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BPH (Benign Prostatic Hyperplasia)

About the Prostate

Illustration of the male urinary and reproductive tract along with the lymph nodes in the groinThe prostate is a reproductive gland in men, that produces a component of semen.  Located just below the urinary bladder, the prostate wraps around the urethra, a small tube that carries urine away from the bladder, and through the penis to its tip.  The prostate also has a layer of muscle that works with the muscles in the bladder to control the flow of urine through the urethra. (Illustration courtesty of the National Cancer Institute)

About Benign Prostatic Hyperplasia (BPH)

BPH is is a noncancerous increase in the size of the prostate gland in middle-aged and elderly men, and is one of the most common health problems men deal with as they grow older.

The size of a man's prostate remains fairly constant from the time of puberty throughout early adult life. But by age 50, when hormonal changes occur, the prostate begins to grow larger. This condition is referred to as benign prostatic hyperplasia (BPH).

As the prostate grows, it puts pressure on the urethra—the tube that carries urine and semen out of the penis. This increasing pressure on the urethra may cause bothersome urinary symptoms or in some men can lead to serious medical problems over time. BPH can cause urine retention and strain on the bladder which can lead to urinary tract infections, bladder or kidney damage, bladder stones, and incontinence—the inability to control urination. If the bladder is permanently damaged, treatment for BPH may be ineffective. When BPH is found in its earlier stages, there is a lower risk of developing such complications.

Urine retention is a condition in which the bladder does not empty completely, or at all, despite an urge to urinate. This can happen because the prostate is enlarged and thus obstructing the flow of urine from the bladder, through the urethra. Sometimes this happens suddenly to older men after they have taken an over-the-counter cold or allergy medicine. Urinary retention can develop gradually or suddenly. If you can't urinate at all, you should get medical help right away.

BPH is not a sign of cancer, but the early symptoms are the same for both conditions, so it's essential that a health care provider be seen for evaluation of new symptoms. According to the National Cancer Institute (NCI), other than skin cancer, prostate cancer is the most common form of cancer and the second leading cause of cancer-related deaths among men in the United States. But doctors' recommendations on screening for the disease vary. Some encourage annual screenings for men older than age 50; others recommend against routine screening.(4)

Incidence and Cause of BPH

Half of all men over the age of 50 have BPH, although typically in a mild form. By age 70, almost all men have some prostate enlargement. The average age when BPH is diagnosed is 67.(5)

The exact cause of BPH is not completely understood and there is no definite information on risk factors. However, for centuries, it has been known that BPH occurs mainly in older men and that it doesn't develop in men whose testes were removed before puberty.(1)

Symptoms of BPH

In general, symptoms of BPH are due to the interference of the flow of urine through the urethra which results in urinary retention in the bladder (incomplete emptying of the bladder during urination).

The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms, while others whose glands are less enlarged, have more blockage and greater problems.

If you don't find urinary symptoms too bothersome and they don't pose a health threat, you may not need treatment. In some men, symptoms eventually stabilize and may even improve over time. But you should still have your symptoms checked out by a doctor to make sure they aren't caused by another problem such as prostate cancer. If you're unable to pass urine at all, seek immediate medical attention.

Men with BPH can have symptoms ranging from feeling uncomfortable to being seriously debilitated and will have one or more of the following symptoms:

  • Difficulty starting a urine stream (hesitancy and straining). Even though you may have to rush to get to the bathroom, you may still find it hard to start urinating.
  • Difficulty stopping the flow of urine.
  • A hesitant, interrupted, weak stream.
  • Dribbling after urination. Dripping that leaves spots on the clothes.
  • Feeling the bladder is not completely empty.
  • The urge to urinate again soon after urinating.
  • Waking at night to urinate (nocturia).
  • More frequent urination during the day and night.
  • A sudden, uncontrollable urge to urinate.

Note: These symptoms are not always related to an enlarged prostate (BPH) and can be caused by other more serious conditions that require immediate treatment such as urinary tract infections, prostatitis, prostate cancer, diabetes, heart failure, and neurologic diseases.

Diagnosis of BPH

Digital rectal exams and blood tests for prostate-specific antigen (PSA) are often included in routine physical examinations for men over 40. If you have urination problems or if the examination or PSA test indicates that you might have a problem, you will probably be given additional tests

For a questionnaire commonly used in the diagnosis of BPH click here. Once completed, take it to your doctor.

Treatment of BPH

There are a number of different options for treatment of an enlarged prostate. Talk to your doctor about the risks and benefits of each method. The one you choose will depend on the severity of your symptoms, other medical conditions you may have, and your own personal preferences. Your doctor can help you decide what is best for you.

Mild symptoms can sometimes be relieved by limiting nighttime fluid intake and avoiding any drugs that can exacerbate symptoms, such as over-the-counter cold or allergy medicine. In this case, it is important to follow-up frequently with your health care provider to monitor for any worsening or complications.

Medication: Several prescription medicines are available that will help relieve the symptoms but do not actually cure the condition. If the medication is stopped, the symptoms will recur. These medications include two classes of drugs:

  • Cardura (doxazosin), Flomax (tamsulosin), Hytrin (terazosin), and Uroxatral (alfuzosin) are alpha-adrenergic receptor blockers, which work by helping relax the smooth muscle of the prostate and bladder neck to relieve pressure and to improve urine flow. These drugs do not shrink the size of the prostate. For many men, these alpha-blockers can improve urine flow and can reduce symptoms within days. Possible side effects include dizziness, headache, fatigue, and a lowering of blood pressure.

