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BPH: Management (Benign Prostatic Hyperplasia/Enlarged Prostate) 

What is BPH/LUTS?

Benign prostatic hyperplasia (BPH) is a common urological condition caused by the non-cancerous enlargement of the prostate gland as men get older. As the prostate enlarges, it can squeeze down on the urethra.  The symptoms associated with BPH are known as lower urinary tract symptoms.  This can cause men to have trouble urinating and leads to symptoms of BPH. The symptoms associated with BPH are known as lower urinary tract symptoms (LUTS)

Diagnosis of BPH/LUTS 

As a man ages, his prostate may become larger and start to cause urinary symptoms and other problems. But what are some of those problems? How will a man know if he has an enlarged prostate (also known as BPH)? When should a man see his doctor? What kinds of tests will my doctor perform? The following guide should help answer your questions and help you make an informed decision about what your next steps should be.

What is the prostate?

The prostate is part of the male reproductive system; it is about the size and shape of a walnut normally and weighs about an ounce. It is located below the bladder and in front of the rectum, and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce fluid for the semen.

What are the risk factors for BPH?

Risk factors for developing BPH include:

  • Obesity
  • Lack of physical activity
  • Erectile dysfunction
  • Increasing age
  • Family history of BPH

What are the symptoms associated with BPH?

Since the prostate is just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder.  Common symptoms are:

  • the need to frequently empty the bladder, especially at night.
  • difficulty in beginning to urinate
  • dribbling after urination ends.
  • decreased size and strength of the urine stream
  • sensation that the bladder is not empty, even after a man is done urinating,
  • inability to postpone urination once the urge to urinate begins
  • Pushing or straining in order to urinate.

In extreme cases, a man might not be able to urinate at all, which is an emergency that requires prompt attention.

Fill out the AUA Symptom Score and share the results with your health care provider.

How is BPH diagnosed?

The American Urological Association (AUA) designed a series of questions to find out how often symptoms occur. The AUA Symptom Score allows men to rate their symptoms so their doctors can understand how bad they are.

When a health care provider checks a man for an enlarged prostate, he or she takes an in-depth health history.He or she may also ask questions from the AUA Symptom Score. The provider does a physical exam, along with a digital rectal exam (DRE). The health care provider will often do a urine test called a urinalysis for a man with an enlarged prostate. The provider may also run other tests, including:

  • prostate specific antigen (PSA) -  a blood test to screen for prostate cancer
  • urinary cytology - a urine test to screen for bladder cancer
  • a measurement of post-void residual volume (PVR), the amount of urine left in the bladder after urinating
  • uroflowmetry, or urine flow study, a measure of how fast urine flows when a man urinates
  • cystoscopy -  a direct look in the urethra and/or bladder using a small flexible scope
  • urodynamic pressure-flow study -  tests the pressures inside the bladder during urination
  • ultrasound of the kidney or the prostate – to view the enlargement

When should I see a doctor about BPH?

A man should see a doctor if he is bothered by any of the symptoms mentioned previously.  In addition, he should see a doctor immediately if he has blood in the urine, pain with urination, burning with urination or is unable to urinate.

What are some of the medical treatments available for BPH?

Watchful Waiting/Active Surveillance

This treatment option is good for patients who have mild symptoms of BPH or have moderate to severe symptoms but are not bothered by their symptoms.  Patients suffering from kidney problems as a result of BPH, urinary retention (suddenly being unable to urinate), or frequent urine infections, and urinary incontinence are not good candidates for this treatment option. 

During watchful waiting, a patient is closely monitored by his physician but he does not receive any active treatment.   Many patients’ symptoms can be controlled and/or managed by changing their current medications and diet.  Patients will be examined yearly, and findings from the tests will be used to determine if additional treatment is needed in order to control a patient’s BPH.

The risk of watchful waiting may be that the patient’s symptoms cannot be reduced after active treatment is started.

Medical Therapies

Alpha blockers: These drugs, originally used to treat high blood pressure, work by relaxing the smooth muscle of the prostate and bladder to improve urine flow and reduce bladder outlet obstruction. Although alpha blockers may relieve the symptoms of BPH, they usually do not reduce the size of the prostate. They are usually taken orally; once or twice a day and work almost immediately. Commonly prescribed alpha blockers include:

  • alfuzosin
  • terazosin
  • doxazosin
  • tamsulosin

All of these drugs have the same equal level of effectiveness and side effects.  Side effects can include headaches, dizziness, lightheadedness, fatigue and ejaculatory dysfunction. These medications are beneficial for patients who have bothersome to moderate severe BPH. 

