Benign prostate enlargement

Benign prostate enlargement (BPE) is also known as benign prostatic hyperplasia (BPH). It affects older men and anyone with a prostate. It's particularly common in men and anyone with a prostate over 50 years of age, and it isn't usually a serious threat to health.

The prostate is a small gland in the pelvis, between the penis and the bladder. It's the gland affected in benign prostate enlargement, and it helps produce semen.

The prostate makes a thick, white fluid. A protein called prostate-specific antigen (PSA) turns this into a thinner liquid. The liquid then mixes with sperm from the testicles to form semen.

If the prostate becomes enlarged, it can press on the bladder and the urethra (the tube that carries urine out of the body). This can change how you pass urine and may cause:

• difficulty starting urination
• a frequent need to urinate
• difficulty fully emptying the bladder

In some men, and in anyone with a prostate, the symptoms are mild and need no treatment. In others they can be very troublesome and affect daily life a great deal.

Many people worry that an enlarged prostate means a higher risk of prostate cancer. It doesn't. The risk of prostate cancer is no greater for people with an enlarged prostate than for those without one.

Nobody knows for certain what causes benign prostate enlargement. Most experts agree it's linked to the hormonal changes that happen as a man gets older.

If your doctor suspects that you have benign prostate enlargement, you'll be asked to fill in a questionnaire about your symptoms. Each question has 5 possible answers, and each answer carries a score. Your total score shows how severe your symptoms are.

Your doctor will also want to rule out other conditions that cause symptoms similar to an enlarged prostate. You may have some standard tests, such as urine tests, and some more specific ones, such as a blood test that measures PSA.

How your benign prostate enlargement is treated depends on how bad your symptoms are.

If your symptoms are mild to moderate, you won't get any medical treatment straight away. Your doctor will ask you to come for regular check-ups so they can keep a close eye on your prostate. You'll probably be advised to change a few habits too, such as cutting down on caffeine and alcohol and exercising regularly, to see whether your symptoms get better.

For moderate to severe symptoms, medicine is usually recommended along with those lifestyle changes. Finasteride and dutasteride are commonly used. They block the effects of a hormone called dihydrotestosterone (DHT) on the prostate gland, which can make the prostate smaller and ease the symptoms that go with it.

Your doctor may also prescribe alpha blockers. These relax your bladder muscles, so passing urine becomes easier. Tamsulosin and alfuzosin are two alpha blockers commonly used for benign prostate enlargement.

Surgery is usually recommended only when moderate to severe symptoms have not responded to medicine.

Benign prostate enlargement can sometimes cause problems such as a urinary tract infection (UTI) or acute urinary retention. Serious complications are rare.

Benign prostate enlargement is linked to ageing, and it's common in men and in anyone with a prostate who is over 50 years of age.

Benign prostate enlargement causes symptoms because the enlarged prostate presses on the bladder and on the urethra (the tube that carries urine from the bladder to the penis).

This can upset urination in several ways. You may:

• find it hard to start urinating
• notice a weak flow of urine, or a flow that keeps stopping and starting
• strain to pass urine
• need to urinate often
• wake up often during the night to urinate
• feel a sudden urge to urinate, which can lead to urinary incontinence if you can't reach a toilet quickly enough
• not be able to empty your bladder fully
• see blood in your urine (haematuria)

In the later stages, benign prostate enlargement can lead to urine retention and other complications, such as bladder stones, bladder infections and kidney damage.

See a doctor if you notice any problem with your usual pattern of urination, or any change in it. Even if the symptoms are mild, they could be caused by a condition that needs to be investigated.

If you see any blood in your urine, a doctor must investigate it to rule out other, more serious conditions.

No one knows the exact cause of benign prostate enlargement. Research suggests that hormones probably play an important part in how it develops. Hormones are powerful chemicals, and they can affect the cells of the body in many different ways.

One theory is that the level of a hormone called dihydrotestosterone (DHT) rises as some men and anyone with a prostate get older. This rise may stimulate the prostate to grow.