  • Proscar (finasteride) and Avodart (dutasteride) are 5-alpha-reductase inhibitors which shrink the prostate’s size reducing the blockage of the urine flow out of the bladder. According to the FDA, "These drugs work by blocking an enzyme that acts on the male hormone, testosterone, to boost organ growth. When the enzyme is blocked, growth slows down and the gland may shrink. This treatment may not produce a positive effect until after six to 12 months of treatment. It also works best for the larger prostate."(4) Impotence and decreased libido can occur as a side effect in a small number of men taking this drug. Another disadvantage of this type of medication is that it takes longer to begin working than an alpha-blocker. Often an alpha-blocker needs to be used in conjunction with either Proscar or Avodart until the full effects are reached.

    • Note: The Medical Therapy of Prostatic Symptoms (MTOPS) Trial, recently found that using finasteride (Proscar) and doxazosin (Cardura) together is more effective than using either drug alone to relieve symptoms and prevent BPH progression. The two-drug regimen reduced the risk of BPH progression by 67 percent, compared with 39 percent for doxazosin alone and 34 percent for finasteride alone.(1)

Minimally Invasive Procedures are better than medications at relieving symptoms, but they are less effective than surgery: Drug treatment is not effective in all cases in which case minimally invasive procedures or surgery need to be considered. A number of procedures are now available that relieve BPH symptoms and are less invasive than conventional surgery. Minimally invasive procedures are often performed in a doctor's office:

  • Transurethral microwave therapy (TUMT). This procedure uses a microwave antenna attached to a flexible tube that is inserted into the bladder. The microwave heat destroys excess prostate tissue.
  • Transurethral needle ablation (TUNA). This procedure uses a heated needle inserted into the prostate through the urethra to destroy excess prostate tissue

Surgery: Most men who have an enlarged prostate do not need surgery. But as a last resort, surgery may be required to correct the problem. Although there are nonsurgical treatments available to treat BPH, an operation offers the highest chance of alleviating prostate problems. But it also can result in postoperative problems that are important to consider. Some of these conditions include: impotence (small risk); uncontrolled urine leakage (very small risk); a constriction of the urethra (stricture); or the necessity of a second operation at a later date, in some patients.(5)

The following are the various types of surgery. All of which are done with anesthesia:

  • Transurethral resection of the prostate (TURP) is used in 90% of surgeries for BPH. In this surgery, only part of the prostate is removed. No external incisions are made since the scope is inserted thorough the urethra.

  • Transurethral incision of the prostate (TUIP) is a much less invasive procedure than the TURP. It may be used when the prostate is not too large. The doctor makes a few small cuts in the prostate near the opening of the bladder. This relaxes the opening to the bladder, decreasing resistance to the flow of urine out of the bladder. No tissue is removed. This procedure usually requires a 1- to 3-day hospital stay but in some cases, TUIP may be done without a hospital stay.

  • Laser surgery uses laser energy to destroy prostate tissue and shrink the prostate. Laser procedures provide improvements in symptom relief, urinary flow, and quality of life similar to TURP.

  • Open surgery is often used when the prostate is very large, when the bladder has been damaged and needs repair, or when there are other complications. In this procedure, the prostate is removed through an incision in the abdomen or behind the scrotum.

What about Saw Palmetto?

Saw palmetto is used in Europe for symptoms associated with benign prostatic hypertrophy, and several human trials report that saw palmetto improves symptoms of benign prostatic hypertrophy (BPH) such as nighttime urination, urinary flow, and overall quality of life, but it may not significantly reduce the size of the prostate.

A 2006 study, published in the New England Journal of Medicine, found that saw palmetto had no more effect than placebo in relieving symptoms of BPH.(4)

Saw palmetto may cause mild side effects such as stomach discomfort, gas, headaches, tender breasts and a decline in sexual desire.(6)

Saw Palmetto is categorized as a “Dietary Supplement”, which is essentially unregulated by the FDA.  Unlike prescription or over-the-counter drugs, which must be tested and reviewed before they’re sold, federal laws allow the sale of untested, unreviewed, and unregistered Dietary Supplements.  Some products on the store shelves are pure and contain what the label states, and some are not. More and more products with unidentified and harmful ingredients are finding their way into the booming U.S. “Dietary Supplement” marketplace. They are freely advertised on the radio and TV, and are readily available online as well as on the shelves of local grocery stores, pharmacies, and health food stores across the U.S.

Educational Video Tutorials

  • Benign Prostatic Hyperplasia from MerckSource. Select "3D Medical Animations" from the column on the left, then select "Benign Prostatic Hyperplasia" from the pull-down menu of 3D Medical Animations.
  • BPH from 1 on 1 Health. A video tutorial illustrating benign prostatic hyperplasia disorder.
  • Prostate Surgery from Medline Plus. Click on “Interactive Tutorials” in the right column, then scroll down to Surgery: and select “TURP (Prostate Surgery)

Internet References

(1) Prostate Enlargement: Benign Prostatic Hyperplasia from the National Kidney and Urologic Diseases Information Clearinghouse
(2) Prostate Diseases from Medline Plus, A service of the U.S. National Library of Medicine and the National Institute of Health.
(3) Medical Tests for Prostate Problems from the National Kidney and Urologic Diseases Information Clearinghouse
(4) "Prostate Health: What Every Man Needs to Know" from the U.S. Food and Drug Administration
(5) "About Prostatectomy for Benign Prostatic Hyperplasia" from the American College of Surgeons
(6) "Saw Palmetto" from the National Center for Complementary and Alternative Therapy

Written by N Thompson, ARNP in collaboration with M Thompson, MD, Internal Medicine, Last Updated March 2010

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