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Fact sheet: Self-management of enlarged prostate (Benign prostatic hyperplasia)

Last Update: June 2, 2009.

Photo of man
Needing to empty your bladder often, getting up in the night to go to the toilet, and the feeling that your bladder is never really empty are all symptoms of an enlarged prostate. It affects about 1 in 5 men between the ages of 50 and 60 and is even more common in later years.

Mostly, the condition does not become so troublesome that men cannot adjust and cope with it. For some men, though, an enlarged prostate becomes a real burden. The symptoms could be severe. They might be tired during the day because they cannot get a good night's sleep. That can cause problems in their personal, family and work lives.

There may be a lot of important decisions to make: whether to get treatment at all and, if so, which treatment to choose. For a very small proportion of men, the condition can cause complications that require immediate treatment. However, an enlarged prostate is not cancer and it does not mean that men's sex life can no longer be satisfying for them and their partners.

Most men affected by an enlarged prostate will never seek medical help. The problem might get a little worse, but usually not very much. Some men will try out non-prescription ("over-the-counter") herbal medicines for relief. There are also prescribed medications that can help. About 1 in 10 men will decide to have surgery to reduce the size of the prostate or improve urine flow. There is no simple "cure" for an enlarged prostate, but there are many options if you do have the condition.

What is the prostate and why does it get enlarged?

The prostate is a gland that is an important part of a man's sexual organs. When a man has a sexual climax, he will usually ejaculate semen. Semen is made of fluid and sperm. The prostate produces the fluid in semen and the testicles produce the sperm.

The prostate lies between the rectum and the base of the penis, underneath the bladder. It surrounds part of the urethra, which is the canal or tube through which urine passes from the bladder into the penis and then out of the body. If the prostate enlarges, it can put pressure on the bladder and on the urethra.

Prostate graphic

During puberty, the prostate grows to about the size and shape of a walnut. That happens quite quickly. After about the age of 25, the prostate starts growing again, and it keeps on growing very slowly throughout a man's life. A certain amount of growth is a normal part of ageing. The gland usually does not get very big and so it generally does not cause problems.

Why the prostate grows so much more in some men than others is not really clear. Smoking, vasectomy (a surgical procedure for contraception), obesity and high alcohol intake have not been proven to influence whether or not the prostate enlarges. An enlarged prostate appears to just be a result of getting older and the hormone changes that come along with that.

What exactly is BPH and what are the symptoms?

If the prostate grows more than normal, then it might put pressure on the bladder and urethra, and start causing problems with urination. The medical term for this group of symptoms is "benign prostatic syndrome" (BPS) or lower urinary tract symptoms (LUTS).

The enlargement of the prostate is called benign prostatic hyperplasia or benign prostatic hypertrophy (BPH). The word "benign" means that, although it is a growth, it is not cancerous. The word "hyperplasia" comes from the Greek word meaning "enlargement".

When the urethra is squeezed, urine cannot flow through it normally. This is called an obstruction or blockage. The muscles at the bottom of the bladder are also affected by an enlarged prostate. The bladder muscles start contracting even when there is very little urine inside the bladder, so the man feels the need to urinate more often. But the pressure also impairs the functioning of the bladder. It can no longer empty itself properly, so some urine stays behind (residual urine).

BPH can be associated with the following unpleasant symptoms:

  • Needing to urinate more often and urgently, especially at night.
  • Taking a while for the urine to start flowing.
  • A weak urine flow that takes longer to finish.
  • Dripping and leaking after urinating - and the bladder does not feel empty.

One of the most severe complications of BPH is acute urinary retention (anuria). That means that a man quite suddenly cannot empty his bladder at all. Acute urinary retention is a condition that needs medical attention and most likely surgery. But complications as severe as this are not common. Over a five-year period, only about 1 to 3 out of every 100 men with BPH will have acute urinary retention (1-3%). The risk is higher for men who have more severe BPH, though.

BPH is very uncommon before the age of 40, but perhaps 1 in 5 men between the ages of 50 and 59 are affected by it (20%). It becomes more common later in life: perhaps 7 out of 10 men older than 70 will have symptoms caused by an enlarged prostate (70%). Although it is not clear why, there is not always a direct link between the size of the prostate and how severe the symptoms are. Some men with a very enlarged prostate have few symptoms, while others have a lot of problems even though their prostate is not very enlarged.

What tests might be done to find out if you have BPH?

BPH is not the only possible cause of these urinary symptoms, although it is the most common cause. Doctors generally use a series of tests to find out what is causing the symptoms and to judge how enlarged the prostate is.

First the doctor will ask you about your symptoms in detail. This will include asking how often you need to urinate. However, many people find it difficult to say exactly how often they go to toilet, especially during the day. So if you really want to be sure about this, you might need to keep a diary or chart recording how often you empty your bladder. Just a day or two of keeping good notes is enough to give you and your doctor an idea of how severe your problem is.

The doctor will also ask you about what medicines you are taking, because bladder symptoms are an adverse effect of some drugs. You will probably be asked about your everyday activities and how much you drink per day too.

The first physical check is the digital rectal examination. This is where the doctor puts on a glove and inserts a finger into the rectum to feel the size and general condition of the prostate gland.

A urine test is done to check for signs of infection, because an infection of the prostate (called prostatitis) also causes these symptoms. Tests for a variety of other illnesses can be done on the urine as well.

Blood tests often include a PSA test to see how much of a certain protein (called PSA or prostate-specific antigen) is in the blood. An enlarged prostate produces more PSA. Measuring the PSA levels before and after a treatment is one way to see if treatment has reduced the size of the prostate. A PSA test may also be used to look for signs of prostate cancer, although this test has not been proven to be accurate enough to determine for sure whether someone has prostate cancer or not. It is also not clear whether there are advantages to diagnosing prostate cancer early.

