Benign Prostatic Hyperplasia

Benign prostatic hyperplasia is a common condition that affects most men as they age, causing the prostate gland to grow larger and potentially leading to bothersome urinary symptoms, though it is not cancerous and does not increase the risk of prostate cancer.

Table of contents

• What is Benign Prostatic Hyperplasia?
• Associated Anatomy
• How Common is This Condition?
• What Causes Benign Prostatic Hyperplasia?
• Warning Signs and Symptoms
• What Happens Without Treatment?
• How is Benign Prostatic Hyperplasia Diagnosed?
• Treatment Options
• Lifestyle Changes and Self-Management

What is Benign Prostatic Hyperplasia?

Benign prostatic hyperplasia, also called BPH or an enlarged prostate, is a health condition in which the prostate gland grows larger than normal^[1]. The prostate is a small gland about the size of a walnut that helps make semen. It sits just below the bladder and in front of the rectum^[2].

The word “benign” means that the growth is not cancerous. The prostate surrounds part of a tube called the urethra, which carries urine out of the bladder and through the penis^[2]. When the prostate grows larger, it can squeeze the urethra and block the flow of urine, making it difficult to urinate properly^[1].

The prostate has two main growth phases during a man’s life. The first happens early in puberty when the prostate doubles in size. The second growth phase starts around age 25 and continues throughout life^[17]. BPH develops during this second growth phase and is characterized by the growth of stromal and epithelial cells in the prostate’s transition zone, which surrounds the urethra^[3].

Having BPH does not increase your risk of developing prostate cancer. However, BPH and prostate cancer can have similar symptoms, and it is possible to have both conditions at the same time^[2].

• Prostate gland
• Bladder
• Urethra
• Rectum

How Common is This Condition?

Benign prostatic hyperplasia is very common and affects almost all men as they age. It is the most common prostate problem among males^[2].

By age 60, about 50% of men will have some signs of BPH. By age 85, about 90% will have signs of the condition^[2]. Studies also show that the condition affects 5% to 6% of men ages 40 to 64, and 29% to 33% of those ages 65 and older^[17].

While many men develop BPH as they age, not everyone will have symptoms. About half of all men with BPH will develop symptoms that require treatment^[2]. Some men with slightly enlarged prostates can have major symptoms, while others with very enlarged prostates may have minor problems or no symptoms at all^[1].

BPH rarely causes symptoms in men younger than age 40, and by age 50, half of men will have symptoms of an enlarged prostate^[1][5].

What Causes Benign Prostatic Hyperplasia?

Healthcare providers and medical researchers are not completely sure what causes BPH^[2]. The condition is probably related to changes in hormones that happen as men get older.

One theory is that as you age, the amount of testosterone in your body decreases while estrogen levels stay the same. These hormone changes may cause prostate cells to grow^[2]. Interestingly, men who take supplemental testosterone may develop or worsen BPH.

Older men also have higher levels of a hormone called dihydrotestosterone (DHT). DHT is a more potent form of testosterone that increases the size of the prostate^[2].

Several risk factors can increase your chances of developing BPH symptoms. These include age, having a sedentary lifestyle, obesity, hypertension, diabetes mellitus, eating foods high in sugar or unhealthy fats, smoking, excessive alcohol use, and having a family history of BPH^[7][17][20]. Other unmanaged health conditions such as heart and blood vessel disease, chronic kidney disease, and erectile dysfunction also increase risk^[17].

BPH is not contagious. You cannot spread it to another person^[2].

Warning Signs and Symptoms

The prostate surrounds the urethra, so when BPH causes the prostate to grow, it can block the urethra. This blockage leads to various urinary symptoms^[2].

Common symptoms of BPH include^[1][2]:

• Frequent or urgent need to urinate
• Needing to urinate more often at night
• Trouble starting to urinate or slowness when urinating
• Weak urine stream, or a stream that stops and starts
• Dribbling at the end of urination
• Inability to completely empty the bladder
• Feeling that urination is not complete
• Leaking or incontinence (loss of bladder control)

Less common symptoms may include^[1][2]:

• Urinary tract infection
• Being unable to urinate at all
• Blood in the urine
• Pain after ejaculating or while urinating
• Changes in urine color or smell

The symptoms of BPH tend to slowly get worse over time. However, sometimes they stay the same or even improve without treatment^[1]. The size of the prostate does not always determine how serious the symptoms are^[1].