Another theory points to two hormones, testosterone and oestrogen. When men and anyone with a prostate are younger, they produce high levels of testosterone and much smaller levels of oestrogen. As they get older, testosterone levels fall, so oestrogen makes up a higher share of the hormones in the body. It's been suggested that this relative increase in oestrogen may stimulate the prostate to grow.

Research shows that benign prostate enlargement is more common in men, and anyone else with a prostate, who also have high blood pressure and diabetes. But diabetes and high blood pressure both tend to come with natural ageing, so the three conditions may not be directly connected.

You'll need to have a few tests to find out whether your prostate gland is enlarged. Some of these will be done by your doctor, and others by a urologist (a doctor who specialises in urinary problems).

Your doctor will start by asking about your symptoms. If they seem to point to benign prostate enlargement, the next step is to work out your International Prostate Symptom Score (IPSS).

To assess the symptoms of benign prostate enlargement, you'll be asked to complete a questionnaire. Each question has 5 possible answers that carry a score, and your overall score is used to judge how severe your symptoms are.

The checklist includes the following questions.

Over the past month, how often:

• have you had the sensation of not completely emptying your bladder after urinating?
• have you had to urinate again less than 2 hours after finishing urinating?
• have you found that you stopped and started again when urinating?
• have you found it difficult to postpone urination?
• have you had a weak stream of urine?
• have you had to push or strain to begin urinating during the course of one night?
• have you had to get up during the night to urinate?

Once your doctor has assessed how severe your symptoms are, they'll use certain tests to try to rule out other conditions with similar symptoms.

Benign prostate enlargement can cause symptoms that look a lot like those of other conditions, prostate cancer among them. So your doctor will want to be completely sure that cancer isn't the cause of what you're feeling.

A urine test can show whether your symptoms come from an infection in your urinary system, such as a kidney infection or a bladder infection.

You may need a rectal examination so the doctor can check whether you might have prostate cancer. Prostate cancer can make the prostate gland hard and bumpy.

The doctor will put on a glove and lubricate one finger. Then they'll gently push this finger into your bottom and up into your rectum. The rectum is close to the prostate gland, so they can feel whether the surface of the gland has changed. It will feel a little uncomfortable, but it isn't usually painful.

Prostate cancer doesn't always change the prostate gland, so you may need some more specialised tests to rule it out. You will probably be referred to a urologist for these tests.

A blood test can measure how much PSA protein your prostate is producing. A raised PSA level points to an enlarged prostate, and a level that is much higher than normal may point to prostate cancer. But like a rectal examination, a PSA test can't give a definite diagnosis of prostate cancer.

A transrectal ultrasound, or TRUS, is a scan made to look closely at the prostate and the area around it. The doctor places an ultrasound probe into your rectum. The probe uses soundwaves to build a detailed picture of your prostate.

With this scan, the doctor can measure the size of your prostate. It can also be used to confirm or rule out a diagnosis of prostate cancer.

A CT urogram is a scan that looks at your urinary tract. That means the bladder and the tubes that carry urine, which are called the ureter and the urethra.

Doctors use a CT urogram to check for blockages in your urinary system that could be causing your symptoms, such as a kidney stone or a bladder stone. It can also pick up any damage in the urinary tract.

For the scan, you're given an injection of a harmless radioactive dye, which shows up on X-rays. The dye needs 30-60 minutes to pass into your urinary tract. Once it has, a series of X-rays is taken. Sometimes you may be asked to pass urine before the final X-ray is taken.

A voiding chart is a urination diary, and your doctor may ask you to keep one for 24 hours. You'll write down how often you urinate, and also how you urinate. For example, you might note whether your urine stops and starts, or whether it's hard to get started.

The chart is a good way to learn more about your symptoms. It can also help your doctor decide which treatment would work best to control them.

Uroflowmetry is a test that measures the pressure inside your bladder and shows how well your bladder works when you pass urine.

