[The Indian Practitioner (1971): 6, 281] Clinical Studies with Speman in Cases of Benign Enlargement of Prostate Agarwal, V.K., M.S., F.I.C.S., Professor of Surgery, and Gupta, R.K., M.B.,B.S., Research Scholar, Department of Surgery, G.R. Medical College, Gwalior. (Paper read at the Annual Conference of the Indian Medical Association, Gwalior Branch at Gwalior, March, 1971) INTRODUCTION Second only to atheroma, senile enlargement of the prostate forms the major problem of the rapidly growing science of Geriatrics. Enlargement of the prostate is very common in men over 60 years, and approximately 10 of them develop progressive symptoms of prostatism due to prostatic hyperplasia. Romanis and Mitchiner (1952) recorded the maximum number of, between 55 and 65 years of age. These mostly have difficulty in voiding the urine which they keep on tolerating till an acute condition like retention occurs. This postponement of the treatment is due to the fear of surgery and too often the treating family doctor asks a specialist at the request of the patient, if surgery can be avoided. Generally, the removal of the gland is thought to be the only answer. Right from McGill who first published a report on suprapubic prostatectomy, there has been a constant search for a suitable technique and most of the urogenital surgeons prefer, trans-urethral resection as the best in which only a tubular passage is nibbled out from the gland, so that the obstruction to the urinary flow is removed. Surgery in these is not free from pre- and postoperative morbidity and complications which are a real problem to the surgeon. Moreover, we are faced at times with the problem of patients coming to us for treatment of hernia with prostate, when we have to first remove the urinary obstruction (i.e. to do the prostatectomy) and then operate for hernia. This has led to a constant search for some conservative management of these. Usually, available methods are hormonal treatment and Injection treatment which are not always successful. With the same aim, the present study was undertaken with the use of Speman tablets, an indigenous product (Himalaya Drug Co.) in 150 of benign enlargement of prostate of different grades, who attended the outpatient clinic and were admitted to J.A. Hospital, Gwalior. A detailed clinical history of each case was taken and a thorough general, abdominal and rectal examination was done. INVESTIGATIONS Routine urine and blood examination. Blood urea estimation Serum acid and alkaline phosphatase estimation. Measurement of residual urine. Biopsy (per rectum) in doubtful.
Cases which came as retention of urine were catheterised and in those where a catheter could not be passed, suprapubic cystomy was done to relieve the retention and Speman two tablets three times a day was given, initially for 15 days and when improvement was seen, Speman therapy was continued for 3 months. OBSERVATIONS Table 1 shows the presenting symptoms. In the present series 42 had an acute retention of urine. Table I Presenting symptoms Percentage Acute retention of urine 62 42 Burning & difficulty in passing urine 29 19 Frequency of micturition 28 18 Dribbling of urine 24 16 Haematuria 7 5 Table II shows main complaints. The main complaints were frequency of micturition, pain and burning during micturition. These were present in over 60 of the. Dribbling of urine was present in over 46 of. Table II Complaints Percentage Frequency of micturition 105 70 Dribbling of urine 69 46 Pain & burning during micturition 89 63 Haematuria 12 8 Feeling of fullness in rectum & perineum 13 9 Retention of urine 74 49 Table III shows age-wise distribution. Sixty-eight per cent were between the ages of 51-70 years. Table III Age Percentage 41 to 50 years 23 15.25 51 to 60 years 51 34 61 to 70 years 51 34 71 to 80 years 24 16 81 and above 1 0.75 Table IV shows residual urine. Amongst the clinical investigations, measuring the residual urine is quite reliable and only in 36 (24), it was found to be normal. In 25.3 of it was between 1 and 4 oz. and in 39 (25.9) it was above 4 oz. In the remaining it could not be measured. Table IV Residual urine Percentage Nil 36 24 1 oz. to 4 oz. 38 25.3 5 oz. to 8 oz. 16 10.6 8 oz. and above 23 15.3 Could not be measured 37 24.8
Table V shows blood urea levels. Blood urea was found raised above 40 mg./100 ml. in 20.6 of. Table V Blood urea level Percentage Below 40 mg. per 100 cc. 117 78 Above 40 mg. per 100 cc. 31 20.6 Could not be measured 2 1.4 Table VI: For purpose of evaluation, the were divided into three grades according to per rectum size of the prostate. Forty-two were in Grade I, 70 in Grade II and 38 in Grade III. Table VI Grades Size of prostate as felt per rectum Percentage Grade I + 42 28 Grade II ++ 70 46.5 Grade III +++ 38 24.5 Table VII shows response to Speman in Grade I hypertrophy of prostate. Cases in Grade I were 42, out of which frequency was present in 36 and was relieved in 33, showing 91 response. Pain and burning were present in 29, out of which 27 were relieved showing a response of 96. Dribbling of urine was present in 17 and was relieved in 14, giving a response of 83. Residual urine was present in 15 and it was nil in all after the treatment. Per rectum size of the prostate was after treatment in 10. Table VII Complaints present Frequency of micturition 36 24 66 9 25 33 91 3 8 Pain & burning during micturition 28 22 77 5 18 27 96 1 