Enlarged Prostate (BPH): Symptoms, Causes & Treatment Options

What Is Benign Prostatic Hyperplasia (BPH)?

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland that occurs naturally as men age. The enlarged prostate can press on the urethra and bladder, causing urinary symptoms like frequent urination, weak stream, and difficulty starting urination.

The prostate is a walnut-sized gland located just below the bladder that surrounds the urethra, the tube that carries urine from the bladder out of the body. The prostate's primary function is to produce fluid that nourishes and transports sperm during ejaculation. Throughout a man's life, the prostate continues to grow, and this growth is what leads to benign prostatic hyperplasia in many older men.

Understanding the anatomy helps explain why prostate enlargement causes urinary symptoms. Because the prostate wraps around the urethra like a donut, any increase in its size can squeeze the urethra and restrict urine flow. This mechanical compression is responsible for many of the bothersome symptoms that bring men to seek medical care.

The term "benign" is important because it means this condition is not cancerous and does not spread to other parts of the body. While BPH and prostate cancer can sometimes occur together (since both become more common with age), having BPH does not make you more likely to develop prostate cancer. This is a crucial distinction that provides reassurance to many men diagnosed with prostate enlargement.

BPH is one of the most common conditions affecting older men worldwide. Research shows that approximately 50% of men will have some degree of prostate enlargement by age 60, and this percentage increases to about 80% by age 80. However, not all men with an enlarged prostate experience bothersome symptoms. Studies indicate that only about half of men with BPH develop lower urinary tract symptoms significant enough to require treatment.

Why Does the Prostate Enlarge?

The exact cause of benign prostatic hyperplasia is not fully understood, but it is clearly linked to hormonal changes that occur with aging. Testosterone and its more potent form, dihydrotestosterone (DHT), play key roles in prostate growth. As men age, changes in the balance of sex hormones appear to stimulate prostate cell growth.

Interestingly, men who are castrated before puberty (and therefore have very low testosterone levels throughout life) do not develop BPH. This observation supports the hormonal theory of prostate enlargement. The enzyme 5-alpha reductase converts testosterone to DHT within the prostate, and this process becomes a target for one class of BPH medications.

Genetic factors also play a role in BPH development. Men with a family history of prostate enlargement, particularly if a father or brother required treatment at a relatively young age, are more likely to develop significant BPH themselves. Studies suggest that men with affected first-degree relatives have a four-fold increased risk of needing surgical treatment for BPH.

Risk Factors for Enlarged Prostate

Several factors increase the likelihood of developing BPH or experiencing more severe symptoms. Age is the most significant risk factor, with prevalence increasing steadily after age 40. By the eighth decade of life, histological evidence of BPH is present in the vast majority of men.

• Age over 50: Risk increases progressively with each decade of life
• Family history: Genetic predisposition plays a significant role
• Obesity: Higher body mass index is associated with larger prostate size
• Diabetes: Metabolic syndrome and diabetes increase BPH risk
• Heart disease: Cardiovascular conditions are linked to worse urinary symptoms
• Physical inactivity: Sedentary lifestyle may worsen symptoms

What Are the Symptoms of an Enlarged Prostate?

Common symptoms of BPH include needing to urinate frequently (especially at night), a weak or interrupted urine stream, difficulty starting urination, feeling that your bladder doesn't empty completely, and sudden urges to urinate. Symptoms typically develop gradually and may worsen over time without treatment.

The symptoms of benign prostatic hyperplasia are often referred to as lower urinary tract symptoms (LUTS). These symptoms can significantly impact quality of life, affecting sleep, daily activities, and even emotional well-being. Understanding the different types of symptoms helps both patients and doctors assess the severity of the condition and choose appropriate treatment.

Symptoms of BPH are typically divided into two categories: obstructive (voiding) symptoms and irritative (storage) symptoms. Obstructive symptoms occur because the enlarged prostate physically blocks urine flow, while irritative symptoms result from the bladder's response to chronic obstruction. Most men with BPH experience a combination of both types.

It's important to recognize that symptom severity doesn't always correlate with prostate size. Some men with significantly enlarged prostates have minimal symptoms, while others with modest enlargement experience substantial bother. The location of the enlargement (how much it grows toward the urethra) and individual bladder function play important roles in determining symptom severity.

Obstructive (Voiding) Symptoms

Obstructive symptoms occur when the enlarged prostate physically restricts urine flow through the urethra. These symptoms are often the first to appear and are typically most noticeable during urination itself.

