Benign prostate enlargement

Prostate enlargement doesn't have a single known cause, but most doctors agree it's linked to the hormonal changes that come with getting older.

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 and anyone with a prostate gets 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 and anyone with a prostate produce high levels of testosterone and much smaller levels of oestrogen. But as they get older, 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 and anyone with a prostate 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.

How is benign prostate enlargement diagnosed?

If your GP suspects that you have an enlarged prostate, you will be asked to complete a questionnaire to assess your symptoms. Each question has 5 possible answers, and each one carries a score, so your overall score shows how severe your symptoms are.

Your GP will also want to rule out other conditions that can cause symptoms similar to prostate enlargement. You may be given a number of standard tests, such as urine tests, along with some more specific tests, such as a blood test that measures PSA.

Read more about diagnosing benign prostate enlargement below.

Diagnosing benign prostate enlargement

To find out whether your prostate gland is enlarged, you will need to have a few tests. Some of these 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 do have symptoms of benign prostate enlargement, the next step is to work out your International Prostate Symptom Score, known as the IPSS.

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.

Read more about treating benign prostate enlargement

The treatment for an enlarged prostate gland will depend on how severe your symptoms are.

The 3 main treatments are:

• lifestyle changes
• medication
• surgery

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.

Surgery

Surgery is usually only recommended for moderate to severe symptoms of benign prostate enlargement that have failed to respond to medication.

Various procedures can be used to reduce the pressure on your bladder.

Transurethral resection of the prostate (TURP)

Transurethral resection of the prostate (TURP) involves inserting a small instrument called a resectoscope into your urethra, the tube that carries urine from the bladder to the 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 people are well enough to leave hospital 2 to 3 days after the operation.

After 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 to 48 hours after surgery.

A common complication of TURP is 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).

Bladder neck incision (TUIP)

Bladder neck incision involves widening the urethra so it is easier to pass urine. It is also known as transurethral incision of the prostate (TUIP).

Like TURP, the surgeon will insert a resectoscope into your urethra. The resectoscope has a heated wire loop at the end and is used to make small cuts (incisions) in the muscle where the prostate meets the bladder.

This type of surgery relaxes the opening to the bladder, helping urine 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.

Holmium laser enucleation of the prostate (HoLEP)

Holmium laser enucleation of the prostate (HoLEP) is similar to a TURP. Excess prostate tissue is removed using an instrument inserted through the urethra. However, it uses a laser, rather than a wire loop.

There are some advantages to using this technique rather than a TURP, but also some disadvantages.

If you have been offered a HoLEP, you may want to ask your surgeon to explain why this was chosen for you, and the risks and benefits compared with TURP.

Insertion of prostatic urethral lift implants

The insertion of prostatic urethral lift implants is a new surgical procedure that can help relieve urinary symptoms.

The procedure can be carried out under local anaesthesia or general anaesthesia.

It involves inserting tiny implants through the urethra. The implants are then positioned to hold the enlarged prostate away from the urethra so it isn’t blocked.

One of the big advantages of prostatic urethral lift implants compared with TURP and TUIP is a reduced risk to your sexual function – there is less chance of erectile dysfunction and ejaculation problems.

There’s also less tissue injury, which means your recovery will be quicker and you won’t need to stay in hospital as long.

However, prostatic urethral lift implants are unlikely to provide permanent symptom relief in all cases. And as it’s a new procedure, the long-term outcomes are unknown and availability may be limited.

Read more about the use of prostatic urethral lift implants to relieve symptoms of prostate enlargement.

Transurethral vaporisation of the prostate (TUVP)

Transurethral vaporisation of the prostate (TUVP) is similar to a TURP, but parts of the prostate are destroyed (vaporised) rather than cut away.

Studies have shown that TUVP is as effective as TURP at improving symptoms. But some men and anyone with a prostate may need more treatment in the future.

Greenlight laser surgery (PVP)

A laser can sometimes be used to destroy the prostate tissue. This particular form of TUVP is called photoselective vaporisation of the prostate (PVP), or Greenlight laser surgery.

A thin, flexible instrument called a cytoscope is inserted into the urethra. A laser fibre is then passed through the cytoscope to destroy the excess prostate tissue that is blocking the urine flow.

The procedure is recommended for those who don’t have a high risk of developing complications from treatment, such as men and anyone with a prostate who:

• doesn’t have urinary retention
• doesn’t have an increased risk of bleeding
• has a prostate smaller than 100ml

In these ‘low-risk’ groups, Greenlight laser surgery is thought to be as effective as TURP, but also has several benefits.

These include:

• a shorter hospital stay – the procedure is often carried out as a day case
• the catheter can be removed sooner
• recovery is quicker
• there’s a lower risk of complications

The National Institute for Health and Care Excellence (NICE) website has more information about GreenLight XPS for treating benign prostatic hyperplasia.

Open prostatectomy

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 other techniques have been developed, such as HoLEP.

During an open prostatectomy, an incision will be made in your 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 after TURP.

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)
• nausea
• vomiting
• 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

Phone 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.

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Benign prostate enlargement can occasionally lead to problems such as a urinary tract infection (UTI) or a sudden, complete blockage in passing urine, known as acute urinary retention. Serious complications are uncommon.

Read more about the complications of benign prostate enlargement

Benign prostate enlargement can occasionally lead to problems such as a urinary tract infection or acute urinary retention.

How common is benign prostate enlargement?

Benign prostate enlargement is linked to ageing and is a common condition in men, and in anyone with a prostate, past the age of 50.