Analysis of temperament/mizaj of men with benign prostatic hyperplasia: a novel research

INTRODUCTION

Benign prostatic hyperplasia (henceforth BPH) refers to the prostate gland enlargement which is one of the commonest non-malignant neoplasm to affect men beyond middle age.¹ It has been found to influence approximately 10% of men in their 30s, 20% of men in their 40s, 60% of men in their 60s, 80% of men in their 70s, and 90% of men in their 80s. Dihydrotestosterone (DHT) derived from testosterone with the help of 5-α reductase is probably a major stimuli for stromal and glandular proliferation of prostate in men with nodular hyperplasia.^2,3 Unani system of medicine is based on the humoral theory proposed by Hippocrates, father of medicine, which states that any disturbance in the ratio of four humors, Akhlat, viz; blood, bile, phlegm and black bile, is responsible for disease, and so is in BPH. In this system of medicine, BPH can be traced under the headings of waram-i-unuq al-mathāna (swelling at the bladder neck) and insidād majrā-i-mathāna (bladder outlet obstruction).^4-6 The most common manifestations of BPH known as lower urinary tract symptoms (LUTS), are divided into obstructive and irritative symptoms.¹ Obstructive symptoms include; hesitancy, straining, weak flow, prolonged voiding, partial or complete urinary retention, and overflow incontinence, while as irritative symptoms are much disturbing to the patient include; increased frequency of micturition, urgency with urge incontinence, nocturia and painful urination. In terms of Unani literature these symptoms are discussed as ‘usr al-bawl (dysurea), ihtibas al-bawl (anuria), taqtīr al-bawl (dribbling), salas al-bawl (incontinence), etc.^5,6 Severity of symptoms is quantified by American urological association symptom index. A symptom score of <8 is considered to be mild disease which needs watchful waiting, a score of >8 indicates moderate to severe symptoms where treatment plan is devised, and in case of complications surgical intervention is mandatory.^7,8 The basic principle of Unani treatment is to normalize the humoral disequilibrium and altered temperament. LUTS has been managed for centuries with herbal medicines yet demanding a comprehensive scientific validation. Knowing the temperament of men having LUTS associated with BPH will help in appropriate selection of herbs and other Unani remedies for its treatment and productive research. It might prove a breakthrough in managing BPH and decreasing the burden on conventional medicines and their side-effects.

The current study was thus performed to assess the temperament (mizaj) of men having BPH.

METHODS

In a cross sectional study sixty (60) diagnosed cases of BPH were assessed for temperament according to the temperament chart recommended in Unani literature (Table 1). The study was conducted along with a randomized controlled trial at Regional Research Institute of Unani Medicine (RRIUM), Srinagar, Kashmir for a period of one year (December 2018 to December 2019). The data obtained was analyzed by using SPSS, version 20.0.

Range of temperament in numbers are sanguine: 7.5-10; phlegmatic: 5.10-7.50; bilious: 2.51-5.00: melancholic: 0.00-2.50.

Damwī

Balghamī

Safrāwī

Sawdāwī

Inclusion criteria

Men in age group of 40-79 years, patients complaining of LUTS, serum prostate specific antigen <10 ng/dl.

Exclusion criteria

Patients <40 and >80 years of age, intellectually disabled patients, serum prostate specific antigen >10 ng/dl, patients with debilitating diseases like chronic heart disease, chronic kidney disease, liver disease and hypertension.

RESULTS

While assessing the temperament (mizaj) of 60 diagnosed BPH patients, 44 men were found to have phlegmatic temperament (balghamī al-mizaj), 12 men possessing sanguine temperament (damwī al-mizaj) and 4 men were having bilious temperament (safrawī al-miaj). However, it was astonishing to see none of the patient having melancholic temperament (sawdawī al-mizaj). The distribution of patients as per their temperament is shown in Table 2.

Apparently majority of men suffering from BPH are having phlegmatic temperament (73.3%), moderately fair percentage of men are having sanguine temperament and a very little percentage possessing bilious temperament. The derived relationship can be easily understood from the given pie chart (Figure 1) and bar chart (Figure 2).

