Frequent urination, especially at night, is not just a normal part of aging. It could be due to prostate problems. Officially known as ‘benign prostatic hyperplasia'[1], or BPH, an enlarged prostate is the most common prostate problem in men over 50 [2].
While BPH is not cancerous and does not increase the risk of prostate cancer [3], it can significantly impact your quality of life - and you shouldn’t just hope that it gets better on its own.
Here’s everything you need to know about BPH, the signs you should look out for, and what to do if you think you fit the criteria for this condition.
First, where is the prostate, and what does it do?
The prostate is a small, walnut-sized (in a young man) gland located below the bladder, surrounding the urethra. When you urinate, your bladder pushes its contents into the urethra, the tube through which urine exits your body. Because the prostate is wrapped around this opening, when enlarged it can narrow the tube [4].
As part of the male reproductive system, its main job is to produce fluid that nourishes and protects sperm cells. This fluid, together with sperm from the testicles, makes up semen [5].
How your prostate grows
The prostate goes through two main growth periods as you age [6].
The first happens in early puberty, when your prostate doubles in size. The second begins from around age 25, and continues throughout your life [7].
This continued growth is due to age-related hormonal changes - as you age, you tend to produce less testosterone, leaving you with a higher percentage of estrogen [8].
The gland averages about 30-35 grams in size in adult men (about the size of a ping pong ball), and can grow to be larger in older men (anywhere from the size of a tennis ball or larger) [9].
Benign prostatic hyperplasia is when your prostate becomes large enough to cause problems, but as the official name suggests, it is benign, i.e not cancer, and does not raise your risk for prostate cancer [10].
So, why does prostate enlargement cause problems? As the prostate enlarges, it can squeeze down on the urethra (that’s the tube that transports urine from the bladder out of the penis), affecting bladder function [11].
While the symptoms of BPH may be mild to moderate at first, if left untreated, BPH can lead to discomfort, significantly impact the quality of life, and potentially cause complications like bladder, urinary tract or kidney problems [12].
What actually causes prostate enlargement?
The exact cause of benign prostate enlargement, or benign prostatic hyperplasia is not fully understood as what causes the prostate to get bigger, but medical experts have identified several factors that are thought to contribute to its development. These include:
Hormonal changes: Researchers have observed that BPH doesn’t occur in men whose testicles were removed before puberty, suggesting that factors related to aging and the testicles may play an important role in the development of the condition [13].
As men age, there is a gradual decrease in testosterone levels and an increase in the ratio of estrogen to testosterone. This hormonal imbalance is believed to play a role in the growth of the prostate cells [14].
Additionally, the accumulation of the hormone dihydrotestosterone (DHT), a male hormone that contributes to prostate development and growth, may continue even after testosterone levels decline. This ongoing accumulation of DHT can cause prostate cells to keep growing. Notably, men who do not produce DHT have been found not to develop BPH [15].
Aging: Symptoms of benign prostatic hyperplasia typically begin to appear in men over the age of 40, with the prevalence and severity of the condition increasing as men age [16] [17].
Prevalence of BPH by age
The prevalence of benign prostatic hyperplasia increases significantly with age [7]
- 50% of men between the ages of 51 and 60 [18]
- Up to 90% of men older than 80 [18]
In fact, BPH is so common that it has been said that all men will develop an enlarged prostate if they live long enough [19].
Genetics: Studies have suggested that there may be a genetic component to benign prostatic enlargement, with a family history of BPH as a risk factor for clinical BPH [20][17]
It is important to note that while these factors may increase the risk of developing BPH, the condition is not necessarily caused by a single factor alone.
What are the risk factors for BPH?
Risk factors for an enlarged prostate include [21]:
- Aging: An enlarged prostate gland rarely causes symptoms before age 40. After that, the chance of having an enlarged prostate and related symptoms starts to rise
- Family history: Having a blood relative with prostate problems makes you more likely to have problems with your prostate
- Diabetes and heart disease: Diabetes might raise the risk of BPH. So might heart disease
- Lifestyle: Obesity raises the risk of BPH. Exercise can help lower the risk
What are the symptoms in men to watch out for with BPH?