Patients who are undergoing cataract surgery may be advised by their physician against taking this medication until after their surgery. 

5-alpha-reductase inhibitors: Finasteride and dutasteride are oral medications used to treat BPH.   In select men, finasteride and dutasteride can relieve BPH symptoms, increase urinary flow rate and actually shrink the prostate though it must be used indefinitely to prevent symptoms. Studies suggest that these medications may be best suited for men with relatively large prostate glands. These drugs reduce the risk of BPH complications such as acute urinary retention (suddenly being unable to urinate) and the eventual need for BPH surgery. Side effects generally are sexually related and include: erectile dysfunction decreased libido and reduced semen released during ejaculation.

Finasteride should not be used if men do not have prostate enlargement.  Finasertide has been shown to cause more adverse effects in the beginning of its use; however, over a period of time the side effects between finasteride and dutasteride become equal. 

Combination Therapy: The use of both alpha blockers and 5-alpha-reductase inhibitors have shown to be superior to single drug therapies in men with larger prostates.  The combination approach prevents the progression of disease and improves bothersome symptoms.  However, this improved benefit may be associated with more side effects (possible side effects from both medications).

Anticholinergics:  Another medical therapy that is an appropriate and effective treatment alternative for the management of symptoms related to BPH. 

Complementary and Alternative Medicines/Phytotherapies: These compounds, also know as herbal therapies, are very popular self treatment remedies. Currently there is no dietary supplement, complementary alternative medicine or therapy that is recommended for the management of BPH.  Furthermore, the quality and purity of these over-the-counter supplements are not rigorously monitored, adding further uncertainty about the value and safety of these products.

Saw palmetto one of the more popular dietary supplements used by men has been shown to provide no benefit over a placebo for the treatment of BPH conditions and LUTS.

Minimally Invasive Therapies

Since the advent of medical therapy for symptomatic BPH with 5-alpha reductase inhibitors and alpha-adrenergic blockers, the need for immediate surgical intervention in symptomatic prostatic obstruction has been reduced substantially. However, alpha-blockers do not modify prostate growth, and even the use of prostatic growth inhibitors such as finasteride or dutasteride often fails to prevent the recurrent LUTS of BPH and urinary retention. In the past, these patients would almost certainly have undergone more invasive treatment earlier in the disease process.

Transurethral needle Ablation (TUNA) of the prostate

This outpatient treatment requires a urologist to insert a cystoscope-like device into the prostate.  Each needle in the prostate emits low-level frequency radio waves that is sufficient to create a heat that kills the prostate tissue.  The dead tissue from the prostate is absorbed by the body.  The reduction in the size of the prostate alleviates the symptoms caused by BPH. 

In the short term it is a very effective treatment however for long-term treatment patients may need to be retreated for their symptoms.  In addition to the issue concerning the long term effectiveness of the treatment, finding the right candidates for the procedure has proven to be a challenge to doctors and is not consistent.  One of the advantages of this treatment over others is the minimal sexual side effects short term.

Transurethral Microwave Thermotherapy (TUMT)

TUMT is a minimally invasive treatment that uses high-frequency radio waves to cause thermal injury to the prostate while providing relief for bladder obstruction.  This treatment has been advanced in the last couple of years with new higher energy devices creating better long term outcomes.  Yet, the advancement has done little to reduce the greater adverse outcomes that are generally associated with this treatment options. 

Surgical Techniques

There are many surgical procedures to treat BPH.  Surgery is the most invasive approach and is typically reserved for patients suffering from moderate-to-severe BPH related LUTS or complications which arise from BPH (e.g. urinary retention, progressive LUTS, recurrent urine infection).  It is generally reserved for patients who have not been able to successfully treat the condition with other treatment options or for those who present with moderate to severe BPH.  The following are the generally accepted surgical treatment options:

  • Transurethral resection of the prostate (TURP)

Has excellent outcomes and is the gold standard.  All treatment options are generally compared to this approach.  It is not safer with bipolar TURP meaning less risk of water intoxication leading to low sodium levels. 

  • Open prostatectomy

This surgery involves the removal of the inner portion of the prostate via a suprapubic or retropubic incision in the lower abdominal area.  It is reserved for men with significantly enlarged prostate glands.  The major risks associated with this treatment are the potential blood loss, need for transfusions, and a longer hospital stays.   Outcomes are generally very effective with this approach in these patients.  

