BPH treatment: when is it needed and what’s available?

If you’ve ever sat at a table with a bunch of older men, there’s a good chance that at some point, someone in the group will mention how often they have to pee. That’s because most older men experience a condition called benign prostatic hyperplasia or hypertrophy (BPH), also known as enlarged prostate. 

An enlarged prostate can cause all sorts of issues, frequent peeing being the most common. Keep reading to understand what BPH is, what treatments are available, and when they’re needed. 

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Benign prostatic hyperplasia or hypertrophy (BPH), also known as an enlarged prostate, is a common condition of older men. According to the Urology Care Foundation, approximately half of all men between the ages of 51 and 60 have BPH. This number increases with age, and about 90% of men over 80 years old are affected by BPH (Urology Care Foundation, n.d.).

The prostate gland surrounds part of the urethra (so-called “prostatic urethra”). The urethra is the tube through which urine travels from the bladder to the tip of the penis. As the prostate gets bigger with age, it can put pressure on the prostatic urethra and the base of the bladder. This pressure leads to common BPH symptoms, like needing to urinate more often, especially at night.

It is not completely clear why some men develop symptoms of BPH, and some don’t. Some experts believe that a family history of the condition increases a man's risk of developing BPH. You may have heard that having frequent sex or having a vasectomy might increase someone’s chances of developing BPH. Rest assured, there’s no evidence to support that claim (McVary, 2020). 

Currently, research focuses on the role of hormones in the development of BPH. Both testosterone and dihydrotestosterone (DHT) are involved in normal and abnormal prostate growth. Men produce both testosterone, also known as the “male hormone,” and estrogen, often referred to as the “female hormone.” When they’re younger, men make only small amounts of estrogen compared to testosterone. But with aging, the levels of testosterone fall, leaving a higher ratio of estrogen. There’s increasing evidence that a higher proportion of estrogen may promote prostate growth (Ho, 2011). 

At the same time, DHT levels (a male hormone involved in prostate development and growth) rise in the prostate, and this may also encourage continued prostate growth (Rastrelli, 2019). Chronic inflammation may play a role as well (Vignozzi, 2014). Likely, it is a combination of factors that leads to BPH.

According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), other risk factors for BPH include obesity, family history, atherosclerosis, and type 2 diabetes (NIDDK, 2014). 

The diagnosis of BPH usually starts with a history of lower urinary tract symptoms (LUTS). Common symptoms of BPH include (Ng, 2020):

• Needing to urinate frequently

• Needing to urinate more often at night (nocturia)

• Trouble starting urination

• Feeling like your bladder is full, even after you have just finished urinating.

• A weak urine stream

• Starting and frequently stopping during urination

• Having to strain to urinate

After informing your provider of any of the above symptoms, you will likely have a digital rectal exam (DRE). With a DRE, your provider inserts a finger into your rectum to feel for enlargement or other abnormalities in the prostate. Your provider may also want your urine checked (urinalysis) to ensure that you don’t have an infection causing your symptoms. Blood tests looking at kidney function may help in the diagnosis. 

Lastly, you may get a blood test called a prostate-specific antigen or PSA. Prostate-specific antigen (PSA) is a substance made by the prostate, and levels go up as the prostate gets larger. However, it is essential to know that PSA testing does not distinguish between BPH and prostate cancer or other prostate conditions, recent prostate procedures, infection, or surgery.  An elevated PSA blood level is not proof of cancer, and many other things can cause high PSA. Besides BPH, other things that potentially disturb the prostate gland through physical stimulation—such as riding a bicycle or having an orgasm within the past 24 hours—may increase PSA levels. (National Cancer Institute, n.d.).

The goal of treating BPH is to improve your quality of life, especially if you suffer from lower urinary tract symptoms (LUTS). Treatment often depends on your prostate’s size, age, health, and how much your symptoms affect you. 

