Overview
Benign prostatic hyperplasia (BPH) is non-cancerous enlargement of the prostate gland, a very common age-related condition. As the prostate enlarges, it can compress the urethra and obstruct urine flow. BPH does not increase the risk of prostate cancer. Symptoms are called lower urinary tract symptoms (LUTS).
How common is it?
BPH is the most common benign tumour in men. It affects about 50% of men by age 60 and over 80% by age 80. However, symptom severity varies widely and many men with BPH have no significant problems.
Causes and risk factors
BPH results from proliferation of stromal and epithelial cells in the periurethral zone of the prostate, driven by androgens and ageing.
Common risk factors
- Age (BPH is an almost universal feature of male ageing)
- Testosterone and DHT (dihydrotestosterone) stimulation of prostate growth
- Family history
- Obesity and metabolic syndrome
- Type 2 diabetes
Symptoms
- Voiding symptoms: weak urinary stream, hesitancy, straining to start, intermittent stream, prolonged voiding
- Storage symptoms: urinary urgency, frequency, nocturia (waking at night to urinate)
- Post-micturition: terminal dribbling, feeling of incomplete emptying
- Urinary retention (complete inability to void) in severe cases — a urological emergency
When to see a doctor
See a GP for significant urinary symptoms. Seek emergency assessment for complete inability to urinate, or urinary retention with lower abdominal pain and distension.
Diagnosis
International Prostate Symptom Score (IPSS) questionnaire quantifies symptom severity. Urinalysis and MSU to exclude infection. PSA test (after discussion) to screen for prostate cancer. Renal function. Flow rate and post-void residual measurement. Flexible cystoscopy if haematuria is present.
Treatments
Watchful waiting and lifestyle advice
For mild to moderate symptoms. Reduce fluid intake in the evening, limit caffeine and alcohol, and void when first feeling the urge. Bladder training and pelvic floor exercises help storage symptoms.
Alpha-1 blockers
Tamsulosin, alfuzosin, or doxazosin relax smooth muscle in the prostate and bladder neck, improving flow rate within days. First-line pharmacological treatment. Side effect: postural hypotension (doxazosin more than tamsulosin).
5-alpha reductase inhibitors
Finasteride or dutasteride reduce prostate size by blocking DHT production. Takes 3 to 6 months to show effect. Reduces the need for surgery and the risk of acute urinary retention. Best for large prostates (above 40ml). Side effects: erectile dysfunction, reduced libido.
Surgical treatment (TURP)
Transurethral resection of the prostate (TURP) removes obstructing tissue endoscopically. Gold standard surgical treatment. Laser procedures (Holmium laser enucleation) are increasingly used and have less bleeding risk.
Self-care and lifestyle
- Reduce fluid intake in the 2 to 3 hours before sleep to reduce nocturia
- Limit caffeine and alcohol, which have diuretic effects
- Double voiding (urinating twice) reduces post-void residual
- Avoid cold and cough medications containing antihistamines or decongestants which can worsen retention
Prevention
BPH is a universal consequence of male ageing and cannot be prevented. Maintaining a healthy weight and staying physically active may reduce LUTS severity.