Benign Prostatic Hyperplasia (BPH)

Overview

Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland that develops in most men as they age. The prostate sits below the bladder and surrounds the urethra, the tube that carries urine out of the body. As the prostate grows larger, it compresses the urethra and creates resistance to urine flow, causing the characteristic lower urinary tract symptoms associated with this condition.

BPH affects approximately half of men in their 50s and up to 90% of men by age 80. The condition does not cause prostate cancer and does not increase cancer risk, though both conditions can exist simultaneously. While BPH is not life-threatening, its symptoms can significantly impact sleep, daily activities, and overall quality of life.

Symptoms

BPH symptoms result from the enlarged prostate obstructing urine flow and the bladder’s compensatory response to this obstruction. Symptoms typically progress gradually over years and fall into two categories.

Storage symptoms include frequent urination (voiding more than eight times daily), urgency with sudden strong urges to urinate, and nocturia (waking two or more times per night to void). Some men develop urge incontinence, losing urine before reaching the toilet.

Voiding symptoms include a weak urine stream, hesitancy when starting urination, straining to void, an interrupted stream that stops and starts, prolonged urination, a sensation of incomplete bladder emptying, and terminal dribbling after finishing.

Without treatment, BPH can lead to complications including acute urinary retention (complete inability to urinate), urinary tract infections, bladder stones, bladder wall thickening with reduced capacity, and in rare cases kidney damage from chronic back-pressure.

Causes

The exact cause of BPH remains incompletely understood, though hormonal changes with aging play a central role. As men age, testosterone levels decline while estrogen levels remain stable, and this altered ratio appears to promote prostate cell growth. Additionally, dihydrotestosterone (DHT), a hormone derived from testosterone, accumulates in prostate tissue and stimulates cell proliferation even as overall testosterone decreases.

Risk factors for BPH include advancing age (the primary factor), family history of the condition, obesity and higher body mass index, diabetes, cardiovascular disease, and a sedentary lifestyle. Men with a father or brother who had BPH requiring treatment face significantly higher risk themselves.

Diagnosis

Evaluation begins with a thorough history focusing on urinary symptoms. The International Prostate Symptom Score (IPSS) questionnaire quantifies symptom severity on a scale of 0-35, with scores of 0-7 indicating mild symptoms, 8-19 moderate, and 20-35 severe.

Physical examination includes a digital rectal exam to assess prostate size, shape, and texture. Laboratory testing typically includes urinalysis to exclude infection and PSA (prostate-specific antigen) measurement to help evaluate for prostate cancer.

Additional testing may include post-void residual measurement to determine how much urine remains in the bladder after voiding, uroflowmetry to measure urine flow rate and pattern, ultrasound to assess prostate size and bladder wall thickness, and in selected cases urodynamic studies to evaluate bladder function in detail.

Treatment

Treatment selection depends on symptom severity, prostate size, patient preferences regarding side effects and recovery, and any complicating factors.

Watchful Waiting

Men with mild symptoms (IPSS below 8) that do not significantly affect quality of life may reasonably choose monitoring without active treatment. This approach involves annual symptom assessment and lifestyle modifications including limiting evening fluid intake, reducing caffeine and alcohol consumption, avoiding decongestants and antihistamines that can worsen symptoms, practicing double voiding, and urinating promptly when the urge arises.

Medications

Alpha-blockers relax smooth muscle in the prostate and bladder neck to reduce obstruction. Tamsulosin (Flomax) is most commonly prescribed; alternatives include alfuzosin, silodosin, doxazosin, and terazosin. These medications provide symptom relief within days to weeks. Side effects may include dizziness, retrograde ejaculation, and nasal congestion.

5-alpha reductase inhibitors block conversion of testosterone to DHT, gradually shrinking the prostate. Finasteride reduces prostate volume by approximately 25%, while dutasteride provides more complete DHT blockade. These medications require 6-12 months for full effect. Side effects may include decreased libido, erectile dysfunction, and reduced ejaculate volume.

Combination therapy using both drug classes proves more effective than either alone for men with larger prostates. Tadalafil (Cialis), a PDE5 inhibitor, has approval for BPH treatment and can address both urinary symptoms and erectile dysfunction.

Minimally Invasive Procedures

UroLift uses permanent implants to hold the prostate lobes apart, opening the urethral channel. Performed under local anesthesia as an outpatient procedure, it preserves sexual function and provides durable symptom improvement for moderate BPH.

Rezum water vapor therapy delivers steam injections that destroy obstructing prostate tissue. Also performed as an outpatient procedure with preservation of sexual function, improvement develops over several weeks as treated tissue is absorbed.

Surgical Options

TURP (transurethral resection of the prostate) remains the gold standard surgical treatment. Through a scope inserted via the urethra, the surgeon removes obstructing prostate tissue. The procedure provides excellent, durable symptom relief. Risks include bleeding, retrograde ejaculation, and rare incontinence.

HoLEP (holmium laser enucleation) uses laser energy to remove the entire inner prostate. Effective for any prostate size with less bleeding than TURP, this technique requires specialized surgical training. Greenlight laser vaporizes prostate tissue with minimal bleeding, making it suitable for patients on anticoagulation.

Open or robotic simple prostatectomy removes the inner prostate through an incision, reserved for very large glands exceeding 80-100 grams.

When to See a Doctor

Consult a urologist if urinary symptoms affect your sleep, work, or daily activities, or if symptoms progressively worsen. Seek urgent evaluation for complete inability to urinate, significant blood in the urine, bladder pain, or fever with urinary symptoms suggesting infection.

Men with BPH should maintain regular follow-up to monitor symptom progression and adjust treatment as needed. Prostate size and symptoms do not always correlate, so treatment decisions focus on how symptoms affect quality of life rather than prostate measurements alone.