Enlarged prostate (BPH): symptoms, tests and treatment options

What is an enlarged prostate?

The prostate is a walnut-sized gland that sits below the bladder and surrounds the start of the urethra, the tube that carries urine out of the body. With age, under the influence of male hormones, it gradually grows. This non-cancerous growth is called benign prostatic hyperplasia (BPH).

Prostate enlargement is part of normal ageing and is very common: a large proportion of men over 60 have some degree of BPH. However, gland size does not always match symptoms – some men with a large prostate have few problems, and vice versa.

BPH is not cancer and does not turn into cancer. The two conditions can exist together, though, and their symptoms sometimes overlap – read more in our guide to prostate cancer.

Symptoms

The symptoms are known as lower urinary tract symptoms (LUTS) and fall into two groups:

Emptying symptoms

• a weak or interrupted stream;
• difficulty getting started or needing to strain;
• dribbling at the end;
• a feeling that the bladder has not fully emptied.

Storage symptoms

• passing urine often during the day;
• getting up at night to urinate (nocturia);
• sudden urges that are hard to put off;
• sometimes leaking when the urge is strong.

Similar symptoms can have other causes – infection, a narrowed urethra, stones, overactive bladder, neurological disease, diabetes or certain medicines – which is why a medical assessment matters.

Tests

A urologist will usually arrange:

• a symptom questionnaire (such as the International Prostate Symptom Score, IPSS) and a 3-day bladder diary;
• an examination, including a digital rectal examination to assess the size and feel of the prostate;
• a urine test for infection and blood;
• a PSA test after discussing its benefits and limits; PSA also rises with BPH, so results need careful interpretation;
• blood tests for kidney function if kidney damage is suspected;
• uroflowmetry (measuring urine flow) and an ultrasound to check how much urine is left after voiding and the prostate size;
• in unclear cases or before surgery, urodynamic tests or cystoscopy.

Treatment without surgery

For mild symptoms that are not very bothersome, watchful waiting and lifestyle changes are often enough:

• drinking less in the evening, especially caffeine and alcohol;
• emptying the bladder before bed and "double voiding" – trying again after a few minutes;
• bladder training to lengthen the time between visits to the toilet;
• treating constipation, which can worsen symptoms;
• reviewing medicines that may affect urination.

Medicines

For more troublesome symptoms your doctor may prescribe:

• alpha-blockers – relax the muscle in the prostate and bladder neck; they work within days but can cause dizziness and changes in ejaculation;
• 5-alpha reductase inhibitors – gradually shrink a large prostate and lower the risk of urinary retention; the effect takes months; they also lower PSA levels;
• a combination of both for a large prostate with significant symptoms;
• medicines for overactive bladder when urgency and frequency dominate;
• in selected cases, other options such as phosphodiesterase inhibitors.

Choosing treatment and monitoring side effects is the job of your urologist. European guidelines do not find convincing evidence for herbal remedies.

Surgery and minimally invasive procedures

Surgery is recommended when symptoms remain severe despite medicines, or when complications occur: repeated urinary retention, recurrent infections, bladder stones, bleeding or kidney damage.

Common after-effects of TURP and laser enucleation include retrograde ejaculation (semen goes into the bladder), temporary burning and blood in the urine. Less common risks include incontinence, narrowing of the urethra and needing a repeat procedure. Your urologist will discuss the pros and cons of each option with you.

Possible complications

Left untreated, severe obstruction can lead to acute urinary retention, chronic incomplete emptying, infections, bladder stones and, rarely, kidney damage (chronic kidney disease). Men with significant symptoms should therefore be reviewed regularly.

Take care with some over-the-counter medicines, such as decongestant cold remedies and certain antihistamines, which can trigger urinary retention. Tell your doctor or pharmacist that you have an enlarged prostate before starting anything new. Regular physical activity, a healthy weight and good diabetes control can also help keep symptoms milder.

When to see a doctor

See your GP or a urologist if changes in urination bother you, you get up more than once or twice a night, or your stream is getting weaker. Seek emergency care (112 or A&E) if:

• you cannot pass urine at all and your lower abdomen is painful and swollen – acute urinary retention;
• there is visible blood in your urine – bladder cancer also needs to be ruled out;
• you have a fever, shivering and pain when passing urine;
• you develop pain in the back or side, nausea and swelling.

Treatment abroad and in Türkiye

Some men from Bulgaria and across Europe choose planned prostate surgery, such as laser enucleation, at large accredited hospital groups in Istanbul. Check the urologist's experience with the specific technique, the expected effects on ejaculation and continence, how long a catheter will be needed, and how follow-up and the tissue (histology) result will be handled once you are home. Bring your PSA results, scans and other tests. Organisers such as New City Clinic in Istanbul coordinate the hospital, specialist, hotel, transfers and interpreter. If you are unsure, an independent second opinion can help.