Enlarged Prostate

Alternative names
BPH; Benign prostatic hypertrophy (hyperplasia); Prostate - enlarged

Definition

The prostate gland produces the fluid that carries sperm during ejaculation. As the prostate enlarges, which happens to almost all men as they get older, it can press on the urethra (the tube that empties urine from the bladder). This causes problems with urination.

Prostate enlargement is often called benign prostatic hypertrophy or hyperplasia (BPH). It is not cancer and it does not put you at increased risk for prostate cancer.

Causes, incidence, and risk factors

The actual cause of prostate enlargement is unknown. In addition to age, overgrowth of the prostate seems to require normal function of the testicles, which produce testosterone. This is known because men who have had their testicles removed at a young age (for example, for testicular cancer) do not develop BPH. Similarly, if the testicles are removed after a man develops BPH, the prostate begins to shrink in size.

The likelihood of developing an enlarged prostate increases with age. In fact, BPH is so common that it has been said, “All men will have an enlarged prostate if they live long enough!” A small amount of prostate enlargement is present in many men over age 40 and more than 90% of men over age 80. No risk factors have been identified other than having normally functioning testicles.

Symptoms

Less than half of all men with BPH have symptoms of the disease, which include:

     
  • Slowed or delayed start of the urinary stream  
  • Weak urine stream  
  • Dribbling after urinating  
  • Straining to urinate  
  • Strong and sudden urge to urinate  
  • Incomplete emptying of your bladder  
  • Needing to urinate 2 or more times per night  
  • Urinary retention (complete inability to urinate)  
  • Incontinence  
  • Pain with urination or bloody urine (these may indicate infection)

Signs and tests

     
  • A digital rectal exam (where your doctor inserts a finger into the rectum to feel the size and shape of the prostate gland) may reveal an enlarged, firm prostate.  
  • Urine flow rate may be measured.  
  • The amount of urine left in your bladder after urination may be measured. (This is called post-void residual urine.)  
  • Pressure flow studies will measure the pressure in the bladder as you urinate.  
  • An IVP (an x-ray study) may be done to confirm the diagnosis or look for blockage.  
  • Urinalysis may be done to check for blood or infection.  
  • Urine culture may be used to evaluate for infection.  
  • Voiding cystourethrogram (another x-ray study) may be performed.  
  • A prostate-specific antigen (PSA) blood test may be performed to screen for prostate cancer.  
  • Cystoscopy may be performed to visualize the prostate and bladder if surgery is required.

In addition, you may be asked to complete a self-screening form to evaluate the severity of your symptoms and the impact on your daily life. Your score on the screening tool may be compared to past records to evaluate progression of the disease.

Treatment

The choice of a treatment is based on the severity of your symptoms, the extent to which they affect your daily life, and the presence of any other medical conditions. Treatment options include “watchful waiting,” lifestyle changes, medication, or surgery.

If you are over 60, you are more likely to have symptoms. But many men with an enlarged prostate have only minor symptoms. Self-care steps are often enough to make you feel better.

If you have BPH, you should have a yearly exam to monitor the progression of your symptoms and determine if any changes in treatment are necessary.

SELF-CARE

For mild symptoms:

     
  • Urinate when you first get the urge. Also, go to the bathroom when you have the chance, even if you don’t feel a need to urinate.  
  • Avoid alcohol and caffeine, especially after dinner.  
  • Don’t drink a lot of fluid all at once. Spread out fluids throughout the day. Avoid drinking fluids within 2 hours of bedtime.  
  • Try NOT to take over-the-counter cold and sinus medications that contain decongestants or antihistamines. These medications can increase BPH symptoms.  
  • Keep warm and exercise regularly. Cold weather and lack of physical activity may worsen symptoms.  
  • Learn and perform Kegel exercises (pelvic strengthening exercises).  
  • Reduce stress. Nervousness and tension can lead to more frequent urination.

