Enlarged Prostate (BPH): Symptoms, Treatment & Diagnosis

What Is Benign Prostatic Hyperplasia (BPH)?

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland that commonly occurs in men as they age. The prostate surrounds the urethra between the bladder and the penis, and when it grows larger, it can compress the urethra and cause difficulty urinating. BPH does not increase the risk of prostate cancer.

The prostate is a walnut-sized gland that is part of the male reproductive system. Its primary function is to produce seminal fluid that nourishes and transports sperm. The prostate sits just below the bladder and surrounds the upper part of the urethra, the tube that carries urine from the bladder out of the body.

As men age, the prostate naturally tends to grow larger. This growth typically begins after age 40 and continues throughout life. The exact cause of this enlargement is not fully understood, but it is believed to be related to hormonal changes that occur with aging, particularly changes in the balance between testosterone and estrogen. The growth occurs in the inner part of the prostate, which is why it can squeeze the urethra and cause urinary symptoms.

It is important to understand that BPH is a benign condition, meaning it is not cancerous and does not increase your risk of developing prostate cancer. However, both BPH and prostate cancer become more common with age, and they can occur simultaneously. This is why proper medical evaluation is essential to distinguish between the two conditions and rule out cancer.

BPH is extremely common. Approximately 50% of men over 60 years old have histological evidence of BPH, and this percentage increases to over 80% in men over 80. However, not all men with prostate enlargement experience bothersome symptoms. About half of those with BPH will develop symptoms significant enough to require treatment.

Risk Factors for BPH

While BPH is largely a natural consequence of aging, several factors can influence your risk of developing the condition or experiencing more severe symptoms:

• Age: The risk increases significantly after age 50 and continues to rise with each decade
• Family history: Having a father or brother with BPH approximately doubles your risk
• Obesity: Higher body mass index (BMI) is associated with increased risk and more severe symptoms
• Diabetes and heart disease: These metabolic conditions are linked to higher BPH risk
• Sedentary lifestyle: Lack of physical activity is associated with worse urinary symptoms
• Diet: Diets high in fat and red meat may increase risk, while vegetables and fiber may be protective

What Are the Symptoms of an Enlarged Prostate?

The main symptoms of BPH include difficulty starting urination, weak or interrupted urine stream, frequent urination (especially at night), sudden urges to urinate, feeling that the bladder is not completely empty, and dribbling at the end of urination. These symptoms are collectively called lower urinary tract symptoms (LUTS).

BPH symptoms develop gradually over many years and are often initially attributed to "getting older." The symptoms occur because the enlarged prostate compresses the urethra, creating resistance to urine flow. Additionally, the bladder muscle may become thicker and more sensitive over time, contributing to storage and voiding problems.

Medical professionals categorize BPH symptoms into two main groups: voiding symptoms (also called obstructive symptoms) and storage symptoms (also called irritative symptoms). Most men with BPH experience a combination of both types.

Voiding Symptoms (Obstructive)

These symptoms relate to difficulties emptying the bladder:

• Hesitancy: Difficulty starting the urine stream, often requiring straining or waiting
• Weak stream: Reduced force and caliber of the urine flow
• Intermittency: The stream stops and starts during urination
• Straining: Need to push or bear down to urinate
• Incomplete emptying: Feeling that the bladder is not fully empty after urinating
• Terminal dribbling: Prolonged dribbling at the end of urination

Storage Symptoms (Irritative)

These symptoms relate to how the bladder stores urine:

• Frequency: Needing to urinate more often than usual (more than 8 times per day)
• Nocturia: Waking up multiple times at night to urinate
• Urgency: A sudden, compelling need to urinate that is difficult to defer
• Urge incontinence: Leakage of urine with the sudden urge to urinate

Symptom Progression

BPH symptoms typically progress slowly over many years. However, the course is variable. Research shows that about one-third of men with mild symptoms will experience improvement without treatment, one-third will remain stable, and one-third will experience worsening symptoms over time. This unpredictability makes regular monitoring important.