Less than half of all men with BPH actually have symptoms [22], but it’s still a good idea to be aware of what could be a sign of prostate problems. An enlarged prostate can impact or block the bladder, which means frequently needing to urinate is a common symptom of BPH.
Other common symptoms may include [23]:
- Frequent urination, especially at night (nocturia) [24]
- Urgent need to urinate
- Difficulty or delay in starting urination
- Weak or interrupted urine flow, or a stream that stops and starts
- Dribbling at the end of urination
- Not being able to fully empty the bladder
It’s important to note that the severity of symptoms can vary greatly among men with BPH. Some may experience significant discomfort and disruption to their daily activities, while others may have minimal or no symptoms despite an enlarged prostate [25].
If you’re experiencing symptoms like frequent urination, even if they don’t bother you, talk to your health care provider. A routine check could help you determine if you have an enlarged prostate and if there are any causes that could be treated.
Why you should pay attention to signs of an enlarged prostate?
While there’s good news in that BPH doesn’t increase your risk of developing prostate cancer, that doesn’t mean you should ignore the signs of an enlarged prostate.
If left untreated, BPH has a significant risk of progression and can cause further blockage in your urethra, leading to worsening symptoms. It may also cause [26] [27]:
- Urinary tract infection
- Bladder stones, recurrent urine infections and impaired kidney function may all be due to bladder outlet obstruction caused by BPH.
- Blood in your urine (haematuria)
- Kidney damage due to the urine backflow from your bladder up to your kidney. The urine backflow increases pressure on your kidney.
Chapter 2: BPH or Prostate cancer: What’s the difference?
Growing older raises your risk of prostate problems. The three most common prostate problems are inflammation (prostatitis), enlarged prostate (BPH) and prostate cancer [28] [36].
While benign prostatic hyperplasia is not linked to prostate cancer, they do share similar symptoms.
It’s important to understand the difference between the two conditions [29]:
- BPH is a benign (non-cancerous) condition [29]
- Prostate cancer involves the formation of cancerous cells in the prostate tissue [30] [32]
- BPH does not increase the risk of developing prostate cancer, but both conditions share similar risk factors, including being older and having a history of prostate disease [31] [33]
- While BPH has symptoms like difficulty passing urine, acute urinary retention, prostate cancer is typically asymptomatic early on [34]
- In BPH, the prostate enlargement is typically smooth and can be felt during a digital rectal exam [35]
- In prostate cancer, the prostate may feel lumpy or hard during a digital rectal exam [37]
If you experience any concerning symptoms, it’s crucial to consult with a healthcare provider sooner rather than later for an accurate diagnosis.
Can BPH impact sexual function?
Lower urinary tract symptoms associated with BPH are sometimes accompanied by sexual dysfunction, including erectile dysfunction (ED), ejaculatory problems and low libido [38], although there is no direct reason why BPH should cause sexual dysfunction. It may be that these problems all become more common with ageing.
Some treatments of benign prostatic hyperplasia however can lead to side effects that may affect sexual function, such as [39] [40] :
Chapter 3: What should you do if you think you have BPH?
What should you do if you think you have an enlarged prostate, or experience some of the symptoms of BPH?
If you think you have an enlarged prostate or experience symptoms due to BPH, it’s always a good idea to consult a doctor or healthcare provider. Here are steps that you could take:
1. Make an appointment with your doctor or healthcare provider. Describe your symptoms in detail, such as difficulty urinating, weak urine stream, frequent urination, or a feeling of incomplete bladder emptying.
2. When discussing your benign prostatic hyperplasia symptoms, you may be asked to complete a questionnaire like the International Prostate Symptom Score (IPSS) [41] to assess the severity of your symptoms and their impact on your daily life. Your healthcare provider can use this score to assess your condition and monitor its progression over time. By comparing your scores from different visits, they can determine if your symptoms are improving, remaining stable, or worsening.
3. Your doctor can also perform a physical examination, including a digital rectal exam to evaluate the condition and size of the prostate.
