Understanding BPH: Enlarged Prostate Symptoms, Diagnosis and Treatment

What is BPH?

The prostate is a small gland that sits directly beneath the bladder. Its job is to help produce the fluid that carries sperm. In a younger man it is roughly the size and shape of a walnut or a golf ball. The detail that matters most is anatomical: the urethra — the tube that carries urine out of the body — passes straight through the center of the prostate. The gland forms a ring around the channel your urine has to travel through.

The prostate tends to keep growing throughout a man's life. In many men that growth eventually becomes significant enough to squeeze the urethra and restrict the flow of urine out of the bladder. That is benign prostatic hyperplasia. Broken into its parts, the term is reassuring rather than alarming: benign means not cancerous, prostatic means of the prostate, and hyperplasia means an increase in the number of cells.

Think of the urethra as a garden hose running through the middle of a closing fist. The hose itself is fine. The pressure squeezing it from the outside is the problem. Nearly every BPH treatment works by relieving that pressure — either by relaxing the muscle around the channel, shrinking the gland, or removing the tissue that is doing the squeezing.

Is BPH the same as prostate cancer?

BPH and prostate cancer are two different conditions. Having an enlarged prostate is not considered to raise your risk of developing prostate cancer. The confusion is understandable, because the two conditions can produce overlapping urinary symptoms and both involve the same gland. But that overlap is an argument for being evaluated, not against it. A proper workup distinguishes between them.

It is also worth knowing that a PSA blood test, which is part of a standard prostate evaluation, can be elevated simply because the gland is enlarged. An elevated PSA is a reason to investigate further. It is not a diagnosis.

What are the symptoms of an enlarged prostate?

Common symptoms:

• Needing to urinate frequently, or feeling a sudden urgency to go
• Waking up to urinate during the night (nocturia)
• Difficulty getting the stream started
• A weak stream, or one that starts and stops
• Dribbling at the end of urination
• The feeling that your bladder has not fully emptied
• Less common: urinary tract infections, being unable to urinate at all, blood in the urine

Does a bigger prostate mean worse symptoms?

Not reliably. Some men with only mildly enlarged glands have severe symptoms. Others with very large glands have minor complaints, and some men with enlarged prostates have no symptoms whatsoever. This is exactly why treatment decisions cannot be made on gland size alone, and why an evaluation looks at symptoms, measurements, and your overall health together.

If you are completely unable to pass urine, this is a medical emergency. Do not wait for an appointment. Go to an emergency room or call for help right away.

Who gets BPH?

• Age. This is the dominant factor. Symptoms from an enlarged prostate are rare before age 40. After 40, both the likelihood of enlargement and the likelihood of symptoms begin to climb.
• Family history. Having a blood relative who has had prostate problems raises your own likelihood of having them.
• Diabetes and heart disease. Research indicates that both diabetes and heart disease may increase the risk of BPH.
• Weight and activity level. Obesity is associated with a higher risk of BPH. Regular exercise is associated with a lower risk.

What are the treatment options for BPH?

There are more treatment options for an enlarged prostate today than at any point in the history of urology. The right choice for you depends on the size of your prostate, your age, your overall health, and how severely your symptoms affect your life.

• Watchful waiting. If your symptoms are not interfering with your life, it is entirely reasonable to postpone treatment and monitor the situation. Watchful waiting is an active choice, not neglect — it involves periodic reassessment so that a change in direction is caught early.
• Alpha blockers. These relax the smooth muscle of the bladder neck and the prostate, making urination easier.
• 5-alpha reductase inhibitors. These shrink the prostate by blocking the hormonal changes that drive its growth. They can take up to six months to reach full effect and may cause sexual side effects.
• Combination therapy. When neither drug class produces enough relief on its own, an alpha blocker and a 5-alpha reductase inhibitor may be prescribed together.
• Tadalafil. Best known as a treatment for erectile dysfunction, tadalafil has also been shown in studies to relieve the symptoms of an enlarged prostate.
• Procedures and surgery. A procedure may be appropriate if medication has not provided enough relief, if you would rather not take medication, if you are unable to urinate, if your kidneys have been affected, or if you have recurring bladder stones, blood in the urine, or urinary tract infections.

Rezūm™ and GreenLight™ at Lief Urology

Both are outpatient procedures performed through the urethra, with no incisions. Rezūm™ uses steam to treat obstructing tissue in about 5 to 15 minutes and is best suited to prostates of roughly 30 to 80 mL. GreenLight™ uses laser energy to vaporize tissue, takes longer, and works across all prostate sizes, including larger glands. Both preserve sexual function better than traditional TURP surgery.

Which one is right for you depends primarily on the measured volume of your prostate, along with your health history, your medications, and your priorities. Your prostate is measured during the evaluation, and the recommendation follows from that.

What can I do at home?

None of the following will cure an enlarged prostate, and none should replace an evaluation. But these adjustments genuinely reduce symptom burden for many men, and they cost nothing to try.

• Stop drinking earlier in the evening. Avoid fluids for an hour or two before bed to reduce overnight trips to the bathroom.
• Cut back on caffeine and alcohol. Both increase urine production and irritate the bladder, which makes symptoms worse.
• Go when you first feel the urge. Holding it for long stretches can overstretch the bladder muscle and cause damage.
• Try double voiding. Urinate, wait a moment, then urinate again to empty the bladder more completely.
• Be careful with decongestants and antihistamines. These tighten the muscles around the urethra that control urine flow, making it harder to go.

Questions to bring to your consultation

• Do I actually have an enlarged prostate, or could something else explain my symptoms?
• What tests do I need, and what will they tell us?
• How large is my prostate, and how does that affect my options?
• What are all of my treatment options — including the ones you do not perform here?
• How will each option affect my sexual function?
• What will this cost, and what does my insurance cover?

Download the full patient guide

This article is drawn from Dr. Lief's patient education guide, Understanding BPH (PDF).