Benign prostatic hyperplasia
Benign prostate enlargement (BPE), also known as benign prostatic hyperplasia (BPH), is a condition that affects older men.
It's particularly common in men over 50 years of age and isn't usually a serious threat to health.
The prostate is a small gland found only in men, 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, 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.
Many men 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 men with an enlarged prostate than it is for men 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.
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.
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.
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.
How common is benign prostate enlargement?
Benign prostate enlargement is a condition associated with ageing and is common in men over 50 years of age.
Around 4 out of 10 men (40%) over 50, and 3 out of 4 men (75%) in their 70s have urinary symptoms caused by an enlarged prostate.
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 get 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 produce high levels of testosterone and much smaller levels of oestrogen. But as men get older, their 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 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:
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.
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 to prevent nocturia
stop drinking alcohol and caffeine, or limit your consumption of them –they can irritate your bladder and make your symptoms worse
exercise regularly – research has shown that moderate exercise, such as walking for 30 to 60 minutes a day, can improve symptoms (although it's unclear exactly why this is)
join a patient support group – your doctor should be able to recommend one; it 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 increase the amount of urine your bladder can hold.
You'll be given a target, such as waiting for 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 record 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) (see causes of prostate enlargement) on the prostate gland, which can reduce the size of the prostate and improve your associated symptoms.
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, because 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 to 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. They include:
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, because 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.
Transurethral resection of the prostate (TURP)
Transurethral resection of the prostate (TURP) is a surgical procedure where excess prostate tissue is removed to reduce the pressure on your bladder.
The surgeon will insert a small instrument called a resectoscope into your urethra (the tube that carries urine from your bladder to your 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 men are well enough to leave hospital two to three days after the operation.
Following 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 24-48 hours after surgery.
A common complication of TURP is that 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).
Transurethral incision of the prostate (TUIP)
Transurethral incision of the prostate (TUIP) is a surgical procedure where the urethra is widened, making it easier to pass urine.
Like TURP, the surgeon will insert a resectoscope into your urethra that has a heated wire loop at the end. This will be used to make small incisions in the muscle where the prostate meets the bladder.
This type of surgery relaxes the opening to the bladder, helping urine to 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.
There are also a number of newer surgical techniques that may lead to fewer side effects or a quicker recovery than TURP and TUIP.
However, as these treatments are still fairly new, they may not be available and their long-term effectiveness isn't always clear. These alternative techniques are explained below.
Bipolar transurethral resection of the prostate – different instruments are used to perform the procedure, which allow saline water to be pumped into the urethra, rather than a fluid called glycine. This is thought to lead to a lower risk of TURP syndrome (see risks of a TURP).
Holmium laser enucleation of the prostate – a laser is used to remove excess prostate tissue, using a similar route to a TURP. The procedure has shown good results in medium-term follow-up (five to seven years) and is emerging as a promising alternative. It doesn't use glycine, so there's no risk of TURP syndrome.
KTP laser vaporisation – a small tube known as a cystoscope is inserted into your urethra. The cystoscope fires pulses of laser energy to burn away prostate tissue.
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 of the development of other techniques, such as holmium laser enucleation of the prostate (see above).
During an open prostatectomy, an incision will be made in your abdomen (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 following TURP.
Preventing benign prostate enlargement
There's evidence to suggest that a diet high in protein and vegetables and low in red meat and fat may reduce your risk of developing an enlarged prostate.
Foods that are a good source of protein include:
Complications of 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.
Benign prostatic hyperplasia