4. Additional tests may be ordered [42], such as urine tests or a blood test. Imaging tests like an ultrasound or cystoscopy could also be ordered to get a better view of your prostate and bladder.
5. Based on the severity of your symptoms, your age, and overall health, your doctor will recommend the appropriate treatment plan. For mild to moderate symptoms, you may be recommended lifestyle changes and self-care measures to help the management of benign prostatic hyperplasia. However, if your symptoms are more severe or if you have complications related to benign prostatic hyperplasia, your healthcare provider may refer you to a specialist urologist for further evaluation and treatment.
A urologist has specialised training in diagnosing and treating conditions affecting the urinary tract and male reproductive system.
Remember, early detection and intervention can help prevent complications and improve your quality of life. Don't hesitate to discuss any concerns or changes in your symptoms with your healthcare provider, as they can work with you to develop a personalised treatment plan that best suits your needs.
To diagnose BPH, healthcare providers may use various tests and tools, including:
1. International Prostate Symptom Score (IPSS)
The IPSS is a validated questionnaire that helps assess the severity of BPH symptoms [43][44]. It consists of seven questions related to urinary symptoms, with scores ranging from 0 to 35:
- Mild symptoms 0-7
- Moderate symptoms 8-19
- Severe symptoms 20-35
While the IPSS is not a standalone diagnostic tool, it can help to quantify the severity of symptoms, and monitor treatment response.
2. Digital Rectal Exam
A digital rectal exam (DRE) is often the next step for diagnosis [45].
During a DRE, you’ll be asked to lie on your side or bend over while a healthcare provider inserts a gloved, lubricated finger into your rectum to feel the prostate’s size, shape and consistency. This generally 10-15 second examination is an important way for your doctor to find problems, and can help detect prostate enlargement, tenderness, lumps, or hard spots.
3. Urinalysis and Urine flow tests
These tests are performed give your healthcare provider an idea of how badly the urethra is obstructed, as well as checking for infection.
There are a few different types of urine tests [46] [52]:
- Urinalysis: Checks for important things such as blood, signs of infection, glucose (sugar), protein and other abnormalities in the urine. Urine tests are also used to screen for bladder cancer.
- Post-void residual volume (PVR): This measures the amount of urine left in the bladder after urination. This may also be performed before surgery.
- Uroflowmetry: This measures the speed and volume of urine flow.
- Urodynamic pressure flow study: This evaluates bladder pressure during urination.
4. Prostate imaging
Tests can also be performed to see the size and shape of the prostate. These can include [47] [52]:
- Ultrasounds: Visualises the size and shape of the prostate
- Cystoscopy: Uses a small camera to examine the urethra and bladder
- Magnetic resonance imaging (MRA) and computed tomography (CT). These provide detailed images of the prostate and surrounding structures. These are performed if surgery is necessary to reopen the flow of urine.
5. Prostate Specific Antigen (PSA) blood test
PSA is a protein made in the prostate, and these levels go up when the prostate becomes enlarged [48].
The PSA test measures the level of prostate-specific antigen in the blood. While it’s mainly used to screen for prostate cancer, PSA levels can also be elevated in men with BPH. The PSA blood test can be done in a lab, hospital or your doctor’s office. It is advised to avoid sexual activity several days before the test as this could artificially increase the PSA reading [49].
There are a wide variety of benign prostatic hyperplasia treatments available. The best choice of treatment for you depends on how serious your symptoms are, the size of your prostate, and your overall health and your age [50].
Your healthcare provider will help you decide which option is right for you. For some, no treatment may be needed at all, while others may see a benefit from a combination of treatments. Some options include:
Watchful waiting and lifestyle changes
For men with mild to moderate symptoms, a watchful waiting approach might be recommended as the initial approach [51]. This involves regular check-ups with your healthcare provider to monitor symptom progression and prostate health, but no active treatment unless symptoms worsen significantly.
