:

  • Mediterranean Diet: A diet rich in fruits, vegetables, nuts, and whole grains, and low in red meat, can decrease ED prevalence and improve sexual activity

  • Salt Reduction: Excessive salt intake can lead to hypertension and atherosclerosis, impairing blood flow and exacerbating ED. Avoid high-salt foods like bacon, ham, and chips

 


Chronic kidney disease.

Diet should be individualized by a dietitian according to the stage of kidney disease, blood results and whether dialysis is initiated.


Dietary recommendations are focused on limiting electrolytes such as sodium, potassium, phosphate, limiting protein and restricting fluids intake.

 


Bladder cancer

Dietary recommendations:

  • Cruciferous Vegetables: Consuming vegetables like broccoli sprouts, kale, and cabbage may lower the risk of bladder cancer. These vegetables contain isothiocyanates, which have protective effects against cancer

  • Tea Consumption: Drinking tea may also help reduce the risk of bladder cancer

  • Avoid Contaminated Water: Drinking water contaminated with arsenic can increase the risk of bladder cancer, so ensuring clean water is essential

  • The ongoing BLEND study aims to further explore the relationship between diet and bladder cancer risk

 

Certain foods have both benefits and risks related to urologic issues. However, adopting a sensible diet, such as the Mediterranean, MIND, or DASH diet, can reduce the risk of these conditions, help manage their symptoms, and improve overall health.


 


Prostate Cancer


Prostate cancer  


The American Cancer Society reports that one in seven men will have prostate cancer in his lifetime but only one in 36 will die of this disease. PSA levels between 4 and 10 ng/ml indicate a risk of prostate cancer higher than normal. A sign of prostate cancer may present as difficulty urinating- as prostate cancer may cause postrenal urinary tract obstructions.  Family history, age and race are risk factors for prostate cancer development. The prostate tends to starts to slightly enlarge from the age of 40 years old.

 

Obesity:

  • Obesity, age, hyperglycemia, and the incidence of metabolic syndrome play a role in the circulating levels of insulin-like growth factor-1 (IGF-1), a potentially cancer-causing compound. It can promote the development and progression of prostate.

 

Dietary fat:

  • It is important to avoid your intake of Saturated Fatty acids such as red meats, fatty foods, processed foods, fast foods. As this may increase the risk of prostate cancer.

 

Omega 3:

  • Omega 3 has protective qualities against prostate Cancer. Look for an Omega 3 with a high EPA and DHA content. Aim for 1-2g of Omega 3 per day. Omega 3 can be found in fatty fish, nuts and seeds. Often and supplement is recommended (Please note this only refers to Omega 3, not Omega 6 and Omega 9).

 

Plant-based diet:

  • Plant foods may aid in cancer prevention by functioning as cancer inhibitors through anti-inflammatory mechanisms and changes in gene expression and hormone activity


  • Fruits, vegetables, and whole grains contain biologically active phytochemicals, vitamins, minerals, and dietary fiber that have demonstrated functions in preventing and treating disease. Eating more vegetables and fruits further benefit by experiencing less weight gain, and greater satiety and are at a lower risk of developing obesity, thereby reducing overall cancer risk

 

Cooking methods:

  • Avoid smoked foods. Avoid processed meats.

 

Soy:

  • Soy is a plant-based protein, and it contains phytoestrogens (very weak plant-based estrogens) and isoflavones


  • Men with hormone-sensitive cancer such as prostate cancer may benefit from regular consumption of soy foods. Prostate cancer is a testosterone-driven cancer and estrogens (or phytoestrogens) are antagonists


  • Preferred soy-based foods includes: Edamame beans, tofu, or soy milk (Not processed food alternatives)

 

Lycopene:

  • Some studies indicate that foods high in lycopene may provide a protective role in lowering the risk factors for developing prostate cancer. Lycopene is a non-provitamin A carotenoid that is responsible for the red to pink colors seen in tomatoes, pink grapefruit, and other foods

 

Avoid excessive Vitamin E intake:

  • D-alpha tocopherol is the natural form of vitamin E and dl- alpha tocopherol is the synthetic form. Natural forms with mixed tocopherols, specifically gamma tocopherol, may have cardioprotective effects


  • HOWEVER: Doses above 400 IU/day may increase risk for bleeding, prostate cancer, and have prooxidant effects. Avoid exceeding Vitamin E daily requirements. 

 

Decrease calcium intake in you have hypercalcemia:

  • There has been a link proven between high calcium (hypercalcemia) and prostate cancer. It is important to first check for the presence of high calcium before restricting from the diet. Avoid supplementation of calcium.

