What is BPH?

 

Benign Prostatic Hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland. The prostate is a walnut-sized gland located just below the bladder in men, surrounding the upper portion of the urethra (the tube that carries urine and semen out of the body). As a man ages, hormonal changes—specifically shifts in testosterone and dihydrotestosterone (DHT)—cause the prostate tissue to gradually multiply and expand. As the prostate grows larger, it squeezes the urethra and presses against the base of the bladder, making it harder for urine to flow normally.

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• BPH is a natural part of aging for most men. It affects about 50% of men in their 50s and up to 90% of men over age 80.

• BPH is not prostate cancer, nor does having BPH increase your risk of developing prostate cancer. However, both conditions can cause similar urinary symptoms, which is why a proper medical evaluation is essential.

 

Symptoms

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BPH symptoms are generally grouped into two categories: obstructive symptoms (caused by the blocked tube) and irritative symptoms (caused by the bladder working harder against resistance).

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Obstructive Symptoms (Difficulty Emptying)

• Weak or Interrupted Stream: A slow, weak, or dribbling stream of urine.

• Hesitancy: Trouble starting to urinate, or having to strain to begin.

• Terminal Dribbling: Dribbling at the end of urination.

• Incomplete Emptying: Feeling like the bladder is never completely empty.

 

Irritative Symptoms (Storage Issues)

• Frequency: Needing to urinate frequently, often every 1 to 2 hours.

• Urgency: A sudden, compelling need to urinate that is difficult to delay.

• Nocturia: Waking up multiple times during the night to urinate.

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Complications

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• Acute urinary retention, which can lead to hydronephrosis, acute kidney failure, urinary tract infection, and bladder rupture.

• Chronic urinary retention, which can cause overactive bladder and incontinence/leaks, infection, decompensation of the bladder, bladder stones, hematuria from friable new vessel rupture, chronic kidney disease, and more. 

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Diagnostics

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Evaluating BPH involves ruling out other conditions (like prostate cancer, urinary tract infections, or bladder dysfunction) and measuring how much the enlarged prostate affects urinary flow and quality of life.

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1. Initial Clinical Evaluation

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• Medical History & Symptom Score: A thorough review of symptoms using a standardized questionnaire, such as the American Urological Association Symptom Index (AUA-SI) or the International Prostate Symptom Score (IPSS). This measures symptom severity (mild, moderate, or severe) and tracks response to treatment over time.

• Digital Rectal Exam (DRE): A physical examination where a provider inserts a lubricated, gloved finger into the rectum to feel the back surface of the prostate gland. This helps estimate prostate size, shape, smoothness, and consistency, while checking for hard nodules or irregularity that might suggest prostate cancer.

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2. Standard Laboratory Tests

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• Urinalysis (Dipstick or Microscopic): Tests a urine sample to rule out urinary tract infections (UTIs), blood in the urine (hematuria), diabetes, or kidney dysfunction as the root cause of urinary symptoms.

• Prostate-Specific Antigen (PSA) Blood Test: PSA is a protein produced by the prostate. Elevated levels can occur in BPH, prostate infections (prostatitis), or prostate cancer. Establishing a baseline PSA helps assess prostate cancer risk and estimate future prostate growth.

• Serum Creatinine / Kidney Function: Evaluates kidney function to ensure severe urinary retention is not backing up into the ureters and damaging the kidneys.

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3. Objective & Advanced Diagnostic Tests (When Indicated)

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• Post-Void Residual (PVR) Volume: An ultrasound or bladder scan performed immediately after you urinate to measure how much urine remains trapped in the bladder. High residual volume suggests significant obstruction or weak bladder muscles.

• Uroflowmetry: Measures the speed and volume of urine flow as you urinate into a special funnel-shaped device. A low peak flow rate indicates obstruction caused by the prostate.

• Transrectal Ultrasound (TRUS): An ultrasound probe placed in the rectum to measure the exact size, volume, and shape of the prostate gland. Often used prior to surgical procedures or to evaluate elevated PSA levels.

• Cystoscopy: A specialized procedure where a doctor passes a thin, lighted tube with a camera through the urethra into the bladder. This allows direct visualization of the urethral blockage, prostate enlargement, and bladder wall changes.

 

Management

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1. Lifestyle Modifications & Education (Mild Symptoms)

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• Fluid Timing: Limit fluid intake 2 to 3 hours before bedtime to reduce nighttime urination (nocturia).

• Limit Bladder Irritants: Reduce consumption of caffeine, alcohol, artificial sweeteners, and highly acidic or spicy foods, which irritate the bladder lining.

• Review Medications: Avoid over-the-counter decongestants (e.g., pseudoephedrine) and antihistamines (e.g., diphenhydramine), as they tighten the prostate muscle or relax the bladder muscle, making urination much harder.

• Double Voiding: After finishing urination, wait a few moments and try again to help fully empty the bladder.

• Stay Active: Regular physical activity helps reduce urinary retention and improves pelvic muscle tone.

 

2. Prescription Medications (Moderate to Severe Symptoms)

 

Alpha-1 Blockers

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• Examples: Tamsulosin (Flomax), Alfuzosin (Uroxatral), Silodosin (Rapaflo), Doxazosin (Cardura).

• Mechanism: Relaxes the smooth muscle tissues in the prostate and bladder neck, making it easier to urinate.

• Onset: Works quickly, often providing noticeable symptom relief within a few days to two weeks.

• Key Considerations & Side Effects: Dizziness or lightheadedness when standing up (orthostatic hypotension), nasal congestion, and retrograde ejaculation (semen entering the bladder during orgasm, which is harmless but can be surprising).

 

5-Alpha Reductase Inhibitors (5-ARIs)

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• Examples: Finasteride (Proscar), Dutasteride (Avodart).

• Mechanism: Blocks the conversion of testosterone to dihydrotestosterone (DHT), the hormone responsible for prostate growth. This physically shrinks the enlarged prostate over time.

• Onset: Works slowly; requires 3 to 6 months of continuous use to achieve significant reduction in prostate size and symptom relief.

• Key Considerations & Side Effects: Reduces blood levels of Prostate-Specific Antigen (PSA) by about 50% (important for prostate cancer screening context). Side effects can include decreased libido, erectile dysfunction, or breast tenderness/enlargement (gynecomastia).

 

Combination Therapy

• Combining an alpha-blocker (for immediate symptom relief) and a 5-ARI (for long-term prostate shrinkage) is often prescribed for men with significantly enlarged prostates or high risk of disease progression.

 

Procedures & Surgical Options

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For severe symptoms, urinary retention, recurrent urinary tract infections, or when medications fail to provide adequate relief, minimally invasive procedures or surgery may be recommended to remove or move blocking prostate tissue (e.g., TURP, HoLEP, or prostate urethral lift/UroLift).