Lifestyle changes
Certain lifestyle modifications can help manage symptoms and may be advised along with watchful waiting and other treatments. These can include [52]:
- Limiting caffeine, alcohol, and fluid intake before bedtime
- Maintaining a healthy weight
- Staying hydrated
- Staying physically active
Watchful waiting combined with lifestyle changes can be an effective first-line strategy for men with mild to moderate symptoms. However, if symptoms progress or interrupt quality of life, medications or surgical interventions may be recommended by the healthcare provider.
Medication
There currently isn’t a cure but medications may help manage mild to moderate symptoms of an enlarged prostate. Options include:
Alpha-blockers: these medications help relax the muscles of the prostate and around the outlet of your bladder to reduce urinary symptoms. These pills do not shrink the prostate, but can provide symptom relief. Side effects may include dizziness, fatigue, and retrograde ejaculation [53] [54] [55].
5-Alpha Reductase inhibitors: 5-ARIs work by blocking the conversion of testosterone to dihydrotestosterone (DHT), a hormone that contributes to prostate growth. These medications can shrink the prostate and improve urine flow over time, and may lower the need for surgery [53] [54] [55].
Continuous use is required to prevent symptoms returning (and may take months to become fully effective), and other side effects include erectile dysfunction and reduced libido [56].
Both these types of medications can be given individually or combined in one capsule.
Minimally Invasive Surgery
For men who do not achieve enough relief with medication or experience significant side effects, minimally invasive surgical procedures may be an option [57] [58].
These are often done as an outpatient and don’t require you to stay overnight [59].
There are several types of minimally invasive surgeries, including [60]:
Prostatic Urethral Lift (PUL)
This minimally invasive outpatient procedure uses a needle to place tiny implants in the prostate that hold open the urethra without cutting, heating or removing prostate tissue [64].
Benefits of PUL can include:
- Minimally invasive outpatient procedure which may be able to be performed under local anesthesia [61]
- Fewer sexual side effects compared to other types of prostate surgery [61] [62] [63]
- Rapid improvement in urinary symptom relief and flow rates, durable to at least 5 years [63]
Success and durability:
- Studies show less than 14% of patients need additional treatment within 5 years after PUL [65]
- Clinical data from a 206-patient study demonstrated rapid and durable symptom relief without compromising sexual function [65]
- Peak flow rates typically improved by 30% [66]
- Current studies have evaluated five years of treatment with PUL and future studies may help to determine long term durability [67].
Potential complications include [68]:
- Risk of needing a repeat PUL or surgery in the future if symptoms return
- Temporary side effects like increased urinary frequency, pain or discomfort during urination, blood in urine, or urinary tract infection.
Considerations include [69]:
- Discuss with your doctor if PUL may impact future MRI quality for prostate cancer detection [69]
- Inform your doctor if you have allergies to nickel, titanium, or stainless steel (common materials used in PUL implants.
Water Vapor Thermal Infusion (WVTT)
This minimally invasive procedure uses a special handheld device with a needle at the end to inject steam directly into the prostate under cystoscopic guidance, destroying prostate cells squeezing the urethra [70] [71].
Benefits of WVTT can include [72]:
- Can be possibly be performed under minimal anesthesia
- Fewer sexual side effects compared to many other surgical treatments [73]
- Efficacy is similar to PUL, but WVTT is considered to be less costly
Success and durability:
- Prostate size diminishes by about 30% over time, localised to the obstructing lobes [74]
- A recent study found efficacy in selected patients with prostates larger than 80ml, with 70% improvement in IPSS score and 59% increase in peak urinary flow after 12 months. [75]
- Studies currently suggest that symptom improvement lasts for at least five years [76].
Potential complications include [77]:
- Temporary side effects like blood in urine, painful or frequent urination, dry ejaculation or narrowing of your urethra.
Considerations include [78]:
- Takes longer to perform and requires more time until peak efficacy is achieved (typically 3 months) compared to prostatic lift procedures.
- Most patients will require a catheter to drain the bladder for the first few days after this procedure.