• Weak urine stream: Reduced force and caliber of the urinary stream
• Hesitancy: Difficulty initiating urination, needing to wait before flow begins
• Intermittency: Urine stream that stops and starts during voiding
• Straining: Need to push or bear down to urinate
• Prolonged urination: Taking longer than normal to empty the bladder
• Terminal dribbling: Continued dripping after urination should be complete
• Incomplete emptying: Sensation that the bladder is not fully empty after urinating

Irritative (Storage) Symptoms

Irritative symptoms develop as the bladder adapts to chronic obstruction. Over time, the bladder muscle may become overactive, leading to these bothersome symptoms that affect quality of life even between urinations.

• Frequency: Needing to urinate more often than normal (more than 8 times per day)
• Nocturia: Waking up multiple times at night to urinate
• Urgency: Sudden, compelling need to urinate that is difficult to delay
• Urge incontinence: Involuntary urine leakage associated with urgency

How Symptoms Progress Over Time

BPH symptoms typically develop gradually over many years. In the early stages, men may notice only minor changes in their urinary pattern, such as a slightly weaker stream or needing to urinate once during the night. These mild symptoms often go unnoticed or are dismissed as normal aging.

Without treatment, symptoms may slowly progress. However, progression is not inevitable. Research shows that about one-third of men with mild BPH will see their symptoms improve spontaneously, one-third will remain stable, and one-third will experience worsening over time. This variability makes regular monitoring important.

Some men experience acute urinary retention, a sudden and complete inability to urinate despite having a full bladder. This is a medical emergency that requires immediate catheterization to drain the bladder. Acute retention can occur spontaneously or be triggered by factors like cold medications, alcohol, or prolonged bladder overdistension.

When Should You See a Doctor for Urinary Symptoms?

See a doctor if urinary symptoms affect your quality of life, you notice blood in your urine, have pain when urinating, or symptoms are getting progressively worse. Seek emergency care immediately if you cannot urinate at all, have severe abdominal pain, or develop fever with urinary symptoms.

Many men delay seeking medical care for urinary symptoms because they assume it's just a normal part of aging. While BPH is indeed common, it's important to have symptoms evaluated by a healthcare provider. A proper diagnosis ensures you receive appropriate treatment and rules out other conditions that may require different management.

Your doctor can help determine whether your symptoms are likely due to BPH or another condition, assess severity, and discuss treatment options tailored to your situation. Even if your symptoms are mild, establishing a baseline allows for better monitoring over time.

Consider scheduling an appointment if you experience any of the following:

• Urinary symptoms that bother you or affect your daily activities
• Waking up more than twice per night to urinate
• Feeling that your bladder never fully empties
• Difficulty starting or maintaining your urine stream
• Blood in your urine (even if only occasional)
• Pain or burning during urination
• Symptoms that are gradually getting worse

How Is an Enlarged Prostate Diagnosed?

BPH is diagnosed through a combination of medical history, symptom questionnaires (IPSS), physical examination including digital rectal exam (DRE), urinalysis, PSA blood test, and often ultrasound to measure prostate size and post-void residual urine. Additional tests like uroflowmetry may be recommended.

The diagnostic process for BPH typically begins with a thorough medical history and physical examination. Your doctor will ask about your symptoms, including when they started, how severe they are, and how they affect your daily life. They'll also inquire about your medical history, medications you take, and any family history of prostate problems.

A standardized questionnaire called the International Prostate Symptom Score (IPSS) is commonly used to assess symptom severity. This seven-question survey helps quantify symptoms and track changes over time. Scores range from 0 to 35, with higher scores indicating more severe symptoms.

Physical Examination

The physical examination includes a digital rectal exam (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 it may feel awkward, the DRE takes only a few seconds and provides valuable information.

During the DRE, the doctor checks for any unusual firmness, nodules, or asymmetry that might suggest prostate cancer. A normal prostate should feel smooth and slightly rubbery. The DRE also helps estimate prostate size, although ultrasound provides more accurate measurements.

Laboratory Tests

Several laboratory tests are typically ordered as part of the BPH evaluation:

• Urinalysis: Checks for blood, signs of infection, or other abnormalities in the urine
• PSA (Prostate-Specific Antigen): A blood test that can be elevated in BPH, prostatitis, or prostate cancer. PSA helps rule out cancer, though elevation alone is not diagnostic
• Blood creatinine: Assesses kidney function, which can be affected by long-standing urinary obstruction

It's important to understand that PSA levels can be elevated in BPH, not just prostate cancer. Larger prostates produce more PSA, and inflammation can also cause temporary elevations. Your doctor will interpret your PSA result in context with other findings.