 

Homeopathic:

  • Serenoa repens (W. Bartram) Small, also known as saw palmetto

    • Some research claims that it is one of the most widely used herbal preparations for the treatment of lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH)

 

Avoid hormone enhancing supplements (such as steroids):

  • Consumption of a prohormone supplement can alter a patient’s hypothalamic-pituitary-gonadal axis. Andro-related hormones may elevate abnormally estrogen-related hormones and alter elevations of serum estrogen, which is thought to increase the risk for developing prostate or pancreatic cancers. Taking DHEA supplements may also enhance the risk of prostate cancer


A man and his son

Genetic Factors:

Prostate cancer (PrCa) is highly heritable, with genetic factors contributing approximately 58% of its risk. Recent large-scale genome-wide association studies (GWAS) have identified 269 germline risk variants. These variants are combined into a polygenic risk score (PRS), which predicts PrCa risk effectively. Men in the top decile of the PRS have over a 50% lifetime risk of developing PrCa, whereas those in the bottom decile have less than a 10% risk. However, current PRS models do not distinguish between aggressive and non-aggressive forms of the disease. Despite this, nearly half of aggressive PrCa cases occur in men within the top quartile of the PRS.

 

Key Genetic Variants:

  • BRCA1/2 and ATM: Men with these variants often face more aggressive PrCa and poorer outcomes. They are at higher risk of disease progression during active surveillance (AS), potentially leading to more severe disease grades


  • NBN and CHEK2: Variants in these genes are linked to increased PrCa risk and poorer survival, particularly in certain populations


  • HOXB13: This variant is associated with a significantly increased risk of PrCa, especially in populations from Sweden and Finland


  • Lifestyle Factors:

    • While no definitive relationship between lifestyle factors and overall PrCa risk is established, evidence suggests that a healthy lifestyle may reduce the risk of dying from PrCa. It is currently unknown how much benefit men at high genetic risk derive from lifestyle modifications

 

Plym, A., Zhang, Y., Stopsack, K.H., Delcoigne, B., Wiklund, F., Haiman, C., Kenfield, S.A., Kibel, A.S., Giovannucci, E., Penney, K.L., and Mucci, L.A., 2023. A Healthy Lifestyle in Men at Increased Genetic Risk for Prostate Cancer. European Urology, 83(4), pp.343-351. Elsevier.

Ni Raghallaigh, H., & Eeles, R. (2021). Genetic predisposition to prostate cancer: an update. Prostate Cancer and Prostatic Diseases, 24(1), 1-13. Received: 29 September 2020 / Accepted: 4 January 2021 / Published online: 24 January 2021.






Testicular Cancer



Testicular cancer occur when malignant (cancer) cells form in one or both testicles.  It is the most diagnosed cancer among men aged 15 to 45 years and its incidence has doubled over the past 40 years. Majority of these tumors are germ cell tumors (GCT), arising from primordial germ cells – the cells destined to become spermatozoa.


Symptoms:

  • Lump on testes

  • Swelling

  • Pain or discomfort

  • Lower abdominal pain or scrotum pain

  • Advanced testicular cancer: low back pain, headaches, shortness of breath, chest pain, confusion


Men are encouraged to do self-examination or to get checked regularly by a doctor.

With effective management, the prognosis is excellent with >90% cure rate and >95% five-year survival rate – most testicular cancers can be cured.

 

 

Environmental and genetic risk factors are involved in the development of testicular cancer.

The primary risk factor for mediastinal germ cell tumors (GCT) is the genetic condition Klinefelter syndrome – when a male is born with an extra copy of the X chromosome – associated with hypogonadism, oligospermia and azoospermia. Genomic sequencing has identified multiple single nucleotide variants associated with an increased risk of testicular cancer.



Genomic Findings:


  • Chromosome 12: GCTs often have a specific genetic change involving the short arm of chromosome 12 (i12p), though the exact genes involved are still unclear


  • Resistance to Treatment: Changes in the TP53 gene and other related pathways are linked to resistance to cisplatin, a common chemotherapy drug. This resistance is often seen in patients who don’t respond well to treatments


  • Tumor Analysis: Studies are examining various aspects of GCTs, such as epigenetics and protein levels. Different GCT types (like seminomas and embryonal carcinomas) have unique mutations, helping to understand their distinct behaviors



Genetic Predisposition:

  • Family Risk: GCTs can run in families, with higher risks for relatives of affected individuals. This suggests a genetic component, but no single high-risk gene has been found yet


  • Current Research: Studies have identified multiple low-to-moderate risk genes and factors that may contribute to GCT risk. The CHEK2 gene has been noted for its moderate association with GCT risk


