Men often dread even the idea of having a prostate check. But because enlarged prostate, or benign prostatic hyperplasia (BPH), is a common condition that affects men as they age, it's important to know the facts.

About 50% of men between the ages of 51 and 60 have BPH, and that number jumps to 70% among men aged 60 to 69 and around 80% of men over 70 years of age. While some men who have BPH do not experience any bothersome symptoms, for many it causes problems with urination including increased urinary frequency, urgency, and an inability to completely empty the bladder.

Fortunately, a range of treatments are available for BPH, from lifestyle changes to medications to surgical interventions.

“BPH and the associated urinary symptoms are one of the most common reasons for a man to visit a urologist,” says urologist Daniel Kellner, MD. “Many men tend to accept urinary problems from BPH as a normal part of aging; they may not realize there is help available to improve their urination and quality of life.”

The prostate is a walnut-sized gland that rests below the bladder and in front of the rectum. It surrounds the urethra, the tube through which urine flows from the bladder, through the penis, and out of the body. The prostate produces a fluid that is a component of semen.

As men age, the cells of the prostate proliferate in response to the presence of a hormone called dihydrotestosterone. This causes prostate to grow in size, resulting in an enlarged prostate, also known as benign prostatic hyperplasia, or BPH.

The size to which the prostate grows is variable; in some cases, the prostate grows only slightly larger than normal, while in others, the prostate is greatly enlarged.  

While this is a benign growth, meaning it is not cancerous, it can nevertheless cause problems. In particular, the enlarged prostate can physically press against the urethra and obstruct the flow of urine. In turn, the obstruction of the urethra can prompt changes to the muscles of the bladder, which can result in incomplete emptying of the bladder during urination.

The precise cause of BPH is not fully understood, though it is associated with the exposure of cells within the prostate to a hormone known as dihydrotestosterone in aging men. This hormone stimulates the proliferation of certain cells in the prostate, which results in an enlarged prostate gland.

It’s worth noting that dihydrotestosterone levels are the same in men with and without BPH; doctors do not yet know why some men develop enlarged prostates while others do not.

Several risk factors increase the chances that a man will develop BPH:

• Age. BPH is often considered a normal part of aging. The risk for BPH increases as men get older.
• Family history. Several studies have shown that men who have a family history of BPH are more likely to develop it than men without a family history of the condition.
• Metabolic Syndrome and obesity. Some evidence suggests that men who are obese or who have the metabolic syndrome (a group of risk factors for cardiovascular disease and diabetes including, among others, abdominal obesity, high blood pressure, insulin resistance, and low HDL cholesterol levels) are at increased risk for developing BPH.

Benign prostatic hyperplasia can cause a number of lower urinary tract symptoms, including the following:

• Urinary hesitancy, or difficulty starting urination
• Weak urinary stream
• Need to strain muscles to begin the flow of urine
• Urinary stream that starts and stops one or more times
• Inability to completely empty bladder of urine
• Increased frequency of urination
• Increased urge to urinate
• Increased frequency of urination at night, which often disrupts sleep (called nocturia)
• Urge incontinence, or the involuntary loss of urine
• Flow of urine slows to a dribble toward end of urination

In some cases, BPH can lead to damage to the kidney, bladder stones, hematuria (blood in the urine), urinary tract infections (UTIs), and acute urinary retention, a condition characterized by the inability to urinate and accompanied by pain and swelling in the lower abdomen.

To diagnose BPH, doctors evaluate a patient’s medical history, perform a physical exam, and run diagnostic tests.

As a first step, the doctor will collect information about the patient’s medical history. Typically questions center on urinary symptoms associated with BPH including urination frequency, nighttime urination habits, the feeling of incomplete bladder emptying and urgency to urinate, and whether the patient needs to strain to urinate. The doctor may also ask about daily fluid intake, consumption of caffeine and alcohol, and whether the patient takes medications that can affect urination.

During the physical exam, the doctor will examine the abdomen and pelvic area, and perform a digital rectal exam. During a digital rectal exam, the doctor will insert a finger into the patient’s rectum to feel the prostate to check for enlargement or other abnormalities.

In most cases, the doctor will order some additional tests to help confirm a diagnosis of BPH, including bloodwork to measure the levels of prostate-specific antigen (PSA), a protein produced by the prostate gland. Elevated levels of PSA may be a sign of an enlarged prostate. A urinalysis, a test in which a patient urinates into a container, is sometimes recommended. This test checks for signs of a urinary tract infection, blood in the urine (hematuria), and kidney function. 