For people with mild or mild-moderate symptoms that don't bother them too much, the American Urological Association (AUA) recommends watchful waiting (AUA, 2014). Watchful waiting involves yearly physical exams, including digital rectal exams, education, and lifestyle modifications to improve symptoms. These modifications include (McVary, 2020):

• Limiting your consumption of caffeine and alcohol

• Decreasing your liquid intake during the two hours before you go to bed

• Urinating before bedtime

• Trying to empty your bladder as completely as possible with each urination (but don’t strain or push to empty the bladder)

• Avoiding medications like antihistamines and decongestants, as these can make BPH symptoms worse

• Maintaining a healthy weight and exercising regularly (AUA, 2014)

In men whose BPH is causing problems, medical treatment is a potential option. There are three main classes of medications used for BPH: alpha-blockers, 5-alpha-reductase inhibitors, and phosphodiesterase-5 (PDE5) inhibitors; your healthcare provider may prescribe them individually or in combination.

Alpha-blockers

Alpha-blockers relax the muscles of the prostate and bladder to help improve your symptoms and make urination easier. They begin to work quickly to improve urine flow, lessen blockage of the urethra, and decrease many of the BPH symptoms. However, they do not make the prostate smaller. Side effects may include dizziness, low blood pressure with sitting or standing (orthostatic hypotension), fatigue, and retrograde ejaculation (semen goes back into the bladder instead of out the tip of the penis). Examples of alpha-blockers (McVary, 2020):

• alfuzosin (brand name Uroxatral)

• doxazosin (brand name Cardura)

• silodosin (brand name Rapaflo)

• terazosin (brand name Hytrin)

• tamsulosin (brand name Flomax)

5-alpha-reductase inhibitors

Another option for treatment is 5-alpha-reductase inhibitors. This type of medicine can decrease the size of your enlarged prostate. They do this by blocking DHT production, which may be one of the triggers for prostate growth; it may take up to six months of use before seeing an improvement in your symptoms. Possible side effects include erectile dysfunction, decreased sex drive, and retrograde ejaculation. Examples of 5-alpha-reductase inhibitors (McVary, 2020):

• finasteride (brand name Proscar)

• dutasteride (brand name Avodart)

Men with severe symptoms, with an extremely large prostate, or who did not have enough improvement with a single medication may benefit from combination therapy with alpha-blockers and 5-alpha reductase inhibitors. It’s important to remember that pregnant women or women who may become pregnant should not even touch this kind of medication. Finasteride can be absorbed through the skin and cause birth defects in male babies (FDA, 2011).

Phosphodiesterase-5 (PDE5) inhibitors

Lastly, phosphodiesterase-5 (PDE5) inhibitors, which were initially approved to treat erectile dysfunction, can also decrease urinary symptoms. Currently, one PDE5 inhibitor, tadalafil (brand name Cialis), is FDA-approved for BPH treatment. Some men taking this drug may experience headaches, facial flushing, stuffy nose, and upset stomach. You should not take PDE5 inhibitors if you take nitrates (such as nitroglycerin) or have kidney problems (McVary, 2020).

For some men, minimally invasive procedures or surgical treatments may help, especially if medications have not improved your symptoms. These treatments are often same-day procedures, usually under local anesthesia, and are less likely to cause sexual dysfunction. 

Minimally invasive procedures and surgical treatments include (NIDDK, 2014):

Transurethral resection of the prostate (TURP)

TURP is a common procedure and considered the gold standard for the surgical treatment of BPH; according to the AUA, approximately 150,000 men in the U.S. have a TURP each year (Urology Care Foundation, 2019). 

In this procedure, your surgeon inserts a thin, lighted scope into your urethra. Then, they cut away the excess prostate tissue with an electrified wire without removing the entire prostate. This procedure is quickly effective, but you may need to use a catheter to help you get rid of urine for a few days afterward. TURP does require general anesthesia and a short hospital stay, but it can be effective for 15 years or more. The side effects include retrograde ejaculation, erectile dysfunction, risk of UTIs, urinary incontinence. Lastly, full recovery takes about four to six weeks (UCF, 2019).

