Prostate enlargement (BPH): symptoms and treatment

The prostate is a small gland that sits just below the bladder. It makes the fluid that carries sperm, and the urethra, the tube that drains the bladder, runs straight through it. As the gland grows, it can press on that tube, a bit like a thumb on a garden hose.

Doctors use several names for the same thing: benign prostatic hyperplasia (BPH), benign prostate enlargement (BPE) and simply enlarged prostate. "Benign" means it is not cancerous. NICE uses the wider label lower urinary tract symptoms, or LUTS, for the whole group of waterworks problems in men, because not every man with these symptoms has a large prostate.

The NHS notes that the cause is thought to be a change in hormone levels as men get older. Being over 50 and having family members with the same problem both make it more likely.

The symptoms usually creep in slowly and may gradually worsen with age. The NHS groups the main ones as problems with peeing. NICE splits them into two families that help a clinician decide what to do: voiding symptoms, which concern getting urine out, and storage symptoms, which concern the bladder holding it.

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

• A weak flow that stops and starts, and takes longer than usual to finish.

• A feeling that the bladder has not fully emptied.

• Dribbling a little urine after you have finished.

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

See a GP if you have difficulty peeing or need to go more often. The NHS tells men to try not to feel embarrassed, because GPs are used to talking about these symptoms.

Ask for an urgent GP appointment or call NHS 111 if you notice blood in your pee, which may look pink, red or brown, if it hurts to pee, or if you cannot pee at all. Being completely unable to pass urine is called acute retention. NICE advises that a man in acute retention is catheterised straight away, meaning a thin tube is passed into the bladder to drain it. If you cannot get through to anyone and are in severe pain or distress, go to A&E.

These warning signs matter because they can also come from infection, stones or cancer. Early checking is the safest route.

At a first appointment, NICE advises a review of your medical history and of every medicine you take, including herbal and over-the-counter ones, because some can affect the bladder. You can expect an examination of the abdomen and genitals, and a digital rectal examination, where a gloved finger checks the size and feel of the prostate through the back passage.

The NHS says you will usually be asked to keep a record for at least 3 days of how much you drink and how often and how much you pee. NICE calls this a frequency volume chart. A urine dipstick test checks for blood, sugar, protein and signs of infection.

• PSA blood test: NICE says men should be given information and time to decide whether to have one if the symptoms suggest a blocked outflow, if the prostate feels abnormal, or if they are worried about cancer.

• Symptom score: a questionnaire called the International Prostate Symptom Score rates symptoms as mild, moderate or severe and gives a baseline to compare later.

• Kidney blood test: only if kidney problems are suspected, for example a swollen bladder or repeated infections.

• Specialist tests: a urine flow test, where you pee into a machine, a bladder ultrasound scan, and sometimes a camera test of the bladder called cystoscopy.

NICE says men whose symptoms are not bothersome should be reassured, given advice on lifestyle such as fluid intake, and offered a review if things change. The NHS offers a practical list that many men find helpful.

• Cut down on alcohol and caffeine, which can make you pee more.

• Drink less in the hours before bed or before going out, while still drinking enough through the rest of the day.

• Eat enough fibre to avoid constipation, which can press on the bladder.

• Keep to a healthy weight, as being overweight can make symptoms worse.

• Wait a moment after you finish and try again to empty the bladder.

• To clear the last drops, press gently with your fingertips behind the scrotum and stroke forwards and upwards. NICE calls this urethral milking.

• Ask a doctor or pharmacist whether any medicine you take for another condition could be adding to the problem.

If urgency and frequency are the main complaint, NICE suggests supervised bladder training, along with fluid advice. This means holding on for a short time when the urge comes and gradually lengthening the gap over a few weeks. NICE adds that for men with proven blockage of the outflow, bladder training is less effective than surgery.

Pelvic floor muscle exercises strengthen the muscles that help control the bladder. For men who leak, pads, pants or sheaths can keep life manageable while a diagnosis and plan are agreed. The NHS adds two cautions: do not strain or push when peeing, and do not cut fluids too far, since that can cause problems such as urinary tract infections.

NICE says drug treatment should be offered for bothersome symptoms only when conservative measures have not worked or are unsuitable. The NHS says medicines are offered for moderate or severe symptoms and that your doctor will explain the benefits and side effects so you can decide together.

NICE sets out that a 5-alpha reductase inhibitor can be offered to men with symptoms, a prostate estimated at over 30 g or a PSA above 1.4 ng/ml, and a high risk of progression, for example older men. A combination of the two drug types can be considered when symptoms are moderate to severe and the same size or PSA thresholds are met.

For men who still have storage symptoms on an alpha blocker alone, an anticholinergic can be added. For night-time urine production, NICE mentions a late afternoon water tablet or, when other causes are excluded, desmopressin, with a sodium blood check three days after the first dose. NICE notes that some of these uses were outside UK licences when the guideline was last updated.

NICE also says not to offer phosphodiesterase-5 inhibitors solely for treating these symptoms outside a trial, and not to offer homeopathy, phytotherapy or acupuncture. That guideline was last updated in 2015, so ask your doctor whether newer advice applies.

The NHS says surgery may be offered if medicines have not helped or symptoms are severe. NICE agrees that surgery for voiding symptoms should be offered only when symptoms are severe or when drug treatment and conservative options have failed or are unsuitable, with the alternatives and likely outcomes discussed first.

The most common operation, according to the NHS, is transurethral resection of the prostate (TURP), which removes part of the gland through a thin tube passed up the penis. For men with an enlarged prostate, NICE lists TURP, transurethral vaporisation and holmium laser enucleation (HoLEP) as the main options, and says HoLEP should be done at a specialist centre or with mentoring in place. Transurethral incision of the prostate suits those with a smaller gland, and open surgery is kept for very large prostates.

The NHS also describes other approaches, such as using lasers, steam or water to remove or destroy tissue, or a small implant to hold the urethra open. NICE, in its 2010 recommendations, advised against several minimally invasive techniques as alternatives to the main operations. Your surgeon will explain which are suitable for you.

NICE recommends that men taking tablets are reviewed: alpha blockers at 4 to 6 weeks and then every 6 to 12 months, and 5-alpha reductase inhibitors at 3 to 6 months and then every 6 to 12 months. A review should ask about symptoms, quality of life and side effects. NICE also supports discussing active surveillance, meaning reassurance and lifestyle advice with regular follow-up, for men with mild or moderate bothersome symptoms.

GPs should refer men to a specialist if symptoms are bothersome and have not responded to treatment, or if they come with repeated urine infections, retention, suspected kidney problems or suspected cancer. In the UK, most men start in primary care. A private urology consultation is another route for assessment, and the same NICE principles on tests and treatment ladder apply.

If you cannot empty your bladder at all, a catheter may be needed in the short or long term. NICE says intermittent self-catheterisation is considered before an indwelling catheter in many cases. The NHS can also point you to a decision support tool produced by NHS England to help weigh up options.