4 Dribbling of urine 17 22 70.5 2 12 14 83 3 17 Residual urine 15 12 80 3 20 15 100 Per rectum size of prostate (+) 42 19 24 10 24 32 76 Table VIII shows response to Speman in Grade II hypertrophy of prostate. Under Grade II, there were in all 70. Frequency was relieved in 34 out of 38, i.e. in 74. Pain was relieved in 31 out of 45, i.e. in 69. Dribbling of urine was relieved in 20 out of 41. Residual urine was in 15 out of 31 (49), prostate in size after treatment in 10. Fifteen patients only required 1st stage operation and in 10 both stages were done. Table VIII Complaints present No. oaf Frequency of micturition 48 13 27 21 47 34 74 14 26 Pain & burning during micturition 45 11 25 20 44 31 69 14 31 Dribbling of urine 41 6 14 14 34 20 48 21 52 Residual urine 31 5 16 10 33 15 49 16 51 Per rectum size of prostate (++) 70 5 14 5 14 10 28 60 72 1st stage done 15 15 2nd stage done 10 10
Table IX shows response to Speman in Grade III hypertrophy of prostate. Thirty-eight were grouped under Grade III. Pain and burning were relieved in 3 out of 21 and slight reduction in residual urine was observed in one case. Per rectum size was not affected in any case. First stage was done in 13. Both stages were done in 17. Table IX Complaints present Frequency of micturition 20 20 100 Pain & burning during micturition 21 3 14 3 14 17 56 Dribbling of urine 16 16 100 Residual urine 16 1 6 1 6 15 94 Per rectum size of prostate (+++) 38 38 100 1st stage done 13 1st & 2nd stage done 17 DISCUSSION Benign hypertrophy mainly affects the lateral and median lobes of the prostate. The bilateral lobe enlargement compresses the urethra with intravesical enlargement of the prostate which leads to obstruction to the urinary flow. As pointed out early, the only accepted treatment is surgical and in that too the T.U.R. is said to be the best, where a tubular passage in the prostatic urethra is nibbled out to remove the obstruction. If the same objective could be achieved by conservative methods, where the compression of the prostatic urethra may be relieved by the reduction in the size of the prostate, it would give great relief to the patients and their doctors. Out of the conservative methods available, hormonal treatment has not been very successful. The other procedure of injection of sclerosing agents in the prostatic tissue to reduce the size is a more drastic approach and has limitation in the selection of. The results cannot be predicted and in the event of failure of the treatment, successive operation becomes more difficult due to fibrosis and there are many reported complications like haematuria, urethritis, epididimo-orchitis and the stay in the hospital is about three weeks to 3 months which is almost the same as after prostatectomy. While in the present series with Speman tablets the results were excellent in Grade I where symptoms like frequency of micturition, burning during micturition and dribbling of urine were relieved in over 90, while the residual urine was abolished in all the, which may be accounted either to the reduction in the size of the prostate or to the improvement of the tone and contractibility of the bladder due to the relief of the exhaustion produced by frequency and chronic stretching of the bladder wall. The response to Speman had practically no response. Seven which were not included in the series, were detected to have malignancy of the prostate by raised acid phosphatase level and later confirmed by biopsy. These showed no response to Speman though the size of the prostate was of Grade I and II. The exact action of Speman is not known. It is a combination of drugs which have decongestant, astringent, anti-inflammatory and diuretic actions. There is experimental evidence that Speman potentiates the action of the adrenaline on the seminal vesicles; adrenaline is known to cause contraction of the smooth muscles including those of splenic capsule. Hence, by the same
mechanism Speman may potentiate the action of adrenaline on the prostatic capsule and thus cause a reduction in the size of the prostate as well as relieved prostatic congestion. Speman is practically completely non-toxic and since it has yielded satisfactory results in of benign enlargement of the prostate the potential utility of this therapeutic approach is advocated, particularly because of the serious nature of the complications and morbidity of operative treatment. SUMMARY A clinical study with Speman in 150 of different grades of benign enlargement of prostate was carried out over a period of two years at the Department of Surgery, G.R. Medical College, Gwalior. Speman gave excellent results in Grade I, good in Grade II and no effect in Grade III : thus showing that the effect of Speman can be predicted in these. This therapy is free from any complications and due to the simplicity of its use by general practitioners, it has opened a new era in the conservative management of benign enlargement of the prostate. ACKNOWLEDGEMENT We are thankful to Dr. I.P. Agarwal, M.S., F.A.M.S., Dean, G.R. Medical College, Gwalior, for permission to publish the hospital records. We are also thankful to the Himalaya Drug Co., for the research grant and the generous supply of Speman tablets. REFERENCES 1. Romanis, W.H.C. and Mitchiner, P.H. (1952): The Science and Practice of Surgery, 1952. 2. Talwar, G.L. (1966): Inj. Treatment of Enlargement of Prostate, Brit. J. Surgery, 53: 421.