Imaging and Functional Tests

Several additional tests may be recommended depending on your symptoms and initial findings:

• Transabdominal ultrasound: Measures prostate size and checks for residual urine after voiding
• Transrectal ultrasound (TRUS): Provides more detailed prostate images, often used if cancer is suspected
• Uroflowmetry: Measures the rate and pattern of urine flow, helping assess obstruction severity
• Post-void residual (PVR): Measures how much urine remains in the bladder after urination
• Cystoscopy: Direct visualization of the urethra and bladder with a thin scope
• MRI: May be recommended if there's concern about prostate cancer

How Is Benign Prostatic Hyperplasia Treated?

BPH treatment options include watchful waiting for mild symptoms, medications (alpha-blockers and 5-alpha reductase inhibitors), and surgery for severe cases. The best treatment depends on symptom severity, prostate size, overall health, and personal preferences. Many men with mild symptoms don't need active treatment.

Treatment for BPH is tailored to each individual based on symptom severity, prostate size, the presence of complications, overall health status, and personal preferences. The good news is that multiple effective treatment options exist, and most men can find significant relief from their symptoms.

The three main treatment approaches are watchful waiting (active surveillance), medical therapy, and surgical intervention. The choice between these depends on how much symptoms bother you, the risk of disease progression, and your willingness to accept potential treatment side effects.

Watchful Waiting (Active Surveillance)

For men with mild symptoms that don't significantly impact quality of life, watchful waiting may be the best initial approach. This doesn't mean ignoring the problem; rather, it involves regular monitoring along with lifestyle modifications to manage symptoms.

Lifestyle changes that can help reduce BPH symptoms include:

• Limit fluids before bedtime: Stop drinking 2-3 hours before sleep to reduce nighttime urination
• Reduce caffeine and alcohol: Both can irritate the bladder and increase urine production
• Double voiding: After urinating, wait a moment and try again to empty the bladder more completely
• Timed voiding: Urinate on a schedule rather than waiting until you feel urgent
• Stay physically active: Regular exercise can help reduce urinary symptoms
• Review medications: Some drugs (decongestants, antihistamines, diuretics) can worsen symptoms

With watchful waiting, you'll typically have annual check-ups to monitor symptoms and watch for any progression. Many men with mild BPH never need more aggressive treatment.

Medication Treatment

When symptoms are moderate or lifestyle changes aren't providing enough relief, medications can be very effective. Two main classes of drugs are used for BPH, and they work through different mechanisms:

Alpha-Blockers

Alpha-blockers (such as tamsulosin, alfuzosin, silodosin, and doxazosin) work by relaxing the smooth muscle in the prostate and bladder neck. This reduces the pressure on the urethra and improves urine flow. These medications provide relatively quick relief, with most men noticing improvement within 1-2 weeks.

Common side effects of alpha-blockers include dizziness, low blood pressure when standing, fatigue, and retrograde ejaculation (where semen goes into the bladder instead of out through the penis during orgasm). Newer, more selective alpha-blockers like tamsulosin tend to have fewer cardiovascular side effects.

5-Alpha Reductase Inhibitors

5-alpha reductase inhibitors (finasteride and dutasteride) block the conversion of testosterone to dihydrotestosterone (DHT), the hormone primarily responsible for prostate growth. These medications can actually shrink the prostate by 20-30% over time, reducing both symptoms and the risk of complications.

Unlike alpha-blockers, 5-alpha reductase inhibitors take 3-6 months to reach full effect. They work best for men with larger prostates (over 40 grams) and are particularly effective at reducing the risk of acute urinary retention and the need for surgery. Side effects may include decreased libido, erectile dysfunction, and reduced ejaculate volume.

Combination Therapy

For men with moderate to severe symptoms and larger prostates, combining an alpha-blocker with a 5-alpha reductase inhibitor may be more effective than either drug alone. Major clinical trials have shown that combination therapy reduces symptoms and disease progression more than monotherapy.

Surgical Treatment Options

Surgery may be recommended when medications don't provide adequate relief, you develop complications (recurrent urinary retention, bladder stones, kidney problems), or you prefer a more definitive treatment. Modern surgical options are generally safe and highly effective.

Transurethral Resection of the Prostate (TURP)

TURP has been the gold standard surgical treatment for BPH for decades. During this procedure, a surgeon inserts a scope through the urethra and uses an electrical loop to remove excess prostate tissue blocking the urethra. No external incisions are needed.