The doctor may also recommend other tests that measure the rate of urine flow and the amount of urine that remains in the bladder after urination. In some cases, doctors may order an ultrasound of the prostate and/or a cystoscopy, a procedure in which a cystoscope—a tube equipped with a small lens—is inserted into the urethra to allow the doctor to examine the urethra and bladder.

Some men who have BPH do not experience any symptoms or experience only mild symptoms. In these cases, a doctor might recommend a “watchful waiting” strategy, which entails regular monitoring of the condition without the use of medications or other therapies.

Lifestyle changes. Doctors often advise men with BPH to make certain lifestyle and behavioral changes. While these behaviors will not stop the prostate from continuing to grow, they can mitigate some of the symptoms caused by BPH. These lifestyle changes include the following:

• Reducing daily consumption of fluids, especially before bed
• Reducing or avoiding consumption of diuretics like caffeine and alcohol, which can increase urine production and excretion
• Avoiding the use of decongestants and antihistamines, which may increase the retention of urine in the bladder
• Double voiding, a urination technique that helps empty the bladder completely. It entails urinating, waiting a minute or two, then urinating again.

Medications. In general, medication is the first-line treatment for men with BPH. A range of medications are commonly used to treat BPH, including the following:

• Alpha-blockers. These medications relax the muscles in the bladder and urethra, which results in improved urine flow.
• 5-Alpha reductase inhibitors. By suppressing hormones that contribute to the growth of the prostate, these medications reduce the size of the prostate and stop it from growing larger.
• Phosphodiesterase inhibitors. These drugs relax muscles in the lower urinary tract, which increases urinary flow.
• Anticholinergics. For men who have lower urinary tract symptoms caused by BPH but no signs of increased retention of urine in the bladder after urination, doctors may prescribe an anticholinergic. These medications relax the muscles in the bladder.
• Combination of medications. Often, doctors prescribe two of these medications in combination.

Surgery. For some men, medications and lifestyle changes do not significantly improve BPH symptoms. In these cases, a doctor may recommend surgery. Surgery is also usually recommended for men with BPH who experience continuing urinary tract infections, blood in their urine, bladder stones, kidney problems, or acute urinary retention.

Several surgical treatments are available, each of which aims to alleviate symptoms by reducing the size of the prostate. Most of these procedures are “transurethral,” meaning the surgeon accesses the prostate through the urethra.

• Traditional surgical treatments:
  • Transurethral Resection of the Prostate (TURP). One of the most common surgical procedures for treating BPH, during TURP a surgeon removes prostate tissue using a special loop of wire through which an electric current passes. TURP usually requires a 1- to 2-day hospital stay.
  • Transurethral Incision of the Prostate (TUIP). In this procedure, a surgeon makes small incisions in the prostate where it meets the bladder. This enlarges the opening of the urethra, which results in improved flow of urine. Most men can go home the day of surgery.
  • Simple Prostatectomy. During this procedure, a surgeon removes excess prostate tissue through an incision or a series of incisions in the lower abdomen, or perineum. Because it is more invasive than other surgical treatments, it usually entails a 2- to 4-day hospital stay and longer recovery times. Sometimes the surgeon performs the surgery using a robotic arm which they control via a specialized computer console.
• Minimally invasive treatments:
  • Laser Surgery. A few types of laser surgery are used to treat BPH. In these procedures, a surgeon uses a laser to remove or destroy prostate tissue that is obstructing the flow of urine.
    • Holmium Laser Enucleation of the Prostate (HoLEP). Because this procedure is less invasive than traditional surgical approaches to treating BPH, HoLEP typically allows for shorter hospital stays and recovery times. A large percentage of patients are able to go home the same day as the procedure, and most others can leave the hospital the next day. In general, HoLEP offers long-lasting results, which reduces the need for future treatment.
    • Photovaporization of the Prostate (PVP). In this procedure, a surgeon uses a laser known as the GreenLight laser to vaporize excess prostate tissue. This procedure is often performed in the ambulatory setting.
      
    • Prostatic Urethral Lift (UroLift). Rather than removing or destroying prostate tissue that constricts the urethra and thus impairs urination, in this outpatient procedure a urologist inserts permanent implants into the part of the urethra surrounded by the prostate. These implants pull excess prostate tissue away from the urethra, effectively opening it, which allows for improved flow of urine.