It is worth noting that symptoms can fluctuate based on various factors, including fluid intake, caffeine and alcohol consumption, certain medications, stress, and even cold weather. Understanding these triggers can help manage symptoms more effectively.

When Should You See a Doctor for Urinary Problems?

See a doctor if urinary symptoms affect your quality of life, if you have blood in your urine, if you experience pain when urinating, or if you notice a significant change in your symptoms. Seek emergency care immediately if you cannot urinate at all and have severe abdominal pain, as this indicates urinary retention requiring urgent treatment.

Many men are reluctant to discuss urinary problems with their doctor, often attributing symptoms to normal aging. However, these symptoms can significantly impact quality of life and may indicate underlying conditions that benefit from treatment. A medical evaluation can provide peace of mind and access to effective treatments.

You should schedule a routine appointment with your doctor if you experience:

• Urinary symptoms that bother you or affect your daily activities
• Need to urinate frequently, especially if it disrupts your sleep
• Difficulty starting or maintaining your urine stream
• A noticeable change in your urinary habits

How Is an Enlarged Prostate Diagnosed?

BPH is diagnosed through a combination of medical history, physical examination including digital rectal exam (DRE), urine tests, blood tests including PSA, and often ultrasound to measure prostate size and residual urine volume. Additional tests like uroflowmetry, cystoscopy, or MRI may be needed for complex cases.

Diagnosing BPH involves ruling out other conditions that can cause similar symptoms, such as prostate cancer, prostatitis, urinary tract infection, overactive bladder, or urethral stricture. A thorough evaluation helps your doctor recommend the most appropriate treatment.

Initial Assessment

Your doctor will begin by taking a detailed medical history, asking about your symptoms, their duration and severity, and how they affect your daily life. You may be asked to complete a standardized questionnaire called the International Prostate Symptom Score (IPSS), which helps quantify your symptoms and track changes over time.

Physical Examination

The physical examination includes a digital rectal examination (DRE), where the doctor inserts a gloved, lubricated finger into the rectum to feel the prostate gland. This allows assessment of the prostate's size, shape, and consistency. While the DRE may feel uncomfortable, it is quick and provides valuable information. Most men do not find it painful.

Laboratory Tests

Standard tests include:

• Urinalysis: Checks for blood, infection, or other abnormalities in the urine
• PSA blood test: Prostate-specific antigen (PSA) levels can be elevated in BPH, prostatitis, and prostate cancer. While PSA alone cannot diagnose cancer, it helps guide further evaluation
• Kidney function tests: Blood tests to assess how well your kidneys are working

Imaging and Specialized Tests

Depending on your symptoms and initial findings, your doctor may recommend additional tests:

• Transabdominal ultrasound: Measures prostate size and checks for residual urine (urine left in the bladder after voiding)
• Uroflowmetry: Measures the rate and pattern of your urine flow
• Post-void residual measurement: Determines how much urine remains in your bladder after urinating

Advanced Testing

If initial evaluation raises concerns or symptoms are complex, you may be referred to a urologist for further assessment:

• Transrectal ultrasound (TRUS): Provides detailed prostate images and can guide biopsies if needed
• MRI: Multiparametric MRI can help detect suspicious areas that might indicate cancer
• Cystoscopy: A thin camera inserted through the urethra to directly visualize the prostate, urethra, and bladder
• Urodynamic studies: Detailed tests of bladder function and pressure during filling and voiding
• Prostate biopsy: If cancer is suspected based on PSA or imaging findings

How Is BPH Treated?

BPH treatment depends on symptom severity. Options include watchful waiting for mild symptoms, lifestyle modifications, medications (alpha-blockers, 5-alpha reductase inhibitors), minimally invasive procedures, and surgery (TURP being the gold standard). Many men can effectively manage symptoms without surgery.