Prostatic urethral lift (PUL)

By going through the urethra, your provider can insert an implant that holds the prostatic urethra open, improving urine flow. This procedure does not cause sexual dysfunction. However, side effects include irritation from the implant, which can, in turn, cause mild pain with urination, blood in the urine, pelvic discomfort, and urgency (the sudden need to urinate).

PUL is a newer treatment, and there are concerns as to how effective this procedure is long-term; 33% of men need additional surgeries or to go back on BPH medications after having this procedure. PUL is an outpatient procedure (you can go home the same day) done under local anesthesia (UCF, 2019).

Convective water vapor (steam) ablation (CWVA)

Sterile water is heated until it turns into steam and is then used to kill excess prostate tissue, causing the prostate to shrink. CWVA is an outpatient procedure that can be done with local anesthesia. 

Common side effects include some pain with urination, blood in the urine, risk of urinary tract infections (UTIs), and urgency, but these usually resolve a few weeks after the procedure. The long-term benefits, however, are uncertain. There is no reported sexual dysfunction with this procedure. This procedure is not considered surgery, so men who prefer not to have surgery or want to avoid sexual side effects may also be good candidates (UCF, 2019).

Transurethral microwave thermotherapy (TUMT)

TUMT uses microwaves, via a catheter running inside the urethra, to heat up and destroy portions of the enlarged prostate. TUMT is an outpatient procedure that can be done with local anesthesia. 

Side effects include the risk of UTIs, urinary incontinence (involuntary leakage of urine), scarring of the urethra, urinary urgency, and burning with urination. This therapy has been around for more than 20 years, and newer treatments have mostly replaced this practice (UCF, 2019).

Transurethral incision of the prostate (TUIP)

Your surgeon inserts a lighted scope into your urethra and creates one or two small incisions in your prostate gland to widen the urethra and allow urine to pass through easier. Some men need additional treatment after undergoing a TUIP. Side effects include urinary retention (inability to urinate), risk of UTIs, dry orgasm (orgasms without ejaculation), and erectile dysfunction (UCF, 2019).

Laser therapy (ablation or enucleation)

A laser is sometimes used to remove excess prostate tissue and may benefit men who cannot undergo other prostate procedures. 

In ablative procedures, such as photoselective vaporization (PVP) and holmium laser ablation of the prostate (HoLAP), the laser vaporizes the prostate tissue affecting urine flow. There are few side effects. 

Alternatively, enucleation procedures remove portions of the prostate using lasers rather than open surgery. Examples include holmium laser enucleation of the prostate (HoLEP) and thulium laser enucleation of the prostate (ThuLEP); these procedures differ mainly in the type of laser used. Side effects include blood in the urine and pain with urination for a few days (UCF, 2019). 

Catheterization

Catheterization is a temporary fix to provide relief to men who cannot empty their bladders. A thin, hollow, plastic tube (catheter) is inserted via the urethra into the bladder to drain the collected urine. Sometimes, your provider will need to insert the catheter through a small hole just above the pubic bone (suprapubic catheter). 

The biggest downside of this therapy is the risk of infection, which goes up the longer the catheter is left in place. Catheterization is a temporary measure that does not affect the prostate in any way (UCF, 2019). 

BPH is common and will likely affect you at some point in your life. The prostate naturally enlarges to some degree in all men with advancing age,  but not all men require treatment because not everyone has symptoms. BPH doesn’t have to stop you from living your life. Be sure to keep the lines of communication open with your healthcare provider and talk about any sexual or urinary problems you may be having. Treatment options vary from lifestyle changes to medications to surgery. Your provider will help you navigate the choices to determine which path is right for you.

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Current version

April 23, 2021

Written by

Chimene Richa, MD

Fact checked by

Felix Gussone, MD

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About the medical reviewer

Felix Gussone, MD, Ro

Felix Gussone is a physician, health journalist and a Manager, Medical Content & Education at Ro.