DISCUSSION

Sixty (60) BPH patients were assessed for their temperament during a study conducted at RRIUM Srinagar. For statistical analysis, recorded data was entered in a spread sheet and SPSS version 20.0. Variables were expressed in terms of percentage. Table 2 shows ceiling number of patients i.e., 44 (73.3%) in the sample having phlegmatic temperament (balghamī al-mizāj) followed by 12 (20%) of patients having sanguine temperament (damwī al-mizāj) and only 4 (6.7%) of patients having bilious temperament (safrāwī al-mizāj). None of the patients among study groups was having melancholic temperament (sawdāwī al-mizāj). This study indicates that BPH is more prevalent in patients of phlegmatic temperament. These finding can be supported in several ways; firstly it is much accepted theory that hormones especially testosterone and dihydrotestosterone are responsible for causing BPH and in Unani concept all the hormones belong to the white humor (khilt-i-balgham) among the four humors.^3,9-13 Secondly the swelling (waram) of the prostate in BPH is not painful or tender nor have any burning sensation as found in inflammation and moreover in such a swelling induration is felt.⁹ All these properties are those of swelling produced due to overindulgence or altered white humor/phlegm (khilt-i-balgham).⁶ Lastly, obesity and decreased physical activity tend to increase the risk of BPH according to latest researches and the humor responsible for both, obesity as well as decreased physical activity, is phlegm (khilt-i-balgham) according to Unani perspective.^12,14 Furthermore, Unani books of medicine have given detailed list of symptoms produced in phlegmatic diseases (amarād-i-balghamīyya), some of the most important symptoms of it include, abnormally white colored urine (bawl-i-abyad), increased frequency of micturition or polyurea (kathrat-i-bawl), urgency and incontinence (salas al-bawl).^15,16 The current study reflects the preponderance of patients with phlegmatic temperament. All this discussion makes it more obvious and rational that benign prostatic hyperplasia (sal`a ghudda-i-madhī/waram ghudda-i-madhī) is more prominent in men with phlegmatic temperament and is most likely a phlegmatic disease (marad-i-balghamī).

The present study however may not be considered extensive one due to the small sample size, limited data and also because the study sample was selected from a limited geographical area. Thus much extensive studies with larger sample size, carried out at multiple centers, from different geographical regions are required.

CONCLUSION

According to Unani concept a person can have any type out of four given temperaments, i.e., sanguine, bilious, phlegmatic or melancholic, depending upon which type of humor is in predominance. The current study advocates that BPH is commonest among men with phlegmatic temperament (balghami al-mizaj) and is a phlegmatic disease (marad-i-balghami). This study hence could pave the way for further researches that help in achieving best possible alternative treatment and prevention plan for BPH.

ACKNOWLEDGEMENTS

The authors are thankful to Dr. Naquibul Islam, HOD Moalajat and Dr. Seema Akbar, head of the institute, RRIUM, Srinagar for their support during the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Das S. A concise text book of surgery. 10th ed. Kolkata: Das; 2018: 1140-1145,1152,1154.
2. 2. Longo L, Fauci S, kasper L, Braunwald E, Hauser L, Jamesom L, eds. Harrison’s principles of internal medicine. 18th edn. Vol I. New York: McGraw Hills; 2012:804-805.
3. 3. Roehrborn CG. Male lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH). Med Clin North Am. 2011;95(1):87-100.
4. 4. Ahmad SI. Kulliyat-i-Asri. New Delhi: New Public Press and Aala Public Press; 1983:9, 91, 184.
5. 5. Sina SR. Alqanoon fil tib (The Canon of Medicine) (Urdu translation by Ghulam Hasnain kantoori). Vol III. New Delhi: Ejaz Publishing House; 2010:1018-1019,1023-1024,1028-1030.
6. 6. Jurjani AH. Zakhīra khwarzam shahi (The Treasure of Khwarzam Shah) (Urdu translation by Khan Hadi Hussain). New Delhi: Idara Kitābul Shifa; YNM. Vol VI. 525, 526, 531.
7. 7. Patel ND, Parsons JK. Epidemiology and etiology of benign prostatic hyperplasia and bladder outlet obstruction. Indian J Urol. 2014;30(2):170-6.
8. 8. American Urological Association Practice Guidelines Committee. AUA guidelines on management of benign prostatic hyperplasia: diagnosis and treatment recommendations. J Urol. 2003;170(2 Pt 1):530-47.
9. 9. Kumar V, Abbas AK, Fausto, Mitchel, eds. Robin’s basic pathology. 8th ed. Philadelphia: Saunders; 2007: 696-697.
10. 10. Nicholson TM, Ricke WA. Androgens and estrogens in benign prostatic hyperplasia: past, present and future. Differentiation. 2011;82:184-99.
11. 11. Ajayi A, Abraham K. Understanding the role of estrogen in the development of benign prostatic hyperplasia. Afr J Urol. 2018;24(2):93-7.
12. 12. Kabiruddin M. Kitāb Al-Akhlāt. New Delhi: CCRUM; 2009: 79,85.
13. 13. Kabiruddin M. Kulliyat-i-Nafeesi. Part I. New Delhi: Idara Kitābul Shifa; 1954:62-63.
14. 14. Parsons JK, Sarma AV, McVary K, Wei JT. Obesity and benign prostatic hyperplasia: clinical connections, emerging etiological paradigms and future directions. J Urol. 2013;189:102-6.
15. 15. Chandpuri Q. Mojiz al-Qanūn. 3rd edn. New Delhi: NCPUL; 1998:116,120.
16. 16. Khan MA. Aksīr-i-Azam (New version by Kabiruddin). New Delhi: Ejaz Publishing House; 2010:728-734.