You'll be given a local anaesthetic, and then a small flexible tube (a catheter) is put into your urethra and moved up into your bladder. Water is then injected through the catheter into the bladder. A computer connected to the catheter records the pressure inside your bladder, and this helps the doctor judge how well the bladder is working.

Like voiding charts, uroflowmetry is a good way of working out which treatment will help control your symptoms.

How your enlarged prostate gland (benign prostate enlargement) is treated depends on how severe your symptoms are.

There are 3 main treatments:

• lifestyle changes
• medicine
• surgery

If your symptoms are mild to moderate, you may not get any medical treatment straight away. Instead, you'll have regular check-ups so your doctor can keep a close eye on your prostate gland. This is often called "watchful waiting".

You may also be advised to make some lifestyle changes, to see whether they improve your symptoms.

If you have benign prostate enlargement, your doctor may advise you to make a few changes to your daily habits:

• avoid drinking any liquids for 1 to 2 hours before going to bed, which will reduce your chances of waking up during the night to pass urine (nocturia)
• try different times for taking your prescribed medicine, because taking it at 7pm, for example, may help prevent nocturia
• stop drinking alcohol and caffeine, or cut down on them, as these drinks can irritate your bladder and make your symptoms worse
• exercise regularly, since research shows moderate exercise, such as walking for 30 to 60 minutes a day, can improve symptoms (although it's unclear exactly why this is the case)
• join a patient support group, which your doctor should be able to recommend and which may help you manage mild symptoms without the need for medicine

Bladder training is an exercise programme for benign prostate enlargement. It helps you wait longer between each time you urinate, and it helps your bladder hold more urine.

You'll be given a target, such as waiting at least 2 hours between each time you urinate.

It's a good idea to use a bladder training chart. On it you record each time you pass urine and how much you passed, so you'll need a plastic jug to measure the amount. Your doctor should give you a chart to take home.

You'll also be taught a number of exercises, such as breathing, relaxation and muscle exercises. These help take your mind off the need to urinate.

Over time, your target time will be increased. By the end of the programme you should find that you can go for longer without urinating.

Bladder training should only be carried out under medical supervision.

Doctors usually recommend medicine for moderate to severe symptoms of benign prostate enlargement, and you'd take it together with the lifestyle changes mentioned above.

Finasteride and dutasteride are widely used to treat benign prostate enlargement. They block the effects of a hormone called dihydrotestosterone (DHT) on the prostate gland. This can shrink the prostate and ease the symptoms that come with it.

If your doctor prescribes one of these medicines, you may notice your symptoms improve straight away. But you'll need to take it for at least six months to get the maximum benefit, and your doctor will need to monitor you every year.

Use condoms if you're sexually active, because both finasteride and dutasteride can have an adverse effect on your sperm. If you get a woman pregnant, there's a risk the baby could develop birth defects.

Other possible side effects include impotence, and little or no sperm when you ejaculate. In many cases these side effects improve as your body gets used to the medicine. See your doctor if the side effects are troubling you.

Alpha blockers help relax the muscles of your bladder, so passing urine becomes easier. Your doctor may prescribe them as your main treatment for benign prostate enlargement, or together with finasteride.

Tamsulosin and alfuzosin are 2 alpha blockers commonly used for this condition. Their side effects are uncommon and usually mild. They include:

• dizziness
• headaches
• weakness
• little or no sperm when you ejaculate

Start taking alpha blockers over a restful weekend when you're not planning to drive, because they could cause low blood pressure (hypotension) and fainting.

Generally, if you feel dizzy while taking this medicine, don't drive or operate heavy machinery until the dizziness has passed.

Doctors usually recommend surgery for benign prostate enlargement only when the symptoms are moderate to severe and haven't improved with medicine. There are several different procedures, and all of them work by reducing the pressure on your bladder.

Transurethral resection of the prostate, or TURP, is done by passing 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 then used to remove the extra tissue from your prostate.

You'll have 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 operation can take up to an hour, depending on how much tissue has to be removed. Most people are well enough to leave hospital 2 to 3 days afterwards.