Treatment decisions are based on how much your symptoms bother you, the presence of complications, and your personal preferences. The goal is to improve urinary function and quality of life while minimizing side effects. For many men with mild symptoms, no active treatment is needed.

Lifestyle Modifications and Watchful Waiting

For men with mild symptoms that do not significantly impact quality of life, conservative management may be sufficient. This approach, called watchful waiting or active surveillance, involves regular monitoring without active treatment. Studies show that symptoms often remain stable or even improve over time.

Lifestyle modifications that can help manage BPH symptoms include:

• Reduce evening fluid intake: Limit fluids 2-3 hours before bedtime to reduce nighttime urination
• Limit caffeine and alcohol: These substances irritate the bladder and increase urine production
• Double voiding: After urinating, wait a moment and try again to empty the bladder more completely
• Bladder training: Practice holding urine longer to gradually increase bladder capacity
• Timed voiding: Urinate on a schedule rather than waiting for urgency
• Regular exercise: Physical activity can improve urinary symptoms and overall prostate health
• Review medications: Some medications (decongestants, antihistamines, diuretics) can worsen urinary symptoms

Medication Treatment

When symptoms are moderate or bothersome despite lifestyle changes, medications are typically the first-line treatment. Several classes of drugs are effective for BPH:

Alpha-Blockers

Alpha-blockers relax the smooth muscle in the prostate and bladder neck, reducing obstruction and improving urine flow. They work relatively quickly, often within days to weeks. Common alpha-blockers include:

• Tamsulosin (Flomax)
• Alfuzosin (Uroxatral)
• Silodosin (Rapaflo)
• Doxazosin (Cardura)
• Terazosin (Hytrin)

Side effects may include dizziness (especially when standing up), fatigue, and in some cases, retrograde ejaculation (semen going into the bladder instead of out of the penis during orgasm). Newer, more selective alpha-blockers tend to have fewer side effects.

5-Alpha Reductase Inhibitors

5-alpha reductase inhibitors block the conversion of testosterone to dihydrotestosterone (DHT), the hormone that promotes prostate growth. These medications can shrink the prostate by 20-30% over several months. They include:

• Finasteride (Proscar)
• Dutasteride (Avodart)

These drugs take 3-6 months to show full effect and are most beneficial for men with larger prostates. Side effects may include reduced libido, erectile dysfunction, and decreased ejaculate volume. They also lower PSA levels by about 50%, which must be considered when interpreting PSA tests for cancer screening.

Combination Therapy

For men with larger prostates and more significant symptoms, combining an alpha-blocker with a 5-alpha reductase inhibitor may be more effective than either drug alone. Studies show that combination therapy reduces the risk of symptom progression and the need for surgery.

Other Medications

• Tadalafil (Cialis): This phosphodiesterase-5 (PDE5) inhibitor, typically used for erectile dysfunction, is also approved for BPH treatment. It can improve both urinary symptoms and erectile function.
• Anticholinergics: May be added if overactive bladder symptoms (urgency, frequency) persist despite other treatments

Surgical and Minimally Invasive Treatments

Surgery may be recommended when medications are ineffective, side effects are intolerable, or complications develop (such as recurrent urinary retention, bladder stones, or kidney problems). Several surgical options are available:

Transurethral Resection of the Prostate (TURP)

TURP has been the gold standard surgical treatment for BPH for decades. A resectoscope is inserted through the urethra, and excess prostate tissue is removed using an electrical loop. The procedure typically takes 60-90 minutes and requires spinal or general anesthesia.

TURP has a success rate of 85-90% in improving urinary symptoms. Recovery typically involves 1-3 days in the hospital and several weeks of healing. Most men notice improved urination within days to weeks.