TURP typically provides excellent symptom relief, with 85-90% of men experiencing significant improvement. The procedure requires general or spinal anesthesia and usually involves 1-2 nights in the hospital. Recovery takes 4-6 weeks, during which time you may experience some bleeding and urinary symptoms.

Laser Procedures

Various laser techniques have been developed as alternatives to TURP. These include:

• HoLEP (Holmium Laser Enucleation): Removes prostate tissue using a holmium laser. Effective for very large prostates and may cause less bleeding than TURP
• PVP (Photoselective Vaporization): Uses a green light laser to vaporize prostate tissue. Often performed as an outpatient procedure with faster recovery
• ThuLEP (Thulium Laser Enucleation): Similar to HoLEP, using a different laser type

Minimally Invasive Procedures

Several newer, less invasive options are available for men who want to avoid traditional surgery or who may not tolerate more extensive procedures:

• UroLift: Small implants hold the enlarged prostate tissue away from the urethra. Preserves sexual function and can be done as an outpatient procedure
• Rezum (Water Vapor Therapy): Uses steam to destroy excess prostate tissue. Minimally invasive with quick recovery
• TUMT (Transurethral Microwave Therapy): Uses microwave energy to heat and destroy prostate tissue

Open or Robotic Prostatectomy

For very large prostates (typically over 80-100 grams), open surgery through an abdominal incision or robotic-assisted surgery may be recommended. These procedures remove the enlarged portion of the prostate and provide excellent long-term results but require longer hospital stays and recovery time.

What Complications Can Occur with Untreated BPH?

Untreated severe BPH can lead to acute urinary retention (complete inability to urinate), recurrent urinary tract infections, bladder stones, bladder damage, and kidney problems. Most men don't develop serious complications, but symptoms that progressively worsen should be evaluated.

While many men with BPH never develop serious complications, long-standing urinary obstruction can lead to problems if left untreated. Understanding these potential complications helps emphasize the importance of proper monitoring and timely treatment when needed.

Acute Urinary Retention

Acute urinary retention is the sudden, complete inability to urinate despite having a full bladder. This condition is painful and requires emergency catheterization to drain the bladder. Triggers can include certain medications (decongestants, antihistamines), alcohol, cold temperatures, or prolonged bladder overdistension.

Men who experience acute urinary retention are at higher risk for recurrence and often benefit from definitive treatment such as surgery to prevent future episodes.

Chronic Urinary Retention and Bladder Problems

When the bladder can never fully empty, the muscle wall may stretch and weaken over time. This chronic overdistension can lead to overflow incontinence, where small amounts of urine leak continuously. The bladder may eventually lose its ability to contract effectively, making emptying even more difficult.

Urinary Tract Infections

Incomplete bladder emptying creates a stagnant pool of urine where bacteria can grow. Men with significant post-void residual urine are at increased risk for recurrent urinary tract infections. Symptoms include burning with urination, cloudy or foul-smelling urine, and sometimes fever.

Bladder Stones

Minerals in retained urine can crystallize and form bladder stones. These stones can cause pain, blood in the urine, and worsen urinary obstruction. Bladder stones usually require treatment in addition to addressing the underlying BPH.

Kidney Damage

In severe, long-standing cases, back pressure from an obstructed, overdistended bladder can affect the kidneys. This condition, called hydronephrosis, can potentially lead to kidney damage if not corrected. Fortunately, kidney function usually improves once the obstruction is relieved.

How Can You Manage Life with an Enlarged Prostate?

Managing BPH involves lifestyle modifications such as limiting evening fluids, avoiding caffeine and alcohol, staying physically active, and practicing bladder training techniques. Regular monitoring with your doctor, taking medications as prescribed, and addressing symptoms early helps maintain quality of life.

Living with BPH is manageable for most men, especially with proper treatment and lifestyle adjustments. Many men find that simple behavioral changes significantly reduce symptom bother, even without medication.

Creating good habits around fluid intake is one of the most effective self-management strategies. Spreading fluid intake throughout the day rather than drinking large amounts at once helps prevent bladder overdistension. Limiting fluids for 2-3 hours before bedtime can substantially reduce nighttime urination.

Physical activity provides multiple benefits for men with BPH. Regular exercise helps maintain a healthy weight (obesity worsens BPH), reduces sympathetic nervous system activity that can affect urinary symptoms, and promotes overall prostate health. Even moderate activities like daily walking can make a noticeable difference.

Bladder training techniques can help improve control over urination. Timed voiding (urinating on a schedule rather than waiting for urgency) helps train the bladder and prevents overdistension. When you feel urgency, pausing and doing pelvic floor contractions can help suppress the urge and allow you to delay urination until convenient.