Saw palmetto may ease prostate symptoms. Look for fat-soluble saw palmetto extract with 85-95% fatty acids and sterols.

Sit in an aisle seat at the theatre or on an airplane. This won’t reduce your symptoms, but it may relieve your anxiety about having to urinate often or suddenly.

If these measures are not enough to ease your symptoms, talk to your doctor, who may consider medications or surgery.

MEDICATIONS

     
  • Finasteride lowers levels of hormones produced by the prostate, reduces the size of the prostate gland, increases urine flow rate, and decreases symptoms of BPH. It may take 3 to 6 months before you notice a significant improvement in your symptoms. Potential side effects related to use of finasteride include decreased sex drive and impotence.  
  • Alpha 1-Blockers (like doxazosin, prazosin, tamsulosin, and terazosin) are a class of medications also used to treat high blood pressure. These medications relax the muscles of the bladder neck, allowing easier urination. Two thirds of the people treated with alpha 1-blocker medications report an improvement in symptoms.  
  • Antibiotics may be prescribed to treat chronic prostatitis (inflammation of the prostate), which may accompany BPH. Some men note relief of their BPH symptoms after a course of antibiotics.

SURGERY

Prostate surgery may be recommended if you have:

     
  • Incontinence  
  • Recurrent blood in the urine  
  • Urinary retention  
  • Recurrent urinary tract infections

The choice of a specific surgical procedure is usually based on the severity of your symptoms and the size and shape of your prostate gland.

     
  • TURP: Transurethral resection of the prostate (TURP) is the most common surgical treatment for BPH. The TURP is performed by inserting a scope through the penis and removing the prostate piece by piece.  
  • TUIP: Transurethral incision of the prostate (TUIP) is similar to TURP, but is usually performed in men who have a relatively small prostate. This procedure is usually performed as an outpatient without need for a hospital stay. Like the TURP, a scope is inserted through the penis until the prostate is reached. Then, rather than removal of the prostate, a small incision is made in the prostatic tissue to enlarge the opening of the urethra and bladder outlet.  
  • Open Prostatectomy: An open prostatectomy is usually performed using general or spinal anesthesia. An incision is made through the abdomen or perineal area (i.e., through the pelvic floor, including the region from the scrotum to the anus). Then, the prostate is removed. This is a lengthy procedure, and it usually requires a hospital stay of 5 to 10 days.

The majority of men who have prostate surgery have improvement in urine flow rates and symptoms. Possible complications include impotence, urinary incontinence, retrograde ejaculation (semen flowing back into the bladder rather than out the penis), infertility, and urethral stricture (narrowing). Rates of these complications vary, depending on the surgical procedure that you and your doctor decide is best.

Various studies are underway to evaluate the effectiveness of other treatments, such as hyperthermia, laser therapy, and prostatic stents.

Support Groups
Several national groups provide information on BPH. See BPH support groups.

Expectations (prognosis)


Studies show that of the men who receive no treatment for BPH, as many as 31 to 55% actually show an improvement, and only 1 to 5% ever develop complications.

Complications

Men who have had long-standing BPH with a gradual increase in symptoms may develop:

     
  • Sudden inability to urinate  
  • Urinary tract infections  
  • Urinary stones  
  • Damage to the kidneys  
  • Blood in the urine

Even after surgical treatment, a recurrence of BPH may develop over time.

Calling your health care provider

Call your doctor right away if you have:

     
  • Less urine than usual.  
  • Fever or chills.  
  • Back, side, or abdominal pain.  
  • Blood or pus in your urine.

Also call your doctor if:

     
  • Your bladder does not feel completely empty after you urinate.  
  • You take medications that may cause urinary problems, like diuretics, antihistamines, antidepressants, or sedatives. DO NOT stop or adjust your medications on your own without talking to your doctor.  
  • You have taken self-care measures for 2 months without relief.

 

Johns Hopkins patient information

Last revised: December 3, 2012
by Gevorg A. Poghosian, Ph.D.

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