Straight after surgery, you won't be able to urinate normally because your urethra is swollen. A thin tube called a catheter is put into your urethra and up into your bladder so the urine can drain away. It's usually taken out 24 to 48 hours after the operation.

One common complication of TURP is that you no longer produce semen when you ejaculate. This is called retrograde ejaculation. The sperm go into your bladder instead of coming out through your penis. You will still feel the physical pleasure of ejaculation (the climax), though.

Bladder neck incision, also called transurethral incision of the prostate (TUIP), is an operation that widens the urethra so it's easier to pass urine.

As with TURP, the surgeon puts a resectoscope into your urethra. It has a heated wire loop at the end, and the surgeon uses it to make small cuts (incisions) in the muscle where the prostate meets the bladder.

These cuts relax the opening to the bladder, which helps urine flow out of it. TUIP is done under a spinal or general anaesthetic, the same as TURP.

After the operation you may not be able to urinate, and a catheter may be needed to empty your bladder. As with TURP, you'll only need the catheter for a short time, until you can urinate normally.

The risk of retrograde ejaculation is lower with TUIP than with TURP, although it can still sometimes happen.

Holmium laser enucleation of the prostate (HoLEP) is a lot like a TURP. In both, the surgeon removes the extra prostate tissue with an instrument passed through the urethra. The difference is that HoLEP uses a laser, not a wire loop.

Compared with a TURP, this technique has some advantages, and it also has some disadvantages.

If your doctor has offered you a HoLEP, you may want to ask your surgeon why it was chosen for you, and what the risks and benefits are when set against a TURP.

Inserting prostatic urethral lift implants is a new surgical procedure that can help relieve the urinary symptoms of benign prostate enlargement. It can be done under local anaesthesia or general anaesthesia.

The surgeon passes tiny implants through the urethra. They are then positioned to hold the enlarged prostate away from the urethra, so the urethra isn't blocked.

Compared with TURP and TUIP, one big advantage is a lower risk to your sexual function. There's less chance of erectile dysfunction and ejaculation problems. There's also less tissue injury, so you should recover more quickly and won't need to stay in hospital as long.

However, prostatic urethral lift implants are unlikely to give permanent symptom relief in all cases. And because it's a new procedure, the long-term outcomes are unknown and it may not be easy to get.

Transurethral vaporisation of the prostate (TUVP) is similar to a TURP, but the surgeon destroys (vaporises) parts of the prostate instead of cutting them away.

Studies have shown that TUVP improves symptoms just as well as TURP does. But some men, and anyone with a prostate, may need more treatment in the future.

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

The surgeon passes a thin, flexible instrument called a cytoscope into the urethra. A laser fibre then goes through the cytoscope and destroys the extra prostate tissue that is blocking the flow of urine.

The procedure is recommended for people who don't have a high risk of 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, and it has several benefits too. 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.

An open prostatectomy may work better than TURP if you have severe benign prostate enlargement. But doctors now rarely use it, even for larger prostates, because newer techniques such as HoLEP have been developed.

In this operation, the surgeon makes a cut in your tummy and removes the outer portion of your prostate.

The risk of complications is higher with an open prostatectomy, and these include erectile dysfunction and urinary incontinence. There's also a greater chance that these problems will become permanent than if they happen after TURP.

Benign prostate enlargement can sometimes cause complications, such as a urinary tract infection or acute urinary retention.

If you can't empty your bladder properly, bacteria in your urinary system may not get flushed out. They can then spread through the urine and 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

A UTI can be treated with antibiotics. One UTI on its own 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 (AUR) means you suddenly can't pass any urine at all. Treat it as a medical emergency. Without quick treatment, urine can pass back up into the kidneys, and that can damage them.

The symptoms of AUR are:

• the sudden inability to pass urine
• severe lower abdominal pain
• swelling of the bladder that you can feel with your hands

If you or someone you know has these symptoms, phone 999 and ask for an ambulance.

AUR can be treated with a thin tube (catheter) that drains the urine out of your bladder. In very serious cases, surgery may be needed to empty the bladder.