  • Transurethral holmium laser ablation of the prostate (HoLAP)
  • Transurethral holmium laser enucleation of the prostate (HOLEP)
  • Holmium laser resection of the prostate (HoLRP)
  • Photoselective vaporization of the prostate (PVP)
  • Transurethral incision of the prostate (TUIP)
  • Transurethral
  • Transurethral vaporization of the prostate (TUVP)

Before deciding if any of these treatment options are best make sure to discuss with your physician the following:

  • Current symptoms and bother from these symptoms
  • Size of prostate
  •  The potential benefits and risks associated with any form of treatment including watchful waiting

The following are things a patient should consider before deciding on a particular option:

  • presentation (symptoms and how they feel about those symptoms)
  • Size of prostate
  • Surgeon’s experience
  • Discussion with physician about the potential risks and benefits

Where can I get more information?

AUA Guidelines: Management of BPH

BPH: Diagnosis

BPH: Medical Management

BPH: Minimally Invasive Management

BPH: Surgical Management

Download the free Acrobat reader.

Common misspellings/other names used: enlarged prostate, big prostate



Reviewed: January 2011

Last updated: July 2013

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BPH: Management (Benign Prostatic Hyperplasia/Enlarged Prostate) Glossary
  • abdominal: in the abdomen, the cavity of this part of the body containing the stomach, intestines and bladder.

  • ablation: Removal of diseased or unwanted tissue from the body by surgery or other means.

  • acute: Acute often means urgent. An acute disease happens suddenly. It lasts a short time. Acute is the opposite of chronic, or long lasting.

  • alpha-adrenergic blockers: Also known as alpha-blockers. Drugs used to treat high blood pressure and other conditions like an enlarged prostate or stress urinary incontinence.

  • alpha-blockers: Also known as alpha-adrenergic blockers. Drugs used to treat high blood pressure and other conditions like an enlarged prostate.

  • anatomy: The physical structure of an internal structure of an organism or any of its parts.

  • bladder: The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.

  • BPH: Also known as benign prostatic hyperplasia. An enlarged prostate not caused by cancer. BPH can cause problems with urination because the prostate squeezes the urethra at the opening of the bladder.

  • cancer: An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.

  • cholinergic: Fibers in the parasympathetic nervous system that release a chemical called acetylcholine.

  • continence: The ability to control the timing of urination or a bowel movement.

  • cyst: An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.

  • cystoscope: A narrow, tube-like instrument fitted with lenses and a light passed through the urethra to look inside the bladder. The procedure is called cystoscopy (sis-TAW-skuh-pee).

  • cystoscopy: Also known as cystourethroscopy. An examination with a narrow, flexible tube-like instrument passed through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.

  • cytology: The examination of cells obtained from the body tissue or fluids, especially to establish if they are cancerous.

  • cytology: Examination of cells obtained from the body tissue or fluids, especially to determine if they are cancerous.

  • DRE: Also known as digital rectal examination. Insertion of a gloved, lubricated finger into the rectum to feel the prostate and check for any abnormalities.

  • ejaculation: Release of semen from the penis during sexual climax (orgasm).

  • ejaculatory: Involved in or related to the structure involved in the release of semen from the penis during orgasm.

  • erectile: Capable of filling with blood under pressure, swelling and becoming stiff.

  • erectile dysfunction: Also known as ED or impotence. The inability to get or maintain an erection for satisfactory sexual intercourse. Also called impotence.

  • erectile dysfunction: The inability to get or maintain an erection for satisfactory sexual intercourse. Also called impotence.

  • frequency: The need to urinate more often than is normal.

  • gene: The basic unit capable of transmitting characteristics from one generation to the next.

  • gland: A mass of cells or an organ that removes substances from the bloodstream and excretes them or secretes them back into the blood with a specific physiological purpose.

  • high blood pressure: Medical term is hypertension.

  • hyperplasia: Excessive growth of normal cells of an organ.

  • incision: Surgical cut for entering the body to perform an operation.

  • incontinence: Loss of bladder or bowel control; the accidental loss of urine or feces.

  • infection: A condition resulting from the presence of bacteria or other microorganisms.

  • invasive: Not just on the surface; with regard to bladder cancer, a tumor that has grown into the bladder wall.

  • invasive: Having or showing a tendency to spread from the point of origin to adjacent tissue, as some cancers do. Involving cutting or puncturing the skin or inserting instruments into the body.

  • ions: Electrically charged atoms.

  • kidney: One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.

  • laser: Device that utilizes the ability of certain substances to absorb electromagnetic energy and re-radiates as a highly focused beam of synchronized single wave-length radiation.