More invasive surgery
For men with severe symptoms or complications, or when other options fail, more invasive surgical interventions may be necessary:
Transurethral resection of the prostate (TURP)
Although developed in the early 1940s, TURP is still considered the ‘gold standard’ surgical treatment for BPH [79].
TURP is a common surgical procedure that uses electric current or laser light to cut and remove obstructing prostatic tissue, and relieve symptoms of obstruction creating an adequate channel for urine flow [80].
The surgery generally takes about 1 hour, and is performed under anesthesia, with a tool called a resectoscope inserted through the penis, cutting tissue and sealing blood vessels [81].
Benefits of TURP can include [82]:
- Definitive removal of blocking tissue, with no prostate size or shape limits
- Substantial tissue provided for pathological examination
- Quick relief of symptoms and stronger urine flow soon after the procedure
Success and durability:
- Roughly 90% of patients indicate resolution or significant improvement in urinary symptoms after TURP, with an average reported degree of improvement of 85% [83]
Potential complications include [83]:
- It is expected that most, if not all, post-TURP patients will develop retrograde ejaculation and have no ejaculate, but erectile function is otherwise preserved in 90% of patients
- Persistent urinary symptoms
- Transurethral resection syndrome (TUR syndrome)
- Infection (UTI)
- Incontinence (usually resolves within 3 months)
- Urinary retention
Considerations include:
- A catheter is likely to be needed to drain the bladder for a short period after TURP [85]
Laser Therapy (Holmium laser enucleation of the prostate (HoLEP)
HoLEP uses high-powered laser to remove excess prostate tissue. In general, it removes the prostate tissue blocking urine flow and prevents tissue from growing back [86].
Benefits can include [87]:
- Lower risk of bleeding compared to TURP
- Ability to manage larger prostates (>75 to 100g) without the need for an open procedure [88]
- Generally lower risks of sexual dysfunction post-surgery compared to traditional surgery, although still carries a high risk of retrograde (backward) ejaculation
- No incisions are needed, and you may only be required to stay one night at the hospital [89]
Success and durability:
- In a 2021 study, researchers found the success rate was 80.5% among 266 people who went home on the same day of their surgery between 2013 and 2019. The success rate was 87% for people who had surgery after 2017 [90]
- Meta-analysis has shown significantly improved urinary flow rates, reduced PVRs, and overall symptom improvement comparable to TURP [91]
Potential complications include [92]:
- Temporary urinary incontinence (accidental urine leaking) reported in 16% to 44% of people within 3 months of surgery
- Erectile dysfunction similar to that of TURP
Considerations include [93]:
- Requires specialised equipment and training, making it less readily available
- The number of prostates large enough to require this technique is relatively small, so training and substantial experience with this technique can take time
- A catheter is required for a short time with this type of surgery in most cases
Deciding on a treatment plan
The best course of treatment really depends on your symptoms and testing results. When considering treatment options for BPH, it’s important that you have an open discussion with your healthcare provider about your symptoms of benign prostatic hyperplasia, lifestyle and personal preferences. Not every treatment option is a good option for all patients with an enlarged prostate.
Chapter 7: Can I prevent BPH from happening to me?
While there is no guaranteed way to prevent BPH, adopting a healthy lifestyle may help manage symptoms and reduce the risk of progression. These can include [94]:
Maintain a healthy weight
Exercise regularly
Eat a balanced diet rich in fruits and vegetables
Limit alcohol and caffeine consumption
Manage stress
Stay hydrated
Empty your bladder completely when urinating
Avoid holding urine for extended periods
Benign prostatic hyperplasia is a common condition causing enlargement of the prostate affecting a significant portion of the male population as they age. While not life-threatening, it can significantly impact quality of life if left untreated.
By understanding the signs, symptoms, causes and available treatment options, you can take proactive steps to manage your prostate health and maintain a good quality of life.
If you experience any concerning symptoms or have questions about your prostate health, don't hesitate to consult with a healthcare provider for personalised guidance and support.
Remember, early detection and intervention can help prevent complications and improve treatment outcomes.
With the right approach and medical support, most men with BPH can successfully manage their symptoms and enjoy a fulfilling life.
