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About benign prostate enlargement
Benign prostate enlargement (BPE), also known as benign prostatic hyperplasia (BPH), is a condition that affects older men and anyone with a prostate.
It's particularly common in men and anyone with a prostate over 50 years of age and isn't usually a serious threat to health.
The prostate is a small gland, located in the pelvis, between the penis and bladder. It's involved in the production of semen.
The prostate produces a thick, white fluid that's made into a thinner liquid by a protein called prostate-specific antigen (PSA). The liquid is then mixed with sperm, produced by the testicles, to create semen.
If the prostate becomes enlarged, it can place pressure on the bladder and urethra (the tube through which urine passes). This can affect how you pass urine and may cause:
- difficulty starting urination
- a frequent need to urinate
- difficulty fully emptying the bladder
In some men and anyone with a prostate, the symptoms are mild and don't require treatment. In others, the symptoms can be very troublesome and have a major impact on a person's quality of life.
Read more about the symptoms of benign prostate enlargement
Many people worry that having an enlarged prostate means they have an increased risk of developing prostate cancer. This isn't the case. The risk of prostate cancer is no greater for people with an enlarged prostate than it is for those without an enlarged prostate.
What causes benign prostate enlargement?
The cause of prostate enlargement is unknown, but most experts agree that it's linked to hormonal changes that occur as a man gets older.
Read more about the causes of benign prostate enlargement
How is benign prostate enlargement diagnosed?
If your GP suspects that you have an enlarged prostate, you'll be asked to complete a questionnaire to assess your symptoms.
Each question has five possible answers that carry a score, and your overall score indicates the severity of your symptoms.
Your GP will also want to rule out other conditions that cause similar symptoms to prostate enlargement.
You may have a number of standard tests, such as urine tests, plus some more specific tests, such as a blood test that measures PSA.
Read more about diagnosing benign prostate enlargement
Treating benign prostate enlargement
Treatment for an enlarged prostate is determined by the severity of your symptoms.
If you have mild to moderate symptoms, you won't receive any immediate medical treatment, but you'll have regular check-ups to carefully monitor your prostate.
You'll probably also be advised to make lifestyle changes, such as limiting your caffeine and alcohol intake, and exercising regularly, to see if they improve your symptoms.
As well as lifestyle changes, medication is usually recommended to treat moderate to severe symptoms of benign prostate enlargement. Finasteride and dutasteride are medications that are commonly used. They block the effects of a hormone called dihydrotestosterone (DHT) on the prostate gland, which can reduce the size of the prostate and improve associated symptoms.
Alpha blockers may also be prescribed. They help to relax your bladder muscles, making it easier to pass urine. Tamsulosin and alfuzosin are two alpha blockers commonly used to treat benign prostate enlargement.
Surgery is usually only recommended for moderate to severe symptoms of benign prostate enlargement that have failed to respond to medication.
Read more about treating benign prostate enlargement
Complications of benign prostate enlargement
Benign prostate enlargement can sometimes lead to complications such as a urinary tract infection (UTI) or acute urinary retention. Serious complications are rare.
Read more about the complications of benign prostate enlargement
How common is benign prostate enlargement?
Benign prostate enlargement is a condition associated with ageing and is common in men and anyone with a prostate over 50 years of age.
Symptoms of benign prostate enlargement
The symptoms of benign prostate enlargement are caused by the enlarged prostate placing pressure on the bladder and urethra (which carries urine from the bladder to the penis).
This can affect urination in a number of ways. For example, it can:
- make it difficult for you to start urinating
- weaken the flow of urine or cause "stopping and starting"
- cause you to strain to pass urine
- cause you to need to urinate frequently
- cause you to wake up frequently during the night to urinate
- cause a sudden urge to urinate, which can result in urinary incontinence if you can't find a toilet quickly enough
- cause you to not be able to empty your bladder fully
- cause blood in the urine (haematuria)
In the later stages, benign prostate enlargement can cause urine retention and other complications such as bladder stones, bladder infections and kidney damage.
When to seek medical advice
See your GP if you notice any problems with, or changes to, your usual pattern of urination. Even if the symptoms are mild, they could be caused by a condition that needs to be investigated.
Any blood in the urine must be investigated by your GP to rule out other more serious conditions.
Causes of benign prostate enlargement
The exact cause of benign prostate enlargement is unknown, but research suggests that hormones probably play an important role in the condition's development.
Hormones are powerful chemicals that can have a wide range of effects on the cells of the body.
One theory is that as some men and anyone with a prostate gets older, the levels of a type of hormone called dihydrotestosterone (DHT) increases, which may stimulate the growth of the prostate.
