Enlarged prostate and urinary symptoms: assessment and treatment

The NHS describes the prostate as a small gland below the bladder that makes semen and controls the flow of pee from the bladder to the penis. When it enlarges it can press on the urethra, causing problems with peeing. It can affect anyone with a prostate and is most common over 50. NICE uses the term lower urinary tract symptoms (LUTS) for the whole group of urinary difficulties in men, which may or may not be caused by prostate enlargement.

The NHS lists the main symptoms as problems with peeing, which usually develop slowly and may gradually get worse as you get older:

• Difficulty starting to pee, or having to push or strain.

• A weak flow that stops and starts, and takes longer than usual to empty the bladder.

• A feeling that the bladder cannot fully empty.

• Dribbling after you finish.

• Needing to pee more often or urgently, including getting up in the night.

The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you have blood in your pee, pain when peeing or cannot pee at all. It stresses that urinary symptoms can sometimes have more serious causes such as prostate cancer, and that finding cancer early may make it easier to treat, so do not put off seeing a GP out of embarrassment. A man who cannot pass urine at all needs emergency care.

The NHS says a GP will ask about symptoms, may examine your tummy and penis and feel the prostate with a finger through the back passage, and will usually ask you to keep a record for at least 3 days of how much you drink and how often and how much you pee. A urine test and a PSA blood test may be done. NICE says at initial assessment men should have a medical history that includes reviewing medicines (including herbal and over-the-counter ones that may contribute), an examination, a frequency volume chart and a urine dipstick, and should be given information, advice and time to decide whether to have PSA testing if their symptoms suggest obstruction from benign enlargement, the prostate feels abnormal or they are worried about cancer.

NICE says not to routinely offer cystoscopy, upper tract imaging, flow-rate measurement or post-void residual measurement at initial assessment in uncomplicated cases; these are offered at specialist assessment when indicated. It also advises offering a validated symptom score such as the International Prostate Symptom Score (IPSS) to track change.

The NHS says doctors will usually recommend lifestyle changes first when symptoms are not causing many problems: cutting down on alcohol and caffeine, reducing how much you drink before bed or going out, eating enough fibre to avoid constipation, keeping to a healthy weight, waiting a moment after peeing and trying again, and checking whether any medicines you take could be making symptoms worse. It advises not straining when you pee and not cutting down on fluids too much, which can lead to infections. Bladder training and pelvic floor muscle training are also described.

The NHS says men with moderate or severe symptoms may be offered medicines that help you pee (tamsulosin, doxazosin or alfuzosin), medicines for urgency and frequency (such as oxybutynin or tolterodine), and, if you are at high risk of the condition worsening, medicines that stop the prostate growing by reducing hormone levels (finasteride or dutasteride). NICE says drug treatment should be offered only when conservative options have been unsuccessful or are not appropriate, an alpha blocker is offered for moderate to severe symptoms, a 5-alpha reductase inhibitor for men with a prostate estimated to be larger than 30 g or a PSA level above 1.4 ng/ml who are at high risk of progression, and a combination may be considered.

NICE says not to offer phosphodiesterase-5 inhibitors solely to treat these symptoms outside a trial. All of these are prescription medicines with side effects your doctor will explain; the NHS says you will have regular check-ups to see how well they work.

The NHS says surgery may be offered if medicines have not helped or symptoms are severe. TURP involves removing part of the prostate through a thin tube passed up the penis. The NHS also lists other procedures that may not suit everyone, using lasers, electrical current, steam or a water jet to remove or destroy tissue, an implant that holds part of the prostate open, small cuts around the bladder opening, or open surgery.

NICE says that if surgery is offered for voiding symptoms caused by benign enlargement, the options are TURP, transurethral vaporisation of the prostate or holmium laser enucleation (HoLEP), and that open prostatectomy should only be an alternative for prostates estimated to be larger than 80 g. NICE advises against offering minimally invasive treatments such as TUNA, TUMT and HIFU as an alternative to these. Ask the surgeon what each option means for your symptoms, sexual function and continence, as the sources reviewed do not give outcome figures.

NICE says to refer men for specialist assessment if symptoms are complicated by recurrent or persistent urinary tract infection, retention, suspected kidney impairment or suspected urological cancer, or if bothersome symptoms have not responded to conservative or drug treatment. The NHS also describes pads, pants or sheaths for leaks, and a urinary catheter for men who cannot empty the bladder.

The GP is the usual first step, with referral to NHS urology when needed. Private urology offers quicker access to flow tests, ultrasound, cystoscopy or MRI. Whichever route you take, ask whether the PSA discussion has covered the pros and cons, what the plan is if medicines fail, and what the evidence is for any newer procedure being recommended in place of TURP or laser surgery.