  • libido: Sexual desire.

  • nocturia: Excessive urination at night.

  • obstruction: something that obstructs, blocks, or closes up with an obstacle

  • penis: The male organ used for urination and sex.

  • placebo: Drug with no active ingredients.

  • post-void residual volume: A diagnostic test that measures how much urine remains in the bladder after urination.

  • prostate: A walnut-shaped gland in men that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.

  • prostatectomy: Surgical procedure for the partial or complete removal of the prostate.

  • prostatic: Pertaining to the prostate.

  • PSA: Also referred to as prostate-specific antigen. A protein made only by the prostate gland. High levels of PSA in the blood may be a sign of prostate cancer.

  • radio waves: Electromagnetic waves.

  • rectal: Relating to, involving or in the rectum.

  • rectum: The lower part of the large intestine, ending in the anal opening.

  • resection: The surgical removal of a portion of a body part.

  • retention: In ability to empty urine from the bladder, which can be caused by atonic bladder or obstruction of the urethra.

  • semen: Also known as seminal fluid or ejaculate fluid. Thick, whitish fluid produced by glands of the male reproductive system, that carries the sperm (reproductive cells) through the penis during ejaculation.

  • semen: The thick whitish fluid, produced by glands of the male reproductive system, that carries the sperm (reproductive cells) through the penis during ejaculation.

  • Side effects: An action or effect of a drug other than that desired. Commonly it is an undesirable effect (e.g., nausea, headache, insomnia, acute toxic reaction or drug interaction).

  • stent: With regard to treating ureteral stones, a tube inserted through the urethra and bladder and into the ureter. Stents are used to aid treatment in various ways, such as preventing stone fragments from blocking the flow of urine.

  • suprapubic: An area of the central lower abdomen above the bony pelvis and overlying the bladder.

  • symptomatic: Having to do with a symptom or symptoms that arise from and accompany a particular disease or disorder and serves as an indication of it.

  • tissue: Group of cells in an organism that are similar in form and function.

  • transfusion: Transfer of whole blood, blood components or bone marrow from a healthy donor into the bloodstream of somebody who has lost blood or who has a blood disorder.

  • TUIP: Also referred to as transurethral incision of the prostate. A procedure that widens the urethra by making a few small cuts in the bladder neck where the urethra joins the bladder and in the prostate itself. Treatment for BPH.

  • TUMT: Also referred to as transurethral microwave thermotherapy. Destroys excess prostate tissue interfering with the exit of urine from the body by using a probe in the urethra to deliver microwaves. Treatment for BPH.

  • TUNA: Also referred to as transurethral needle ablation. Destroys excess prostate tissue with electromagnetically generated heat by using a needle-like device in the urethra. Treatment for BPH.

  • TURP: Also referred to as transurethral resection of the prostate. Surgical procedure where a lighted tube with an attached electrical loop is inserted through the urethra into the prostate. Serves as a diagnostic and therapeutic role in the treatment of bladder cancer.

  • ultrasound: Also referred to as a sonogram. A technique that bounces painless sound waves off organs to create an image of their structure to detect abnormalities.

  • urethra: A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.

  • urethral: Relating to the urethra, the tube tha carries urine from the bladder to outside the body.

  • urge: Strong desire to urinate.

  • urinal: A portable device that is used as a receptacle for urine.

  • urinalysis: A test of a urine sample that can reveal many problems of the urinary system and other body systems. The sample may be observed for physical characteristics, chemistry, the presence of drugs or germs or other signs of disease.

  • urinary: Relating to urine.

  • urinary cytology: Inspection under a microscope of cells found in the urine.

  • urinary incontinence: Involuntary loss of urine associated with a sudden strong urge to urinate.

  • urinary incontinence: Inability to control urination.

  • urinary retention: Failure to empty the bladder totally.

  • urinary tract: The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.

  • urinate: To release urine from the bladder to the outside. Also referred to as void.

  • urination: The passing of urine.

  • urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.

  • urine flow study: A test in which the patient urinates into a special device that measures how quickly the urine is flowing.

  • uroflow: Urination flow.

  • uroflowmetry: A urodynamic test that measures urine flow either visually, electronically, or with the use of a disposable flowmeter unit.

  • urologist: A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)

  • urology: Branch of medicine concerned with the urinary tract in males and females and with the genital tract and reproductive system of males.

  • vas: Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.

  • void: To urinate, empty the bladder.

  • watchful waiting: An approach to handling localized, slow-growing prostate cancer by having regular checkups instead of immediate treatment.

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