Another theory suggests that two hormones, testosterone and oestrogen, play a role. Younger men and anyone with a prostate produce high levels of testosterone and much smaller levels of oestrogen. But as they get older, levels of testosterone decrease, which means they then have a higher proportion of oestrogen in their body. It's been suggested that the relative increase in oestrogen may stimulate prostate growth.
Research has shown that rates of benign prostate enlargement are higher among men and anyone with a prostate with high blood pressure and diabetes. However, both diabetes and high blood pressure are associated with the natural ageing process, so there may not be a direct connection between the three conditions.
Diagnosing benign prostate enlargement
To find out whether your prostate gland is enlarged, you'll need to have a few tests.
Some tests will be carried out by your GP and others will be carried out by a urologist (a doctor who specialises in urinary problems).
First, your GP will ask about your symptoms. If it seems that you have symptoms of benign prostate enlargement, the next stage is to calculate your International Prostate Symptom Score (IPSS).
International Prostate Symptom Score (IPSS)
You'll be asked to complete a questionnaire to assess your symptoms. Each question has five possible answers that carry a score, and your overall score is used to assess the severity of your symptoms.
The checklist includes the following questions.
Over the past month:
- How often have you had the sensation of not completely emptying your bladder after urinating?
- How often have you had to urinate again less than two hours after finishing urinating?
- How often have you found that you stopped and started again when urinating?
- How often have you found it difficult to postpone urination?
- How often have you had a weak stream of urine?
- How often have you had to push or strain to begin urinating during the course of one night?
- How often have you had to get up during the night to urinate?
After your GP has assessed the severity your symptoms, they'll aim to rule out other conditions with similar symptoms using certain tests.
Ruling out other conditions
The symptoms of benign prostate enlargement are similar to those of other conditions, including prostate cancer. Therefore, your GP will need to be completely sure that your symptoms aren't caused by cancer.
A urine test can be used to check whether your symptoms are caused by an infection in your urinary system, such as a kidney infection or bladder infection.
You may need a rectal examination to check whether you might have prostate cancer. Prostate cancer can cause the prostate gland to become hard and bumpy.
Your GP will put on a glove and lubricate one of their fingers, before gently pushing this finger into your bottom and up into your rectum. As the rectum is close to the prostate gland, they'll be able to check whether the surface of the gland has changed. The procedure will feel a little uncomfortable, but it isn't usually painful.
Prostate cancer doesn't always cause changes to the prostate gland, so you may need to have some more specialised tests to rule it out. You will probably be referred to a urologist for these tests.
Prostate-specific antigen (PSA) test
A blood test can be used to measure the amount of the PSA protein that's produced by the prostate.
A raised PSA level indicates enlargement of the prostate, and a significantly raised level may indicate prostate cancer. However, as with a rectal examination, a PSA test can't provide a definitive diagnosis of prostate cancer.
Transrectal ultrasound (TRUS)
A TRUS is a type of ultrasound scan specifically designed to study the prostate and the surrounding area.
An ultrasound probe is placed into your rectum and uses soundwaves to build a detailed image of your prostate.
This type of scan measures the size of your prostate and can be used to either confirm or rule out a diagnosis of prostate cancer.
Computer tomographic (CT) urogram
A CT urogram is used to study the urinary tract (the bladder and the tubes through which urine passes, also known as the ureter and urethra).
A CT urogram can be used to check for blockages in your urinary system that could be causing your symptoms, such as a kidney stone or bladder stone. It can also be used to detect any damage in the urinary tract.
During a CT urogram, you’ll be injected with a harmless radioactive dye, which will be visible on X-rays. After 30-60 minutes, the dye should have passed into your urinary tract and a series of X-rays will be taken. In some cases, you may be asked to pass urine before the final X-ray is taken.
A voiding chart is a urination diary, which you may be asked to keep for 24 hours. You'll be asked to record how often you urinate, as well as details about how you urinate – for example, whether your urination is stopping and starting, or whether it's difficult to start urinating.
A voiding chart is a good way of finding out more information about your symptoms and can be used to determine the type of treatment that would be most effective in controlling your symptoms.
Uroflowmetry measures the pressure of your bladder and how well your bladder works when you urinate.
You'll be given a local anaesthetic and a small flexible tube (catheter) will be inserted into your urethra and moved up into your bladder.
Water will then be injected through the catheter and into your bladder. A computer connected to the catheter measures the pressure inside your bladder and can assess how well your bladder is working.
As with voiding charts, uroflowmetry is a good way of determining what type of treatment will help to control your symptoms.
Treating benign prostate enlargement
The treatment for an enlarged prostate gland will depend on how severe your symptoms are.
The three main treatments are:
- lifestyle changes
If your symptoms are mild to moderate, you may not receive any immediate medical treatment, but you'll have regular check-ups to carefully monitor your prostate gland. This is often referred to as "watchful waiting".