What Happens Without Treatment?

As the prostate grows, it squeezes the urethra more tightly. The bladder muscles have to work harder to push urine through the narrowed urethra, which can make symptoms worse^[17]. Eventually, the bladder muscles may weaken and be unable to empty completely, leaving some urine in the bladder. This condition is called urinary retention^[17].

Without treatment, BPH can cause further blockage in the urethra, and symptoms may worsen. It may also lead to^[2][17]:

• Urinary tract infections (UTIs)
• Bladder stones
• Blood in the urine (hematuria)
• Kidney damage caused by urine backing up from the bladder to the kidneys, which increases pressure on the kidneys

Sometimes the flow of urine becomes completely blocked, so you cannot urinate at all. This is called acute urinary retention, and it causes the bladder to quickly fill with urine and become extremely painful. This is a medical emergency that requires immediate care^[5].

How is Benign Prostatic Hyperplasia Diagnosed?

Your healthcare provider will start by asking questions about your symptoms and medical history. You will also get a physical exam that likely includes a digital rectal exam. During this exam, the doctor inserts a gloved finger into your rectum to feel your prostate. If you have BPH, your prostate will feel large and smooth^[5][8].

Your doctor may use a symptom scoring system called the International Prostate Symptom Score (IPSS) to track your symptoms and determine how much BPH affects your quality of life^[7].

After the initial exam, you might need additional tests, which may include^[8]:

• Urine test: A lab checks a sample of your urine to find out if you have an infection or other problems that can cause similar symptoms
• Blood test: The results can show if you have kidney problems
• Prostate-specific antigen (PSA) blood test: PSA is a protein made in the prostate. PSA levels go up when the prostate becomes enlarged, but higher PSA levels can also be caused by recent procedures, illnesses, surgery, or prostate cancer
• Urinary flow test: You urinate into a container attached to a machine that measures how strong your urine flow is and how much urine you pass
• Postvoid residual volume test: This test measures whether you can empty your bladder fully. It can be done using ultrasound or with a tube (catheter) placed into your bladder after you urinate
• 24-hour voiding diary: You note how often and how much you urinate, which can be especially helpful if you make more than a third of your daily urine at night

If your condition is more complex, you may need additional tests such as^[8]:

• Transrectal ultrasound: A device that uses sound waves to make pictures is inserted into the rectum to measure the size of your prostate
• Prostate biopsy: If your PSA level is high or the doctor finds a hard lump in your prostate, you may need a biopsy to check for prostate cancer. The doctor uses a hollow needle to take samples of tissue from your prostate
• Urodynamic studies and cystoscopy: These tests examine how well your bladder and urinary system are working

It is important to distinguish BPH from prostate cancer because both conditions can make the prostate larger. Every man with a prostate should get a prostate screening every year between the ages of 55 and 69. If you are Black or have a family history of prostate cancer, you should start getting prostate screenings at age 40^[2].

Treatment Options

Many treatments can help BPH. Your healthcare provider can help you choose the right option based on your symptoms, the size of your prostate, your age, and other health problems you might have^[1].

Watchful Waiting

If your symptoms are not particularly bothersome, your doctor may recommend watchful waiting. This involves regular monitoring to make sure complications are not developing, but no active treatment^[13].

Medications

Medications are often the first treatment for BPH^[7]. There are several types:

Alpha blockers relax the muscles in the prostate and bladder neck, which helps urine flow better. Common examples include tamsulosin and alfuzosin. These medications offer rapid benefit and can even be used for acute urinary retention^[7][12].

5-alpha reductase inhibitors target the hormones that cause the prostate to grow. Finasteride and dutasteride are common examples. These medications slow the growth of the prostate and improve urinary symptoms over time. They can take up to one year to reach their full effect^[7][12]. They are most effective when the prostate volume is 30 mL or greater and are often more effective when taken together with alpha blockers^[7].