  • Tumor Development: Research on tumor samples shows that GCTs often have genetic amplifications and deletions and are usually wild-type for TP53. KRAS mutations can develop as GCTs progress from early stages to more advanced forms



The most common environmental risk factors for testicular cancers can be summarized as below:


  • Cryptorchidism (a condition where one or both testicles fail to descend into the scrotum) —2–4 fold increase in risk

  • Family history—relative risk increased 6–10 fold in brothers or sons of affected man

  • Infections - Human papillomavirus (HPV), Epstein-Barr virus (EBV), Cytomegalovirus (CMV), Parvovirus B-19, and Human immunodeficiency virus (HIV)

  • History of subfertility or infertility

  • Testicular trauma

  • High maternal estrogen levels

  • Carcinoma in situ (intratubular germ cell neoplasia)

  • Prior history of testis cancer or extragonadal germ cell tumor

  • Frequent marijuana use may be a risk – data are however lacking

 

The cause of testicular cancer (TC) is not well understood, and limited research has explored the impact of diet on TC risk. In a study of 117 testicular cancer patients and 334 age-matched controls, researchers investigated the relationship between diet and TC. They found that vitamin E intake might lower the risk of nonseminoma and mixed germ cell TC but could increase the risk of seminoma. Fat intake did not affect nonseminoma or mixed germ cell TC risk but was associated with an increased risk of seminoma. Overall, diet was not strongly linked to TC, but different types of TC (seminoma, nonseminoma, and mixed) may have different causes. Future research should continue examining these types separately.

 

Jemal, A., Siegel, R., Xu, J. and Miller, K.D. (2017) 'Cancer statistics, 2017', CA: A Cancer Journal for Clinicians, 67(1), pp. 7-30. Available at: https://acsjournals.onlinelibrary.wiley.com/doi/epdf/10.3322/caac.21819 (Accessed: 12 July 2024). 





Andropause


In men, testosterone is the most prominent androgen. Andropause occurs in some men when testosterone production drops gradually over time as they age. It may take years to notice symptoms. Testosterone levels drop with about 1% per year close to the age of 40. Testosterone deficiency that occur later in life is called late onset hypogonadism, which will result in symptoms. 


Symptoms include:

  • Fatigue

  • Low sex drive

  • Erectile dysfunction

  • Poor concentration

  • Increased body fat mass

  • Depression

  • Decreased bone density

  • Sleep difficulty

  • Mood swings

 

There is an association between androgen deficiency and osteoporosis, cognitive decline and metabolic dysfunction. Testosterone plays a crucial role in reducing risks associated with metabolic syndrome and cardiovascular disease. Low levels of testosterone are linked to higher mortality from cardiovascular issues and a range of metabolic syndrome components, including obesity, hypertension, dyslipidemia, impaired glucose regulation, and insulin resistance. The main treatment includes testosterone replacement to correct hormone deficiency and relieve symptoms. Testosterone therapy is however contraindicated in men with prostate cancer. 


Key points:

  • Relationship with Obesity and Diabetes: Obese men and those with type 2 diabetes often have lower testosterone levels. Low testosterone is associated with a higher risk of metabolic syndrome, particularly in non-overweight, middle-aged men. Regular monitoring of testosterone levels is advised for diabetic men showing symptoms of deficiency


  • Testosterone Treatment: The impact of testosterone replacement on glycemic control and lipid levels is uncertain. While some studies show benefits for insulin sensitivity and anemia, the effects on cholesterol are mixed, with potential risks from high testosterone levels


  • Cognitive Function: Lower testosterone levels might correlate with poorer cognitive performance, especially in older men. Testosterone therapy may have potential benefits, but existing studies are small and inconsistent


  • Mood and Quality of Life: Testosterone therapy can positively affect mood and quality of life, particularly in hypogonadal individuals. However, results vary, possibly due to genetic differences in androgen receptors



Balanced diet, maintaining a healthy body composition and including specific nutrients can play a role in testosterone levels and managing symptoms.


Here are the key considerations:

  • Maintain a healthy body weight. Obesity supresses the production of testosterone by decreasing sex-hormone-binding globulin


  • Include calcium rich foods as testosterone levels effects bone mineral density


  • Zinc Is important for reproductive health and regulating hormones like testosterone. A deficiency is linked to decreased testosterone levels. Include foods like oysters, legumes, meats, chicken liver, nuts…


  • Vitamin D may increase testosterone levels.  Include: salmon, tuna, dairy, mushrooms…


  • Sufficient protein is needed to maintain a healthy muscle mass. A study however found that very high protein diets >3,4g/kg/d may decrease testerone, but moderate protein (1,25-3,4g/kg) do not.


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