An enlarged prostate, known in medicine as benign prostatic hyperplasia (BPH), is the most common cause of difficulty passing urine in adult men. The gland grows slowly over the years, presses on the first part of the urethra and gradually stops the bladder from emptying completely.
Roughly half of men over 50 have the tissue changes typical of BPH in their prostate, and after the age of 70 they are found in most men. Not everyone develops symptoms, but in many men the symptoms slowly disrupt sleep, work and peace of mind when travelling. The condition is benign and well understood, and treatment is effective at every stage – the problems come when symptoms are put up with for years until complications set in.
What is an enlarged prostate
The prostate is a gland about the size of a chestnut. It sits below the bladder and surrounds the urethra like a ring. It produces part of the seminal fluid. In BPH the glandular and muscle cells around the urethra multiply, creating a double obstruction – a mechanical one, from the bulk of the tissue, and a dynamic one, from the increased tension of the smooth muscle in the prostate and the bladder neck.
At first the bladder compensates by thickening its wall and contracting more strongly. Over time its muscle becomes exhausted, urine is left behind after each time you pass water (residual urine), and conditions are created for infections and stones. BPH is not cancer, although the two conditions can exist at the same time.
Symptoms
The symptoms fall into two groups. Voiding (emptying) symptoms include:
- a weak, thin or interrupted stream;
- a delay before the stream starts and the need to strain;
- a feeling that the bladder has not emptied completely;
- dribbling after you have finished.
Storage symptoms are caused by an irritated bladder:
- passing small amounts of urine often during the day;
- sudden urges that are hard to put off;
- getting up at night to pass urine – known as nocturia, especially when it happens twice or more.
Their severity is assessed with a standardised international prostate symptom questionnaire, which you fill in within a few minutes and which is later used to track the effect of treatment.
Some situations cannot wait. Being completely unable to pass urine with a painfully swollen bladder is acute urinary retention – go to an emergency department or call 112 (the European emergency number) without waiting for a booked appointment. The same applies to a high temperature with chills, or blood in the urine, together with difficulty passing urine.
Causes and risk factors
The two main factors are age and the long-term effect of male sex hormones on the prostate tissue. Without them hyperplasia does not develop, which is why the condition is practically never seen in young men. The risk and the speed of progression are higher if your father or brother has had an enlarged prostate, with excess weight, diabetes and high blood pressure, with a sedentary lifestyle, and with a larger gland volume and a higher PSA at the first test. Sexual activity, or the lack of it, does not cause BPH, and an enlarged prostate is not an infection.
Diagnosis
The consultation with Dr Penev in Plovdiv or Karlovo begins with a conversation about your symptoms, how long you have had them and how they affect your daily life. It is important to mention all the medicines you take – some cold, allergy and depression medicines make it harder to pass urine and can trigger retention.
This is followed by a rectal examination to assess the size and consistency of the gland and any firm areas in it, and an ultrasound scan of the urinary tract, which measures the volume of the prostate, the bladder wall and the residual urine and shows whether the kidneys are dilated. Uroflowmetry records the strength of the stream and gives an objective measure of the degree of obstruction. The laboratory tests needed are a urine test, creatinine and PSA – both to rule out cancer, which causes similar symptoms, and because its value suggests how fast the gland is likely to grow. You can read separately about how a prostate examination works.
Treatment
The choice depends on how severe the symptoms are, the size of the gland, the residual urine and, above all, how much the symptoms bother you. With mild symptoms and no complications, active monitoring with a check-up once a year is a sensible approach.
Changes in habits
It helps to spread your fluids through the day and limit them before bed, to drink less coffee and alcohol in the evening, to exercise regularly, to treat constipation and to use so-called double voiding – a short pause and a second attempt to empty the bladder completely.
Medication
Alpha-blockers relax the smooth muscle of the prostate and the bladder neck and improve the stream within the first few weeks; possible side effects are dizziness on standing up and retrograde ejaculation. 5-alpha-reductase inhibitors reduce the size of the gland by about a quarter, but they act slowly, over 6–12 months, and are suitable for larger prostates; they lower PSA by roughly half, which Dr Penev takes into account when interpreting it. If urges are marked, medicines that calm the bladder are added, and if there is also erectile dysfunction, a phosphodiesterase-5 inhibitor, which helps with both conditions.
Surgery
Surgery is considered when medication does not help enough or is not tolerated, and in cases of repeated urinary retention, bladder stones, frequent infections or kidney involvement. The standard methods today are endoscopic – through the urethra, without an incision: transurethral resection of the prostate (TURP) and laser techniques that vaporise the enlarged tissue or remove it in one piece; for a very large gland, laparoscopic or open removal of the adenoma is considered. Dr Penev decides on the right method for each patient according to the size of the gland, other health conditions and the options available at the department. Dr Penev performs prostate operations at the Department of Urology at Kaspela University Hospital (UMBAL Kaspela), Plovdiv, while preparation and follow-up take place at the practice.
When to see a urologist
Book a consultation if your stream has become weaker, you get up at night more than once, you feel that your bladder has not emptied completely or you have had an episode of being unable to pass urine. Do not delay either if you have blood in your urine, repeated infections or pain low in your abdomen. Men over 50 – or over 45 if there is a family history – should have a preventive check-up even without symptoms.
Prevention
The growth of the prostate cannot be stopped with certainty, but a healthy weight, regular exercise, good diabetes control and moderate drinking slow the progression of symptoms, and a preventive check-up catches changes early, when treatment is at its simplest.
There is treatment for an enlarged prostate at every stage – from changes in habits to modern endoscopic surgery. If passing urine is already causing you discomfort, book an appointment with Dr Penev in Plovdiv or Karlovo for an unhurried, thorough consultation.
Frequently asked questions
Should I drink less water so that I urinate less often?
No – concentrated urine irritates the bladder. Spread your fluids through the day, cut down 2–3 hours before bed and limit coffee and alcohol in the evening.
How long do you take medication for an enlarged prostate?
Usually long term, for as long as it works and is well tolerated – if you stop, the symptoms come back. If the effect is not good enough, a change of treatment or surgery is discussed.
Will I still have erections after surgery for an enlarged prostate?
With endoscopic operations, as a rule, yes. A common after-effect is retrograde ejaculation – the semen goes into the bladder. It is harmless, but it matters if you are planning to have children.
Do herbs and food supplements help?
Plant extracts are well tolerated, but in controlled studies their effect is not substantially greater than that of a placebo. Do not put off your examination and treatment because of them.
The information on this website is for general education and does not replace an examination and consultation with a doctor. If you have urgent symptoms, seek medical help immediately or call 112.