Benign Prostatic Hyperplasia (BPH)

What BPH is

The prostate is a walnut-sized gland below the bladder that surrounds the urethra, the tube carrying urine out of the body. It makes part of the fluid in semen. From around age 40, the inner (transition) zone of the prostate often starts to grow. Because it wraps around the urethra, even modest growth can narrow the outflow. The bladder muscle works harder to push urine out, thickens, and over time may become overactive or weak.

Prostate size does not closely match symptoms. Some men with large prostates have few symptoms, while others with modest enlargement have severe ones.

Symptoms

Doctors call these lower urinary tract symptoms (LUTS). They fall into two groups.

Voiding (emptying) symptoms

• weak or slow stream
• difficulty starting (hesitancy)
• straining
• stop-start stream (intermittency)
• dribbling at the end
• a feeling of not emptying fully

Storage symptoms

• needing to urinate often, more than about 8 times a day
• urgency, sometimes with leaking
• waking at night to urinate (nocturia)

Symptoms are often scored with the International Prostate Symptom Score (IPSS), a 7-question form rating mild (0 to 7), moderate (8 to 19) or severe (20 to 35) symptoms, plus a quality-of-life question.

Causes and risk factors

The exact cause is not fully understood. Contributing factors include:

• age: the strongest risk factor
• hormones: testosterone is converted to dihydrotestosterone (DHT) in the prostate, which drives growth. Men without testicles do not develop BPH
• family history
• metabolic factors: obesity, type 2 diabetes, heart disease and lack of exercise are linked to more symptoms

Things that commonly worsen symptoms: caffeine and alcohol, drinking large amounts in the evening, cold weather, and medicines such as decongestants (pseudoephedrine) and antihistamines, which can trigger urinary retention.

BPH vs prostate cancer and prostatitis

BPH does not turn into cancer, but both are common and can coexist. Discuss PSA testing with your doctor. See prostate cancer and prostatitis.

Diagnosis

• Symptom history and IPSS score, plus a 3-day bladder diary if night-time urination is prominent
• Digital rectal exam to estimate size and feel for hard or irregular areas
• Urinalysis for blood and infection
• PSA blood test after discussion of benefits and limitations
• Kidney function blood test if retention is suspected
• Uroflowmetry: measures the speed of your stream
• Post-void residual: a bladder ultrasound after urinating to see how much is left
• Prostate ultrasound, cystoscopy or urodynamics before procedures or if the diagnosis is unclear

Treatment

The choice depends on how bothersome symptoms are, prostate size, side effect preferences and whether complications are present.

Watchful waiting and lifestyle

For mild symptoms:

• cut down caffeine and alcohol, especially in the evening
• reduce fluids in the 2 hours before bed, while drinking enough during the day
• double voiding: wait a moment after urinating and try again
• treat constipation
• review medicines that worsen symptoms
• bladder training to stretch the time between visits

Medicines

• Alpha-blockers (tamsulosin, alfuzosin, silodosin, doxazosin, terazosin): relax prostate and bladder neck muscle, improving flow within days. Side effects include dizziness on standing and reduced ejaculate. Tell your eye surgeon if you take one before cataract surgery.
• 5-alpha reductase inhibitors (finasteride, dutasteride): shrink the prostate by about a quarter over 6 to 12 months and reduce the risk of retention and surgery. Best for larger prostates. They lower PSA by about half, which your doctor must account for. Possible sexual side effects.
• Combination therapy: an alpha-blocker plus a 5-alpha reductase inhibitor for larger prostates with moderate to severe symptoms.
• Tadalafil (a PDE5 inhibitor) daily, useful when erectile dysfunction is also present.
• Bladder medicines (antimuscarinics or beta-3 agonists) added for persistent urgency and frequency.
• Desmopressin for night-time overproduction of urine in selected men.

Saw palmetto and other herbal supplements have not shown benefit over placebo in large trials.

Minimally invasive procedures

• Prostatic urethral lift (UroLift): implants hold the prostate lobes apart. Preserves ejaculation.
• Water vapor therapy (Rezum): steam destroys excess tissue.
• Prostatic artery embolization: blocks part of the prostate's blood supply to shrink it.
• Temporary implanted devices in selected cases.

Surgery

• TURP (transurethral resection of the prostate): removes the obstructing tissue through the urethra. A long-established standard.
• Laser procedures: holmium laser enucleation (HoLEP) and photoselective vaporization, useful for large prostates or men on blood thinners.
• Aquablation: water-jet removal of tissue.
• Simple prostatectomy for very large glands.

Surgery gives the greatest improvement in flow but can cause retrograde ejaculation (semen goes into the bladder) and, rarely, incontinence or erectile problems.

Complications

• Acute urinary retention, often triggered by cold medicines, alcohol, constipation or surgery
• Urinary tract infections
• Bladder stones from retained urine
• Blood in the urine from fragile prostate vessels
• Bladder damage and, rarely, kidney damage from long-term obstruction

These complications are reasons to consider procedures rather than continued medicines.

Frequently asked questions

What are the symptoms of an enlarged prostate?

The main symptoms are a weak or interrupted stream, difficulty starting, straining, dribbling, a feeling of not emptying, frequent or urgent urination, and getting up at night to urinate. Some men develop sudden inability to urinate, which is an emergency.

Does BPH lead to prostate cancer?

No. BPH is noncancerous and does not increase the risk of prostate cancer. However, both are common in older men and can occur together, so new urinary symptoms should be checked and PSA testing discussed with your doctor.

What is the best medication for an enlarged prostate?

Alpha-blockers such as tamsulosin work fastest to improve flow. For larger prostates, 5-alpha reductase inhibitors such as finasteride shrink the gland and reduce long-term risks, often combined with an alpha-blocker. Tadalafil helps when erectile dysfunction is also present.

Can an enlarged prostate shrink naturally?

The prostate does not usually shrink on its own. Lifestyle changes can ease symptoms, and 5-alpha reductase inhibitor medicines can shrink it by about a quarter. Weight loss and exercise may help symptoms but do not reliably reduce size.

When is surgery needed for BPH?

Surgery or a procedure is recommended when symptoms remain bothersome despite medicines, or when complications develop: repeated urinary retention, recurrent infections, bladder stones, persistent bleeding or kidney problems. Many men also choose procedures to avoid lifelong medicines.