Phosphodiesterase-5 inhibitors can also be used as primary medical treatment. They have similar effects to alpha blockers, with only slight benefit when combining these medications^[7].

While medications can be effective, some people may experience side effects such as lightheadedness, dry mouth, low blood pressure, falls, headaches, erectile dysfunction, retrograde ejaculation, reduced libido, nausea, or vomiting^[12].

Minimally Invasive Procedures

Beyond medications, several minimally invasive procedures can treat BPH symptoms. These include newer options like iTind, which uses a temporary stent to gently and gradually increase space in the prostate for urine flow while preserving sexual function^[12].

Surgery

Only about 1% of patients with lower urinary tract symptoms require surgery^[7]. Surgery may be needed if medications and lifestyle changes are not effective.

Transurethral resection of the prostate (TURP) is the most effective surgical procedure and has long been considered the gold standard. During TURP, the doctor puts a scope up the penis all the way to the prostate and uses instruments or a laser to remove part of the prostate. Most often, this procedure will relieve symptoms^[5][7].

Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive procedure that uses a laser to remove extra prostate tissue through the urethra. It has one of the lowest retreatment rates of BPH surgeries and a high long-term success rate^[19].

Other surgical options include simple prostatectomy (when the prostate is very large), transurethral incision of the prostate (TUIP), and various newer techniques. Although TURP improves symptoms, many less invasive options with varying effectiveness and lower risks of bleeding, incontinence, and sexual adverse effects can be considered^[7][19].

Lifestyle Changes and Self-Management

Simple lifestyle changes and self-management methods can help alleviate symptoms of BPH and improve your quality of life^[7][13].

Managing Fluid Intake

Limit your total fluid intake to about 2 liters or 2 quarts per day. Avoid drinking fluids in the evening, especially a few hours before going to bed or before going out. Cut back on drinks with caffeine and alcohol, as these substances can make you feel like you need to urinate more often and can irritate the bladder^[13][16].

Dietary Changes

Eat lots of different vegetables every day and include a few servings of fruit daily, especially citrus fruits such as oranges or grapefruits. Eat plenty of fresh fruits and vegetables, particularly those high in beta-carotene and vitamin C^[15][16].

The type of protein you eat may matter. Some studies found a higher risk of enlarged prostate in men who ate more red meat. Getting protein from plant sources such as beans is recommended. Fish high in omega-3 fatty acids, such as salmon and sardines, are also good choices^[15].

Avoid foods high in sugar or unhealthy fats^[20]. Some men may benefit from avoiding high doses of zinc supplements, which can worsen BPH symptoms^[16].

Exercise and Weight Management

Do some moderate to vigorous exercises or activities, such as brisk walking, biking, or playing sports, most days of the week. Stay at a healthy body weight^[15]. Regular physical activity helps reduce stress and improve overall health^[18].

Bathroom Habits

Double voiding can help empty your bladder more completely. Simply urinate as much as possible, relax for a few minutes, and urinate again^[18]. Try to urinate at least every 3 hours^[16].

When you go to the bathroom, take the time to empty as much of your bladder as you can. After urinating, you can “milk out” residual urine by placing two or three fingers an inch behind your scrotum and gently pressing upward toward the base of the penis^[13].

Evidence suggests that sitting provides a better urodynamic profile for men with prostate and lower urinary tract symptoms^[18].

Pelvic Floor Exercises

Perform Kegel exercises to reduce urine leakage and strengthen bladder control. Try to stop the flow of urine for 20 seconds while you are urinating. Repeat the same muscle contractions 5-15 times, three to five times daily^[16][20].

Stress Management

Reduce stress by exercising regularly and practicing relaxation techniques such as meditation. Stress can trigger activity in the sympathetic nervous system, causing muscles around the prostate to tense and compress the urethra^[13][18].

Other Considerations

Stay warm and avoid getting chilled. Talk with your doctor about all your prescription and over-the-counter medications, as some drugs such as antihistamines and decongestants may worsen urination problems^[13][16].

Avoid nicotine, as smoking can worsen symptoms^[16][20]. Avoid bicycling or use a soft, wide bicycle seat and padded shorts to reduce pressure on the prostate^[16].