The creatinine level in the blood might also be tested if the doctor wants to check whether there are kidney problems or whether there is a danger of urinary retention. Creatinine is a waste product in the body that the kidneys usually filter out. High levels of creatinine in the blood are a sign that the kidneys might not be working as well as they should be. The medical term for that is poor renal function or renal insufficiency.

A urine flow test, called uroflowmetry, involves urinating into a special device that will measure how quickly the urine is flowing. Usually this is more than 15 millilitres per second.

Ultrasound is often used to try to see how much urine is left over in the bladder after urination. This is called the post-void residual volume. Ultrasound might also be used to look for other problems, such as kidney stones. There are further tests called urodynamic tests which can be done if bladder or kidney problems are suspected, or to check the muscles around the base of the bladder.

What are the treatment options for BPH?

Your treatment options depend a great deal on how bothersome your symptoms are and how high your risk is of experiencing a complication like urinary retention. Most men with BPH will have mild to moderate symptoms that they can adjust to and cope with. Sometimes the symptoms will even improve or go away without treatment. For most men, though, the symptoms will slowly get a little worse over the years. It will take some time to see whether BPH will stabilise at a manageable level or develop into a difficult problem.

These are the treatment options for BPH:

  • Active monitoring of symptoms (often called "watchful waiting"): After initial assessment, your doctor will explain what you need to look out for and provide advice on how to self-manage your symptoms. Then your doctor will monitor your symptoms regularly - usually once a year. That is what most men choose if they do not have signs of urinary retention or their symptoms are not interfering too much with their lives and wellbeing. Monitoring might be all that is needed for about 30% of the men who have sought medical help for BPH (30 out of every 100 men).
  • Herbal medicine products: There are several over-the-counter products that are marketed for the relief of BPH symptoms. We discuss these below in the section on self-management. Around 1 in 4 men with BPH in Germany try these, but this can vary from country to country. You can read more on this topic in our fact sheet on medicines.
  • Medicines to reduce the size of the prostate or to work on the bladder muscles: Medicines are the most commonly used treatments for BPH. As many as 7 out of every 10 men with BPH who see a doctor for help will use medications (70%). There are several medicines that can reduce the size of the prostate and therefore help to relieve the urinary problems BPH causes. It has been estimated that 6 out of 10 of those men using medication will notice an improvement (60%). You can read about the possible benefits and adverse effects in our fact sheet on medicines.
  • Surgical procedures to reduce the size of the prostate: Along with standard surgery, there are various newer procedures that are used to remove or destroy prostate tissue. Most men will never need surgery for BPH, but it may be necessary if there are complications or if nothing else has provided enough relief. You can read about this in our fact sheet on surgical options.

There are a lot of different treatment options - each with its own possible benefits and drawbacks. Your options will depend on the specific problems with your prostate and other factors related to your health. The adverse effects of the different treatments vary greatly. There could be several issues you need to weigh up. Each man will have his own priorities and feelings about the pros and cons of individual treatments.

What are my options for self-management?

Most men cope well with an enlarged prostate. If the symptoms are quite mild, it can just be a case of adjusting to the changes and learning how to minimise the symptoms or cope with them. The following strategies have not been specifically tested for BPH, but you could try them and see if they help you manage:

  • Limiting the amount of fluids you drink in situations where needing to go to the toilet may be most inconvenient, like before going to sleep or when leaving to go somewhere where you will not be in easy reach of a bathroom. Men still need to get enough fluids in the day, though, or it can cause other health problems.
  • Avoiding drinks that are diuretics: these can increase the amount of urine you produce. Diuretics include drinks with caffeine (like coffee and cola) and alcohol.
  • Using what is called a double-voiding technique when you urinate. You urinate until you are finished, then wait a moment or two and try again, so that there is a better chance that your bladder really is empty.
  • Learning bladder training techniques, such as regularly practising holding on longer before urinating and not going to the toilet as soon as you feel the need, in order to increase the bladder's ability to hold urine.
  • Techniques to help you cope with the annoyance that your symptoms cause, such as developing techniques to distract yourself from the feeling that you urgently need to urinate.
  • Taking a closer look at the medications you are using. Check with your doctor or pharmacist to see if there are any that could be causing urinary effects. There might be a substitute that has less of an impact on your symptoms.

Reviewing your medicines with your doctor or pharmacist is an important part of reducing unwanted side effects and drug interactions.

How do other men manage the symptoms and weigh up their treatment options?

BPH symptoms can come on gradually over years, and they might even go away again. When the changes come on slowly, it might be easier to adjust. However, men often feel embarrassed about needing to go to the toilet more often and having problems that are closely related to their sexual organs.

Many men who have prostate problems will also be dealing with other age-related health developments and changes in their sex lives. Many men know relatively little about their prostate and its functions, so they may have a lot of questions that need to be answered before they are ready to make decisions about treatment. They often do not feel comfortable talking about the symptoms or problems, but many get used to talking about them and asking questions, too.

How men weigh up the pros and cons of their treatment options depends a lot on what their symptoms are like and how they feel about the adverse effects that come with treatment. Most men who have prostate-related problems get by without any treatment at all, or do not try treatment until they are over 65 years old. For some, medication provides a good alternative and others may try medication first, but eventually have surgical treatment if their symptoms become unmanageable.

More information on treatment options for enlarged prostate is available here on www.informedhealthonline.org. And you can read about two men's personal experiences with prostate problems, medication and surgery here.

Author: German Institute for Quality and Efficiency in Health Care (IQWiG)

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