You may also be advised to make lifestyle changes to see whether they improve your symptoms.
The various treatments for prostate enlargement are outlined below. You can also read a summary of the pros and cons of the treatments for prostate enlargement, allowing you to compare your treatment options.
If your prostate gland is enlarged, you may be advised to:
- avoid drinking any liquids for one to two hours before going to bed – this will reduce your chances of waking up during the night to pass urine (nocturia)
- experiment with the time you take prescribed medication – for example, taking it at 7pm may help prevent nocturia
- stop drinking alcohol and caffeine, or limit your consumption of them – these drinks can irritate your bladder and make your symptoms worse
- exercise regularly – research shows moderate exercise, such as walking for 30 to 60 minutes a day, can improve symptoms, although it's unclear exactly why this is the case
- join a patient support group – your doctor should be able to recommend one, which may help you manage mild symptoms without the need for medication
Bladder training is an exercise programme that aims to increase the time between urination and the amount of urine your bladder can hold.
You'll be given a target, such as waiting at least two hours between each time you urinate.
It's a good idea to use a bladder training chart, which allows you to record each time you pass urine and the volume of urine passed – you'll need a plastic jug to measure this. Your doctor should give you a chart to take home.
You'll also be taught a number of exercises, such as breathing, relaxation and muscle exercises, to help take your mind off the need to urinate.
Over time your target time will be increased, and at the end of the programme you should find that you're able to go for longer without urinating.
Bladder training should only be carried out under medical supervision.
Medication, in combination with the lifestyle changes above, is usually recommended to treat moderate to severe symptoms of benign prostate enlargement.
Finasteride or dutasteride
Finasteride and dutasteride are widely used to treat benign prostate enlargement.
They block the effects of a hormone called dihydrotestosterone (DHT) on the prostate gland, which can reduce the size of the prostate and improve your associated symptoms.
Find out about the causes of prostate enlargement
If you're prescribed one of these medications, you may experience an immediate improvement in symptoms.
However, you'll need to take it for at least six months to get the maximum benefit, and your doctor will need to monitor you every year.
Use condoms if you're sexually active – both finasteride and dutasteride can have an adverse effect on your sperm. If you get a woman pregnant, there's a risk the baby could develop birth defects.
Other possible side effects can also include impotence and little or no sperm when you ejaculate.
In many cases, these side effects will improve as your body gets used to the medication. See your GP if the side effects are troubling you.
Alpha blockers help relax the muscles of your bladder, making it easier to pass urine. You may be prescribed alpha blockers as your primary treatment or in combination with finasteride.
Tamsulosin and alfuzosin are two alpha blockers commonly used to treat benign prostate enlargement. Side effects of tamsulosin and alfuzosin are uncommon and usually mild.
- little or no sperm when you ejaculate
You should only begin taking alpha blockers over a restful weekend when you're not planning to drive, as there's a risk they could cause low blood pressure (hypotension) and fainting.
Generally, if you experience dizziness while taking this medication, avoid driving or operating heavy machinery until it's passed.
Surgery is usually only recommended for moderate to severe symptoms of benign prostate enlargement that have failed to respond to medication.
Various procedures can be used to reduce the pressure on your bladder.
Transurethral resection of the prostate (TURP)
Transurethral resection of the prostate (TURP) involves inserting a small instrument called a resectoscope into your urethra, the tube that carries urine from the bladder to the penis.
A wire loop heated by an electric current is used to remove excess tissue from your prostate.
TURP is carried out using either a general anaesthetic, where you're asleep, or a spinal anaesthetic, where you're awake, but the lower half of your body is numbed.
The procedure can take up to an hour, depending on how much tissue needs to be removed. Most people are well enough to leave hospital two to three days after the operation.
After surgery, you'll be unable to urinate normally at first because of your swollen urethra.
A thin tube called a catheter will be inserted into your urethra and up into your bladder to allow urine to drain away. This will usually be removed 24 to 48 hours after surgery.
A common complication of TURP is you'll no longer produce semen when you ejaculate. This is known as retrograde ejaculation.
It causes sperm to go into your bladder rather than out of your penis during ejaculation. However, you'll still experience the physical pleasure associated with ejaculation (the climax).
Bladder neck incision (TUIP)
Bladder neck incision involves widening the urethra so it is easier to pass urine. It is also known as transurethral incision of the prostate (TUIP).
Like TURP, the surgeon will insert a resectoscope into your urethra. The resectoscope has a heated wire loop at the end and is used to make small cuts (incisions) in the muscle where the prostate meets the bladder.