Potential complications include:

• Retrograde ejaculation (common, occurring in 65-75% of men)
• Erectile dysfunction (uncommon, 5-10%)
• Urinary incontinence (rare, 1-2%)
• Need for repeat procedure (10-15% at 10 years)
• Bleeding requiring transfusion (uncommon)

Laser Procedures

Several laser techniques offer alternatives to TURP with potentially fewer complications:

• Holmium laser enucleation (HoLEP): Effective for larger prostates, with excellent long-term results
• Photoselective vaporization (PVP/Greenlight): Uses high-powered laser to vaporize tissue, often with less bleeding
• Thulium laser: Similar to HoLEP with comparable outcomes

Minimally Invasive Therapies

Several newer treatments offer less invasive options with shorter recovery times:

• Transurethral microwave therapy (TUMT): Uses microwave energy to heat and destroy prostate tissue
• Water vapor thermal therapy (Rezum): Uses steam to ablate prostate tissue
• Prostatic urethral lift (UroLift): Implants hold prostate lobes apart without removing tissue
• Temporary prostatic stent: A device placed in the urethra to hold it open

These procedures may be performed as outpatient procedures with local anesthesia and may preserve ejaculatory function better than TURP. However, they may be less effective for very large prostates and may have higher retreatment rates.

Open Prostatectomy

For very large prostates (typically over 80-100 grams), open or robotic-assisted prostatectomy may be recommended. This involves removing the inner portion of the prostate through an incision in the lower abdomen. Recovery takes longer than TURP but results are excellent and durable.

What Complications Can BPH Cause?

Untreated or severe BPH can lead to complications including acute urinary retention (inability to urinate), recurrent urinary tract infections, bladder stones, bladder damage, overflow incontinence, and in rare cases, kidney damage. These complications usually develop gradually and can often be prevented with appropriate treatment.

While most men with BPH do not develop serious complications, long-term obstruction can affect bladder and kidney function. Understanding these potential complications helps emphasize the importance of proper monitoring and treatment.

Acute Urinary Retention

This is the sudden, complete inability to urinate despite having a full bladder. It is extremely painful and requires emergency catheterization. Triggers may include:

• Cold weather
• Certain medications (antihistamines, decongestants, some antidepressants)
• Alcohol consumption
• Prolonged immobility
• Surgery requiring anesthesia

Chronic Urinary Retention

This occurs when the bladder cannot empty completely over time. Large amounts of residual urine can lead to overflow incontinence (urine leaking in small amounts) and increase the risk of infections and stones.

Urinary Tract Infections

Incomplete bladder emptying allows bacteria to multiply, leading to recurrent UTIs. Symptoms include painful urination, frequency, urgency, and sometimes fever.

Bladder Stones

Minerals in residual urine can crystallize and form stones. Bladder stones can cause pain, blood in urine, and worsening urinary symptoms.

Bladder Damage

Over time, the bladder muscle can become weakened or overly thick from working against obstruction. This can lead to permanent bladder dysfunction even after the obstruction is relieved.

Kidney Damage

In severe cases, back-pressure from a chronically full bladder can affect kidney function, potentially leading to kidney damage or failure. This is rare with modern diagnosis and treatment.

How Can You Live Well with BPH?

Living well with BPH involves following your treatment plan, making lifestyle adjustments to manage symptoms, attending regular follow-up appointments, and communicating openly with your doctor about any changes. Many men successfully manage BPH for years with minimal impact on their quality of life.

BPH is a chronic condition that requires ongoing management. With proper care, most men can maintain good quality of life and minimize the impact of urinary symptoms on their daily activities.

Regular Monitoring

Even if your symptoms are well-controlled, regular check-ups are important. Your doctor may recommend:

• Annual or biannual symptom assessments
• Periodic PSA testing (frequency depends on individual risk factors)
• Occasional ultrasound to monitor residual urine

Managing Daily Life

Practical strategies for managing BPH symptoms include:

• Know bathroom locations: When out, familiarize yourself with restroom locations
• Plan ahead: Use the bathroom before long trips or events
• Stay active: Regular exercise improves overall urinary health
• Manage stress: Stress can worsen urinary symptoms
• Communicate: Don't be embarrassed to discuss symptoms with your doctor