This type of surgery relaxes the opening to the bladder, helping urine flow out of it. As with TURP, TUIP is carried out under a spinal or general anaesthetic.
After surgery, you may not be able to urinate and a catheter may be needed to empty your bladder. Like TURP, you'll only need to use a catheter for a short time until you're able to urinate normally.
There's less of a risk of retrograde ejaculation with TUIP compared with TURP, although it can sometimes still occur.
Holmium laser enucleation of the prostate (HoLEP)
Holmium laser enucleation of the prostate (HoLEP) is similar to a TURP. Excess prostate tissue is removed using an instrument inserted through the urethra. However, it uses a laser, rather than a wire loop.
There are some advantages to using this technique rather than a TURP, but also some disadvantages.
If you have been offered a HoLEP, you may want to ask your surgeon to explain why this was chosen for you, and the risks and benefits compared with TURP.
Insertion of prostatic urethral lift implants
The insertion of prostatic urethral lift implants is a new surgical procedure that can help relieve urinary symptoms.
The procedure can be carried out under local anaesthesia or general anaesthesia.
It involves inserting tiny implants through the urethra. The implants are then positioned to hold the enlarged prostate away from the urethra so it isn't blocked.
One of the big advantages of prostatic urethral lift implants compared with TURP and TUIP is a reduced risk to your sexual function – there is less chance of erectile dysfunction and ejaculation problems.
There's also less tissue injury, which means your recovery will be quicker and you won't need to stay in hospital as long.
However, prostatic urethral lift implants are unlikely to provide permanent symptom relief in all cases. And as it's a new procedure, the long-term outcomes are unknown and availability may be limited.
Read more about the use of prostatic urethral lift implants to relieve symptoms of prostate enlargement.
Transurethral vaporisation of the prostate (TUVP)
Transurethral vaporisation of the prostate (TUVP) is similar to a TURP, but parts of the prostate are destroyed (vaporised) rather than cut away.
Studies have shown that TUVP is as effective as TURP at improving symptoms. But some men and anyone with a prostate may need more treatment in the future.
Greenlight laser surgery (PVP)
A laser can sometimes be used to destroy the prostate tissue. This particular form of TUVP is called photoselective vaporisation of the prostate (PVP), or Greenlight laser surgery.
A thin, flexible instrument called a cytoscope is inserted into the urethra. A laser fibre is then passed through the cytoscope to destroy the excess prostate tissue that is blocking the urine flow.
The procedure is recommended for those who don't have a high risk of developing complications from treatment, such as men and anyone with a prostate who:
- doesn't have urinary retention
- doesn't have an increased risk of bleeding
- has a prostate smaller than 100ml
In these "low-risk" groups, Greenlight laser surgery is thought to be as effective as TURP, but also has several benefits.
- a shorter hospital stay – the procedure is often carried out as a day case
- the catheter can be removed sooner
- recovery is quicker
- there's a lower risk of complications
The National Institute for Health and Care Excellence (NICE) website has more information about GreenLight XPS for treating benign prostatic hyperplasia.
An open prostatectomy is a procedure that may be more effective than TURP if you have severe benign prostate enlargement.
However, it's now rarely used, even for larger prostates, because other techniques have been developed, such as HoLEP.
During an open prostatectomy, an incision will be made in your tummy and the outer portion of your prostate will be removed.
The procedure carries a higher risk of complications, such as erectile dysfunction and urinary incontinence. There's also a greater chance that these complications will become permanent than if they occur after TURP.
Complications of benign prostate enlargement
Benign prostate enlargement can sometimes lead to complications, such as a urinary tract infection or acute urinary retention.
Urinary tract infections
If you're unable to empty your bladder properly, there's a risk that bacteria in your urinary system won't get flushed out and will spread through the urine to cause a urinary tract infection (UTI).
Symptoms of a UTI include:
- cloudy, bloody or bad-smelling urine
- pain in your lower abdomen (tummy)
- shaking and chills
- a high temperature of 38C (100.4F) or above
UTIs can be treated with antibiotics. A single UTI isn't usually serious, but repeated UTIs can damage your kidneys and bladder. If you have a history of repeated UTIs, you may need to have surgery.
Acute urinary retention
Acute urinary retention (AUR) is the sudden inability to pass any urine. AUR should be treated as a medical emergency, because without prompt treatment urine may be passed back up into the kidneys, which can damage them.
Symptoms of AUR include:
- the sudden inability to pass urine
- severe lower abdominal pain
- swelling of the bladder that you can feel with your hands
Dial 999 and ask for an ambulance if you or someone you know experiences the symptoms of AUR.
AUR can be treated using a thin tube (catheter) to drain the urine out of your bladder. In very serious cases, surgery may be required to empty the bladder.
13 February 2023
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